We report a rare clinical case of a malignant prolactinoma in which the exponential increase of prolactin levels with minimal tumor growth and no response to treatment led to diagnosis of abdominal, thoracic, and vertebral metastases.
Diabetes is a risk factor for greater severity of coronavirus disease 2019 (COVID-19). The stress hyperglycemia ratio (SHR) is an independent predictor of critical illness, and it is reported to have a stronger association than absolute hyperglycemia. The aim of this study was to assess the relationship of absolute hyperglycemia and SHR with the severity of COVID-19, since there are no studies investigating SHR in patients with COVID-19. We conducted a retrospective observational study on hospitalized patients with COVID-19 in the first months of the pandemic, regarding absolute hyperglycemia, SHR, and severity outcomes. Of the 374 patients, 28.1% had a previous diagnosis of type 2 diabetes. Absolute hyperglycemia (64.8% versus 22.7%; p < 0.01) and SHR [1.1 (IQR 0.9-1.3) versus 1.0 (IQR 0.9-1.2); p < 0.001] showed a statistically significant association with previous diabetes. Absolute hyperglycemia showed a significant association with clinical severity of COVID-19 (79.0% versus 62.7%; p < 0.001), need for oxygen therapy (74.8% versus 54.4%; p < 0.001), invasive mechanical ventilation (28.6% versus 11.6%; p < 0.001), and intensive care unit (30.3% versus 14.9%; p = 0.002), but not with mortality; by contrast, there was no statistically significant association between SHR and all these parameters. Our results are in agreement with the literature regarding the impact of absolute hyperglycemia on COVID-19 severity outcomes, while SHR was not a significant marker. We therefore suggest that SHR should not be evaluated in all patients admitted in the hospital for COVID-19, and we encourage the standard measures at admission of blood glucose and HbA1c levels.
INTRODUCTION: Parathyroid adenoma is the most frequent cause of primary hyperparathyroidism. In recent years, the preoperative location of parathyroid adenomas allowed minimally invasive surgical techniques that have become preferred over the traditional bilateral neck exploration. The more recent guidelines on this subject highlight the role of nuclear medicine imaging tests. The aim of this study was to review the current role of Doppler ultrasound (US) in assessing the preoperative location of parathyroid adenomas in patients with primary hyperparathyroidism. MATERIAL AND METHODS: Retrospective study based on data from patients with primary hyperparathyroidism that underwent parathyroidectomy between January 2013 and January 2022 at the Centro Hospitalar Universitário Lisboa Central. Statistical analysis was performed with IBM SPSS Statistics, version 26.0.0.0®. RESULTS: Parathyroidectomy was performed in 171 patients (77.8% females) with primary hyperparathyroidism. Cervical Doppler ultrasound was the most performed test (64.3%, n = 110) for preoperative location and detected a suspicious lesion in 98 patients (89.1%). The preoperative location of the parathyroid adenomas was assessed through the Doppler ultrasound and was compared with the surgical reports and histological findings; a correct identification was made in 76 patients (77.6%). Doppler ultrasound slightly underestimated the mean adenoma size (18.1 ± 7.7 mm preoperative versus 22 ± 8.4 mm postoperative). Calcium, parathyroid hormone levels, adenoma size and concomitant presence of thyroid nodules did not affect the accuracy of Doppler ultrasound. CONCLUSION: Doppler ultrasound showed high diagnostic accuracy even in patients with nodular thyroid disease regardless of calcium and parathyroid hormone levels and adenoma size. Furthermore, its safety, affordability and availability should favor its use as first line test in primary hyperparathyroidism to assess the preoperative location of parathyroid adenomas.
