Subclinical Hypothyroidism: Frequency, clinical presentations and treatment indications

Objective: To determine the frequency, modes of clinical presentation and indications for replacement therapy in a cohort of patients with subclinical hypothyroidism [SCH]

Methods: This study was conducted at the Endocrine and Diabetes Unit of Jinnah Postgraduate Medical Centre from September 2007 - October 2015. This was a retrospective chart analysis of prospectively collected data in which the medical records of 4448 patients who had presented to the Endocrine Clinic from 2007 to 2015 were reviewed. A total of 2760 [62.05%] patients were diagnosed with thyroid disorders, whereas 260 [9.42%] patients had SCH. The SCH patients were between the age of 12 to 70 years; TSH was >4mlU/l with normal levels of FT3 and FT4. Patients were enrolled using a predesigned structured proforma. Those having chronic systemic diseases were excluded from this study. SPSS 13 was used to evaluate the data

Results: Female patients comprised 93.8% [244 patients] of those with SCH, whereas only 6.2% [16 patients] were male. Common presenting symptoms were, lethargy in 146 patients [56.2%]; increase in weight in 102 patients [39.2%] and menstrual irregularities in 90 patients [34.6%]

TSH level of < 10mlU/l [4-10] was seen in 177 patients [68.1%] and 83 patients [31.9%] had TSH > 10mU/l. Thyroxine was given to 183 [70.4%] of these patients. Common treatment indications were TSH of > 10, which was seen in 83 patients [31.9%], subfertility in 32 patients [12.3%], troublesome symptoms suggestive of hypothyroidism in 31 patients [11.9%] and high titers of antibodies in 23 patients [8.8%]

Conclusion: SCH is frequently seen in our population, with most patients complaining of lethargy. The most common treatment indications were a TSH > 10mlU/l, whereas troublesome symptoms of hypothyroidism and subfertility were the common treatment indications in patients who had a TSH of < 10mlU/l

Delayed conventional DMARDs therapy is effective in Rheumatoid Arthritis

Objective: To determine the disease severity in patients with Rheumatoid Arthritis [RA], at baseline and the impact of treatment on disease activity [DA] after six months of disease modifying anti-rheumatic drugs [DAAARDs] therapy

Methods: This prospective study was conducted at the 'Rheumatology Clinic' of Jinnah Postgraduate Medical Centre [JPMC], Karachi, from June 2014 to May 2015. A total of 111 patients, with the diagnosis of RAwere included in the study. DA was calculated using 'Clinical Disease Activity Index [CDAI] score at base line and after 6 months of DMARDs therapy

Results: Out of 111 patients, 17 [15.3%] were male and 94 [84.7%] were female. The mean age was 37.16+/-11.3 years and the mean duration of joint pain was 3.8+/-3.6 years [median 2.5 years]. The mean Hb was 10.8+/-1.8 g/dl and the mean ESR at baseline was 59.63+/-30.9 mm/Hr. The mean initial CDAI score was 18.14+/-11.69; reflecting moderate to severe disease. Of all of these patients, 32 [28.8%] patients received monotherapy, 78 [70.3%] received dual therapy and 1[0.9%] was given triple DAAARDs therapy. The mean ESR was 39.5+/-27.31 mm/Hr, and mean CDAI was 7.36+/-7.8 with a median of 6.0 after 6 months of DAAARDs treatment

Conclusion: The CDAI score and the ESR reflected that majority of our patients were in remission or at low disease activity, after six months of DAAARDs therapy. It is possible to control DA in RA, in a low resource health care facility with conventional DAAARDs therapy. Continuity of treatment was ensured through motivation, regular supply of drugs and regular follow-up

Lipid abnormalities in patients with rheumatoid arthritis

Objective: To determine the frequency of dyslipidemia in patients with Rheumatoid Arthritis

Methods: This is a prospective, cross-sectional, observational study, conducted at the 'Rheumatology Clinic' of Jinnah Postgraduate Medical Center [JPMC], Karachi, from November 2013 to May 2014. A total of 200 patients of Rheumatoid Arthritis [RA], diagnosed according to the ACR/EULAR criteria 2010, were included in the study. Laboratory investigations including creatinine, ALT, CBC, TSH and fasting lipid profile [LDL, HDL, and Total cholesterol] were done for all patients

