How does pregnancy affect the patients with pituitary adenomas: a study on 113 pregnancies from Turkey.

OBJECTIVE: Data regarding pregnancies in relation to pituitary tumors are limited. The effects of pregnancy on pituitary adenomas and the effects of adenoma itself (hormonal activity, mass effects and pituitary insufficiency) and/or treatment on the ongoing gestation and developing fetus were evaluated. METHODS: The study was a retrospective study. A questionnaire involving questions regarding medical history before index gestation, history of related pregnancy, result of index gestation and postpartum follow-up of the patients was filled by the investigator in one of the eight Referral Endocrinology Centers from Turkey. RESULTS: One hundred and thirteen (83 prolactinoma, 21 acromegaly, 8 NFPA and 1 plurihormonal pituitary adenoma) pregnancies of 87 (60 prolactinoma, 19 acromegaly, 7 NFPA and 1 plurihormonal pituitary adenoma) patients were reviewed. The clinically important pregnancy-related tumor growth of pituitary adenomas was found to be low in previously treated adenomas. Prolactinomas were more likely to increase in size during pregnancy especially if effective prior treatment was lacking. The risk of hypopituitarism is also minimal due to pituitary adenomas during pregnancy. The results of pregnancies did not differ in patients who were on medical treatment or not for prolactinomas and acromegaly during gestation. Neural tube defect and microcephaly associated with maternal cabergoline use; Down syndrome and corpus callosum agenesis associated with maternal bromocriptine use; unilateral congenital cataract, craniosynostosis and microcephaly associated with maternal acromegaly were detected for the first time. CONCLUSION: Medical treatment can be safely done stopped in patients with prolactinoma and acromegaly when pregnancy is confirmed and reinstituted when necessary. Prospective studies may help to determine the effects of medical treatment during gestation on the mother and fetus.

UNCOMPLICATED PREGNANCY IN A PATIENT WITH CUSHING'S DISEASE.

The coexistence of Cushing's syndrome (CS) and pregnancy is uncommon due to the suppression of gonadotropin secretion in CS. Adrenocorticotropic hormone (ACTH) dependent CS in pregnancy is less frequent than adrenal causes. The diagnosis of CS during pregnancy is difficult since physiological changes in the hypothalamo-pituitary-adrenal axis may cause dynamic tests to be misinterpreted. Radiological imaging is limited. We report the case of a 27-year old woman with Cushing's disease (CD) diagnosed in the 5th-week of pregnancy. The mild symptoms of hypercortisolism did not lead to serious complications for the mother or the fetus, so insulin was the only treatment used. The pregnancy was completed without any complications, and at 38 weeks of gestation a healthy female infant was delivered vaginally. Complications, such as hypocortisolemia and hypoglycemia, were not observed in the infant. Postpartum tests were consistent with CD. Contrast-enhanced pituitary magnetic resonance imaging revealed a microadenoma which was removed with transsphenoidal surgery. Histopathology revealed a pituitary adenoma with positive immunohistochemical staining for ACTH. Biochemical remission required prednisolone treatment, but the insulin requirement decreased significantly over time. As a conclusion, CD with mild features can be well tolerated during pregnancy, but the mother and the fetus must be monitored closely.

Double benefit of long-acting somatostatin analogs in a patient with coexistence of acromegaly and ulcerative colitis.

WHAT IS KNOWN AND OBJECTIVE: Somatostatin analogs control GH/IGF-1 excess in acromegaly. Somatostatin receptors also mediate the complex effects of somatostatin on the gastrointestinal tract and may be defensive in inflammatory bowel diseases, such as ulcerative colitis. We present a patient who showed good response to long-acting octreotide (OCT-LAR) treatment in terms of both acromegaly and ulcerative colitis (UC). CASE SUMMARY: A 58-year-old female patient with diagnosis of acromegaly and ulcerative colitis was started on long-acting somatostatin treatment as a first-line treatment for acromegaly as she refused to undergo transsphenoidal surgery. During the follow-up period, a significant amelioration was also observed in the course of ulcerative colitis, and clinical remission of both diseases was achieved uneventfully. WHAT IS NEW AND CONCLUSION: Somatostatin appears to be a promising candidate in the treatment of inflammatory bowel diseases.

