Octreotide in the management of active acromegaly due to inoperable growth hormone-secreting adenoma.

Active acromegaly displays high morbidity and mortality. It should be treated aggressively with surgery, radiotherapy and medical therapy. In order to confirm the effectiveness and tolerability of octreotide in refractory acromegaly, we studied six patients after unsuccessful transsphenoidal surgery, or surgery and conventional radiotherapy performed for pituitary macroadenomas. After nuclear magnetic resonance imaging and hormonal studies, they were submitted to octreotide therapy (100 micrograms subcutaneously every eight hours), reevaluated every six weeks for six months, and followed-up for further six months. A clear reduction of subjective symptoms including headache was noticed. Two patients, however, suffered from recurrent malaise and reduced octreotide doses (one case, who also developed cholelithiasis), or refused to continue the treatment. GH and IGF-I levels were normalized (1 patient), improved (3 patients) or unmodified (2 patients). Not every acromegalic patient responds to low-dose octreotide therapy with normalization of GH levels. In selected cases, however, octreotide may be usefully employed for active acromegaly in support of surgery and radiotherapy.

[Evaluation of the thyroid function in healthy aged patients residing in 2 geriatric institutions]. / Valutazione della funzione tiroidea in pazienti anziani sani ricoverati in due istituti geriatrici.

Thyroid function assessment in elderly inpatients. It is not well known whether normal ageing might lead to an impairment of thyroid function. We evaluated 297 elderly inmates in two geriatric institutions. After having excluded from the study those who were affected by chronic hepatic or renal disease, were under pharmacologic treatment or had suffered from acute ailments during the previous two months, we assessed thyroid function by determining circulating T4, T3, rT3, FT4, FT3 and TSH in 130 apparently healthy subjects. They could be divided into three groups composed of patients mentally competent, affected by either vascular or senile dementia, or affected by chronic psychosis. Results were also assessed with reference to three different age ranges (65-74, 75-84 and over 85 years). Two patients had subnormal thyroid hormone levels with elevated basal thyrotropin, while other two demonstrated only elevated thyrotropin levels, qualifying respectively for a diagnosis of primary hypothyroidism and subclinical hypothyroidism. In the remaining 126 patients thyroid function was normal, and no differences in thyroid hormone levels could be noticed among the various groups of patients, divided for sex, age range and mental condition. The results of our study confirm the presence of a high percentage of subclinical thyroid dysfunction in old age. They also suggest that in healthy aged subjects thyroid function parameters are not significantly different in reference to sex, age range and mental condition.

Primary empty sella syndrome and hypogonadotropic hypogonadism in young male patients.

Twelve male patients with absence of pubertal development and hypogonadotropic hypogonadism underwent a contrast-enhanced computed tomography of the sellar region and dynamic endocrine testing consisting of insulin-induced hypoglycemia, GnRH and TRH test. In two patients, clinically indistinguishable from the others, the presence of an empty sella turcica was demonstrated. They also showed, in comparison with patients with normal sellar morphology, an absent prolactin response to hypoglycemia with otherwise normal pituitary function. Empty sella, either due to congenital incompetence of the diaphragma sellae or to pituitary shrinkage due to regressive changes by hemorrhage, infarction and possibly autoimmune phenomena, may rarely be associated with hypogonadotropic hypogonadism.

Comparison between computed tomography and magnetic resonance imaging in the postoperative evaluation of acromegalic patients.

Twelve acromegalic patients who underwent transphenoidal resection of a GH-secreting pituitary adenoma were evaluated postoperatively by Computed Tomography (CT) and Magnetic Resonance (MR). CT and MR findings were compared with surgical and clinical results. MR was more accurate than CT in delineating postoperative abnormalities of the infundibulum, diaphragma sellae and optic chiasm. In three cases MR differentiated packing materials from adenomatous tissue. In cases with biochemical evidence of residual or recurrent tumor, MR clearly demonstrated intra- or extrasellar adenomatous tissue and the spatial relationship between the soft tissue mass and the cavernous sinuses. CT was superior to MR only in demonstrating sellar floor disruption. MR imaging detected the anatomical causes of clinical abnormalities in almost all acromegalic patients with incomplete recovery after surgery. On the basis of MR results it is possible to plan additional surgery, radiation therapy or medical treatment. MR may be the radiological procedure of choice for both surgical treatment planning and postoperative follow-up.

