Introduction: The 2021 IDF-DAR risk calculator had been previously evaluated in multiple studies and subsequently widely accepted and applied in clinical practice as a practical standardized tool for patient risk stratification. Recently updated, the 2026 IDF-DAR Risk calculator enables a more individualized, evidence-related evaluation of patientrelated and disease-related risk factors, incorporating modern diabetes technologies, including continuous glucose monitoring (CGM), automated insulin delivery (AID) systems, and advanced insulin formulations to enhance risk stratification. This tool allows medical professionals to tailor Ramadan practices based on overall factors toward promoting safe fasting. Methodology: This prospective multicentre observational study recruited adults with Type 1 and Type 2 diabetes attending public hospitals nationwide. People with diabetes (PwD) intending to perform Ramadan fasting were invited to participate and assessed using the 2026 IDF-DAR Risk Calculator in the 6-week pre-Ramadan period between 30th January and 19th March 2026. Results: A total of 458 PwD were evaluated and stratified into low (15.7%), moderate (41%), and high risk (43.3%) categories. Most participants had Type 2 diabetes (83.6%), with 60.3% having a disease duration exceeding 10 years and 43% exhibiting poor glycemic control (hemoglobin A1c >9%). Insulin therapy was used by 76.4% of participants, including two individuals with Type 1 diabetes using AID systems. Most participants reported no recent hypoglycemia (76.4%), 81.0% performed glucose monitoring, and 3.3% used CGM. Severe comorbidities were uncommon, with 1.1% having unstable macrovascular disease and 4.4% advanced chronic kidney disease (estimated glomerular filtration rate <30). Notably, 72.2% received structured Ramadan education. Conclusion Majority of PwD attending tertiary diabetes clinics were in the moderate- to high-risk category and intended to fast despite medical advice against fasting in some cases. Although most participants were on insulin therapy, hypoglycemia was low in the pre-Ramadan period. Integration of modern technologies, advanced insulin therapies, and structured education may support safer fasting practices.
Risk Assessment ; Diabetes Mellitus ; Hospitals ; Fasting

Introduction: The Warburg effect refers to a metabolic shift in which cells preferentially utilize aerobic glycolysis rather than oxidative phosphorylation despite adequate oxygen availability. This phenomenon is increasingly recognized as the mechanism for tumor-associated hypoglycemia, or paraneoplastic syndromes such as insulin-like growth factor-2 (IGF-2)– mediated non-islet cell tumor hypoglycemia. We present a case of Warburg effect with management challenges. Case: A 47-year-old male with advanced, treatment-naive retroviral disease presented with chronic cough, progressive right thigh swelling, constitutional symptoms over several months, followed by reduced responsiveness for 2 days prior to admission. Clinically, he was delirious, cachectic with generalized lung crepitations and right thigh mass. He was diagnosed with smear-negative disseminated tuberculosis, and thigh mass was considered either a tuberculous granuloma or sarcoma. During hospitalization, he developed recurrent hypoglycemia with lactatemia despite intravenous dextrose, optimized enteral feeding and a 1-day course of intravenous octreotide. His blood investigations showed full blood count, renal function test, liver function test, and serum ketone within normal range. His arterial blood gas analysis showed type B lactic acidosis with persistent lactatemia. At the time of hypoglycemia (RBS: 3.1 mmol/L), his serum insulin was suppressed, C-peptide was low–normal, morning cortisol was elevated, and IGF-1 was markedly reduced suggestive of non-insulin-mediated hypoglycemia secondary to Warburg effect. Conclusion In patients with retroviral disease and tuberculosis, Warburg effect may lead to poorer clinical outcomes and management may be challenging. Thus, definitive antimicrobial therapy with second generation somatostatin analogues (Pasireotide) may be considered in selected cases to modulate dysregulated hormonal and metabolic pathways. Early identification and timely targeted intervention are crucial to improving outcomes in this high-risk population.
Persistent Infection ; Hypoglycemia

