A follow up report: recurrent Cushing's syndrome after bilateral adrenalectomy.

This is a case report of a 23 year old female. She had earlier been diagnosed to have Cushing's syndrome due to macronodular adrenal hyperplasia, for which bilateral adrenalectomy was performed three years before. The initial full recovery was sustained for about one and a half years, following which there was progressive recurrence of obesity, hypertension and hypercalcaemia. Plasma cortisol concentrations were markedly elevated and a diagnosis of recurrent Cushing's syndrome was made. Pre-operative localisation of the source of hypercortisolism through intravenous urogram, abdominal ultrasonogram and computerised tomogram was unfruitful, thus an exploratory laparatomy was undertaken. At surgery, extensive and dense adhesions were seen which caused difficult dissection and accidental injury to the patient's liver and kidney, necessitating massive intra-operative blood transfusions. The patient died within two hours of recovery from anaesthesia of acute massive pulmonary embolism. We postulate that the recurrent Cushing's syndrome in this patient could have been due autografting of remnants of adrenal tissue within the abdominal cavity. A pre-operative localisation with radio-labelled cholesterol scanning may have made reoperation of the patient easier.

The effect of oral hypoglycaemic agents on dyslipidaemia in Nigerian patients with newly diagnosed non-insulin dependent diabetes mellitus--a prospective study.

Thirty-five patients with non-insulin dependent diabetes (NIDDM) were treated and followed up for 24 weeks. Six of whom were managed with diet and/or metformin, nine received glibenclamide, twelve had a combination of metformin and glibenclamide, while the remaining eight patients received metformin and/or some other type of sulphonylurea (chlorpropamide or glipizide). By an analysis of variance, the different drug regimes showed equivalent glycaemic controlling effects, but the influence on dyslipidaemia was variable within the treatment groups, while these changes were insignificant between the groups. It is thus concluded that commonly used oral hypoglycaemic agents do not adversely affect plasma lipid levels in Nigerian patients with NIDDM.

The effect of glycaemic control on the prevalence and pattern of dyslipidaemia in Nigerian patients with newly diagnosed non insulin dependent diabetes mellitus.

Dyslipidaemia (DL) is a common condition in patients with NIDDM, but its prevalence and the effect of glycaemic control on the disorder have only been scantily reported in Nigerians. The present study is therefore aimed at determining the effect of diabetic control on prevalence and pattern of DL in Nigerian patients with NIDDM. Thirty six diabetics were followed up for 24 weeks. Indices determined included anthropometric measurements, fasting (FBG) and two hour post prandial blood glucose (2 hours PPBG), together with glycated haemoglobin (GHb) levels, and fasting lipids at presentation, 12 and after 24 weeks of treatment. The prevalence rates of raised total cholesterol/high density lipoprotein cholesterol (TC/HDL) ratio reduced HDL-cholesterol and mixed DL decreased significantly between 0-week and 24 weeks of treatment (57.1% vs 14.3% 50% vs 11.4% and 44% vs 22.2% respectively, P < 0.001 for each). The proportion of patient with elevated low-density lipoprotein-cholesterol also decreased significantly from 21.4% at 0-week to 8.8 after 24 weeks (P < 0.025). On the other hand, the prevalence of hypercholesterolaemia and hypertriglycerilaemia were not significantly changed between 0 and 24 weeks (P > 0.05). Patients with DL despite treatment were characterised by higher FBG at 24 weeks of treatment compared with normolipidaemic patients (P < 0.001). It is concluded from this study that improved glycaemic control reduced some dyslipidaemia, and may therefore suffice to correct them in some Nigerian patients with NIDDM.

Congenital adrenal hyperplasia due to 11-hydroxylase enzyme deficiency in three siblings. A brief report.

To appraise clinicians of the presence of an uncommon cause of congenital adrenal hyperplasia in a Nigerian family, we present case reports of three siblings comprising two males (aged 4 years 10 months and 3 years 10 months) and a female (aged 16 months). The male patients presented with features of precocious pseudopuberty and had body weights and heights that were above the 95th percentiles on a standard growth chart. There was radiologic evidence for an advanced bone age of over 11 years in both patients, together with findings of sustained systemic hypertension. The female patient was discovered to have an abnormal hormonal profile during a screening of the unaffected children of their non-cosanguinous monogamous parents. The three siblings had morning plasma cortisol concentrations in the lower range of reference values together with markedly elevated levels of plasma androgens. These biochemical abnormalities together with the clinical features of precocious pseudopuberty in the two male patients led to the clinical suspicion of congenital adrenal hyperplasia (CAH). The enzymatic defect was believed to be due to 11-hydroxylase enzyme, because of the presence of sustained systemic hypertension in the male subjects. As routine family screening was instrumental in the discovery of the subclinical CAH in the female subject, it is thus suggested that clinicians should endeavour to undertake a detailed hormonal screening of family members of patients.

Unilateral macronodular adrenal hyperplasia as an unusual cause of Cushing's syndrome--a case study.

To appraise clinicians of the problems that may be encountered in the diagnosis and management of Cushing's syndrome, we present a case report of a 20-year old female, who was admitted with a recently developed central obesity, ammenorrhea hirsuitism, proximal myopathy and depression. She was found to have multiple striae, thin skin, elevated blood pressure glycosuria and hyperglycaemia. Morning and mid-night plasma cortisol concentrations revealed elevated levels, with a loss of diurnal variation. There was a failure of the normal suppressibility of cortisol secretion by low doses of dexamethasone, while a significant suppression of plasma cortisol concentration was observed with high doses of dexamethasone. There were no significant abnormalities observed in the pituitary fossa on skull radiograph and on the cranial computerised tomographic scan. After a period of stabilisation, she had a bilateral adrenalectomy done, with a histopathological finding of a left adrenal macronodular hyperplasia, while the right adrenal gland was small and friable. There was an uneventful post-operative period, with a gradual return to normality of most of the presenting complaints. The hyperglycaemia and hypertension got controlled without medications, while her menstrual cycles resumed within three months of bilateral adrenalectomy. This case report illustrates that an adrenal-dependent Cushing's syndrome may mimic a pituitary-dependent one, especially as regards the suppressibility of plasma cortisol secretion by high doses of dexamethasone.