[Preparation for assisted reproductive technology in the course of infertility treatment in the female soldiers].

The level of obstetric morbidity in servicewomen remains high. Infertility occurs more often among the families of servicemen, than among the other families. The leading causative factor among the families suffering from infertility is tuboperitoneal or tubal (up to 85%). Assisted reproductive technologies are often the only possible mean to solve the problem of infertility in case of these forms of infertility.. The families of servicemen suffering from infertility were suggested the echelon principle of health care in military-medical institutions of the Ministry of Defence of the Russian Federation. Defined selection rules and directions, requiring the separation of the assisted reproductive technologies Clinic of Obstetrics and Gynaecology of the Kirov Military Medical Academy to carry out in vitro fertilization procedures.

Dopamine agonist for the rapid improvement of visual field defects in giant and macro-prolactinomas.

PURPOSE: To evaluate effect of first-line dopamine agonist (DA) therapy as an alternative to surgery for visual field defect (VFD) recovery in giant and macro-prolactinoma. METHODS: In this retrospective study, 125 patients with giant and macro-prolactinoma, except those with a history of previous surgery or radiotherapy, were evaluated. Those who underwent visual field examinations using the Humphrey Visual Field analyser upon initial assessment and after treatment were included for analysis. Twelve patients with VFD were included. The effects of DA therapy on both VFD and tumor size were evaluated within the first three months. RESULTS: There were twelve patients analysed: three females and nine males, five giant and seven macroprolactinomas; eight patients received cabergoline (CAB) and four patients received bromocriptine (BRC). The mean adenoma diameter was 35±13mm (range 15-60), and the mean PRL level was 3,523ng/dL (range 312-11,703). Eight patients (67%) complained of blurred vision, while four patients (33%) reported no visual symptoms. After a median duration of three weeks, the VFD completely resolved in ten patients (83%) but only partially improved in two (17%). The mean initial doses of CAB and BRC that provided VFD improvement were 0.5±0.2mg/week and 6.3±1.4mg/day, respectively. After a mean duration of 2.2±0.9months, the mean decrease in adenoma size was 43.6±24.5% (range 10-95%). CONCLUSION: The use of DA as a first-line treatment for at least one month before deciding on surgery is recommended in giant and macro-prolactinomas with VFD. Surgery should be considered only in cases with DA resistance or persistent visual impairment despite medical therapy.

The value of Tc-99m tetrofosmin in the imaging of pituitary adenomas.

AIM: Magnetic resonance imaging (MRI) and computerized tomography (CT) are used in the diagnosis and follow-up of pituitary adenoma cases. Sometimes, these methods cannot display the post-operative residual tissue. It has been shown that some radionuclides were taken up by the pituitary adenomas. The aim of this study was to evaluate the uptake of the technetium-99m (Tc-99m) tetrofosmin (TF) in the pituitary adenoma and normal pituitary tissue and assess the ability of Tc-99m TF to predict tumor malignancy in pituitary gland. METHODS: The patients with pituitary adenoma (7 invasive and 8 non-invasive) were compared with control group (no. 13). Single-photon emission computed tomography (SPECT) imaging of pituitary gland was performed in both groups. Tc-99m uptake indices were evaluated statistically with the use of Mann-Whitney U test. RESULTS: The average tetrofosmin uptake index of pituitary adenoma is 2.44+/-1.54 for the patients and 1.69+/-0.71 for the control group. Any significant difference was not observed between the groups (p 0.3). The average index was calculated as 3.04+/-2.15 for invasive adenomas and 1.92+/-0.33 for the non-invasive group, and there was no significant difference between the two groups regarding uptake of the agent (p 0.53). Furthermore, it was determined that the invasive and non-invasive adenomas displayed an uptake of Tc-99m TF similar to normal pituitary tissue. CONCLUSIONS: Since the pituitary adenoma and normal pituitary tissue gave similar results regarding Tc-99m TF uptake, it was concluded that this agent would not be useful in the diagnosis of pituitary adenoma.

