ACTA ENDOCRINOLOGICA (BUC)

Hypothyroidism is a common endocrine disease with characteristic symptoms and signs such as fatigue, weight gain, intolerance of cold, constipation, depression, mental slowdown and muscle cramps. Myopathic changes are observed in 30-80% of patients with hypothyroidism, but muscular hypertrophy with muscle stiffness has been reported in less than 10% of patients. Hoffmann’s syndrome is a specific form of the hypothyroid-associated myopathy, rarely seen. Symptoms of this syndrome include proximal muscle weakness, hypertrophies in extremities, stiffness, muscle cramps, spontaneous muscle pain; and are associated with increased muscle enzymes. These findings can be seen at any time during hypothyroidism. Hofmann’s syndrome has a very good prognosis. Its response to hormone replacement therapy is very good. Therefore, in patients with myopathylike symptoms, considering in the differential diagnosis that the myopathy may be a reflection of hypothyroidism will facilitate the diagnosis and treatment. In this case, we aimed to present together Hashimoto thyroiditis and muscular hypertrophy, which is an atypical presentation of hypothyroidism and rarely seen in the literature, namely Hoffmann’s syndrome.

Objective. Parathyroid gland hyperplasia is diffuse or nodular in secondary hyperparathyroidism (sHPT) in patients with renal failure. Whether the nodular growth starts from the beginning or is the transformation of a diffusely-growing gland into nodular hyperplasia in parallel\r\nwith increases in the severity of the disease is unknown. The disease might be unresponsive to medical treatment when\r\nnodular hyperplasia develops. This study aims to differentiate the characteristics of the parathyroid glands with and without nodular hyperplasia in sHPT, and to\r\ninvestigate if there is any similarity between the nodular hyperplastic glands of sHPT and the parathyroid adenomas of primary hyperparathyroidism.\r\nMaterials and Methods. Hyperplasia types (nodular or diffuse) and parathyroid cell types, and the expression of\r\nproliferating cell nuclear antigen (PCNA) and Ki-67 in parathyroid tissue were investigated histopathologically and\r\nimmunohistochemically in 94 parathyroid glands of 42 patients with hyperparathyroidism.\r\nResults and Discussion. 63 glands showed nodular hyperplasia and 16 diffuse hyperplasia in sHPT. Chief cells predominated across the whole series. Vacuolated chief cells most frequently accompanied chief cells in both nodular\r\nhyperplasia (28.6%) and adenomas (53%). The median ratio of PCNA LI (labelling index) was 30/10? (min: 4-max: 720) cells in nodular hyperplasia, 16/10? (min: 2-max: 180) cells in diffuse hyperplasia and 30/10? (min: 10-max: 707) cells in adenomas (p>0.05). The highest PCNA LI according to all the cell types in the series was in chief cell and vacuolated chief cell combinations (53/10?, p=0.04). These findings suggest that parathyroid adenoma and nodular hyperplasia have histopathologically- and immunohistochemically - simil ar characteristics suggesting that both have aggressive cell proliferation.

Context. Red cell distribution width (RDW) has been associated with type 2 diabetes (T2DM), however data in relation to diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar non-ketotic acidosis (HONK) remains unclear. Objective. The aim of this study was to evaluate the association between RDW, MCV, and RDW/MVC values and acute complications in T2DM. Patients and Methods. RDW was measured in 90 T2DM patients (30 DKA, 30 HONK and 30 T2DM without acute complications). Clinical variables were analyzed by One –Way ANOVA, Kruskal-Wallis and Pearson analysis with SPSS software. Diagnostic screening tests and ROC curve analysis determined the cut-off point of MCV,RDW and RDW/MCV values. Results. DKA patients had higher levels of plasma glucose (524.20±201.43mg/dL, p<0.001), HbA1c (10.73±2.29%, p<0.001), osmotic pressure (310.32 mosm/L, p<0.001), RDW (14.61±1.75g/L, p<0.01), and the RDW/MCV ratio (0.17±0.04%, p<0.01), compared to HONK patients. RDW/MCV cut-off value was 0.15 with 90% sensitivity 50% specifity these values for only MCV were 76.67%-70%, for only RDW were 76.67%- 63.33% respectively. The area under curve values for the ability to reflect DKA for RDW and the RDW/MCV ratio were 0.708 and 0.766, respectively (p<0.001). Conclusions. RDW and RDW/MCV ratio were found associated with DKA and valuable in predicting DKA. However these parameters were not valuable in predicting HONK.

Background. Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of advanced cancers. Antibodies directed against programmed cell death receptor 1 (PD-1) interrupt the ability of the cancerous cell to depress the immune system. Methods and results. We report three patients who developed different endocrine abnormalities after treatment with nivolumab, a monoclonal antibody directed against PD-1. First, we report a 76-year-old male presenting with generalized fat loss after treatment with nivolumab which predominantly affected his face and trunk. Second, we described the development of thyroiditis that presented with thyrotoxicosis and the expression of thyroid-stimulating hormone receptor antibodies (TRAb). Finally, we observed the emergence of adrenal insufficiency due to hypophysitis in another case. Conclusion. Although immune checkpoint inhibitors are an effective anticancer treatment modality, adverse effects are evident that can affect the endocrine system. These adverse events may relate to different endocrine systems that include the thyroid and pituitary glands. Also, acquired generalized lipodystrophy should be suspected in patients developing unusual fat loss after treatment with ICIs.

