Diabetes Mellitus, Type 2 ; Disease Management ; Philippines ; Practice Guideline

OBJECTIVE: To discuss a case of pituitary abscess presenting with amenorrhea and diabetes insipidus, and to enumerate the differential diagnosis for this condition
SIGNIFICANCE: By presenting this case, the author aims to increase awareness regarding the possibility of infectious causes of pituitary masses, thereby prompting early recognition and treatment of similar cases
CASE REPORT: This is the case of a 42-year old woman admitted due to severe generalized headache, amenorrhea and polyuria of three months duration, preceded by a one-month history of remittent fever. Physical examination was normal except for bitemporal hemianopsia
LABORATORY TEST RESULTS: On admission, she had mild anemia, hypernatremia with elevated serum osmolality, and failure to concentrate urine. Hormonal examinations showed normal thyroxine and growth hormone levels, low basal serum cortisol, and elevated prolactin levels. Cranial CT scan showed widening of the sella turcica with a homogenous, isodense, slightly enhancing focus in the sellar and suprasellar area.
COURSE: Initial considerations were chiasmatic glioma versus a pituitary adenoma. Transphenoidal surgery was done and intraoperatively, purulent fluid was noted. Aspirate gram stain showed 1-2 white blood cells per high power field but with no growth on culture. Subsequently, vision was fully restored but prolactin levels continued to be slightly elevated. Basal cortisol and urine specific gravity were persistently low. Repeat CT scan showed disappearance of the pituitary mass. Six months after the operation, the patient was able to go back to work but continues to take steroids and carbamazepine for the diabetes insipidus.
REVIEW OF LITERATURE: There are about 100 cases of pituitary abscess in literature mimicking pituitary adenoma and presenting with headaches, amenorrhea, visual field cuts, hypopituitarism, fever and meningitis. As in this case, the abscess is frequently sterile. Pituitary abscess should be considered in patients with a primary diagnosis of pituitary adenoma with accompanying signs and symptoms suggestive of an infection. (Author)

Human ; Female ; Adult ; Pituitary Neoplasms ; Sella Turcica ; Hemianopsia ; Hydrocortisone ; Carbamazepine ; Hypernatremia ; Diabetes Insipidus

OBJECTIVES: To determine the effect of malunggay leaf capsules on LDL (primary efficacy outcome measure); weight, BMI, FBS, serum glucose 2 hours after a 75 g oral glucose load, cholesterol, HDL and triglycerides (secondary efficacy outcome measures); creatinine, ALT and CBC (secondary safety outcome measures); and to determine if these are associated with adverse events.

STUDY DESIGN: randomized controlled trial

PARTICIPANTS: Seventy nine Filipinos, 18-55 years old with LDL>2.6 mmol/L (100 mg/dL) but of low cardiovascular risk were randomized into malunggay and placebo groups.

INTERVENTION: Malunggay capsules for 30 days versus placebo

RESULTS: 33 and 35 participants in the malunggay and placebo groups, respectively, completed the treatment. There was a reduction of 13.76 mg/dL in the LDL of the malunggay group, compared to a 19.28 mg/dL reduction in the placebo group (p=0.564).

CONCLUSION: Malunggay leaf capsules given for 30 days among adults with serum LDL >2.6 mmol/L (100 mg/dL) but with low cardiovascular risk decreased LDL levels to the same degree as placebo. There were no significant differences in the change in the secondary efficacy and safety outcome measures, and in the occurence of adverse events.

Human ; Male ; Female ; Middle Aged ; Adult ; Adolescent ; Triglycerides ; Creatinine ; Capsules ; Cardiovascular Diseases ; Body Mass Index ; Risk Factors ; Cholesterol, Hdl ; Body Weight ; Lipoproteins, Ldl ; Glucose

BACKGROUND: The role of chromium in human nutrition was first reported in 1977 on a patient on total parenteral nutrition manifesting with neuropathy and impaired glucose tolerance attributed to chromium deficiency. After correction, nerve conduction and glucose tolerance tests normalized. Chromium is postulated to act as a cofactor for insulin action by enhancing insulin receptor phosphorylation and stimulating insulin receptor tyrosine kinase.
OBJECTIVE: To compare the effect of chromium picolinate versus placebo on glycated hemoglobin (HbA1C), fasting blood sugar (FBS), 2-hours postprandial blood sugar (2HPPBS), fasting insulin (FI) and lipid profile among T2DM patients.
METHODS: Literature search in Medicine, Cochrane and Herdin was made using terms such as chromium, chromium picolinate intake of >= 3 months among T2DM patients. Two reviewers independently screened abstracts and full articles. Results were plotted using Revman 4.2.
RESULTS: Thirty four trials were found and six trials were included in the meta-analysis. The pooled data for 467 patients with T2DM reported lowering of HbA1c -0.34% (CI -0.45, 0.24 p0.06); FBS -16.6 mg/dl (CI -18.9, -14.41 p 0.30); 2HPPBS -17.33 mg/dL (CI -20.21, -18..81 p <0.01) and FI -19.51 mg/dL (CI -20.21, -18.81 p<0.01). Chromium picolinate has no effect on lipids.
CONCLUSION: Chromium picolinate lowers HbA1c, FBS, 2HPPBS and FI moderately but it has no effect on lipids, However, the short duration of studies, variable quality and large heterogeneity across these data limits the strength of our conclusion, hence further studies are recommended.

