Iatrogenic myxoedema madness following radioactive iodine ablation for Graves' disease, with a concurrent diagnosis of primary hyperaldosteronism.

UNLABELLED: Myxoedema madness was first described as a consequence of severe hypothyroidism in 1949. Most cases were secondary to long-standing untreated primary hypothyroidism. We present the first reported case of iatrogenic myxoedema madness following radioactive iodine ablation for Graves' disease, with a second concurrent diagnosis of primary hyperaldosteronism. A 29-year-old woman presented with severe hypothyroidism, a 1-week history of psychotic behaviour and paranoid delusions 3 months after treatment with radioactive iodine ablation for Graves' disease. Her psychiatric symptoms abated with levothyroxine replacement. She was concurrently found to be hypertensive and hypokalemic. Primary hyperaldosteronism from bilateral adrenal hyperplasia was diagnosed. This case report serves as a reminder that myxoedema madness can be a complication of acute hypothyroidism following radioactive iodine ablation of Graves' disease and that primary hyperaldosteronism may be associated with autoimmune hyperthyroidism. LEARNING POINTS: Psychosis (myxoedema madness) can present as a neuropsychiatric manifestation of acute hypothyroidism following radioactive iodine ablation of Graves' disease.Primary hyperaldosteronism may be caused by idiopathic bilateral adrenal hyperplasia even in the presence of an adrenal adenoma seen on imaging.Adrenal vein sampling is a useful tool for differentiating between a unilateral aldosterone-producing adenoma, which is managed surgically, and an idiopathic bilateral adrenal hyperplasia, which is managed medically.The management of autoimmune hyperthyroidism, iatrogenic hypothyroidism and primary hyperaldosteronism from bilateral idiopathic adrenal hyperplasia in patients planning pregnancy includes delaying pregnancy 6 months following radioactive iodine treatment and until patient is euthyroid for 3 months, using amiloride as opposed to spironolactone, controlling blood pressure with agents safe in pregnancy such as nifedipine and avoiding ß blockers.Autoimmune hyperthyroidism and primary hyperaldosteronism rarely coexist; any underlying mechanism associating the two is still unclear.

The relationship between insulin sensitivity and insulin-like growth factor-binding protein-1.

Insulin has been shown to regulate insulin-like growth factor-binding protein-1 (IGFBP-1) in vivo and in vitro. Insulin resistance is a feature of the polycystic ovary syndrome (PCOS). We have studied the relationship between insulin sensitivity (S1) and the circulating concentration of IGFBP-1 in a group of young women and in some who had PCOS. A case-control study has been carried out comparing reproductively normal women with women with PCOS (defined as women with oligo- or amenorrhea associated with androgen excess). Fifteen women with clinical PCOS and ten age- and weight-matched controls were studied. S1 was measured by the frequently sampled intravenous glucose tolerance test (FSIGT) using the minimal model technique. IGFBP-1, insulin-like growth factor-I (IGF-I) and growth hormone levels were measured before and during the FSIGT. Circulating testosterone, dehydroepiandrosterone (DHEA) and its sulfate (DHEAS) levels were measured while the subjects were fasting. S1 and IGFBP-1 levels were significantly lower in the PCOS group than in controls (S1/10(-5) min-1/pM] mean +/- SE 3.8 +/- 0.8 vs. 8.5 +/- 1.3, p < 0.03; IGFBP-1 [ng/ml] mean +/- SE 26.6 +/- 4.2 vs. 56.0 +/- 5.9, p < 0.005). In women with PCOS, IGFBP-1 concentrations related negatively to the body mass index (BMI) (r = -0.77, p < 0.003) and positively to S1 (r = 0.76, p < 0.003). S1 remained a significant predictor of IGFBP-1 concentrations when controlled for BMI (combined r2 = 0.35, p < 0.05). No relationship was found between androgen levels and IGFBP-1. Insulin sensitivity contributed to the difference in IGFBP-1 levels found in women with PCOS. Whether the reduced concentrations of IGFBP-1 play a role in the pathophysiology of PCOS is uncertain, but it may act to alter delivery of IGF to peripheral tissues in insulin-resistant individuals.

Adipose tissue distribution changes during rapid weight loss in obese adults.

