Leucocyte volume, conductivity, and scatter at presentation in COVID-19 patients.

Background: In COVID-19 patients, besides changes in leucocyte count, morphological abnormalities of circulating blood cells have been reported. Aim: This study aims to investigate the relationship between the morphological and functional properties of leucocytes and the severity of the disease in COVID-19 patients. Materials and Methods: Blood samples were collected from COVID-19 patients (n = 130) at the time of admission. The patients were stratified according to the comorbidity, age, LDH, lymhocyte count score as mild, moderate, and severe. Complete blood count and the cell population data were analyzed by the Volume, conductivity, scatter (VCS) technology on Beckman Coulter LH-780 hematology analyzer. Kruskal-Wal'lis test was used to assess the differences between the groups with subsequent Bonferroni correction. Results: Neutrophil count was increased, and lymphocyte count was decreased in severe patients compared to mild patients. The increase in the percent of neutrophils and the neutrophil/lymphocyte ratio in the severe patient group was significant in comparison to both the moderate and the mild group. The dispersion of the neutrophil volume and conductivity showed significant changes depending on the severity of the disease. The lymphocyte volume, lymphocyte-volume-SD and lymphocyte-conductivity as well as the monocyte-volume and monocyte-volume-SD were significantly increased in severe patients in comparison to mild patients. The increase of lymphocyte and monocyte volume in severe patients was also significant in comparison to moderate patients. Conclusions: COVID-19 infection leads to important changes in cell population data of leucocytes. The volumetric changes in lymphocytes and monocytes are related to the severity of the disease.

ASSOCIATION BETWEEN HASHIMOTO'S THYROIDITIS AND PAPILLARY THYROID CANCER: A SINGLE CENTER EXPERIENCE.

Purpose: To investigate the association between papillary thyroid cancer (PTC) and Hashimoto's thyroiditis (HT). Design: This study is a retrospective study that conducted during 7 consecutive years with a median 119.5 months follow-up. Subjects and Method: Patients who underwent thyroidectomy in Dokuz Eylül University Hospital during 7 consecutive years were included. Patients' demographics, biochemical, radiological, and pathological results were retrospectively assessed. Results: Four hundred sixty nine patients were evaluated. Among 469 patients who underwent thyroidectomy, 132 (28.1%) were malignant, while 182 patients were diagnosed with HT (38.8%). PTC was ranked first at 92.4% (n: 122). The prevalence of HT was 54.9% in patients with PTC and 33.1% in patients without PTC diagnosis (p<0.001). Younger age and the presence of HT were independently associated with PTC. The presence of HT was associated with increased risk of development of PTC (OR: 2.2, %95 CI: 1.4-3.5, p<0.001) but not with TNM stage or recurrence. Lymph node metastasis at presentation was the strongest predictor of recurrence (OR: 13.9, CI: 3.5-54.6, p<0.001). Conclusions: HT was an independent risk factor for development of PTC. According to our findings, HT patients (particularly with nodular HT) should be observed carefully and thyroid fine needle aspiration biopsy (TFNAB) should be encouraged if necessary.

Risk factors for diabetic foot ulcers in metreleptin naïve patients with lipodystrophy.

AIM: Patients with lipodystrophy are at high risk for chronic complications of diabetes. Recently, we have reported 18 diabetic foot ulcer episodes in 9 subjects with lipodystrophy. This current study aims to determine risk factors associated with foot ulcer development in this rare disease population. METHODS: Ninety metreleptin naïve patients with diabetes registered in our national lipodystrophy database were included in this observational retrospective cohort study (9 with and 81 without foot ulcers). RESULTS: Patients with lipodystrophy developing foot ulcers had longer diabetes duration (p = 0.007), longer time since lipodystrophy diagnosis (p = 0.008), and higher HbA1c levels (p = 0.041). Insulin use was more prevalent (p = 0.003). The time from diagnosis of diabetes to first foot ulcer was shorter for patients with generalized lipodystrophy compared to partial lipodystrophy (p = 0.036). Retinopathy (p < 0.001), neuropathy (p < 0.001), peripheral artery disease (p = 0.001), and kidney failure (p = 0.003) were more commonly detected in patients with foot ulcers. Patients with foot ulcers tended to have lower leptin levels (p = 0.052). Multiple logistic regression estimated significant associations between foot ulcers and generalized lipodystrophy (OR: 40.81, 95% CI: 3.31-503.93, p = 0.004), long-term diabetes (≥ 15 years; OR: 27.07, 95% CI: 2.97-246.39, p = 0.003), and decreased eGFR (OR: 13.35, 95% CI: 1.96-90.67, p = 0.008). CONCLUSIONS: Our study identified several clinical factors associated with foot ulceration among patients with lipodystrophy and diabetes. Preventive measures and effective treatment of metabolic consequences of lipodystrophy are essential to prevent the occurrence of foot ulcers in these high-risk individuals.

