Cases

This 35 year- old- female elsewhere diagnosed having toxic multinodular goiter(TMNG) with biochemical confirmation of hyperthyroidism was put on methimazole without prior scintigraphy.Now i want to know whether its is really TMNG or nodular variant of Graves' disease.What is the best test to do without withdrawing the medication?
A:TSH-R antibodies
PN: Titer of TSH-R abs decrease during treatment with antithyroid drugs.So how much sensitive this test will be?
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A 60 year- old- man presented with left side hemiparesis due to bleed in right basal ganglionic area and he is found to have multinodular goiter.TSH was <0.01mIU/ml with normal FT4 & FT3.Heart rate was 90/minute & with no signs of TAO.TSH-R antibodies are negative.Patient's relatives refused scintigraphy due to economic constraints.On 6th day he developed atrial fibrillation which was controlled with amiodarone injection.Now whether he should be treated with antithyroid drugs and if so in what doses? PN: I have put him on methimazole 20 mg/day and patient is yet to turn for follow-up. ******************************************************************************
A 40 year- old- man diagnosed with tuberculosis meningitis when he had seizures & fever was treated subsequently with anti tuberculous drugs and prednisolone 30mg/day else where (which was tapered over 3 months).Now he presented with generalized weakness gradually increasing in severity after steroid withdrawal.Review of previous MRI brain shows partial empty sella turcica on 2 images done 6 months apart.ITT obviously is not a choice.250 microgm Synacthen stimulation test at 8 am shows basal value of 430 nmol/L with 30- & 6- minute values being 650 nmol/L and 740 nmol/L respectively.His TSH is 7.4 mIU/mL(N,0.3-5.0) with low FT4 and low-normal FT3. Serum TPO antibodies are within normal range.Serum IGF-1 was low compared to age and sex matched range.Other anterior pituitary hormones are within normal range and testosterone(8 am) was 18nmol/L.I have put him on LT4 and plan to repeat FT4 after 6weeks.My plan is to evaluate for GH deficiency.Doubt is about the role of IGF-1 as screening test in such setting where patient is clinically euthyroid but hormonal profile is of central hypothyroidism.Hypothyroidism irrespective of etiology is known to cause decreased GH secretion and impaired responsiveness to IGF-1 (but not impaired response of IGF-1 generation to GH). I think when FT4 is normal & repeat IGF-1 is still low, it indirectly indiactes damage to somatotrophs. PN: S. IGF-1 has no role as screening test for GH deficiency in the setting of hypothyroidism.We have to do thyroid function tests before embarking on IGF-1.Already it is well known fact that normal S.IGF-1 does not rule out GH deficiency.
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A 28-year-old female with complaints of hirsutism,oligomenorrhea of 15 years duration has been diagnosed as PCOS and on treatment with metformin,OCPs and laser treatment for hair, has no contributive family history.Her last menstrual period was 6 month back when on metformin.As PCOS is a diagnosis of exclusion baseline investigations were done. 8am 17-OHP was 30 ng/ml with E2 of 1200 pmol/L. S.LH & FSH were o.17 & o.o1 µIU/ml and S.PRL of 69.2 ng/ml with S.TSH of 2.24µIU/ml.Other investigations are normal.She recently noticed serous discharge from her breasts.To establish the diagnosis of LOCAH,current Williams doesnt recommend to do ACTH stimulation test once 17OHP levels are > 8 ng/ml;but as 2006 JCEM article by Dr.Maria New still advocates it.Any how my plan is to put her on dexamethasone 0.25mg bedtime,as she now desires fertility.Also i want her endometrium to be evaluated by a gynecologist.About breast discharge and slightly elevated PRL,this might be due to elevated E2 ( feature of such PCOS- & related states).Once she is on treatment,in due course i prefer to repeat E2 & PRL.
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A 64- year-old female has been consulting me for DM & hypothyroidism for past 3 days because her previous endocrinologist is sick. She has past history of rheumatic heart disease and subsequently detected to have DCMP and has been on diuretics and digoxin. She has under gone hysterectomy 20 years back for fibroid uterus and ovaries were preserved She is known case of Left side carcinoma of breast(Ductal ca),under gone radical mastectomy(1998) with ER & PR positivity but HER2 was not done. Subsequently she received local RT, Doxorubicin based CT (4 CYCLES) and thereafter treated with tamoxifen for 2 years(at NTR cancer center). She was off treatment for 2 years and when she complained of new growth on right breast,investigations else where done showed lung and bone metastases. CT guided FNAC from lung nodules evinced metastasis. The new growth was assumed to be metastasis and no local procedure was done. She has been on once monthly zolendronate 4mg and anastrozole 1mg/day for past 8 months. When I saw her for first time this was the basic picture and I asked her to undergo biopsy of right breast mass as in most cases its new primary event rather than metastasis and if she is found to have HER2 positivity can benefit from Trastuzumab. Also as response rate is better with letrozole compared to anastrozole, I asked her to switch the medications. MRI(with contrast) breast is advised. About DM,her s.creatinine is 1.6 mg/dl and is on insulin with TSH of 8.3 úIU/ml and LT4 dose was escalated. Also S.TPO abs are requested.
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Does this patient has insulinoma?
One of most common dilemmas an Endocrinoologist do face is differentiating psychiatric diseases which have predominant manifestations of giddiness&/or sweating from causes of hypoglycemia.In an outpatient practice,nearly 99% such cases being referred are of former type.But it is mandatory to establish or rule out endocrine diagnosis.The gold standard test is 72-hour fast for insulinoma,for which the doctor always has a needle of suspicion.But without good resident doctor & nursing care it is difficult to evaluate such cases and often patient's relatives complain that he is not able to tolerete after few hours and if not convinced properly ends in premature termination of test.The alternatives we have got are C-peptide suppression test,which carries a fear of irreversible damage that too with not so good diagnostic sensitivity.Another option is glucagon stimulation test,which is safer .But it is notoriously difficult to find a chemist in this country who sells that drug.I dont know why it has so much limited availability.Ofcourse, tolbutamide is out of question!!!