The Recurrence Rate of Graves' Disease among Patients with Subclinical Thyrotoxicosis after Initial Remission with Antithyroid Agents

BACKGROUND AND OBJECTIVES: The recurrence rate of patients with Graves' disease (GD) is estimated to be 50-55% after withdrawal of antithyroid drug therapy, and relapse is frequent in the first year after discontinuing the medication. Follow-up examination of these patients frequently reveals laboratory findings consistent with subclinical thyrotoxicosis in the first year after stopping the antithyroid agents. We investigated the risk of recurrence of GD among patients with resurfacing subclinical thyrotoxicosis state after remission of initial GD with antithyroid treatments. MATERIALS AND METHODS: We reviewed the patients diagnosed with GD who visited the Department of Endocrinology at two tertiary medical centers: Wonju Severance Christian Hospital and Gangneung Asan Hospital. We enrolled patients whose GD was completely treated after initial treatment with antithyroid agents who then developed subclinical thyrotoxicosis after discontinuation of antithyroid agents. RESULTS: We reviewed a total of 44 patients (29 females, 15 males; age, 48.93±18.04; range, 17-85 years). The recurrence rate was 27.3% (12/44 patients), and recurrence occurred 3 months to 12 months later resurfacing of subclinical thyrotoxicosis. Patients with recurred GD was significantly older than non-recurred patients (44.63±17.75 years vs. 58.58±15.48 years, p=0.02). Other clinical parameters measured at the time of initial diagnosis were not different between the two groups. CONCLUSION: The recurrence rate of GD in patients with resurfacing subclinical thyrotoxicosis after initial remission of the disease was less than 30%. A close monitoring is recommended in these subgroup patients, especially in older patients.

Encephalopathy Associated with Autoimmune Thyroid Disease Accompanied by Graves' Disease / 대한내과학회지

A patient with encephalopathy associated with autoimmune thyroid disease (EAATD), which is one of the most important differential diagnoses of treatable dementia, presents with various neurological symptoms, such as repetitive epileptic seizures, altered mental status, and cognitive dysfunction. Steroid treatment is effective for EAATD. The incidence of EAATD increases considerably with age, particularly in female patients. Most patients with EAATD have normal thyroid function test results or mild hypothyroidism. Patients with EAATD with Graves' disease are very rarely reported. Here, we report a case of a 63-year-old woman who complained of declining cognitive ability and ataxia. She was diagnosed with EAATD accompanied by Graves' disease. Her neurological symptoms improved after intravenous steroid administration.

Diabetic ketoacidosis with pulmonary thromboembolism / 영남의대학술지

Diabetic ketoacidosis (DKA), a fatal acute diabetic complication, is characterized by severe metabolic decompensation and intravascular volume depletion. These conditions may result in hypercoagulability and prothrombic state. Pulmonary thromboembolism (PTE) could be presented as an uncommon and life-threatening complication of DKA. Reported herein is a case involving a 54-year-old male patient who was admitted with DKA due to chronic alcohol consumption and stopping the intake of oral antidiabetic drugs. After low-molecular-weight heparin and warfarin treatment because of PTE during the DKA treatment, the patient's condition improved over the week that he was discharged on insulin and warfarin.

Thrombotic Thrombocytopenic Purpura and Rhabdomyolysis Associated With Acute Renal Failure in Hypothyroidism

Myopathy due to hypothyroidism can be detected in its early stage, but as the symptom is mild, complications such as rhabdomyolysis are rare. Thrombotic thrombocytopenic purpura in hypothyroidism is not yet clearly defined, and rare cases of it are reported. Reported herein is a case of thrombotic thrombocytopenic purpura and rhabdomyolysis associated with acute renal failure in hypothyroidism. A 70-year-old male was admitted to the hospital due to general weakness and muscle pain. Later, based on the laboratory findings, he was diagnosed with rhabdomyolysis associated with acute renal failure and thrombotic thrombocytopenic purpura combined with hypothyroidism. Initially, he was treated with fluid resuscitation due to rhabdomyolysis combined with acute renal failure but eventually, the levothyroxine supplement lowered the thyrotropin-stimulating hormone level. As a result, the patient recovered from rhabdomyolysis and thrombotic thrombocytopenic purpura without receiving plasmapheresis treatment.