Physical activity in women with subclinical hypothyroidism.

PURPOSE: Physical activity is associated with many health-related benefits. However, there is a shift towards inactive lifestyles around the world. Subclinical hypothyroidism (SCH) may have adverse effects similar to hypothyroidism. The presence of symptoms and reduced physical performance in SCH may contribute to an inactive lifestyle. Therefore, the present study aimed to compare physical activity levels (PALs) between women with subclinical hypothyroidism and healthy controls. METHODS: Thirty-two women with newly diagnosed SCH and 28 healthy women were enrolled in this cross-sectional study. Arterial stiffness was evaluated by pulse wave velocity (PWV). Neuromuscular symptoms were questioned. Participants wore a physical activity monitor (SenseWear® Armband) for 4 consecutive days. Handgrip and quadriceps muscle strength were assessed by dynamometer. Functional exercise capacity was assessed by 6-minute walk test (6MWT). RESULTS: There was no significant difference in sociodemographic variables between the groups. PWV was significantly higher in the SCH group (P = 0.006). Physical activity duration and number of steps were significantly lower in the SCH group (P < 0.05). There was significant difference in neuromuscular symptoms, handgrip and quadriceps muscle strength, and 6MWT distance between the groups (P < 0.05). CONCLUSIONS: This study demonstrates that women with SCH had lower PALs compared to healthy controls. Women with SCH should participate in exercise programs to increase physical activity and muscle strength to achieve adequate PALs.

Evaluación de la adherencia a la dieta mediterránea en pacientes con antecedentes de revascularización coronaria / Evaluation of Mediterranean diet adherence in patients with a history of coronary revascularization

Introducción: Los cambios en el estilo de vida son un elemento importante de las estrategias de prevención secundaria, y una dieta sana es una de las piedras angulares del manejo de la enfermedad coronaria (EAC). Nos propusimos investigar los hábitos alimentarios de pacientes con antecedentes de revascularización coronaria y las características de aquellos con buena adherencia, utilizando para ello el cuestionario DMed adaptado. Métodos: Incluimos a pacientes ambulatorios con antecedentes de revascularización coronaria, al menos 6 meses antes de ser inscritos en el estudio. Cada participante rellenó un cuestionario con el fin de recopilar los datos demográficos y las características clínicas. Las puntuaciones obtenidas de la Escala DMed adaptada se calcularon para evaluar la adherencia a la dieta mediterránea. Esta escala adaptada se basa, originalmente, en un cuestionario de 14 ítems; lo ajustamos para la población relevante (sobre una puntuación máxima de 13 puntos). Resultados: Incluimos a 226 pacientes consecutivos (edad 61,7±10,9 años, 72% varones). La mediana de tiempo transcurrido desde la revascularización fue de 60 meses. Un total de 112 (49,6%) pacientes habían sido sometidos a una intervención coronaria percutánea, 77 (34,1%) a cirugía de revascularización coronaria y 36 (15,9%) a ambas. La puntuación mediana obtenida en la Escala DMed fue de 6. Los pacientes fueron estratificados en 2 subgrupos (puntuación en la Escala DMed≥7 vs. <7). Un total de 61 (26,9%) pacientes obtuvieron una puntuación ≥7 en la Escala DMed. En el análisis multivariado las buenas puntuaciones en la Escala DMed se asociaron a una mayor edad, menores circunferencia de cintura, e índice de masa corporal, a un mayor nivel educativo, a un seguimiento regular de la dieta, al tiempo transcurrido desde la primera revascularización y a revascularización con cirugía de revascularización coronaria quirúrgica y percutánea. En el análisis multivariado un nivel educativo alto (p=0,002, OR=8.212; IC 95%: 2,155-31,291) y el tiempo transcurrido desde la revascularización (p=0,034, OR=1,007, IC 95%: 1,001-1,013) resultaron ser predictores independientes de buenas puntuaciones en la Escala DMed. Conclusión: El índice de adherencia a una dieta sana fue bajo en pacientes previamente sometidos a revascularización coronaria. La Escala DMed parece ser una herramienta práctica y útil para evaluar los hábitos alimentarios en el entorno ambulatorio. Los índices de adherencia a la dieta mediterránea se asociaron a un nivel educativo alto y al tiempo transcurrido desde la revascularización

