Evaluation of trans-sphenoidal surgery in pituitary GH-secreting micro- and macroadenomas: a comparison between microsurgical and endoscopic approach.

AIM: Acromegaly is caused by a GH-secreting pituitary adenoma, associated with many comorbidities and increased risk of mortality. Surgery is the first-line therapy. Success of therapy is measured by symptomatic improvement, preservation of pituitary function and biochemical control. Trans-sphenoidal surgery (TSS), endoscopic or microscopic, is the preferred treatment. To evaluate surgery effectiveness and individuate the technique associated with a higher remission rate, patients undergoing TSS were retrospectively selected. METHODS: Thirty-seven consecutive patients underwent surgery between 1996 and 2006. Tumors were classified into macroadenomas or microadenomas and into intrasellar, extrasellar and extrasellar with cavernous sinus invasion. Surgery was performed in 22 patients with endoscopic technique, in 15 patients with microsurgical approach. The hormonal assays were performed 6 months and yearly after surgery for an average of 5 years. RESULTS: Ten patients were affected by microadenoma, 27 by macroadenoma. In microadenomas remission rate was independent of the used technique. Within macroadenomas, remission percentage in endoscopic approach (68.75%) was significantly higher than in microscopic approach (18.18%) (P=0.018). Postsurgical biochemical remission was calculated combining the surgical technique and tumor extension: the endoscopic approach was associated with a significantly higher remission rate in extrasellar than both in intrasellar and extrasellar with cavernous sinus invasion. In the latter group, any technique had not reached biochemical remission. CONCLUSION: TSS is able to induce a long-term remission of acromegaly, with low risk of recurrence and complications. Endoscopic approach is more suitable than microscopic technique in macroadenomas and adenomas with suprasellar extension.

Henoch-Schönlein purpura in a patient with bowel bypass syndrome.

Henoch-Schönlein purpura (HSP) is a common vasculitis being characterized by the classic tetrad of nonthrombocytopenic palpable purpura, arthritis or arthralgias, gastrointestinal and renal involvement. Antigen-antibody (IgA) complexes activate the alternative complement pathway, resulting in inflammation and small vessels vasculitis. We present the case of a 53 years old Italian woman with HSP who was previously hospitalized for purpura skin lesions of the lower legs and diarrhea; a skin biopsy showed a leukocytoclastic vasculitis with perivascular accumulation of neutrophils and mononuclear cells. She was treated with immunosuppressive therapy. After 8 months she was hospitalized again for a recurrent episode of purpura skin lesions of the lower legs. At age 49 she was affected by obesity (BMI = 41.6 Kg/m2), treated via a bilio-pancreatic diversion that led, within a year, to a BMI reduction (25 Kg/m2). We suppose that bariatric surgery played a role on the development of autoimmune phenomena and that the formation of immunecomplexes is secondary to the excess of intestinal bacterial antigens. A cyclic therapy with Paromomicine 500 mg twice daily and Metronidazole 250 mg twice daily was performed with a clear up of the clinical picture. In medical literature are described numerous complications which include arthritis, erythema nodosum-like lesions, eruptions and other skin manifestations in patients who have undergone jejunocolic bypass. This case report describes for the first time the presence of HSP in a patient with bowel bypass syndrome and it is also able to demonstrate the relationship between the intestinal bacterial overgrowth and the systemic autoimmune system.

Prevalence of celiac disease in patients with autoimmune thyroiditis.

AIM: Many autoimmune disorders are associated to celiac disease (CD) but the association with autoimmune thyroiditis has been more frequently documented; this is in part explained by a shared immunogenetic make-up, and in part caused to time gluten-exposition, as suggested by the significant correlation observed in celiac patients between the increase occurrence of autoimmune diseases and the length of exposure to gluten. The aim of this study was to establish the prevalence of celiac disease in a group of subjects with autoimmune thyroiditis newly diagnosed on the basis of antibodies anti-peroxidase (TPO). METHODS: A total of 113 untreated patients with TPO >70 IU/mL were enrolled. CD was screened by measuring anti-endomysial antibodies (EMA) both IgA and IgG; an high prevalence of positive serology was resulting in this group, justified, in part, from EMA IgG investigation. RESULTS: In fact 31/113 patients showed IgA and/or IgG positivity and were diagnosed as celiacs with jejunal biopsy. CONCLUSION: On the basis of this paper, such as in according to current research-setting studies, the greater frequency of CD in association to autoimmune thyroid disease suggests that all subjects with TPO should be routinely screened for CD, through EMA IgA and IgG. However, the performance of this screening has never been evaluated until now, even if it could, in fact, be valid in order to increment diagnosis of CD, today still undiagnosed.