Paradoxic elevation in serum GH by hypothalamic releasing hormones predicts GH response to acute SMS 201-995 administration.

Acromegalic patients do not respond with the same degree of growth hormone (GH) inhibition to long-term therapy with the somatostatin analogue SMS 201-995. In order to find a parameter predictive of the effectiveness of the drug, we studied in twelve patients with active acromegaly the relationship between paradoxical GH response to gonadotropin- and thyrotropin-releasing hormone (GnRH and TRH) and GH inhibition after a single standard dose (100 micrograms) of SMS 201-995. Four hours after the subcutaneous injection of the analogue, only those patients who responded to the releasing hormones demonstrated a persistent inhibition of somatotropic cell function. SMS 201-995 appears an effective means for suppressing the elevated GH levels in active acromegaly. Its activity may be more pronounced and its use more beneficial in those patients who react paradoxically to GnRH and TRH.

Liver enzyme abnormalities in subacute thyroiditis.

In a retrospective study of liver function tests in subacute thyroiditis, 13 out of 22 patients with the disease demonstrated an elevation of alkaline phosphatase level. Less prevalent abnormalities were elevations in gamma-glutamyl transpeptidase (5 pts), alanine (4 pts) and aspartate (3 pts) aminotransferase activities. These enzyme alterations were not correlated with thyroid hormone levels, concomitant diseases, drugs or alcoholic intake, and normalized in six patients followed until recovery. A benign, short-lived and subclinical hepatic involvement is common in subacute thyroiditis.

Iodine-induced subacute thyroiditis with thyrotoxicosis presenting as fever of unknown origin.

A 26-year-old woman with features of bulimia nervosa presented with fever of unknown origin, hepatomegaly, marked leukocytosis, and increased erythrocyte sedimentation rate. Following prolonged observation, slight tenderness over the thyroid gland and signs of thyrotoxicosis occurred. A thyroid scan demonstrated no isotope uptake and the patient admitted abusing an organic iodine preparation in order to control her weight. The diagnosis of iodine-induced subacute thyroiditis with thyrotoxicosis was, therefore, considered. A brief course of low-dose steroids normalized both thyroid function and hematological parameters. On followup evaluation, urinary iodine excretion and thyroid function tests were normal.

[Double filtration plasmapheresis in the treatment of vascular complications of hyperlipidemia]. / La plasmaferesi a doppia filtrazione nella terapia delle complicanze vascolari delle iperlipidemie.

Double-filtration plasmapheresis is a therapeutic procedure for the extracorporeal depuration of atherogenic lipoproteins, which does not require the administration to the patient of exogenous fluids. We have used it in two patients affected by hyperlipidemia with severe cardiovascular complications. Both patients presented a dramatic improvement of their symptoms (angina pectoris and claudicatio intermittens) shortly after the beginning of treatment. By the brisk reduction of circulating low-density lipoproteins, plasma-filtration may favor the removal of cholesterol from atheromatous plaques of vessel walls. Furthermore, this procedure may modify platelet aggregation and blood viscosity. Our observation suggests that plasma-filtration may be useful not only for delaying coronary heart disease in the rare cases of homozygous familial hypercholesterolemia, but also in the management of patients with other primary hyperlipoproteinemias and clinical manifestations of already established cardiovascular complications.

[Use of activated charcoal plasmafiltration in the treatment of hyperthyroidism]. / Impiego della plasmafiltrazione su carbone attivato nella terapia dell'ipertiroidismo.