Introduction. Primary hyperparathyroidism (PHPT) is a prevalent endocrine condition that presents with significant clinical symptoms. Ectopic adenomas commonly occur in the tracheo-esophageal groove, thymus, intrathyroidal, and mediastinum. While mediastinal ectopic adenomas are frequently observed, pericardial ectopic adenomas are only documented in case reports in the literature. Case report. We present a 65-year-old female patient who had persistent PHPT and underwent resternotomy and excision of a pericardial ectopic parathyroid adenoma. The typical treatment for PHPT has generally been conventional bilateral neck exploration without preoperative imaging. Conventional bilateral neck exploration has decreased in popularity because of the rise in the minimally invasive parathyroidectomy (MIP) procedure. The use of MIP is prevalent in surgical procedures, and it is crucial to have precise preoperative localization. Due to the ectopic localization of certain parathyroid adenomas, they are regarded as an important cause of the failure of primary surgery. Hence, particularly when dealing with persistent and recurrent PHPT, modern imaging techniques like 4D CT enhance the efficacy of surgical interventions. Therefore, particularly in cases of ectopic parathyroid adenomas located in the mediastinum, it is important to consider the possibility that if the adenoma cannot be found after surgery, it may be located in the pericardial region.

Objective. TSH-secreting pituitary adenomas (TSH-omas) are very rare disorders. This report describes the diagnosis and treatment of a thyroid-stimulating hormonesecreting ectopic pituitary adenoma in the nasopharyngeal region. Subjects and Methods. We report a 37-year-old male patient with thyroid-stimulating hormone-secreting ectopic pituitary adenoma in nasopharyngeal region. Results. A patient suffering from sweating, palpitations, dizziness and abnormality in thyroid tests was referred to our clinic. Thyroid function tests showed high basal levels of free thyroxine (FT4), free tri-iodothyronine (FT3), and serum TSH. TRH stimulation test results indicated blunted response. Scintigraphy showed increased radionuclide uptake (iodine-123), and a thyroid ultrasound scan revealed diffuse enlargement of the thyroid gland. A pituitary MRI indicated a normal pituitary. However, MRI showed a mass in the nasopharynx that was confirmed with endoscopy. Endoscopic total endonasal resection was done and the mass was removed. The pathology reported a TSHsecreting pituitary adenoma. Conclusion. In this report, an identified case of thyroid-stimulating hormone-secreting ectopic pituitary adenoma in nasopharyngeal region is reported and it is the only tenth case in the literature indicated in the nasopharyngeal region. Ectopic TSH-omas should be considered during inappropriate secretion of TSH as a candidate cause to enable correct diagnosis and improve the treatment of patients.

Previous studies have demonstrated that female patients with coronavirus disease 2019 (COVID-19) demonstrate more favorable prognosis relative to male patients. In this article, we elaborate the possible role of estrogen in the modulation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection severity. The potential interplay between several factors, including inherently lower estradiol (E2 ) and slightly higher estrogen receptor β (ERβ) levels in males, with inflammatory mediators are described. Altogether, there seems to be a sexually dimorphic response towards SARS-CoV-2 infection, and a possibility that COVID-19 severity is dependent on both E2 levels and ERα:ERβ expression ratio in lymphoid and lung cells.

Aim. Histology and cytology consultations of thyroid fine needle aspiration biopsy (FNAB) of thyroidectomy specimens can change management of the patient. We aimed to determine compliance rates of pathology results between urban centers and a tertiary institution and its impact on patient management.\r\nMethods. This retrospective study includes 101 patients, who were referred to our center, between January 2008 and December 2008. After admission, all FNAB or thyroidectomy specimens of patients managed elsewhere were consulted by the pathology department. Comparison of FNAB and histology reports of our institution and the medical centers elsewhere had been carried out.\r\nResults. A total of 76% concordance rate was found between the FNAB results of other centers and consultation results. The highest concordance was observed in the malignant cytology group (77%). The cytological or histological outcomes of 24 (23.7%) patients were interpreted differently. After second opinion, patient management\r\nchanged in 21 of the 101 patients.\r\nConclusion. Since FNAB results can change the type of surgical treatment and the management plan, the results especially reported as suspicious may need a second\r\nopinion. We suggest that cytology or histology results of thyroid patients referred to tertiary centers for further evaluation and treatment should always be reviewed.

Context. Mealtime insulin bolus is traditionally administered before meals in children with type 1 diabetes (T1D). Controlled studies on the use of pre-and postprandial insulin bolus have shown variable results. There are no realworld studies on postprandial bolusing of insulin in young children with T1D. Methods. Children with T1D aged <7 years were grouped into preprandial (Group 1) or postprandial (Group 2) groups according to the practice of prandial insulin use. Their retrospective data on mean glycosylated hemoglobin (HbA1c), hypoglycemic events, and diabetic ketoacidosis (DKA) episodes were compared. Results. Forty-four children (mean age 4.1±1.3 years, range 2-7 years) with mean diabetes duration of 2.0±0.7 years (range, 1-4 years) were identified; 23 (52.3%) belonged to Group 1 and 21 (47.7%) to Group 2. There were no differences in the mean HbA1c levels, mean hypoglycemic events, and DKA episodes between the two groups during a mean follow-up duration of two years. Conclusion. Young children with T1D administered insulin bolus during or immediately after meals showed similar long-term glycemic control and diabetesrelated adverse event profile compared to the premeal timing of insulin bolus. Larger real-world studies are needed on flexible insulin bolus timing in young children with T1D.

Primary Pigmented Micronodular Adrenal Disease is a rare cause of Cushing’s syndrome, typically observed in children and young adults. It is often associated with the Carney complex. A typical, subclinical, or cyclic Cushing's syndrome clinic can be seen clinically. Treatment options include bilateral-unilateral adrenalectomy or medical treatment. This case presentation aims to draw attention to a rare condition by presenting a patient diagnosed with isolated PPNAD unrelated to the Carney complex.