Central diabetes insipidus following COVID-19 mRNA vaccination: a case report / 고신대학교의과대학학술지

The coronavirus disease 2019 (COVID-19) has been a major public health emergency worldwide. Vaccines were rapidly developed and approved to prevent the spread of viral infection. However, various side effects of the COVID-19 messenger RNA (mRNA) vaccines have been reported after their commercialization. A 24-year-old man visited our emergency department with polyuria and polydipsia that occurred after he received a COVID-19 mRNA vaccine 10 days beforehand. The initial laboratory findings showed very low urine osmolality with hyperosmolar hypernatremia. Based on these findings, diabetes insipidus was suspected, and sella magnetic resonance imaging showed an enlarged pituitary gland and the absence of posterior pituitary higher intensity. After 12 hours of using oral desmopressin acetate, urine volume decreased, and after 5 days of administration, serum electrolyte and serum osmolality improved. This case report of diabetes insipidus occurring after vaccination with the BNT162b2 mRNA COVID-19 vaccine is presented as a reminder that close monitoring is necessary for patients with polyuria and polydipsia after vaccination.

A Position Statement of the Utilization and Support Status of Continuous Glucose Monitoring in Korea / 임상당뇨병

The accuracy and convenience of continuous glucose monitoring (CGM), which efficiently evaluates glycemic variability and hypoglycemia, are improving. There are two types of CGM: professional CGM and personal CGM. Personal CGM is subdivided into real-time CGM (rt-CGM) and intermittently scanned CGM (isCGM). CGM is being emphasized in both domestic and foreign diabetes management guidelines. Regardless of age or type of diabetes, CGM is useful for diabetic patients undergoing multiple insulin injection therapy or using an insulin pump. rt-CGM is recommended for all adults with type 1 diabetes (T1D), and can also be used in type 2 diabetes (T2D) treatments using multiple insulin injections. In some cases, short-term or intermittent use of CGM may be helpful for patients with T2D who use insulin therapy other than multiple insulin injections and/or oral hypoglycemic agents. CGM can help to achieve A1C targets in diabetes patients during pregnancy. CGM is a safe and cost-effective alternative to self-monitoring blood glucose in T1D and some T2D patients. CGM used in diabetes management works optimally with proper education, training, and follow up. To achieve the activation of CGM and its associated benefits, it is necessary to secure sufficient repetitive training and time for data analysis, management, and education. Various supports such as compensation, insurance coverage expansion, and reimbursement are required to increase the effectiveness of CGM while considering the scale of benefit recipients, policy priorities, and financial requirements.

Anxiolytic Action of Taurine via Intranasal Administration in Mice

Taurine has a number of beneficial pharmacological actions in the brain such as anxiolytic and neuroprotective actions. We explored to test whether taurine could be transported to the central nervous system through the intranasal route. Following intranasal administration of taurine in mice, elevated plus maze test, activity cage test and rota rod test were carried out to verify taurine’s effect on anxiety. For the characterization of potential mechanism of taurine’s anti-anxiety action, mouse convulsion tests with strychnine, picrotoxin, yohimbine, and isoniazid were employed. A significant increase in the time spent in the open arms was observed when taurine was administered through the nasal route in the elevated plus maze test. In addition, vertical and horizontal activities of mice treated with taurine via intranasal route were considerably diminished. These results support the hypothesis that taurine can be transported to the brain through intranasal route, thereby inducing anti-anxiety activity. Taurine’s anti-anxiety action may be mediated by the strychnine-sensitive glycine receptor as evidenced by the inhibition of strychnine-induced convulsion.

