Takotsubo Cardiomyopathy Associated with Primary Hyperthyroidism Secondary to Toxic Multinodular Goiter.

Takotsubo cardiomyopathy is increasingly recognized as a distinct clinical entity. An association with thyroid disease has been identified in several case reports, mostly in the context of Grave disease. We report the case of a 67-year-old woman presenting with takotsubo cardiomyopathy and thyrotoxicosis secondary to toxic multinodular goiter. Previously unreported, this suggests that this association is related to the direct effects of thyroid hormone, rather than an autoimmune mechanism. Thyroid disease should be considered in patients presenting with takotsubo cardiomyopathy.

Neurofibromatosis-related phaeochromocytoma: two cases with large tumours and elevated plasma methoxytyramine.

UNLABELLED: We present two cases of adrenal phaeochromocytoma in patients with a previous diagnosis of neurofibromatosis type 1 (NF1). One had an adrenergic phenotype. The other had a more noradrenergic phenotype. Both had large primary tumours, which increases the likelihood of malignancy. Both also had elevated plasma-free methoxytyramine, which has been linked with malignancy even in non-SDHB phaeochromocytomas. LEARNING POINTS: Phaeochromocytoma can have varied clinical presentations.Methoxytyramine can be useful in the biochemical work-up of both SDHB-positive and SDHB-negative phaeochromocytoma.The utility of methoxytyramine as a marker of malignancy in NF1-related phaeochromocytoma is unclear, and cases with elevated titres warrant longer follow-up.

Macrosomia in non-gestational diabetes pregnancy: glucose tolerance test characteristics and feto-maternal complications in tropical Asia Pacific Australia.

OBJECTIVE: To look into the glucose tolerance test characteristics and determine complications in non-gestational diabetes pregnant subjects. METHODS: From 2006 to 2009 all non-gestational diabetes mellitus (non-GDM) pregnant women who delivered macrosomia at the North Australia's Townsville Hospital were retrospectively reviewed by extracting data from clinical record. Glucose tolerance tests results were analysed in the light of an earlier diagnosis of non-GDM. RESULTS: Ninety-one non-GDM mothers with macrosomia were studied and compared with 41 normoglycemic subjects without macrosomia. Of the subjects with non-GDM macrosomia, 45 (49.4%) had normal 50 g glucose challenge test (GCT) without further testing, another 8 (8.8%) had abnormal GCT but normal 75 g oral glucose tolerance test (OGTT). A total of 4 (4.4%) subjects had normal GCT and OGTT. Interestingly, 14 out of 16 (87.5%) subjects who were tested with OGTT owing to past history of macrosomia had normal results but delivered macrosomic babies. Only 12 subjects had both GCT and OGTT, the rest of the cohort had either of the two tests. Subjects with non-GDM macrosomia had higher frequency of neonatal hypoglycaemia 34% as compared to 10% in non-macrosomic babies (P=0.003). Other feto-maternal complications were similar in both groups. CONCLUSIONS: No significant pattern of glucose tolerance characteristics was identified in non-GDM mothers with macrosomic babies. In spite of being normoglycemic significant neonatal hypoglycaemia was recorded in non-GDM macrosomic babies. Further prospective studies on a larger population are needed to verify our findings.

Autoimmune thyroid disease in the use of alemtuzumab for multiple sclerosis: a review.

