Testicular adrenal rest tumours in young adult males with congenital adrenal hyperplasia: prevalence and impact on testicular function.

Testicular adrenal rest tumours (TARTs) have been described in patients with congenital adrenal hyperplasia (CAH). The aim of the study was to determine the prevalence of TARTs in patients with CAH, the associated factors and their impact on gonadal function. It is a prospective study concerning six young adult men with CAH, four cases with 21-hydroxylase deficiency and two cases with 11-hydroxylase deficiency. All patients were under glucocorticoid therapy. The mean age was 25 years (range: 20-31). All patients underwent a physical examination with testicular palpation, scrotal ultrasonography, a blood sample for serum testosterone, FSH, LH, inhibin B, ∆4-androstenedione and 17-OH-progesterone measurements and a semen analysis. Ultrasound revealed TARTs in four patients; three were bilateral. The mean tumour size was 6.3 ml (range: 0.02-14.1). The tumours were palpable in two cases. 17-OH-progesterone was <10 ng/ml in all cases. Decreased testosterone level was found in one case. The semen analysis revealed azoospermia in one case and poor semen quality in four patients. TARTs were common and associated with impaired spermatogenesis.

Metabolic syndrome in Tunisian psoriatic patients: prevalence and determinants.

BACKGROUND: A significant association between psoriasis and the metabolic syndrome (MetS) has been frequently reported. OBJECTIVE: The aim of this study was to specify the main factors that determine the MetS in psoriatic Tunisian patients. METHODS: A case-control study has included 164 psoriatic patients and 216 controls. RESULTS: The prevalence of MetS was higher in cases than in controls but without statistical differences [35.5% vs. 30.8%, odds ratio (OR): 1.39 CI: 0.88-2.18; P=0.095]. According to gender, the prevalence of MetS was significantly increased only in psoriatic women (47.4% vs. 30%, OR: 1.89, CI: 1.11-3.21; P=0.01). A multiple logistic regression, considering the effect of age, and gender, showed that the prevalence of MetS was significantly higher in cases than in controls (OR: 1.73, CI: 1.06-2.82; P=0.03). MetS components analysed seperately showed a significantly higher prevalence of decreased high-density lipoprotein cholesterol (HDLc) (60.9% vs. 35.9%, OR: 2.77, CI: 1.8-4.27, P<0.001) and for increased hypertension (50% vs. 40%, OR: 1.48, CI: 0.97-2.257, P=0.04) in psoriatic patients. According to gender, HDLc was significantly decreased in both genders (male: OR: 2.075, CI: 1.24-3.47, P=0.004; female: OR: 3.58, CI: 2.07-6.19, P<0.0001), while hypertension was increased only in psoriatic men (OR: 2.09, CI: 1.24-3.51, P=0.004) and abdominal obesity only in psoriatic women (OR: 2.31, CI: 1.30-4.11, P=0.002). CONCLUSION: Decreased HDLc is the main biological abnormality that characterized MetS in Tunisian psoriatic patients. Moreover, contrary to men, psoriatic women have shown a significantly higher prevalence of MetS, which is, in addition to decreased HDLc, mainly attributed to abdominal obesity.

Ketosis-onset diabetes in Tunisian adults: immunological markers and beta-cell function.

The aim of this study in Tunisia was to classify ketosis-onset diabetes in adult patients. All patients aged > 30 years without known diabetes, presenting with ketosis and admitted to our department were studied. Patients with secondary or gestational diabetes and those on corticoid therapy or with coinciding infection were excluded. The data included clinical characteristics, immunological markers and beta-cell function. Of the 63 patients, islet-cell antibodies were present in 27.0%, glutamic acid decarboxylase antibodies in 25.4% and thyrosin phosphatase antibodies in 19.0%. Beta-cell functional reserve was preserved in 54.0%. Our results confirm that patients with ketosis-onset diabetes mellitus in adulthood are a heterogeneous group.

[Diabetic papillopathy after intensification of insulin therapy: A case report]. / Papillopathie diabétique après insulinothérapie intensive : à propos d'un cas.

