JCEM case reports最新文献

Maturity-onset diabetes of the young (MODY) represents 1% to 5% of patients with diabetes mellitus (DM), and numerous genes associated with MODY have been identified. While mutations of the insulin gene (INS) are known to cause permanent neonatal DM, rare disease-causing variants have also been found in MODY. These patients demonstrate variable clinical phenotypes-from milder forms requiring lifestyle or oral agent interventions to severe forms requiring lifelong insulin. We present a case of MODY arising from a novel disease-causing INS variant, in an adolescent with atypical features. He was obese with clinical evidence of insulin resistance, diagnosed with DM through opportunistic oral glucose tolerance testing. He developed symptomatic hyperglycemia with worsening glycemic trend, requiring treatment with high-dose insulin and metformin. After 2.5 years, his glycemic profile normalized following weight loss, and pharmacotherapy was discontinued. Targeted gene testing revealed a de novo novel missense variant in exon 2 of the INS gene (p.His29Tyr), confirmed using bidirectional Sanger sequencing. Insulin resistance in patients with MODY can worsen their clinical course and increase risks of long-term complications. Management of these patients should be individualized. This case highlights the utility of genetic testing in diagnosing uncommon and variable forms of MODY, particularly those with atypical features.

As the leading cause of hyperthyroidism, Graves disease (GD) does not often present with its classical triad of pretibial myxedema, goiter, and exophthalmos but instead is often recognized by various manifestations such as tachycardia, weight loss, jaundice, or dermatopathy and requires utmost clinical vigilance. Three treatment modalities for GD exist as antithyroid drugs (ATDs), radioactive iodine (RAI), and surgery, but each bears its own serious side effects. Furthermore, there have been several reports in the literature about ATD resistance that can complicate management. We describe a rare complex case of methimazole (MMI)-resistant GD in a 58-year-old woman with multiple comorbidities including heart failure, atrial fibrillation, liver cirrhosis, and hypertension. She presented with an initial complaint of diffuse swelling and was found to have severe thyrotoxicosis. Despite high doses of MMI, her thyroid function remained significantly elevated. Thyroid uptake and scan while on MMI showed high radioactive iodine uptake. After receiving RAI therapy, her thyroid function and bilirubin improved markedly, liver enzymes remained stable, and anasarca responded to diuretics. This case highlights the challenges in managing resistant GD and emphasizes the necessity of personalized treatment plans.

Patients with intermediate-risk thyroid cancers may undergo treatment with radioactive iodine-131 (I-131). They often undergo a pretreatment diagnostic iodine scan that typically shows areas of physiological uptake in the stomach, bladder, parotid glands as well as thyroid-remnant uptake and sites of metastatic disease. A 48-year-old woman with intermediate-risk papillary thyroid cancer with metastases to lateral compartment lymph nodes was found to have increased retention of iodine in the medial portion of her left orbit on the diagnostic scan. This was suggestive of preexisting nasolacrimal duct stenosis leading to retention of secretions in the lacrimal sac, raising concerns that the I-131 used in treatment would have delayed clearance that could further damage her lacrimal sac and eye. In consultation with ophthalmology, the patient received pretreatment azelastine and prednisolone drops and underwent treatment with radioactive iodine followed by saline lacrimal irrigation. Though she had subsequent eye pain and swelling necessitating repeated irrigation, the patient was able to undergo treatment for her papillary thyroid cancer and retained full function of her eye. This case highlights an approach that could be used for patients with nasolacrimal duct stenosis in whom radioactive iodine treatment is deemed beneficial.

Familial glucocorticoid deficiency (FGD) is a rare autosomal recessive disorder that causes isolated glucocorticoid deficiency. Here, we report on 22-month-old twin females of Native American ancestry who presented within 1 week of each other in adrenal crisis and were ultimately diagnosed with FGD because of a novel pathogenic variant, c1924G>T (p. Gly642*), in the nicotinamide nucleotide transhydrogenase (NNT) gene. This is the first report of FGD in a Native American population. The process of reaching the final diagnosis was complicated by several social determinants including geographic rurality, access to subspecialists, financial constraints, and challenges obtaining approval for genetic testing despite having insurance. Concerted efforts by the family, the local pediatrician, the Indian Health Service, and our tertiary care pediatric health system were required to reach the final diagnosis and develop an appropriate plan of care for the patients.

We report a case of new-onset, nonautoimmune, nonketotic, and noninsulinopenic type 2-like diabetes in a previously normoglycemic middle-aged man debuting after vaccination against COVID-19. This was not a mild or short-lived glucose intolerance, but severe and long-standing hyperglycemia with a high glycated hemoglobin level. However, the course of the diabetes was highly atypical and surprising in that it spontaneously disappeared after a few months and did not recur despite the patient being off all antidiabetic drugs for several months and without any changes in body weight or lifestyle. The mechanisms by which severe diabetes unfolded and later remitted in this patient remain elusive. Nonetheless, and notwithstanding whether or not there was a cause-and-effect relation between the vaccinations and his diabetes, the highly atypical course of spontaneously remitting nonautoimmune diabetes lends itself to mechanistic efforts aimed at understanding the biology and pathophysiology of insulin-producing β cells in health and disease. This case report should not be construed as vaccine skepticism or deter anyone, especially with diabetes/obesity, from vaccination against COVID-19. However, it calls for increased vigilance among health care providers for unusual and unexpected metabolic effects of COVID-19 and its vaccines.

