Journal of the ASEAN Federation of Endocrine Societies

ANCIENT SCHWANNOMA

2024-07-18T01:12:31-07:00

INTRODUCTION/BACKGROUND
Retroperitoneal schwannoma is a benign neoplasm arising from the neural crest cells. Pre-operative diagnosis of this rare tumour is often difficult due to its enormous size at the time of presentation and the lack of distinctive imaging phenotypes. We share a case of an incidentally discovered huge right periadrenal ancient schwannoma in an elderly patient who suffered from an underlying nasopharyngeal carcinoma.

CASE
A 70-year-old male was found to have a 15-cm right suprarenal mass when he underwent CT scan for the staging of nasopharyngeal carcinoma. He had no paroxysmal symptoms or hypertension. There were no features of Cushing syndrome. Endocrine evaluation showed no evidence of functioning pheochromocytoma or adrenocortical carcinoma. The patient underwent open adrenalectomy and tumour excision uneventfully. Pathology examination revealed a large ancient schwannoma consisting of spindle cells with nuclear and cytoplasmic S-100 positivity.

CONCLUSION
The pre-operative diagnosis of retroperitoneal schwannoma remains challenging despite the advances in imaging modalities. Th definitive diagnosis relies on biopsy or

CARNEY COMPLEX

2024-07-18T04:44:55-07:00

INTRODUCTION/BACKGROUND
Carney complex (CNC) is a rare multiple endocrine neoplasia characterized by spotty skin pigmentation, myxomas and endocrine overactivity. We report a case of a young female with multiple typical manifestations of CNC over the past 12 years, including bilateral primary pigmented nodular adrenocortical disease, bilateral breast ductal adenoma, cardiac myxoma and thyroid nodule.

CASE
This female first presented at age 28 for secondary amenorrhea, weight gain and uncontrolled hypertension. She had pigmentation over her lips and features of Cushing syndrome, such as facial plethora, purple striae and proximal myopathy. She had a right breast fibroadenoma at age 17 and young-onset hypertension at age 25 on past medical history. There were no familial diseases noted. The initial work-up was suggestive of ACTH-independent Cushing syndrome. The adrenal CT showed a 2.3 x 1.2 cm right adrenal adenoma and a normal left adrenal gland. She underwent a right adrenalectomy with a tissue histopathology suggestive of pigmented nodular adrenal cortical hyperplasia. She was then subjected to a left adrenalectomy as she remained hypercortisolemic after the initial surgery. She went into remission after the bilateral adrenalectomy. At age 29, a surveillance scan showed a left solitary thyroid nodule and multiple bilateral breast lumps with a tissue biopsy suggestive of ductal adenoma. Excision of atrial myxoma was done at age 33 following the detection of cardiac myxoma from an echocardiogram when she complained of palpitations. Unfortunately, she was diagnosed with left breast carcinoma at age 38, requiring a left mastectomy. A recent tissue biopsy of a right breast lump showed intraductal papilloma.

CONCLUSION
The diagnosis of CNC is often delayed owing to its rarity and complexity. Clinical and biochemical screening are the gold standard for the diagnosis of CNC. This patient requires a lifelong follow-up for the recurrence of cardiac myxoma and other associated manifestations of CNC.

THE RIFAMPICIN RED FLAG

2024-07-18T00:56:53-07:00

INTRODUCTION/BACKGROUND
Rifampicin is an essential first-line anti-tuberculosis (TB) drug which exhibits potent hepatic enzyme-inducing properties. It has significant drug interactions with an array of other medications, including hydrocortisone as we report in this case.

CASE
A 65-year-old male, HIV positive, treatment-naive, with concurrent primary adrenal insufficiency (Synacten done: Cortisol 0 hour 247.8 nmol/L, 60 minutes 316 nmol/L, and normal ACTH 7.76 pmol/L) on hydrocortisone 10 mg/5 mg replacement for 4 months was admitted for prolonged fever and lethargy. He was diagnosed to have extrapulmonary TB by urine lipoarabinomannan (LAM) test and was started on isoniazid, rifampicin, pyrazinamide plus ethambutol – HREZ regime. On Day 12 of HREZ, he exhibited hypoglycaemia, postural hypotension, and hyponatremia. Serial monitoring of his sodium levels showed a decreasing trend from a normal level initially of 135 mmol/L to a nadir of 116 mmol/L on day 21 of rifampicin. A diagnosis of adrenal insufficiency secondary to rifampicin was made. Rifampicin accelerates cortisol metabolism resulting in low levels of serum cortisol. The patient was started on IV hydrocortisone 50 mg QID. He responded well to treatment with amelioration of symptoms and normalization of sodium levels. Steroids were then tapered to oral hydrocortisone with the lowest replacement dose of 20 mg/10 mg daily (double the usual physiological dose) given the ongoing use of rifampicin. The patient was started on hydrocortisone tablet 20/10 mg daily and with no further dose reduction planned while concurrently on rifampicin. The hydrocortisone dosage will be gradually reduced to the standard physiological dose upon the patient's completion of rifampicin treatment.

CONCLUSION
Prompt identification of drugs that can affect cortisol metabolism is essential to for patients on hydrocortisone replacement therapy. Close monitoring, multidisciplinary collaboration, personalized dose adjustments and careful tapering of hydrocortisone with biochemical and clinical correlation are paramount in navigating the challenges posed by rifampicin-hydrocortisone interaction.

MANAGING STEROIDS IN A FEMALE WITH NCCAH COMPLICATED WITH COVID-19 IN PREGNANCY

2024-07-18T04:31:26-07:00

INTRODUCTION
We report a case of a female with Non-Classical Congenital Adrenal Hyperplasia (NCCAH) which was complicated by COVID-19 during her pregnancy. This is the second such case to be reported so far; the first being in Italy in 2020. The role of steroid management throughout her pregnancy is highlighted.

CASE
This is a case of a 28-year-old female diagnosed with NCCAH since age 21 and maintained on oral prednisolone 7.5 mg OD pre-pregnancy. At the 20th week of gestation, she was switched to oral hydrocortisone 10 mg BD as she developed mild Cushingoid features. Consequently, she presented at 30 weeks of gestation to the ED with symptoms of breathlessness, dehydration and compensated shock and was diagnosed with COVID-19 Category 5. She received fluid boluses and low-dose inotrope and was placed under ICU care due to worsening hypoxia. She was initiated on maintenance fluids and Remdesivir for COVID-19 and intravenous hydrocortisone 100 mg bolus with maintenance of 50 mg QID to prevent an adrenal crisis. In the ICU, her condition stabilized with inotropic and oxygen support weaned off. Her intravenous hydrocortisone was maintained at 50 mg QID. Throughout her stay, no foetal compromise was observed. She was discharged well on day 5 of illness with a supraphysiological dose of hydrocortisone 20 mg/10 mg. Further steroid adjustments were planned at the outpatient clinic on follow-up.

CONCLUSION
Managing acute COVID-19 infection during late pregnancy, especially with an underlying adrenal condition, poses significant challenges due to therapeutic uncertainties. A multidisciplinary team and close ICU monitoring were vital for ensuring a successful outcome for both mother and child. Steroid management in NCCAH patients, particularly during pregnancy, is critical. Early treatment with appropriate antivirals and steroids can mitigate illness progression and severity, reducing morbidity and mortality associated with COVID-19.

TWO’S COMPANY - UNEXPECTED MEN 2 PRESENTING AS INCIDENTALOMA

2024-07-17T21:22:01-07:00

INTRODUCTION/BACKGROUND
Bilateral pheochromocytomas are uncommon, classically described as occurring in 10% of cases. Such presentation should raise suspicion of the presence of a hereditary syndrome or predisposing genetic mutations.

CASE
A 43-year-old female presented with renal colic. A computed tomography scan showed nonobstructing renal calculi and bilateral adrenal incidentaloma measuring ~3.8 cm. Serum calcium was normal (2.16 mmol/L). Twenty-four-hour urinary metanephrines were elevated sevenfold above normal with normal normetanephrines. Physical examination was unremarkable except for labile blood pressure (SBP 135-170 mmHg). She only reported symptoms of occasional palpitations and mild headache. Family history was significant for the death of unknown cause of her mother and 2 elder siblings before the age of 60 years. MEN 2A was suspected. Ultrasound of the neck revealed four TIRADS-5 thyroid nodules measuring 0.7- 1.3 cm, FNAC confirmed medullary thyroid carcinoma (MTC). Carcinoembryonic antigen was 13.6 ng/ml (<5). She underwent bilateral retroperitoneoscopic adrenalectomy uneventfully following adrenergic blockade. Postoperatively, she was normotensive and received hydrocortisone and fludrocortisone replacement. Histopathological examination confirmed bilateral pheochromocytoma with no malignant features. She awaits total thyroidectomy. Her kindred were advised to undergo screening for MEN 2, albeit the lack of genetic study due to financial constraints.

CONCLUSION
Genetic testing for RET proto-oncogene would be useful to guide management and screening in MEN 2. Medullary thyroid carcinoma is the most common manifestation of MEN 2 with 100% penetrance and should be actively sought for in patients suspected of having MEN 2.

EUGLYCEMIC DIABETIC KETOACIDOSIS PRECIPITATED BY HYPERTRIGLYCERIDEMIAINDUCED PANCREATITIS, LIVER ABSCESS AND SODIUM-GLUCOSE COTRANSPORTER-2 INHIBITOR USE IN A PATIENT WITH FAMILIAL HYPERTRIGLYCERIDEMIA

2024-07-18T22:20:33-07:00

INTRODUCTION/BACKGROUND
Euglycemic diabetic ketoacidosis (EDKA) has a worse outcome than typical DKA as it is relatively rare and remains a diagnostic challenge. Conditions such as sepsis, pancreatitis, use of sodium-glucose cotransporter-2 inhibitors (SGLT-2i), pregnancy and starvation are known to be associated with EDKA. We report a case of a patient with Type 2 Diabetes Mellitus (T2DM) and familial hypertriglyceridemia on SGLT-2i who presented with hypertriglyceridemia-induced pancreatitis (HTGP) concurrently with EDKA.

CASE
A 31-year-old female presented with epigastric pain, vomiting and lethargy. The clinical exam revealed tender epigastrium with no guarding and negative Murphy’s. Serum amylase was 242 U/L (Imrie score 2, BISAP 1) and C-reactive protein (446 mg/L). The ultrasound of the abdomen revealed an ill-defined collection (2.3 x 3.2 cm) at segment V of the liver with findings suggestive of chronic pancreatitis. She had three prior admissions due to acute pancreatitis and once complicated by an infected pancreatic pseudocyst. She was diagnosed with T2DM and familial hypertriglyceridemia five years ago, with poorly controlled glucose and lipid profile (HbA1c 8.4%, triglycerides 33.4 mmol/L). She is on an SGLT2 inhibitor, amongst other medications, which she continued taking despite her illness. She developed EDKA in the ward (pH 7.43, PCO2 20, HCO3 14, serum ketone 3.6, lactate 0.8). She was started on DKA treatment, then continued with variable rate insulin sliding scale, fasting, statin, fibrates and intravenous antibiotics. Dietary and lifestyle advice were reinforced. She was discharged well after two weeks (triglyceride 4.2 mmol/L, C-reactive protein 2 mg/L) with resolved symptoms and liver lesions.

CONCLUSION
EDKA should be a well-recognised diagnosis in an era where there is growing use of SGLT2i, especially in patients with multiple precipitating factors. Physicians must have a high clinical suspicion in patients who are on SGLT-2i in acute illness. In addition, we need to consider that EDKA can precipitate HTGP and vice versa. In both conditions, early initiation of continuous intravenous insulin infusion can improve outcomes.

A RARE CASE OF ANTIPHOSPHOLIPID SYNDROME PRESENTING AS ADRENAL CRISIS AND BILATERAL ADRENAL HEMORRHAGE

2024-07-18T02:14:56-07:00

INTRODUCTION/BACKGROUND
Bilateral adrenal haemorrhage is a rare condition with potentially life-threatening consequences due to adrenal crisis. It can be the first presentation of antiphospholipid syndrome (APLS). We report a rare case of APLS presenting as an adrenal crisis and bilateral adrenal haemorrhage.

