Double-phase parathyroid 99mTc-Sestamibi scintigraphy in chronic haemodialysis patients: correlation with biochemical markers of parathyroid function.

99mTc-Sestamibi identifies the presence of hyperfunctioning autonomous parathyroid glands in patients with secondary hyperparathyroidism (SHP). The objectives of this study were: (i) to evaluate the interdependence between biochemical markers of SHP and 99mTc-Sestamibi uptake; and (ii) to determine whether 99mTc-Sestamibi uptake could be efficiently predicted by any combination of the former variables. Double-phase parathyroid 99mTc-Sestamibi uptake and total serum calcium, phosphorus, intact parathormone, 25-OH vitamin D and 1,25(OH) vitamin D determinations were performed simultaneously in 74 patients (36 female, 38 male) with SHP. Planar images of the neck and upper thorax were obtained in anterior view, 15 min (early phase) and 120 min (delayed phase) after the injection of 740 MBq of 99mTc-Sestamibi. In each patient, a final parathyroid/thyroid (P/T) activity index was obtained by adding the results of the P/T index of all parathyroid lesions. There was a significant correlation between intact parathormone levels and delayed 99mTc-Sestamibi uptake ( r=0.656; P<0.01). Of all the variables, intact parathormone was the only significant predictor of delayed 99Tc-Sestamibi uptake ( r=0.487; P<0.001). Calcium, phosphorus, vitamin D metabolites, age, gender, time spent on haemodialysis and cause of chronic renal failure displayed no significant correlation with 99mTc-Sestamibi uptake. It can be concluded that 99mTc-Sestamibi uptake is a potential predictor of parathyroid function in SHP patients. Hence, 99mTc-Sestamibi scintigraphy could be useful to assess parathyroid function and in the clinical follow-up of these patients.

[Hypovitaminosis D: its high prevalence in elderly outpatients in Barcelona. Associated factors]. / Hipovitaminosis D: alta prevalencia en ancianos de Barcelona atendidos ambulatoriamente. Factores asociados.

BACKGROUND: Hypovitaminosis D is a frequent finding in the elderly of northern countries. In Spain because of high sun irradiation it has been traditionally considered that hypovitaminosis D is not a frequent problem. In this study we have evaluated the prevalence of hypovitaminosis D in the elderly and the associated factors. SUBJECTS AND METHODS: All individuals older than 65 years attending a primary care unit (november 1995-march 1996) and without any disease modifying vitamin D status were included. The following data were recorded: age, gender, height, weight, white and red cell counts, glycaemia, serum ions, albuminemia, plasma creatinine, creatinine clearance, urinary creatinine and calcium, parathyroid hormone (PTHi), calcidiol and calcitriol. Sun exposure and fish ingestion was also determined by questionnaire. RESULTS: 127 individuals were evaluated (age: mean [SD] 74.8 [6.4] years; 47 men, 37.0%). Forty-four subjects (34.6%; CI 95%: 26.3-42.9%) had calcidiol levels < or = 10 ng/ml, 15 (11.8%; CI 95%: 6.2-17.4%) low values of calcidiol, and 13 (10.2%; CI 95%: 4.9-15.5%) high PTHi values. Subjects with hypovitaminosis D (calcidiol levels < or = 10 ng/ml) were mainly women, older, short stature, had a lower values of body surface, albuminemia, phosphatemia, creatinine clearance, sun exposure and fish intake and higher PTHi levels. In the logistic regression model, hypovitaminosis D was positively associated with age and negatively with sun exposure, albuminemia, height and phosphoremia. CONCLUSIONS: Hypovitaminosis D is a very frequent finding in Spanish elderly people. Its presence is independently associated with age (positively) and sun exposure, serum albumin, height and phosphoremia (negatively).

Effects of long-term antiepileptic therapy on the catabolism of testosterone.