Dynamic postural stability in patients with diabetic peripheral neuropathy and relationship to presence of autonomic neuropathy

@#Diabetic neuropathy is a common complication that can negatively influence balance and is a major cause of falls. We evaluated the association between postural sway and diabetic autonomic neuropathy (DAN) among patients with diabetic peripheral neuropathy (DPN). Patients with DPN documented by typical symptoms with abnormal results of nerve conduction study were included and postural stability was assessed using dynamic posturography. Composite autonomic scoring scale (CASS) score was calculated by evaluating sudomotor, cardiovagal, and adrenergic functions. CASS score ≥2 indicated DAN and the severity of DAN was indicated by the CASS scores divided into three subscales of 10-point total CASS: none or mild autonomic failure (0-3), moderate failure (4-6), and severe failure (7-10). A total of 34 patients comprised the DAN group (n=19) and non-DAN group (n=15). Patients with DAN had higher prevalence of diabetic retinopathy(p=0.011), higher urine albumin-creatinine ratio (p = 0.009), and lower HbA1c levels (p<0.001) than those with non-DAN. With regard to dynamic postural instability, the presence (p=0.025) as well as the severity of DAN (p<0.05) was associated with postural instability in the eyes-opencondition. Interestingly, the poorer dynamic postural instability in moderate/severe DAN compared to mild DAN was observed only in medio-lateral direction and this association remained significant after adjusting for age, sex, and glycemic control state (HbA1c). In patients with DAN accompanied by DPN, the dynamic postural instability was affected by visual feedback and medio-lateral directional instability was closely associated with the severity of DAN.

Fulminant Type 1 Diabetes Developing during Pregnancy in Patient with Gestational Diabetes Mellitus / 대한내과학회지

A 32-year-old pregnant woman (34 + 5 weeks) was admitted with dizziness, nausea, and vomiting. Previously, she was diagnosed with gestational diabetes mellitus at 28 weeks with 100 g-OGTT and insulin therapy was started. Her average fasting glucose level was 97 mg/dL and postprandial 1-hour glucose level was 130 mg/dL with basal-bolus insulin therapy (total dose of 28-30 IU/day). At 34 + 0 weeks of gestational age, polyuria and unexpected weight loss (2 kg/week) with hyperglycemia occurred, and total dose of daily insulin requirement was increased up to 50 IU/day. At admission, her serum glucose level was high (502 mg/dL), and urinalysis revealed ketonuria +3. Arterial blood gas analysis revealed pH of 6.83, pCO2 of 9 mmHg, and bicarbonate of 2 mmol/L with an anion gap of 23.5 mmol/L. The diagnosis of diabetic ketoacidosis was established and emergency caesarean section was conducted due to fetal distress. She was finally diagnosed with fulminant type 1 diabetes mellitus, and multiple daily insulin injection therapy was continued after delivery.

Follow-up of thyroid ultrasonography in patients with hemodialysis / 영남의대학술지

BACKGROUND: Chronic kidney disease is considered a risk factor for thyroid nodules as well as thyroid dysfunction such as hypothyroidism. Among patients on hemodialysis, we assessed the size of thyroid nodule and goiter at baseline and 1 year later with ultrasonography. METHODS: We prospectively selected 47 patients with hemodialysis at January 2012 and reviewed their medical records. We checked goiter and thyroid nodules at January 2012 and December 2012. RESULTS: In the hemodialysis patients (n=47), 24 patients (51.1%) had thyroid nodules and 33 patients (70.2%) had goiter at baseline. Parathyroid hormone (PTH) was higher in patients with thyroid nodules (204.4±102.9 vs. 129.9±93.6 pg/mL, p=0.01). Thyroid ultrasonography was conducted in 29 patients after 1 year. The thickness of the thyroid isthmus increased (2.8±1.6 vs. 3.2±1.9 mm, p=0.003), but the number of nodules did not change (1.2±1.9 vs. 1.4±2.0, p=0.109). PTH was associated with the enlargement of thyroid nodules significantly through logistic regression analysis. CONCLUSION: Thyroid goiter and nodules in hemodialysis patients were more prevalent than in the general population. PTH influenced the production of thyroid nodules in hemodialysis patients. Regular examination with thyroid ultrasonography and thyroid function test should be considered in hemodialysis patients.