Introduction: Lifestyle modification is an important component of the secondary prevention strategies; and a healthy diet is one of the cornerstones in management of the coronary heart disease. We aimed to investigate the dietary habits of the patients with history of coronary revascularization, characteristics of the ones with good adherence by using alternate MedDiet questionnaire. Methods: We included outpatients who had a history of coronary revascularization at least 6 months prior to enrollment. Each participant filled out a questionnaire to collect the data of demographics and clinical characteristics. Alternate MedDiet score was calculated to evaluate the Mediterranean style dietary adherence. Alternate MedDiet was originally based on 14-item questionnaire; we adjusted it to our population (max 13 points). Results: We enrolled 226 consecutive outpatients (age 61.7±10.9 years, 72% males). The median duration after revascularization was 60 months. A total of 112 (49.6%) patients had previous percutaneous coronary intervention (PCI), 77 (34.1%) had coronary by-pass graft surgery (CABG), and 36 (15.9%) had both revascularization procedures. The median MedDiet score was 6. Patients were stratified into two subgroups (MedDiet score ≥7 vs. <7). A total of 61 (26.9%) patients had MedDiet score ≥7. By univariate analysis, good MedDiet scores were associated with older age, waist circumference, body mass index, high education level, regular follow-up, duration after first revascularization and revascularization with CABG+PCI. In the multivariate analysis, high education level (P=.002, OR=8.212, 95%CI: 2.155-31.291) and duration after revascularization (P=.034, OR=1.007, 95%CI: 1.001-1.013) were independent predictors of good MedDiet scores. Conclusion: The adherence rate to a healthy diet was low in patients with previous coronary revascularization. MedDiet score seems to be practical and useful item to evaluate the dietary habits in outpatient setting. Mediterranean diet adherence rates were associated with high education level, and duration after revascularization

Evaluation of Mediterranean diet adherence in patients with a history of coronary revascularization. / Evaluación de la adherencia a la dieta mediterránea en pacientes con antecedentes de revascularización coronaria.

INTRODUCTION: Lifestyle modification is an important component of the secondary prevention strategies; and a healthy diet is one of the cornerstones in management of the coronary heart disease. We aimed to investigate the dietary habits of the patients with history of coronary revascularization, characteristics of the ones with good adherence by using alternate MedDiet questionnaire. METHODS: We included outpatients who had a history of coronary revascularization at least 6 months prior to enrollment. Each participant filled out a questionnaire to collect the data of demographics and clinical characteristics. Alternate MedDiet score was calculated to evaluate the Mediterranean style dietary adherence. Alternate MedDiet was originally based on 14-item questionnaire; we adjusted it to our population (max 13 points). RESULTS: We enrolled 226 consecutive outpatients (age 61.7±10.9 years, 72% males). The median duration after revascularization was 60 months. A total of 112 (49.6%) patients had previous percutaneous coronary intervention (PCI), 77 (34.1%) had coronary by-pass graft surgery (CABG), and 36 (15.9%) had both revascularization procedures. The median MedDiet score was 6. Patients were stratified into two subgroups (MedDiet score ≥7 vs. <7). A total of 61 (26.9%) patients had MedDiet score ≥7. By univariate analysis, good MedDiet scores were associated with older age, waist circumference, body mass index, high education level, regular follow-up, duration after first revascularization and revascularization with CABG+PCI. In the multivariate analysis, high education level (P=.002, OR=8.212, 95%CI: 2.155-31.291) and duration after revascularization (P=.034, OR=1.007, 95%CI: 1.001-1.013) were independent predictors of good MedDiet scores. CONCLUSION: The adherence rate to a healthy diet was low in patients with previous coronary revascularization. MedDiet score seems to be practical and useful item to evaluate the dietary habits in outpatient setting. Mediterranean diet adherence rates were associated with high education level, and duration after revascularization.