Adenoma , Hyperparathyroidism, Primary , Parathyroid Neoplasms , Female , Humans , Male , Parathyroid Neoplasms/complications , Parathyroid Neoplasms/diagnostic imaging , Parathyroid Neoplasms/surgery , Hyperparathyroidism, Primary/diagnostic imaging , Hyperparathyroidism, Primary/etiology , Hyperparathyroidism, Primary/surgery , Calcium , Retrospective Studies , Parathyroid Hormone , Adenoma/complications , Adenoma/diagnostic imaging , Adenoma/surgery , Ultrasonography, Doppler/adverse effects
Diabetes Mellitus (DM) is a complex disease with a significant impact in today's world. Studies have emphasized the crucial role of genetics in DM, unraveling the distinction of monogenic diabetes from the most common types that have been recognized over the years, such as type 1 diabetes (T1DM) and type 2 diabetes (T2DM). A literature search was carried out to scrutinize the subtypes of maturity-onset diabetes of the young (MODY), as well as the connection between the recognized genetic and molecular mechanisms responsible for such phenotypes. Thus far, 14 subtypes of MODY have been identified. Here, the authors review the pathophysiological and molecular pathways in which monogenic diabetes genes are involved. Despite being estimated to affect approximately 2% of all T2DM patients in Europe, the exact prevalence of MODY is still unknown, enhancing the need for research focused on biomarkers. Due to its impact in personalized medicine, a follow-up of associated complications, and genetic implications for siblings and offspring of affected individuals, it is imperative to diagnose the monogenic forms of DM accurately. Currently, advances in the genetics field has allowed for the recognition of new DM subtypes, which until now were considered to be slight variations of the typical forms. New molecular insights can define therapeutic strategies, aiming for the prevention, correction, or at least delay of ß-cell dysfunction. Thus, it is imperative to act in the close interaction between genetics and clinical manifestations to improve diagnosis and individualize treatment.
Diabetes Mellitus, Type 1 , Diabetes Mellitus, Type 2 , Humans , Diabetes Mellitus, Type 2/epidemiology , Diabetes Mellitus, Type 1/genetics , Phenotype , Signal Transduction/genetics , Mutation
Diabetes mellitus (DM) has emerged as a major risk factor for COVID-19 severity and SARS-CoV-2 infection can worsen glycemic control and may precipitate new-onset diabetes. At-admission hyperglycemia (AH) is a known predictor for worse outcomes in many diseases and seems to have a similar effect in COVID-19 patients. In this study, we aimed to assess the impact of AH regardless of pre-existing diabetes mellitus and new-onset diabetes diagnosis in the clinical severity of COVID-19 inpatients in the first months of the pandemic. A retrospective monocentric study on 374 COVID-19 inpatients (209 males) was developed to assess associations between AH (blood glucose levels in the Emergency Department or the first 24 h of hospitalization greater than 140 mg/dL) and severity outcomes (disease severity, respiratory support, admission to Intensive Care Unit (ICU) and mortality) in patients with and without diabetes. Considering diabetic patients with AH (N = 68;18.1%) there was a correlation with COVID-19 severity (p = 0.03), invasive mechanical ventilation (p = 0.008), and ICU admission (p = 0.026). No correlation was present with any severity outcomes in diabetic patients without AH (N = 33; 8.8%). All of the New-onset Diabetes patients (N = 15; 4%) had AH, and 12 had severe COVID-19; additionally, five patients were admitted to the ICU and three patients died. However, severity outcomes did not reach statistical correlation significance in this group. In nondiabetic patients with AH (N = 51; 13.6%), there was a statistically significant association with the need for oxygen therapy (p = 0.001), invasive mechanical ventilation (p = 0.01), and ICU admission (p = 0.03). Our results support data regarding the impact of AH on severity outcomes. It also suggests an effect of AH on the prognosis of COVID-19 inpatients, regardless of the presence of pre-existing diabetes or new-onset diabetes. We reinforce the importance to assess at admission glycemia in all patients admitted with COVID-19.