Follow-up of thyroid ultrasonography in patients with hemodialysis / 영남의대학술지

BACKGROUND: Chronic kidney disease is considered a risk factor for thyroid nodules as well as thyroid dysfunction such as hypothyroidism. Among patients on hemodialysis, we assessed the size of thyroid nodule and goiter at baseline and 1 year later with ultrasonography.METHODS: We prospectively selected 47 patients with hemodialysis at January 2012 and reviewed their medical records. We checked goiter and thyroid nodules at January 2012 and December 2012.RESULTS: In the hemodialysis patients (n=47), 24 patients (51.1%) had thyroid nodules and 33 patients (70.2%) had goiter at baseline. Parathyroid hormone (PTH) was higher in patients with thyroid nodules (204.4±102.9 vs. 129.9±93.6 pg/mL, p=0.01). Thyroid ultrasonography was conducted in 29 patients after 1 year. The thickness of the thyroid isthmus increased (2.8±1.6 vs. 3.2±1.9 mm, p=0.003), but the number of nodules did not change (1.2±1.9 vs. 1.4±2.0, p=0.109). PTH was associated with the enlargement of thyroid nodules significantly through logistic regression analysis.CONCLUSION: Thyroid goiter and nodules in hemodialysis patients were more prevalent than in the general population. PTH influenced the production of thyroid nodules in hemodialysis patients. Regular examination with thyroid ultrasonography and thyroid function test should be considered in hemodialysis patients.

Predictive Factors for the Therapeutic Response to Concomitant Treatment with DPP-4 Inhibitors in Type 2 Diabetes with Short-Term Follow-Up / 고신대학교의과대학학술지

OBJECTIVES: To evaluate the efficacy and predictive factors of Dipeptidyl peptidase-4 (DPP-4) inhibitors in type 2 diabetes mellitus (T2DM) patients who were not well controlled with other oral antidiabetic drugs or insulin in real clinical practice. METHODS: From December 2012 to January 2014, retrospective longitudinal observation study was conducted for patients with T2DM who were not reached a glycemic target (glycated hemoglobin [HbA1c] > 6.5%) with other oral antidiabetic drugs or insulins. Type 1 diabetes or other types of diabetes were excluded. Responders were eligible with decreased HbA1c from baseline for more than 5% during follow up period. RESULTS: Of total 135 T2DM patients having an average 9.0 months follow-up period, 84 (62.2%) of patients were responder to DPP-4 inhibitors. After concomitant treatment with DPP-4 inhibitors, patients had a mean decrease in HbA1c of 0.69 ± 1.3%, fasting plasma glucose of 13 ± 52 mg/㎗, and postprandial plasma glucose of 29 ± 85 mg/㎗ from baseline (all P < 0.05). Independent predictive factor for an improvement of glycemic control with DPP-4 inhibitors was higher baseline HbA1c (odds ratio 2.07 with 95% confidence interval 1.15-3.72) compared with non-responders. CONCLUSIONS: A clinical meaningful improvement in glycemic control was seen when DPP-4 inhibitors were added to other anti-diabetic medications in patients with T2DM regardless of age, duration of T2DM, type of combination treatment regimen. Patients who had higher HbA1c were more easily respond to DPP-4 inhibitors treatment in short-term follow-up period.

A Case of Cerebral Venous Thrombosis in a Patient with Graves' Disease / 고신대학교의과대학학술지

Superior sagittal sinus thrombosis is an uncommon disease, and 25% of cases are considered to be idiopathic. Hypercoagulability, local bloodstream stasis, and vessel wall abnormalities may contribute to the development of this condition. The thyrotoxic phase of Graves’ disease is associated with venous thrombosis caused by hypercoagulability, which is in turn induced by increased levels of homocysteine and factor VIII and decreased fibrinolytic activity. Here, we report the case of a 39-year-old male who presented with superior sagittal sinus thrombosis and concomitant hyperthyroidism.