Pituitary gigantism (PG) is a rare endocrine disorder that may present with multiple pituitary hormone abnormalities in pediatric patients. A hallmark presentation is accelerated growth due to growth hormone (GH) excess. Current treatment modalities include surgery, radiation, and medical therapy. We describe a 14-year-old girl who presented with recurrent slipped capital femoral epiphysis with GH excess and multiple other hormonal abnormalities. A sellar mass was identified on magnetic resonance imaging of the brain and was surgically resected. The pathology report was consistent with pituitary gland adenoma with mammosomatotrophs hyperplasia. Post surgery, serial laboratory results showed persistently elevated growth factor and GH levels, and residual tumor was reported on follow-up imaging. Even though we found limited data on the efficacy and safety of a long-acting somatostatin analogue, lanreotide, in the treatment of PG, a total of 4 doses of lanreotide successfully reduced growth factor and GH levels to normal ranges in our patient. Repeat imaging 5 weeks post discontinuation of lanreotide showed reduction of residual tumor volume. This case reveals that a short course of lanreotide may be used as an effective medical treatment in pediatric patients with PG who have residual disease after surgical intervention.

Primary malignant lymphomas originating in the adrenal gland, particularly of T-cell origin, are extremely rare. Here we present the primary unilateral adrenal anaplastic large cell lymphoma case. A 64-year-old Japanese male initially presented with fatigue and appetite loss. Computed tomography imaging revealed a unilateral adrenal mass with multiorgan invasion, posing challenges in differentiation from adrenal carcinoma. A biopsy from the metastatic site in the right lateral vastus muscle was obtained, and immunohistochemistry revealed that tumor cells were positive for CD30 and CD56 and negative for CD3, CD15, CD20, CD43, perforin, granzyme B, epithelial membrane antigen, and anaplastic lymphoma kinase. Ultimately, the patient was diagnosed with primary unilateral adrenal anaplastic large cell lymphoma. Although he achieved complete response to chemotherapy, he died 4 months after complete response due to cholecystitis and lymphoma recurrence.

A 49-year-old woman presented with irregular menstrual bleeding, elevated estradiol (E2) (665 pg/mL [2441.21 pmol/L]) (reference range [RR]: menstrual period [MP] 20-50 pg/mL; 73.42-183.55 pmol/L), unsuppressed follicle-stimulating hormone (FSH) (19.3 mIU/mL [19.3 IU/L]) (RR: MP 3.5-10.0 mIU/mL; 3.5-10.0 IU/L), and cystic ovarian enlargement (right ovary, 109 mL; left ovary, 146 mL). A 7-mm pituitary microadenoma was also observed, and 6 months after referral, endoscopic transsphenoidal surgery was performed, resulting in a diagnosis of FSH-producing pituitary adenoma. Nine months postoperatively, the ovarian cysts had markedly shrunk. Although FSH-producing pituitary adenomas are rare, approximately 64% of nonfunctioning pituitary adenomas are positive for gonadotropin immunostaining. FSH-producing pituitary adenomas are often endocrinologically silent, with symptoms typically triggered by pituitary tumor enlargement. Early diagnosis can be facilitated by measuring FSH and E2 levels in cases of irregular vaginal bleeding, abnormal menstruation, ovarian enlargement, ovarian hyperstimulation syndrome, or infertility. If E2 is elevated but FSH is not suppressed, pituitary magnetic resonance imaging should be performed to identify FSH-producing pituitary adenomas. In cases of FSH-producing pituitary adenomas, including microadenomas, symptoms may improve after tumor resection, making surgery the preferred treatment option.

The widespread use of statins for cardiovascular diseases has unveiled a new subset of inflammatory myopathy, immune-mediated necrotizing myopathy (IMNM). We describe below an unusual case of anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (anti-HMGCR) myopathy. A 64-year-old male individual with type 2 diabetes, hyperlipidemia, and coronary artery disease presented with progressive proximal muscle weakness and pain for 3 months. He took atorvastatin 40 mg for 4 years, which was discontinued due to elevated liver enzymes and resumed treatment with rosuvastatin 5 mg later due to worsening hyperlipidemia. Physical examination showed significant weakness of the hip, shoulder girdle, and biceps/triceps. Creatinine kinase (CK) was found to be 232.48 µkat/L (13 921 IU/L) (normal: 0.833-5.133 µkat/L; 50-308 IU/L). Electromyography and left vastus lateralis muscle biopsy showed findings of myonecrosis. Anti-HMGCR assay was strongly positive with antibodies > 200 chemiluminescent units (CU) (normal: 0-20 CU). He was started on prednisone followed by human-immunoglobulin (IVIG) which led to a decline in CK. Statin-induced necrotizing autoimmune myopathy (SINAM) is an exceptionally rare side effect of statins. Although statins come with a good side-effect profile, one should be aware of marked, persistent elevations in muscle enzyme levels. Prompt confirmation with antibody levels, drug discontinuation, and early initiation of immunosuppression can lead to good outcomes.