Resistant hypertension after shockwave lithotripsy: the rude awakening of an adrenal incidentaloma.

A 41-year-old woman presented to the hospital because of left flank pain. CT scan of the kidneys revealed left-sided calculi and an incidental right adrenal mass, no other symptoms noted. She then underwent shockwave lithotripsy (SWL). However, immediately postoperatively, she had elevated blood pressure and remained hypertensive despite having four different medications. How SWL could have increased blood pressure could not be identified. On endocrine consult 16 months after SWL, she was found to now exhibit signs and symptoms of Cushing's syndrome. Further workup revealed the adrenal incidentaloma to be cortisol-secreting. After undergoing right laparoscopic adrenalectomy, her blood pressure normalised, cortisol levels decreased and signs of Cushing's syndrome gradually improved. We hypothesise that the performance of the SWL could have triggered the adenoma to 'awaken' from being non-functioning to cortisol-producing since this was the only intervening event. Observations of other patients are needed to validate our hypothesis.

3-in-1: bilateral subcutaneous leg abscesses and liver abscess from Klebsiella pneumoniae.

Hypervirulent strains of Klebsiella pneumoniae are known to cause liver abscesses and other metastatic infections. Being Asian and having diabetes are known host risk factors. Here we present an unusual case of a Filipino ballet dancer-choreographer with diabetes presenting with bilateral leg pains initially thought to be cellulitis, but was eventually diagnosed as bilateral subcutaneous leg abscesses. He also had a liver abscess, thankfully asymptomatic, which was only discovered on imaging. The occurrence of three distant abscesses in one patient, hence '3-in-1,' makes this case worth reporting. Bilateral subcutaneous leg abscesses as the presenting manifestation of this infection have not been reported yet. We hypothesise that his occupation which makes use of frequent contractions of leg muscles led to increased blood flow and preferentially directed blood-borne bacteria to localise in both legs. We have also characterised the pathogen with regards to its hypermucoviscous phenotype, capsular type, virulence genes and phylogeny.

Bilateral adrenal histoplasmosis presenting as adrenal insufficiency in an immunocompetent host in the Philippines.

Disseminated histoplasmosis, with the adrenal glands as being the only site of demonstrable disease in an immunocompetent adult, is a rare infection leading to adrenal insufficiency. This disease carries high mortality when unrecognised. We describe the first reported case of adrenal histoplasmosis in the Philippines in a 72-year-old immunocompetent, Filipino man who presented with a 3-month history of intermittent flank pain, weight loss and generalised weakness. His imaging demonstrated bilateral adrenal masses on ultrasonography and contrast-enhanced CT scan. The initial impression was adrenal cancer, however, fine-needle aspiration cytology revealed the presence of yeast cells and blood culture grew Histoplasma capsulatum The diagnosis of the case represents a diagnostic challenge in immunocompetent individuals because they manifest with non-specific symptoms. A heightened suspicion is therefore needed to prevent significant morbidity and mortality.

Glucosuria without diabetes: key to the diagnosis of fragility fractures due to Fanconi syndrome.

A 64-year-old woman had fragility fractures which caused her to have gross deformities and confined her to bed. These were initially ascribed to vitamin D deficiency. However, despite correction of the deficiency, she did not improve. A review of previous records already showed glucosuria in the absence of diabetes, but this finding was overlooked. Eight years into the disease, it was realised that the glucosuria despite normal blood sugar could also mean that the patient was losing other substances needed for proper bone formation. Further investigations showed hypophosphataemia, renal phosphate wasting, hypokalaemia, mild metabolic acidosis, alkaline urine pH, hypouricaemia and aminoaciduria, all compatible with a proximal renal tubular defect (Fanconi syndrome). The fragility fractures were due to poor bone mineralisation because of hypophosphataemia induced by the inability of the kidneys to conserve phosphorus.

Successful treatment of tumour-induced osteomalacia after resection of an oral peripheral ossifying fibroma.

Tumour-induced osteomalacia is a paraneoplastic syndrome wherein bone is affected by a hormone from a tumour that causes renal phosphate wasting and hypophosphataemia. Here, we present the case of a 31-year-old man who has been suffering from generalised bone pains and a spine deformity that led to loss of height. Pertinent findings are low serum phosphorus, low vitamin D and decreased bone mineral density. These findings led to a diagnosis of osteomalacia. However, the finding of an oral mass raised some questions as to what role it plays in the patient's disease. It was suspected that the oral mass (fibroma) was producing a hormone that led to renal phosphate wasting, hypophosphataemia and then osteomalacia. This hypothesis was proven after surgical removal of the mass led to normalisation of the metabolic derangements and eventually led to a resolution of the bone pains.