INTRODUCTION: Diabetic papillopathy is a rare ocular complication of diabetes. Its pathophysiology is not well known. It is a unilateral or bilateral optic disc edema with variable degrees of visual loss. OBSERVATION: A 66-year-old woman, with a twelve years old type 2 diabetes mellitus, suddenly presented a unilateral decreased vision. Her ocular examination was normal eight months earlier. Ocular examination, radiological investigations and laboratory analysis were conclusive of diabetic papillopathy. Medical history revealed a recent rapid improvement of blood glucose control after intensification of insulin therapy. A visual acuity improvement with spontaneous regression of papillary edema was observed. CONCLUSION: There is a risk of diabetic papillopathy associated with the rapid control of blood glucose levels after intensification of insulin therapy, even in diabetic patients without known retinopathy.

The -2548G/A LEP polymorphism is associated with blood pressure in Tunisian obese patients.

OBJECTIVE: To examine the association of a common -2548G/A (rs7799039) promoter variant of the human leptin gene (LEP) with obesity or body mass index (BMI) and its associated phenotypes such as blood pressure variability and the prevalence of hypertension in a sample of the Tunisian population. DESIGN AND METHODS: Two hundred and twenty-nine obese patients were screened and compared with 251 normal weight subjects. The -2548G/A LEP polymorphism was analysed by PCR-RFLP procedure. RESULTS: No significant association was found between the -2548G/A polymorphism and obesity or BMI. However, in obese patients subjects with AA genotype had significantly higher systolic (p = 0.003) and diastolic (p = 0.002) blood pressure compared with those with GA or GG genotypes. Stratified analysis by gender revealed that male patients but not female homozygous for -2548A allele exhibited significantly increased systolic (p = 0.01) and diastolic (p<0.001) blood pressure than did carriers of -2548G allele. Multiple linear regression analysis revealed that AA genotype significantly affect systolic and diastolic blood pressure in obese men. Additionally, significant association between AA genotype and higher prevalence of hypertension was found in male patients (p = 0.03). CONCLUSION: The present study showed that the -2548G/A LEP polymorphism is associated with blood pressure in obese male patients.

Unusual presentation of multiple endocrine neoplasia type 2A in a patient with the C634R mutation of the RET-protooncogene.

The aim of this paper is to report an atypical presentation of MEN2A, in a patient carrying the C634R mutation of the RET-protooncogene. A 41-year-old Tunisian woman was admitted to our department with newly diagnosed hyperglycemia. She had a history of bilateral urinary stone recurrence, managed successfully on two occasions. On physical examination a thyroid node of 1cm on the left side was found. Laboratory evaluation and imaging findings confirmed the diagnosis of primary hyperparathyroidism. During cervicotomy, the parathyroid adenoma was resected and the thyroid node was suspected to be a carcinoma. Total thyroidectomy, with appropriate neck nodal resection, was performed. Histological examination confirmed the diagnosis of parathyroid adenoma and revealed a multifocal and bilateral medullary carcinoma. These findings led to the diagnosis of multiple endocrine neoplasia. DNA-analysis demonstrated a germline Cys634Arg mutation in the RET-protooncogene. During the postoperative follow-up, blood pressure as well as the level of urinary methoxylated metabolites increased progressively. Imaging findings were compatible with the diagnosis of bilateral pheochromocytoma. In conclusion, this case report of MEN 2A linked to a 634 RET mutation was peculiar by its revelation mode (1) hyperparathyroidism moreover linked to an adenoma and (2) associated with diabetes, mechanisms of which are probably multifactorial (familial type 2 diabetes, hypercalcemia, catecholamines excess).

[Pseudo pheochromocytoma induced by professional stress: A case report]. / Un pseudophéochromocytome induit par le stress professionnel ; à propos d'un cas.

INTRODUCTION: An elevation of plasma or urinary catecholamines or their metabolites in the context of a suspicion of a secondary hypertension associated with paroxysms generally leads to the diagnosis of pheochromocytoma. However, this is not always true. CASE REPORT: We report the case of a 39-year old man with a severe hypertension that was resistant to drug therapy and associated with paroxysms. Urinary fractioned metanephrines were elevated. However, no tumor could be found on tomodensitometry and MIBG scintigraphy. Thus, the causes of pseudopheochromocytoma were reviewed and the diagnosis of professional stress was finally held. In fact, his professional redeployment resulted in an improvement of blood pressure levels, the disappearance of paroxysms and the normalization of urinary metanephrines. CONCLUSION: This observation involves professional stress in pseudo pheochromocytoma.

