Confounder factors masking a Leydig-cell ovarian tumor in a post-menopausal woman treated for androgen-positive receptor breast cancer.

Post-menopause hyperandrogenism is a condition that needs careful evaluation. Aromatase inhibitors (AI), which are important in the management of positive estrogen breast cancer, and chronic kidney disease (CKD) can puzzle the evaluation of this condition. A postmenopause female with type-2 diabetes and advanced CKD was attended due to progressive virilization, which has started after the introduction of an AI for breast cancer 5 years earlier. Clinical and radiological investigation has confirmed a pure Leydig cell tumor as source of hyperandrogenism. Re-evaluation of the breast tumor immunohistochemistry has shown positive androgen receptor expression and negative expression for estrogen, progesterone and HER-2 receptors. Even though an ovarian tumor was the source of androgen excess, we discuss that AI could exert a slight contribution to patient's virilization by reducing estradiol counterbalance. Also, although the onset of hyperandrogenic symptoms was unclear, we could not exclude that the ovarian tumor had produced enough androgens to play a role in breast tumor progression. This case report supports the literature regarding the possible association between Leydig cell tumor and androgen-receptor-positive breast cancer development. Finally, progressive hyperandrogenic symptoms in postmenopause, even under AI therapy or the presence of advanced CKD, impose a more detailed investigation.

The imbalance of sex-hormones related to depressive symptoms in obese men.

Obese men may present hypogonadothrofic hypogonadism, mainly related to higher insulinemia and aromatase activity. Our objectives were to evaluate the relationship of sex-hormones profiles and frequency of depressive symptoms in 43 obese men, in a cross-sectional study. They had 19-60 years, and body mass index 30-50 kg/m(2). LH, total and free testosterone (TT and FT), estradiol (E2), sex hormone binding globulin, estradiol/total testosterone ratio (E2/T) were analyzed. Depressive symptoms were evaluated by "beck depression inventory" (BDI), and significant depression was considered if BDI ≥ 16.Thirty-four (80%) presented low TT levels, but only 4 (14%) had low free testosterone and hypogonadism symptoms; 12 of 43 (28%) presented increased E2. Forty five (56%) presented depressive symptoms, but 16 (28% of the 45) had significant depression. BDI correlated positively with E2 (r = 0.407; p = 0.001) and E2/T (r = 0.473; p = 0.001), but not TT or FT. Patients with significant depressive showed higher levels of estradiol (136 ± 48 versus 103 ± 48 pg/ml, p = 0.02) and E2/T (16.0 ± 9.9 versus 9.8 ± 4.6; p = 0.002) (mean ± SD).In conclusion, obese men may present relatively excess of estradiol and deficiency in testosterone, leading to an imbalance between these two hormones. The greater this imbalance, the more depressive symptoms had our patients.

The evolution of diabetic chronic complications after pancreas transplantation.

Pancreas transplantation is an invasive procedure that can restore and maintain normoglycemic level very successfully and for a prolonged period in DM1 patients. The procedure elevates the morbimortality rates in the first few months following the surgery if compared to kidney transplants with living donors, but it offers a better quality of life to patients.Although controversial, several studies have shown the stabilization or the improvement of some of the chronic complications related to diabetes, as well as the extra number of years of life that patients submitted to a double pancreas-kidney transplantation may gain.Recent studies have demonstrated clashing outcomes regarding isolated pancreas transplantations, a fact which reinforces the need for a more discerning selection of patients for this procedure.

Role of vasopressin in 24-hour blood pressure regulation in diabetic patients with autonomic neuropathy.

To evaluate the role of vasopressin (AVP) on blood pressure (BP) in diabetic patients with autonomic neuropathy (AN), 10 patients were studied on a fixed sodium and potassium diet. On days 4 and 7, a 24-h BP monitoring, as well as blood and urine samples for sodium, potassium, creatinine, and osmolality determinations were obtained for every 4-h period; either placebo or an AVP-V1-antagonist (d(CH2)5Tyr(me)AVP; 0.5 mg; AVPi) were given iv at 1 PM. On placebo, systolic BP (SBP) showed a progressive elevation during the day, declining after 12 PM (8 AM to 12 AM 122+/-9; 12 AM to 4 PM 125+/-11; 4 PM to 8 PM 134+/-14; 8 PM to 12 PM 136+/-14; 12 PM to 8 AM 131+/-17 mm Hg). On AVPi this rise in SBP was blunted: 8 AM to 12 AM 125+/-122; 12 AM to 4 PM 121+/-21; 4 PM to 8 PM 126+/-16; 8 PM to 12 PM 129+/-14; 12 PM to 8 AM 124+/-12 mm Hg. Creatinine clearance and diureses were greater during the night, both with placebo and AVPi. Plasma osmolality did not change on either day, although serum sodium decreased after AVPi, reaching the lowest values at 4 PM to 8 PM period (137+/-4.7 v 131+/-3.8 mEq/L; P < .05). With placebo, fractional excretion of sodium (FENa) increased from 0.43%+/-0.32% during 12 h of orthostasis to 0.92%+/-1.05% during 12 h of recumbency (P < .02). With AVPi, the FENa on orthostasis did not differ from that with placebo, although BP values were lower and did not increase with recumbency (0.58+/-0.57 v 0.73%+/-0.49%; NS). In conclusion, our results show that in diabetic patients with AN, vasopressin participates in BP control by stimulating vascular and renal V1 receptors, which results in vasoconstriction and sodium reabsorption.

Monitorizaçäo da pressäo arterial de 24 horas: método para diagnóstico precoce da complicaçäo renal no diabetes mellitus insulino-dependente? / Monitoring of blood pressure in 24 hours: methods for early diagnosis of kidney complication in diabetes mellitus insulin-dependent?