Severe osteomalacia in a patient with idiopathic chronic pancreatitis.

We report a 30-year-old woman who was confined to a wheelchair because of severe myopathy. She was first seen by a neurologist because of a convulsive syndrome of unknown etiology when she was nine. She was started on anticonvulsive drugs but the drug was stopped when her serum calcium level was found to be very low. She had a history from childhood of steatorrhea and abdominal pain after a fatty meal and became vegetarian at age five years. She worked in a hospital as a nurse and at home her living room received no direct sunlight. As a result of these conditions osteomalacia progressed. We believe an awareness of chronic pancreatitis (CP) during childhood could have prevented the consequences of the disease in this case.

Propylthiouracil-induced cutaneous vasculitis.

Cutaneous reactions to propylthiouracil and methimazole occur in 3%-5% of adults. Generalized maculopapular and papular purpuric eruptions are perhaps the most common thionamide-induced reactions. We report 3 patients who developed cutaneous vasculitis which is a rare and serious side-effect during antithyroid drug therapy. The observation of cutaneous vasculitis during administration of propylthiouracil suggested that clinical awareness of this complication should be of considerable importance.

Scintigraphic varieties in Hashimoto's thyroiditis and comparison with ultrasonography.

The scintigraphic findings in Hashimoto's thyroiditis are highly variable and can mimic any thyroid abnormality. In this study, we compared the scintigraphic findings with ultrasonography in 48 patients with Hashimoto's thyroiditis. Thyroid scintigrams revealed diffuse hyperplasia in 12 patients, multinodular goiter in 20 patients and a solitary nodule in 16 patients (toxic adenoma, n = 1; hypoactive nodule, n = 4; hyperactive nodule with no suppression, n = 3; normoactive nodule, n = 8). Ultrasonography revealed diffuse hyperplasia in 19 patients, multinodular goiter in 20 patients and a solitary nodule in 9 patients. The thyroid scan and ultrasonography revealed the same findings of diffuse hyperplasia in 12 patients and multinodular goiter in 20 patients. Of the 16 patients with a solitary nodule on scintigraphy, only 9 showed the same finding on ultrasonography, with the other 7 showing diffuse hyperplasia. The difference in nodularity between thyroid scanning (74.9%) and sonography (60.4%) has been attributed to pseudonodularity in Hashimoto's thyroiditis. In conclusion, our results confirmed that Hashimoto's thyroiditis can mimic any thyroid abnormality, including diffuse hyperplasia, nodular goiter and multinodular goiter on scintigraphy. Therefore, scintigraphy, ultrasonography and serum thyroid hormone estimation alone may not be helpful for the final diagnosis of Hashimoto's disease. To eliminate unnecessary surgical intervention, all patients should be evaluated by means of physical examination and thyroid autoantibodies, in addition to a thyroid scan, ultrasonography, serum thyroid hormones and fine-needle aspiration biopsy when necessary.

Association of Fallot Tetralogy with Carney's complex.

The Carney complex is an inherited, autosomal disease of multicentric tumors in many organs. Some components of Carney's complex are cardiac myxoma, spotty pigmentation, and endocrine overactivity. Primary pigmented nodular adrenocortical dysplasia (PPNAD) is an exceedingly rare cause of Cushing's syndrome in infants, children, and young adults. PPNAD occurs sporadically or as part of a familial syndrome called Carney's complex. Up to our knowledge, the association of Fallot Tetralogy with Carney's complex has not been previously reported. We presented, a 20-year-old woman, who had been operated for Fallot Tetralogy at the age of 3 years, had Carney's complex, i.e. left atrial myxoma, two facial spotty pigmented areas, and PPNAD.

Etiology of hypopituitarism in tertiary care institutions in Turkish population: analysis of 773 patients from Pituitary Study Group database.