CASE
A 37-year-old male with a history of a motor vehicle accident 2 weeks ago presented with abdominal pain for 1 week, accompanied by nausea, vomiting, and lethargy. During the accident, where his motorbike skidded, he sustained an open fracture of the proximal phalanx of his little finger. Wound debridement was performed and a K-Wire was inserted. Clinical examination showed left-hand cellulitis, tenderness over the bilateral flank, and slightly low blood pressure (90/46 mmHg). Blood investigations revealed thrombocytopenia, hyponatremia, prolonged APTT that did not correct in the coagulation mixing study, and a low cortisol level (67 nmol/L). Abdominal CT scan revealed bilateral adrenal haemorrhage without any other solid organ and bowel injury. He was treated for acute adrenal crisis and subsequently started on hydrocortisone and fludrocortisone, resulting in significant clinical improvement. However, the left-hand cellulitis triggered digital artery thrombosis, leading to left-hand gangrene. Despite anticoagulation and ilioprost administration, he ended up with a left transradial amputation. Antiphospholipid syndrome was suspected in this patient based on the bilateral adrenal haemorrhage, digital artery thrombosis and abnormal coagulation profile. A full autoimmune work-up confirmed the presence of anticardiolipin, lupus anticoagulant, and anti-beta-2 glycoprotein. The anti-nuclear antibody was also positive 1:320, with a speckled pattern. C3, C4, anti-double stranded DNA and extractable nuclear antibodies were otherwise negative. He was discharged well on warfarin, hydrocortisone and fludrocortisone.

CONCLUSION
Adrenal insufficiency is a rare manifestation of APLS. This case highlights the importance of maintaining a high index of suspicion for APLS in patients presenting with bilateral adrenal haemorrhage and thrombotic events. Failure to diagnose or treat this condition promptly may lead to significant morbidity and mortality.

DIABETES CONTROL AMONG ELDERLY DIABETIC PATIENTS IN KUANTAN, MALAYSIA

2024-07-18T22:05:09-07:00

INTRODUCTION/BACKGROUND
The transformation of the aging population in Malaysia carries a significant healthcare burden in chronic diseases like Type 2 Diabetes Mellitus (T2D).

METHODOLOGY
This study aims to measure the patients’ diabetes control and to identify its related factors among elderly diabetic patients in Kuantan. This cross-sectional study was conducted in six selected government health clinics in Kuantan (chosen from stratified random sampling) where 300 elderly patients with T2D were recruited via proportionate random sampling. The related factors studied were sociodemographic profile, health and treatment characteristics and quality of life using the RVDQOL13 questionnaire. The data were analysed using SPSS version 26.

RESULTS
The mean age of the patients was 68.1 years old (SD=6.009). Most patients were female (57.3%), Malay (70.3%), married (66%), living independently (Modified Barthel Index = 99%) and from B40 (96.3%). The prevalence of good diabetes control was 59.3% (cut-off point = HbA1c ≤7.5%). The significant predictors for good diabetes control identified were non-Malay (aOR = 3.92, 95%CI 1.907-8.060, p <0.001), treatment with insulin injection (aOR = 0.193, 95%CI 0.094- 0.395, p <0.001), abnormal capillary blood glucose (CBG) (aOR = 0.655, 95%CI 0.489-0.878, p <0.001), having higher LDL-C (aOR = 0.655, 95%CI 0.489-0.878, p = 0.005), and poor satisfactory impact from RV-DQOL13 (aOR = 0.919, 95%CI 0.884-0.954, p <0.001).

CONCLUSION
Elderly diabetic patients in Kuantan have good diabetes control. However, follow-up for this group needs to be emphasized among Malay patients, those on insulin treatment, poor CBG during TCA, high LDL-C and those who are unsatisfied with diabetes care to maintain good diabetes control prevalence.

A PERPLEXING MIXED CORTICAL AND MEDULLARY ADRENAL NEOPLASM PRESENTING WITH INDETERMINATE ADRENAL MASS

2024-07-18T02:03:53-07:00

INTRODUCTION
A mixed cortical and medullary adrenal neoplasm originating in the adrenal gland is an exceedingly rare tumour characterized by the coexistence of cell nests from both the adrenal cortex and medulla within a singular mass, which results in the production of adrenocortical steroid hormones and catecholamines (CA). We report a case of mixed cortical medullary adrenal neoplasm presenting with indeterminate adrenal mass.

CASE
A 51-year-old female, with a known case of left breast mucinous carcinoma, underwent a right mastectomy and axillary clearance and completed 6 cycles of systemic chemotherapy. The computed tomography of the thorax, abdomen and pelvis (CT TAP) surveillance post-treatment revealed left adrenal indeterminate incidentaloma. Computed tomography adrenal protocol showed that the left adrenal mass was heterogeneous with a size of 1.8 x 2.2 x 2.4 cm, with a plain HU of 18 HU, absolute contrast washout of 21%, and relative contrast washout of 15%. Biochemically, both the overnight dexamethasone suppression test (ODST) and low dose dexamethasone suppression test (LDDST) were not suppressed with values of 81 nmol/L and 119 nmol/L, respectively. A 24-hour urine metanephrine collection demonstrated results within the normal range: metanephrines 0.4 umol/ day (0.1-6.2), normetanephrine 1 umol/day (0.2-1.3) and 3-methoxytyramine 0.8 umol/day (0.1-1.79). Given that the left adrenal indeterminate incidentaloma had autonomous cortisol secretion, a left adrenalectomy was performed. Remarkably, the histopathological examination (HPE) unveiled a mixed corticomedullary adrenal tumour.

CONCLUSION
A mixed cortical and medullary adrenal neoplasm is extremely rare. Therefore, knowledge about long-term clinical course and prognosis is limited. Long-term follow-up is recommended to assess the recurrence in the contralateral adrenal gland.

UNVEILING EARLY CARDIOVASCULAR DISEASE PREDICTION IN TYPE 2 DIABETES

2024-07-18T21:54:29-07:00

INTRODUCTION/BACKGROUND
Type 2 diabetes individuals are at higher risk of developing cardiovascular disease compared to the general population. Cardiovascular disease remains the leading cause of death in type 2 diabetes despite vigilant monitoring. Early detection of type 2 diabetes patients predisposed to cardiovascular complications is important to reduce the disease burden.

METHODOLOGY
This study aimed to investigate the potential role of cardiometabolic biomarkers in cardiovascular risk prediction among type 2 diabetes patients. A case-control study consisting of type 2 diabetes with cardiovascular disease outcome, type 2 diabetes without cardiovascular complications and healthy control group was conducted in 221 participants. We employed a machine learning algorithm to develop a cardiovascular risk prediction model.

RESULT
A combination of sociodemographic, anthropometry and routine biochemical data was assessed using ensemble classifier as the base model for predicting cardiovascular risk (84.8% accuracy, 76.5% positive predictive value in high-risk). The predictive ability was improved when serum ferritin, vitamin D and NT-proBNP (89.4% accuracy, 83.3% positive predictive value in high-risk) were added to the model.

CONCLUSION
As cardiometabolic biomarkers may potentially improve cardiovascular prediction, further analysis can be performed to validate their clinical utility in diverse type 2 diabetes individuals.

CT STAGING THAT UNVEILS A MYSTERY – ASYMPTOMATIC PHEOCHROMOCYTOMA ASSOCIATED WITH NEUROFIBROMATOSIS TYPE 1

2024-07-18T01:49:24-07:00

INTRODUCTION/BACKGROUND
Pheochromocytomas and paraganglioma (PPGL) are catecholamine-secreting tumours, derived from chromaffin cells. The classical triad comprises paroxysms of headache, palpitation, and diaphoresis. About 10% of patients are asymptomatic. At least one-third of patients with PPGLs have hereditary disease caused by germline mutations. This includes neurofibromatosis type 1 (NF-1) which may predispose patients to pheochromocytoma and occurs in 0.1-5.7% of cases. We report a case of a 57-year-old female with hypertension and diabetes who was referred from the surgical team after an incidental finding of a right adrenal mass on abdominal CT performed for rectal adenocarcinoma staging. She denied paroxysms or other symptoms that suggest catecholamine or cortisol excess. Blood pressure was well controlled with a single agent. Examination revealed axillary freckling, multiple cafè au lait spots and generalized cutaneous nodules which were present since adolescence.

CASE
Serial abdominal CT scans showed increasing size of right adrenal mass measuring 4.4 x 5.4 x 5.9 cm (previously 4.4 x 5.1 x 5.6 cm) with presence of fluid-fluid level within, with HU ranging from HU 20 (anteriorly) and HU 70 (posteriorly). Metanephrine 5.42 umol/L (0.33- 1.53), normetanephrine 8.0 umol/L (0.88-2.88) and 3-methoxytyramine 1.16 umol/L (0.66-2.60) were elevated on 24-hour urine collection. Thyroid function test and serum calcium were normal. Histopathological examination of the cutaneous nodule confirmed neurofibromas. She underwent open right adrenalectomy and HPE was consistent with pheochromocytoma. Three months post adrenalectomy, urine metanephrines had normalized, and there was no tumor residual or recurrence on CT imaging. She no longer requires any anti-hypertensive drug, and we were able to withdraw insulin therapy.

CONCLUSION
Though rare, the combination of NF-1 with pheochromocytoma in our patient is an offbeat presentation of adrenal incidentaloma in a patient with multiple cutaneous nodules, hypertension and diabetes. Screening for pheochromocytoma should be done in a patient with NF-1 and hypertension. Prompt treatment will alleviate the detrimental effect of catecholamine excess and improve the patient’s quality of life.

ANALYSIS OF DIABETIC KETOACIDOSIS CASES IN HOSPITAL TELUK INTAN IN 2023

2024-07-18T05:42:15-07:00

INTRODUCTION
There is an increase in the incidence of diabetes mellitus (DM) in Malaysia and worldwide. Diabetic ketoacidosis (DKA) is one of the most serious acute complications of diabetes and is even the first presentation of diabetes in some patients.

METHODOLOGY
This study aims to evaluate the incidence and outcome of DKA patients in a district hospital Hospital Teluk Intan (HTI) in 2023. This is a retrospective audit which included every patient who was admitted for DKA in HTI from January 2023 until December 2023. The data was collected from clinical notes and electronic medical records.

RESULT
Forty subjects were included in this audit which comprised 20 males and 20 females. The median age of the study population was 53.5 years and most patients were Malay (82.5%), followed by Indian (10%) and Chinese (7.5%). Most of them had type 2 DM [34 (87.5%)] whereas the rest had type 1 DM [4 (10.3%)] and newly diagnosed DM [1 (2.6%)]. The most common causes of DKA were sepsis [22 (55%)] and non-compliance to medications [16 (40%)]. The mean HbA1c during admission was 13.9% and the median length of stay was 5.5 days. Twelve patients (30%) had severe DKA and 17 patients (42.5%) required ICU/HDU admission in which 2 patients (5%) required intubation. About 2/3 of patients [24 (60%)] had DKA resolution within 24 hours of admission and most patients were discharged home [37 (92.5%)]. The low mortality rate could be due to early diagnosis and high admission to ICU/HDU.

CONCLUSION
The high number of DKA cases is mainly caused by sepsis and non-compliance to medication, which are critical areas to address to prevent DKA occurrences. While infections may be inevitable, it is essential to counsel diabetes patients on the importance of strict adherence to their medications to avoid serious complications.

MALIGNANT PARAGANGLIOMA IN AN ADOLESCENT

2024-07-18T01:39:37-07:00

INTRODUCTION/BACKGROUND
Pheochromocytomas (PCC) and paragangliomas (PGL) (PPGL) are rare neuroendocrine tumours occurring in children and adolescents. Nevertheless, they are the most common endocrine tumours in the paediatric population and account for 0.5–1% of paediatric hypertensive cases. We describe a 16-year-old female with malignant paraganglioma.

CASE
A previously healthy 16-year-old female presented with a one-month history of intermittent headaches associated with palpitations and presyncopal attacks. The first blood pressure reading revealed that she was hypertensive, with a BP of 159/116. She had no chest pain, shortness of breath, diaphoresis, abdominal pain, or diarrhoea. There is no family history of hypertension in the young or endocrine disorder. The patient is lean with a BMI of 14.2 kg/m2 . No goitre, cushingoid or acromegalic features were present. The hormonal workup done was consistent with phaeochromocytoma (normetanephrine: 55.30 umol/ day) (35.5 X ULN) ). Other forms of work-up for secondary hypertension were unremarkable. Adrenal CT imaging revealed an enhancing mass at the left pararenal space measuring 4.1 x 4.7 x 4.7 cm with local infiltration to the tail and body of the pancreas complicated by a left renal infarct. Therefore, she was diagnosed with left paraganglioma with local infiltration. Preoperatively, she was started on oral prazosin 1 mg, 6 hourly and oral bisoprolol 2.5 mg daily and successfully underwent open resection of the left paraganglioma. Unfortunately, she remained hypertensive post-surgery, indicating a possible malignant paraganglioma. Thus, she was restarted on antihypertensive medications. Gallium-DOTATE scan and genetic testing have been arranged to aid further management.

