A 53-year-old lady was referred to the Endocrinology department of our institute for management of postsurgical metabolic complaints following near total thyroidectomy done elsewhere for obstructive nodular goitre 2 weeks back.She was started on thyroxine of 150 mcg and calcium of 3 g in divided doses postoperatively.Her clinical evaluation showed her to have positive Chvostek's (video 1) and delayed Trousseau's sign.Her calcium was documented to be 1.4 mmol/l (normal range (NR) 2-2.5), phosphate 2.4 mmol/l (NR 0.8-1.5)and iPTH 0.5 pmol/l (NR 1.2-5.8).Her fT4 was 12.2 pmol/l (NR 10.3-23.2) and thyroid stimulating hormone was 3.8 mIU/l (NR 0.5-4.5).Her biopsy was confirmed to be nodular goitre.Postsurgical hypothyroidism with hypoparathyroidism was diagnosed.She was additionally started on calcitriol (0.25 mcg twice daily) and calcium dose modified (2 g in divided doses) and soon her Chvostek's sign resolved.High doses of calcium may not be sufficient in the management of hypoparathyroidism and often requires addition of active vitamin D.Chvostek's sign was attributed initially to increased sensitivity of the facial nerve to mechanical stimuli in idiopathic epidemic tetany. 1 2 Traditionally, it is elicited by tapping on the face at a point just anterior to the ear and just below the zygomatic bone. 3A positive response is represented by twitching of the ipsilateral facial muscles, suggesting neuromuscular excitability caused by hypocalcaemia.Although, classically described with hypocalcaemia due to hypoparathyroidism, it is also elicited in some young healthy children and alkalotic states as during vomiting and hyperventilation.It is very easy to test in clinical practice compared with Trousseau's sign and hence its clinical significance.
To study the effect of choosing ICMR reference values on the classification of bone mineral density in Indian patients.Retrospective analysis of Dual Energy X-ray absorptiometry (DEXA) and clinical data.Totally, 316 patients aged more than 65 years attending a tertiary care hospital in South India who underwent DEXA scan were included in the study.DEXA scan at femoral neck and lumbar spine.A total of 316 patients were studied. The mean age was 61.98 ± 7.66 years. There were 46.84% females and 53.16% males. The average BMI was 26.37 ± 4.51. Of these patients, 46 had history of hip fracture (14.55%). The adoption of the ICMR normative data resulted in a significant increase in T scores in both the hip (+0.51, P < 0.05) and the spine (+1.64, P < 0.01). The adoption of ICMR normative values, resulted in reduction of osteoporosis prevalence from 26.58% to 5.06%.There is a clinically significant reduction in diagnosis of osteoporosis with the adoption of ICMR reference standard. Clinicians should be recommended to use raw BMD values in gm/cm2 in FRAX calculation and avoid the use of T scores, to avoid overestimation of fracture risk. If our results are replicated, the implications are enormous - Osteoporosis is currently being over diagnosed.
Context: Recent studies provide ample evidence of the benefits of yoga in various chronic disorders. Diabetes mellitus is a group of metabolic diseases characterized by chronic hyperglycemia and Sandler coined the term "Diabetic Lung" for the abnormal pulmonary function detected in diabetic patients due underlying pulmonary dysfunction. Yoga therapy may help in achieving better pulmonary function along with enhanced glycaemic control and overall health benefits. Aim: To study the effect of adjuvant yoga therapy in diabetic lung through spirometry. Settings and Design: Randomized control trial was made as interdisciplinary collaborative work between departments of Yoga Therapy, Pulmonary Medicine and Endocrinology, of MGMC & RI, Sri Balaji Vidyapeeth Puducherry. Materials and Methods: 72 patients of diabetic lung as confirmed by spirometry (<70% of expected) were randomized into control group (n=36) who received only standard medical treatment and yoga group (n=36) who received yoga training thrice weekly for 4 months along with standard medical management. Yoga therapy protocol included yogic counseling, preparatory practices, Asanas or static postures, Pranayama or breathing techniques and relaxation techniques. Hathenas of the Gitananda Yoga tradition were the main practices used. Spirometry was done at the end of the study period. Data was analyzed by Student's paired and unpaired 't' test as it passed normality. Results: There was a statistically significant (P < 0.05) reduction in weight, and BMI along with a significant (P < 0.01) improvement in pulmonary function (FEV1, FVC) in yoga group as compared to control group where parameters worsened over study period. Conclusion: It is concluded from the present RCT that yoga has a definite role as an adjuvant therapy as it enhances standard medical care and hence is even more significant in routine clinical management of diabetes, improving physical condition and pulmonary function.
