The presence of cortisol - secret ing adenoma concomitantly with rheumatic heart disease, schizophrenia and myoma uteri is rare. This is a case of a 40 year old female with Schizophrenia who gradually developed Cushing's syndrome from an adrenal adenoma. She suffered a cardio-embolic stroke from Rheumatic heart disease which delayed hysterectomy for a bleeding intrauterine myoma. As ide f rom the phys ical f indings of Cushing's syndrome laboratory work up revealed an elevated 24 hour urine free cortisol with loss of normal diurnal cortisol secretion, suppressed 8AM ACTH level and negative suppression after a high dose dexamethasone. The patient underwent laparoscopic adrenalectomy for a 3.8 x 2.4 x 3 cm left adrenocortical adenoma. She required steroid supplementation. Menstrual flow immediately normalized, functional capacity improved and metabolic parameters such as weight, blood pressure and blood sugar were controlled six months after the surgery. Relapse of psychotic symptoms occurred eight months postoperatively because of non-compliance to antipsychotic medications. Cushing's syndrome if untreated can cause significant morbidities such as metabolic, hemodynamic, cardiovascular, bleeding disorder and psychiatric illness. These complications however can also be caused by primary medical illnesses like schizophrenia, rheumatic heart disease and myoma uteri. Treatment of the Cushing's syndrome may resolve some but not all the metabolic and hemodynamic problems and theoretically should also decrease the risk of complications of other primary illnesses concomitantly present. The presence of concomitant primary disease that can cause psychosis, cerebrovascular disease and metrorrhagia should also be investigated in a patient who has Cushing's syndrome. Prompt management of Cushing's syndrome would lessen the risk of complication attributed to schizophrenia, rheumatic heart disease and myoma uteri.

Human ; Female ; Adult ; Adrenocortical Adenoma ; Cerebrovascular Disorders ; Cushing Syndrome ; Dexamethasone ; Psychotic Disorders ; Rheumatic Heart Disease ; Schizophrenia ; Stroke ; Myoma

Background: A rare case of Mayer-Rokitansky-Kuster-Hauser syndrome is reported here. A 26 year old Filipina with primary amenorrhea consults for inability to consummate sexual intercourse with a male partner. She is phenotypically female - has female secondary sexual characteristics, and has normal female external genitalia. There is a shallow vaginal dimple. Absence of the upper vagina and uterus has been demonstrated by transrectal ultrasound. Ultrasound and intravenous pyelography have documented the absence of the left kidney. Chromosomal analysis reveals a normal female karyotype (46, XX). Endocrine evaluation shows normal levels of estradiol, follicle-stimulating hormone and luteinizing hormone. Radiographs did not reveal any associated skeletal abnormalities. Aside from this being a rare case of a disorder of sexual development, this is worth reporting because it illustrates the diagnostic work-up of a patient presenting with primary amenorrhea.

BACKGROUND: Cushing's syndrome is a state of hypercortisolism manifesting non-specific clinical; features where its diagnosis entails biochemical confirmation of cortisol excess. this study aims to validate the efficacy of midnight salivary cortisol as a screening test for Filipino suspected with Cushing's syndrome and determine the cut-off value applicable in the local setting.

METHODS: This is a cross-sectional study of Filipinos suspected with endogenous Cushing's syndrome seen at a tertiary hospital. Modification of plasma cortisol measured by RIA was used to measure salivary cortisol. The sensitivity, specificity, positive predictive curve, negative predictive curve and area under the screening tests were estimated and compared using 48 hour low dose dexamethasone suppression test (LDDST) as the reference standard.

RESULTS: The determine cut-off value (? 7.0 nmol/L) for salivary cortisol showed a relatively high sensitivity (91.3%) and specificity (89.5%) in detecting cases suspected of Cushing's syndrome. One milligram (1mg) dexamethasone suppression test had the highest sensitivity (100%) but had the lowest specificity (68.4%) as a screening test. The area under the curve of the three diagnostic test appeared to be similar when compared with the low dose dexamethasone suppression test.

CONCLUSIONS: Using a cut-off value of 7nmol/L, local utility if late-night salivary cortisol has a high sensitivity and specificity in detecting Cushing's syndrome. It has a similar efficiency with 24-hour urine free cortisol and 1mg dexamethasone suppression test as a screening test for Cushing's syndrome. Salivary cortisol may be considered as a valid initial screening test for Filipinos suspected of cushing's syndrome.

Human ; Hydrocortisone ; Saliva ; Cushing Syndrome ; Urine ; Dexamethasone ; Serum

SYNOPSIS: Cardiac tamponade among systemic lupus erythematosus (SLE) patients is an unusual event. The pericardial effusion may be a consequence of uremia, infections in the pericardium, or the lupus pericarditis itself. We present four atypical cases of cardiac tamponade from pericarditis of connective tissue disease (CTD), all of which were treated with drainage and immunosuppressants. Due to the rarity of this combination, management was a challenge.
CLINICAL PRESENTATION: Four females each sought consult for dyspnea associated with typical manifestations of connective tissue disease such as arthritis, characteristic rashes, serositis, typical laboratory features, and a positive ANA and/or anti-dsDNA. The first three cases fulfilled the criteria for SLE, while the fourth fulfilled the criteria for SLE-dermatomyositis overlap syndrome. Echocardiography was done due to suspicion of pericardial involvement and revealed massive pericardial effusion in tamponade physiology in all cases.
DIAGNOSIS: Cardiac tamponade from serositis due to connective tissue disease [SLE (case 1 to 3) or SLE-dermatomyositis overlap (case 4). Other common etiologies of tamponade such as bacterial, tuberculous, malignant, and uremic pericardial effusion were ruled out by clinical and laboratory tools, including Gram stain and culture, cytology, PCR, and biochemical testing. The pericardial fluid of the first case tested positive for lupus erythematosus (LE) cells, indicative of lupus serositis.
TREATMENT AND OUTCOME: All patients underwent pericardial drainage via tube pericardiostomy. They received high dose glucocorticoids after infectious etiologies for the pericardial effusion were ruled out. The fourth case with the overlap syndrome, however, required more immunosuppressants using azathioprine and methotrexate. Resolution of pericardial effusion was noted with this approach. Three of four were discharged improved, however, the third case suffered from worsening nephritis and pulmonary hemorrhage leading to her demise.
SIGNIFICANCE AND RECOMMENDATIONS: Four cases of cardiac tamponade as a manifestation of connective tissue disease were presented. Literature underlines the rarity of this condition anytime during the course of SLE. Despite this, SLE should be considered as one of the differential diagnosis of cardiac tamponade, especially in patients who manifest with multi-systemic findings. Likewise, massive pericardial effusion should be considered in patients with a connective tissue disease presenting with subtle evidence of pericardial involvement. It requires timely identification and treatment with high dose steroids, after other causes such as infections have been excluded. Immediate drainage through pericardiocentesis or pericardiostomy in combination with immunosuppressants may be life-saving.

