A 36-year-old male patient initially presented with hypertension, tinnitus, bilateral carotid masses, a right jugular foramen, and a periaortic arch mass with an elevated plasma dopamine level but an otherwise normal biochemical profile. On surveillance MRI 4 years after initial presentation, he was found to have a 2.2-cm T2 hyperintense lesion with arterial enhancement adjacent to the gallbladder, which demonstrated avidity on ⁶⁸Ga-DOTATATE PET/CTand retrospectively on ¹⁸F-FDOPA PET/CT but was nonavid on ¹⁸F-FDG PET/CT. Biochemical work-up including plasma catecholamines, metanephrines, and chromogranin A levels were found to be within normal limits. This lesion was surgically resected and was confirmed to be a paraganglioma (PGL) originating from the gallbladder wall on histopathology. Pheochromocytoma (PHEO) and PGL are rare tumors of the autonomic nervous system. Succinate dehydrogenase subunit D (SDHD) pathogenic variants of the succinate dehydrogenase complex are usually involved in parasympathetic, extra-adrenal, multifocal head, and neck PGLs. We report an unusual location of PGL in the gallbladder associated with SDHD mutation which could present as a potential pitfall on ¹⁸F-FDOPA PET/CT as its normal excretion occurs through biliary system and gallbladder. This case highlights the superiority of ⁶⁸Ga-DOTATATE in comparison to ¹⁸F-FDOPA and ¹⁸F-FDG in the detection of SDHD-related parasympathetic PGL.ClinicalTrials.gov Identifier: NCT00004847.
Adult ; Autonomic Nervous System ; Biliary Tract ; Catecholamines ; Chromogranin A ; Dopamine ; Gallbladder ; Head ; Humans ; Hypertension ; Magnetic Resonance Imaging ; Male ; Neck ; Paraganglioma ; Pheochromocytoma ; Plasma ; Positron-Emission Tomography and Computed Tomography ; Retrospective Studies ; Succinate Dehydrogenase ; Tinnitus

A 36-year-old male patient initially presented with hypertension, tinnitus, bilateral carotid masses, a right jugular foramen, and a periaortic arch mass with an elevated plasma dopamine level but an otherwise normal biochemical profile. On surveillance MRI 4 years after initial presentation, he was found to have a 2.2-cm T2 hyperintense lesion with arterial enhancement adjacent to the gallbladder, which demonstrated avidity on ⁶⁸Ga-DOTATATE PET/CTand retrospectively on ¹⁸F-FDOPA PET/CT but was nonavid on ¹⁸F-FDG PET/CT. Biochemical work-up including plasma catecholamines, metanephrines, and chromogranin A levels were found to be within normal limits. This lesion was surgically resected and was confirmed to be a paraganglioma (PGL) originating from the gallbladder wall on histopathology. Pheochromocytoma (PHEO) and PGL are rare tumors of the autonomic nervous system. Succinate dehydrogenase subunit D (SDHD) pathogenic variants of the succinate dehydrogenase complex are usually involved in parasympathetic, extra-adrenal, multifocal head, and neck PGLs. We report an unusual location of PGL in the gallbladder associated with SDHD mutation which could present as a potential pitfall on ¹⁸F-FDOPA PET/CT as its normal excretion occurs through biliary system and gallbladder. This case highlights the superiority of ⁶⁸Ga-DOTATATE in comparison to ¹⁸F-FDOPA and ¹⁸F-FDG in the detection of SDHD-related parasympathetic PGL.ClinicalTrials.gov Identifier: NCT00004847.

Introduction: Postprandial lipemia represent an important risk factor for lifetime development of cardiovascular disease in patients with type 2 diabetes mellitus. Daily administration alone or combined statin and fi brate therapy has been shown to be an effective therapeutic approach but brings about serious logistics problem in our local setting. To address this concern, we report this observation where alternate day statin and fi brate treatment given alone or in combination in type 2 diabetes mellitus and similar effectiveness in lowering postprandial dyslipidemia has been obtained. Methodology: This is a retrospective case study in an endocrine clinic involving 53 patients seen from April 2014 to October 2015. The patients were on statin and fi brate combination (atorvastatin 20- 40mg and gemfi brozil 300-600 mg or fenofi brate 145-160mg), statin alone (atorvastatin 20-40mg) and fi brate alone (gemfi brozil 300-600mg/fenofi - brate 145-160mg) given on alternate days. Percent reductions of cholesterol, triglycerides, LDL for combined statin and fi brate; cholesterol and LDL for atorvastatin alone; and triglyceride for fi brate alone were determined. Results: In this preliminary report, 26 patients have available data. Follow-up period range was 4 to 48 weeks (mean 22.76+ 11.8 weeks). Alternate statin and fi brate (gemfi brozil) treatment yielded percent reductions from baseline as follows: cholesterol 7%, triglycerides 15%, and LDL 37% (P values= 0.02, 0.10 and 0.019, respectively). On the other hand, alternate statin and fi brate (fenofi brate) yielded percent reduction from baseline as follows: cholesterol 41% and LDL 20.4% (P=0.15 and 0.13, respectively). The population is small, the decrease did not yield signifi cant difference from baseline, however there is a tendency for triglyceride to decrease (P=0.09) with the combined statin and fenofi brate. With statin alone the percent reduction from baselinewere as follows: cholesterol 39% and LDL 62% (P= 0.29 and 0.11, respectively). No percent reduction of triglyceride is seen with fi brate given on alternate day with P= 0.19 The monthly cost reduction with combined alternate statin and fi brate treatment is at 34-48% while alternate day administration of the statin reduced cost by 60%. Conclusion This study showed lowering of postprandial total cholesterol, triglyceride and LDL with alternate statin and fi brate treatment, and total cholesterol and LDL with alternate day statin. The cost of treatment was also signifi cantly lowered with the alternate regimen. However, a follow through study with adequate sample size is recommended to support these observations.
Hydroxymethylglutaryl-CoA Reductase Inhibitors