Changes in adipose tissue distribution as defined by the waist-to-hip ratio (WHR), were evaluated in 16 android, obese subjects (seven male and nine female) given a very low energy ketogenic diet of 1.72 MJ (411 kcal) for 4 weeks. Total weight loss was significantly greater for the males (11.2 +/- 2.5 kg) compared to females (8.3 +/- 0.8 kg); the relative weight loss however, was similar (9.9 vs 9.3 percent). Female and male losses in percent body fat and lean body mass were not significantly different. For both groups, significant (P less than 0.01) changes in waist and hip circumferences were observed; however, no significant changes were observed in WHR. These results indicate that in obese android male and female subjects, adipose tissue distribution as measured by WHR, does not change in response to rapid weight loss.

Uterine growth in the follicular phase of spontaneous ovulatory cycles and during luteinizing hormone-releasing hormone-induced cycles in women with normal or polycystic ovaries.

The uterine response to follicular growth in luteinizing hormone-releasing hormone (LH-RH)-induced ovulatory cycles was assessed by serial ultrasound measurement of uterine cross-sectional area and endometrial thickness in 23 cycles in women with normal ovaries and 24 cycles in women with polycystic ovaries. Nine women with spontaneous ovulatory cycles also were studied. The authors correlated uterine cross-sectional area and endometrial thickness with follicle diameter (FD) and serum estradiol-17 (E2). In women with either normal or polycystic ovaries, there was an E2-related increase in uterine cross-sectional area and endometrial thickness, but both uterine area and endometrial thickness were greater in the late follicular phase of women with polycystic ovaries compared with those with normal ovaries.

The response of patients with organic hypothalamic-pituitary disease to pulsatile gonadotropin-releasing hormone therapy.

Treatment with pulsatile gonadotropin-releasing hormone (GnRH) therapy has been attempted in 13 women and 5 men with hypogonadotropic hypogonadism caused by structural lesions of the hypothalamic-pituitary axis. Ten patients responded to treatment with induction of ovulation or spermatogenesis. Of these subjects, seven had primary suprasellar lesions, and one had an apparently empty pituitary fossa on reconstructive computerized tomographic scanning. The eight patients who failed to respond to treatment all had extensive intrafossa damage, as a result of either surgery, irradiation, or infarction. Pulsatile GnRH therapy is not effective in patients with extensive intrafossa lesions.

Multifollicular ovaries: clinical and endocrine features and response to pulsatile gonadotropin releasing hormone.

By means of pelvic ultrasonography, a multifollicular ovarian appearance was observed in women with weight-loss-related amenorrhoea. Multifollicular ovaries (MFO) are normal in size or slightly enlarged and filled by six or more cysts 4-10 mm in diameter; in contrast to women with polycystic ovaries (PCO), stroma is not increased. Unlike PCO patients, women with MFO were not hirsute and serum concentrations of luteinising hormone and follicle stimulating hormone were normal and decreased, respectively. The uterus was small indicating oestrogen deficiency. In MFO, treatment with gonadotropin releasing hormone (LHRH) induced ovulation in 83% of cycles and there were seven pregnancies in 8 women; in PCO, only 40% of cycles were ovulatory and there were eleven pregnancies (8 women) but six of these aborted. In MFO ovarian morphology reverted to normal in ovulatory cycles, whereas in PCO the polycystic pattern persisted despite the presence of a dominant follicle. MFO may represent a normal ovarian response to weight-related hypothalamic disturbance of gonadotropin control.

Hirsutism.

The endocrine abnormalities associated with the development of androgen-dependent hirsutism have been presented and discussed in the light of the frequent finding of ultrasonographic abnormalities suggestive of polycystic ovary syndrome. A simple protocol of investigation, which should ideally include pelvic ultrasonography, has been presented. The treatment of hirsutism by combined anti-androgen and oestrogen therapy has been detailed and other approaches discussed.

The investigation of female gonadal dysfunction.

An approach to the investigation of ovarian dysfunction has been presented here with a particular emphasis on the importance of effective imaging of the ovary and uterus by ultrasonography. Essential endocrine investigations in the various clinical manifestations of altered ovarian function have been placed in the context of recent research on the control of female reproduction.

Hypothalamic hypopituitarism in a patient with a basal encephalocoele--treatment with luteinizing hormone-releasing hormone.