Multiple endocrine neoplasia (MEN) refers to the synchronous or metachronous development of tumours in two or more endocrine organs. MEN 2B is associated with medullary thyroid carcinoma and phaeochromocytoma along with classic morphological features such as marfanoid habitus and mucosal neuromas. Dominantly inherited germline mutations involving the REarranged during Transfection (RET) proto-oncogene are responsible. Affected patients usually present in childhood with thyroid mass or gastrointestinal symptoms. We describe the case of a 28-year-old man who presented to us with metastatic medullary thyroid carcinoma. He lacked the classic marfanoid habitus, but had mucosal neuromas and thickened corneal nerves. Whole-body metaiodobenzyl guanidine scan (MIBG) showed tracer uptake in adrenal and thyroid-confirming phaeochromocytoma and medullary thyroid carcinoma. This case exemplifies the late presentation of multiple endocrine neoplasia 2B and emphasises the need to screen all cases of medullary thyroid carcinoma for phaeochromocytoma.
The coronavirus (CoV) (severe acute respiratory syndrome [SARS]-CoV-2) has taken the world by storm. From humble origins in China's wet meat markets, the virus has crashed even the biggest stock markets. Every special group has only one question in mind "What does this virus mean to me?" From a thyroid point of view, little is known about the virus at this juncture; however, useful information can be parsed from the existing literature[1] to answer two important questions – the effect of the thyroid on virus (susceptibility) and the effect of the virus on the thyroid. Patients with thyroid disease, either hyperthyroidism or hypothyroidism, are not at increased risk of contracting the virus or developing complications. Neither thyroxine nor antithyroid drugs alter this risk, as they are not immunomodulators. While autopsy studies of patients with COVID-19 (the recognized term for CoV infection) are lacking, autopsy studies of SARS-CoV-1-affected patients show no involvement of thyroid follicular cells.[2] The virus is confined to the blood vessels that course through thyroid and has no predilection for thyroid cells per se direct viral effect on the thyroid, therefore seems unlikely. However, this does not rule out the indirect effects of the cytokine storm that a serious viral illness like COVID-19 can cause. Unfortunately, the looming threat of mortality, the difficulty in distinguishing thyroid illness from nonthyroidal illness, and the lack of even intermediate-term follow-up data make it hard to predict the indirect effect of systemic inflammatory response or the treatment. However, like any other viral illness, postviral thyroiditis is possible, which the treating physician should bear in mind. Favipiravir is another drug tried in the treatment of SARS-CoV-2 infection. Its effects on thyroid are not known. Remdesivir, a nucleotide analog used for the treatment of Ebola and Marburg viruses, has also been tried in SARS-CoV-2 infection. Its effect on thyroid is not known. Chloroquine, hydroxychlroquine, and azithromycin have been tried in COVID-19 with varying results. Chloroquine can potentially accelerate the metabolism of thyroxine and thus elevate thyroid-stimulating hormone.[3] However, this effect is likely to be modest. Table 1 summarizes the effect of various drugs used to treat SARS-CoV-2 on thyroid.Table 1: Effect of medications tried for COVID19 on ThyroidThe more important issue is whether a thyroid function assessment is indicated at all for suspected viral respiratory illnesses during the COVID-19 pandemic. Indiscriminate thyroid function testing only serves to add to the confusion and should therefore be eschewed. The SARS-CoV-2 virus itself may be novel (as evidenced by the initial moniker nCoV-novel CoV), but the approach to this virus with respect to thyroid is likely same as any other virus. Sound clinical judgment should form the basis of testing and treatment. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Sir, Thank you for showing interest in our recent article on Paget disease of bone (PDB). We have addressed your queries below. This disease appears to be more common in south India based on the number of cases and case series reported in the Indian literature so far (Ref: 8,9,11,17-64 in the article). Prevalence of any disease is generally considered to be overrated when published from an institute due to the possible referral bias. The cases reported in this paper were seen in private outpatient clinics of mainly two authors and moreover two major case series from India are also from Vellore (near Chennai, South India). In addition, as mentioned in our article, the series from North had pooled patients from all over India and not exclusively from that region. Thus we strongly feel that this disease probably has some predominance in south India. However, this needs more exploration with prospective collaborative studies from all zones. Bisphosphonates especially zoledronate has been shown to be very efficacious in PDB remission. This study reiterates the same observation. The patients included in this study had atleast 1 year follow up following zoledronate. The last patient was followed up in January 2020 and hence the time period was mentioned as until 2020. All the series from the west (17 cases), north (21 cases - out of which only 4 were from Chandigarh) and south (51 cases) were published in 2006, but the number of cases from south was strikingly more than the other zones. In 2018, another large series from Vellore (south) was