Introduction: Primary bilateral macronodular adrenal hyperplasia (PBMAH), characterized by bilateral adrenal macronodules >1 cm, is a rare genetic disease contributing to <2% of Cushing syndrome. Case: A 56-year-old male with underlying diabetes mellitus and hypertension presented with worsening proximal muscle weakness. Detailed neurological assessment was unremarkable. Re-assessment revealed more apparent cushingoid features, prompting referral to endocrinology. Basal cortisol was markedly elevated at 957 nmol/L (145.4– 619.4 nmol/L). Unsuppressed cortisol after 1 mg overnight dexamethasone and low-dose dexamethasone test confirmed Cushing Syndrome. Suppressed adrenocorticotropic hormone (ACTH <0.33 pmol/L) suggested autonomous cortisol secretion from adrenal glands. Computed tomography adrenal reported massively enlarged hypodense multinodular adrenal glands of varying sizes. Oral ketoconazole, an adrenal steroidogenesis inhibitor, was initiated. Despite careful titration to keep serum cortisol 400–500 nmol/L, he experienced glucocorticoid withdrawal syndrome. Bilateral adrenalectomy was planned but deferred as he continued to lose weight despite persistent hypercortisolism. Extensive investigations were conducted for possible opportunistic infections or malignancy. His chest X-ray revealed a suspicious right lung cavity. Positive serum galactomannan and bronchial alveolar lavage galactomannan suggested pulmonary aspergillosis. Voriconazole was introduced, with drug-drug interaction judiciously addressed. He underwent bilateral adrenalectomy and required lifelong glucocorticoid and mineralocorticoid replacement. Histopathological report confirms bilateral macronodular adrenocortical disease. A referral to a genetic clinic was made to explore the potential hereditary basis. Conclusion PBMAH is a highly heterogeneous disease with variable presentation and a wide spectrum of hypercortisolism. Definitive management remained controversial and individualized. Multidisciplinary discussion is crucial, and genetic study is highly recommended for long-term prognostication and familial screening.

Introduction: Diabetes literacy represents personal knowledge and competencies related to diabetes mellitus (DM) among people living with DM (PLWD). It is a crucial component for optimizing care and empowering effective selfmanagement. Methodology: A cross-sectional study was conducted at Hospital Tuanku Ja’afar Seremban (HTJS) and Klinik Kesihatan Seremban (KKS) using a validated simplified Diabetes Knowledge Test (DKT). DKT assessed understanding in six domains, namely, awareness, lifestyle modification, diet and monitoring, general knowledge, preventive screening, and insulin. A score of >75% was classified as adequate diabetes literacy. Significant predictive factors identified from univariate Pearson Chi Square were further analyzed using multivariate logistic regression. Results: A total of 250 PLWDs, with equal contribution from each centre, were recruited with a mean (SD) age of 50.3 (13.6) years, 58.4% female, and 43.2% Malays. A total of 21.2% demonstrated adequate diabetes literacy. The results demonstrated the highest proficiency in the preventive screening domain (92.6%) and the lowest in the awareness domain (50.2%). Unemployed PLWDs had significantly lower odds of adequate diabetes literacy (odds ratio [OR] = 0.20, p = 0.010). Similarly, PLWDs with hemoglobin A1c levels >10% exhibited approximately 2.6-fold lower odds of adequate diabetes literacy. In contrast, PLWDs who reported healthcare personnel as their primary source of diabetes-related information had significantly higher odds of adequate literacy (OR = 1.59, p = 0.017). No significant association was demonstrated between diabetes literacy and frequency of hospital admissions, medication adherence, and diabetes-related target organ damage Conclusion Diabetes literacy among PLWD in HTJS and KKS is suboptimal, with notable gaps in awareness of the disease. Targeted, culturally tailored education strategies are essential to address these disparities and to empower them for effective diabetes self-management.
Literacy ; Diabetes Mellitus

Extramedullary hematopoiesis (EMH) is a rare cause of adrenal mass. We present a 44-year-old woman who has thalassaemia intermedia, referred to Endocrinology clinic for huge adrenal mass. Along with a paraspinal lesion discovered in this patient, the leading diagnosis was EMH. The patient was treated with hypertransfusion and hydroxyurea, which led to a reduction in the size of the right adrenal mass and paraspinal mass. This case highlights the challenges in managing this rare condition. Although EMH is a rare cause of adrenal mass, the diagnosis must be considered in any patient with a history of a congenital hemolytic disorder, to avoid unnecessary surgical procedures.
Hematopoiesis, Extramedullary

Primary hypoparathyroidism is caused by a group of heterogeneous conditions in which hypocalcemia and hyperphosphatemia occur as a result of deficient parathyroid hormone (PTH) secretion. The most common cause is surgical excision and damage to the parathyroid gland(s). Nonetheless, autoimmune endocrine disorder of primary hypothyroidism has been well-described in polyglandular autoimmune syndromes (PAS).1 Its association with pituitary lesion may be autoimmune lymphocytic hypophysitis as the cause for pituitary disorder. In this report, we encountered a patient with primary hypoparathyroidism who had a non-functioning pituitary tumour. It was confirmed as pituitary adenoma rather than lymphocytic hypophysitis from the histopathological examination. To our knowledge, this is the first reported case of non-functioning pituitary macroadenoma and primary hypoparathyroidism.
Hypopituitarism ; Autoimmune Hypophysitis ; DiGeorge Syndrome