CONCLUSION
Diagnosis of pheochromocytoma and paraganglioma is paramount during the evaluation of secondary hypertension in the paediatric population. Although they are uncommon, possible curative surgery can be offered. All children should be subjected to genetic testing given the high rate of inheritance of these tumours. Subsequently, all patients with genetic mutations ought to be under lifelong surveillance in view of the risk of recurrence and malignancy.

GLYCEMIC CONTROL AND BODY WEIGHT EFFECTS OF SGLT2 INHIBITORS (EMPAGLIFLOZIN 25 MG, EMPAGLIFLOZIN 12.5 MG AND DAPAGLIFLOZIN 10 MG) IN THE TREATMENT OF TYPE 2 DIABETES MELLITUS

2024-07-18T05:17:54-07:00

INTRODUCTION/BACKGROUND
Sodium-glucose co-transporter 2 (SGLT2) inhibitors have emerged as promising therapeutic agents for the management of type 2 diabetes mellitus (T2DM), offering a novel mechanism of action that targets renal glucose reabsorption.

METHODOLOGY
This study investigates the glycaemic control and body weight effects of SGLT2 inhibitors, specifically empagliflozin 25 mg, empagliflozin 12.5 mg and dapagliflozin 10 mg, in the context of their availability within Hospital Teluk Intan. This is a cross-sectional study which involved patients who had been prescribed SGLT2 inhibitors for a duration exceeding one year. Inclusion criteria encompassed patients meeting the specified duration of SGLT2 inhibitor use, while exclusion criteria comprised individuals with less than one year of SGLT2 inhibitor therapy, those procuring SGLT2 inhibitors independently, those admitted within one year of commencing SGLT2 inhibitors and those lacking documented body weight data due to mobility constraints. Patient records were systematically reviewed to extract demographic details and pertinent clinical parameters, including pre- and post-initiation measurements of glycated haemoglobin (HbA1c), body weight and insulin dosage.

RESULT
The study included 24 patients taking dapagliflozin 25 mg, 14 patients on empagliflozin 12.5 mg and 3 patients on dapagliflozin 10 mg, all meeting the inclusion criteria with available data. Among those on empagliflozin 25 mg, there was no significant reduction in HbA1c or weight. In the empagliflozin 12.5 mg group, while HbA1c reduction was not significant, there was a notable decrease of 3.1 kg in body weight. Similarly, in the dapagliflozin 10 mg group, HbA1c reduction was not significant, but there was a weight reduction of 2.7 kg post-treatment. Initial observations from the enrolled participants suggest significant improvements in body weight, indicating a potential benefit of SGLT2 inhibitors, particularly empagliflozin 12.5 mg and dapagliflozin 10 mg, in fostering weight loss among T2DM patients. However, further examination is necessary to determine the statistical significance of these results and understand the extent of the effect across various doses and types of SGLT2 inhibitors.

CONCLUSION
This study offers valuable insights into the impact of SGLT2 inhibitors, including empagliflozin and dapagliflozin, on glycaemic control and body weight management in T2DM patients. The findings highlight the potential of SGLT2 inhibitors in addressing weight concerns, albeit without significant effects on glycaemic control.

PHEOCHROMOCYTOMA

2024-07-18T01:31:54-07:00

INTRODUCTION/BACKGROUND
Pheochromocytoma is a rare tumour derived from chromaffin cells of the adrenal medulla or extra-adrenal paraganglia. It is a rare cause of secondary hypertension and is commonly overlooked in pregnancy due to limitations in investigation during pregnancy. It occurs in 0.1-1% of the hypertensive population and is even more rare in pregnancy.

CASE
A 33-year-old pregnant female with a parity of 8, diagnosed with chronic hypertension and with a history of severe preeclampsia in her previous pregnancy, presented again at 34 weeks of gestation with severe preeclampsia. Blood pressure was 179/124, and heart rate ranged from 100 to 120 bpm. Urinary examination revealed proteinuria. Despite treatment with conventional antihypertensives, her blood pressure remained uncontrolled. Thus, she was planning for emergency C-section. Intubation was done due to cardiorespiratory compromise, which was complicated by cardiac arrest. She was successfully resuscitated. Computed tomography (CT) of the adrenal glands showed a large, heterogeneously enhancing right adrenal lesion measuring 7.4 x 7 x 8 cm. Twenty-four-hour urinary catecholamine levels were elevated, with normetanephrine at 67.80 umol/ day (0-2.13), metanephrine at 97.30 umol/day (0-1.62), and 3-methoxytyramine at 7.60 umol/day (0.1-1.79). The classical presentation of pheochromocytoma with paroxysmal hypertension, headaches, sweating, and palpitations may not be simultaneously present, especially during pregnancy. Labile BP and difficult to control hypertension should raise suspicion for pheochromocytoma, to prompt appropriate investigations that will facilitate an early diagnosis. Measurements of urinary or plasma catecholamines have reasonable sensitivity for detecting most pheochromocytomas, particularly in patients with sustained hypertension. Radioisotope scans, including iodine 131-labeled metaiodobenzylguanidine scanning, should be avoided during pregnancy due to foetal concerns and, if required, should be postponed until the postpartum period.

CONCLUSION
Pheochromocytoma in pregnancy is a life-threatening condition. Early suspicion and recognition are essential to prevent fetomaternal morbidity and mortality.

MINIMED™ 780G ADVANCED HYBRID CLOSED-LOOP SYSTEM IN TYPE 1 DIABETES DURING RAMADAN

2024-07-18T05:06:50-07:00

INTRODUCTION/BACKGROUND
The MiniMed™ 780G automated insulin delivery system has improved outcomes for people with type 1 diabetes. In Putrajaya Hospital, most patients with type 1 diabetes fall in the high-risk category and are advised to avoid fasting during Ramadan, yet many still choose to observe it.

METHODOLOGY
We aim to review the effectiveness and safety of the MiniMed™ 780G use during Ramadan. We report a prospective observational, single-centre study of Type 1 diabetes patients using the MiniMed™ 780G during Ramadan 2024. Four patients were selected and had their CareLink personal data extracted before and during Ramadan to examine safety and glycemic metrics. Changes were made to their pump settings when necessary.

RESULT
All patients were able to fast for more days with the MiniMed™ 780G compared to previous years, with a mean of 13.5 days (8-20 days) on the pump vs 8.3 days (3-12 days) on basal-bolus insulin. All our patients demonstrated hyperglycemia after Iftar which needed 4-5 hours to resolve. Three of 4 patients developed hypoglycemia 1-4 hours before iftar requiring intervention. One patient developed one episode of severe hypoglycemia requiring hospitalization. No patients developed diabetic ketoacidosis. The average TIR was 72% before Ramadan and 70% during Ramadan.

CONCLUSION
The MiniMed™ 780 G increased the number of days of completion in fasting among our patients. However, incidences of hypoglycemia and hyperglycemia persisted requiring adjustments in the pump settings throughout Ramadan. This system allowed our patients to fast confidently and safely. Improvement in the outcome is to be expected with continuous experience in the future.

THE FAST AND FURIOUS CUSHING’S SYNDROME

2024-07-18T01:16:06-07:00

Introduction Ritonavir is a commonly prescribed protease inhibitor for human immune deficiency (HIV) treatment. It is a potent inhibitor of hepatic cytochrome P450 (CYP450) enzyme. Interaction between ritonavir and corticosteroids induces iatrogenic Cushing’s Syndrome. We share a case of an acute onset of Cushing’s Syndrome in a young female with HIV. Case A 25-year-old female with stable retroviral disease on ritonavir along with tenofovir, emtricitabine and atazanavir developed Cushing’s syndrome within 2 weeks of receiving injectable hydrocortisone from a general practitioner's clinic for skin itchiness. Facial swelling, hirsutism, abdominal striae, body acne, weight gain and proximal myopathy were noted. Early morning cortisol was 28 nmol/L and the 24-hour urine-free cortisol was 45 nmol/day. She was diagnosed with iatrogenic Cushing’s syndrome with suppression of the hypothalamic-pituitary adrenal (HPA) axis secondary to drug interaction between ritonavir and intravenous hydrocortisone. She was started on oral hydrocortisone 20 mg in the morning and 10 mg in the evening. Throughout her hospitalization and upon discharge, she remained clinically well. She is planning for a Synacthen test on an outpatient basis to reassess her HPA axis. Conclusion Drug interaction between ritonavir and corticosteroids may result in increased levels of plasma corticosteroids, potentiated by the CYP450 metabolism which prolongs the half-life of hydrocortisone, that can lead to Cushing’s syndrome. This highlights the importance of a thorough review of the patient’s medications to prevent drug-todrug interaction. If corticosteroid administration cannot be avoided, the patient needs to be monitored for symptoms of Cushing’s syndrome.

ASSESSING THE POTENTIAL OF DULAGLUTIDE IN DE-INTENSIFICATION OF BACKGROUND ORAL GLUCOSELOWERING DRUG (OGLD) AND INSULIN THERAPY IN MALAYSIANS WITH TYPE 2 DIABETES MELLITUS

2024-07-18T04:53:08-07:00

INTRODUCTION/BACKGROUND
Many Malaysian T2DM patients are on multiple glucoselowering drugs (i.e. ≥2 OGLDs ± insulin). Dulaglutide, a once-weekly GLP-1RA, has been shown to significantly lower HbA1c levels in T2DM patients. However, there is a lack of real-world data to show the reduction of background treatment after patients start dulaglutide.

METHODOLOGY
This study aims to assess the potential of dulaglutide in deintensifying background OGLDs and total daily dose (TDD) of insulin in T2DM patients in a real-world clinical setting. This is a retrospective study of 45 T2DM patients who initiated dulaglutide in 3 Ministry of Health (MOH) hospitalbased endocrinologist-led diabetes clinics conducted in Hospital Putrajaya, Hospital Selayang and Hospital Tuanku Ja’afar. The primary outcome was a change in OGLDs and insulin therapy at 6 and 12 months of dulaglutide therapy.

RESULTS
At baseline, 91% (n = 41) of patients were on ≥2 OGLDs, while 82% (n = 37) were on insulin therapy with a mean baseline TDD of 64 units. After 6 months of dulaglutide therapy, 18% (n = 8) of the patients had at least one of their OGLD doses reduced, 38% (n = 17) of patients were able to stop one OGLD, and 4% (n = 2) of patients were even able to stop two OGLDs. At 12 months, 22% (n = 10) of patients had at least one of their OGLD doses reduced, 40% (n = 18) of patients were able to stop one OGLD, 9% (n = 4) of patients were able to stop two OGLDs from baseline, 56% (n = 25) of insulin-treated patients on dulaglutide had a TDD reduction of 23 units (-36%) at 6 months and 19 units (-30%) at 12 months.

CONCLUSION
Dulaglutide, with its once-weekly dosing, can effectively simplify patients' diabetes treatment by allowing the reduction of OGLDs and TDD of insulin. This de-intensification of medication could reduce the medication burden on patients and lessen the total drug cost for T2DM patients.

A DECADE OF INITIAL EXPERIENCE IN ADMINISTRATION OF METAIODOBENZYLGUANIDINE THERAPY FOR ADVANCED STAGE PARAGANGLIOMA AND PHEOCHROMOCYTOMA

2024-07-18T01:05:08-07:00

INTRODUCTION/BACKGROUND
Metaiodobenzylguanidine (MIBG) labeled with radioactive iodine can be utilised for imaging and therapy in advanced stage paraganglioma and pheochromocytoma. Our centre became a local pioneer and started to offer MIBG therapy in 2013. Patients received 200 mCi of Iodine-131 MIBG for each therapy session. We present a case series to highlight the clinical complexity of these rare endocrine neoplasms and our early experience with MIBG therapy.