published that excluded the cases from their previous series but there were no major case series from any other zone since 2006 other than isolated case reports. In our paper, we had mentioned as the largest cohort that has ever been studied in India since we had included 66 patients. FDG PET scan was not done in all patients as it is not required for diagnosis. But out of 66 patients in our series, 6% of patients underwent FDG PET scan for their symptoms during work up elsewhere and were incidentally diagnosed to have PDB and referred for management. Remission was defined as clinical improvement and normalisation of alkaline phosphatase which occurred in 61 out of 66 patients in 1 year and hence the remission percentage was calculated as 92.4%. We hope that your questions have been satisfactorily answered in our reply. We thank you again for giving us the opportunity. Dr. Shriraam Mahadevan Professor & Head, Department of Endocrinology, Sri Ramachandra Medical College and Research Institute, Porur, Chennai – 600116, Tamil Nadu, India Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Abstract Objectives Congenital adrenal hyperplasia (CAH) is an autosomal recessive disorder, that could rarely be due to 17 α-hydroxylase deficiency (17αOHD) and/or 17,20 lyase deficiency. Mutation of CYP17A1 gene causes deficiency of glucocorticoids and androgens but excess of mineralocorticoids. Lack of genital ambiguity in most children causes a delay in diagnosis even until puberty. Classical presentation with hypertension and hypokalemia is often not encountered. We intended to study the clinical, biochemical and genetic characteristics of children diagnosed with CAH due to 17αOHD. Methods Three children who were diagnosed with CAH due to 17αOHD in our institute and on follow up were included in this retrospective study. Clinical, biochemical and genetic characteristics of these children were retrieved and studied from electronic medical records. Results Two children were genetic females and one was genetic male, but all three were raised as females. All had hypertension at diagnosis except one but none had hypokalemia. All of them had mutation in the CYP17A1 gene. The two females responded well to oestrogen and progesterone and had adequate estrogenization clinically. Conclusions Even though CAH due to 17αOHD is quite rare, it should be considered while evaluating young individuals with hypogonadism, hypertension with or without hypokalemia. Lack of genital ambiguity and absence of classical signs at presentation does not rule out this not so uncommon condition and warrants follow up.
Sir, The risks of failure to provide stress dose of steroids have been well documented so that every endocrinologist spends adequate time to educate the patient regarding the importance of stress dose of steroids. There is a lack of clarity in the literature regarding the type of steroid in stress replacement. The traditional advice is to double or triple the dose of steroid. This is based on the assumption that during medical stress, since the adrenal is unable to augment cortisol production, the patient needs an increase in the dose of exogenous insulin. The normal cortisol production is only about 10 mg/day.[1] Since hydrocortisone is equivalent to cortisol, this would be around 10 mg of hydrocortisone per day. During stress, the serum cortisol increases partly due to Adreno corticotrophic hormone (ACTH) independent mechanism and partly due to decreased elimination.[2] So, there has been a trend away from excessive steroid supplementation even during stress, with a dose of 100 mg/day hydrocortisone for major surgery and 25-mg hydrocortisone at induction for minor surgery.[3] Recently, we encountered a 16-year girl with primary adrenal insufficiency. She had been prescribed 5 mg of prednisolone once daily and fludrocortisone 100 μg/day. She developed abdominal pain with nausea during follow-up and the doctor had increased the dose of prednisolone to 5 mg twice daily. After a month, she had presented to us with Cushingoid striae. The patient had been educated by a practitioner about the stress dose and the symptoms of cortisol deficiency which included nausea and vomiting. She doubled the dose of prednisolone (20 mg/day) whenever she had vomiting/nausea, which was around 3–4 days a week. Consequently, her effective hydrocortisone dose was 80 mg on those days. On endoscopy, she was found to have gastritis with stress ulcers, possibly induced by frequent intake of “stress” dose steroids. Evaluation for Helicobacter pylori was negative. We advised her to take hydrocortisone instead of prednisolone and educated regarding the stress dose of hydrocortisone. The patient was advised that “stress” has a different connotation in medicine. She was advised to increase her threshold for initiation of stress dose. On follow-up, the patient was better and had no further vomiting or abdominal pain. Our case illustrates the importance of patient education in adrenal insufficiency and underscores the pitfalls of using potent synthetic steroids for hormone replacement. Even in the background of misunderstanding, hydrocortisone would have had a better safety margin compared with prednisolone in our patient. Since the word “stress” has a different colloquial meaning, it is vitally important to clarify when and how to take extra dose of the steroid. Otherwise, the pendulum might swing to the other side, and the stress dose can end up causing distress. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
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