Recovery of Adrenal Function in Patients with Glucocorticoids Induced Secondary Adrenal Insufficiency

BACKGROUND: The chronic use of glucocorticoids (GC) suppresses function of the hypothalamic-pituitary-adrenal axis and often results in secondary adrenal insufficiency (AI). The present study aimed to determine the recovery rate of adrenal function in patients with secondary AI within 1 to 2 years and to assess the factors predictive of adrenal function recovery. METHODS: This was a retrospective observational study that enrolled patients diagnosed with GC-induced secondary AI between 2007 and 2013. AI was defined by peak serum cortisol levels <18 µg/dL during a standard-dose short synacthen test (SST). A follow-up SST was performed after 1 to 2 years, and responders were defined as those with adrenocorticotropic hormone (ACTH)-stimulated peak serum cortisol levels ≥18 µg/dL. RESULTS: Of the total 34 patients diagnosed with GC-induced secondary AI at first, 20 patients (58.8%) recovered normal adrenal function by the time of the follow-up SST (median follow-up period, 16.5 months). Although the baseline serum ACTH and cortisol levels at the first SST did not differ between responders and non-responders, the incremental cortisol response during the first SST was higher in responders than that of non-responders (7.88 vs. 3.56, P<0.01). Additionally, higher cortisol increments during the first SST were an independent predictive factor of the adrenal function recovery (odds ratio, 1.58; 95% confidence interval, 1.02 to 2.46; P<0.05). CONCLUSION: In the present study, adrenal function recovery was achieved frequently in patients with GC-induced secondary AI within 1 to 2 years. Additionally, an incremental cortisol response at the first SST may be an important predictive factor of adrenal function recovery.

Current Antiplatelet Treatment Strategy in Patients with Diabetes Mellitus

Patients with diabetes mellitus (DM) have accelerated atherosclerosis with an increased risk for atherothrombotic cardiovascular complications. A state of high platelet reactivity and activation, hypercoagulability (prothrombotic state) and a subdued response to standard antiplatelet agents may explain high rate of adverse cardiovascular events in patients with DM. Several antithrombotic treatment strategies have been developed to control the prothrombotic state in patients with DM: dose modification of commonly used agents; use of potent agents; and addition of a third antithrombotic drug (triple therapy) to commonly prescribed dual antiplatelet therapy of aspirin and a P2Y12 inhibitor. The present review aims to provide an overview of the current knowledge on platelet abnormalities in patients with DM, focusing on the challenges and perspectives of antiplatelet treatment strategies in this population.

The Effect of Brief Thyroid Functional Changes on Arterial Stiffness in Patients Who Preparing Radioactive Iodine Administration

BACKGROUND AND OBJECTIVES: Abnormal thyroid function influences the cardiovascular system. In particular, brief thyroid functional change due to levothyroxine (LT4) suppression therapy and withdrawal in papillary thyroid cancer (PTC) patients can affect cardiovascular system and other biochemical markers. However, the effect of brief thyroid functional change on arterial stiffness has not been evaluated. Therefore, we evaluated the changes in arterial stiffness according to short-term thyroid hormone levels in patients who underwent total thyroidectomy and radioactive iodine (RAI) therapy for PTC. MATERIALS AND METHODS: Patients with PTC (n=17; 15 females, mean age 52 years) who underwent total thyroidectomy and RAI therapy were enrolled in this study. The arterial stiffness was evaluated using the corrected augmentation index for heart rate (AI@75) and brachial-ankle pulse wave velocity (BaPWV). Serum thyroid hormone levels and arterial stiffness parameters were checked three times consecutively: the day before thyroidectomy (Visit 1; baseline euthyroid state), after LT4 withdrawal (Visit 2; pre-RAI hypothyroid state) and 4 weeks after RAI (Visit 3; post-RAI thyrotoxic state). Biochemical markers, which can influence the arterial stiffness, were also measured. RESULTS: The heart rate, AI@75 and serum thyroid hormone levels changed significantly at each visit. BaPWV was not significantly changed. Changes in AI@75 correlated with systolic blood pressure (SBP), serum thyroid hormone levels, total cholesterol and high density lipoprotein cholesterol in univariate analysis. In multivariate analysis, SBP was the independent factor for AI@75 changes. CONCLUSION: These results suggest that brief thyroid functional changes can influence AI@75. And SBP was important factor for AI@75 change.