Renal Damage Frequency in Patients with Solitary Kidney and Factors That Affect Progression.

Background. The aim of this study is to assess renal damage incidence in patients with solitary kidney and to detect factors associated with progression. Methods. Medical records of 75 patients with solitary kidney were investigated retrospectively and divided into two groups: unilateral nephrectomy (group 1) and unilateral renal agenesis/dysplasia (group 2). According to the presence of kidney damage, each group was divided into two subgroups: group 1a/b and group 2a/b. Results. Patients in group 1 were older than those in group 2 (p = 0.001). 34 patients who comprise group 1a had smaller kidney size (p = 0.002) and higher uric acid levels (p = 0.028) than those in group 1b at presentation. Uric acid levels at first and last visit were associated with renal damage progression (p = 0.004, 0.019). 18 patients who comprise group 2a were compared with those in group 2b in terms of presence of DM (p = 0.038), HT (p = 0.003), baseline proteinuria (p = 0.014), and uric acid (p = 0.032) levels and group 2a showed higher rates for each. Progression was more common in patients with DM (p = 0.039), HT (p = 0.003), higher initial and final visit proteinuria (p = 0.014, for both), and higher baseline uric acid levels (p = 0.047). Conclusions. The majority of patients with solitary kidney showed renal damage at presentation. Increased uric acid level is a risk factor for renal damage and progression. For early diagnosis of renal damage and reducing the risk of progression, patients should be referred to a nephrologist as early as possible.

Monitoring of CD3(+) T-cell count in patients receiving antithymocyte globulin induction after cadaveric renal transplantation.

AIM: Although antithymocyte globulin (ATG) has been used for years, its ideal dose and administration period is obscure. Herein, we sought to use the CD3(+) cell count to detect the optimal ATG dosage. MATERIAL AND METHODS: Twenty-one patients who underwent cadaveric donor renal transplantation from January 2009 to January 2012 received a 1 mg/kg ATG initial dose at the time of the operation. Patients were randomized into 2 cohorts. Group 1 (n = 11) received ATG according to the clinical and total lymphocyte count and group 2 (n = 10), the dose was tailored according to the CD3(+) cell count. We compared the total and daily ATG dosages, ATG administration period, side effects of ATG, the number of days to a serum creatinine level <2 mg/dL, graft function at 3 months, acute rejection episodes, infection rates, costs of CD3(+) analysis, and ATG amounts. RESULTS: Both groups showed similar gender, age, and human leukocyte antigen matching data. There was no difference in presensitizing events or panel-reactive antibody class 1 and 2 levels. The number of days to a serum creatinine level of <2 mg/dL was 11 ± 1.5 for group 1 versus 10.4 ± 0.8 for group 2 (P = .45). Between groups 1 and 2, there was a significant difference between the mean total (P = .031) and mean daily ATG dosages (P = .006). We used a total dose of 3800 mg ATG for group 1 and 2200 mg for group 2 and for the group 2 who underwent 43 CD3(+) cell counts. The expenditure per patient was 20% higher among group 1 than group 2. CONCLUSION: Determination of appropriate ATG dosages by CD3(+) cell counts was useful, reliable, and cost effective.

Reduced olfactory bulb volume in total laryngectomy patients: a magnetic resonance imaging study.

OBJECTIVES: The olfactory bulb (OB) is a remarkably plastic structure with highly active afferent neurons, which is partly reflected by its volume. Although deterioration of olfaction after total laryngectomy is reported by many patients, this problem has not received widespread attention. There has been no study that had addresses this loss olfactory ability as a function of OB volume. The aim of this study was to determine OB volume changes after laryngectomy. STUDY DESIGN: Twenty one patients post-total laryngectomy and 17 subjects with normal olfactory function underwent magnetic resonance imaging (MRI) for volumetric measurement of the OB. The history of all participants was taken in detail to exclude other possible causes of smell dysfunction. Volumetric measurement of the OB was performed by manual segmentation of the OB into coronal slices. Olfactory function was assessed with the orthonasal olfaction test. RESULTS: There was no statistically significant difference in volume between the right and left sides of the OB in the study and control groups. However, the study group had smaller OB volumes than the control group. In our assessment of orthonasal olfaction, patients who were post-total laryngectomy had worse orthonasal olfactory function than the control group. There were significant correlations between OB volumes and orthonasal test scores. CONCLUSIONS: Our MRI study showed that post-total laryngectomy patients had higher rates of olfactory bulb atrophy than the control subjects. Laryngectomy is associated with measurable decreases in olfactory function and this study hopes to further clarify this association by demonstrating that patients with total laryngectomy have reduced OB volumes when compared to the normal population.