Clinical and metabolic characteristics of newly diagnosed diabetes patients: experience of a university hospital in Tunis.

PURPOSE: The aim of our retrospective study was to explore the clinical and metabolic characteristics of newly diagnosed diabetes patients over the age of 30 years. METHODS: Study participants were consecutive, newly diagnosed patients with diabetes, over the age of 30 years, presenting to our university hospital department between January 1999 and June 2003. Clinical and metabolic data were collected retrospectively by medical record review. RESULTS: Three hundred seventy patients were included; mean age was 54.1+/-14.0 years; 49% were women and a family history of diabetes was reported in 52% of patients. Patients presented with acute complications in 40% of cases. Symptoms of polyuria-polydipsia and weight loss were present at diagnosis in 87% and 76% of cases respectively. 58% of our patients were obese or overweight (BMI> or =25 kg/m(2)), hypertension was present in 22%, hypertriglyceridemia in 27% and high LDL cholesterol in 27%. Neuropathy was diagnosed in 24%, nephropathy in 13%, coronary heart disease in 9%, retinopathy in 8% of cases, stroke in 3% and peripheral arterial disease in 2%. Insulin was prescribed initially in 47% of cases. CONCLUSIONS: Our results demonstrate that clinical symptoms and acute ketosis are the most common presenting features of diabetes mellitus in adults at the hospital level. Associated chronic complications are frequent.

[Celiac disease revealed by hypocalcemia complicating total thyroidectomy: a case report]. / Maladie coeliaque révélée par une hypocalcémie secondaire à une thyroïdectomie totale: à propos d'un cas.

In order to illustrate a particular circumstance of diagnosis of celiac disease, we report the case of 54-year-old women with a history of thyroid enlargement with normal thyroid function and positive anti-peroxidase antibodies. Immediately after total thyroidectomy with preservation of the parathyroid glands, she developed tetany with total serum calcium level at 50mg/l. Intravenous calcium infusion increased the calcium level and led to resolution of hypocalcemia-induced signs but there was no result when calcium and vitamin D were taken orally. The diagnosis of malabsorption was very probable in light of the family history of celiac disease, the anemia and the hypoalbuminemia. The diagnosis was confirmed by antibodies assay and endoscopy. The PTH level was less than 1 pg/l and radiography showed signs of hyperparathyroidism. Gluten-free diet, calcium and vitamin D led to an improvement of serum calcium.

[Quality of ambulatory care of non-insulin dependent diabetic patients]. / La qualité de la prise en charge ambulatoire des patients diabétiques non insulinotraités.

We assessed the quality of care provided to non-insulin treated diabetic patients by examining the medical records of 248 such patients attending our outpatient department in 2002. The mean age was 59.5 (SD 10.1) years, 62.1% were women and known duration of diabetes was 8.6 (SD 5.9) years. The majority of patients were treated with a combination of sulfonylurea and metformin. Glycaemic control was assessed using fasting blood glucose in 96.8% of patients, post-prandial blood glucose in 31.9% and glycated haemoglobin in 52.4%. Weight was measured at least once for 88.7% of patients, blood pressure for 91.1% of patients and lipid levels for 64.9%. Body mass index was less than 25 kg/m2 in 12.3% of patients and blood pressure less than 140/90 mmHg in 40.3%. Foot examination was noted in only 2% of records, electrocardiography was performed for 25% of patients and fundoscopy for 21%. Proteinuria was documented in 19.8% of patients and plasma urea and/or creatinine in 57.3%.

Quality of care of patients with type 2 diabetes in a Tunisian university hospital.

