The effect of oxidants on 2-MIB concentration with the presence of cyanobacteria.

In this study, the effect of three oxidants, sodium hypochlorite, potassium permanganate, and ozone, were tested for the removal of 2-MIB with presence of cyanobacteria. Algae in water samples from the source water of Feng-Shen waterworks (FSW), Taiwan were cultivated at 30 degrees C with continuous light at an intensity between 2,500 and 3,400 lux. During the cultivating process, water samples were analyzed for nutrients, light absorbance at 665 nm (A665), and 2-MIB concentration. The 2-MIB concentrations within the incubated samples increased to as high as 1,000 ng/L to 2,000 ng/L, although no extra nutrients were added to the raw water. After 2 to 3 days incubation, the intracellular 2-MIB concentration was as high as 70% of the total 2-MIB in the samples. The algae that developed were mainly cyanobateria, and more than 90% belonged to the Genus Oscillatorias. An almost 100% removal of both 2-MIB and geosmin in the raw water was observed after ozonation for 10 minutes at a dosing rate of 0.91 mg/l-min. Chlorine and permanganate were much less effective, both removing only about 11% of the 2-MIB within 60 minutes at oxidant concentration of 10 mg/l. Oxidation of the cultivated samples showed that chlorine and permanganate may damage algae cells causing them to release intracellular 2-MIB. During the 60 minutes of reaction time, the total 2-MIB concentrations (intracellular plus dissolved) varied by no more than 10%, however, the ratios between dissolved and total 2-MIB concentrations increased. Two effects of ozonation on the 2-MIB concentration in the cultivated samples were observed when the algae were young, namely 2-MIB release from damaged cells and 2-MIB oxidization. The rates of 2-MIB release and 2-MIB destruction were similar. However, old algae cells were more easily damaged. As a result, intracellular 2-MIB was released faster, and the soluble 2-MIB was destroyed more quickly by ozonation.

Bilateral adrenocortical adenomas causing ACTH-independent Cushing's syndrome at different periods: a case report and discussion of corticosteroid replacement therapy following bilateral adrenalectomy.

We report a rare case of bilateral adrenocortical adenomas causing ACTH-independent Cushing's syndrome at different periods 9 yr apart. The subject, a 24-yr-old woman, in June 1989 had a typical Cushingoid appearance. Her baseline plasma cortisol levels did not show a diurnal rhythm and she had a very low baseline plasma ACTH level. Plasma cortisol levels could not be suppressed by overnight low-dose or two-day high-dose dexamethasone suppression test. Marked uptake of 131I-6beta-iodomethyl-19-norcholesterol (NP-59) was observed in the right adrenal gland. Abdominal computed tomography (CT) showed a right adrenal tumor. The right adrenal gland with adenoma was removed. The non-tumorous part of the adrenal cortex was atrophic. By April 1998, she had experienced a weight gain of more than 20 kg over a two-yr period. The baseline plasma cortisol levels were at the lower limit of the normal range with loss of diurnal rhythmicity. The baseline plasma ACTH levels were very low. Neither a two-day low-dose nor a two-day high-dose dexamethasone suppression test could suppress serum cortisol or urinary free cortisol levels. NP-59 adrenal scan revealed increased uptake of the left adrenal gland at 72 h after intravenous injection of the tracer. Abdominal CT and magnetic resonance imaging (MRI) all demonstrated a left adrenal mass. Left adrenalectomy was performed in June 1998; histological features showed a cortical adenoma and atrophic change in the non-tumorous part of the adrenal cortex. Elevated plasma ACTH levels after bilateral adrenalectomy could be suppressed with conventional corticosteroid replacement therapy and overnight low-dose dexamethasone suppression test.

Levothyroxine suppression of thyroglobulin in patients with differentiated thyroid carcinoma.

For patients with differentiated thyroid carcinoma, the appropriate degree of TSH suppression by levothyroxine (L-T4) is still unknown. To find the target level of TSH suppression, we analyzed the relationship between the degree of TSH suppression determined by third generation assay and thyroglobulin (Tg) response during the titration of the dosage of L-T4. Ninety-two patients with differentiated thyroid carcinoma (19 males and 73 females; age, 40.5+/-13.5, mean +/- SD) were included. All of the recruited patients had near-total thyroidectomy, 30-150 mCi 131I thyroid ablation, and negative Tg autoantibodies. They were classified into 3 groups. Group A was composed of 25 patients with local or distant relapse. Group B was composed of 12 patients without clinically detectable relapse, but Tg levels either above 2 ng/mL under L-T4 suppression or above 3 ng/mL off L-T4 therapy. Group C included 55 patients who had no active disease and Tg levels below 2 and 3 ng/mL during and off L-T4 suppression, respectively. Serum TSH and Tg were measured simultaneously at the end of 8-12 weeks of a certain dose of L-T4 therapy during dosage titration and also after withdrawal of L-T4 for 4-6 weeks for the total body scan. Wilcoxon signed ranks test was used to compare paired samples of Tg, and Spearman rank correlation was used to determine the correlation of relative changes in TSH to changes in Tg calculated by individual. The results showed that 1) Tg levels were significantly higher during the period off L-T4 therapy than on L-T4, therapy in all 3 groups (P < 0.01); 2) during L-T4, therapy, within the same treatment course, mean Tg levels were higher when TSH levels were normal than when TSH levels were suppressed, statistically significant in group A (P = 0.001), nonsignificant in group B (P = 0.09), and nonsignificant in group C (P = 0.30); and 3) when TSH was suppressed below normal, there was no correlation between the relative changes in TSH and Tg by individual in all 3 groups (P > 0.05). The data suggest a stratified postoperative thyroid hormone management of patients with differentiated thyroid carcinoma. TSH should be lowered to below normal in patients with active disease. If patients are clinically disease free with Tg levels below 2 ng/mL, TSH can be kept within the normal range. For the most controversial group B patients, it is recommended that the TSH be suppressed and be closely followed up.