Prospective evaluation of tumor size and hormonal status in adrenal incidentalomas.

BACKGROUND: Because of the increased use of imaging interventions, more subjects have been diagnosed with adrenal incidentaloma in recent years. AIM: To evaluate the risk of mass enlargement, hormone hypersecretion and development of adrenal carcinomas during short-term followup. SUBJECTS AND METHODS: There were 317 subjects with incidentally discovered adrenal tumors in the registry. Forty subjects were excluded because of clinically overt hormone secretion at diagnosis and subjects with complete data were included in radiological (no.=150) and hormonal (no.=150) follow- up. Radiological evaluation was performed with computed tomography (CT) and/or magnetic resonance imaging (MRI). There were 143 subjects with adrenal adenomas and 7 subjects with other tumor types (cyst or myelolipoma). Median follow-up duration was 24 months. RESULTS: Increase in tumor size was detected in 25 subjects (17.4%) with adenomas and 1 subject with adrenal myelolipoma (14.3%). Decrease in tumor size was found in 7 subjects (4.8%) with adrenal adenomas. One patient was diagnosed with adrenocortical carcinoma during follow-up. In subjects with non-functioning adrenal adenoma (NFA, no.=120) or subclinical Cushing syndrome (sCS) (no.=30), no subject developed clinically overt hormone hypersecretion, while 8 (6%) subjects in the NFA group developed sCS. Tumor diameter and follow-up duration were significantly higher in subjects who developed sCS. CONCLUSION: In conclusion, we demonstrated that, despite being infrequent, adrenal tumors may increase in size, develop overt or subclinical hormone secretion or feature malignant transformation. Therefore, radiological and hormonal follow-up should be recommended to the patients. More investigations are needed for the establishment of long-term follow-up protocols.

Reduction of major amputations after starting a multidisciplinary diabetic foot care team: single centre experience from Turkey.

INTRODUCTION: It is widely recognized that a multidisciplinary team is effective in the management of diabetic foot ulcers. Contrary to developed countries, multidisciplinary diabetic foot care teams and/or clinics have not been constructed in most centres in developing countries. The aim of this study was to present our data regarding amputation rates and profiles before and after starting the Dokuz Eylul University multidisciplinary diabetic foot care team. METHODS: This study includes data from diabetic foot ulcer episodes which were managed in Dokuz Eylul University Hospital between January 1999 and January 2008. The data was collected prospectively during a minimum follow-up of 6 months in all ulcers. After January 2002, management of ulcers was coordinated by the diabetic foot care team (n=437). Amputation rates were compared to those who were admitted before January 2002 (n=137). RESULTS: Overall amputation and minor amputation rates were similar for both periods. However, major amputations were observed to be decreased after starting the Dokuz Eylul University multidisciplinary diabetic foot care team (20.4% vs. 12.6%, p=0.026). CONCLUSIONS: Our results demonstrated that major amputation rates can be reduced by team work. Formation of multidisciplinary diabetic foot care teams and clinics should be encouraged in Turkey.

Plasminogen activator inhibitor-1 and thrombin activatable fibrinolysis inhibitor levels in non-alcoholic steatohepatitis.

