Endocrine causes of bone disease.

Hyperthyroidism, glucocorticoid excess, hyperparathyroidism, hypogonadism, and acromegaly decrease bone mineral density and aggravate the osteoporotic tendencies of elderly individuals. After effective treatment of endocrinopathy, the bone attempts to return to the normal mineral density. In most circumstances, however, this attempt is incomplete. Early diagnosis and treatment of these endocrine problems in older patients helps to maintain their skeletal integrity and prevent osteoporotic fractures.

Thyroid nodules in the elderly.

Thyroid nodules in the elderly are more frequent and more frequently malignant. Fine needle aspiration is the first step to diagnose these type of nodules, and thyroid scans and ultrasounds may be obtained in special cases. Thyroid suppression is frequently not effective in decreasing the size of the nodule and may cause subclinical or clinical thyrotoxicosis. It is not uncommon to discover that what initially was thought to be a solitary nodule is only the dominant nodule of a multinodular goiter.

Erosive spondyloarthropathy in primary hyperparathyroidism without renal failure.

A patient with erosive spondyloarthropathy (ESA) and primary hyperparathyroidism is described. In the past, ESA has been described exclusively in patients with chronic renal failure (CRF) and has been attributed to crystal deposition, amyloidosis, severe secondary hyperparathyroidism, or other abnormalities of chronic renal failure. This patient with normal renal function suggests that secondary hyperparathyroidism plays the major pathogenetic role in ESA in patients with renal failure.

Spontaneous hematoma of a parathyroid adenoma.

A patient with long-standing, asymptomatic, primary hyperparathyroidism developed pain in the anterior neck area, with cough, dysphagia and increasing shortness of breath. This led to respiratory insufficiency, which required endotracheal intubation and respirator assistance. During the ensuing hours the patient developed an area of ecchymosis on the anterior chest. Chest x-ray showed widening of the superior mediastinum, and CT scan showed a large mass with a fluid level. Surgery revealed a large hematoma originating from a mediastinal parathyroid adenoma with a hemorrhagic infarct. Serum calcium, previously elevated, decreased to normal with the onset of neck pain, and the patient remains normocalcemic. Previous reported cases of this rare complication of parathyroid adenomas are reviewed. Hemorrhagic infarct of a parathyroid adenoma may present with a rapidly enlarging mediastinal mass, and/or hypercalcemic crisis. Surgical removal of the infarcted adenoma can return the serum calcium to normal.

¿Han quedado obsoletos los análisis de glucosuria? / Is the urine glucose test obsolete

El control metabólico de la diabetes mellitus realizado por los pacientes se ha llevado a cabo durante muchos años con exámenes de orina. La necesidad de un estricto control, en voga durante los últimos años, pone énfasis en el monitoreo del azúcar sanguíneo en el hogar. Se desea evaluar el estaod y la tecnología de los exámenes de glucosuria en la actualidad, a fin de observar cuál debe ser su papel en el trtamiento diario. El manejo renal de la glucosa depende de la concentración de azúcar, el índice de filtración glomerular y la reabsorción tubular. La mayor parte de los 180 g de glucosa filtrados diariamente en los glomérulos se reabsorbe en los túbulos por un proceso activo. Los métodos actuales utilizados por los pacientes diabéticos para medir el azúcar en la orina en los EEUU son: tabletas Clinitest, Testape, Diastix y Chemstrip uG. Se revisa cada uno de ellos, señalando sus beneficios e inconvenientes, así como sus falsas reacciones piositivos y negativas. Debido a su simplicidad y rango más amplio, parece ser que Chemstrip uG es el mejor en la actualidad, aunque también es uno de los más caros. La recolección de orina para estas determinaciones pueden ser cuantitativa o semicuantitativa. En la práctica diaria los exámenes de glucosuria tienen algunos problemas serios: variaciones en el umbral renal de paciente a paciente y en el mismo paciente, disociación temporal entre el azúcar de sangre y el la orina, variaciones con el estado de hidratación, falsas reacciones positivas y negativas, requiriendo además del paciente esfuerzo, técnicas cuidadosas y gastos

¿Han quedado obsoletos los análisis de glucosuria? / Is the urine glucose test obsolete

El control metabólico de la diabetes mellitus realizado por los pacientes se ha llevado a cabo durante muchos años con exámenes de orina. La necesidad de un estricto control, en voga durante los últimos años, pone énfasis en el monitoreo del azúcar sanguíneo en el hogar. Se desea evaluar el estaod y la tecnología de los exámenes de glucosuria en la actualidad, a fin de observar cuál debe ser su papel en el trtamiento diario. El manejo renal de la glucosa depende de la concentración de azúcar, el índice de filtración glomerular y la reabsorción tubular. La mayor parte de los 180 g de glucosa filtrados diariamente en los glomérulos se reabsorbe en los túbulos por un proceso activo. Los métodos actuales utilizados por los pacientes diabéticos para medir el azúcar en la orina en los EEUU son: tabletas Clinitest, Testape, Diastix y Chemstrip uG. Se revisa cada uno de ellos, señalando sus beneficios e inconvenientes, así como sus falsas reacciones piositivos y negativas. Debido a su simplicidad y rango más amplio, parece ser que Chemstrip uG es el mejor en la actualidad, aunque también es uno de los más caros. La recolección de orina para estas determinaciones pueden ser cuantitativa o semicuantitativa. En la práctica diaria los exámenes de glucosuria tienen algunos problemas serios: variaciones en el umbral renal de paciente a paciente y en el mismo paciente, disociación temporal entre el azúcar de sangre y el la orina, variaciones con el estado de hidratación, falsas reacciones positivas y negativas, requiriendo además del paciente esfuerzo, técnicas cuidadosas y gastos (AU)

Granuloma-related hypercalcemia in lipoid pneumonia.

