Impact of non-severe infections on cortisol and thyroid stimulating hormone baseline levels in hospitalized patients: A monocentric cross-sectional study.

Objective. The hormonal balance is dependent on the internal and external stimuli. The baseline cortisol (BC) and thyroid stimulating hormone (TSH) levels have been observed to vary and have a predictive value in critical illness settings. Few reports have studied their variation in non-severe acute illness. The present study aims to describe the variation of BC and TSH levels and to determine the factors influencing BC and TSH levels in patients admitted with non-severe acute illness. Patients and Methods. This is a cross-sectional study of patients admitted to Infectious Diseases and Endocrinology units at the Department of Endocrinology-Diabetology and Internal Medicine at Tahar Sfar University Hospital between March 15th and September 15th, 2020. BC and TSH levels were obtained during the hospitalization. Results. A total of 143 patients were included in this study with 75 presenting with infection. All infections were community-acquired and predominantly non-severe. The BC levels were higher in patients with infection (p=0.004), especially those admitted via the emergency department (p=0.009) with a fever (p=0.015). The BC positively correlated with the temperature (p=0.002, r'=0.350), CRP levels (p=0.002, r'=0.355), neutrophil to lymphocyte ratio (p=0.045, r'=0.235), and SOFA score (p=0.023, r'=0.262). On the other hand, TSH levels were comparable in the presence of infection (p=0.400). TSH levels did not correlate with the fever, the severity of infection, or inflammation biomarkers. Both BC and TSH did not predict unfavorable outcomes in non-severe infected patients. Conclusion. In patients admitted with critical acute infections, the BC levels seem to indicate a relatively more severe infectious state. On the other hand, TSH levels did not show significant variations in these patients.

Acute adrenal crisis precipitated by thyroid storm in a patient with undiagnosed autoimmune polyglandular syndrome type 2.

Summary: Autoimmune polyglandular syndrome (APS) type 2 is characterized by the presence of Addison's disease (AD) along with autoimmune thyroid disease and/or type 1 diabetes. APS type 2 is known as Schmidt's syndrome when autoimmune adrenal insufficiency is associated with chronic lymphocytic thyroiditis. We report a very rare case of a 28-year-old female patient who had Schmidt's syndrome revealed by a thyroid storm (TS) concomitant with an acute adrenal crisis. The onset of AD resulted in a surgical emergency. The patient presented with cardiogenic shock and an acute abdomen. The precipitation factor was Hashitoxicosis presented as TS. This life-threatening condition was successfully reversed with aggressive medical therapy based on antithyroid drugs and intravenous glucocorticoids. This hyperthyroid phase lasted for a period of 8 months. The patient eventually developed hypothyroidism, suggesting that Hashimoto's thyroiditis was the most likely diagnosis. She was started on levothyroxine replacement therapy and remained euthyroid on levothyroxine. The case we describe had several diagnostic pitfalls that are discussed both at the start as well as during the evolution. Learning points: Autoimmune diseases can appear concomitantly or succeed each other over time. The clinician must be vigilant to detect these diseases in time in order to avoid a misdiagnosis of a life-threatening emergency such as adrenal insufficiency or thyroid storm. Thyroid storm is an uncommon but life-threatening manifestation of hyperthyroidism. Diagnosis is dependent on clinical symptoms, and no specific laboratory tests are available. Glucocorticoids should be used in the treatment of thyroid storm because they have an inhibitory effect on peripheral conversion of T4 to T3. In patients who have severe thyrotoxicosis, especially in conjunction with hypotension, treatment with glucocorticoids has become standard practice because of the possibility of relative adrenal insufficiency or the possibility of undiagnosed Addison's disease. The differential diagnosis of hyperthyroidism can be challenging. Graves' disease can be discussed in view of the severity of the clinical presentation and the prolonged duration of the hyperthyroid phase. Hashitoxicosis is the initial hyperthyroid phase in chronic autoimmune thyroiditis. The hyperthyroid phase is always followed by definitive resolution, with persistent euthyroidism and no hyperthyroid relapses. Synthetic antithyroid drugs may be prescribed during the hyperthyroid phase of Hashimoto thyroiditis if the clinical presentation is severe and the duration of the hyperthyroid phase is prolonged.