The Change of Thyroid Stimulating Hormone Values of Healthy Subjects According to Temperature and Aging / 고신대학교의과대학학술지

OBJECTIVES: We conducted a study to investigate the normal range for TSH and within-individual variations of TSH according to temperature and aging. PATIENTS AND METHODS: We enrolled patients who underwent periodic medical examinations five times over a six year period (2007.8~2013.6). Anthropometric data and thyroid ultrasonography were evaluated, and serum TSH, T3, and T4 were assayed. RESULTS: Subjects were 19-64 years old, 120 were female, and 208 were male. Reference ranges for TSH were 0.53-4.94 mIU/L in the first test, 0.49-5.61 mIU/L in the second test, 0.46-6.06 mIU/L in the third test, 0.48-5.99 mIU/L in the fourth test, and 0.52-6.3 mIU/L in the fifth test. When the TSH level was analyzed according to temperature and sex, mean TSH was higher in months in which the average monthly temperatures were below 10degrees C in Jinju, Gyeongnam and female. The aging and low temperatures are associated with increased serum TSH concentrations in the within-individual. CONCLUSIONS: This study showed that aging is associated with increased serum TSH concentrations in the within-individual and serum TSH concentrations are different in the within-individual according to the temperature.

A Case with Empty Sella Syndrome Combined with Multiple Anterior Pituitary Hormone Deficiencies Presenting as Hypoglycemic Coma / 고신대학교의과대학학술지

A 55-year-old male was admitted to emergency department with a hypoglycemic shock of unknown origin. He was presented with tonic seizure activity after admission. Initial diagnostic procedure could exclude diabetes mellitus, drug side effects, and exogenous insulin application. Detailed evaluation of the patient's history revealed that the patient had experienced repeated hypoglycemic episodes for 2 years. He was diagnosed with hypothyroidism six years ago. Initial laboratory investigations revealed hypoglycemia, hyponatremia, and low plasma cortisol level (0.18 microg/dL). Sellar magnetic resonance imaging showed empty sella. Replacement therapy with hydrocortisone resulted in the improvement of clinical symptoms. Combined pituitary stimulation test with exception of hypoglycemia induced growth hormone and cortisol stimulation test was performed. The response of thyroid stimulating hormone, prolactin, follicle-stimulating hormone, and luteinizing hormone was normal. We report the case of empty sella syndrome associated with hypoglycemic shock due to with multiple anterior pituitary hormone deficiencies.

Acute Pancreatitis Induced by Methimazole Treatment in a 51-Year-Old Korean Man: A Case Report

Methimazole (MMI)-induced acute pancreatitis is very rare but severe adverse reaction. A 51-yr-old male developed a high fever, chills, and abdominal pain, two weeks after commencement on MMI for the treatment of Graves' disease. There was no evidence of agranulocytosis, and fever subsided soon after stopping MMI treatment. However, 5 hr after taking an additional dose of MMI, abdominal pain and fever developed again. His symptoms, biochemical, and imaging studies were compatible with acute pancreatitis. After withdrawal of MMI, he showed clinical improvement. This is the first case of MMI-induced acute pancreatitis in Korea. Clinicians should be aware of the rare but possible MMI-induced pancreatitis in patients complaining of fever and abdominal pain.

Acute Pancreatitis Induced by Methimazole Treatment in a 51-Year-Old Korean Man: A Case Report

Methimazole (MMI)-induced acute pancreatitis is very rare but severe adverse reaction. A 51-yr-old male developed a high fever, chills, and abdominal pain, two weeks after commencement on MMI for the treatment of Graves' disease. There was no evidence of agranulocytosis, and fever subsided soon after stopping MMI treatment. However, 5 hr after taking an additional dose of MMI, abdominal pain and fever developed again. His symptoms, biochemical, and imaging studies were compatible with acute pancreatitis. After withdrawal of MMI, he showed clinical improvement. This is the first case of MMI-induced acute pancreatitis in Korea. Clinicians should be aware of the rare but possible MMI-induced pancreatitis in patients complaining of fever and abdominal pain.

