A case of severe ectopic ACTH syndrome from an occult primary - diagnostic and management dilemmas.

UNLABELLED: Resection of primary tumour is the management of choice in patients with ectopic ACTH syndrome. However, tumours may remain unidentified or occult in spite of extensive efforts at trying to locate them. This can, therefore, pose a major management issue as uncontrolled hypercortisolaemia can lead to life-threatening infections. We present the case of a 66-year-old gentleman with ectopic ACTH syndrome from an occult primary tumour with multiple significant complications from hypercortisolaemia. Ectopic nature of his ACTH-dependent Cushing's syndrome was confirmed by non-suppression with high-dose dexamethasone suppression test and bilateral inferior petrosal sinus sampling. The primary ectopic source remained unidentified in spite of extensive anatomical and functional imaging studies, including CT scans and Dotatate-PET scan. Medical adrenolytic treatment at maximum tolerated doses failed to control his hypercortisolaemia, which led to recurrent intra-abdominal and pelvic abscesses, requiring multiple surgical interventions. Laparoscopic bilateral adrenalectomy was considered but decided against given concerns of technical difficulties due to recurrent intra-abdominal infections and his moribund state. Eventually, alcohol ablation of adrenal glands by retrograde adrenal vein approach was attempted, which resulted in biochemical remission of Cushing's syndrome. Our case emphasizes the importance of aggressive management of hypercortisolaemia in order to reduce the associated morbidity and mortality and also demonstrates that techniques like percutaneous adrenal ablation using a retrograde venous approach may be extremely helpful in patients who are otherwise unable to undergo bilateral adrenalectomy. LEARNING POINTS: Evaluation and management of patients with ectopic ACTH syndrome from an unidentified primary tumour can be very challenging.Persisting hypercortisolaemia in this setting can lead to debilitating and even life-threatening complications and hence needs to be managed aggressively.Bilateral adrenalectomy should be considered when medical treatment is ineffective or poorly tolerated.Percutaneous adrenal ablation may be considered in patients who are otherwise unable to undergo bilateral adrenalectomy.

Prevalence of gingival overgrowth induced by antihypertensive drugs: A hospital-based study.

BACKGROUND: Gingival overgrowth (GO) is a known side-effect of calcium channel blockers. Although there have been several case reports, few studies have examined the prevalence of nifedipine, diltiazem, and amlodipine. This study was conducted to determine the prevalence and risk factors for GO in patients treated with calcium channel blockers. MATERIALS AND METHODS: A cross-sectional study was conducted in out patient Department of Medicine, Government Medical College, Calicut. 133 patients taking antihypertensives were examined for the presence of GO using two different indices: Vertical GO in 6 points around each tooth and horizontal Miranda-Brunet index in the interdental area. Gingival index (GI), plaque index, and probing depth were also evaluated. RESULTS: The frequency of GO was significantly higher in nifedipine-treated cases than other drug groups. Frequency of GO was 75% for nifedipine, 31.4% for amlodipine and 25% for amlodipine + metoprolol. Higher gingival, plaque and calculus were observed in patients taking calcium channel blockers. Among the possible risk factors, only the GI showed a significant correlation with GO. CONCLUSIONS: Patients taking antihypertensives had poor oral hygiene. Patients taking nifedipine showed a higher frequency of GO. Gingival inflammation acts as a predisposing factor.

Prevalence of oral mucosal lesions among fishermen of Kutch coast, Gujarat, India.

BACKGROUND: The aim of the study was to assess the prevalence of oral mucosal lesions among fishermen population in the coastal region of Kutch, Gujarat, India. MATERIALS AND METHODS: A descriptive cross-sectional survey was conducted to assess the prevalence of oral mucosal lesions among the 979 fishermen of Kutch District, Gujarat, India. The proforma included information on demographic details, habits (tobacco and alcohol), oral hygiene practices and presence and location of oral mucosal lesions according to World Health Organisation, 2013. Chi-square test was used for comparisons. Confidence level and p-value were set at 95% and 5%, respectively. RESULTS: The majority of study population consumed tobacco and alcohol (88.1%) in some or the other form and used chewsticks (42.9%) for cleaning their teeth. Amongst all, 30.03% of the study subjects suffered from oral mucosal lesions. Leukoplakia (13.8%) was found to be the most prevalent lesion. The most affected sites were lips and vermillion border. The prevalence of oral mucosal lesions was found to be significantly associated with age, gender, oral hygiene practices and adverse habits. CONCLUSIONS: Oral mucosal lesions were prevalent among 30.03% of the study population. More detailed studies probing this issue should be conducted and efforts should be directed towards primordial prevention of the conditions.