We evaluated the use of activated charcoal plasmaperfusion in four patients already treated with synthetic antithyroid agents affected by severe hyperthyroid. Our patients showed no significant side-effect and a rapid improvement of their symptoms. Thyroid hormone levels were 30% lower after the procedure, but returned to previous levels after 7-10 days. Activated charcoal plasmaperfusion may represent a useful therapeutic adjunct to antithyroid drugs in patients affected by severe hyperthyroidism or thyrotoxic storm.

Tension pneumocephalus after transsphenoidal surgery for acromegaly.

The Authors report the case of a 27-year-old man who developed intraventricular and subarachnoid tension pneumocephalus after removal of a large pituitary adenoma via the transnasal approach. This exceptional complication was probably caused by the combined action of a cerebrospinal fluid fistula plus an external lumbar subarachnoid drain, and resolved after removal of the spinal catheter. Such a conservative treatment was allowed in this case by the absence of a shift of midline structures due to bilateral intraventricular air collection. Usually, however, tension pneumocephalus is a life-threatening condition that requires prompt intervention. Meticulous attention to the cerebrospinal fluid draining system is needed in patients with a fistula to avoid the development of this unusual complication.

[Treatment of hypophyseal prolactin-secreting macroadenomas]. / La terapia dei macroadenomi ipofisari prolattino-secernenti.

We investigated a group of 26 patients with prolactin-secreting pituitary macroadenomas. Seventeen underwent neurosurgical operation alone, nine were also submitted to medical therapy with bromocriptine 7.5 mg/day, immediately after the operation. Patients presented similar clinical and biological characteristics. Fourteen patients without medical therapy showed a persistent hyperprolactinemia and the tumor recurred in 8 of these 17 patients. Of the 9 patients receiving medical and surgical therapy, only 1 presented persistent hyperlactinemia and none relapsed. Our results suggest that combined sequential surgical and medical therapy may be useful in the management of patients with prolactin-secreting pituitary macroadenomas.

Growth hormone deficiency in patients with idiopathic adrenocorticotropin deficiency resolves during glucocorticoid replacement.

Glucocorticoids (GC) have stimulatory effects on GH secretion in vitro and suppressive effects when administered in pharmacological amounts in vivo. We studied six patients with ACTH deficiency and severely impaired serum GH responses to insulin tolerance tests and arginine infusion tests. All patients underwent the same tests during GC replacement while receiving cortisone acetate in doses ranging from 12.5-25 mg/day. The three patients with idiopathic ACTH deficiency and no evidence of pituitary mass lesions had impaired GH secretion, which returned to normal during GC replacement. In contrast, the three patients with ACTH deficiency and hypothalamo-pituitary mass lesions detected by a computed tomography scan had impaired GH secretion during GC replacement therapy. Our data indicate that in patients with idiopathic ACTH deficiency, an impaired GH response to stimuli reversible during GC replacement therapy may be the functional consequence of the low levels of circulating cortisol. We conclude that physiological serum cortisol levels are necessary for normal serum GH responses to provocative stimuli in man.

Effects of the acute subcutaneous administration of synthetic salmon calcitonin in tumoral calcinosis.

We examined the effects of the acute administration of salmon calcitonin on phosphate metabolism in tumoral calcinosis. On two different days, 200 MRC U of the synthetic hormone were administered sc to a 38-year-old patient, either as twice daily 100 MRC U injections, or as a continuous sc infusion via a portable pump. Both ways of calcitonin administration elicited a phosphaturic effect and a lowering of serum phosphate level comparable with that observed after an iv infusion of calcitonin. 1,25 dihydroxyvitamin D level, which was in the normal range during a control study, increased after calcitonin administration. In our patient, long term therapy with diet, a phosphate-binding agent and calcitonin prevented the occurrence of new ectopic calcifications. Owing to its phosphaturic activity, synthetic salmon calcitonin may be a useful adjunct to diet and aluminium-containing antacids in long-term management of tumoral calcinosis.