Delayed Surgery for Parathyroid Adenoma Misdiagnosed as a Thyroid Nodule and Treated with Radiofrequency Ablation

Primary hyperparathyroidism occurs as a result of isolated parathyroid adenoma in 80% to 85% of all cases. A 99mtechnetium (99mTc) sestamibi scan or neck ultrasonography is used to localize the neoplasm prior to surgical intervention. A 53-year-old female was referred for the exclusion of metabolic bone disease. She presented with low back pain that had persisted for the past 6 months and elevated serum alkaline phosphatase (1,253 IU/L). Four years previously, she had been diagnosed at a local hospital with a 2.3-cm thyroid nodule, which was determined to be pathologically benign. Radiofrequency ablation was performed at the same hospital because the nodule was still growing during the follow-up period 2 years before the visit to our hospital, and the procedure was unsuccessful in reducing the size of the nodule. The results of the laboratory tests in our hospital were as follows: serum calcium, 14.6 mg/dL; phosphorus, 3.5 mg/dL; and intact parathyroid hormone (iPTH), 1,911 pg/mL. Neck ultrasonography and 99mTc sestamibi scan detected a 5-cm parathyroid neoplasm in the left lower lobe of the patient's thyroid; left parathyroidectomy was performed. This case indicated that thyroid ultrasonographers and pathologists need to be experienced enough to differentiate a parathyroid neoplasm from a thyroid nodule; 99mTc sestamibi scan, serum calcium, and iPTH levels can help to establish the diagnosis of parathyroid neoplasm.

Concurrent Presence of Sjogren's Syndrome, Warthin Tumor, and MALT Lymphoma in a Parotid Gland and Hashimoto's Thyroiditis / 대한갑상선학회지

A 54-year-old female patient was referred due to a mass in the left salivary gland. A neck CT was performed and surgery was agreed due to a suspected Warthin tumor. The patient was also diagnosed with Sjogren's syndrome and Hashimoto's thyroiditis and treated. Warthin tumor and extranodal marginal zone B-cell lymphoma were also diagnosed after parotidectomy. The coexistence of the two autoimmune diseases, Hashimoto's thyroiditis and Sjogren's syndrome, has been reported, as has the coexistence of Warthin tumor and malignant tumor within a single salivary gland. However, these four diseases have not previously been reported in an individual patient. The authors treated a patient who was first diagnosed with Sjogren's syndrome and Hashimoto's thyroiditis, and subsequently also with Warthin tumor and extranodal marginal zone B-cell lymphoma after superficial parotidectomy. Therefore, this case is reported together with a related literature review.

Improvement of Glycemic Control after Re-Emphasis of Lifestyle Modification in Type 2 Diabetic Patients Reluctant to Additional Medication

PURPOSE: The aim of this study is to observe glycemic changes after emphasizing the importance of lifestyle modification in patients with mild or moderately uncontrolled type 2 diabetes. MATERIALS AND METHODS: We examined 51 type 2 diabetic patients with 7.0-9.0% hemoglobin A1c (HbA1c) who preferred to change their lifestyle rather than followed the recommendation of medication change. At the enrollment, the study subjects completed questionnaires about diet and exercise. After 3 months, HbA1c levels were determined and questionnaires on the change of lifestyle were accomplished. We divided the study subjects into 3 groups: improved (more than 0.3% decrease of HbA1c), aggravated (more than 0.3% increase of HbA1c) and not changed (-0.3%

Spurious Elevation of Glucose Concentration during Administration of High Dose of Ascorbic Acid in a Patient with Type 2 Diabetes on Hemodialysis

We describe herein a case of life-threatening hypoglycemia due to spurious elevation of glucose concentration during the administration of ascorbic acid in a type 2 diabetic patient. A 31-year-old female was admitted for proliferative diabetic retinopathy treatment and prescribed high dose ascorbic acid. During hospitalization, she suddenly lost her consciousness and her glucose concentration was 291 mg/dL, measured using self-monitoring blood glucose (SMBG) device, while venous blood glucose concentration was 12 mg/dL. After intravenous injection of 50% glucose solution, the patient became alert. We reasoned that glucose measurement by SMBG device was interfered by ascorbic acid. Physicians should be aware of this interference; high dose ascorbic acid may cause spurious elevation of glucose concentration when measuring with SMBG devices.