[Transient thickening of the pituitary stalk followed by a supra-pituitary Langerhansian histiocytosis : consequence or mere coincidence ?] / Cas clinique. Épaississement transitoire de la tige pituitaire suivi d'une histiocytose langerhansienne supra-hypophysaire : conséquence ou simple coïncidence ?

One of the difficult challenges in endocrinology is the etiological diagnosis of isolated thickened pituitary stalk (PS). We report the case of a woman in whom a thickened PS was diagnosed following the onset of central diabetes insipidus revealed by polyuria-polydypsia syndrome of late pregnancy and postpartum. The pituitary exploration showed panhypopituitarism with disconnecting hyperprolactinemia. An etiological investigation for an inflammatory, granulomatous or tumour cause was carried out, but was negative. Postpartum lymphocytic hypophysitis was then retained. However, the course was puzzling with a control pituitary MRI showing disappearance of the PS thickening with paradoxical appearance of a supra-pituitary tumour, the biopsy of which concluded of being a Langerhansian histiocytosis. This paradoxical sequence is unusual and has not been reported before. It called into question the autoimmune lymphocytic origin of the thickened PS, initially considered, and raised the likelihood of a causal relationship between this PS thickening and Langerhansian histiocytosis.

Le diagnostic étiologique d'un épaississement isolé de la tige pituitaire (TP) constitue l'un des grands défis en endocrinologie. Nous rapportons le cas d'une patiente chez qui un épaississement de la TP a été diagnostiqué suite à la survenue d'un diabète insipide central révélé par un syndrome polyuro-polydypsique de fin de grossesse et du post-partum. Le bilan hypophysaire a montré un panhypopituitarisme avec une hyperprolactinémie de déconnexion. Une enquête étiologique à la recherche d'une cause inflammatoire, granulomateuse ou tumorale a été menée et s'est avérée négative. Une hypophysite lymphocytaire du post-partum a alors été retenue. Cependant, l'évolution a été déroutante avec, à l'IRM hypophysaire de contrôle, la disparition de l'épaississement de la TP et l'apparition paradoxale d'une tumeur suprahypophysaire dont la biopsie a conclu à une histiocytose langerhansienne. Cette évolution paradoxale est inhabituelle et n'a pas été rapportée auparavant. Elle a remis en question l'origine lymphocytaire auto-immune de l'épaississement de la TP, retenue initialement, et a soulevé la possibilité d'une relation de cause à effet entre cet épaississement de la TP et l'histiocytose langerhansienne.

Hypogonadism in hemodialysis patients: a first snapshot of prevalence and predictive factors in Tunisian patients.

Introduction: patients with chronic kidney disease commonly exhibit testosterone deficiency. We aimed through the current study to assess the prevalence and the risk factors of hypogonadism in male patients on hemodialysis and to establish their relationship with erectile dysfunction. Methods: we conducted a cross-sectional study based on data collected from hemodialysis male patients. Sociodemographic and clinical data as well as hormone levels were collected from January 2017 to December 2017. Sex hormones were measured in all subjects. The International Index of Erectile Function was used to evaluate erectile dysfunction. Data were expressed as mean ± standard deviation, and frequencies (number), and proportions (%). Results: one hundred and ten: 55 male hemodialysis patients were recruited. The level of follicule-stimulating hormone, luteinizing hormone and prolactin were high and the level of testosterone was low in the hemodialysis group. Hypogonadism was significantly linked to advanced age, anemia, and absence of treatment by erythropoietin. The incidence of erectile dysfunction was high and the erectile function score was low. Testosterone significantly dropped in patients with erectile dysfunction. Conclusion: hypogonadism was so prevalent in the hemodialysis men and it was associated with erectile dysfunction. Future studies are needed to determine the effect of testosterone therapy on erectile dysfunction.

The use of baseline cortisol level in predicting the outcome of 1 µg Synacthen tests in an outpatient endocrinology unit.