CASE
The first case involves a 57-year-old male with a large, right pheochromocytoma diagnosed in 2013. Recurrence was noted post-debulking surgery and chemoembolisation. He had 2 MIBG therapies between 2015 and 2016. Surveillance showed a stable underlying tumour and decreasing urine metanephrine level. However, he developed a metastatic pleural nodule and multiple abdominal nodes in 2021. The third MIBG therapy was given in October 2022. Stable disease was noted on a follow-up MIBG scan in April 2023 with markedly decreasing serum Chromogranin A (CgA). For the second case, a 74-year-old male diagnosed with retroperitoneal paraganglioma in 2002 underwent surgery but presented back with metastatic lesions involving the liver and right ilium in 2012. He received 3 cycles of MIBG therapy between 2015 and 2017. Unfortunately, he deteriorated over the subsequent 18 months due to progressive multiple liver, abdominal nodes, lungs and skeletal metastases. The third case is a 50-year-old male with subhepatic paraganglioma diagnosed in 2017. Transarterial embolisations were done as surgery was deemed infeasible. He had 3 MIBG therapies between 2018 and 2020. Surveillance in 2021 showed a stable, focal upper abdomen lesion and decreasing CgA level. However, he developed metastatic disease progression with rebound CgA elevation in February 2022. Fourth MIBG therapy was given in September 2022. A MIBG-avid subhepatic mass was seen with extensive skeletal and cervical, thoracic and abdominal node metastases.

CONCLUSION
MIBG therapy may offer potential palliative benefit in pheochromocytoma and paraganglioma as seen among cases with a solitary large lesion or oligometastasis. However, advanced stage diseases especially those with bone metastasis show a poorer prognosis.

SPECTRUM OF ADRENAL INFECTIONS – FROM SOFT TO HARD

2024-07-18T04:37:30-07:00

INTRODUCTION
Adrenal infections can present in a spectrum from adrenalitis to abscess and calcification. It may either affect the adrenals unilaterally or bilaterally. We present two cases of adrenal infections: a unilateral adrenal abscess following ERCP and a bilateral adrenal calcification due to Histoplasmosis.

CASE
The first case is a 54-year-old male, with a history of alcoholism and diabetes, who presented with abdominal pain. Initial CT-abdomen showed chronic pancreatitis with a right adrenal lesion measuring 4.8 cm. ERCP done showed pancreatitis with infected pseudocyst. However, he presented back 2 months later with fever, abdominal pain and constitutional symptoms. CT-abdomen revealed a small liver abscess and a right adrenal abscess measuring 9 cm with an average HU of 61. He was treated with antibiotics for 8 weeks and underwent abscess drainage. The hormonal work-up was within normal range with adrenal insufficiency ruled out. All bacterial, tuberculous and fungal work-up were negative. A repeat CT of the abdomen after 4 months showed a residual adrenal abscess measuring 4.8 cm and a right adrenalectomy was scheduled. The second case is a 45-year-old male, a smoker with hypertension, who presented with constitutional symptoms, skin darkening, fever and features of adrenal crisis. Steroids and antibiotics were started. CT of the abdomen showed enlarged and calcified bilateral adrenals measuring 5 cm. Primary adrenal insufficiency was confirmed biochemically. CT-guided biopsy showed fibrous and necrotic tissue and PAS, GMS and Ziehl-Nielsen stains were negative. Adrenal tissue PCR was positive for Histoplama capsulatum and a diagnosis of adrenal histoplasmosis was made. The patient underwent a two-week treatment with Amphotericin B and continued with oral Itraconazoleplanned for 1 year. He showed improved general health and increased weight. Repeat CT of the adrenals after 3 months showed no significant change.

CONCLUSION
Adrenal infections have various presentations and can affect both immunocompetent and immunocompromised patients. Treatment of the underlying organism with antimicrobial therapies and steroid replacement is key to avoiding significant morbidity and mortality

RIFAMPIN-INDUCED ADRENAL CRISIS

2024-07-18T00:49:57-07:00

INTRODUCTION/BACKGROUND
Rifampicin is an essential first-line anti-tuberculosis drug. It is crucial for medical practitioners practicing in countries such as Malaysia where tuberculosis is endemic to recognize that rifampicin, an enzyme inducer, can have serious drugdrug interactions and needs to be used cautiously.

CASE
We describe a case of a 30-year-old male who sustained a mild traumatic brain injury with cerebrospinal fluid leakage in 2022. His injury was complicated by panhypopituitarism and secondary adrenal insufficiency, which required hydrocortisone 10mg/5mg BD and desmopressin replacement. He was compliant to hormonal replacement and remained asymptomatic throughout regular follow-up. In February 2024, he presented with submandibular swelling that turned out to be tuberculous lymphadenitis with pulmonary tuberculosis. He was started on first-line antituberculosis medications (Akurit-4), containing rifampicin, isoniazid, pyrazinamide and ethambutol with his usual dose of hydrocortisone. Three days after the initiation of anti-tuberculosis medication, the patient presented with vomiting, fever with postural dizziness without polyuria. Blood pressure was 102/64 mmHg, with postural hypotension and hypoglycaemia. The patient was diagnosed with adrenal insufficiency secondary to rifampicin. The patient was started on intravenous hydrocortisone 50 mg QID. Laboratory investigations revealed serum cortisol of <27 nmol/L with adrenocorticotropic hormone level of 0.36 pmol/L. After adequate hydrocortisone replacement, the patient had polyuria with a gradual reduction of serum sodium to 125 mmol/L, unmasking the presence of central diabetes insipidus. Desmopressin was started and the patient clinically improved with normalisation of serum sodium.

CONCLUSION
In patients with pre-existing adrenal insufficiency, initiation of an anti-tuberculosis regimen containing rifampicin may increase the metabolism of cortisol by inducing cytochrome CYP3A4 activity and precipitate an adrenal crisis. Before initiation of anti-tuberculosis medications, drug-drug interaction should be reviewed. In such cases, dose adjustment of hydrocortisone is necessary to prevent adrenal insufficiency. Increasing the hydrocortisone dose gradually and close monitoring of the patient’s biochemical and clinical state are important to reduce the risk of adrenal crisis and mortality.

A REVIEW OF CLINICAL PROFILE AND GLYCEMIC CONTROL OF PATIENTS WITH YOUNG-ONSET TYPE 2 DIABETES MELLITUS ON INTENSIVE INSULIN THERAPY

2024-07-18T22:26:47-07:00

INTRODUCTION/BACKGROUND
Young-onset type 2 diabetes mellitus (T2D) is a more aggressive subgroup of T2DM with rapid disease progression and rate of complications. Many patients progress to intensive insulin therapy early in the disease process due to decompensation and poor glycaemic control.

METHODOLOGY
We aimed to review the demographic profile, glycaemic control, and prevalence of complications in patients with young T2DM on intensive insulin therapy at the Endocrine Institute of Hospital Putrajaya. A retrospective audit was conducted using electronic medical records. Patients with T2DM between the age of 18-40 years on basal-bolus insulin therapy attending the outpatient diabetes clinic between January 2022 – March 2024 were included. Data about the demographic profile, insulin therapy, glycaemic control and complications were collected. A descriptive analysis using SPSS version 25.0 was performed.

RESULTS
The analysis involved a total of 72 cases, with a mean age of 33.7 years. Females comprised two-thirds (68.1%), with Malays being the majority (81.9%). The mean weight was 85.3 kg and the mean BMI was 32.1 kg/m2 . The mean duration of diabetes was 10.1 years. Among them, 62.5% have comorbidities such as hypertension and dyslipidaemia, and 48.6% are obese. The average duration of insulin therapy was 5.9 years. The mean HbA1c was 10.3% before insulin therapy and 9.5% on current intensive insulin therapy. Microvascular complications were prevalent (73.6%), with nephropathy being the most common (59.6%), followed by retinopathy and neuropathy. Approximately 5% of patients had macrovascular disease. More than two-thirds (70.8%) were on statin and half (56.9%) were on antiproteinuria therapy.

CONCLUSION
Most patients with young-onset T2DM have poor glycaemic control despite being on intensive insulin therapy. Most patients fit the phenotype of obesity with metabolic syndrome suggesting possible insulin resistance, as opposed to depletion, as the key factor driving disease progression. Treatment strategies employed should focus on intensive lifestyle intervention and pharmacotherapy targeting weight reduction and insulin resistance as opposed to excessive insulin in this subgroup.

CLINICAL CONUNDRUM OF STEROID RESISTANT TESTICULAR ADRENAL REST TUMOURS (TARTS)

2024-07-18T04:28:05-07:00

INTRODUCTION/BACKGROUND
Testicular adrenal rest tumours (TARTs) are benign intratesticular masses that occur in male patients with congenital adrenal hyperplasia (CAH), with more than 90% of cases caused by a deficiency of 21-α-hydroxylase. The presence of TART is an important complication leading to irreversible gonadal dysfunction and infertility. TARTs appear to be associated with poor hormonal control with concomitant elevated ACTH. The current mainstay of therapy is intensified glucocorticoid therapy. We describe two challenging cases of steroid-resistant TARTs.

CASE
Case 1 is a 25-year-old male with classical CAH diagnosed at 7 weeks of life. At age 12, he was diagnosed with TARTs. With a 17-OHP elevated to >60.6 nmol/L, his glucocorticoid dose was intensified with dexamethasone 0.5 mg ON for 5 years together with fludrocortisone. The latest 17-OHP was 436.7 nmol/L (1-10), ACTH 80.6 pmol/L (1.6-13.9), Direct renin >550 mU/L (5.3-99.1) and testosterone 21.64 nmol/L (0.58 - 31.28). Testicular ultrasonography demonstrated unresolved TARTs 1.0 x 1.1 x 1.4 cm (right) and 1.3 x 1.2 x 2.3 cm (left). Dexamethasone was subsequently switched to prednisolone 2.5 mg BD together with a referral to the urology team for consideration of testicular-sparing surgery or semen cryopreservation. Case 2 is a 20-year-old male with classical CAH diagnosed as a one-month-old infant and diagnosed with TARTs at age 13 years. Apart from fludrocortisone, his glucocorticoid therapy was intensified with dexamethasone 2.5 mg ON (tapering dose) for 5 years with his latest 17-OHP 116.4 nmol/L, testosterone 23.06 nmol/L, ACTH 128.9 pmol/L and Renin 47.2 mU/L. Testicular ultrasonography revealed increased size of TARTs 2.0 x 1.9 x 3.3 cm (right) and 1.7 x 1.5 x 2.9 cm (left). His case was complicated by exogenous Cushing syndrome secondary to dexamethasone. Dexamethasone was switched to prednisolone 2.5 mg BD with a referral to the urology team for co-management.

CONCLUSION
Intensified glucocorticoid therapy has led to tumour size reduction and improved testicular function in only a subset of patients. However, this approach potentially leads to serious side effects. Further research should aim to identify pharmacological alternatives that can effectively prevent the development of TARTs and treat existing TARTs to improve fertility outcomes.

ADRENAL INCIDENTALOMA

2024-07-17T21:15:11-07:00

INTRODUCTION/BACKGROUND
Adrenal incidentaloma (AI) is found while imaging for a different purpose when there are no overt signs of adrenal illness. A thorough history and examination of a patient with adrenal insufficiency may provide more hints to help diagnose and narrow the differentials.

CASE
The first patient is a 25-year-old male with hypertension and chronic diarrhoea. Blood investigation showed deranged liver function. Ultrasound of the abdomen revealed a heterogenous hyperechoic mass at the right suprarenal region measuring 6.9 x 5.8 x 7.5 cm (APxWxCC) which is compressing the adjacent right liver lobe. Twenty-four-hour urinary-free metanephrine demonstrated that metanephrine and normetanephrine levels were twenty times higher than the upper limit of the reference value. For the second patient, a 49-year-old female with hypertension and asthma presented with acute asthma exacerbation at the ED and POCUS showed an incidental finding of a right liver mass. Ultrasound of the abdomen showed a well-defined, heterogeneous hypoechoic, mixed solid-cystic lesion superior to the right kidney measuring 8.0 x 7.3 x 9.4 cm, suggestive of a right adrenal mass. Twentyfour-hour urinary-free metanephrine showed elevated normetanephrine 37.40 umol/24H (0.88-2.88). The third patient is a 49-year-old female who presented with abdominal discomfort, anorexia and weight loss of 3 kg over 3-4 months. Colonoscopy and OGDS yielded normal results. Ultrasound of the abdomen showed a large, heterogeneous lobulated lesion seen in the left retroperitoneal region measuring 11.9 x 5.4 x 6.2 cm. Twenty-four-hour urine-free metanephrine was normal. Corticoadrenal carcinoma was ruled out. Serial CT of the adrenal done two months apart showed a rapid increase in the size of the left adrenal mass with multiple enlarged lymph nodes. CT-guided biopsy of the left adrenal revealed primary diffuse large B cell lymphoma.