OBJECTIVES: The aim of this retrospective study was to explore the quality of ambulatory management provided to patients with type 2 diabetes. METHODS: Five hundred ninety-three patients with type 2 diabetes attended our outpatient department in 2002. Clinical and biological data were collected from the medical records of these patients. RESULTS: The mean age was 61.7 +/- 10.5 years; 60.5% were women and known duration of diabetes was 11.8 +/- 7.5 years. Eighty-five percent of patients had 2 or more visits and 58% were on insulin. Glycaemic control was assessed using fasting blood glucose in 97.3%, post-prandial blood glucose in 28.3% and glycated haemoglobin in 50.6% of cases. HbA1c was over 8% in 60.7% of patients. Weight was measured at least once in 86.5% of cases, blood pressure in 91.2% and lipids levels estimated in 58%. BMI was less than 25 kg/m2 in 16.2% of patients and blood pressure less than 140/90 mmHg in 40.1% of cases. Foot examination was recorded only in 5% of patients, ECG was performed in 23.8% of cases and fundoscopy in 19.2% of patients. Proteinuria was documented in 19.1% of cases and renal function assessed in 54.4% of patients. CONCLUSIONS: These findings suggest that the management of type 2 diabetes is still inadequately performed in our centre and more progress is needed to prevent micro and macrovascular complications.

[Atrial fibrillation]. / Fibrillation auriculaire.

The aim of transesophageal echocardiography (TOE) in atrial fibrillation milieu is to search a cardiac chamber thrombus. In order to establish the indications of TOE and to raise new issues for the echographic prognosis of maintain of sinus rhythm, 40 patients with atrial fibrillation who underwent cardioversion were prospectively screened. All patients had transthoracic and transesophageal echocardiography before procedure to control the absence or disappearing of atrial thrombus (N = 7). All 40 patients underwent a successful cardioversion. Follow-up was done after one, three and six months for both success group (N = 28) and refibrillation group (N = 12). Our study provides evidence that the only predictive echographic factor of maintain of a good result (sinus rhythm) after cardioversion was a systolic velocity peak > 0.25 metir/sec.

[McCune-Albright syndrome associated with diabetes mellitus]. / Syndrome de McCune-Albright associé à un diabète sucré

McCune-Albright syndrome (MAS) consists of the triad of polyostotic fibrous dysplasia, cutaneous pigmentation, and multiple endocrine abnormalities. Type 1 diabetes mellitus is not included in MAS. We report the case of an 18-year-old girl who presented with McCune-Albright syndrome. The diagnosis was made by the presence of precocious puberty at the age of 6 years, cutaneous pigmentation, polyostotic fibrous dysplasia, and phosphate diabetes. Type 1 diabetes mellitus developed at the age of 16 years. We discuss this case, the relationship between type 1 diabetes mellitus and MAS, with a literature review.

[Evaluation of blood pressure control by ambulatory blood pressure monitoring and study of factors associated with poor blood pressure control in 300 treated hypertensive type 2 diabetic patients]. / Évaluation de l'équilibre tensionnel par la mesure ambulatoire de la pression artérielle et étude des facteurs associés à un mauvais contrôle tensionnel chez 300 diabétiques de type 2 hypertendus traités.

UNLABELLED: Hypertension is frequently associated with type 2 diabetes and is often difficult to control. AIM: Evaluate the frequency of controlled hypertension in our type 2 diabetic patients with known and treated hypertension and determine the factors associated with poor blood pressure control. SUBJECTS AND METHODS: Prospective study concerning 300 type 2 diabetic patients with a known and treated hypertension, sex-ratio: 0.64, mean age: 61.2±9.1 years (37-86). All subjects underwent physical examination, biological investigations and a 24 hours ambulatory blood pressure monitoring (ABPM). RESULTS: Hypertension was well controlled in 70 patients (23.3%). The concordance rate between clinical measure of blood pressure and ABPM was 70.3%. Subjects with uncontrolled hypertension were older (61.8±8.9 vs 59.1±9.3 years, P<0.05), more frequently of male sex (sex-ratio: 0.77 vs 0.34, P<0.01), smokers (36.4 vs 21.7%, P<0.05) and with abdominal adiposity (P<0.05). Duration of diabetes, body mass index and the frequency of peripheral neuropathy, retinopathy and coronary insufficiency were not different between the two groups. Diabetic nephropathy was more frequent (29.8 vs 16.1%, P<0.05) in the group with uncontrolled hypertension. Loss of circadian blood pressure rhythm was noted in 239 patients (79.6%) and it was more frequently observed in patients with uncontrolled hypertension (84 vs 66%, P<0.001). CONCLUSION: Our type 2 diabetic patients had a poorly controlled hypertension. Close monitoring of blood pressure with adjustment of antihypertensive treatment are necessary to improve cardiovascular prognosis of our patients.