Monitorizaçäo pressórica de 24 horas (MP24h) tem sido usada no estudo de complicaçöes crônicas do diabetes pelo seu potencial de identificar distúrbios nao evidenciáveis às mediçöes ambulatoriais. Comparamos 1) a pressäo arterial (PA) de 24h de 23 indivíduos com diabetes insulino-dependente sem nefropatia (normoalbuminúricos ou "Normo"), com 14 portadores de microalbuminúria ("Micro") e com grupo näo-diabético ("NI") (n=10); 2) parâmetros eco-cardiográficos entre os diabéticos. Além de PA e frequência cardíaca (FC), as cargas sistólicas (percentual de registros de PA sistólica > 140 mmHg no período diurno e >120 mmHg no noturno) e diastólicas (valores de corte: 90 e 80 mmHg) foram obtidas e os descensos noturnos da PA calculados. Os grupos diabéticos näo diferiram quanto à dose de insulina e controle glicêmico. A PA sistólica diurna dos diabéticos foi maior que a dos NI, näo diferindo entre Normo e Micro (119+7 vs 126+8 e 130+8 mmHg; NI, Normo e Micro, respectivamente, p<0,01), padräo este observado também para a PA sistólica noturna (103+7 vs 109+8 e 116+13 mmHg; p<0,05). Näo houve diferença entre os grupos quanto às PA diastólicas. As PA médias diurnas (91+4 vs 98+4 mmHg) e noturnas (76+5 vs 85+9 mmHg) foram menores no NI do que nos Micro (p<0,05). A FC näo diferiu entre os grupos. Todos tiveram queda da PA e FC à noite com o sono. A carga sistólica diurna foi maior nos Micro do que nos NI, näo havendo diferença estatística entre Normo e Micro (Mi=0,8 vs 4,5 e 17,8 por cento; NI, Normo e Micro, p<0,01), embora nítida a tendência dos últimos a cargas mais altas. A carga diastólica diurna foi menor nos NI do que nos Micro, sem diferença entre os grupos diabéticos (Mi=2,3 vs 8,1 e 20,8 por cento; p<0,02). As cargas noturnas dos 3 grupos foram similares. O descenso noturno da PA média dos NI foi maior em comparaçäo com os grupos diabéticos (Mi=20,6 vs 14,8 e 14,8 por cento; p<0,05). O índice de massa de ventrículo esquerdo (MVE), dentro da faixa normal, näo diferiu entre Normo e Micro (82,8+23,6 e 89,5+21,3 g/m2). Näo houve correlaçäo entre albuminúria, descenso noturno e MVE. A MP24h revelou que o estado diabético, independente da presença de nefropatia, se associa a aumento da PA. Nesta amostra näo foi possível separar diabéticos Micro e Normo, usando parâmetros como cargas pressóricas e descenso noturno no PA. A MVE näo mostrou utilidade para reconhecer precocemente o dano renal, se comparada à albuminúria. Outras disfunçöes próprias da doença...

Relaçäo cronológica entre o aparecimento do diabetes mellitus do tipo I e das tiroidopatias nas síndromes poliglandulares auto-imunes (SPAs) / Chronologic relation between the appearance of diabetes mellitus type I and of thyroid diseases in the autoimmune polyglandular syndromes

As síndromes poliglandulares auto-imunes (SPAs) caracterizam-se pela associaçäo de duas ou mais endocrinopatias auto-imunes no mesmo indivíduo. A relaçäo cronológica entre o aparecimento das tiroidopatias auto-imunes (moléstia de Basedow Graves e tiroidite de Hashimoto) e do diabetes mellitus tipo I nas SPAs näo está bem estabelecida. A fim de melhor avaliar essa seqüência de eventos, analisamos 44 portadores de diabetes mellitus do tipo I e quadro clínico e/ou laboratorial de outra endocrinopatia ou doença auto-imune associada (SPA), sendo 38 mulheres e seis homens, com idades variando entre 10 e 73 anos. Observamos que nesses pacientes, o diabetes incide predominantemente na quarta década de vida e, em 93 por cento dos casos está associado a uma tiroidopatia auto-imune. A moléstia de Basedow Graves usualmente precede o desenvolvimento do diabetes diferentemente da tiroidite de Hashimoto (p=0,002). Esses dados enfatizam a importância da pesquisa de diabetes mellitus do tipo I em portadores de moléstia de Basedow Graves, assim como da investigaçäo de tiroidite de Hashimoto em portadores de diabetes mellitus do tipo I, através da avaliaçäo da funçao dos órgäos-alvo e/ou verificaçäo de marcadores imunológicos.

Macroprolactinoma invasivo simulando um cordoma / Invasive macroprolactinoma simulating a chrodoma

O adenoma de hipófise é um importante diagnóstico diferencial dos tumores da regiao diencéfalo-hipofisária, em se considerando suas possibilidades terapêuticas e prognóstico. Sete a 1O por cento destes adenomas tem comportamento invasivo, sendo que 44 por cento deles apresentam hipersecreçao hormonal. Relatamos o caso de um paciente de 44 anos de idade com diagnóstico radiológico de cordoma, tendo sido tratado como tal em serviço de neurocirurgia. No entanto, ao realizar-se a avaliaçao hormonal e a imunohistoquímica posteriormente, constatou-se ser um caso de prolactinoma gigante, sendo entao o paciente tratado com Parlodel-LAR (Sandoz). Houve excelente melhora clínica e laboratorial, bem como uma drástica diminuiçao do volume tumoral. Com este caso ressaltamos a importância de se realizar avaliaçao hormonal para o diagnóstico diferencial dos tumores desta regiao.