Human ; Male ; Female ; Aged ; Middle Aged ; Adult ; Blood Glucose ; Chromium ; Glucose Intolerance ; Glucose Tolerance Test ; Hemoglobin A, Glycosylated ; Insulin ; Lipids ; Phosphorylation ; Picolinic Acids ; Postprandial Period ; Protein-tyrosine Kinases ; Receptor, Insulin

The elderly are a peculiar group in terms of health management, as they often present with non-specific complaints which are challenging to interpret and may not present with the usual clinical picture of a disease. Objective. The study aims to determine the prevalence of thyroid dysfunction among asymptomatic, elderly Filipinos seen at the Philippine General Hospital (PGH). Methodology. Subjects aged 60 years and older seeking out-patient medical consult for non-thyroidal illness at the PGH were recruited. Patients with known thyroid or pituitary disease, previous thyroid or pituitary surgery, intake of medications known to affect thyroid hormone levels and critical illness were excluded. Fasting blood sugar (FBS), lipid profile, free thyroxine (FT4), thyroid-stimulating hormone (TSH), and anti-thyroperoxidase (anti-TPO) levels were taken. Based on FT4 and TSH levels, subjects were classified as overt hypothyroid, subclinical hypothyroid, euthyroid, subclinical hyperthyroid, or overt hyperthyroid. Results. One hundred eighty subjects were recruited, of whom 152 (84%) were female. Hypertension was the most common comorbidity (58.33%), followed by diabetes (36.67%). One hundred sixty-two (90%) were euthyroid, 12 (6.7%) subclinical hypothyroid, 4 (2.22%) subclinical hyperthyroid, and two (1.11%) overtly hyperthyroid. No one was overtly hypothyroid. There was a trend toward increasing prevalence of diabetes, hypertension, low HDL, obesity and overall cardiovascular risk among those with subclinical hypothyroidism. Conclusion. Subclinical hypothyroidism was the most prevalent thyroid dysfunction among asymptomatic elderly included in the study.

Human ; Male ; Female ; Aged 80 And Over ; Aged ; Cardiovascular Diseases ; Diabetes Mellitus ; Hospitals, General ; Hypertension ; Hyperthyroidism ; Hypothyroidism ; Iodide Peroxidase ; Iron-binding Proteins ; Obesity ; Outpatients ; Pituitary Diseases ; Thyrotropin ; Thyroxine