Human ; Female ; Adult ; Adolescent ; Pericardiocentesis ; Pericardial Effusion ; Azathioprine ; Cardiac Tamponade ; Methotrexate ; Glucocorticoids ; Serositis ; Dermatomyositis ; Immunosuppressive Agents ; Pericardial Fluid ; Neutrophils ; Lupus Erythematosus, Systemic ;

Objectives: To determine the association of different levels of sunlight exposure, measured using the Filipino sunlight exposure questionnaire (SEQ) with 25-hydroxyvitamin D (25-OHD) levels among working urban adult Filipinos. Methods: Seventy-five adult participants, living and working in Metro Manila, for at least 1 year, were grouped according to their perceived sunlight exposure pattern: low sunlight exposure (mostly indoor work); moderate sunlight exposure (both indoor and outdoor work); and high sunlight exposure (mostly outdoor work). After completion of the self-administered Filipino SEQ, they underwent serum 25-OHD level determination. Strength of correlation between the SEQ scores and 25-OHD levels was computed. Results: Serum 25-OHD levels generally increased with increasing sunlight exposure levels. The overall Pearson’s correlation between the SEQ scores and 25-OHD levels of the participants was 0.396 (P ¼ 0.001). The correlation for the individual domains was 0.342 for intensity of sunlight exposure (P ¼ 0.003), 0.321 for factors affecting sunlight exposure (P ¼ 0.005), and 0.256 for sun protection practices (P ¼ 0.027). Conclusions The sunlight exposure of working urban adult Filipinos, as measured by the Filipino SEQ, has an overall significant, direct and moderate association with serum 25-OHD levels. This Filipino SEQ can serve as a valuable clinical tool for sunlight exposure assessment to identify individuals at risk for vitamin D deficiency.

Pheochromocytoma, a rare cause of hypertension, is potentially fatal if left untreated. Definitive treatment is resection of the mass. Preoperative blockade is important to improve intraoperative hemodynamic stability and reduce morbidity during resection. Phenoxybenzamine, a non-selective alpha adrenergic blocker, has been widely used as preoperative blockade, but is unavailable in the Philippines. Terazosin, a selective alpha 1 antagonist and is widely available as treatment for benign prostatic hypertrophy, has been documented in reports as a suitable preoperative drug in reducing blood pressure in pheochromocytoma patients. The objective is to present four cases of Filipino pheochromocytoma patients who were treated with terazosin as first line preoperative blockade. Four Filipino patients from the Philippine General Hospital were diagnosed with pheochromocytoma based on biochemical and imaging studies. They were started on different doses of terazosin, the maximum dose as high as 4 mg per day. One patient experienced orthostatic hypotension at this dose, but was resolved after reducing the dose to 3 mg per day. A beta blocker (metoprolol on 3 cases, carvedilol) was added for reduction of the symptoms. One patient was also diagnosed with diabetic ketoacidosis, and was treated as such. Two patients experienced labile changes with blood pressure during resection but were resolved with the use of intravenous nicardipine for elevated blood pressure, and crystalloids during bouts of hypotension. All of the patients' blood pressure returned to normal after resection of the mass. Terazosin, a selective alpha 1 antagonist, at a maximum dose of 4 mg per day, may be safely given to Filipino patients diagnosed with pheochromocytoma as first line preoperative blockade.
Pheochromocytoma ; Hypertension

Objective: A diabetes prevention program is being proposed in the rural agricultural town of San Juan, Batangas, Philippines. This study aims to determine the prevailing level of food intake, physical activity, and health beliefs prior to any intervention. Methodology: Adults were recruited via random sampling with proportional allocation. Interviews were done to determine food intake and physical activity. Small group discussions were held to determine prevailing health beliefs. Results: The average energy intake (1,547 kcal/d) is only 72% of the recommended values for Filipinos. Only 12% of the respondents achieved the recommended energy intake. Carbohydrates comprise a large part (71%) of calorie intake. A majority (91%) already have moderate to high levels of physical activity. There are prevailing health beliefs that need to be considered when dietary modifications and physical activity interventions are to be done. Conclusion Internationally recommended diabetes prevention interventions such as reducing calorie intake and increasing physical activity may not be directly applicable here. We recommend that the features of a diabetes prevention program for this locale must include the following: 1) introduction of affordable plant sources of proteins; 2) decreasing the proportion of rice as a source of carbohydrates in the diet; 3) maintaining the level of physical activity; and 4) being sensitive to the prevailing health beliefs.
Culture ; Diet ; Life Style ; Prediabetic State ; Rural Population