CONCLUSION
Hypertension is common in patients with adrenal insufficiency. Symptoms and blood investigation can give clues to the specific adrenal hyperfunction present which can help narrow down the differentials, thus reducing the cost of work-up in a resource limited centre. A patient with phaeochromocytoma might be asymptomatic and a low level of urine metanephrine could be due to a necrotic tumour. Computed tomography of the adrenal is essential to assess the characteristics of the lesion to further risk stratify the patient.

PREVALENCE OF DIABETES DISTRESS AMONG PATIENTS IN AN OUTPATIENT ENDOCRINE CLINIC IN A TERTIARY HOSPITAL

2024-07-18T22:15:01-07:00

INTRODUCTION
Diabetes distress (DD) among diabetes mellitus patients is becoming a major challenge for healthcare providers. Studies have shown that patients with diabetes distress tend to have poorer glycaemic control. The Diabetes Distress Scale is a validated tool featuring 3 major domains: emotional burden (EB), physician distress (PD) and therapeutic support distress (TSD). Our study aimed to investigate the prevalence of diabetes distress among our patients and to identify risk factors associated with this condition.

METHODOLOGY
This is a cross-sectional study involving type 1 and type 2 diabetes patients seen in the HRPB Endocrine Clinic from February-March 2024. Patients who fulfilled the inclusion criteria (n=91) answered the validated Malay version diabetes distress scale questionnaire (MDDS-17). The Total mean score (TS) and the mean score of the 3 domains were analysed using univariate analyses via SPSS. A mean item score >3.0 denotes significant diabetes distress.

RESULT
Median TS is 1.94 (1.59-2.47). 16.5% of the patients had a TS score ≥3. Significant scores in the other domains were: 27.5% for EB, 12.1% for PD and 17.6% for TSD. Those with HbA1c >8.5% had higher median TS scores versus those with HbA1c <6.5% and 6.6-8.4% (2.24 vs 1.71, p = 0.028; 2.24 vs 1.82, p = 0.023) respectively. Patients with HbA1c >8.5% also had higher median TSD scores versus those with HbA1c <6.5% and HbA1c 6.6-8.4% (2.5 vs 1.9, p = 0.03, 2.5 vs 2.06, p = 0.041), respectively. Patients aged between 12-29 had lower median PD scores versus those aged 30-49 and 50-69 (1 vs 1.5, p = <0.001, 1 vs 1.5, p = 0.009), respectively. Patients with retinopathy had higher median PD scores versus those without (1.63 vs 1.0, p = 0.015). There were no significant differences in scores for gender, ethnicity, type of DM, duration of disease, socioeconomic status and other DM complications.

CONCLUSION
The prevalence of diabetes distress is 16.5%. Patients with poor glycaemic control, the middle-aged group and those with retinopathy had significantly higher diabetes distress scores. Efforts should be made to identify these groups of patients for timely intervention.

A SINGLE METASTATIC LARGE ADRENAL MASS MIMICKING ADRENOCORTICAL CELL CARCINOMA

2024-07-18T02:08:52-07:00

INTRODUCTION
Invasive breast ductal carcinoma commonly metastasizes to the lungs, liver, bones and brain. Solitary adrenal metastasis from invasive ductal carcinoma is extremely rare. Hence, a single large adrenal metastasis can mimic a primary adrenal tumour such as adrenocortical carcinoma. We report a case of a rare single metastatic large adrenal mass from invasive ductal carcinoma mimicking adrenocortical carcinoma.

CASE
A 49-year-old female, with a known case of invasive ductal carcinoma of the right breast underwent right mastectomy and axillary clearance and completed 6 cycles of systemic chemotherapy and 15 cycles of radiotherapy. The FDG-PET scan surveillance post-treatment showed FDG-avid left adrenal mass suggestive of metastasis or primary malignancy with no other solid organ or bone metastasis. Subsequent computed tomography (CT) scan also showed a large, irregular lobulated solid left adrenal mass measuring 7.3 x 4.8 x 5.4 cm. Plain HU was 30 HU and the calculated absolute washout was 55%. A large left adrenal mass with the absence of other solid organs and bone metastasis made adrenocortical carcinoma one of the possible aetiologies. Biochemical investigation to assess adrenal tumour functionality, namely, overnight dexamethasone suppression test (ODST), aldosterone renin ratio (ARR) and 24-hour urine metanephrines all yielded normal results. Left open adrenalectomy was performed and histopathological examination (HPE) confirmed left adrenal metastasis from the breast carcinoma.

CONCLUSION
Single large solitary adrenal metastasis from invasive breast ductal carcinoma is rare and can mimic adrenocortical carcinoma. Early recognition and adrenalectomy will probably lead to improved patient survival.

UNVEILING A RARE PRESENTATION

2024-07-18T21:58:06-07:00

INTRODUCTION/BACKGROUND
Type 2 diabetes mellitus (T2D), once considered a predominantly adult-onset disease, has witnessed a concerning surge in prevalence among adolescents worldwide emerging as a significant public health challenge. Studies have suggested that young-onset T2D might represent with more severe and rapidly progressive disorder than adults. We illuminate the clinical journey of a teenage patient who presented with a renal abscess as a rare complication concurrent with the diagnosis of diabetes.

CASE
A 13-year-old Indian female, with no known medical illness, presented with fever and osmotic symptoms for 1 month. Otherwise, she had no other infective symptoms. Upon presentation, she was hemodynamically stable and systemic examinations were unremarkable. Her BMI was 20 kg/m2 , with weight of 45 kg and height of 150 cm. She had acanthosis nigricans, capillary blood sugar of 13.2 mmol/L, serum ketone of 0.4 mmol/L, and no metabolic acidosis. Her investigations showed total white cells of 18.2x103/uL, c-reactive protein 146.9 mg/L and HbA1c 13.1%. Because of persistent fever, an ultrasound of the abdomen was done which revealed a right upper pole renal nephronia (3.1 x 2.5 x 1.8 cm) and a large left lower pole renal abscess (5.4 x 8.5 x 10.1 cm). The renal abscess was removed with pigtail drainage and the abscess culture & sensitivity grew Klebsiella pneumonia, sensitive to amoxicillin-clavulanate. After 6 weeks of adequate antibiotics and intensive insulin therapy, repeated imaging showed a resolved renal abscess. Her pancreatic autoantibodies panel was positive for anti-Islet cell [42.9 IU/ml, (reference range <28)], and negative for anti-IA2 and antiGAD. Distinguishing between the types of diabetes can be challenging in this age group. As she had clinical features of insulin resistance, high c-peptide level (1764 pmol/L) and parental history of T2D, she was diagnosed as young T2D with positive pancreatic autoantibody. During subsequent follow-up, her glycaemic treatment was de-intensified to basal insulin and metformin. In addition to dietary and lifestyle modification, her HbA1c improved to 6.0% with good glycaemic control.

CONCLUSION
There is an increasing prevalence of T2D in adolescents. However, renal abscess remains a rare presentation in teenagers with newly diagnosed diabetes. Successful management involved timely diagnosis, implementation of imaging, source control, adequate antibiotics and optimal glycaemic control.

CORTISOL DAY CURVE TO GUIDE GLUCOCORTICOID REPLACEMENT IN A PATIENT WITH ADRENAL INSUFFICIENCY ON ANTI-TUBERCULOSIS THERAPY

2024-07-18T01:57:59-07:00

INTRODUCTION
Hydrocortisone in divided doses (typically 15 – 25 mg/day) is the most common form of glucocorticoid replacement regimen in patients with adrenal insufficiency (AI). However, this may be inadequate for patients on CYP3A4 inducers which affect glucocorticoid metabolism. While there are no specific guidelines on dose adjustment, cortisol day curve (CDC) could be used to guide optimal replacement. We report a case of a female with AI secondary to pituitary tuberculosis requiring hydrocortisone dose adjustment following initiation of anti-tuberculosis therapy (anti-TB).

CASE
A 45-year-old female presented with a worsening headache for a month, without any constitutional symptoms. Imaging revealed a heterogenous sellar mass (1.3 x 1.5 x 2.1 cm) without chiasmal compression or cavernous involvement. Blood investigations showed serum cortisol <14 nmol/L (reference interval 145-619), FT4 10 pmol/L (reference interval 11.5 – 22.7) and TSH <0.01 m IU/L (reference interval 0.55-4.78). Other blood investigations were normal. She was commenced on hydrocortisone 10 mg BD (8 am, 2 pm) and levothyroxine 50 mcg OD. Trans-sphenoidal resection was performed, and histopathology revealed necrotising granulomatous inflammation with caseating necrosis. The diagnosis of pituitary tuberculosis was made, and first line anti-TB drugs (rifampicin, isoniazid, pyrazinamide, and ethambutol) were initiated. Despite pre-emptively increasing hydrocortisone to 20 mg BD, she experienced postural hypotension, lethargy, and nausea soon after initiation of anti-TB medications, especially in the early afternoon and evening. Cortisol day curve was done by measuring serum cortisol hourly from 8 am – 8 pm while she took her regular hydrocortisone 20 mg BD. Serum cortisol levels were <14 nmol/L (8 am), 1009 nmol/L (9 am), 664 nmol/L (10 am), 386 nmol/L (11 am), 217 nmol/L (12 pm), 88 nmol/L (2 pm), 761 nmol/L (3 pm), 857 nmol/L (4 pm), 521 nmol/L (5 pm), 256 nmol/L (6 pm), and 85 nmol/L (8 pm). Hydrocortisone was adjusted to 20 mg (8 am), 10 mg (1 pm) and 5 mg (6 pm) to counter the trough levels. This led to a marked improvement in her symptoms.

CONCLUSION
CYP3A4 inducers (anti-TB) affect glucocorticoid metabolism and replacement in patients with AI. The cortisol day curve could be used as a guide to tailor therapy in situations where adequate replacement doses and timing are not easily identified.

A CLINICAL AUDIT ON STATIN THERAPY AMONG TYPE 2 DIABETES MELLITUS PATIENTS ATTENDING PUSAT PERUBATAN ANGKATAN TENTERA (PPAT), SUNGAI BESI, MALAYSIA

2024-07-18T21:47:20-07:00

INTRODUCTION/BACKGROUND
Type 2 Diabetes Mellitus (T2DM) patients are at higher risk of developing atherosclerotic cardiovascular disease (ASCVD), which leads to increased morbidity, mortality and use of healthcare resources. Therefore, the primary prevention of ASCVD can be achieved by prescribing the appropriate doses of statin therapy depending on the patient’s risk. This is a clinical audit on the use of statin therapy among type 2 Diabetes Mellitus patients at PPAT, Sungai Besi.

METHODOLOGY
This clinical audit aims to improve the quality of care of adult patients with T2DM in preventing ASCVD by utilizing the T2DM Clinical Practice Guidelines (CPG) 2020. A retrospective clinical audit was conducted using a convenient sampling method that involved 32 medical records from PPAT, Sungai Besi. Adults aged above 40 years with T2DM diagnosed for more than six months, and under active follow-up, were included. The criteria were based on the T2DM Clinical Practice Guidelines (CPG) 2020, with standards set at 90% and 50% based on literature reviews.

RESULT
A total of 32 medical records were audited. Most subjects were male (53%), with a median age of 54 years. 90.63% of T2DM adults were on statin therapy. The usage of statin therapy in T2DM patients above 40 years old is satisfactory and achieved the standard of 90%. However, only 20.69% were on high-intensity statin therapy and did not achieve the standard of 50%.

CONCLUSION
These issues need to be addressed by training healthcare providers. Enhancing clinic protocols to address relevant issues is imperative to enhance overall diabetes care, particularly ensuring appropriate utilization of statin therapy in T2DM patients who are either at high risk or very high risk of ASCVD.

