Graves' disease and recurrence in ectopic thyroid tissue after total thyroidectomy.

We report a case of a 46-year-old woman who presented with a midline neck mass 2 years after total thyroidectomy for Graves' disease. Despite levothyroxine treatment withdrawal, she remained biochemically with subclinical hyperthyroidism. Her thyroid stimulating hormone receptor antibodies were consistently elevated. Neck ultrasonography revealed an infrahyoid solid nodule and pertechnetate scintigraphy confirmed an increased uptake at the same level, without any uptake in the thyroid bed. Treatment with methimazole 5 mg/day was initiated with clinical improvement and achievement of euthyroidism. After that, she received 10 mCi of radioactive iodine. Since then, she experienced regression of the neck mass and is doing well on a replacement dose of levothyroxine. Recurrence of Graves' disease in ectopic thyroid following total thyroidectomy is extremely rare. This diagnose should be considered in patients who underwent total thyroidectomy and remained with thyrotoxicosis despite decreasing the levothyroxine dose.

Successful treatment of pituitary gigantism.

Pituitary gigantism is extremely rare, resulting from excessive secretion of growth hormone (GH) before fusion of epiphysial growth plates. We report a case of a 13-year-old boy, who presented with increased statural growth and headaches since the age of 10 years. On physical examination, his height was 180.7 cm (+3.3 SD) and Tanner stage V. Investigation revealed increased levels of serum age-adjusted and sex-adjusted insulin-like growth factor 1 (IGF-1) and failure of GH suppression during an oral glucose tolerance test (OGTT). MRI of the sellar region revealed a pituitary macroadenoma. He underwent transsphenoidal surgery and histopathological evaluation revealed mammosomatotropic adenoma. Three months after surgery, IGF-1 normalised, nadir GH during OGTT was less than 1 ng/mL and no residual tumour was found on the MRI. Genetic testing identified a mutation in the AIP gene. This case emphasises the importance of early diagnosis of gigantism, as treatment delay increases long-term morbidity.

Pituitary Apoplexy Following Systemic Anticoagulation.

Pituitary apoplexy is a rare medico-surgical emergency that stems from an acute expansion of a pituitary adenoma from infarction or haemorrhage and where the treatment strategy is still controversial. Clinical presentation is highly variable and a high index of suspicion is needed to make the diagnosis. Furthermore, in less than half of cases, a precipitating event is identified. We report a case of a 74-year-old female who, after introduction of anticoagulation for pulmonary thromboembolism, presented with pituitary apoplexy heralded by acute adrenal insufficiency, headaches, visual symptoms and hypogonadotropic hypogonadism. Timely initiation of corticosteroids was crucial, and after stabilisation, a conservative treatment strategy was favoured with good long-term prognosis. Long-term follow-up of pituitary function also revealed new growth hormone deficiency. LEARNING POINTS: Corticosteroid therapy may be crucial in the emergency setting, and it is recommended for all patients with suspected pituitary apoplexy (PA).Early recognition of PA and its predisposing factors is crucial for the best outcome for the patient.Initial conservative treatment strategies are gaining popularity but close clinical monitoring is fundamental to recognise the need for sellar decompression.

Granular cell tumour of the neurohypophysis: an unusual cause of hypopituitarism.

Granular cell tumours (GCT) are rare, slow-growing, benign neoplasms that are usually located in the head and neck. They are more frequent in the female gender and typically have an asymptomatic clinical course, being diagnosed only at autopsy. Symptomatic GCT of the neurohypophysis are exceedingly rare, being less than 70 cases described so far. The authors report on a case of a 28-year-old male that presented to the Endocrinology clinic with clinical and biochemical evidence of hypogonadism. He also reported minor headaches without any major visual symptoms. Further laboratory tests confirmed hypopituitarism (hypogonadotrophic hypogonadism, central hypothyroidism and hypocortisolism) and central nervous system imaging revealed a pituitary macroadenoma. The patient underwent transcranial pituitary adenoma resection and the pathology report described a GCT of the neurohypophysis with low mitotic index. The reported case is noteworthy for the rarity of the clinicopathological entity. LEARNING POINTS: Symptomatic GCTs are rare CNS tumours whose cell of origin is not well defined that usually give rise to visual symptoms, headache and endocrine dysfunction.Imaging is quite unspecific and diagnosis is difficult to establish preoperatively.Surgical excision is challenging due to lesion's high vascularity and propensity to adhere to adjacent structures.The reported case is noteworthy for the rarity of the clinicopathological entity.