A Case of Septo-Optic Dysplasia Resulting in Central Diabetes Insipidus and Nonobstructive Bilateral Hydronephrosis / 대한내과학회지

A 27-year-old male with nonobstructive hydronephrosis was referred from the urology department for polyuria evaluation and management. The patient was hospitalized for urinary tract infection and cystostomy was performed due to neurogenic bladder of unknown origin. The patient was of short stature and had visual impairment. From the interview, we discovered he had been suffering from polyuria and polydipsia for more than 20 years. Urine output was 13 L/day and urine osmolarity was 85 mOsm/kg. The results of a water deprivation test were consistent with central diabetes insipidus. Septo-optic dysplasia (SOD) was observed on brain magnetic resonance imaging (MRI). SOD is a very rare condition characterized by agenesis of the septum pellucidum or corpus callosum, which may cause optic nerve aplasia or hypoplasia, midbrain abnormalities and/or hypopituitarism. After desmopressin treatment, polyuria and hydronephrosis were improved. We report a case of a 27-year-old male diagnosed with SOD including diabetes insipidus, resulting in nonobstructive hydronephrosis.

Effects of Spironolactone and Losartan on Diabetic Nephropathy in a Type 2 Diabetic Rat Model

BACKGROUND: While there is an evidence that the anti-inflammatory properties of spironolactone can attenuate proteinuria in type 2 diabetes, its effects on vascular endothelial growth factor (VEGF) expression in diabetic nephropathy have not been clearly defined. In this study, we examined the effects of spironolactone, losartan, and a combination of these two drugs on albuminuria, renal VEGF expression, and inflammatory and oxidative stress markers in a type 2 diabetic rat model. METHODS: Thirty-three Otsuka-Long-Evans-Tokushima-Fatty (OLETF) rats were divided into four groups and treated with different medication regimens from weeks 25 to 50; OLETF diabetic controls (n=5), spironolactone-treated (n=10), losartan-treated (n=9), and combination of spironolactone- and losartan-treated (n=9). RESULTS: At week 50, the albumin-to-creatinine ratio was significantly decreased in the losartan and combination groups compared to the control OLETF group. No decrease was detected in the spironolactone group. There was a significant reduction in renal VEGF, transforming growth factor (TGF)-beta, and type IV collagen mRNA levels in the spironolactone- and combination regimen-treated groups. Twenty-four hour urine monocyte chemotactic protein-1 levels were comparable in all four groups but did show a decreasing trend in the losartan and combination regimen groups. Twenty-four hour urine malondialdehyde levels were significantly decreased in the spironolactone- and combination regimen-treated groups. CONCLUSION: These results suggest that losartan alone and a combined regimen of spironolactone and losartan could ameliorate albuninuria by reducing renal VEGF expression. Also, simultaneous treatment with spironolactone and losartan may have protective effects against diabetic nephropathy by decreasing TGF-beta and type IV collagen expression and by reducing oxidative stress in a type 2 diabetic rat model.

Aldose Reductase Inhibitor Ameliorates Renal Vascular Endothelial Growth Factor Expression in Streptozotocin-Induced Diabetic Rats