A RARE CASE OF UNILATERAL ADRENAL LYMPHOMA WITH LYMPHADENOPATHY

2024-07-18T01:43:34-07:00

INTRODUCTION/BACKGROUND
Adrenal lymphoma is an extremely rare and highly invasive malignant disease. We report a rare case of unilateral adrenal lymphoma with lymphadenopathy.

CASE
A 68-year-old male presented with abdominal discomfort, polyuria and weight loss of 15 kg over 6 months. Physical examination revealed a thin elderly man with fullness over the left lumbar and inguinal lymph nodes. Laboratory tests showed markedly elevated lactate dehydrogenase (LDH) levels of >690 UI/L (<248) and hypercalcemia. A computed tomography (CT) scan revealed a large left adrenal mass (11.6 x 8.3 x 9.6 cm) with multiple matted abdominal lymph nodes, raising a suspicion of adrenal malignancy. Following this, hormonal profile was done which showed normal cortisol and catecholamines. An ultrasound-guided trucut biopsy of the right inguinal lymph nodes was performed. The microscopic examination showed a malignant tumour composed of mononuclear cells with pleomorphic nuclei with high mitotic figures. On immunohistochemistry, the tumour cells were positive for vimentin, CD20, CD10, BCL-6, leucocytes common antigen (LCA) and Ki67 proliferating index was 60% in the tumour cells. A diagnosis of diffuse large B cell lymphoma (DLBCL) was made. The patient was referred to the haematology team and started on chemotherapy.

CONCLUSION
Primary adrenal lymphoma is a rare entity with a generally poor prognosis. They usually involve both adrenal glands, but unilateral adrenal involvement can occur in about one-third of patients. In patients with large adrenal masses and constitutional symptoms, the initial dilemma is to differentiate between adrenal carcinoma versus other forms of malignancies or chronic infections. Adrenal biopsy is generally avoided in suspected adrenal carcinoma as it may be harmful because it can lead to tumour seeding. In our patient, the presence of multiple lymphadenopathy which was accessible for biopsy helped clinch the diagnosis of adrenal lymphoma. The presence of lymphadenopathy with large adrenal masses, even if unilateral, should prompt suspicion of the diagnosis of adrenal lymphoma.

GAPS IN THE MANAGEMENT OF TYPE 2 DIABETES MELLITUS AMONG WOMEN LIVING WITH HIV IN AN ACADEMIC MEDICAL CENTRE

2024-07-18T05:26:53-07:00

INTRODUCTION
Type 2 Diabetes Mellitus (T2DM) poses significant cardiovascular risks. Individuals with HIV face compounded risks due to accelerated aging, chronic inflammation and certain antiretroviral therapies (ART). Postmenopausal women have increased cardiovascular risk. However, data on women living with HIV (WWH) and T2DM in Malaysia is scarce.

METHODOLOGY
This study examines gaps in the management of T2DM and cardiometabolic health among WWH undergoing routine HIV care in a tertiary hospital. We reviewed the electronic medical records of WWH with T2DM attending the Infectious Diseases (ID) Clinic at Universiti Malaya Medical Centre (UMMC) in 2023. We extracted HIV demographics, anthropometrics, latest HbA1c, fasting plasma glucose (FPG) and lipid levels, and defined targets for control as per the 6th Malaysian Clinical Practice Guidelines for T2DM. Gaps in care were defined as the proportion not achieving targets for control of metabolic parameters.

RESULTS
We collected data from 33 WWH with T2DM, representing 17.8% of all WWH in ID UMMC. Their median age was 54 years (IQR 49, 61) and the median duration since HIV diagnosis was 19 years (IQR 14, 25). All were on ART, with 30 (90.9%) having suppressed viral loads. Menopause status was recorded in 57.6% (n=19), with 78.9% (n=15) being menopausal. Four (12.1%) were active smokers. For T2DM management, 26 (96.3%) were on oral antidiabetic drugs (OADs) and 1 (3.7%) was on insulin. The most used OADs were metformin (65.7%), followed by sulfonylurea (25.7%) and SGLT2i (2.9%). Overall, 60.6% (n = 33) met the HbA1c target of <7% and 66.7% had an FPG within 4.4-7.0 mmol/L (n = 30/33). For lipids, 54.8% (n = 31/33) had triglycerides ≤1.7 mmol/L, 67.7% (n=31/33) HDL >1.2 mmol/L, and 56.7% (n = 30/33) LDL ≤2.6 mmol/L. 72.7% were on statins. For BP, only one (0.03%) had readings within the target range. 36.4% were on an ACE inhibitor or angiotensin-receptor blocker. Only 33.4% had an ideal BMI.

CONCLUSION
There are significant gaps in managing T2D among WWH. Addressing these gaps requires interdisciplinary collaboration for integrated care solutions.

DISSEMINATED HISTOPLASMOSIS WITH BILATERAL ADRENAL INFILTRATION AND PRIMARY ADRENAL INSUFFICIENCY

2024-07-18T01:35:44-07:00

INTRODUCTION/BACKGROUND
Histoplasmosis is a fungal disease caused by Histoplasma capsulatum and characterized by two forms: pulmonary and disseminated histoplasmosis. In the latter form, adrenal infiltration is a common feature, resulting in detection of bilateral adrenal masses radiologically. Bilateral extensive destruction of the adrenal glands results in primary adrenal insufficiency (PAI), which occurs in 5–71% of adrenal histoplasmosis. We present a case of PAI with adrenal histoplasmosis.

CASE
A 71-year-old male, with underlying diabetes, hypertension, and pulmonary tuberculosis, presented with bloody diarrhea and thrombocytopenia. Multiple ulcers were observed over the dorsal surface of the tongue. The histopathological examination (HPE) of the tongue was consistent with histoplasmosis. Colonoscopy examination was unremarkable. The patient was referred to an infectious disease team and was prescribed a course of itraconazole for six weeks. A year later, he had recurrent bloody diarrhea, and repeated colonoscopy revealed inflamed rectal mucosa. Histopathological examination revealed chronic proctitis with noncaseating granulomas that were consistent with fungal infection. Intravenous amphotericin B was administered, followed by oral isavuconazole and itraconazole. Computed tomography (CT) scan demonstrated enlarged bilateral adrenal glands with the right side measuring 4.9 x 2.6 x 6.8 cm, and the medial limb of the left adrenal gland measuring 4.3 x 2.5 cm. The lateral limb of the left adrenal gland was 3.6 x 2.1 cm. Ten weeks after antifungal therapy was started, CT scan revealed a smaller left adrenal lesion, but the right adrenal lesion remains unchanged. Short synacthen test showed PAI with peak cortisol 246 nmol/L, ACTH 20.3 pmol/L (1.6-13.9). He is awaiting adrenal biopsy pending urinary metanephrines. Glucocorticoid replacement was initiated. Antifungal therapy would be continued for no less than one year.

CONCLUSION
Adrenal histoplasmosis is common and histopathological analysis is crucial in managing such cases. It is important to be vigilant about infections like histoplasmosis as a potential cause of PAI. Delay in treatment could result in life-threatening consequences.

RECURRENT HYPOGLYCEMIA IN A TEENAGER WITH OBESITY

2024-07-18T05:13:36-07:00

IINTRODUCTION
Reactive hypoglycaemia is a condition of postprandial hypoglycemia occurring within 2 to 5 hours after meal intake. This condition is characterised by inappropriately increased blood insulin levels due to pancreatic overactivity to carbohydrates, most often refined sugars, thus producing hypoglycaemic symptoms. Recent studies have shown that the prevalence of T2D in obese children and adolescents is 0.18–7.9%, which is five times that in normalweight individuals.

CASE
This is a case of a 16-year-old female with a BMI of 34.28 kg/m2 who presented with frequent symptoms of hypoglycaemia, mainly palpitations, sweating, giddiness and syncopal attacks since January 2023. The frequency of symptoms was noted 5 to 6 times per week, commonly occurring 4 hours post-meal and after strenuous activity. She practices a heavy dietary intake 4 times per day with refined carbohydrates at each meal. Clinically, the patient exhibits signs of insulin resistance such as acanthosis nigricans. She underwent a mixed-meal tolerance test in November 2023 which showed no clinical and biochemical evidence of hypoglycaemia. Following that, continuous glucose monitoring was arranged for a week which showed hypoglycaemic episodes ranging from 3.5 to 3.9 mmol/L in the afternoon of one of the days. She was prescribed Acarbose but declined treatment due to gastrointestinal intolerance. She opted for a high fibre, low glycaemic index diet with frequent small meals which showed improvement of the symptoms.

CONCLUSION
Lifestyle modifications are the mainstay of management and prevention of the development of diabetes mellitus for patients with reactive hypoglycaemia. Furthermore, studies have shown that the addition of metformin or acarbose also plays a vital value in preventing reactive hypoglycaemia.

A CASE OF CLINICALLY AND BIOCHEMICALLY SILENT GIANT PHEOCHROMOCYTOMA

2024-07-18T01:22:33-07:00

INTRODUCTION/BACKGROUND
With the widespread use of computed imaging and genetic testing, up to 60% of pheochromocytomas are diagnosed in the presymptomatic stage, particularly when the lesion is smaller than 3 cm. We report a rare case of clinically and biochemically silent giant pheochromocytoma.

CASE
A 44-year-old Malay male with a two-year history of hypertension was initially admitted to the surgical team for gallbladder empyema. However, abdominal CT showed a lobulated, heterogeneously enhancing mass with an area of necrosis at the right peritoneal region measuring 11 x 13.5 x 15.2 cm. Subsequent ultrasound-guided biopsy of the mass revealed pheochromocytoma. He was then referred to the Endocrine team for further management. No paroxysmal symptoms were reported by the patient and his blood pressure was well-controlled on a single antihypertensive. Laboratory workup including 24-hour urine catecholamines and 24-hour urine metanephrine were not elevated. Thus, 68Ga/Dotatate scan was performed, which demonstrated evidence of somatostatin receptor avid malignancy in the abdominal mass with no evidence of regional or distant metastasis. Following the scan, serum chromogranin A (CgA) was sent and was found to be elevated (2682.4 ng/ml, normal range: 27-94 ng/ml). After adequate alpha- and beta-blockade, he successfully underwent right adrenalectomy with complete removal of the mass with no complications intra- and postoperatively. The HPE of the mass reported the presence of a wellcircumscribed tumour focally encapsulated by a thin fibrous capsule, with the absence of necrosis and invasion of the vascular, adrenal capsular and periadrenal soft tissue, with a Ki-67 proliferative index of 1%. A repeat abdominal CT done two months post-operatively showed no evidence of local recurrence and a normal CgA level (85.8 ng/ml).

CONCLUSION
Surgery is the primary treatment for pheochromocytoma, and pre-operative alpha- and beta-blockade are essential regardless of tumour size and biochemical status. In patients without elevated levels of catecholamines, CgA is the alternative functional diagnostic and surveillance marker.

ASSESSING THE REAL-WORLD EFFICACY OF DULAGLUTIDE IN MALAYSIAN MOH PATIENTS WITH TYPE 2 DIABETES MELLITUS

2024-07-18T04:59:24-07:00

INTRODUCTION/BACKGROUND
An estimated 70% of Type 2 Diabetes Mellitus (T2DM) patients treated in Ministry of Health (MOH) hospitalbased diabetes clinics are still unable to achieve HbA1c targets despite combination glucose-lowering drugs. Moreover, more than 80% of these patients are overweight or obese. In Malaysia, dulaglutide, a once-weekly GLP1RA, was approved in 2018 for use in patients with T2DM. Accessibility to GLP-1RA therapy is much limited in MOH hospitals.

METHODOLOGY
This study aims to assess the glycaemic and weightlowering efficacy of dulaglutide at 6 and 12 months in T2DM patients treated in a real-world clinical setting. We conducted a retrospective study of 69 T2DM patients who initiated dulaglutide in 4 MOH endocrinologist-led hospital-based diabetes clinics (Hospital Putrajaya, Hospital Selayang, Hospital Kuala Lumpur, and Hospital Tuanku Ja’afar). The primary outcome was HbA1c reduction at 6 months of dulaglutide therapy, while the secondary outcomes were HbA1c reduction at 12 months and weight loss at 6 and 12 months.

