Severe Hypokalaemia as a Cause of Reversible Diabetes Mellitus.

Aims: To discuss the likelihood of severe hypokalaemia as a cause of reversible diabetes. Presentation of the Case: A 46 year old patient presented to the Accident and Emergency unit (A&E) with a history of polyuria and polydipsia of recent onset. He was severely hyperglycaemic (glucose = 40 mmol/L, HbA1c = 11%), hypokalaemic (serum potassium < 2.0 mmol/L) and hypertensive [Blood Pressure (BP) = 180/115]. Conn's syndrome was confirmed by finding a raised serum aldosterone (1650 pmol/L; normal value < 440 pmol/L), suppressed renin (< 0.2 ng/ml/h; normal range: 0.2-2.5 ng/ml/h) and a left sided adrenal tumour (2.0 x 2.0 cm) on CT scanning. He was managed initially with IV potassium and insulin (initially 100 units daily) together with oral potassium, spironolactone 100 mg daily, lisinopril 20 mg daily and amlodipine 10 mg daily. After six days his potassium was 3.4 mmol/L and the IV potassium infusion was stopped. Twelve days later his fasting blood glucose, serum potassium and BP's were normal and the insulin and antihypertensive medications, apart from spironolactone, were stopped. He was discharged on spironolactone alone for four months during which time his blood glucose, blood pressure, and serum potassium levels remained normal and his HbA1c had fallen from 11.0 to 5.2%. He then underwent successful laparoscopic adrenalectomy and his serum aldosterone came down to 127pmol/L (within normal range). Histology confirmed the diagnosis of a Conn’s tumour. Conclusion: Although hyperaldosteronism per se predisposes to diabetes we suspect that this patient’s rapidly reversible hyperglycaemia resulted primarily due to a failure of insulin secretion as a result of his severe potassium depletion.

Cushing’s Disease and High Dose Cabergoline Monotherapy: Rapid and Sustained Clinical and Biochemical Improvement, with Reversal of Diabetes, Hypertension and Infertility.

Aims: To assess the effects of high dose long term cabergoline monotherapy in a patient with Cushing's disease refusing any form of surgical intervention. Presentation of the Case: A 32-year-old Omani female with hypertension, diabetes mellitus and secondary infertility of 10 years and amenorrhoea of 2 years duration, was referred with recurrent thigh abscesses. She was on 100 units of mixed insulin in two divided doses, metformin 1 gm bd, lisinopril 20 mg od, amlodipine 10 mg od and indapamide 1.5 mg od ."She had all the features of Cushing’s syndrome, with a blood pressure (BP) of 180/110 mmHg, plethoric facies, central obesity and striae". Investigations revealed diabetes, HBA1c 10.7% and ACTH-dependant Cushing’s syndrome, "cortisol 720 nmol/L (normal <624) and ACTH 14.9 pmol/L. (normal 1.6-13.8)". The pituitary MRI and computerised tomographic ( CT) scans from neck to pelvis “ were normal” A neuroendocrine tumour (NET) was deemed unlikely as serum cortisol levels did not “suppress during by a 72 hours trial” of octreotide 100 mcg 8 hourly and her serum chromogranin- A level (CgA) was normal. A diagnosis of Cushing’s disease was made. She refused inferior petrosal sinus sampling (IPSS) and any form of surgery. A trial of cabergoline was agreed upon. Her response was dramatic: On 1 mg daily initially, the serum cortisol was normal after one week, and by 4 months her blood sugar and blood pressure were normal off all other medications. The HBA1c had fallen from 10.7% to 5.4%. Shortly afterwards she became pregnant and on a reduced dose of cabergoline (1.5 mg/week), she delivered a healthy full term baby, echocardiography was normal in both mother and baby. She has now been in complete remission for more than 4 years on cabergoline 0.5 mg 3 times a week without any side effects. Conclusion: This case provides an example of successful acute and sustained primary “monotherpy” with initially high dose cabergoline in Cushing’s disease. The additional positive metabolic effects and the lack of significant side effects makes high dose cabergoline monotherapy an attractive first or second line treatment for patients with Cushing's disease.

Peak Bone Mineral Density Levels in Normal Omanis, a Pilot Study.

Aims: To determine normal peak bone mineral density (PBMD) values in a cohort of healthy Omanis. Study Design: Cross-sectional study. Place and Duration of the study: in the Departments of Nuclear Medicine and Medicine at Sultan Qaboos University Hospital in Oman between 2012 and 2013. Methodology: Omani employees aged between 25 to 34 years at Sultan Qaboos University Hospital (SQUH) were randomly chosen and invited to participate. Fifty normal males and 50 females were studied. Their fully informed consent was obtained to establish PBMD values using dual energy X-ray absorptiometry (DXA). Blood was also taken to determine their serum calcium, phosphate, alkaline phosphatase and parathyroid hormone (PTH) levels as well as a complete blood count (CBC), serum sodium, potassium and creatinine levels. Statistical analysis was done based on Hologic Delphi Reference Values on a reference curve generation using z-scores and the fitting a polynomial curve of third order. This data was interpolated, sampled and tested to verify the initial results. Results: Our results show that normal Omani PBMD values of L1-L4 in women were 0.94  0.11 and in men 0.99  0.12 g/cm2. These are significantly lower than those of a normal Caucasian population by 26.5% in women P-value (<.001) and by 23.8% in men P-value (<.001). Only three subjects had values on or slightly above the mean Caucasian level but sixteen had values on or below -2SD. The blood tests were within the normal range in all subjects. Conclusion: Omani mean PBMD values obtained in this study are substantially lower than Caucasian values. To avoid the use of inappropriate anti-resorptive therapy we should consider revising our reference range. We recommend using normal Asian reference values as they are almost identical to those obtained in this study until a normal reference range is established for this country.

Chromogranin-A Levels and Refractory Bronchospasm in Interstitial Lung Disease: A Preliminary Report on the Favourable Response to Octreotide.

Aims: A wide variety of lung pathologies are associated with pulmonary neuroendocrine cell hyperplasia (PNECH). Presentation of Case: We report two patients with interstitial lung disease (ILD), severe persistent bronchospasm not responding to conventional therapy, and raised chromogranin-A (Cg-A) levels. A neuroendocrine tumour (NET) was suspected and both were given a therapeutic trial of octreotide. This led not only to a dramatic clinical improvement but also to the normalization of Cg- A levels. Cg-A levels were elevated in 6 additional patients with interstitial involvement but without bronchospasm. The raised Cg-A levels in these 8 patients and the response to octreotide in two who had bronchospasm supports a diagnosis of PNECH in ILD. Conclusion: Cg-A levels should be measured in all patients with ILD. An octreotide trial should be considered in symptomatic patients with interstitial lung disease and elevated chromogranin levels.