Results: Out of 200 patients, 23 [11.5%] were male and 177 [88.5%] were female. The mean age was 36.31 +/- 10.46 years and the mean duration of disease was 3.82 +/- 3.03 years. A total of 107 [53.5%] patients had dyslipidemia, and the commonest abnormality was a low HDL, seen in 83 [41.5 %] patients

Conclusion: Dyslipidemia was frequently observed in Rheumatoid Arthritis. This may be considered as a secondary impact of chronic inflammatory state, seen in RA. Lipid abnormalities should be sought at regular intervals, and corrective actions taken to mitigate increased cardiovascular disease risk

Ankylosing spondylitis: a rheumatology clinic experience

Objective: To determine the frequency, demographics, laboratory and radiological features in patients with Ankylosing Spondylitis

Methods: This is a retrospective analysis of prospectively collected data of patients with a diagnosis of Ankylosing Spondylitis [AS], based on Modified New York criteria. The study was conducted at the Rheumatology Clinic of Jinnah Postgraduate Medical Centre [JPMC], from February 2004 to February 2014. Detailed history, examination and laboratory investigations were recorded in a pre-designed structured proforma. The frequency, demographic characteristics, extra-articular features and associated comorbidities were studied

Results: A total of 603 patients were registered in our Rheumatology Clinic during this period, with a definitive diagnosis of inflammatory rheumatological disorders. Out of these, Ankylosing Spondylitis [AS] was diagnosed in 32 [5.3%] patients. 24 were male and 8 patients were female. The commonest affected age group was between 21-40 years. Majority of the patients belonged to Pathan ethnicity

Conclusion: The demographic features of AS are same as reported in earlier studies from other parts of the world. The predominance of AS in specific ethnic groups is a fact that needs to be studied. Larger studies are required for clarifying the triggers of this disease. It often leads to severe disability, hence an early diagnosis and prompt treatment is required for better disease control and quality of life

Clinical spectrum of disorders of sexual differentiation

Objective: To describe the mode of presentation and causes of the disorders of sexual differentiation in patients presenting in the Endocrine Clinic. Study Design: Observational study. Place and Duration of Study: The Endocrine and Diabetes Unit of Jinnah Postgraduate Medical Centre [JPMC], Karachi, from July 2012 to July 2014

Methodology: Patients with phenotypic, psychosocial gender confusion or absence of gender appropriate secondary sexual maturation were enrolled in the study. Patients having chronic systemic disease, as cause of delayed puberty, were excluded from the study. SPSS 13 was used to evaluate the data

Results: A total of 48 patients registered in the study with mean age of 19.9 +/- 8 years. Female gender was assigned to 28 [58.3%] of which 8 [28.57%] had genital ambiguity. Male gender was assigned to 20 [41.66%] patients at the time of birth and 7 [35%] of them had ambiguous genitalia. Karyotyping could be done in 36 [75%] patients of which 17 [47.2%] were females and 19 [52.7%] were males. Karyotypic gender of the 19 [48.57%] male patients was 46 XX, 46 XY and 47 XXY; in 4 [21.05%], 5 [26.3%] and 10 [52.6%] patients, respectively with 9 Klinfelter syndrome. Karyotypic gender of 17 [47.42%] female patients were 46 XX, 46 XY and 45 X0; in 5 [29.4%], 3 [17.64%] and 9 [52.9%] patients, respectively

Conclusion: Disorder of sexual development constitutes a small but difficult area of endocrinology with disastrous consequences, especially if assigned wrong sex at birth. Mode of presentation of these cases was diverse ranging from delayed puberty, to gender confusion, to pregnancy in a male. Eventually in an adult patient assignment or reassignment of gender identity was primarily the patient's prerogative

Frequency of nonalcoholic fatty liver disease and non-alcoholic steatohepatitis in patients with metabolic syndrome

