Primary Hyperparathyroidism Masquerading as Acute Pancreatitis.

Acute pancreatitis as an initial manifestation of primary hyperparathyroidism (PHPT) is a rare occurrence and timely diagnosis of PHPT is crucial in preventing repeat attack of pancreatitis. The study aimed at evaluating the clinico-radiological profile of patients admitted with acute pancreatitis as the index presentation of PHPT and to determine the factors associated with development of severe pancreatitis. This series included retrospective analysis of medical records of 30 patients admitted with acute pancreatitis as initial manifestation of PHPT. Additionally, we analyzed the data of another 30 patients admitted with PHPT but without any evidence of pancreatitis, to serve as control group. The mean age of the subjects was 44.9±13.9 years with male to female ratio of 1.30. The mean serum calcium level was 12.24±2.79 mg/dl and five (16.6%) patients had normocalcemia at time of presentation. Presence of nephrolithiasis was significantly associated with severe pancreatitis. One patient had refractory hypercalcemia associated with renal failure and was successfully managed with denosumab. Patients with PHPT associated with acute pancreatitis had significantly higher calcium levels and lower frequency of skeletal involvement as compared to PHPT patients without pancreatitis. PHPT masquerading as acute pancreatitis is rare and high index of suspicion is required to diagnose this condition especially in the presence of normocalcemia at presentation. Patients with PHPT associated pancreatitis had male preponderance, higher calcium levels, and lower frequency of skeletal involvement as compared to PHPT patients without pancreatitis.

Evaluation of Urinary Free Light Chains as a Marker of Severity of HIV Disease and Its Correlation with CD4 Count: A Pilot Study.

Human immunodeficiency virus (HIV) infection weakens immunity. Monitoring the immune status of the patient has become an important aspect of evaluating the progression of the disease and informing follow-up after treatment. Estimation of CD4 counts is quite costly and requires expertise in flow cytometry. In certain pathologies, free light chains (FLCs) are secreted in serum and urine and the magnitude can be used to monitor the severity, progression, and therapeutic monitoring of the disease. Urine as a specimen proves cost-effective and presents reduced risks during sample collection. The stability of light chains in urine at room temperature over extended periods simplifies the management of sample transportation as well. Hence, a pilot cross-sectional study was planned to evaluate the levels of urinary immunoglobulins in patients with HIV. The study was conducted at PGIMER, Dr. Ram Manohar Lohia Hospital (presently ABVIMS), New Delhi. Sixty-nine consecutive ART-naive HIV patients aged between 18 and 40 years and 69 age- and sex-matched healthy controls were included in the study. Urinary FLC kappa (κ) and lambda (λ) were measured using an immunoglobulin ELISA kit. Baseline urinary κ light chain levels were significantly higher in cases when compared with controls (p < .001) and were found to be increased with increasing WHO immunological classes (p < .001) and inversely related to CD4 cell count. However, no significant difference in mean urinary λ immunoglobulin light chain between cases and controls was found and no correlation with CD4 cell count or with stages of WHO immunological classification of HIV disease was observed. It is suggested that urinary free κ chain measurements combined with serum light chain measurements may be a useful marker in the follow-up and monitoring of response to therapies in patients with HIV where testing by flow cytometry is not available.

Normative Data for Modified Ferriman-Gallwey Score and the Prevalence of Hirsutism in Young South Indians.

Introduction: The modified Ferriman-Gallwey score (mFGS) cut-offs to define hirsutism vary with ethnicity, whereas no such cut-offs are established for Indian women. Well-conducted studies that report the prevalence of hirsutism in Indian women are limited. Hence, this study was conducted to report the prevalence of hirsutism and population-specific cut-offs for mFGS in South-Indian women. Methods: In this cross-sectional, community-based study, adult women in reproductive age (18-40 years) were screened for hirsutism by two trained medical students. Hirsutism was assessed using the mFGS and case record file. Results: A total of 453 women were included in the study [age: 22.15 ± 5.27 years; body mass index (BMI): 22.5 ± 3.58 kg/m2]. The median (IQR) mFGS was 1(0-3); only eight participants (1.8%) had mFGS ≥8, and all these eight women had at least another PCOS-related feature (irregular menstrual cycles and/or topical therapy-resistant acne). The median (IQR) mFGS in the PCOS phenotype group (n = 52), non-PCOS-phenotype group (n = 401), non-obese group (<25 kg/m2), non-PCOS-phenotype group (n = 322), obese group (≥ 25 kg/m2), non-PCOS-phenotype group (n = 79), overweight group (BMI: 23-25 kg/m2), non-PCOS-phenotype group (n = 74), normal BMI group (<23 kg/m2), and non-PCOS-phenotype group (n = 248) were 4 (1-6), 1 (0-2), 1 (0-2), 2 (1-3), 1 (0-2), and 1 (0-2), respectively. The 97.5th centile mFGS in all groups except the PCOS phenotype group and the obese and non-PCOS phenotype groups was 5. Conclusion: We propose a new mFGS cut-off of 5 in the South-Indian population for evaluation of hirsutism, and the prevalence rates of hirsutism in the South-Indian population were 1.8% and 9.9% using mFGS of ≥8 and ≥5 to define hirsutism, respectively.