Introduction: The clinical requirements and the indication of the Synacthen test are increasing. The objective of our study is to determine a baseline cortisol level that reliably predicts the response to Synacthen test in a low-risk group of patients. Materials and methods: We performed a cross-sectional analysis of all Synacthen tests conducted between January 2017 and June 2018. The diagnostic accuracy of basal cortisol levels as a predictor of an adequate response to Synacthen test was evaluated by ROC curve analysis. Results: One hundred and fifty-three patients were included. A baseline cortisol level <40 ng/mL had a sensitivity of 100% but a specificity of 5.8% for the failure of the Synacthen test, while a baseline cortisol level> 147.5 ng/mL showed a specificity of 100% but a sensitivity of 1.2% for an adequate response to the Synacthen test. According to the ROC curve, the optimal baseline cortisol level for predicting an adequate response to the Synacthen test was 85 ng/mL with an AUC of 0.808 (95% CI [0.738-0.877]). Conclusion: We propose a basal cortisol level assay as a first step in the evaluation of patients with suspected adrenal insufficiency.

Metabolic syndrome, malnutrition, and its associations with cardiovascular and all-cause mortality in hemodialysis patients: Follow-up for three years.

Metabolic disorder contributes to the increase in the mortality rate of patients on hemodialysis (HD). The aim of this study was to estimate the prevalence of metabolic syndrome (MS) and malnutrition in patients on maintenance HD and to evaluate their influence on cardiovascular and all-cause mortality during the follow-up. We carried out a prospective cross- sectional study in which we enrolled 100 patients from a single center who had been followed up for three years. Collected data included demographic characteristics, detailed medical history, clinical variables, MS variables, nutritional status, and laboratory findings. The outcomes were the occurrence of a cardiovascular event and cardiovascular or all-cause mortality during the follow-up period. The Statistical Package for the Social Sciences software was used for statistical analysis. Whereas 50% of patients had MS, 23% showed evidence of malnutrition. Patients with MS were older and had more preexisting cardiovascular diseases (CVDs). All patients were followed for 36 months. During this time, 19 patients with MS and 14 patients without MS died (38% vs. 28%; P = 0.19), most frequently of CVD. Mean survival time was 71.52 ± 42.1 months for MS group versus 92.06 ± 65 months for non-MS group, but the difference was not significant. MS was related with a higher cardiovascular mortality, while malnutrition was significantly associated with all-cause mortality. Our data showed that MS was not related to cardiovascular or all-cause mortality in HD patients and did not influence survival. The independent risk factors for all-cause mortality were older age, preexisting CVD, and malnutrition.

[Corticosurrenaloma: an exceptional cause of primary hyperaldosteronism]. / Le corticosurrénalome: une cause exceptionnelle d'hyperaldostéronisme primaire.

Corticosurrenaloma is a rare malignant tumor of the adrenal gland that often secretes corticosteroids, sex steroids and precursors. Aldosterone-producing corticosurrenaloma is very rare, accounting for 1 case/10million inhabitants. We report the case of a 38-year old man presenting with severe arterial hypertension associated with deep hypokalaemia (2.2 mmol/L). Exploration showed primary hyperaldosteronism (aldosterone = 2645 pmol/l, aldosterone/renin ratio = 327 pmol/MUI), with hypersecretion of glucocorticoids. Abdominopelvic CT scan revealed left poorly differentiated and heterogeneous adrenal mass measuring 9cm, infiltrating into the surrounding adipose tissue and the diaphragm, extending into the left renal vein, with regional adenopathy and hepatic nodule measuring 4cm. The patient underwent radical nephrectomy followed by right hepatectomy two months after resulting in remission. A year after the patient developed lung metastases. This study highlights that corticosurrenaloma should be suspected in patients with primary aldosteronism despite its rarity.

Primary Hyperparathyroidism and Hyperthyroidism in a Patient with Myotonic Dystrophy: A Case Report and Review of the Literature.

Various endocrine manifestations are commonly described in myotonic dystrophy (MD), including primary hypogonadism, diabetes mellitus, and thyroid and parathyroid dysfunction. We describe a 46-year-old woman with a family history of MD with her son. She was diagnosed with cardiac arrhythmia and required the implantation of a pacemaker. She was noted to have a bilateral cataract. She complained of muscle weakness, diffuse myalgia, and palpitation. The electromyography (EMG) showed myotonic discharges. Laboratory tests showed high serum calcium 2.83 mmol/L, serum phosphate 1.2 mmol/L, parathormone 362.5 pg/mL, thyroid stimulating hormone TSH 0.02 mIU/L (normal range: 0.34-5.6 mIU/L), FT4 21.17 ng/mL, and negative anti-thyroperoxidase antibodies. Cervical ultrasound revealed a multinodular goiter. The 99mTc-MIBI scintigraphy localized a lower right parathyroid adenoma. The clinical data, the family history of MD, EMG data, and endocrine disturbances were strongly suggestive of MD associated with hyperthyroidism and primary hyperparathyroidism.