Obesity and metabolic syndrome is an epidemic seen in the developed, as well as developing countries. Early recognition of this disorder may prevent major non-communicable diseases such as type 2 diabetes mellitus, hypertension and dyslipidemia. Non-alcoholic fatty liver disease and non-alcoholic steatohepatitis are the hepatic manifestations of metabolic syndrome. Prospective, observational, cross-sectional study was conducted in Endocrine Clinic of Jinnah Postgraduate Medical Centre, Karachi from June 2008 to September 2010. This study was conducted in patients suspected to have metabolic syndrome, as defined by International Diabetes Federation. Patients fitting the clinical consensus definition, having either palpable liver or ultrasound evidence of fatty infiltration were enrolled. Detailed history, physical examination, anthropometrics and biochemical measurements were recorded. Liver biopsies were performed where possible and were assessed according to Brunt et al's classification. A total of 101 patients who met the inclusion criteria were enrolled in the study. Liver biopsy was done in 31 patients. On biopsy, non-alcoholic fatty liver disease was confirmed in 28 [90%], non-alcoholic steatohepatitis in 18 [58%] and fibrosis in 8 [25%] patients. Of the biopsied cases, fatty infiltration on ultrasound was seen in 14 [87.5%] cases. Alanine aminotransferase was higher in patients having fibrosis. There was a direct correlation of histopathological changes with rising waist circumference, total cholesterol, triglyceride, low density lipoprotein and alanine aminotransferase. There was high prevalence of non-alcoholic fatty liver disease / non-alcoholic steatohepatitis in patients with metabolic syndrome and liver biopsy confirmed this in 90.3% patients who consented to this procedure

Male partial hypogonadotrophic hypogonadism with gynaecomastia and metabolic syndrome

The causal association of childhood obesity and hypogonadotrophic hypogonadism needs to be studied to unravel the cause and effect relationship between the two conditions. The relationship of hypogonadism to the Metabolic Syndrome [MetS] remains valid even when using different definitions of MetS, and following the patients prospectively for over 10 years. This is a case of 19 years male who presented with micropenis, marked gynaecomastia and weight gain. Childhood obesity and family history of diabetes predisposed him to future MetS. Presence of micropenis reflects intrauterine hypogonadotrophic hypogonadism. Both entities exacerbated each other

Virilization with adrenal myelolipoma, adrenal hyperplasia, and fibroadenoma of breast

Adrenal myelolipoma is a rare, benign and usually hormonally inactive tumour. We report a case of a young female who presented with hormonally active tumour causing virilization and associated type-2 Diabetes mellitus. Laparoscopic adrenalectomy was done after CT finding of a large left adrenal mass that was producing large amounts of androgens. Adrenal myelolipoma with cortical hyperplasia was diagnosed on histopathological examination. Her diabetes progressively regressed after the removal of tumour and glucose tolerance remained normal up to 1 year of follow-up after surgery and there was no recurrence of tumour. She also had a lump in her breast which proved to be a fibroadenoma. We report this case due to its rarity, multiplicity of tumours and adrenal cortical hyperplasia-presenting as an unusual cause of severe virilization

Parasite density and the spectrum of clinical illness in falciparum malaria

To determine the impact of percentage parasitemia and clinical features on morbidity and mortality in patients with P. falciparum malaria. Case series. Department of Medicine, Medical Unit II, Jinnah Postgraduate Medical Centre, Karachi, Pakistan from May to November 2005. Seventy-six adult patients of smear positive P. falciparum malaria were selected for the study. Parasite density was estimated on thin blood film and expressed as percentage of red blood cells parasitized. Patients were divided into three groups on the basis of parasite density. The data was analyzed on SPSS version 12. Results were expressed as percentages, mean and standard deviations. P-value <0.05 was taken as significant. Data of 76 study patients who fulfilled the inclusion criteria was analyzed on the basis of parasite density. Thirty-one [40.79%] patients had parasite density < 5%, 22 [28.95%] had parasite densities between 5% and 10% and 23[30.26%] patients had parasite density >10%. Comparative analysis of the groups showed that pallor, impaired consciousness, jaundice or malarial hepatitis, thrombocytopenia, acute renal failure, DIC, and mortality were all strongly associated with the density of Plasmodium falciparum malaria [p=0.001]. Parasite density was not related to age, gender and hepatosplenomegaly. High parasite density was associated with severe clinical illness, complications and mortality. Parasite counts of > 5% may be considered as hyperparasitaemia in this population of the world

Faiciparum malaria or fulminant hepatic failure?

Six cases of severe jaundice and encephalopathy due to falciparum hepatitis initially diagnosed as fulminant hepatic failure are reported. This rare presentation of falciparum malaria should be suspected in patients with persistent fever, jaundice, encephalopathy and hepatomegaly. The diagnosis should be further suspected when the liver function tests show a predominantly conjugated hyperbilirubinemia with only modest elevation of liver enzymes and alkaline phosphatase. Liver biopsy is valuable in establishing the diagnosis at all stages of the disease