Diabetes mellitus and hyperkalemic renal tubular acidosis: case reports and literature review / Diabetes mellitus e acidose tubular renal hipercalêmica: relatos de caso e revisão da literatura

ABSTRACT Hyporeninemic hypoaldosteronism, despite being common, remains an underdiagnosed entity that is more prevalent in patients with diabetes mellitus. It presents with asymptomatic hyperkalemia along with hyperchloraemic metabolic acidosis without significant renal function impairment. The underlying pathophysiological mechanism is not fully understood, but it is postulated that either aldosterone deficiency (hyporeninemic hypoaldosteronism) and/or target organ aldosterone resistance (pseudohypoaldosteronism) may be responsible. Diagnosis is based on laboratory parameters. Treatment strategy varies according to the underlying pathophysiological mechanism and etiology and aims to normalize serum potassium. Two clínical cases are reported and the relevant literature is revisited.

RESUMO Apesar de comum, o hipoaldosteronismo hiporeninêmico continua a ser uma entidade sub-diagnosticada, com maior prevalência em pacientes com diabetes mellitus. A doença cursa com hipercalemia assintomática acompanhada de acidose metabólica hiperclorêmica sem disfunção renal significativa. O mecanismo fisiopatológico subjacente não é entendido em sua totalidade, mas postula-se que a deficiência de aldosterona (hipoaldosteronismo hiporeninêmico) e/ou a resistência à aldosterona no órgão-alvo (pseudo-hipoaldosteronismo) possam ser responsáveis. O diagnóstico é fundamentado em parâmetros laboratoriais. A estratégia terapêutica varia de acordo com o mecanismo fisiopatológico subjacente e a etiologia, mas seu objetivo é normalizar o potássio sérico. O presente artigo relata dois casos e analisa a literatura relevante sobre o assunto.

Diabetes mellitus and hyperkalemic renal tubular acidosis: case reports and literature review.

Hyporeninemic hypoaldosteronism, despite being common, remains an underdiagnosed entity that is more prevalent in patients with diabetes mellitus. It presents with asymptomatic hyperkalemia along with hyperchloraemic metabolic acidosis without significant renal function impairment. The underlying pathophysiological mechanism is not fully understood, but it is postulated that either aldosterone deficiency (hyporeninemic hypoaldosteronism) and/or target organ aldosterone resistance (pseudohypoaldosteronism) may be responsible. Diagnosis is based on laboratory parameters. Treatment strategy varies according to the underlying pathophysiological mechanism and etiology and aims to normalize serum potassium. Two clínical cases are reported and the relevant literature is revisited.

Prevalence and distribution of the main cardiovascular risk factors in Portugal--the AMALIA study.

OBJECTIVES: To assess the self-reported prevalence of the main risk factors for cardiovascular disease in Portugal and their distribution by gender, age-group and region. METHODS: We surveyed 38,893 individuals aged 40 or over, with a distribution by region and age-group proportional to the national population, through a questionnaire applied in the community in a household approach using the random route method, between October 2006 and February 2007. RESULTS: The self-reported prevalence of hypertension was 23.5%, increasing with age in both genders, but slightly higher in women (24.9% vs. 21.8%). The prevalence of hypercholesterolemia, based on respondents' statements, was 19.7%, and higher in women (20.7% vs. 18.6%), with the highest values in the 6th and 7th decades of life (23.9% and 23.6%). The prevalence of diabetes was 8.9%, increasing with age, and slightly higher in women (9.3% vs. 8.5%). The prevalence of smoking was 16.3%, decreasing with age, but always higher in men (25.3% vs. 8.8%). The prevalence of overweight/obesity (BMI equal to or higher than 25/30 kg/m2) was 51.6%, higher in those aged 60-69 (57.1%) and 70-79 years (56%). Most participants (65.3%) declared they never took part in structured physical activity, while 24% claimed to take exercise, on average for 11 years, and 10.6% stated that they no longer exercised. In the Azores, there was a higher prevalence of hypertension, hypercholesterolemia, diabetes and overweight/obesity, while the North and Algarve regions presented the lowest values of these risk factors, although they had higher levels of smoking. CONCLUSIONS: Based on respondents' statements, the AMALIA study found the following prevalences of the six risk factors under investigation, in descending order: sedentarism--76%; overweight/obesity--52%; hypertension--24%; hypercholesterolemia--20%; smoking--16%; and diabetes--9%. Notwithstanding possible under-reporting, the differences in prevalence of these major risk factors by gender and region could influence cardiovascular prevention strategies in Portugal.