Intracranial Germinoma Masquerading as Secondary Granulomatous Hypophysitis: A Case Report and Review of Literature.

Germinomas are highly immunogenic tumors eliciting a strong peri-tumoral immune response that can spillover into the surrounding healthy tissues. This phenomenon can also occur in intracranial germinomas, manifesting as secondary hypophysitis. Herein, we report a case of 12-year-old-girl presenting with polyuria and polydispsia. She had central diabetes insipidus (CDI) and panhypopituitarism. Imaging revealed a sellar-suprasellar mass with infundibular stalk thickening. Transphenoidal biopsy revealed epithelioid granulomas with immunostaining negative for germinomatous cells. Other causes of hypophysitis were ruled out. Accordingly, she was diagnosed as primary granulomatous hypophysitis and treated with high-dose corticosteroids. Three years later she again presented with headache, vomiting and diminution of vision. Imaging showed a heterogeneous, solid-cystic peripheral rim-enhancing lesion at the same location with involvement of hypothalamus, ependyma and pineal gland. Cerebrospinal fluid beta-human chorionic gonadotropin was markedly elevated, confirming the diagnosis of an intracranial germ cell tumor. She was started on chemotherapy; however, she succumbed to febrile neutropenia. We performed a literature search and found 18 anecdotal cases of secondary hypophysitis associated with intracranial germinomas. There was a slight male preponderance (male:female 5:4). Two-thirds of the cases were below 18 years of age. Polyuria was the most common presenting manifestation (83%). CDI and panhypopituitarism were seen in 89 and 78% cases, respectively. Imaging evidence of pituitary stalk thickening was seen in 12 cases (67%), while pituitary enlargement and/or sellar mass were reported in 11 cases (61%). Pineal involvement was extremely rare, being reported in only 1 case, implying the predilection of suprasellar (rather than pineal) germinomas in causing secondary hypophysitis. Histologically, 82% had lymphocytic hypophysitis, while 18% had granulomatous hypophysitis. Initially, the diagnosis of germinoma was missed in 60% of the cases who were wrongly treated with corticosteroids. To conclude, physicians should make it a dictum that all children and adolescents presenting with CDI and pituitary stalk thickening should be rigorously screened for an underlying intracranial germinoma before labeling them as primary hypophysitis.

Skeletal Health in Patients With Mitochondrial Diabetes: Case Series and Review of Literature.

Monogenic diabetes, including mitochondrial diabetes, constitutes 1% to 3% of all diabetes. Although there is an increased interest in understanding the mechanisms of bone fragility in people with diabetes, skeletal research is mostly focused on type 1 and type 2 diabetes. Little is known on skeletal health among people with mitochondrial diabetes. In this single-center study, we presented clinical characteristics of individuals with mitochondrial diabetes and clinical diagnosis of osteoporosis. Of 10 patients with mitochondrial diabetes, 4 (40%) had a clinical diagnosis of osteoporosis. Patients with osteoporosis were older, had lower body mass index, longer diabetes duration, lower fasting C-peptide, and presence of multiple comorbidities compared with patients without osteoporosis. In addition to our cases, we also systematically reviewed literature on skeletal health in people with mitochondrial diabetes and provided an overview of potential factors affecting skeletal health and future clinical and research directions to improve the care of people with mitochondrial disease. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Peripubertal hypoglycemia--an unusual cause.

A 9-year-old boy presented with recurrent episodes of hypoglycemic seizures. He had classical facies and body asymmetry suggestive of Russell-Silver syndrome. On evaluation, he was found to have ketotic hypoglycemia with growth hormone deficiency.

A Deceptive Preoperative Imaging of an Ectopic Supernumerary Parathyroid Adenoma in a Secondary Hyperparathyroidism.

Ectopic and supernumerary parathyroid glands in the neck is a real surgical challenge especially in multi-gland pathologies. We report a supernumerary ectopic gland at a rare site in the neck in a chronic kidney disease patient which required a re-exploration following a deceptively successful bilateral neck dissection.

Cardiometabolic vigilance in COVID-19 and resource husbandry in resource-challenged times: Clinical practice- based expert opinion.