RESULT
In this study, the patients’ mean baseline age, HbA1c and weight were 54 years old, 8.33% and 91.2 kg, respectively. The mean absolute reduction of HbA1c at 6 months was -0.93% and -0.87% at 12 months. The percentage of patients that achieved ≥2%, 1-2% and 0.5-<1% HbA1c reductions were 16%, 28% and 21% at 6 months, respectively, and 17%, 33% and 11%, at 12 months, respectively. For the secondary outcome analyses, patients experienced a mean weight loss of 3.73 kg at 6 months, and 4.83 kg at 12 months. The percentage of patients that achieved ≥10 kg, 5-10 kg and 1-<5 kg weight reductions at 6 months were 13%, 25%, and 34%, respectively; and at 12 months, 16%, 22% and 41%, respectively.

CONCLUSION
Dulaglutide therapy was shown to be effective in reducing HbA1c and weight at 6 and 12 months of therapy in Malaysian patients with type 2 diabetes currently treated with at least two or more OGLDs, with or without insulin.

T1DM PATIENTS IN HOSPITAL SELAYANG

2024-07-17T21:08:04-07:00

INTRODUCTION
Type 1 Diabetes Mellitus (T1DM) patients in Malaysia are characterized by poor glycaemic control and with high prevalence of diabetic ketoacidosis (DKA) among children and adolescents. This study aimed to examine the clinical characteristics of adult T1DM patients and to explore the association with recurrent DKA.

METHODOLOGY
All adult T1DM patients under Endocrine Unit follow-up in Selayang Hospital were included. Socio-demographic data associated with co-morbidities, macrovascular and microvascular complications, acute complications such as hypoglycaemia or DKA, metabolic profile and anthropometric measurements were extracted from medical records. Diabetes distress was evaluated using the diabetic distress scale (DDS).

RESULT
This cohort included 97 patients with a median age of 28 (IQR 15) and 64.9% of them were male. The ethnic distribution was Malay (51.5%), Chinese (29.9%) and Indian (15.5%). Majority (57.9%) received only primary or secondary school education while 75.8% were from the B40 (bottom-tier household income) category. The median disease duration was 10.0 (IQR 12.0) years. Seventy-one percent of Insulin users were on an analogue insulin-based regimen. Mean HbA1c was 9.9 ± 2.9%. Diabetes complications, predominantly retinopathy and diabetic kidney disease were present in 29.9% of the cohort. Of the cohort, 35.1%, had recurrent DKA in the past 5 years. This was associated with Indian ethnicity (p = 0.047), lower education group (p = 0.023), higher diabetes distress (p = 0.013), higher HbA1c (p = <0.001), non-obese (p = 0.017) and patients with diabetes complications such as retinopathy (p = 0.012) and diabetic kidney disease (p =<0.001). The association remained significant in the adjusted analysis for higher HbA1c (OR 1.352, 95%CI 1.073, 1.703), Indian ethnicity (OR 12.956, 95%CI 1.962, 85.56), retinopathy (OR 8.087, 95%CI 1.309, 49.95), diabetic kidney disease (OR 9.173, 95%CI 1.888, 44.56) and nonobese (OR 44.543, 95%CI 2.644, 750.43).

CONCLUSION
Our T1DM cohort had poor glycaemic control with a high burden of recurrent DKA associated with higher HbA1c, greater diabetic distress, microvascular complications and a non-obese state. Further research is warranted to explore the causal association between these factors to develop effective strategies to improve glycaemic control and the burden of DKA.

IMPACT OF METABOLIC SURGERY ON CARDIOMETABOLIC RISK FACTORS IN OBESE PATIENTS WITH TYPE 2 DIABETES, PREDIABETES AND NORMOGLYCAEMIA

2024-07-17T06:11:10-07:00

INTRODUCTION
Metabolic surgery has shown promising results in managing obesity-associated conditions, including type 2 diabetes mellitus (T2DM). Despite its efficacy, its impact on obese individuals at different stages of T2DM remains underexplored, particularly in Malaysia. This study aimed to assess the effect of bariatric surgery on cardiometabolic risk factors in obese patients and compare outcomes among patients with T2DM, prediabetes, and without diabetes over 12 months.

METHODOLOGY
This study included 86 obese patients from various centres in Klang Valley, Malaysia, who underwent metabolic surgery procedures such as laparoscopic sleeve gastrectomy, Roux-en-Y gastric bypass, mini-gastric bypass, and one-anastomosis gastric bypass. They were stratified into three groups based on baseline HbA1c measurements according to Malaysia's CPG of Management of Type 2 Diabetes Mellitus 6th Edition: no diabetes (n = 42), prediabetes (n = 25), and diabetes (n = 19). Changes in weight, HbA1c, lipid profiles, and liver function markers (ALT, AST, and GGT) were evaluated at 6 and 12 months. Postoperative changes in cardiometabolic risk factors were analysed using the generalized estimating equations.

RESULTS
The patients were mostly female (67.4%) and Malay (65.3%), with a mean age of 39.0 ± 7.7 years and a mean BMI of 39.7 ± 8.1 kg/m2 . Significant improvements were observed in weight, HbA1c, HDL-C, triglycerides, AST, ALT, and GGT levels after 12 months across all groups (p <0.05), with the diabetes group showing the most substantial improvement in most variables. Comparison between groups highlighted significant differences in mean HbA1c and TG levels between the diabetes and prediabetes groups compared to the normoglycemia group (p <0.01).

CONCLUSION
Metabolic surgery improves cardiometabolic risk factors in obese patients, particularly in those with T2DM. Its potential benefits extend to individuals at high risk of developing diabetes, underscoring the need for further research to assess their eligibility for surgical intervention.

ADRENAL INSUFFICIENCY AND ITS ASSOCIATED FACTORS AMONG MULTI-ETHNIC PEOPLE LIVING WITH HIV/AIDS CONSULTING AT TERTIARY HOSPITALS

2024-07-17T05:23:13-07:00

INTRODUCTION
Adrenal insufficiency (AI) is one of the most common potentially life-threatening endocrine complications in people living with HIV/AIDS. This study aims to describe AI among them, where data on this topic are scarce.

METHODOLOGY
A cross-sectional study was conducted at the Infectious Diseases clinics of two tertiary centres. A total of 110 stable adults living with HIV/AIDS, aged 18 to 80 years old from the outpatient setting, were recruited. Clinical and laboratory data were collected and cosyntropin stimulation tests were performed. Adrenal antibody was analysed among those who had an inadequate response.

RESULT
The mean age of the studied population was 37.5 ± 10.6 years. Majority of the subjects were male (81.8%). Only 23.6% of subjects had a normal BMI, with 10.9% classified as underweight and 64.5% as overweight/obese. The mean disease duration was 6.6 ± 6.2 years. All subjects were receiving highly active antiretroviral therapy (HAART), with a mean treatment duration of 4.9 ± 4.2 years. Among these, 22 individuals (20%) experienced treatment failure, and 46 individuals (41.8%) had a history of opportunistic infections. Five individuals (4.5%) had autoimmune disease. The mean nadir CD4 count among the studied population was 202 cells/mm3 , with 60% of them having a nadir CD4 <200 cells/mm3 . At the time of the cosyntropin stimulation test, the majority of individuals, 97 (88.2%), had a viral load (VL) <40 copies/ml, and 89 (89.1%) had a CD4 count >200 cells/mm3 . In the assessment for adrenal insufficiency, 7 individuals (6.4%) exhibited symptoms suggestive of adrenal insufficiency. However, only 2 individuals (1.8%) were found to have an inadequate response to cosyntropin. Adrenal antibodies were negative, and ACTH was not elevated in these two patients.

CONCLUSION
This study reveals a low prevalence of AI (1.8%) among stable patients with HIV/AIDS on antiretroviral therapy. Individualized screening and ongoing monitoring are crucial. These findings emphasize the importance of tailored care strategies for this population.

VITAMIN D DEFICIENCY IN PATIENTS WITH NON-ALCOHOLIC FATTY LIVER DISEASE AND TYPE 2 DIABETES MELLITUS

2024-07-17T06:17:32-07:00

INTRODUCTION
Low vitamin D levels have been associated with type 2 diabetes mellitus and non-alcoholic fatty liver disease. Insulin resistance, inflammation and oxidative stress have been suggested to be responsible for the development of NAFLD. These mechanisms are linked to vitamin D’s anti-inflammatory effect. Vitamin D deficiency is highly prevalent among patients with T2DM and NAFLD and is an independent risk factor for developing NAFLD in patients with T2DM.

METHODOLOGY
The study aimed to determine the prevalence and associated risk factors of vitamin D deficiency in patients with NAFLD and T2DM. We conducted a cross-sectional study in patients with T2DM (n=110). The patients were divided into 2 groups: NAFLD (n=86) and no NAFLD (n = 24). The patients within the NAFLD group were further divided into 2 groups (vitamin D deficient and non-deficient). Serum total 25 (OH) D3 was analysed using electrochemiluminescence immunoassay (Roche), and deficiency was defined as a level of <50 nmol/L. Diagnosis of NAFLD was based on the abdominal ultrasound performed by 2 experienced radiologists. Steatosis was defined as increased liver echogenicity.

RESULT
The prevalence of vitamin D deficiency in patients with T2DM and NAFLD was 52.3% (45/86), as compared to only 33.8% (8/24) in those without NAFLD. Vitamin D level was significantly lower in patients with NAFLD as compared to those without NAFLD (51.53 ± 19.68 vs 60.61 ± 20.25, p <0.05). There was no difference in the age (57.74 ± 8.42 vs 57.96 ± 7.97 years, p = 0.91), gender (male 55.7% vs 70.8%, p = 0.18), BMI (28.99 ± 3.80 vs 28.24 ± 3.74 kg/m2 , p = 0.40), and diabetes duration (12.43 ± 7.92 vs 10.42 ± 6.51, p = 0.25), between the 2 groups. Multivariate analysis demonstrated that HbA1c (AOR 1.89; 95%CI 1.15-3.09; p = 0.01) and vitamin D deficiency were the independent risk factors for NAFLD (AOR 3.15 95%CI 1.10-9.04; p = 0.03), after adjustment for age, gender, diabetes duration and eGFR.

CONCLUSION
This study demonstrated a high prevalence of vitamin D Deficiency in patients with NAFLD and T2DM. In patients with T2DM, those with vitamin D deficiency were three times more likely to develop NAFLD. Vitamin D levels of <50 nmol/L and higher HbA1c were the two independent risk factors for developing NAFLD.

EARLY METABOLIC AND WEIGHT LOSS OUTCOMES IN LAPAROSCOPIC SLEEVE GASTRECTOMY PLUS PROXIMAL JEJUNAL BYPASS (SLEEVE PJB)

2024-07-17T05:40:48-07:00

INTRODUCTION
Sleeve plus procedures are sleeve gastrectomy variations that include numerous procedures such as SADI-S (single anastomosis duodenoileal bypass with sleeve), loop duodenojejunal bypass with sleeve gastrectomy (Loop DJB) and sleeve gastrectomy plus proximal jejunal bypass (Sleeve PJB). We have performed Sleeve PJB for selected patients in our centre.

METHODOLOGY
We did a retrospective analysis of patients who underwent laparoscopic sleeve PJB in Hospital Raja Permaisuri Bainun Ipoh in 2023. We analysed demographics, weight, BMI and HbA1c. All patients had a sleeve gastrectomy utilizing our standard operative technique. For the proximal jejunal bypass (PJB), jejunum was transected at 50 cm distal to the ligament of Treitz. Subsequently, another 270 cm to 300 cm of jejunum was measured from the divided region and a side-to-side jejunojejunostomy was done.

RESULT
A total of 6 patients underwent this procedure. All patients were not amenable to gastric bypass and wanted a more durable surgery in terms of weight loss and metabolic outcomes. Four of them had pre-diabetes and two patients had diabetes based on HbA1c. Cumulative mean age, weight and BMI were 44 years, 109 kg and 44 kg/m2 respectively. The HbA1c for the prediabetes and diabetes group preoperatively were 6% and 8% respectively. Postoperatively at 6 months, the HbA1c was 5.4% and 5.9% respectively for each group. Cumulative postoperative mean current weight and mean percentage of total weight loss (%TWL) at 6 months were 91.5 kg and 20.57%.

CONCLUSION
This study shows that early outcomes for sleeve PJB are favourable and likely a non-inferior option for patients who are not amenable to a standard gastric bypass.