Introduction: Cushing’s disease in adolescents is rare and frequently difficult to diagnose due to overlapping features with common pubertal and metabolic conditions. We present an adolescent who underwent inferior petrosal sinus sampling (IPSS) with possible cyclical Cushing’s disease, highlighting the diagnostic challenges and the interpretive value of IPSS. Case: A 16-year-old female presented with progressive weight gain, acne, hirsutism, secondary amenorrhea, proximal myopathy, violaceous striae, and facial plethora over 1 year. Her 24-hour urinary cortisol was >3,310 nmol/L with failure of suppression following a 1-mg overnight dexamethasone suppression test (701 nmol/L). Her adrenocorticotropic hormone (ACTH) was raised (77.9 pg/mL), consistent with ACTH-dependent Cushing syndrome. Her hemoglobin A1c was 5.9%, and she has low bone mass for age with a Z score of -2.9 at the Lumbar spine. Pituitary magnetic resonance imaging identified a rightsided microadenoma measuring 0.6 × 0.5 cm, while computed tomography of the thorax, abdomen, and pelvis showed no ectopic source. IPSS with desmopressin stimulation was performed to confirm the ACTH source. No steroidogenesis inhibitors were administered prior to testing. Notably, cortisol levels during IPSS were relatively low, with midnight cortisol of 91 nmol/L and morning cortisol of 200 nmol/L, suggesting testing during a trough phase of possible cyclical hypercortisolism. Despite this, IPSS demonstrated a significant central-to-peripheral ACTH gradient supporting a pituitary source. Conclusion This case highlights the diagnostic dilemma of interpreting IPSS in suspected cyclical Cushing’s disease. Fluctuating cortisol secretion may result in discordant biochemical findings and complicate localization studies. IPSS findings should be interpreted cautiously and integrated with clinical features, imaging, and serial biochemical monitoring. Recognition of cyclical disease patterns is essential to ensure appropriate management in adolescent patients.
Adolescent ; Humans ; Petrosal Sinus Sampling

Introduction: Acromegaly is an endocrine disorder caused by excess growth hormone (GH), causing somatic overgrowth, multiple comorbidities, and premature mortality. It is confirmed biochemically by an elevated GH level, which is not suppressed post oral glucose tolerance test (OGTT). The serum level of insulin-like growth factor-1 (IGF-1) is recommended for diagnosis, monitoring, and screening, and a normal level effectively excludes the disease. We report a patient with acromegaly who presented with normal IGF-1. Case: A 21-year-old female, with no known medical illness, presented with a persistent, progressive headache and amenorrhea for the past 6 months. She also noticed a change in facial appearance and an increase in the size of her hands and feet. Blood parameters revealed raised GH level of >50 ng/mL, normal IGF-1 30.3 nmol/L (12.17–44.80), mildly raised prolactin 692 mIU/L, low am cortisol 62 nmol/L (166–507), thyroid-stimulating hormone of 0.63 mIU/L (0.27–4.20), free thyroxine 4 11 pmol/L (12–22), low follicle-stimulating hormone 0.90 IU/L, luteinizing hormone <0.30 IU/L, estradiol <18.4 pmol/L, and fasting blood sugar of 17.7 mmol/L with hemoglobin A1c 9%. In view of normal IGF-1 with a high index of suspicion for acromegaly, she underwent OGTT which showed unsuppressed GH. Magnetic resonance imaging pituitary showed sellar mass 2.4 × 2.9 × 2.1 cm with suprasellar extension as well as extension into the right cavernous sinus, suggestive of pituitary macroadenoma. She was diagnosed with acromegaly with secondary adrenal insufficiency and central hypothyroidism with hypogonadotropic hypogonadism, complicated with poorly controlled diabetes. She was started on thyroxine and hydrocortisone replacement and required basal bolus insulin of 1.3 u/kg/day. Repeated IGF-1 showed a raised value, 85.4 nmol/L, after optimization of diabetes. She underwent endoscopic transsphenoidal surgery with normalization of blood sugar post-surgery. Blood pressure was normal throughout. Conclusion False negative or normal IGF-1 levels may result in patients with hepatic or renal failure, hypothyroidism, malnutrition, use of oral estrogen, severe infection, and poorly controlled diabetes mellitus. Hence, a low or normal IGF1 does not exclude acromegaly in patients with a high index of suspicion and warrants further investigation.
Acromegaly ; Insulin-Like Growth Factor I