Multiple brown tumours from parathyroid carcinoma.

We report a case of a 29-year-old woman who suffered from severe bilateral inguinal pain and left mandibular mass. CT scan showed innumerable expansile osteolytic bone masses on the iliac wings, femur, ribs and vertebral bodies, diffuse skeletal osteopaenia, calyceal lithiasis on the right kidney and a left thyroid mass. Ionised calcium and intact parathyroid hormone (PTH) were elevated. Parathyroid sestamibi scan showed a hyperfunctioning left inferior parathyroid gland. Biopsy of the left mandibular mass was consistent with brown tumour. The patient underwent parathyroidectomy of the enlarged parathyroid gland. Final histopathology, however, revealed parathyroid carcinoma, 4.7 cm in widest dimension, with capsular and vascular space invasion. The patient underwent repeat surgery, specifically, left thyroid lobectomy, isthmectomy and central node dissection. Intact PTH decreased from 681.3 to 74 pg/mL (normal range: 10-65) 24 hours postoperatively. Follow-up at 6 months showed normal serum calcium levels, size reduction of bone lesions and improvement of quality of life.

Salt-losing nephropathy in hypothyroidism.

A 35-year-old man presented with recurrent lower extremity weakness associated with polyuria later progressing to generalised weakness with difficulty in breathing. The patient was hypotensive and dry, with normal thyroid and chest examination, weak lower extremity and carpopedal spasm. Workup revealed hypokalaemia, hyponatraemia, hypocalcaemia, hypomagnesaemia, hypochloraemia and hypophosphataemia. Arterial blood gas showed respiratory alkalosis with good oxygenation. Twenty-four-hour urine collection showed normal volume with electrolyte wasting. Thyroid function test revealed overt hypothyroidism with negative antithyroid peroxidase. The patient was well after treatment with levothyroxine, volume and electrolyte replacement and was discharged. Thyroid hormones are related to the expression of the Na-K-ATPase, Na-Pi cotransporter, Mg-ATPase and Na-Ca exchanger pumps in the renal tubules. Sodium, potassium, phosphate, calcium, magnesium and water losses result from decreased expression of these pumps.

The interplay of Graves' disease and twin molar pregnancy.

Twin molar pregnancy with coexistent viable fetus in a patient with Graves' disease is a rare entity. The patient is a 37-year-old woman who was hospitalised owing to persistent vomiting and vaginal bleeding. The pregnancy test was positive and the pelvic ultrasound disclosed twin gestation of complete mole and a coexistent viable 12-week fetus. ß-Human chorionic gonadotropin (ß-HCG) and free thyroid hormones were both elevated. The patient was also a diagnosed case of Graves' disease prior to this pregnancy. Given the risks for perinatal complications, the patient was offered early termination of pregnancy. She, however, decided to continue her pregnancy and control the hyperthyroidism with an antithyroid drug (ATD). A week after her discharge from the hospital, she had spontaneous abortion and the histopathology of the abortus revealed complete hydatidiform mole and a 13-week fetus.

Crossing the other side of the algorithm: a challenging case of adrenal Cushing's syndrome.

The diagnosis of endogenous Cushing's syndrome and its aetiology involved documenting the hypercotisolism and then determining whether that hypercortisolism is adrenocorticotropic hormone-dependent (ACTH-dependent) or not. Hence, following the algorithm, an undetected ACTH level points to an adrenal Cushing's while a detectable or elevated ACTH level points to either a pituitary or ectopic Cushing's syndrome. The authors present a case of florid adrenal Cushing's syndrome initially presenting with a normal ACTH level, which led to the investigation for an ACTH-secreting tumour. Adding to the confusion, a MRI done showed an intrasellar focus. Knowledge of how ACTH-dependent (versus ACTH-independent) Cushing's syndrome manifests clinically, supported by results of repeat laboratory tests, led to the true diagnosis. This case illustrates that a detectable ACTH does not rule out an adrenal Cushing's syndrome nor does a positive pituitary imaging confirm Cushing's disease.

Hypercalcaemia from genitourinary tuberculosis in a female with multiple exostoses.

The authors present a puzzling case of nephrolithiasis, hypercalcaemia, amenorrhoea, short stature and gross skeletal deformities in a 30-year-old female. Multiple pituitary hormone deficiency and metabolic bone disease were initially considered but were eventually excluded. The final diagnosis is genitourinary tuberculosis (TB) which caused the hypercalcaemia, nephrolithiasis and amenorrhoea, and also found to have the syndrome of multiple exostoses which explained the gross skeletal deformities and the short stature. After treatment with anti-TB therapy, there was resolution of hypercalcaemia and return of regular menstruation. The short stature and gross skeletal deformities remain as part of the congenital syndrome.