Hypopituitarism in adult life is commonly acquired and the main causes are known as pituitary tumors and/or their treatments. Since there are new insights into the etiology of hypopituitarism and presence of differences in various populations, more studies regarding causes of hypopituitarism are needed to be done in different ethnic groups with sufficient number of patients. Therefore, we performed a multi-center database study in Turkish population investigating the etiology of hypopituitarism in 773 patients in tertiary care institutions. The study was designed and coordinated by the Pituitary Study Group of SEMT (The Society of Endocrinology and Metabolism of Turkey). Nineteen tertiary reference centers (14 university hospitals and 5 training hospitals) from the different regions of Turkey participated in the study. It is a cross-sectional database study, and the data were recorded for 18 months. We mainly classified the causes of hypopituitarism as pituitary tumors (due to direct effects of the pituitary tumors and/or their treatments), extra-pituitary tumors and non-tumoral causes. Mean age of 773 patients (49.8 % male, 50.2 % female) was 43.9 ± 16.1 years (range 16-84 years). The most common etiology of pituitary dysfunction was due to non-tumoral causes (49.2 %) among all patients. However, when we analyze the causes according to gender, the most common etiology in males was pituitary tumors, but the most common etiology in females was non-tumoral causes. According to the subgroup analysis of the causes of hypopituitarism in all patients, the most common four causes of hypopituitarism which have frequencies over 10 % were as follows: non-secretory pituitary adenomas, Sheehan's syndrome, lactotroph adenomas and idiopathic. With regard to the type of hormonal deficiencies; FSH/LH deficiency was the most common hormonal deficit (84.9 % of the patients). In 33.8 % of the patients, 4 anterior pituitary hormone deficiencies (FSH/LH, ACTH, TSH, and GH) were present. Among all patients, the most frequent cause of hypopituitarism was non-secretory pituitary adenomas. However, in female patients, present study clearly demonstrates that Sheehan's syndrome is still one of the most important causes of hypopituitarism in Turkish population. Further, population-based prospective studies need to be done to understand the prevalence and incidence of the causes of hypopituitarism in different countries.

HLA-DRB1*03 is a susceptibility gene in patients with Graves' disease with and without ophthalmopathy.

We sought an association between certain human leucocyte antigen (HLA) markers and Graves' disease (GD) with and without ophthalmopathy (OP). One hundred and thirty-one Turkish patients with GD (50 without OP, 81 with OP) and 250 local healthy controls were studied. HLA-DRB1 typing was performed by using polymerase chain reaction-sequence-specific primers (PCR-SSP) method. The frequencies of DRB1*03 was significantly increased in GD compared to controls (OR = 2.07; 95% CI = 1.24-3.44), whereas DRB1*13 (OR = 0.33; 95% CI = 0.18-0.61) and DRB1*07 (OR = 0.31; 95% CI = 0.13-0.70) were significantly increased in controls compared to patients. None of the three associations showed any specificity to the OP group.

Hypoglycemia due to ectopic release of insulin from a paraganglioma.

Insulin-secreting pancreatic tumors and insulin-like growth hormone-secreting non-islet cell tumors can cause hypoglycemia. However, insulin-releasing paraganglioma or pheochromocytoma has almost never been reported. A 67-year-old female patient was admitted to our hospital because of headache, palpitation, perspiration, faintness, frequent sense of hunger and absent-mindedness. These intermittent symptoms had begun approximately a year before admission. On physical examination, she had high blood pressure of 150/90 mm Hg. Hormonal studies demonstrated increased urinary norepinephrine levels, and hyperinsulinemic hypoglycemia was confirmed while the patient was symptomatic. Abdominal MRI revealed a retroperitoneal mass measuring 4.5 cm in the pancreatic region. She was treated with an alpha-blocking agent to control blood pressure preceding the removal of the mass. Histopathological diagnosis was paraganglioma, and immunohistochemically insulin staining in the neoplastic cells was demonstrated. Her blood pressure normalized and hypoglycemia relieved after the operation. The patient did not have recurrence of hypoglycemia after a year of follow-up. Paraganglioma is a rare tumor of the neural crest, and co-secretion of insulin and catecholamines has been reported only by a single case report in the literature. The present patient is another case with this co-secretion.