Abstract Research on the constitution of subjectivity continues to be a relevant topic for Psychology. This study aimed to analyze the relevance of exploring autobiographical narratives as a methodological resource for understanding this process. Anchored in the premises of historical-cultural psychology in dialogue with other theoretical perspectives, the defended thesis is that, through this theoretical-methodological alternative, it is possible to investigate the different interrelated domains in the processes of constitution of subjectivities, such as the works of memory, language and the dynamic character that they establish with historical and cultural circumstances. The text comprises four parts: the first explores the challenges involved in researching subjectivity; the second, the contributions of Vygotskian psychology to the understanding of the phenomenon; the third, the fecundity of narratives as methodological resources for the study of subjectivation processes. In the last topic, considerations are made about some results of research carried out from school memories.
Resumo A pesquisa sobre a constituição da subjetividade continua sendo um tema relevante para a Psicologia. Este estudo objetivou analisar a pertinência da exploração das narrativas autobiográficas como recurso metodológico para a compreeensão de tal processo. A tese defendida, ancorada nas premissas da psicologia histórico-cultural em diálogo com outras perspectivas teóricas, é que, por meio dessa alternativa teórico-metodológica, é possível investigar os diferentes domínios inter-relacionados nos processos de constituição das subjetividades, como os trabalhos da memória, da linguagem e o caráter dinâmico que estabelecem com as circunstâncias históricas e culturais. Quatro partes compõem o texto: a primeira explora os desafios envolvidos na pesquisa sobre a subjetividade; a segunda, as contribuições da psicologia vygotskiana para a compreensão do fenômeno; a terceira, a fecundidade das narrativas como recursos metodológicos para o estudo dos processos de subjetivação; no último tópico, são feitas considerações sobre alguns resultados de pesquisas realizadas a partir das memórias escolares.
Resumen La investigación sobre la constitución de la subjetividad continúa siendo un tema relevante para la Psicología. Este estudio tuvo como objetivo analizar la pertinencia de explorar las narrativas autobiográficas como recurso metodológico para la comprensión de este proceso. La tesis defendida, anclada en los presupuestos de la psicología histórico-cultural en diálogo con otras perspectivas teóricas, es que, a través de esta alternativa teórico-metodológica, es posible investigar los diferentes dominios interrelacionados en los procesos de constitución de las subjetividades, como el obras de memoria, lenguaje y el carácter dinámico que establecen con las circunstancias históricas y culturales. Cuatro partes componen el texto: la primera explora los desafíos que implica investigar la subjetividad; el segundo, los aportes de la psicología vygotskiana a la comprensión del fenómeno; el tercero, la fecundidad de las narrativas como recursos metodológicos para el estudio de los procesos de subjetivación; en el último tema, se hacen consideraciones sobre algunos resultados de investigaciones realizadas a partir de las memorias escolares.
Psychology , Statistics, Nonparametric , Constitution and Bylaws , Autobiography , Educational Measurement , Health Resources , Memory
Congenital hyperinsulinism (CHI) is a heterogenous disease caused by insulin secretion regulatory defects, being ABCC8/KCNJ11 the most commonly affected genes. Therapeutic options include diazoxide, somatostatin analogues and surgery, which is curative in focal CHI. We report the case of two siblings (born two years apart) that presented themselves with hypoketotic hyperinsulinemic persistent hypoglycemias during neonatal period. The diagnosis of diffuse CHI due to an ABCC8 compound mutation (c.3576delG and c.742C>T) was concluded. They did not benefit from diazoxide therapy (or pancreatectomy performed in patient number 1) yet responded to somatostatin analogues. Patient number 1 developed various neurological deficits (including epilepsy), however patient number 2 experienced an entirely normal neurodevelopment. We believe this case shows how previous knowledge of the firstborn sibling's disease contributed to a better and timelier medical care in patient number 2, which could potentially explain her better neurological outcome despite their same genotype.
