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.

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.