A patient with hypercalcemia, suppressed serum PTH levels, and elevated serum levels of calcitriol was found to have a granulomatous lipoid pneumonia due to chronic aspiration of a "vaporizing ointment." After the surgical removal of the largest granuloma, the serum calcium and calcitriol levels rapidly returned to normal. This is a new instance of granuloma-induced hypercalcemia, probably mediated by the activation of vitamin D by cells of the granulomatous reaction.

Untreated thyrotoxicosis as a manifestation of anorexia nervosa.

A patient with anorexia nervosa refused treatment for her thyrotoxicosis for 18 years in an attempt to keep her weight low. Severe congestive heart failure and impending thyroid storm prompted her family to force her to seek medical attention.

Tetany induced by hypokalemia in the absence of alkalosis.

A 36-year-old patient developed tetany manifested only by a positive Trousseau's sign and with a negative Chvostek's sign 8 weeks after gastric bypass surgery for obesity. The usual causes of tetany (hypocalcemia, hypomagnesemia and alkalosis) were absent. The only possible etiology found was hypokalemia. Previous cases of hypokalemia induced tetany reported were always accompanied by alkalosis. Its absence in our patient makes this case unique and determines that hypokalemia per se in the absence of alkalosis may be a cause of tetany. It is suggested that the Trousseau's sign should be investigated in patients with severe potassium deficiency.

Iatrogenic Cushing's syndrome due to dexamethasone nasal drops.

Iatrogenic Cushing's syndrome presents all of the metabolic and immunologic abnormalities of the disease plus a suppressed hypothalamic-pituitary-adrenal axis. Most of the time the intake of steroids is quite evident, but occasionally it is not. This report presents such a patient who was using dexamethasone nasal drops for allergic rhinitis and in whom Cushing's syndrome developed. Five other similar cases were found in the literature. All except one were reported from outside the United States where these nasal steroid preparations are easily obtained over the counter. Absorption through the nasal mucosa and partly through the intestinal mucosa after a portion of the dose is swallowed is the mechanism of the systemic effect. Treatment consists in the discontinuation of the intranasal steroid preparation and tapering doses of prednisone to cover the secondary adrenal insufficiency until the axis recovers. Patients with Cushing's syndrome and suppressed levels of ACTH and cortisol should be asked about steroid intake, including nasal sprays and drops, particularly if they come from outside the United States. All of the cases reported occurred with dexamethasone. The newer intranasal steroids (beclomethasone and flunisolide) are not absorbed as readily through the nasal mucosa and are inactivated in the liver after gastrointestinal absorption. Therefore, it is not expected that they will produce Cushing's syndrome or adrenal suppression.

Alkalemia in diabetic ketoacidosis.

A patient with a history of diabetes mellitus and congestive heart failure was taking furosemide and metolazone as diuretics. Diabetic ketoacidosis developed, and the patient became lethargic and confused. Initial biochemical determinations showed an alkalemic pH, serum and urine ketones with an anion gap, and hyperventilation. The hyperventilation was appropriate for the degree of ketoacidosis but it was grossly inappropriate for the alkalemia. This could be explained by a direct effect of ketones on the respiratory center or a sudden increase in hydrogen ion concentration superimposed on previously chronic alkalemic pH due to the potent combination of furosemide and metolazone.

Coagulopathy associated with the use of cephalosporin or moxalactam antibiotics in acute and chronic renal failure.

Nine azotemic patients who developed a coagulopathy associated with the use of either cephalosporin or moxalactam antibiotics are reported. The acute renal failure patients had neoplastic disorders and were considered to be septic at the time that multiple antibiotics were administered. Four of 5 chronic hemo- or peritoneal dialysis patients also received multiple antibiotics. Nevertheless, the coagulopathy seemed to be most closely associated with the administration of the cephalosporin. One patient received moxalactam as part of the combination therapy for diffuse pulmonary infiltration during renal transplant rejection. Bleeding occurred into the gastrointestinal tract in four patients, into the kidney-urinary tract in three patients, into vascular surgical sites in two patients, and one each into the pulmonary-bronchial and cerebral-ventricular systems. Five operations were performed in four patients: a nephrectomy for massive subcapsular hemorrhage with a prothrombin time that exceeded 100 seconds; arteriovenous graft complicated by post-operative bleeding associated with prolongation of the prothrombin time; elective femoral-popliteal bypass complicated by a prolonged prothrombin time, bleeding into the graft site, hypotension, and a subendocardial myocardial infarction; elective cholecystectomy complicated by a two unit bleed associated with a slightly prolonged prothrombin time, followed by elective femoral-popliteal bypass complicated by a fatal intercerebral bleed associated with a more than twice normal prothrombin time. Cephalosporins are most likely associated with Vitamin K deficiency. Moxalactam is more likely to be associated with platelet dysfunction. Monitoring of the prothrombin time for cephalosporins or the bleeding time for moxalactam is the most reliable way to prevent what may be rapid emergence of clinical bleeding in patients with renal failure.