BACKGROUND AND SIGNIFICANCE: McCune Albright Syndrome (MAS) is a rare disorder characterized by the clinical triad of precocious puberty, polyostotic fibrous dysplasia of the bones and café-au-lait spots. Prevalence is estimated at 1/100,000-1/1,000,000. We report a case of polyostotic fibrous dysplasia in a patient with McCune Albright Syndrome who had symptomatic relief of hip pains and non-recurrence of stress fractures in a dysplastic right hip bone following treatment with loading intravenous pamidronate followed by an oral alendronate for almost a year, as an off-label indication. While intravenous bisphosphonates have been well-recognized in the treatment of fibrous dysplasia, only case reports are available to support its utility.
CASE REPORT: We report an 18 year old female with leg length discrepancy following repeated episodes of hip fracture for the past six years. She was referred to the Philippine General Hospital for recurrent severe leg pains which occurred usually at menstrual mid-cycle. This condition was associated with lateral bowing of the proximal part of the right thigh, widening of the right hip region, and shortening of the right lower limb also known as Shepherd's Crook deformity. She also had café-au-lait spots at the back of her left legs and buttocks. Skeletal survey showed radiolucent medullary expansile lytic lesions with ground glass appearance of the right femur, tibia, fibula, humerus, scapula, pubis, ischium, carpal and metacarpal bones. Patient was noted to have short stature with height of 142 cm. Arm span was 139 cms, upper body segment (crown to the coccyx) was 70cms while lower body segment (coccyx to heel left foot) was 72 cms. The difference between the left and right leg was 7 cms. Mean parental height was 160 cm. She was then referred to the Endocrinology service of this institution for evaluation of the short stature and associated endocrinopathies. On review, she had adrenarche at 8 years old followed by menarche at 10 years old. She had no goiter. She had no cushingoid features. Patient had irregular menstrual cycles with oligomenorrhea (cycle: 60-180 days). Breast development and pubic hair were staged Tanner 5. In the approach to short stature where height age is less than either the bone age or chronological age, constitutional
dwarfism, hypothyroidism, growth hormone deficiency and fibrous dyplasia must be ruled out. Constitutional dwarfism was ruled out with a midparental height of 160 cm. A normal free thyroxine (17, normal: 9-23 pmol/L), thyroid stimulating hormone (2.4, normal: 0.25-4 ulU/ml) ruled out hypothyroidism, and a normal IGF-1 (103, normal: 91-223 nmol/L) ruled out growth hormone deficiency. This left us with the consideration of fibrous dysplasia of the bone which was consistent with the earlier radiographic findings. The combination ofpolyostotic fibrous dysplasia and café au lait spots led to the impression of McCune Albright Syndrome. The most common endocrinopathy associated with McCune Albright Syndrome is a peripheral hyperfunctioning ovaries which also harbors the G-protein mutation. This was evident in our case with a high estrogen (655.8, normal: 50-250 pg/ml) and suppressed LH (1.2, normal: 1.5-5 pg/ml) and FSH (3, normal 3.5-12.5 pg/ml) with a transrectal ultrasound finding of a 2.6 x 1.7 x 1.6 cm cyst at the right ovary. This precipitated the precocious puberty andearly closure of the epiphyseal plates resulting to short stature. To screen for other endocrinopathies, a 24 hour urine free cortisol (44, 20-90 ug/day), serum prolactin (15ng/ml, normal: 0-30ng/ml), free thyroxine (17, normal: 9-23.2 pmol/L) and parathyroid hormone (13.9, normal 10-65pg/ml) was documented and ruled out associated hypercortisolemia, prolactinoma, hyperthyroidism and hyperparathyroidism respectively. The patient had no history of change in shoe size, and no coarsening of facial features that was suggestive ofacromegaly.                                                                                                                                          
TREATMENT: Pat ient underwent bone graf t ing and osteotomy to correct the shepherd's crook deformity. Three cycles of intravenous pamidronate infusion in three consecutive days was given prior to the operation. Postoperatively, patient tolerated the procedure and was discharged after three days.
OUTCOME: Shepherd's crook deformity was successfully corrected. Patient still had limp but with no pain and no new fractures for almost a year already. At present she is maintained on alendronate 70mg 1 tab once a week and calcium 1 gram per day.
CONCLUSION: We repor t a case of McCune Albright Syndrome presenting with bone deformity which was later diagnosed to be fibrous dysplasia with polyostotic involvement, and was successfully treated with initial intravenous bi sphosphonates maintained on oral bisphosphonates following a surgical procedure to correct the shepherd's crook deformity. At present, she has had no new fractures.

Human ; Female ; Young Adult ; Adolescent ; Coccyx ; Cysts ; Dwarfism ; Estrogens ; Fibrous Dysplasia, Polyostotic ; Fractures, Stress ; Growth Hormone ; Hydrocortisone ; Hyperparathyroidism ; Hyperthyroidism ; Hypothyroidism ; Mutation ; Ovary ; Parathyroid Hormone ; Thyrotropin ; Thyroxine

OBJECTIVES:(1) To determine the prevalence of autoimmune thyroid disease among patients with autoimmune rheumatic disorders seen at the Philippine General Hospital. (2) To determine clinical features that are associated with the occurrence of autoimmune thyroid disease in these patient.
METHODOLOGY:This is a cross sectional analytical study that included 155 adult Filipinos diagnosed with an autoimmune rheumatic disorder. Clinical characteristics were recorded. Serum thyrotropin, thyroxine, triiodothyronine, anti-thyroid peroxidase antibody, anti-thyroglobulin antibody and urinary iodide excretion were determined. The prevalence of autoimmune thyroid disease was computed. Associations between clinical factors and autoimmune thyroid disease were determined.
RESULTS:Overall 21.94% of the population had autoimmune thyroid disease. There was significant association between duration of the autoimmune rheumatic disorder and autoimmune thyroid disease (p-= 0.018). No significant association was noted with the other clinical factors although there was an almost significant association observed for the presence of goiter (p=0.054).
CONCLUSION:Autoimmune thyroid disease commonly occurs in patients with autoimmune rheumatic disorders. As such, it is important to consider screening these patients for the coexistence of thyroid disease to help prevent the complications associated with thyroid dysfunction and avoid adding up to the morbidity of the existing autoimmune rheumatic disorder.