Introduction: Polycystic ovary syndrome (PCOS) is the most common cause of hyperandrogenism in women of reproductive age. However, several endocrine disorders, particularly Cushing disease (CD), can closely mimic the clinical, biochemical, and radiological features of PCOS. This overlap may lead to misdiagnosis and delayed recognition of hypercortisolism, with significant metabolic and reproductive consequences. Case: We report a 24-year-old female with young-onset diabetes mellitus who was referred for endocrine co-management during admission for recurrent mons pubis and labial abscesses with poorly controlled glycemia. She had a 5-year history of progressive hirsutism, oligomenorrhoea, scalp hair loss, significant weight gain, and insulin resistance, and had previously been labelled as having PCOS during adolescence, with subsequent default of follow-up. On examination, she was obese (body mass index 33 kg/ m²) with plethoric facies, acanthosis nigricans, proximal myopathy, and hirsutism (Ferriman–Gallwey score 10), without overt virilization or acromegalic features. Biochemical evaluation demonstrated severe hyperandrogenism with markedly elevated total testosterone (7.05 nmol/L), suppressed gonadotropins, and adrenocorticotropic hormone (ACTH)-dependent hypercortisolism. Cortisol failed to suppress on low-dose dexamethasone testing, and 24-hour urinary free cortisol was markedly elevated (>4,900 nmol/24 h). Pelvic ultrasonography and computed tomography imaging showed polycystic ovarian morphology without evidence of an ovarian mass. Pituitary magnetic resonance imaging revealed a small right-sided pituitary microadenoma measuring 2.6 × 3.7 mm. Inferior petrosal sinus sampling demonstrated a central-to-peripheral ACTH gradient with adequate prolactin ratios, confirming pituitary CD. Conclusion This case highlights how Cushing disease can closely mimic PCOS, including polycystic ovarian morphology and hyperandrogenism. Progressive symptoms, severe biochemical androgen excess, and marked insulin resistance should prompt evaluation for secondary causes of hyperandrogenism, particularly hypercortisolism, to avoid delayed diagnosis and prolonged morbidity.
Female ; Hyperandrogenism ; Pituitary ACTH Hypersecretion ; Polycystic Ovary Syndrome

Introduction: Acromegaly is usually diagnosed by elevated age- and sex-adjusted insulin-like growth factor-1 (IGF-1) levels reflecting chronic growth hormone (GH) excess. IGF-1 is preferred as a screening biomarker due to its longer half-life and reduced pulsatility compared with GH. However, IGF1 levels may be disproportionately low or only modestly elevated in certain clinical contexts, leading to diagnostic uncertainty. Pituitary apoplexy is one such condition in which acute tumor hemorrhage or infarction may disrupt sustained GH secretion and attenuate IGF-1 production Case: A 48-year-old female with hypertension, type 2 diabetes mellitus, and dyslipidemia presented with a 2-day history of severe headache, vomiting, and visual disturbance, on a background of progressive acral enlargement over 2 years. Examination revealed coarse facial features, prognathism, enlarged hands, and cranial nerve involvement. Magnetic resonance imaging demonstrated an invasive sellar– suprasellar pituitary macroadenoma with optic chiasmal compression and cavernous sinus encasement. Intravenous dexamethasone was initiated pre-operatively due to a significant mass effect. Biochemical evaluation showed markedly elevated random GH levels (>50 ng/mL) with only mildly elevated IGF-1 at 1.19 times the upper limit of normal, below the threshold at which confirmatory oral glucose tolerance testing may be omitted according to current guidelines. Other pituitary axes suggested evolving hypopituitarism. During admission, she developed severe hyperglycemia with marked insulin resistance, requiring high-dose insulin therapy (approximately 1.5 U/kg/day). She underwent urgent transsphenoidal surgery, with histopathology confirming a pituitary neuroendocrine tumor with extensive hemorrhage and infarction, consistent with pituitary apoplexy. Postoperatively, GH levels were suppressed to <5 ng/mL, insulin requirements decreased markedly, and hormone replacement was initiated for secondary adrenal insufficiency and central hypothyroidism. Conclusion This case highlights that IGF-1 levels below conventional diagnostic thresholds do not exclude clinically significant acromegaly, particularly in the setting of pituitary apoplexy. Integration of clinical phenotype, GH levels, and imaging findings is essential to avoid diagnostic delay and ensure timely management.
Acromegaly ; Insulin Resistance ; Pituitary Apoplexy

Multiple endocrine neoplasia type 1 (MEN1) is a rare autosomal dominant disease caused by a mutation in the MEN1 gene. We present a 65-year-old man with MEN1 who has primary hyperparathyroidism, microprolactinoma, meningioma and gastrinoma. He had undergone parathyroidectomy followed by tumour excision of meningioma. The duodenal gastrinoma lesion was inoperable as it was close to the superior mesenteric artery with high surgery risk. Medical therapy with octreotide LAR had been initiated and showed good biochemical response as well as disease progression control. Chemoembolization was proposed if the duodenum lesion reduces in size on maintenance treatment with octreotide LAR. This case highlights the challenges in managing this rare condition and octreotide LAR has shown to be effective in controlling the disease progression in MEN1 with inoperable gastrinoma
meningioma ; octreotide ; gastrinoma