AIM: This study was conducted to demonstrate the plasminogen activator inhibitor- 1 (PAI-1) and thrombin activatable fibrinolysis inhibitor antigen (TAFI-Ag) levels in non-alcoholic steatohepatitis (NASH). MATERIALS AND METHODS: Twenty-seven patients with biopsy-proven NASH and 18 healthy controls (HC) were recruited for the study. Anthropometric data, liver histology (no.=20) and laboratory parameters including PAI-1 and TAFI-Ag assessments were recorded. RESULTS: When compared with HC, patients with NASH had higher body weight, higher waist circumference, elevated blood pressure, higher fasting plasma glucose (FPG) levels and higher homeostasis model assessment (HOMA) scores. The mean plasma PAI-1 levels of patients was found to be higher than HC (87.60 ng/ml vs 30.84 ng/ml p=0.000) and mean plasma TAFI-Ag levels of patients was found to be significantly lower (8.69 microg/ml vs 12.19 microg/ml p=0.000). PAI-1 levels were correlated with systolic blood pressure, age, body weight, transaminases, waist circumference, FPG, body mass index, and HOMA score. TAFI-Ag levels were found to be negatively correlated with transaminases, waist circumference, and body weight. In multiple regression analysis, BMI was the independent variable effecting PAI-1 levels. We did not show any association between PAI-1, TAFI-Ag, disease activity score and fibrosis score. HOMA was the independent variable effecting liver fibrosis in our patients. CONCLUSION: In this study we demonstrated that patients with biopsy-proven NASH had higher PAI-1 and lower TAFI-Ag expression than HC. Elevated levels of PAI-1 in NASH is the consequence of insulin resistance state. Lower TAFI-Ag levels may be related to the overactivation of TAFI pathway resulting in TAFI-Ag depletion. Furthermore, liver function disturbances may impair TAFI production in NASH. We also showed that NASH patients even with slight elevations of transaminases feature marked insulin resistance and components of metabolic syndrome.

Low transforming growth factor-beta1 serum levels in idiopathic male osteoporosis.

INTRODUCTION: Although the etiology of osteoporosis is different between men and women, the underlying pathophysiological mechanism is similar, namely an absolute or relative increase in bone resorption, leading to progressive bone loss. Transforming growth factor (TGF)-beta1 is a growth factor in human bone, which is produced by osteoblasts, and which has various effects on osteoclasts and osteoblasts. The aim of our study was to determine serum TGF-beta1 levels in male patients with idiopathic osteoporosis. METHODS: Twenty five males with idiopathic osteoporosis and 25 age-matched controls were studied. Osteoporosis was defined by a T score of <-2.5 in the lumbar spine or at the femoral neck. We measured levels of TGF-beta1, estradiol, total and bioactive testosterone. Various markers of bone remodeling were also measured. RESULTS: TGF-beta1 was significantly lower in osteoporotic patients than in controls (3.706 ng/dl, 25-75 percentiles: 2.81-5.33 vs 8.659 ng/dl, 25-75 percentiles: 4.837-11.835; p=0.000). Moreover, TGF-beta1 levels were positively correlated with bone mineral density (BMD) at the femoral neck (r=0.439, p=0.028), and at the lumbar spine (r=0.41, p=0.042). No correlation was found between serum estradiol, testosterone and TGF-beta1 levels. DISCUSSION: Serum TGF-beta1 levels are depressed in osteoporotic men and are positively correlated with hip and spine BMD. The results of our study suggest that TGF-beta1 may play a role in the pathogenesis of idiopathic male osteoporosis.

Transforming growth factor-beta 1 levels in women with prior history of gestational diabetes mellitus.

It is known that women with prior history of gestational diabetes mellitus (pGDM) feature obesity, insulin resistance and endothelial dysfunction which cause premature atherosclerosis. Transforming growth factor-beta 1 (TGF-beta1) is a key cytokine in obesity and insulin resistance and also play important roles in the development of atherosclerosis. This study was conducted to demonstrate the serum TGF-beta1 levels of people with pGDM. Thirty women with pGDM, 20 women with type 2 diabetes mellitus (T2DM) and 20 healthy women were enrolled. Serum TGF-beta1 levels of people with pGDM were found to be significantly higher than healthy controls and significantly lower than women with T2DM. TGF-beta1 levels were found to be correlated with postprandial glucose and age and inversely correlated with body mass index (BMI) and waist circumference. On multiple regression analysis postprandial glucose level, age and BMI were determined as the most important factors affecting TGF-beta1 levels. This study demonstrates elevated TGF-beta1 levels in pGDM. The inflammatory response to hyperglycemia and insulin resistance could be the major factors for the increased expression of TGF-beta1.

Cushing's syndrome due to ectopic CRH secretion by adrenal pheochromocytoma accompanied by renal infarction.