Human ; Male ; Female ; Middle Aged ; Adult ; Autoantibodies ; Autoimmune Diseases ; Goiter ; Hospitals, General ; Iodide Peroxidase ; Iodides ; Philippines ; Prevalence ; Thyroid Diseases ; Thyrotropin ; Thyroxine ; Triiodothyronine ; Lupus Erythematosus, Systemic

Background: Hyperglycemia occurs in 60% of acute stroke patients, 12-52% of which maybe previously undiagnosed with diabetes. A retrospective study by Gacutan showed 21% admission hyperglycemia at the Philippine General Hospital. Screening for glucose disorders among hyperglycemic stroke patients provides a venue for secondary prevention. There are no current guidelines on screening for post-stroke hyperglycemia by the Stroke Society of the Philippines. Objective: To determine the prevalence and outcomes of unrecognized diabetes and prediabetes among acute stroke patients. Secondarily, we aim to determine the clinical and biochemical predictors of unrecognized/newly diagnosed diabetes mellitus among the acute stroke patients. Methodology: Cross-sectional prospective study. Acute stroke patients admitted from January to December, 2008 with admission hyperglycemia were included. Random blood sugar, glycosylated hemoglobin & the National Institute of Health Stroke Scale (NIHSS) were done on admission. All were followed up six weeks post-discharge for an FBS and 75-grams OGTT except those discharged with anti-diabetes medications who were considered newly-diagnosed diabetes. Outcomes: Glucose disorders were classified at six weeks post-discharge. Mortality was measured at six weeks and 12 weeks. Functional outcomes using the Modified Rankin Score & the Barthel’s Index were measured at the OPD 6-weeks postdischarge. Results: There were 504 stroke patients of which 178(35%) had admission hyperglycemia. Majority were newly diagnosed diabetes 32.7%, stress hyperglycemia 29.56%, impaired glucose tolerance, (IGT) 13.8%, impaired fasting blood sugar, (IFG) 8.8%, combined IGT and IFG 3.7%, previous diabetes 11.32%. Age, body mass index, alcohol abuse, smoking, hypertension, nosocomial infections, acute coronary syndrome were associated with diabetes. No association was noted with diabetes and atrial fibrillation. By Kruskal-Wallis test, admission RBS and HbA1c were higher among diabetics compared to prediabetics and stress hyperglycemics. Triglycerides was higher and HDL was lower among diabetic versus the stress hyperglycemia. No trends were noted for total cholesterol and LDL cholesterol across groups. On multiple logistic regression, age (OR: 1.06, p0.07), smoking (OR: 9.81, p0.05) and Hba1c (OR:11.39, p<0.01) were the predictors for newly diagnosed diabetes classification among the acute stroke patients. Higher Modified Rankin and lower Barthel’s index were seen among diabetics compared to the other groups measured on follow-up. Mortality at six weeks was higher among diabetics (OR: 2.34, p<0.01) compared to non-diabetics. A trend towards higher mortality at 12 weeks was also noted among diabetics (OR: 1.81, p0.063) compared to other groups. Conclusion: Admission hyperglycemia was seen in 35% of admitted stroke patients, majority of which were unrecognized diabetes. By screening for post-stroke hyperglycemia, we identified 59.1% (32.7% unrecognized diabetes; 26.4% prediabetes) patients eligible for treatment and secondary prevention. Short-term mortality was higher among acute stroke patients with diabetes. Age, smoking and admission HbA1c were the clinical and biochemical predictors of a newly diagnosed diabetes mellitus

The global burden of diabetes and its accompanying risk factors is upon us. Asia is the focus of this burden, owing to huge population numbers and increasing prevalence rates. The Philippines National Health and Nutrition Survey (NNHeS) of 2013, has provided the latest health and disease score with prevalence rates of the major risk factors among adults >20 years of age: diabetes (5.4%), hypertension (22.3%), dyslipidemia, low HDL (71.3%), obesity, BMI >25 kg/m2 (31.1%), and smoking (25.4%). Metabolic syndrome as of the 2008 survey reports a 27% prevalence rate (unpublished data). Efforts have to be directed to achieve improvement in prevention, survival, and quality of life for all diabetics. The health infrastructure under the leadership of the Department of Health, in partnership with governmental and non-governmental organizations has to provide a cohesive plan engaging all partners in various aspects of care. Strategies to enhance outcomes include: 1) a national screening program, 2) implementation of practice guidelines that will elevate the quality of care for all, 3) access to healthcare, medications, 4) development of an environment for research in institutions to allow a better understanding of these conditions among Filipino patients and 5) enhancement of training, education and service to benefit the Filipino diabetic. Indeed, the challenge is upon all of us as a nation, and we need to stand up and move forward with an organized and accessible system of care, as we aim to combat the epidemic of diabetes and its complications.