Congenital Hyperinsulinism/genetics , Congenital Hyperinsulinism/therapy , Mutation/genetics , Siblings , Sulfonylurea Receptors/genetics , Diazoxide/therapeutic use , Female , Genotype , Humans , Infant, Newborn , Male , Pancreatectomy/methods , Phenotype , Somatostatin/analysis , Treatment Outcome
SUMMARY Congenital hyperinsulinism (CHI) is a heterogenous disease caused by insulin secretion regulatory defects, being ABCC8/KCNJ11 the most commonly affected genes. Therapeutic options include diazoxide, somatostatin analogues and surgery, which is curative in focal CHI. We report the case of two siblings (born two years apart) that presented themselves with hypoketotic hyperinsulinemic persistent hypoglycemias during neonatal period. The diagnosis of diffuse CHI due to an ABCC8 compound mutation (c.3576delG and c.742C>T) was concluded. They did not benefit from diazoxide therapy (or pancreatectomy performed in patient number 1) yet responded to somatostatin analogues. Patient number 1 developed various neurological deficits (including epilepsy), however patient number 2 experienced an entirely normal neurodevelopment. We believe this case shows how previous knowledge of the firstborn sibling's disease contributed to a better and timelier medical care in patient number 2, which could potentially explain her better neurological outcome despite their same genotype.
Humans , Male , Female , Infant, Newborn , Siblings , Congenital Hyperinsulinism/genetics , Congenital Hyperinsulinism/therapy , Sulfonylurea Receptors/genetics , Mutation/genetics , Pancreatectomy/methods , Phenotype , Somatostatin/analysis , Treatment Outcome , Diazoxide/therapeutic use , Genotype
Gitelman syndrome(GS) is a rare autosomal recessive salt-losing tubulopathy of young adults, characterised by hypokalaemia, hypomagnesaemia, hypocalciuria and secondary hyperaldosteronism. Hypercalcaemia due to hypocalciuria in these patients is extremely rare.A 25-year-old healthy woman was referred to the Endocrinology clinic for evaluation of persistent hypokalaemia. She presented with fatigue, myalgias, cramps and paraesthesia. Her physical examination was normal. Laboratory workup revealed: K+ 2.7 mEq/L (r.v.3.5-5.1), 24 hours urinary K+ 84.7 mEq/24 hours (r.v.25-125), Mg2+ 0.71 mg/dL (r.v.1.6-2.6), 24 hours urinary Mg2+ 143.1 mg/24 hours (r.v.73-122), Ca2+ 12 mg/dL (r.v.8.4-10.2), aldosterone 47.1 ng/mL (r.v. 4-31) and active renin 374.7 uUI/mL (r.v.4.4-46.1). She was diagnosed with GS and was treated with spironolactone, oral K+ and Mg2+ supplementation. Further investigation confirmed hypercalcaemia due to primary hyperparathyroidism owing to a single parathyroid adenoma. Following parathyroidectomy serum calcium normalised.Current knowledge favours that hypomagnesaemia in patients with GS protects them from hypercalcaemia. In this context of multiple electrolyte imbalances, correction of hypomagnesaemia is a challenge and should be done carefully. Like in our patient, aetiology of hypercalcaemia should be promptly diagnosed and reversed.
Adenoma/complications , Gitelman Syndrome/complications , Hyperparathyroidism, Primary/complications , Parathyroid Neoplasms/complications , Adenoma/diagnostic imaging , Adult , Female , Gitelman Syndrome/diagnosis , Humans , Hyperparathyroidism, Primary/diagnostic imaging , Mutation , Parathyroid Neoplasms/diagnostic imaging , Tomography, X-Ray Computed
Monocarboxylate transporter 8 (MCT8) is an active and specific thyroid hormone transporter into neurons. MCT8 mutations cause an X-linked condition known as Allan-Herndon-Dudley syndrome and are characterized by impaired psychomotor development and typical abnormal thyroid function. We describe a 10-year-old boy with severe cognitive disability, axial hypotonia, spastic quadriplegia and sporadic dyskinetic episodes. He initially presented with thyroid dysfunction (high FT3, low rT3, low FT4 and normal TSH) and generalized retardation of the cerebral and cerebellar myelination in brain magnetic resonance imaging. The clinical and laboratory findings led to sequencing of the SLC16A2/MCT8 gene, which identified a novel missense mutation in exon 5. The study of peripheral markers of thyroid function suggests a paradoxical state of thyrotoxicosis in some peripheral tissues. Our patient had a typical clinical presentation at birth but because of the rarity of his disease his diagnosis was not made until the age of 7. The delay can also be explained by the omission of the free T3 assay in the first thyroid evaluation performed. This case therefore highlights the possible benefit of including the T3 assay in the study of patients with severe psychomotor disability of unknown etiology, thus eliminating extra costs for unnecessary complementary diagnostic tests.