The serum levels of testosterone, sex hormone binding globulin, and free testosterone index were measured in 51 epileptic men (age 18-45) in order to assess the possible effects of antiepileptic drugs on sexual dysfunction. An analytical gas chromatography-mass spectrometry method was developed to assess the urinary excretion of testosterone, epitestosterone, androsterone, etiocholanolone, 11-OH androsterone and 11-OH etiocholanolone and to evaluate if the catabolism of testosterone had been increased. Twenty normal healthy males of similar age, 18-45 years, served as control group. Patients receiving polytherapy (n = 34) or monotherapy with carbamazepine (n = 8) or phenytoin (n = 9) showed higher levels of sex hormone binding globulin and testosterone, and lower levels of free testosterone than did the controls (P < 0.03). Urinary excretion of the metabolites androsterone and 11-OH androsterone was significantly reduced (P < 0.02) in the polytherapy group, while the monotherapy group showed only significant differences (P < 0.02) in the elimination of 11-OH androsterone. Our results suggest that an induction of the hepatic synthesis of sex hormone binding globulin may be the mechanism by which the antiepileptic drugs lower the levels of free testosterone in serum. However, the reduced excretion of androsterone and the normal levels of etiocholanolone show that the antiepileptic drugs do not produce an increase in the main catabolism pathway of testosterone.

[Isolated ACTH deficiency]. / Déficit aislado de ACTH.

The isolated ACTH deficiency is a scarcely diagnosed disease of heterogeneous nature. Two patients with isolated deficiency of ACTH in whom the initial diagnosis was of primary suprarrenal failure are reported. In the first case this diagnosis was performed after hospital admission for deterioration of the level of consciousness and the development of an acute suprarrenal crisis in the course of nosocomial pneumonia. In the second case the clinical manifestations began as weakness, anorexia, weight loss and lymphocytosis with eosinophilia. In both patients an increase in the thyrotropic hormone was detected leading to suspicion of the existence of associated primary hypothyroidism. Finally, several studies were carried out (basal measurements of cortisol and ACTH, stimulation with continual perfusion of ACTH, insulinic hypoglycemia, global study of adenohypophysary function, ACTH CRF release factor test, computerized tomography of the pituitary region) in both patients leading to the definitive diagnosis of isolated ACTH deficiency of idiopathic cause of possible pituitary origin without the existence of other associated hormonal deficiencies.

Primary localized cutaneous amyloidosis and familial medullary thyroid carcinoma.

We have studied a family with an autosomal dominant inheritance of primary localized cutaneous amyloidosis (PLCA) and familial medullary thyroid carcinoma (MTC). Ten family members were screened for multiple endocrine neoplasia (MEN) 2; five were found to have MTC and two had C-cell hyperplasia. None had evidence of phaeochromocytoma or parathyroid abnormalities. Five of these seven patients presented characteristic interscapular hyperpigmented lesions, showing dermal amyloid deposits in two of the four patients in which a biopsy was performed. The data are analysed in the light of two recent reports of MEN 2A associated with identical lesions. We conclude that PLCA should be sought in MTC patients, even if no other endocrinopathies are present. This may be informative of the familial character of MTC in index cases and also of the tumour gene status in family members who are being screened.

Evaluation of clinical and hormonal effects in hirsute women treated with ketoconazole.

Seven hirsute women were treated with 200 mg/12 h po of ketoconazole during 6 months. We evaluated clinical and hormonal effects during this period. Ketoconazole treatment decreased testosterone, androstenedione and dehydroepiandrosterone sulfate, while 17-alfahydroxyprogesterone increased. This finding suggests a steroidogenic blockade at the level of C17-20 lyase. We did not observe changes in LH, SHBG and cortisol values. In spite of this findings after 6 months treatment, hirsutism remained unmodified. We conclude that ketoconazole inhibits androgen synthesis in hirsute women, but the use of this drug as an alternative and effective treatment of hirsutism warrants further evaluation.

[Evaluation of the treatment of Cushing's syndrome using ketoconazole]. / Evaluación del tratamiento del síndrome de Cushing con cetoconazol.

