Rising HbA1c in the presence of optimal glycaemic control as assessed by self-monitoring - iron deficiency anaemia.

HbA1c can be affected by determinants other than glucose and an awareness of this is important to avoid unnecessary hypoglycaemia.

Acute Transient Stress Induced Adrenal Hypertrophy and Adrenal Medullary Hyperactivity.

OBJECTIVES: Adrenal gland hypertrophy can be related to acute stress with abnormal adrenal function tests. It may not always need treatment. MATERIAL AND METHODS: An acute presentation of adrenal gland hypertrophy following an abdominal emergency, with subsequent hypoadrenalism was investigated. RESULTS: Adrenal medullary and cortical function fully recovered without treatment. CONCLUSIONS: We postulate that the adrenal glands became enlarged and hypertrophied during an acute stress event, possibly caused by acute adrenal medullary hypersecretion and subsequent cortical hyposecretion. A wait and watch policy should be followed if no other clinical symptoms and signs of adrenal disease are present. CT scan remains an important diagnostic tool. LEARNING POINTS: Abnormal adrenocortical function tests and hypertrophy can occur in an acutely ill patient as a stress response.It is possible to have both hypersecretion and hyposecretion of adrenal hormones.A wait and watch policy should be followed if no other clinical symptoms and signs of adrenal disease are present in an acutely ill patient.

Hypoglyceamia in a Patient with a Solitary Fibrous Tumour.

OBJECTIVE: To illustrate an unusual mechanism causing hypoglycaemia. MATERIAL AND METHODS: A 76-year-old man presented with episodes of agitation and confusion and was resuscitated with oral glucose gel when found to be hypoglycaemic. RESULTS: A CT scan for an abdominal mass confirmed a solitary fibrous tumour (SFT). The sarcoma multidisciplinary team suggested conservative management. The patient's episodic hypoglycaemia was managed with diet modification including corn-based starch, scheduled snacks and dexamethasone. Glucose levels were within normal range at discharge from hospital. The patient was referred to the palliative care team for follow-up. CONCLUSION: SFTs causing non-islet cell tumour hypoglycaemia are difficult to treat. LEARNING POINTS: To be aware of rarer causes of hypoglycaemia and to consider unusual causes in acute presentations of hypoglycaemia, especially in patients who do not have diabetes.This case illustrates the importance of a thorough general physical and systemic examination, as identifying the abdominal mass is essential to the early diagnosis of this rare condition.Solitary fibrous tumours causing non-islet cell tumour hypoglycaemia are difficult to treat, and even when surgical resections are applicable, recurrence rates are high.

Dysautonomia: an Explanation for the Medically Unexplained?

OBJECTIVE: To identify dysautonomia as a collection of conditions with variable presentation that may be mistaken for medically unexplained symptoms. METHODS: Case series. RESULTS: Tilt table testing and 24 h electrocardiographic monitoring provided useful diagnostic tools to confirm the diagnosis. CONCLUSION: A greater awareness and recognition of the disorders that result from dysautonomia and recognition of the disability that results from these disorders will improve patients' quality of life. LEARNING POINTS: Dysautonomia is protean in presentation and clinicians need to have a high degree of suspicion as, if diagnosed, symptomatic improvement is possible leading to improved quality of life.Tilt table testing and 24 h electrocardiographic monitoring are useful diagnostic tools.Greater awareness and recognition of the disorders that result from dysautonomia with appropriate use of these tests by medical professionals is necessary.

Adrenal insufficiency due to the development of bilateral adrenal haemorrhage following hip replacement surgery.

Bilateral adrenal haemorrhage should be considered as a differential diagnosis in patients presenting with non-specific symptoms and hypotension postoperatively.