Outcome of Graves' disease after antithyroid drug treatment in Taiwan.

The outcome of Graves' disease after treatment with antithyroid drugs (ATDs) varies widely among countries, and large-scale studies in Asia are rare. We investigated the associations of various clinical and laboratory features with the outcome of ATD therapy for Graves' disease in Taiwan. A total of 210 patients (177 women, 33 men; mean +/- SD age, 41.7 +/- 15.1 yr) treated with ATD in Taiwan were included. ATD therapy started with methimazole 30 mg daily or propylthiouracil 300 mg daily and was continued until a euthyroid state was achieved. Afterwards, 154 patients received a maintenance dose of ATD alone, while 56 patients received a combination of an ATD and thyroxine (L-T4). Patients were considered to be in remission if they remained in a euthyroid state for more than 2 years after drug withdrawal. The mean follow-up periods were 45.0 +/- 20.9 months for patients with remission and 30.4 +/- 19.8 months for those with relapse. Relapse occurred in 126 (60%) patients during the follow-up period, within 3 months after drug withdrawal in 47 (37%), and within 6 months in 60 (46%). The relapse rate was 100% among patients with two or more previous relapses. Patients with a second occurrence had a higher relapse rate than those with a first occurrence (84% vs 43%). Past history of recurrence, goiter size, thyroid-stimulating hormone level and thyrotropin-binding inhibition immunoglobulin activity at the end of ATD treatment were independently associated with relapse. Prolonged duration of treatment did not yield better results in patients with larger goiters or a history of recurrence, or both. Combination therapy with L-T4 yielded similar results to those achieved with ATD treatment alone. In conclusion, the relapse rate of Graves' disease after ATD treatment in Taiwanese patients was high, especially in those with a history of recurrence. The treatment duration and drug regimen did not affect the outcome.

Glucocorticoid remediable aldosteronism: a case report.

Glucocorticoid remediable aldosteronism (GRA) is a hereditary cause of mineralocorticoid hypertension. The most common presentation is asymptomatic hypertension. Hypokalemia, hyperaldosteronism and suppressed plasma renin activity are other forms of primary hyperaldosteronism. However, the aldosterone secretion in these patients is regulated by adrenocortico-tropic hormone (ACTH) rather than the reninangiotension system. Here, we report a patient with a 12-year history of hypertension without response to any treatment until dexamethasone was administered. The diagnosis of GRA was confirmed by elevated plasma level of 18-oxocortisol, which is a unique steroid biochemical abnormality of this disease. In GRA, hybrid steroids (18-oxocortisol and 18-hydroxycortisol) are synthesized at the C-18 carbon of cortisol in a similar way as when corticosterone is converted to aldosterone. The gene duplication defect is on chromosome 8 codes for a chimerical 11 beta-hydroxylase/aldosterone synthase enzyme, causing ectopic expression of aldosterone synthase in zona fasiculata. Because this hypertension is remediable by exogenous glucocorticoid, this case was reported to raise attention about treatable aldosteronism.

The effect of ketoconazole in pre-operative treatment in Cushing's syndrome: three cases report.

Ketoconazole is an orally active imidazole derivative that is an effective therapeutic drug in the treatment of mycotic infection. The development of gynecomastia in male patients treated with ketoconazole has led to investigation of its potent inhibitory effect on adrenal steroidogenesis. In this study, we present our preliminary experience using high dose ketoconazole, which was used safely as a palliative treatment in 3 patients with Cushing's syndrome prior to surgery. The 24-hour urinary free cortisol excretion was decreased by more than 52% in 1 to 2 days and fell to within normal limits of less than 120 micrograms by the 1st day, 2nd day or 15th day in these 3 patients. Cushing's syndrome was either adrenocorticotropin-dependent or -independent during treatment. In case 3, the plasma adrenocorticotropin level was unchanged during treatment in the first week, despite marked reductions in plasma and 24-hour urinary free cortisol levels. The most significant improvement of clinical symptoms was that the patients could sleep much more comfortably at night following the suppression of hypercortisolism by ketoconazole. Monitoring of liver function and addition of dexamethasone are recommended to prevent the possibility of reversible adverse effects such as severe hepatic injury and adrenal insufficiency or even crisis.