A 20-year-old patient presented with primary amenorrhoea and growth hormone deficiency caused by a basal encephalocoele. She was found to have developed diabetes insipidus in the 8 years following diagnosis. Gonadotrophin release in response to bolus injection of luteinizing hormone-releasing hormone (LHRH) was normal, as was thyrotrophin and adrenocorticotrophin (ACTH) secretion. Pulsatile administration of LHRH by the subcutaneous route resulted in normal ovulation and subsequent menstruation. The investigation and management of patients with basal encephalocoeles are discussed in the light of these findings.

The treatment of hypogonadotrophic hypogonadism in men by the pulsatile infusion of luteinising hormone-releasing hormone.

The effects of chronic subcutaneous infusion of luteinising hormone-releasing hormone (LHRH) have been studied in a group of 17 male patients with hypogonadotrophic hypogonadism (HH). Ten of the patients had primary and seven secondary failure of gonadotrophin release, and all but four had previously been treated with gonadotrophin injections. Treatment was continued for between one and 18 months and was well tolerated by all except one patient who became allergic to LHRH. An increase in the basal gonadotrophin concentrations occurred in all except four patients within one week of the initiation of therapy, and this was associated with a rise in the serum testosterone level in eight patients. Increased spermatogenesis was demonstrated in seven cases and three pregnancies have resulted thus far. Pituitary desensitisation to the effects of LHRH was found in five subjects with primary HH who failed to produce any increase in testosterone secretion despite an initial stimulation of gonadotrophin release. We conclude that chronic pulsatile infusion of LHRH is an effective technique for the treatment of some cases of hypogonadotrophic hypogonadism.

Pancreatic cancer and diabetes mellitus.

In a series of 6,500 patients with diabetes mellitus there were 37 cases of primary carcinoma of the pancreas which significantly exceeded the expected number for the patient years at risk in both males and females (p less than 0.01). There was no evidence that pancreatic cancer was more common in patients with long-standing diabetes. The increased incidence of pancreatic cancer in diabetic patients is probably the result of patients presenting with the symptoms of diabetes as long as four years before the cancer becomes manifest. An underlying pancreatic tumour should be suspected when an elderly diabetic proves difficult to control and loses weight despite adequate treatment.

Ultrasound assessment of changes in the ovary and the uterus during LHRH therapy.

Twenty-seven women with secondary amenorrhoea have been treated with pulsatile subcutaneous luteinising hormone releasing hormone (LHRH). Serial ultrasonic observations of increasing follicular diameters and changes in the size of the uterus have been recorded. The rate of the increase of the diameter of dominant follicles in LHRH induced cycles is identical to that observed in women undergoing spontaneous cycles. An interesting correlation was observed between follicular diameter and uterine size. The correlation suggests that uterine size measured ultrasonically can be used as a bio-assay of follicular oestradiol production. Uterine growth continues throughout the luteal phase of conception cycles and can be used as a very early sign of pregnancy.

Induction of ovulation with pulsatile luteinising hormone releasing hormone.

Ovulation was successfully induced with luteinising hormone releasing hormone in 28 women with hypothalamic amenorrhoea who had failed to respond to treatment with clomiphene. Luteinising hormone releasing hormone was administered in a pulsatile manner with miniaturised automatic infusion systems. The rate of ovarian follicular maturation, as monitored by serial pelvic ultrasonography, was similar to that observed in spontaneous cycles. Endocrine assessment by serial measurement of gonadotrophin, oestradiol, and progesterone concentrations showed hormone concentrations to be within the normal range. Intravenous treatment was required in only two patients, the remainder responding satisfactorily to subcutaneous infusion. All patients conceived within six cycles of treatment, and only one multiple pregnancy occurred.

Photocoagulation for optic disc new vessels in diabetes mellitus.

The effects of treatment by argon laser and xenon arc photocoagulation in 165 diabetic patients with optic disc new vessel formation have been studied retrospectively. Visual acuity and degree of new vessel formation have been assessed over a period of between six months and seven years of follow-up (mean 23 months). Visual acuity improved in 36% of treated eyes and remained unchanged in 34%. Improvement was most marked in those with initially poor acuity (less than 6/36). There was no association between improvement in visual acuity and regression of disc vessels, the latter occurring in 79% of treated eyes. Only 6% of eyes became blind during the period of follow-up, principally as a result of vitreous haemorrhage and retinal detachment. There was no difference between the results produced by the use of separate or combined argon laser and xenon arc photocoagulation on the regression of disc new vessels. However, our results suggest that argon laser treatment was more effective than xenon arc photocoagulation in improving visual acuity. These findings suggest that either form of treatment or a combination offers considerable benefit in the management of proliferative diabetic retinopathy, even when very severe at presentation.

