Vitamin D Deficiency and the Presentation of Primary Hyperparathyroidism: A Mini Review.

The clinical presentation of primary hyperparathyroidism (PHPT) has evolved over the years from a symptomatic disorder to a predominantly asymptomatic condition. Altered vitamin D metabolism seems to play a role in the presentation of PHPT and may exacerbate the severity of disease. The epidemiology of PHPT differs in the developing versus the developed world, where more severe phenotypes occur in regions where vitamin D deficiency is common. Although it has been validated that patients with PHPT should be vitamin D sufficient, the threshold to supplement in relation to the severity of PHPT and the degree of vitamin D deficiency remains controversial. This review will highlight some of the controversy regarding vitamin D deficiency and the different phenotypes of PHPT.

Multiple myeloma presenting as acute tubulointerstitial nephritis.

BACKGROUND: Acute tubulointerstitial nephritis (ATIN) is a very rare paraneoplastic manifestation in patients with multiple myeloma (MM). It is an uncommon pattern of renal disease in such patients. CASE PRESENTATION: We report a case of an 82-year-old male who was admitted with acute kidney injury. Renal biopsy showed typical findings of light chain-associated ATIN with scattered inflammatory cells in the interstitium and associated active tubulitis. No other common manifestations of MM were present at the time of presentation, including hypercalcemia, hyperuricemia, proteinuria, bone pain or lytic bone lesions. Subsequent immunoassays revealed significant serum lambda light chain burden and Bence Jones protein in urine. Immunofluorescence demonstrated linear tubular basement membranes with positive staining for lambda light chain (3+). Electron microscopy (EM) further showed interstitial edema and inflammation. All the aforementioned findings are consistent with ATIN and supported the diagnosis of MM. CONCLUSIONS: In conclusion, light chain-associated ATIN should be considered in the differential diagnosis of acute interstitial nephritis. Henceforth, serum free light chains as well as serum and urine protein electrophoresis should be included in the workup of such patients.

Multiple myeloma presenting as acute tubulointerstitial nephritis

Background Acute tubulointerstitial nephritis (ATIN) is a very rare paraneoplastic manifestation in patients with multiple myeloma (MM). It is an uncommon pattern of renal disease in such patients. Case presentation We report a case of an 82-year-old male who was admitted with acute kidney injury. Renal biopsy showed typical findings of light chain-associated ATIN with scattered inflammatory cells in the interstitium and associated active tubulitis. No other common manifestations of MM were present at the time of presentation, including hypercalcemia, hyperuricemia, proteinuria, bone pain or lytic bone lesions. Subsequent immunoassays revealed significant serum lambda light chain burden and Bence Jones protein in urine. Immunofluorescence demonstrated linear tubular basement membranes with positive staining for lambda light chain (3+). Electron microscopy (EM) further showed interstitial edema and inflammation. All the aforementioned findings are consistent with ATIN and supported the diagnosis of MM. Conclusions In conclusion, light chain-associated ATIN should be considered in the differential diagnosis of acute interstitial nephritis. Henceforth, serum free light chains as well as serum and urine protein electrophoresis should be included in the workup of such patients.

SILICONE GRANULOMATOUS INFLAMMATION RESULTING IN HYPERCALCEMIA: A REVIEW OF THE LITERATURE.

OBJECTIVE: Silicone usage for cosmetic enhancement is common, although it is not approved by the U.S. Food and Drug Administration. Granulomatous inflammation leading to hypercalcemia is a rare complication. We present a case of non-parathyroid hormone (PTH), calcitriol-mediated hypercalcemia in a woman with a history of cosmetic injections. METHODS: Case report and review of the literature. RESULTS: A 48-year-old female with metabolic syndrome was evaluated for severe hypercalcemia (calcium >15 mg/dL). Laboratory tests revealed low-normal PTH, normal 25-hydroxyvitamin D, elevated 1,25-dihydroxyvitamin D, and hypercalciuria. Imaging studies, including a computed tomography (CT) scan of the lungs, was nonrevealing. Positron emission tomography/CT showed symmetric hypermetabolic subcutaneous stranding of bilateral gluteus and proximal thighs. She admitted to silicone injections in the buttocks 10 years prior. Her examination was unremarkable except for an intermittent pruritic rash over the right thigh. Labs revealed total serum calcium 11.3 mg/dL, PTH 18 pg/mL, 24-hour urinary calcium 509 mg, and PTH-related peptide 18 pg/mL. Serum and urine electrophoresis were normal, 25-hydroxyvitamin D was 47 pg/mL, and 1,25-dihydroxyvitamin D was 121 pg/mL. Angiotensin-converting enzyme level was 80 U/mL. A diagnosis of granulomatous inflammation resulting in calcitriol-mediated, PTH-independent hypercalcemia was entertained. CONCLUSION: Silicone-induced hypercalcemia should be thought of in those with prior cosmetic injections. Tissue biopsy confirms the diagnosis, which is often delayed. We reviewed 19 cases with silicone usage and variable levels of hypercalcemia. Renal injury was common. One death was reported. Glucocorticoids, calcium restriction, and hydration have been used to treat calcitriol-mediated hypercalcemia but are not curative. Ketoconazole and bisphosphonates have been used with variable success. Surgical excision tends to be ineffective due to silicone migration. The treatment of this disorder is difficult and often ineffective.