Value of petrosal sinus sampling: coexisting acromegaly, empty sella and meningioma.

Simultaneous occurrence of an intracranial meningioma and a growth hormone (GH)-producing pituitary adenoma is exceedingly rare, as is coexistence of an empty sella and acromegaly. We report all these rare entities in the same patient. We evaluated the role of inferior petrosal sinus sampling for lateralisation of an adenoma in this patient.

Concomitant association of thyroid sarcoidosis and Graves' disease.

OBJECTIVE: Graves' disease (GD) with sarcoid involvement of the thyroid gland has rarely been reported. METHOD: We report a case of GD with thyroid sarcoidosis in a 28-year-old woman. Thyroid function was assessed by triiodothyronine (T(3)), thyroxine (T(4)), thyroid-stimulating hormone (TSH) and TSH receptor antibodies (TSH-R Ab). Thyroid scintigraphy, ultrasound and fine-needle aspiration biopsy were performed. The patient underwent surgery. RESULT: The patient had a nodular goiter. Serum T(3), T(4) and TSH-R Ab levels were elevated with suppressed TSH level. Scintigraphy showed diffuse activity as seen in GD, and ultrasound revealed that parenchyma was heterogenous. Sarcoidosis was discovered on routine chest X-ray. Although no sarcoid involvement was found on specimen, the thyroid gland showed non-caseating granulomas on histology. CONCLUSION: Since sarcoid involvement of the thyroid gland can cause hypofunction, we report the uncommon infiltration of sarcoidosis with hyperthyroidism.

The effect of methimazole on the oxidant and antioxidant system in patients with hyperthyroidism.

The present study was designed to evaluate the changes in the plasma lipid peroxidation and antioxidant system in 15 adult volunteer patients in hyperthyroid and euthyroid states. In these patients, plasma concentrations of lipid peroxides were decreased and, ascorbic acid and vitamin E levels were significantly increased in euthyroid status in comparison to hyperthyroid status. A significant increase in the plasma GPx activity (P < 0.01) and a decrease in GST (P < 0.001) was observed after euthyroidism was sustained with methimazole therapy. In conclusion, hyperthyroidism tends to enhance lipid peroxide content and an increase in GST and decreases in GPx, vitamin E and ascorbic acid levels accompany to this change in the plasma. The achievement of euthyroidism led an improvement in these parameters.

Sunlight exposure and vitamin D deficiency in Turkish women.

Vitamin D is an essential steroid involved in bone metabolism, cell growth, differentiation, and regulation of the minerals in the body. The main sources of this vital vitamin are adequate diet and photosynthesis in the skin. The aim of this study was to investigate the efficiency of vitamin D synthesis in 48 premenopausal women (14-44 years) in relation to three different types of dressing in summer. Women in the first group (Group I) dressed in a style which exposed the usual areas of the skin to sunlight; women in the second group (Group II wore traditional clothing with the skin of the hands and face uncovered, while the third group (Group III) dressed in traditional Islamic style, covering the whole body including hands and face. Serum 25OHD levels of Group I, Group II, and Group III were 56+/-41.3 nmol/l, 31.9+/-24.4 nmol/l, 9+/-5.7 nmol/l, respectively (Group I vs Group III, p<0.001; Group II vs Group III, p<0,03; Group I vs Group II, p>0.05). Vitamin D levels were low in 44 percent of the Group I and 60% of the Group II, which suggested that sun exposure of skin areas of hands and face may partially provide vitamin D synthesis, but may not be enough to eliminate vitamin D deficiency. All the patients in group III had vitamin D levels below normal. This study emphasizes the necessity of vitamin D fortification of food even in a sunny country where some people may not be exposed to sunlight because of inappropriate clothing or an indoor-life.