High Diagnostic Accuracy of Thyroid-Stimulating Hormone (TSH) Receptor Antibodies in Distinguishing Graves' Disease and Subacute Thyrotoxicosis in the Indian Population.

BACKGROUND AND OBJECTIVE: Thyrotoxicosis is a common clinical condition encountered in endocrine practice. Graves' disease and subacute thyroiditis are the two common causes of thyrotoxicosis and often have overlapping clinical and biochemical features. 99mTc thyroid scintigraphy is the most commonly used confirmatory test to differentiate the two conditions but is not available in the majority of the second-tier cities of India. However, obtaining thyroid stimulating hormone (TSH) receptor antibodies (TSHrAb), another accurate test to differentiate the two conditions, in second-tier cities by outsourcing to labs in major cities is a feasible option nowadays. However, the data on the performance of TSHrAb to differentiate the two conditions in Indian patients is limited. Hence, we have evaluated the diagnostic accuracy of TSHrAb in the Indian population to differentiate Graves' disease and subacute thyroiditis. MATERIALS AND METHODS: This prospective study was conducted on 115 consecutive newly diagnosed thyrotoxicosis patients presenting to the Department of Endocrinology at a tertiary health care centre in India. Clinical parameters like throat pain, duration of symptoms, and grade of goitre were noted. Measurement of total tri-iodothyronine (TT3), total thyroxine (TT4), TSH, TSHrAb, and 99mTc thyroid scintigraphy were performed in all participants. All participants were followed up at least for six months after the recruitment. Increased tracer uptake (>4%) and/or increased thyroid to parotid trace uptake ratio (>2.5) were used to diagnose Graves' disease. RESULTS: Eighty-one and 34 patients were diagnosed with Graves' disease and subacute thyroiditis, respectively. TT3/TT4 ratio had low diagnostic accuracy (area under the curve (AUC): 0.6, best cut-off: 15.6, sensitivity: 53.1%, specificity: 79.4%). TSHrAb had the best AUC (0.9) to distinguish Graves' disease from subacute thyroiditis (cut-off: 2.0 IU/L, sensitivity: 97.5%, specificity: 100%). In contrast, the kit manufacturer's reference range (1.75 IU/L) was slightly more sensitive (98.8%), but less specific (94%). CONCLUSION: The TT3/TT4 ratio is not a good test to differentiate Graves' disease and subacute thyroiditis. TSHrAb is accurate in distinguishing Graves' disease from subacute thyroiditis and a level of 2.0 may be a more accurate cut-off to differentiate the two conditions in the Indian population.

Radiological evolution of pituitary hyperplasia in primary hypothyroidism and its differentiation from nonfunctioning pituitary adenoma coexisting with primary hypothyroidism.