Thyroid Abscess: Challenges in Diagnosis and Management.

Thyroid abscess is an uncommon infectious pathology. The thyroid is highly resistant to infection due to high iodine content, capsular encasement, and rich vascularity. Acute suppurative thyroiditis represents <1% of thyroid diseases that could potentially become a life-threatening endocrine emergency. A 48-year-old woman with AIDS presented with 3 days of fever, tender neck swelling, and methicillin-resistant Staphylococcus aureus bacteremia. Apart from leukocytosis, initial laboratory values including thyroid function tests were normal. The initial plain computed tomography scan of the neck and ultrasound scan of the neck were inconclusive as well. By day 4, she worsened, and on repeat computed tomography scan of the neck with contrast, multiloculated abscesses in the thyroid and retro pharynx were seen, which needed emergent drainage. Acute suppurative thyroiditis, a rare disease, occurs in patients with either preexisting disorders of the thyroid or in the immunocompromised. The most common pathogen is Staphylococcus aureus. In our case, we highlight the fact that initial imaging may be negative in the early stages of acute suppurative thyroiditis and lead to an erroneous diagnosis of subacute thyroiditis. There are less than 5 cases of methicillin-resistant Staphylococcus aureus suppurative thyroiditis reported.

Role of laparoscopy in diagnosing genital tuberculosis in suspected women: A cross-sectional study from a tertiary care hospital in Northern India.

This study was included 60 women with suspected genital tuberculosis, attending outpatient department of a tertiary care hospital. The aim was to evaluate the role and accuracy of laparoscopy in the diagnosis of genital tuberculosis. The patients were investigated for tuberculosis with Erythrocyte Sedimentation Rate, Montoux, chest X-ray, serum ELISA, CA125, ultrasonography, endometrial biopsy and laparoscopic biopsy. Culture or histopathology was taken as a gold standard for confirming the cases of genital tuberculosis. 30 patients were confirmed as positive. Comparison was made between the various diagnostic modalities. Baseline investigations like complete blood count, differential leukocyte count, ESR, Montoux, and some special tests like CA125 and serum ELISA were helpful in supporting the diagnosis in only some patients. The sensitivity, specificity, positive and negative predictive value of endometrial biopsy in diagnosing GT was 6.6%, 100%, 100% and 51.7% respectively. Laparoscopic gross visualization alone, staining, culture and histology were able to detect 86.6%, 33.3%, 50% and 63.3% of cases respectively. Many patients would have been missed if laparoscopy was not performed. It helps in macroscopic visualization of pelvic cavity and obtaining biopsies for ZN staining, culture and histopathology. This increases the pickup rate of positive cases and helps in confirmation of the diagnosis.

Hemoglobin E disease and glycosylated hemoglobin.

Glycosylated hemoglobin (HbA1C) is a routinely measured parameter to monitor long-term glycemic control in people with diabetes mellitus. The presence of hemoglobin (Hb) variants can affect the accuracy of HbA1C methods. Hb E variant is the most common Hb variant in South-east Asia and North-east India. In the presence of Hb E, HbA1C may not be detectable by ion-exchange chromatography (high-pressure liquid chromatography), but may be estimated by immunoassay technique and boronate affinity chromatography. However, the result may be underestimated when correlated with plasma glucose and serum fructosamine levels. Clinicians should be aware of this limitation of HbA1C estimation in patients with Hb E and other Hb variants.

Breast stimulation in low-risk primigravidas at term: does it aid in spontaneous onset of labour and vaginal delivery? A pilot study.

AIMS: The aim of the study was to elicit the safety and efficacy of breast stimulation as an intervention to prevent postdatism and as an aid in spontaneous onset of labour. METHODS: Primigravidas with cephalic presentation, without any high-risk factor, were recruited between 36 to 38 weeks of gestation. 200 patients were recruited and randomized into two groups (n = 100). Breast stimulation was advised to one group but not to the other group. Bishop's scoring was done at 38 weeks and repeated at 39 weeks of gestation. Maternal and fetal outcomes were compared in two groups. RESULT: Bishop's score changed from 3.12 (±1.01) to 3.9 (±1.08) in control group and from 3.02 (±0.82) to 6.08 (±1.29) in breast stimulation group after one week (P value < 0.0001). The period of gestation at delivery was 39.5 (±2.3) weeks in control group and 39.2 (±2.8) weeks in intervention group (P value: 0.044). There were increased chances of vaginal delivery in intervention group (P value: 0.046). Duration of labor, hyperstimulation, presence of meconium stained liquor, postpartum hemorrhage, and neonatal outcomes were similar in both groups. CONCLUSION: Breast stimulation in low-risk primigravidas helps in cervical ripening and increases chances of vaginal delivery.