diagnosis and management of severe hypercalcaemia a simplified approach - report of five cases

Hypercalcaemia, a common medical problem, can be a manifestation of various diseases. When severe, it can represent a medical emergency. Correct diagnosis is important to prevent unnecessary investigations and parathyroidectomies. We here present five patients with severe hypercalcaemia, most misdiagnosed for months or years before being referred to Sultan Qaboos University Hospital, Oman. We report how clinical examination, evaluation of fasting serum calcium, phosphate, creatinine and 24-hour urine calcium levels together with a review of their radiographics predicted the pathophysiology of the disorder and guided investigative procedures before hormone assays results were available

Clinically-defined maturity onset diabetes of the young in Omanis: absence of the Common caucasian gene mutations

We are seeing a progressive increase in the number of young patients with clinically defined maturity onset diabetes of the young [MODY] having a family history suggestive of a monogenic cause of their disease and no evidence of autoimmune type 1 diabetes mellitus [T1DM]. The aim of this study was to determine whether or not mutations in the 3 commonest forms of MODY, hepatic nuclear factor 4alpha [HNF4 alpha], HNF1alpha and glucokinase [GK], are a cause of diabetes in young Omanis. The study was performed at Sultan Qaboos University Hospital [SQUH], Oman. Twenty young diabetics with a family history suggestive of monogenic inheritance were identified in less than 18 months; the median age of onset of diabetes was 25 years and the median body mass index [BMI] 29 at presentation. Screening for the presence of autoimmune antibodies against pancreatic beta cells islet cell antibody [ICA] and glutamic acid decarboxylase [GAD] was negative. Fourteen of them consented to genetic screening and their blood was sent to Prof. A. Hattersley's Unit at the Peninsular Medical School, Exeter, UK. There, their DNA was screened for known mutations by sequencing exon 1-10 of the GCK and exon 2-10 of the HNF1alpha and HNF4alpha genes, the three commonest forms of MODY in Europe. Surprisingly, none of the patients had any of the tested MODY mutations. In this small sample of patients with clinically defined MODY, mutations of the three most commonly affected genes occurring in Caucasians were not observed. Either these patients have novel MODY mutations or have inherited a high proportion of the type 2 diabetes mellitus [T2DM] susceptibility genes compounded by excessive insulin resistance due to obesity

Multiple bone metastases in a patient with differentiated thyroid cancer [DTC]: complete resolution following thyroidectomy and four ablation doses of 1-131

Multiple bone metastases from a differentiated thyroid cancer are usually incurable. We report the case of a young Omani woman who presented with 8 discrete skeletal lesions three years after a total thyroidectomy. Following four ablation doses of I-131 she has remained in clinical and biochemical remission for over five years. An extraordinary aspect of this case was the persistent refusal of her husband to use contraception either for himself or his wife. This resulted in her treatment being delayed for more than 6 years during which time the patient delivered and breastfed four additional healthy babies

Familial mineralocorticoid induced hypertension in the Sultanate of Oman

In Oman, many hypertensive patients with a family history of the disease respond to treatment with spironolactone, a mineralocorticoid receptor [MC-R] blocking agent thus suggesting a high prevalence of mineralocorticoid [MC] induced disease. The aim of this study was to document the prevalence of MC induced disease in patients with a positive family history of hypertension [HTN]. Serum calcium, potassium, creatinine, aldosterone and renin levels were measured under standard conditions in all patients together with an abdominal ultrasound scan and an adrenal computed tomography [CT] scan in four patients. In this small study, we show that 18 of the 27 patients [66%] had undetectable [suppressed] renin levels with usually normal aldosterone values [14 patients] and respond to treatment with spironoactone. We suggest that MC induced hypertension is likely to be common in the Middle East. In evolutionary terms, this makes sense as the ability to conserve salt in hot climates might be expected to confer a definite survival advantage

Severe osteoporosis in childhood anorexia nervosa: Dramatic remineralisation of bone and vertebral body remodelling during recovery

At the age of 12 years a slightly overweight Omani girl started to diet and exercise excessively. This continued for 2 years and her weight fell from 32 to 16 kg accompanied by reddish discoloration of the hair and darkening of the skin due to severe protein calorie malnutrition. Anorexia nervosa [AN] was diagnosed and nasogastric feeding was started. This was complicated by severe transient refeeding oedema. After three weeks of this treatment the patient decided to eat normally. We first saw her six months later, at the age of fourteen and a half years complaining of backache. Examination revealed an intelligent prepubertal girl with a moderate kyphosis weighing 31 kg. Spinal radiographs revealed severe osteopenia and multiple wedge fractures. Her lumbar bone mineral density [BMD] was less than half that of her 12 and 15-year-old normal sisters. Supplemental calcium, multivitamins and low dose oestrogen was added to her normal family After one year, a dramatic improvement was observed; her height and BMD had increased by 10 cm and nearly 40 percent respectively and bone remodelling was observed evidenced by a relative increase in vertebral body height over width. This is the first reported case of AN in an Arabian child Severe osteoporosis is potentially reversible in young people

Malignant otitis externa and temporal bone osteomyelitis: Complete recovery following the adjunctive use of hyperbaric oxygen and antibiotics

Malignant otitis externa is an uncommon potentially fatal infection of the external ear caused by Pseudomonas aeruginosa. It occurs usually in elderly diabetics and is followed by rapid invasion of the deep periauricular tissue and bone leading to osteomyelitis. We present such a patient whose disease persisted inspite of two months antibiotic therapy until the concomitant use of hyperbaric oxygen therapy was given over a period of four weeks. Complete recovery followed

Paget's disease in a Bedouin: Successful management with calcitonin and sodium etidronate

We describe a Bedouin suffering from Paget's disease. This is the first reported case occurring in the Arabian peninsula. He responded successfully to treatment with salmon calcitonin initially and subsequently a combination of salmon calcitonin and sodium etidronate, both of which were withdrawn after the serum alkaline phosphatase returned to normal

High-dose iodine 131 treatment of hyperthyroidism: experience at King Faisal Specialist Hospital and Research Centre

We have treated 186 Saudi patients [110 females, 76 males] with hyperthyroidism in the last 10 years. Case records of 100 patients were randomly selected for review. The female: male ratio was 1.4:1. The thyroid gland was diffusely enlarged in 46%, small, nodular, or gritty in 46%, and impalpable in 8%. Thyroid scanning revealed diffuse isotope uptake in 40% and patchy uptake in 60%. Ablative doses of 10 or 15 mC[i] of iodine 131 were given to 78 patients. The patients who become hypothyroid have been followed for a median of 18 months. Of these, 37% were hypothyroid at 3 months, 58% at 6 months, 36% at 9 months, and 68% at 12 months. The clinical presentation of hyperthyroidism appears to differ in Saudi Arabia compared with Western countries. The female: male ratio is significantly lower [P< 0.001], and classical Graves' disease less frequent. In large countries where follow-up may be difficult, ablative radioiodine treatment and subsequent thyroxine replacement have advantages over other treatment