Is preoperative localisation of insulinomas necessary?

During the past 20 years 33 patients suspected of harbouring an insulinoma have been investigated. 29 had laparotomy, and tumours were removed from 27.2 of the 29 and 1 other proved not to have an insulinoma, although preoperative imaging had suggested a tumour. Four different localisation procedures were used, and in some patients more than one technique was applied. Selective arteriography of branches of the coeliac axis showed the position of the insulinoma correctly in 9 out of 18 cases, but in all of these the tumour was felt at operation, so that the information provided was unnecessary. Arteriography gave false localisation in 4 patients and missed the tumour completely in 4 but was also negative in 1 patient not harbouring a tumour. Ultrasonic examination provided correct localisation in only 2 out of 11 instances and computer-assisted tomography in 1 out of 8. Insulin estimation in blood obtained at percutaneous transhepatic portal-venous sampling (THPVS) provided correct localisation in 2 out of 8 cases, but in only 1 of these was it needed to guide pancreatic resection. Localisation was spurious in 5 patients, and in 1 there was no evidence of a tumour at all. In 23 patients the surgeon felt and removed the insulinoma at the first operation. In 3 tumour was palpable at a second laparotomy some years later. In only 1 was no tumour felt at operation. The false-positive findings in the THPVS were caused by misinterpretation of data. For a peak of insulin concentration in the portal vein to be meaningful, it should exceed 200 mU/l and to be fully diagnostic it should be greater than 500 mU/l. Present imaging techniques are not precise enough to localise an insulinoma. An experienced surgeon has a very high probability of being able to palpate the tumour at operation, and preliminary localisation is therefore not needed in most cases.

Fatal dependence on kaolin and morphine mixture.

A patient is described who had a long history of abuse of kaolin and morphine mixture which ultimately proved fatal.

Insulin deficient diabetes. Contrasts with other endocrine deficiencies.

Comparisons are made between the incidence, prognosis and treatment of juvenile-onset diabetes and other endocrinopathies in the young. 548 patients with insulin deficient diabetes diagnosed before 20 years of age have been reviewed. Excess mortality, especially at 35--40 years of age was found. Profiles of blood glucose and serum insulin have been studied and compared to those of normal subjects. The variation of insulin absorption and effect of insulin antibodies on the free insulin levels achieved after exogenous insulin injections have been demonstrated. The common occurrence of nocturnal subclinical hypoglycaemia following intermediate or long-acting insulin was often found to be the cause of poor diabetic control. Five out of 33 patients with 'difficult' diabetes had an unexplained resistance to high levels of free-insulin. The value of self-monitoring and HbAl measurements in the improvement of diabetic control and possibly life expectation is reviewed. The incidence of thyroid disease was found to be increased in 1779 insulin deficient diabetics of all ages and persistence of islet-cell antibodies suggests that the diabetes may be due to autoimmunity in some of these patients.

[Surgical management of divergent strabismus (author's transl)]. / Le traitement chirurgical des strabismes divergents.

This study, about 111 cases of exodeviations, establishes a guideline for surgical management of divergent strabismus. First the main points of the clinical examination, and the different classifications of the exodeviations are exposed. Then the technics of surgical treatment are defined, with or without pre or post surgical orthoptic treatment. The conclusions are as following: -- some clinical elements guide our treatment: the refraction, the age at onset, the study of the deviation after constant use of prisms, the existence of A or V syndrome. -- The main points of the surgical management are: the age of surgery, the choice of technic (symmetrical or not), the usefulness of a transient overcorrection, and above all the quantative rules for the surgical treatment. So it as been possible to stress the functional result is quite depending on the clinical type of exodeviation.

Male pseudohermaphroditism due to partial end-organ insensitivity to androgens.

A 46XY individual with incomplete male pseudohermaphroditism was studied. The phenotype was distinctive, with a masculine habitus despite a small phallus, gynaecomastia and diminished virilization. Plasma levels of testosterone, oestrogens, gonadotrophins and sex-hormone binding globulin were elevated. It is proposed that this syndrome is a variant of Type I incomplete male pseudohermaphroditism.