Ectopic parathyroid adenoma with severe hungry bone syndrome: a case report.

The presentation rate of ectopic mediastinal parathyroid adenoma is about 5 approximately 22%. Ectopic parathyroid adenoma is a common etiology of failed parathyroid surgery as well as a diagnostic challenge to clinicians. We reported a case of ectopic mediastinal parathyroid adenoma. A 20-year-old girl presented with arthralgia for 2 years before hyperparathyroidism was diagnosed. Parathyroid ultrasonography failed to find the lesion, but a vivid uptake in the superior mediastinum was discovered by thallium-201 (Tl-201) and technetium-99m-sestamibi (Tc-99m-MIBI) images. Removal of the ectopic adenoma resulted in severe Hungry bone syndrome, which required a large amount of calcium and phosphorous supply. Later, the patient suffered from bilateral femoral neck fracture due to marked osteoporosis. Bone mineral density study revealed marked increase of fracture risk. Although bone disorder is rare in cases of hyperparathyroidism nowadays, it still should be considered in patients with arthritis of unknown etiology like our case. Early diagnosis and treatment can reduce the morbidity.

Skin metastases from follicular thyroid carcinoma: a case report.

Thyroid carcinomas metastasizing to the skin are rare. We report a case of skin metastases from a follicular thyroid carcinoma. A 73-year-old man developed multiple painless skin nodules about 6 years after thyroidectomy for the primary thyroid carcinoma. A biopsy disclosed a dermal tumor composed of small thyroid follicular structures with colloid material. The diagnosis was confirmed by immunohistochemistry using monoclonal antithyroglobulin antibodies performed on the skin biopsy specimens. The patient died 9 months later with multiple metastases after the development of skin lesions.

Ectopic ACTH syndrome with nocardiosis--a case report.

A 25-year-old man was admitted with chief complaints of multiple ecchymoses over face and both arms after a trivial trauma since one month before entry. Physically, he was thin without moon face, buffalo hump, or purple striae, while extensive fungus infection was present. Mild hyperglycemia, hypokalemic alkalosis were also found. Chest x-ray revealed multiple cavitary nodular lesions over bilateral lung fields. Needle biopsy from a rib lesion showed small cell carcinoma with strongly positive ACTH stain. The patient's basal cortisol level was greater than 62 micrograms/dl and failed to be suppressed by both low and high dose dexamethasone. The 24 hours urine free cortisol, 17 KS, and 17 OHCS were 8454 micrograms/24h, 49.8 mg/24h, and 50.8 mg/24h respectively. His plasma ACTH level was 725 pg/ml and remained high (1210 pg/ml) after high dose dexamethasone suppression. On the 10th day after admission, the patient's general condition got worse rapidly. Fever, dyspnea developed with progression of the lung lesions. Nocardia infection was proved. He expired three days later in spite of antibiotics and ketoconazole treatment.

Tc-99m pertechnetate trapping and thyroid function in Hashimoto's thyroiditis.

Tc-99m pertechnetate thyroid imaging was studied in 52 patients with Hashimoto's thyroiditis, with special reference to the thyroid functional state and Tc-99m trapping by the gland. The most common finding was diffusely increased trapping of radioactivity, a pattern similar to Graves' disease. On the other hand, the increased trapping in Hashimoto's thyroiditis was usually associated with hypothyroidism. The degree of Tc-99m trapping did not correlate with the degree of the endogenous TSH elevation. However, increased Tc-99m trapping could predict the reversibility of hypothyroidism in just 3 months.

Limited joint mobility of the hand: prevalence and relation to chronic complications in non-insulin-dependent diabetes mellitus patients.

A total of 170 non-insulin-dependent diabetes mellitus (NIDDM) patients admitted to Kaohsiung Chang Gung Memorial Hospital during the period from January 1988 to December 1989 were examined for the presence of cheiroarthropathy. Fifty-four percent (92 patients) had limited joint mobility (LJM) of the hand, a prevalence significantly higher than that of non-diabetic controls (7%). Duration of diabetes was positively related to the severity of LJM (p = 0.03, chi-square contingency table). Chronic diabetic complications such as cataracts (p = 0.04) and overt proteinuria (p = 0.03) were also associated with the presence of LJM, and diabetic retinopathy (p = 0.007); vision-threatening retinopathy was strongly associated with the presence of LJM (p = 0.0002). The sex ratio, HbA1c and creatinine clearance rates did not show significant differences between patients with and without LJM. In conclusion, the occurrence of LJM of the hand in NIDDM patients observed at this hospital is common and is often accompanied by other chronic diabetic complications. Its presence should alert physicians to other associated diabetic complications with increased morbidity and mortality.