Developmental Disabilities/diagnosis , Dyskinesias/diagnosis , Intellectual Disability/diagnosis , Mental Retardation, X-Linked/diagnosis , Monocarboxylic Acid Transporters/genetics , Muscle Hypotonia/diagnosis , Muscular Atrophy/diagnosis , Quadriplegia/diagnosis , Thyrotoxicosis/diagnosis , Child , Developmental Disabilities/genetics , Dyskinesias/genetics , Humans , Intellectual Disability/genetics , Male , Mental Retardation, X-Linked/genetics , Muscle Hypotonia/genetics , Muscular Atrophy/genetics , Mutation, Missense , Quadriplegia/genetics , Symporters , Thyrotoxicosis/genetics
SUMMARY: PBMAH is a rare etiology of Cushing syndrome (CS). Familial clustering suggested a genetic cause that was recently confirmed, after identification of inactivating germline mutations in armadillo repeat-containing 5 (ARMC5) gene. A 70-year-old female patient was admitted due to left femoral neck fracture in May 2014, in Orthopedics Department. During hospitalization, hypertension (HTA) and hypokalemia were diagnosed. She presented with clinical signs of hypercortisolism and was transferred to the Endocrinology ward for suspected CS. Laboratory workup revealed: ACTH <5 pg/mL; urinary free cortisol (UFC), 532 µg/24 h (normal range: 20-90); failure to suppress the low-dose dexamethasone test (0.5 mg every 6 h for 48 h): cortisol 21 µg/dL. Abdominal magnetic resonance imaging (MRI) showed enlarged nodular adrenals (right, 55 × 54 × 30 mm; left, 85 × 53 × 35 mm), and she was submitted to bilateral adrenalectomy. In 2006, this patient's 39-year-old daughter had been treated by one of the authors. She presented with severe clinical and biological hypercortisolism. Computed tomography (CT) scan showed massively enlarged nodular adrenals with maximal axis of 15 cm for both. Bilateral adrenalectomy was performed. In this familial context of PBMAH, genetic study was performed. Leucocyte DNA genotyping identified in both patients the same germline heterozygous ARMC5 mutation in exon 1 c.172_173insA p.I58Nfs*45. The clinical cases herein described have an identical phenotype with severe hypercortisolism and huge adrenal glands, but different ages at the time of diagnosis. Current knowledge of inheritance of this disease, its insidious nature and the well-known deleterious effect of hypercortisolism favor genetic study to timely identify and treat these patients. LEARNING POINTS: PBMAH is a rare etiology of CS, characterized by functioning adrenal macronodules and variable cortisol secretion.The asymmetric/asynchronous involvement of only one adrenal gland can also occur, making disease diagnosis a challenge.Familial clustering suggests a genetic cause that was recently confirmed, after identification of inactivating germline mutations in armadillo repeat-containing 5 (ARMC5) gene.The insidious nature of this disease and the well-known deleterious effect of hypercortisolism favor genetic study of other family members, to diagnose and treat these patients timely.As ARMC5 is expressed in many organs and recent findings suggest an association of PBMAH and meningioma, a watchful follow-up is required.