BILATERAL ADRENAL MASSES

2024-07-17T05:19:49-07:00

INTRODUCTION
Bilateral adrenal masses are uncommon and present with varied clinical manifestations and aetiologies. Understanding the prevalence and characteristics of different aetiologies of adrenal masses is crucial for instituting effective management strategies.

METHODOLOGY
A retrospective analysis was conducted on 34 patients with bilateral adrenal masses evaluated at the Endocrine Centre, Hospital Putrajaya, from 2015 to 2024.

RESULT
The mean age of our cohort was 53.7 ± 16.7 years, the majority being male (58.8%). Pheochromocytoma was the most common aetiology (10 cases, 28.6%), presenting at a younger mean age of 41.2 ± 17.5 years, with half of the cases being clinically silent. The mean size of the adrenal masses was 3.47 ± 1.94 cm. Seventy percent of patients had confirmed genetic defects, and all had benign histopathology except one with features of a tumour likely to have a malignant behaviour. This patient had a positive VHL variant. Similarly, non-functioning bilateral adenomas contributed 10 cases (28.6%), which were all asymptomatic. The mean age at presentation was 64.3 ± 8.9 years, and the mean size of the adrenal masses was 1.32 ± 0.44 cm. Chronic infection was found in seven cases (20%) of bilateral adrenal masses (three tuberculosis, two histoplasmoses, one MRSA/salmonella bacteraemia and one adrenalitis from an unknown infectious agent), with 85.7% of them exhibiting symptoms of hypocortisolism. Malignancy represented a minority of cases (4, 11.4%), with one case of adrenal lymphoma and three cases of adrenal metastasis. These cases presented at an older age (mean age: 62 ± 10.3 years) with no disturbance of adrenocortical function. The mean size of the adrenal masses was 5.67 cm for lymphoma and 1.92 ± 0.48 cm for adrenal metastasis. Other etiologies observed included two cases of cortisol-secreting adenoma, one case of adrenal oncocytoma, and one case of unknown cause.

CONCLUSION
This retrospective analysis reveals diverse aetiologies of adrenal masses, including pheochromocytoma, nonfunctioning adenomas, infections, and malignancies. Variability in presentation, age, and size underscores the need for comprehensive evaluation and tailored management strategies for this complex patient population.

BRAIN NATRIURETIC PEPTIDE

2024-07-17T02:55:30-07:00

INTRODUCTION
Brain natriuretic peptide (BNP) is a cardiac biomarker used in the assessment of heart failure. Potentially, BNP levels can be used to stratify patients with thyroid storm (TS) who are at risk of complications such as heart failure and atrial fibrillation. We compared BNP levels in patients admitted with TS or impending TS (study group) with patients with newly diagnosed hyperthyroidism (control group) and to determine if BNP is a predictor of morbidity and mortality in patients with thyroid storm.

METHODOLOGY
This is a cross-sectional study conducted at University Malaya Medical Centre (UMMC) over one year (January 2023-December 2023). Fifty patients with impending TS/TS (TSG) and fifty patients with newly diagnosed hyperthyroidism (HG) were recruited and their serum BNP was measured. Patients’ morbidity and mortality outcomes were recorded.

RESULTS
FT4 and FT3 levels were higher in impending TS/TS (TSG) compared to newly diagnosed hyperthyroidism (HG): [FT4: 64.5 (27.4-129.1) pmol/L vs 30.5 (21.9-131.2) pmol/L, p <0.001; FT3 13.5 (7.9-45.4) pmol/L vs 13.5 (7.9 – 45.4) pmol/L, p = 0.038]. BNP levels were significantly higher in TSG [TSG vs HG:316 (2.0-8148.0) pg/ml vs 27.0 (2.0-310.0) pg/ml, p <0.001]. Those with impending TS/TS experienced higher rates of respiratory failure, atrial fibrillation, sinus tachycardia, and heart failure. In those with impending TS/TS, 80% had elevated BNP compared to 12% in HG. Those with elevated BNP also had significantly longer hospital stays [TSG vs HG: 5 (1-45) days vs 3 (2-7) days, p = 0.019]. Atrial fibrillation and sinus tachycardia were independently associated with elevated BNP detected by multivariable logistic regression. There was no mortality in either group.

CONCLUSION
This study demonstrated that BNP levels are elevated in impending/thyroid storms and can be potentially used to predict outcomes.

PREVALENCE AND ASSOCIATED RISK FACTORS OF LOW BONE MINERAL DENSITY IN MALAYSIANS LIVING WITH HIV

2024-07-17T02:32:48-07:00

INTRODUCTION
The global impact of HIV/AIDS has led to improved survival rates due to treatment efforts, but it has also resulted in a rise in chronic comorbidities such as low bone mineral density (BMD). Contributing factors to low BMD in HIV-positive individuals include the virus itself, treatment, and lifestyle factors. This study aims to describe the prevalence of low BMD and associated risk factors among individuals living with HIV. Findings from this research can potentially influence future screening practices.

METHODOLOGY
This cross-sectional study involved patients aged 25-45 years old with HIV undergoing follow-up in an infectious disease clinic. Participants underwent DXA scans to evaluate bone density, with T scores used to categorize BMD levels according to WHO criteria. Data were analysed to determine associations between low BMD and various risk factors.

RESULT
The study found that 65.5% (226 out of 345) of patients had low BMD, with 91.1% (206) having osteopenia and 8.2% (20) having osteoporosis. Binary logistic regression analysis revealed associations between low BMD and male gender and lower BMI. Additionally, BMD was observed to improve with a longer duration of antiretroviral therapy (ART).

CONCLUSION
The study underscores the high prevalence of low BMD among people living with HIV, emphasizing the need for vigilance, particularly among those with risk factors such as low BMI and male gender. Therefore, it is crucial to pay attention to this population subgroup, promote a healthy lifestyle, normal body weight, and adherence to antiviral medication to enhance overall bone health.

METABOLICALLY HEALTHY OBESITY AND ASSOCIATED RISK FACTORS AMONG MALAYSIAN ADULTS

2024-07-17T02:12:41-07:00

INTRODUCTION
Metabolically Healthy Obese (MHO) describes the subset of people with obesity (PwO) who do not exhibit overt cardiometabolic abnormalities, namely dysglycaemia, dyslipidemia or hypertension. While Malaysia has one of the highest obesity rates regionally, prevalence of MHO is unclear. This study aims to investigate the local prevalence of MHO among PwO and predisposing factors to Metabolically Unhealthy Obesity (MUO).

METHODOLOGY
Subjects were recruited at Universiti Malaya Medical Centre (UMMC) via convenience sampling. Healthcare workers in UMMC with no known chronic metabolic conditions were invited to participate and were included if their BMI was 23 kg/m2 and above. Data collected on demographics, anthropometric measurements, bioimpedance analysis (BIA), and a fasting blood sample for glucose and lipid metrics were collected. The subjects were classified as MHO if no metabolic abnormalities were detected, and otherwise as MUO. Statistical analysis was done using SPSS Version 25.

RESULT
Two hundred ninety-seven subjects were recruited. Mean age was 36.26 ± 7.37 years, majority were female (71.00%) and Malay (90.20%). Overall, 172 (57.9%) were classified as MHO. Males were more likely to be MUO, Χ2 (1, N=297) =4.09, p = 0.05. The MUO subgroup, compared to MHO subgroup, had significantly higher weight [median=77.65 (IQR:19.15) kg versus 70.55 (14.91) kg; p<0.01], BMI [30.10 (6.00) kg/m2 versus 26.80 (4.67) kg/m2 , p <0.01], waist [94.40 (4.02) cm versus 90.50 (10.00) cm, p<0.01] and hip [105.40 (5.70) cm versus 101.90 (10.38) cm, p <0.01] circumferences, and waist-to-height ratio (WHtR) [0.59 (0.09) versus 0.56 (0.07), p<0.01] but not waist-to-hip ratio [0.89 (0.11) versus 0.86 (0.09), p >0.05]. On BIA, MUO subgroup had higher body fat percentage (BFP) [42.40 (11.32) % versus 39.90 (9.87) %, p <0.01] and Fat Mass Index (FMI) [12.75 (5.72) kg/m2 versus 10.65 (4.20) kg/m2 , p <0.01]. After adjusting for age, gender, WHtR, BMI and BFP, neck circumference remained a significant predictor for MUO status [Odds Ratio = 1.16 (95%CI 1.02-1.31), p = 0.01].

CONCLUSION
A large proportion of PwO have MUO. High neck circumference is an independent predictor of MUO status among PwO and should prompt early screening for metabolic disturbances.

THE NAFLD THREAT IN HYPOTHYROID PATIENTS

2024-07-17T02:35:43-07:00

INTRODUCTION
Non-alcoholic fatty liver disease (NAFLD) is a rapidly progressing condition with a concerning rise in prevalence. Studies suggest a potential association between NAFLD and hypothyroidism, another prevalent condition. However, in the Indian context, not much has been reported on this association. This study aimed to determine the prevalence of NAFLD in a cohort diagnosed with hypothyroidism at our hospital.

METHODOLOGY
We conducted a hospital-based, cross-sectional observational study. Patients with confirmed hypothyroidism based on established criteria (elevated TSH with normal or low T4) were recruited. Standardized diagnostic tools for NAFLD were employed, including liver ultrasound to assess the grade of fatty infiltration and Fibro Scan® to measure liver stiffness. Descriptive statistics were used to report the prevalence of NAFLD within the hypothyroid population.

RESULT
A total of 120 patients with hypothyroidism participated (87.2% female, ages 15-66 years, majority 21-50 years). Over half (51.3%) had overt hypothyroidism. We observed a prevalence of NAFLD of 46.7% (31.6% Grade 1 fatty liver, 15% Grade 2) on ultrasound. Notably, the prevalence of NAFLD was higher in overt hypothyroidism (43.5% Grade 0, 32.3% Grade 1, 24.2% Grade 2) compared to subclinical hypothyroidism (62% Grade 0, 31% Grade 1, 7% Grade 2). Fibro Scan® revealed 65% with no fibrosis (F0-F1), 18.3% with F2 fibrosis, and 16.7% with F3 fibrosis. Statistical analysis showed a positive correlation between TSH levels and both NAFLD severity on ultrasound and liver fibrosis on Fibro Scan®.

CONCLUSION
This study investigated the co-occurrence and potential association of NAFLD in patients with hypothyroidism. We found a high prevalence of NAFLD (46.7%) and a positive correlation between TSH levels and NAFLD severity/fibrosis. These findings suggest a potential link between hypothyroidism and NAFLD. Further research is warranted to explore the underlying mechanisms and potential therapeutic implications.

BARIATRIC SURGERY IN A PUBLIC HOSPITAL IN MALAYSIA

2024-07-17T02:18:41-07:00

INTRODUCTION
Obesity in Malaysia has reached an alarming rate and various treatment modalities are available for patients depending on the severity of their obesity. Bariatric surgery has been proven to be part of the armamentarium to combat obesity; however, only a few public hospitals in Malaysia are capable of providing such a niche service. This study reports our experience over the past 3 years in a long-standing multidisciplinary bariatric clinic that was established in 2014 and based in a public hospital.

METHODOLOGY
Retrospective analysis of a prospectively maintained database of all patients undergoing bariatric surgery from January 2021 until April 2024 was performed. We analysed patient demographics, comorbidities and peri-operative complications. Prior to surgery, patients are thoroughly assessed, management of comorbidities is optimised, and the type of procedure and its expected outcomes are discussed in detail. Patients are required to be placed on an outpatient-based very low-calorie diet (VLCD) from 10 to 14 days prior to surgery. Peri-operative deep vein thrombosis prophylaxis is generally practiced unless contraindicated.

RESULT
A total of 125 patients underwent various bariatric procedures (75 sleeve gastrectomies, 40 Roux-en-Y gastric bypasses, 7 sleeve plus procedures, and 3 revisional procedures) with a mean age of 39.5 years and a mean BMI of 49.1 kg/m2 . The percentage of patients with diabetes, hypertension, and dyslipidaemia was 28.8%, 50.4% and 32% respectively. One patient was excluded as she required a conversion back to normal anatomy after gastric bypass. Throughout the study period, 3 major complications (Clavien-Dindo Grade III and above) were observed and 2 patients required readmission within one month due to dehydration.

CONCLUSION
This study shows that a multidisciplinary team with sufficient training and experience can provide bariatric surgery within a constrained public health system.