PURPOSE: The vascular endothelial growth factor (VEGF) expression of podocyte is one of the well-known major factors in development of diabetic nephropathy. In this study, we investigated the effects of aldose reductase inhibitor, fidarestat on diabetic nephropathy, and renal VEGF expression in a type 1 diabetic rat model. MATERIALS AND METHODS: Twenty four Sprague-Dawley male rats which were performed intraperitoneal injection of streptozotocin and normal six rats were divided into four groups including a normal control group, untreated diabetic control group, aldose reductase (AR) inhibitor (fidarestat, 16 mg.kg(-1).day(-1)) treated diabetic group, and angiotensin receptor blocker (losartan, 20 mg.kg(-1).day(-1)) treated diabetic group. We checked body weights and blood glucose levels monthly and measured urine albumin-creatinine ratio (ACR) at 8 and 32 weeks. We extracted the kidney to examine the renal morphology and VEGF expressions. RESULTS: The ACR decreased in fidarestat and losartan treated diabetic rat groups than in untreated diabetic group (24.79 +/- 11.12, 16.11 +/- 9.95, and 84.85 +/- 91.19, p < 0.05). The renal VEGF messenger RNA (mRNA) and protein expression were significantly decreased in the fidarestat and losartan treated diabetic rat groups than in the diabetic control group. CONCLUSION: We suggested that aldose reductase inhibitor may have preventive effect on diabetic nephropathy by reducing renal VEGF overexpression.

A case of acromegaly with empty sella syndrome associated with colonic neoplasm / 대한내과학회지

Acromegaly is a disorder caused by hypersecretion of growth hormone (GH) and insulin-like growth factor-1 (IGF-1). The most common cause of acromegaly is a pituitary GH-producing adenoma. Complete or partial disappearance of the adenoma, probably as a result of hemorrhage or infarction, may lead to empty sella. A case of acromegaly with empty sella syndrome has rarely been reported in Korea. It has been suggested that acromegaly might be associated with the incidence of colon neoplasm. Here, we describe a case of acromegaly with empty sella syndrome in a patient who was diagnosed with colon cancer.

Short Insulin Tolerance Test Can Determine the Effects of Thiazolidinediones Treatment in Type 2 Diabetes

PURPOSE: The short insulin tolerance test is a simple and reliable method of estimating insulin sensitivity. This study was designed to compare the insulin sensitizing effects of thiazolidinediones (TZDs) on the degree of insulin resistance, determined by a short insulin tolerance test (Kitt) in type 2 diabetic patients. PATIENTS AND METHODS: Eighty-three subjects (mean age = 57.87 +/- 10.78) with type 2 diabetes mellitus were enrolled and received daily one dose of rosiglitazone (4mg) or pioglitazone (15mg). The mean follow-up duration was 25.39 +/- 9.66 months. We assessed insulin sensitivity using HOMA-IR and the short insulin tolerance test before and after TZDs treatment. RESULTS: When we compared patients' characteristics before and after TZDs treatment, the mean fasting glucose level was significantly decreased (183.27 +/- 55.04 to 137.35 +/- 36.42mg/dL, p or = 2.5%/min; 3.50 +/- 0.75%/min to 2.75 +/- 1.12%/min, p = 0.002). CONCLUSION: The glucose lowering effects of TZDs by improving insulin resistance could be determined by using Kitt. However, Kitt may be a beneficial tool to determine TZDs' effects only when patients' Kitt values are less than 2.5%/min.

Relationship between Menopausal Status and Metabolic Syndrome Components in Korean Women / 당뇨병

BACKGROUND: Postmenopausal status is associated with a 60% increased risk for metabolic syndrome. It is thought to be associated with decreased estrogens and increased abdominal obesity in postmenopausal women with metabolic syndrome. The purpose of this study was to investigate the association between metabolic syndrome components and menopausal status. METHODS: A total of 1,926 women were studied and divided into three groups according to their menstrual stage (premenopausal, perimenopausal or postmenopausal). The presence of metabolic syndrome was assessed using the National Cholesterol Education Program's (NCEP) Adult Treatment Panel III criteria. RESULTS: The prevalence of metabolic syndrome was 7.1% in premenopause, 9.8% in perimenopause, and 24.2% in postmenopause. The strong correlation was noted between the metabolic syndrome score and waist circumference in postmenopause (r = 0.56, P < 0.01) and perimenopause (r = 0.60, P < 0.01). Along the menopausal transition, the risk of metabolic syndrome increased with high triglyceride after the age-adjusted (odds ratio (OR) 1.517 [95% confidence interval (CI) 1.014~2.269] in perimenopausal women and OR 1.573 [95% CI 1.025~2.414] in postmenopausal women). In addition, the prevalence of metabolic syndromeincreased in accordance with elevated alanine aminotransferase (ALT) and gamma-glutamyl transpeptidase (GGT) levels. CONCLUSION: Triglyceride and waist circumference were important metabolic syndrome components, though ALT and GGT may also be related for predicting metabolic syndrome during the transition to menopause.

