Cushing's syndrome and chronic venous ulceration--a clinical challenge.

Cushing's syndrome is a condition caused by high levels of glucocorticoids, or most commonly as a result of prolonged exposure to exogenous steroids. Clinical features include diabetes, hypertension, obesity, skin atrophy, immune suppression and delayed wound healing. We report a patient with iatrogenic Cushing's syndrome, in whom long-term topical steroid therapy was used to treat varicose eczema, which contributed to the development of type 2 diabetes, morbid obesity, sleep apnoea and chronic wound sepsis. In this case, repeated hospital admissions and systemic antibiotics were associated with considerable comorbidity. Aggressive local treatment, consisting of potassium permanganate soaks and irrigating gels, was highly effective in reducing the amount of exudate, pain and preventing from further deterioration of the patient's legs.

Invasive breast cancer after initiation of testosterone replacement therapy in a man--a warning to endocrinologists.

OBJECTIVE: To alert fellow endocrinologists of a rare side effect of testosterone therapy, for which men with hypogonadism must receive appropriate counseling and monitoring. METHODS: We present clinical features, laboratory data, and histopathologic findings in a man with hypogonadism who received testosterone replacement therapy. RESULTS: A 61-year-old man was referred to an endocrinologist after presenting to his general practitioner with erectile dysfunction and low libido. He had no history of hypothalamic, pituitary, or testicular disorders. There were no other illnesses or medications to account for low testosterone levels. Physical examination was unremarkable. There was no family history of malignant disease. Biochemical investigations confirmed the presence of primary hypogonadism, for which no cause (including Klinefelter syndrome) was identified. Testosterone therapy was initiated to improve sexual function and preserve bone density. Five weeks later, the patient returned to his general practitioner, complaining of a gradually enlarging lump in his right breast. When biopsy showed breast cancer, testosterone therapy was discontinued. Right mastectomy and axillary node clearance were performed. Further histologic examination revealed estrogen receptor-positive, invasive carcinoma, without nodal involvement. The patient remains on tamoxifen therapy and is undergoing follow-up in the breast clinic. After 6 months of treatment, estradiol levels were undetectable, and testosterone levels remained low. CONCLUSION: Although breast cancer has been described in men with hypogonadism receiving long-term testosterone replacement therapy, to our knowledge this is the first report of breast cancer becoming clinically manifest after a short duration (5 weeks) of testosterone treatment. This case should remind clinicians that men receiving testosterone therapy should be warned of the risk of not only prostate cancer but also breast cancer. Patient self-monitoring and breast examinations by the attending physician are recommended.

Acute anuric renal failure secondary to intravenous immunoglobulin in diabetic nephropathy.

We present a case of acute renal failure in a diabetic patient who received intravenous immunoglobulin therapy. Vigam liquid immunoglobulin was used successfully to treat vancomycin induced toxic epidermal necrolysis, but 4 days later the patient became anuric. Renal function was restored after haemofiltration. Immunoglobulin therapy is used to treat immune-mediated conditions, many of which affect the diabetic population. Renal failure is a rare side effect of immunoglobulin in patients with diabetes and impaired renal function, of which many clinicians are unaware. Caution must be exercised in such patients and the risks of immunoglobulin treatment weighed against the benefits.

Prospective screening for coeliac disease in patients with Graves' hyperthyroidism using anti-gliadin and tissue transglutaminase antibodies.

INTRODUCTION: Coeliac disease (CD) is associated with autoimmune thyroid disease (AITD) although its prevalence among those with Graves' hyperthyroidism in the UK is unknown. We determined the prevalence and evaluated the role of screening for CD prospectively in a consecutive cohort of patients with Graves' hyperthyroidism using IgA class antibodies to gliadin (AGA) and tissue transglutaminase (anti-tTG). METHODS: All patients with Graves' hyperthyroidism attending the thyroid clinic over a 9-month period were offered screening for CD using AGA (normal < 3 mg/l) and anti-tTG (normal < 15 micro/ml). Comparison was made with an age- and sex-matched healthy control group from the local population whose sera were tested for anti-tTG. In patients with borderline or raised anti-tTG (> 7 micro/ml) endomysial antibody (EmA) was measured. Serum IgA was also measured to exclude IgA deficiency. Patients with raised AGA, raised or borderline anti-tTG, positive EmA, IgA deficiency or haematinic deficiencies were offered endoscopic duodenal biopsy. RESULTS: A total of 115 patients (97 female and 18 male) with Graves' hyperthyroidism were offered screening tests and 111 accepted. AGA was raised in 15 patients, anti-tTG was raised in two (both positive for EmA) and equivocal in six (one positive for EmA). IgA deficiency was present in three. Four patients were known to have haematinic deficiencies. Twenty-five patients were invited and 19 agreed to have endoscopic duodenal biopsy. Three new patients were found to have CD while two patients were already known to have CD, thus five of 111 patients with Graves' hyperthyroidism had CD. One of 115 healthy controls had a strong positive anti-tTG (> 200 micro/ml) and EmA indicating probable CD. CONCLUSIONS: Screening 111 consecutive patients with Graves' hyperthyroidism revealed AGA in 14%, anti-tTG in 2% and IgA deficiency in 3%. Two patients were known to have CD. Screening detected three new cases. The prevalence of CD in patients with Graves' hyperthyroidism was 4.5% as compared with 0.9% in matched healthy controls. Routine screening for CD should be considered.