PURPOSE: In a patient with elevated thyroid stimulating hormone (TSH, >50 µIU/ml) with sellar mass, it is crucial to differentiate isolated pituitary hyperplasia (IPH) from primary hypothyroidism coexisting with nonfunctioning pituitary adenoma (PHCNFPA) pre-operatively to avoid unwarranted surgery in the former condition. Here, we describe patients having pituitary mass/enlargement with markedly elevated TSH (>50 µIU/ml) and attempt to find the differentiating features between IPH and PHCNFPA. METHODS: This is a retrospective study conducted at a tertiary care center. Case records of patients presenting between January 2020 and December 2022 with elevated TSH (>50 µIU/ml) for whom magnetic resonance imaging (MRI) of the sella was available were reviewed. Demographic details, symptomatology, clinical examination findings, thyroid function tests, data on pituitary hormonal excess and deficiencies, MRI findings, and details regarding levothyroxine supplementation were noted. Based on the final diagnosis, the patients were categorized into two groups: PHCNFPA and IPH. RESULTS: Five and 11 patients were diagnosed with PHCNFPA and IPH, respectively. The median (IQR) age at presentation of patients with PHCNFPA was significantly higher than that of IPH patients [37 (28-60.5) vs. 21 (10-21.5) years, p: 0.002]. A longer duration of hypothyroid symptoms was noted in the IPH group whereas visual field defects and corticotropin deficiency were more frequent and the pituitary lesion size was greater in PHCNFPA. Thyroid function tests were not different between the two groups. The pituitary enlargement in IPH was initially an increase in pituitary height that progressed to symmetrical nipple-, dome- or tent-shaped enlargement. Besides this characteristic enlargement pattern, isointense appearance on T1-weighted and T2-weighted images, homogeneous contrast enhancement, and prompt regression of pituitary lesion with levothyroxine replacement were characteristic of IPH whereas heterogeneous enhancement, cystic/hemorrhagic change, and ≥Knosp III invasion were characteristic of PHCNFPA. Peripheral rim enhancement and Knosp I-II parasellar extension were not uncommon in patients with IPH and did not distinguish it from PHCNFPA. CONCLUSIONS: The present study reports the radiological evolution of IPH and a unique series of PHCNFPA along with the distinguishing characteristics between them.

High Prevalence of Additional Cardiovascular Risk Factors in Eastern-Indian Young Adults with Type 2 Diabetes Mellitus.

Background and Aims: The American Diabetes Association recommends statin therapy for young type 2 diabetes mellitus (T2DM) adults only if one additional cardiovascular (CV) risk factor coexists. The data regarding CV risk factors in young Indian T2DM adults is limited. Hence, we assessed the prevalence of CV risk factors in young adults with T2DM from eastern India. Methods: In this cross-sectional study, diabetic medical health check records of eastern-Indian T2DM patients performed between March 2018 and March 2019 were retrospectively reviewed and the relevant data of T2DM patients (n = 3564) including CV risk factors [serum LDL-cholesterol of ≥100 mg/dL, hypertension (>140/90 mmHg), smoking, chronic kidney disease (eGFR of <60 ml/min), microalbumin to creatinine ratio of ≥30 mg/mg, and obesity/overweight (body mass index ≥23 kg/m2)] were analysed. Results: There were 3280 T2DM patients from eastern India and 679 (20.7%) were ≤40 years of age. Overweight/obesity (74.3%) and serum LDL-cholesterol of ≥100 mg/dL (69.2%) were the two most common additional CV risk factors. At least one additional CV risk factor was present in 576 (95.36%) patients, whereas at least two additional CV risk factors were present in 409 (67.7%) patients. At least one non-obesity/overweight CV risk factor was present in 472 (78.1%) patients. Conclusions: The study demonstrates a high prevalence of additional CV risk factors in young eastern-Indian adults with T2DM. Hence, there is a need for an intensive approach to managing the CV risk factors in young Indian adults with T2DM.

Early detection of cutaneous complications of insulin therapy in type 1 and type 2 diabetes mellitus.

BACKGROUND: Subcutaneous insulin therapy is associated with important injection site complications, which can influence insulin pharmacokinetics resulting in glycemic fluctuations above and below target levels for blood glucose. OBJECTIVE: Our objective was to assess the prevalence and risk factors of cutaneous complications including insulin derived amyloidosis in insulin-injecting diabetes patients and to study the role of ultrasonography (in comparison to gel-assisted palpation) in early diagnosis of lipohypertrophy (LH). METHODS: This was a cross-sectional study conducted at a tertiary care center in India, wherein 500 patients injecting insulin for ≥2 years were randomly enrolled and evaluated for the presence of cutaneous complications of insulin therapy through clinical examination, ultrasonography and punch biopsy of skin. RESULTS: Clinical examination detected LH in 44.6% of patients. Ultrasonography diagnosed additional 13.4% of patients with LH which were missed on clinical examination. Incorrect rotation of sites (P < 0.001) and insulin syringe reusage for more than five times (P < 0.001) significantly increased the risk of LH. Skin biopsy was performed in 100 cases, out of which two patients showed apple green birefringence and its association with insulin was confirmed by positive staining with anti insulin antibody in these two patients. CONCLUSION: Improper rotation of sites and reuse of needles were the leading causes of LH in Indian diabetic patients. Ultrasonography is more objective and reliable method of detecting LH. Insulin-derived amyloidosis may be a more common complication of insulin therapy than previously thought.