A case of Hashimoto's thyroiditis coexisting with thyroid papillary and follicular carcinoma / 대한내과학회지

We report here on a rare case of papillary and follicular carcinoma of the thyroid gland that developed in a 31 years old woman who was previously diagnosed with Hashimoto's thyroiditis. Her chief complaint was a palpable neck mass. The antimicrosomal and antithyroglobulin antibody levels were elevated. Ultrasonography of the left thyroid gland revealed a 2.5x2.0 cm sized thyroid nodule. Fine needle aspiration biopsy of the thyroid nodule was done and this was diagnosed as Hashimoto's thyroiditis. There was no evidence of thyroid cancer. After 1 year, thyroid ultrasonography and biopsy were repeated for examining an enlarged thyroid nodule. Total thyroidectomy was then performed. The histopathologic examination revealed that the right and left thyroid glands were in accordance with the diagnosis of papillary and follicular cancer, respectively. Until now, no known case of simultaneous papillary and follicular carcinoma in Hashimoto's thyroiditis has been reported. This case suggests that adequate follow up for Hashimoto's thyroiditis patients with thyroid nodule may help the early detection and management of thyroid cancer.

A Case of Acute Perithyroiditis with Transient Thyrotoxicosis in Childhood / 대한내분비학회지

Acute thyroiditis is a rare disease because of the sufficient supply of blood vessels and lymphatics in thyroid tissue, the high concentration of iodide in the thyroid tissue and the nearly completely isolated structure of the thyroid gland from the surrounding tissue via its capsule. The most common route of infection is from a pyriform sinus fistula and then the inflammation spreads from the sinus to the perithyroidal space. Computed tomography (CT) and magnetic resonance imaging (MRI) can show a low echogenic mass encircling thyroid gland and swelling of the perithyroidal tissue in acute suppurative thyroiditis. We experienced a case of acute perithyroiditis with thyrotoxicosis that developed in a 13-year old boy and he was diagnosed by the CT findings. The patient had complained of a low graded fever and neck swelling. The laboratory diagnosis and clinical course was like that of subacute thyroiditis, but the CT finding showed a show low echogenic mass encircling the thyroid glands and swelling of the perithyroidal tissue. Therefore, we diagnosed this patient with acute perithyroiditis. After treatment with antibiotics, he displayed clinical improvement and was discharged.

A Case of Adrenocortical Adenoma Causing Subclinical Cushing's Syndrome Mistaken for Liddle's Syndrome / 대한내분비학회지

Subclinical Cushing's syndrome is defined as an autonomous cortisol hyperproduction without specific clinical signs of cortisol excess, but detectable biochemically as derangements of the hypothalamic-pituitary-adrenal axis function. We report a case of a 33-year-old woman with subclinical Cushing's syndrome caused by left adrenocortical adenoma, mistaken for Liddle's syndrome. The patient complained of fatigue. Laboratory findings showed metabolic alkalosis, hypokalemia, high TTKG (transtubular K concentration gradient), low plasma renin activity, and low serum aldosterone level, that findings implied as Liddle's syndrome. So we performed further study. Hormonal and radiologic studies revealed subclinical Cushing's syndrome with a left adrenal mass. The adrenal mass was resected and pathologically diagnosed as adrenocortical adenoma. After the resection of the left adrenal mass, patient's hormonal levels showed normal range.