The effectiveness of ketoconazole for the therapy of Cushing's syndrome, both of adrenal and pituitary origin, was retrospectively evaluated. To this end, the clinical and hormonal results in 5 patients were assessed. There were 4 females and one male, with ages ranging between 17 and 64 years. Three of them, who had Cushing's disease, received sustained treatment with ketoconazole when other therapeutic measures had failed. The two remaining patients (one with Cushing's disease and the other with adrenal adenoma) were treated with this drug in the preoperative period to alleviate the deterioration in the clinical condition caused by hypercortisolism. The clinical evolution of the patients is described, as well as the plasma adrenocorticotropin (ACTH) and the free cortisol in 24 hour urine in the subsequent controls. In view of the study results, we feel that ketoconazole is an effective treatment for the long term control of Cushing's syndrome. In addition, it may be also useful as preoperative therapy in those patients severely deteriorated by the sustained hypercortisolism.

Inhibition of intratesticular testosterone synthesis by inorganic lead.

The alterations in testicular testosterone synthesis produced by exposure to inorganic lead were investigated in BALB/c+ mice. Lead concentration in blood and testes and the levels of testosterone and delta 4-androgen biosynthesis pathway precursors (4-androstenedione, 17-hydroxyprogesterone, and progesterone) were measured in animals which were exposed to lead acetate in the drinking water (366 mg/l, 0.97 +/- 0.12 mg lead/animal/day) during 6 months. The results showed a significant reduction of the intratesticular testosterone levels after 30 days of exposure and of the androstenedione levels after 150 days. Intratesticular progesterone and hydroxyprogesterone levels showed no changes during the assay.

Dexamethasone suppression test and primary obsessional compulsive disorder.

This report explores the role played by DSM-III Major Depression in the Nonsuppressor status of a sample of 29 subjects suffering from DSM-III Obsessive Compulsive Disorder (OCD). Five subjects were found to be Nonsuppressors. Further analysis showed that it is likely that Nonsuppressor status depended upon the concomitant presence of Major Depression rather than upon the OCD itself.

Diagnosis of lung carcinoid with cutaneous hyperpigmentation eight years after bilateral adrenalectomy.

A 26-yr-old male was submitted to bilateral adrenalectomy in 1977 for Cushing's syndrome. Some months later he developed intense skin hyperpigmentation together with increased ACTH levels (149 to 4000 ng/l). The sellar region was always normal in X-ray studies. In April 1985, when the patient complained of chest pain, a chest x-ray showed a polycyclic mass in the upper left lobe of the lung. ACTH ranged from 20,000 to 100,000 ng/l, with no response to CRF or cyproheptadine administration. Urinary 5-OH-indolacetic acid was negative. Thoracotomy was performed in July 1985 with resection of two intrapulmonary masses. Histologic study demonstrated a carcinoid tumor, with positive neuron-specific enolase and ACTH immunochemical stain. ACTH concentration in tumoral tissue was 91 pg/g tissue. After surgery ACTH fell dramatically to 37 ng/l, and has remained at this level since then, associated with resolution of the skin hyperpigmentation.

Treatment of pituitary macroadenomas secreting PRL, HGH or ACTH with long-acting bromocriptine.

Long-acting im bromocriptine was administered to 7 patients with pituitary macroadenomas (4 acromegalics, 1 Nelson's syndrome and 2 prolactinomas), with good tolerance except during the first 24 h. During a 42-day period hormonal, CT-scan and visual field variations were followed. In acromegalics HGH decrease was not evident, except in some isolated sample. In Nelson's syndrome ACTH showed a 94% fall on day 14, even though a spontaneous oscillation cannot be ruled out, and recovery took place from day 21 on. PRL remained undetectable in both. In prolactinomas, PRL suffered a great decrease (91.8% and 96.3% on days 21 and 28 respectively) and remained well below its initial values up to the end of the study, in spite of partial recovery. In these 2 patients CT-scan evidenced shrinkage of tumor mass, which was not observed in the remaining 5 cases. Visual fields did not improve in the 2 cases initially affected (Nelson's syndrome and 1 prolactinoma). Long-acting bromocriptine seems to have the same therapeutic uses of the oral form with the possible advantage of a better tolerance of full initial doses.