Seizures and movement disorders induced by hyperglycemia without ketosis in elderly.

BACKGROUND: Non-ketotic hyperglycemia (NKHG) may increase the probability of seizures and movement disorders. METHODS: We describe a series of 14 elders admitted for seizures and movement disorders linked to NKHG. RESULTS: Twelve patients developed motor seizures and two others movement disorders. Glucose levels varied 9.28 to 32 mmol/l, while osmolarity values varied from 302.28 to 328 mosmol/l. All patients responded well to insulin therapy and four of them needed anti-epileptic drugs. CONCLUSION: Seizures or movement disorders in elderly with NKHG could be misdiagnosed as neurological diseases. Blood glucose must be audited whenever patients with seizures or movement disorders are encountered, as the condition may quickly resolve when NKHG is controlled.

Multifocal diabetic muscle infarction: a rare complication of poorly controlled diabetes mellitus.

Diabetic muscle infarction (DMI) is a rare complication of long-standing poorly controlled diabetes mellitus. We herein describe the case of a 56-year-old man with a 10-year history of poorly controlled type 2 diabetes mellitus with multiple microvascular and macrovascular complications who presented with the sudden onset of left thigh pain and swelling. MRI suggested muscle infarction. A muscle biopsy demonstrated coagulation necrosis in the skeletal muscle with inflammation and infarction in the walls of small blood vessels. Physicians should consider DMI in the differential diagnosis of patients with diabetes who present with painful, swollen muscles without systemic signs of infection.

Pyogenic sacroiliitis and pyomyositis in a patient with systemic lupus erythematous.

Pyogenic sacroiliitis and pyomyositis are uncommon infectious diseases and their diagnoses are often delayed. They are typically seen in children and young adults and are rare in middle-aged people especially in those affected by rheumatic diseases. We present the first case of a Staphylococcus aureus related pyogenic sacroiliitis associated with iliacus and gluteal pyomyositis occurring in a patient with systemic lupus erythematosus. Antibiotic treatment was administered for a total of 6 weeks with a total recovery. Pyogenic sacroiliitis and pyomyositis, although remaining rare events, should be remembered as severe complications in immunosuppressed patients with inflammatory diseases. Early clinical suspicion, imaging diagnosis, and adequate therapy are decisive for the satisfactory outcome.

Cerebral Aneurysms: A Rare Feature of Behçet's Disease-A Case Report and Review of the Literature.

Behçet's disease (BD) is a multisystem vascular inflammatory disease with several clinical manifestations. Intracranial aneurysms are an extremely rare but nevertheless severe complication of BD. We report a case of a 44-year-old man. The diagnosis of BD was made based on the presence of recurrent oral aphthous ulcers and positive human leukocyte antigen (HLA-) B51 in the absence of evidence of other diseases. MRI showed an ancient ischemic right capsulolenticular lesion, subacute white matter hypersignals of the left capsule lenticular region, and multiple arterial aneurysms. The patient underwent two-month systemic high-dose corticosteroids and immunosuppressive therapy associated with severe neurological deficiency upon admission and severe impairment upon discharge. A thorough review of the literature showed 20 case reports of intracranial aneurysms in BD.

48XXYY Syndrome in an Adult with Type 2 Diabetes Mellitus, Unilateral Renal Aplasia, and Pigmentary Retinitis.

A 45-year-old male was referred for diabetes mellitus. Clinical examination found a family history of multiple precocious deaths, strong consanguinity, personal history of seizures during childhood, small testicles, small penis, sparse body hair, long arms and legs, dysmorphic features, mental retardation, dysarthria, tremor, and mild gait ataxia. Investigations found pigmentary retinitis, metabolic syndrome, unilateral renal aplasia, and hypergonadotropic hypogonadism, and ruled out mitochondrial cytopathy and leucodystrophy. Karyotype study showed a 48XXYY chromosomal type. Renal aplasia and pigmentary retinitis have not been described in 48XXYY patients. They may be related to the chromosomal sex aneuploidy, or caused by other genetic aberrations in light of the high consanguinity rate in the patient's family.