BACKGROUND AND AIMS: The ongoing pandemic of coronavirus disease 2019 (COVID-19) is rapidly evolving, thereby posing a profound challenge to the global healthcare system. Cardiometabolic disorders are associated with poor clinical outcomes in persons with COVID-19. Healthcare challenges during the COVID-19 pandemic are linked to resource constraints including shortage of Personal Protective Equipment's (PPE), laboratory tests and medication. In this context, a group of clinical experts discussed the endocrine and cardiology vigilance required in times of COVID-19. Further, the group proposed certain resource husbandry recommendations to be followed during the pandemic to overcome the constraints. METHOD: The clinical experts discussed and provided their inputs virtually. The expert panel included clinical experts comprising endocrinologists, Consultant Physicians and cardiologists from India. The panel thoroughly reviewed existing literature on the subject and proposed expert opinion. RESULTS: The expert panel put forward clinical practice-based opinion for the management of cardiometabolic conditions including diabetes mellitus and hypertension. As these conditions are associated with poor clinical outcomes, the expert panel recommends that these persons be extra-cautious and take necessary precautions during the ongoing pandemic. Further, experts also provided appropriate, affordable, available and accessible solution to the resource constraint situations in times of COVID-19 pandemic. CONCLUSION: The clinical expert opinion put forward in this article will serve as a reference for clinicians treating diabetes and cardiovascular disease during the COVID-19 pandemic.

Efficacy of laparoscopic sleeve gastrectomy and intensive medical management in obese patients with type 2 diabetes mellitus.

BACKGROUND: There are a dearth of studies comparing laparoscopic sleeve gastrectomy (LSG) and intensive medical treatment (IMT) in obese type 2 diabetes mellitus (T2DM) patients. This study compares these modalities in terms of weight loss, metabolic parameters and quality of life (QOL) score. METHODS: We evaluated the efficacy of LSG (n = 14) vs. IMT (n = 17) comprising of low calorie diet, exenatide, metformin and if required insulin detemir in 31 obese T2DM patients with BMI of 37.9 ± 5.3kg/m(2) and target HbA1c < 7 %. The mean (±SD) age of the patients was 49.6 ± 11.9 years and 74 % were women. The mean duration of diabetes was 8.5 ± 6.1 years and mean HbA1c was 8.6 ± 1.3 %. Primary end point was excess body weight loss (EBWL) at the final follow-up. RESULTS: The mean duration of follow-up was 12.5 ± 5.0 (median 12) months. EBWL was 61.2 ± 17.6 % and 27.4 ± 23.6 % in LSG and IMT group respectively (p < 0.001). Glycemic outcomes improved in both with mean HbA1c of 6.6 ± 1.5 % in LSG and 7.1 ± 1.2 % in IMT group. In LSG group, there was resolution of diabetes and hypertension in 36 and 29 % of patients respectively while none in the IMT group. HOMA-IR, hsCRP, ghrelin and leptin decreased while adiponectin increased significantly in LSG compared to IMT group. QOL score improved in LSG as compared to IMT. CONCLUSIONS: In obese T2DM patients, LSG is superior to IMT in terms of weight loss, resolution of comorbidities and QOL score.

"Petrified ears" with idiopathic adult-onset pituitary insufficiency.

"Petrified ears" or calcification of auricular cartilage is an uncommonly reported condition. The most common causes of this phenomenon are local trauma, frost bite, and inflammation. Adrenal insufficiency is the most frequent systemic disease associated with auricular calcification. We present a case of idiopathic adult-onset pituitary insufficiency with hypocortisolism and bilateral auricular calcification. Recognition of the association between auricular calcification and adrenal insufficiency can be an important step toward the identification of a life-threatening cortisol deficiency.

Emphysematous cystitis in a patient with type-2 diabetes mellitus.

Emphysematous cystitis is a relatively rare clinical entity caused by gas-fermenting bacteria or fungus. Presentation is often nonspecific and imaging is the best diagnostic modality. We report a case of a 45-year-old male who presented with fever, dysuria, and pneumaturia, and was found to have emphysematous cystitis.