OBJECTIVE: The monoclonal antibody alemtuzumab has been demonstrated to reduce the risks of relapse and accumulation of sustained disability in multiple sclerosis (MS) patients when compared to ß-interferon. The development of autoimmune diseases, including thyroid disease, has been reported in the literature with a frequency of 20 to 30%. In this article, we describe 4 cases of alemtuzumab-induced thyroid disease in patients with MS. We also performed a systematic review of the available literature. METHODS: Four patients who had received alemtuzumab for MS and subsequently developed thyroid dysfunction are presented. We compared our patients' clinical courses and outcomes to established disease patterns. We also undertook a systematic review of the published literature. RESULTS: All 4 patients presented with initial hyperthyroidism associated with elevated thyroid-stimulating hormone (TSH) receptor antibodies (TRAb). In 2 cases, hyperthyroidism did not remit after a total of 24 months of carbimazole therapy, and they subsequently underwent subtotal thyroidectomy. The third case subsequently developed biochemical hypothyroidism and required thyroxine replacement, despite having a markedly raised initial TRAb titer. Autoimmunity following alemtuzumab therapy in MS appears to occur as part of an immune reconstitution syndrome and is more likely in smokers who have a family history of autoimmune disease. CONCLUSION: Management of alemtuzumab-induced thyroid disease is similar to the management of "wild-type" Graves' disease. The use of alemtuzumab in this setting will necessitate close monitoring of thyroid function and early intervention when abnormalities are developing.

Metabolic control with insulin pump therapy: the Waikato experience.

AIM: To report the effect of insulin pump therapy on glycaemic control and on hypoglycaemia and ketosis rates in Type 1 diabetic patients. METHODS: A retrospective audit of the management of patients with Type 1 diabetes treated with insulin pump therapy at the Waikato Diabetes Service (Hamilton, New Zealand) between September 1997 and December 2004. RESULTS: The data of 105 patients currently on continuous subcutaneous insulin infusion (CSII) at the time of data collection were examined. CSII use had occurred for a mean of 3.0+/-2.6 years. HbA1c% improved significantly from 8.9+/-1.3% to 7.9+/-1.0% (P<0.001) at 3 months and 7.9+/-0.95% (P<0.001) at 6 months post CSII. This reduction was maintained after 1, 2, and 3 years and the difference was statistically significant (P<0.001). In the adolescent subgroup (n=27) we observed a similar significant reduction in HbA1c% that was maintained after 1 year of pump therapy. The incidence of severe hypoglycaemia was reduced from 0.75 cases per patient-year during multiple daily injection (MDI) pre-pump to 0.05 cases per patient-year during CSII (P<0.001). In some cases hypoglycaemia awareness was restored. There was no evidence to suggest increased tendency for diabetic ketoacidosis (DKA) with continuing use of insulin pumps. Conclusion Our experience showed that insulin pump therapy was effective and safe for both adults and adolescents with Type 1 diabetes. The reduction in HbA1c% was both statistically and clinically highly significant. Wider usage of this technology in New Zealand is warranted.

Screening for diabetic retinopathy using the mobile retinal camera: the Waikato experience.

AIM: To report the results of the Waikato Regional Mobile Diabetic Retinopathy Photoscreening Programme. METHODS: We audited the results of a diabetic retinal photoscreening programme using the mobile retinal camera in the Waikato region for the period August 1993 to December 2001. RESULTS: A total of 8172 patients were screened one or more times, with a total of 15 555 photoscreens, representing approximately 79% of the expected number of patients with diabetes for the region. Seventy eight per cent showed no diabetic retinopathy (NDR), 9.3% had evidence of non-vision-threatening retinopathy (NVR), and 3.1% had evidence of vision-threatening retinopathy (VTR). A further 2281 (14.7%) led to a referral to an eye clinic for specialist review. The percentage of all screening episodes resulting in VTR fell from 11.5% in 1993 to 1.5% in 2002. The overall failure-to-attend rate for photoscreening was high (18.7%), especially in the Maori population (32.3%). CONCLUSION: Mobile retinal photoscreening is practical in a large rural area, and its implementation has been associated with a reduction in presentations with vision-threatening retinopathy within the total community. The rate of subsequent development of VTR in the group with normal eyes on initial photoscreening was low and supports a two-yearly repeat photoscreening schedule for this group. Despite significant efforts to improve physical access to photoscreening, the failure-to-attend rates in all ethnic groups other than Europeans are disappointingly high.