Ectopic production of corticotropin-releasing hormone (CRH) by a pheochromocytoma is an infrequent cause of Cushing's syndrome. We report the case of a 43-year-old man with Cushing's syndrome due to a CRH-producing adrenal pheochromocytoma. The patient had clinical and biochemical evidence of hypercortisolism in conjunction with high ACTH levels and non-suppressible serum cortisol levels on low-dose and high-dose dexamethasone suppression testing. In addition to these clinical features of one month's duration, the patient developed symptoms of pheochromocytoma including headache, hypertension that was resistant to conventional therapy and excessive sweating. Biochemical testing confirmed elevated 24-hour urinary catecholamines and metabolites. Abdominal CT revealed a 4.5 x 4 x 3.5 cm mass in the left adrenal gland. He underwent elective left adrenalectomy. Light microscopic and immunochemical studies revealed a pheochromocytoma that contained immunoreactive CRH and was negative for ACTH. Plasma ACTH and dexamethasone supression tests normalized after surgery. This is an unusual case of a CRH-secreting pheochromocytoma. This was complicated by renal infarction, illustrating further the complexity of Cushing's syndrome in a patient with pheochromocytoma caused by CRH hypersecretion.

Spontaneous bilateral perirenal hematoma as a complication of polyarteritis nodosa in a patient with human immunodeficiency virus infection.

We present a 29-year-old man with polyarteritis nodosa (PAN) having human immunodeficiency virus (HIV) infection. This patient fulfilled the American College of Rheumatology (ACR) 1990 criteria for PAN, and the diagnosis was confirmed by typical arteriographic findings, including microaneurysms. Due to the rupture of microaneurysms, perirenal hematomas occurred in both kidneys. Unilateral nephrectomy was performed, and renal histology confirmed that aneurysm rupture was the etiology of the perirenal hematoma. The occurrence of renal hematomas is a usual complication of PAN. However, bilateral renal hematoma during the course of HIV-associated PAN is quite rare, and to our knowledge, this would be the second case reported in the literature. When compared with other viral agents, the association of HIV with PAN may be considered rare. However, as suggested by various reports in the literature, HIV infection should always be kept in mind while evaluating patients with PAN.

Low basal androstenedione levels plus augmented 17alpha-hydroxyprogesterone and low dehydroepiandrosterone sulfate responses to adrenocorticotropic hormone stimulation in patients with adrenal incidentaloma.

OBJECTIVE: To investigate the androstenedione, 17a-hydroxyprogesterone (17-OHP), and dehydroepiandrosterone sulfate (DHEAS) basal levels and responses to adrenocorticotropic hormone (ACTH) in patients with adrenal incidentalomas in order to determine which enzyme defects are present. METHODS: In a study group of 23 patients (18 women and 5 men who ranged in age from 16 to 70 years) with incidentally discovered asymptomatic adrenal masses, ACTH stimulation was performed to evaluate the secretory responses of 17-OHP and DHEAS. The same test was performed in 15 age- and sex-matched control subjects. RESULTS: Of the 23 patients, 16 (70%) had a 17-OHP peak >30 nmol/L. The 17-OHP response to ACTH stimulation was significantly higher in patients with adrenal incidentalomas than in control subjects (P<0.001). Fourteen patients had basal DHEAS levels below the 3rd percentile of the control group (1.4 +/- 0.1 mmol/L). The mean stimulated DHEAS level was 1.7 +/- 0.2 mmol/L (range, 0.8 to 4.1) in patients with incidentalomas and 4.2 +/- 0.4 mmol/L (range, 1.8 to 5.6) in the control group (P<0.001). In 13 patients, stimulated DHEAS levels were low in association with high 17-OHP levels. Basal ACTH levels did not differ significantly between patients (8.14 +/- 1.2 pmol/L) and control subjects (8.73 +/- 0.7 pmol/L). Basal androstenedione levels were significantly lower in patients (1.9 +/- 0.3 nmol/L) than in control subjects (5.7 +/- 2.5 nmol/L) (P<0.001). No significant correlation was found between 17-OHP levels and tumor size. CONCLUSION: Enzyme defects may have an important role in adrenal incidentalomas. Two possible explanations for the observed abnormalities of steroid metabolism in patients with incidentalomas are that (1) the incidentalomas are true primary tumors that have aberrant steroid metabolic pathways or (2) such patients have underlying congenital adrenal hyperplasia that leads, over time, to development of pseudotumors. To assess these two possibilities, we need further studies such as genetic investigations, postoperative test results, and evidence relating the size of the adrenal mass to steroid-suppressible treatment.