Faculty Bibliography

OBJECTIVE: To report the first case of severe osteoporosis associated with a vertebral pathologic fracture and osteonecrosis of femoral heads in an HIV-infected man receiving inhaled corticosteroids and ritonavir-boosted antiretroviral therapy. METHODS: We describe an HIV-infected man with severe osteoporosis, bilateral hip osteonecrosis, and secondary adrenal suppression, including detailed clinical, laboratory, and radiographic data, and review the related literature. RESULTS: A 60-year-old man with a 15-year history of HIV infection and a medical history of long-standing bronchiectasis treated with inhaled corticosteroids and hypogonadism treated with testosterone was referred to the endocrinology clinic after experiencing an osteoporotic vertebral fracture. He was taking ritonavir-boosted antiretroviral therapy. Osteonecrosis of both hips was also diagnosed, which required total hip replacement therapy. Laboratory evaluation revealed adrenal insufficiency due to increased effect of exogenous inhaled steroids and no other secondary causes of osteoporosis. A bone densitometry study showed osteoporosis of both hips and the lumbar spine. He was treated with intravenous pamidronate. During treatment, he developed bilateral femoral fractures after minor trauma. CONCLUSIONS: Given the potential for increased serum levels of inhaled corticosteroids in patients taking ritonavir-boosted highly active antiretroviral therapy, attention must be paid to the risk of bone loss in HIV-infected patients taking inhaled corticosteroids. Prescribing calcium and vitamin D supplementation and considering early osteoporosis screening are reasonable measures for this patient population. Interaction between inhaled corticosteroids and ritonavir may increase risk of hypothalamus-pituitary-adrenal axis suppression

BACKGROUND: It has been the authors' clinical experience that hypothyroid patients who achieve a euthyroid state on a steady dose of oral levothyroxine often become hypothyroid over time if the medication is given via a feeding tube. The authors hypothesize that the tubing and enteral feeds may adsorb a significant percentage of the levothyroxine and thereby reduce its bioavailability. To the authors' knowledge, no previous research has been reported on this subject. They therefore performed an in vitro assessment of the degree of levothyroxine adsorption to quantify the amount of drug adsorbed to the percutaneous endoscopic gastrostomy (PEG) tube and how enteral tube feeds mitigate or exacerbate this adsorption. METHODS: Using levothyroxine radiolabeled with an I 125 tracer, a known dose of levothyroxine was passed through 60 new PEG tubes. One-half of the tubes were pretreated with Jevity feeds, and the other half were not. The authors measured the activity of the radiolabeled levothyroxine before and after it had passed through the tubes and, using a subtraction analysis, inferred the amount of thyroxine left within the tube. RESULTS: Tubes presoaked with feeds had a greater uptake in radioactivity by 326.4 cpm (95% confidence interval, 226.7-426.1), corresponding to a 45.08% relative increase in uptake compared with virgin PEG tubes without feeds. CONCLUSIONS: Although the authors found statistically significant differences in mean drug concentrations, they conclude that the amount of uptake of levothyroxine by PEG tubes and adsorption of levothyroxine by PEG tubes is probably clinically insignificant. The differences found may be attributed to the amount of drug lost during crushing and transfer.

We report a 73-year-old woman who presented with chest pain, electrocardiogram changes, and serum troponin levels consistent with an acute myocardial infarction. Cardiac catheterization showed normal coronaries and a left ventriculogram was consistent with reversible left ventricular apical ballooning, or "takotsubo" cardiomyopathy. She had a 5-cm left adrenal mass on a recent abdominal computed tomography. The cardiomyopathy resolved in I week, and she was later diagnosed with a pheochromocytoma. The tumor was successfully removed with full recovery. This case illustrates the association between pheochromocytoma and reversible left ventricular apical ballooning. This kind of case has only been reported once before

OBJECTIVE: To determine whether a 5-mCi dose of 123I can be used as an effective radiotracer for assessing the presence of remnant thyroid tissue and for searching for metastatic lesions in patients with well-differentiated thyroid cancer as well as to attempt to ascertain whether a scan performed only at 4 hours is sufficient for accurate diagnosis and might replace the conventional protocol of scanning at both 4 hours and 24 hours. METHODS: We prospectively studied 27 patients who had undergone near-total thyroidectomy and had a documented diagnosis of well-differentiated thyroid carcinoma. Patients underwent scanning after receiving a 5-mCi dose of 123I, at a time when they had discontinued thyroid replacement therapy and had a thyrotropin level in excess of 30 mIU/mL. Whole-body images at 4 hours and 24 hours were obtained and were compared with posttherapy scans obtained 5 to 7 days after administration of 131I. Scans were interpreted by two board-certified nuclear medicine physicians. RESULTS: Of the 27 patients, 2 (7.4%) showed discordance between the 123I scan performed at 24 hours and the posttherapy 131I scan. When 4-hour images after administration of 123I were compared with the posttherapy 131I scans, a discordance rate of 14.8% (4 of 27 patients) was noted. In addition, two of these four patients showed lesions on the 24-hour images that were not seen on the 4-hour images (one with new lung metastatic involvement and the other with a local recurrence in the lower neck area). The prognosis and treatment of these two patients were substantially changed by the result of the 24-hour images. CONCLUSION: On comparison of scans obtained after administration of a 5-mCi dose of 123I with those obtained after 131I therapy, we conclude that 5 mCi of 123I produces images that have excellent quality and resolution and also compare favorably with those obtained after 131I therapy. Furthermore, a decrease in the dose of 123I from 10 mCi to 5 mCi lowered the cost of the study without compromising the diagnostic accuracy or image quality. Finally, use of 24-hour images will occasionally disclose additional areas of radioiodine uptake not detected on the 4-hour scans and is therefore recommended.

OBJECTIVE: To present a case report of the occurrence of non-Hodgkin's lymphoma in the thyroid gland of a patient who had previously undergone successful treatment of Hodgkin's lymphoma. METHODS: We describe pertinent historical features and current symptoms and laboratory findings in a 62-year-old man who had had successful treatment of Hodgkin's lymphoma 10 years previously and had been free of disease for a decade. We also review the related medical literature on the course of patients after therapy for Hodgkin's lymphoma. RESULTS: Because of a progressively enlarging anterior neck mass, hoarseness, and difficulty with breathing, a patient sought medical attention. Ten years previously, he had undergone irradiation and splenectomy for treatment of Hodgkin's lymphoma. In the current assessment, fine-needle aspiration and open biopsy yielded the diagnosis of non-Hodgkin's lymphoma, for which the patient received irradiation and chemotherapy. Review of the literature pertaining to diseases after treated Hodgkin's lymphoma, including second cancers, failed to identify any such prior reported case. CONCLUSION: Because the clinical profile of our patient was consistent with primary non-Hodgkin's lymphoma of the thyroid gland developing after radiation-treated Hodgkin's lymphoma, we conclude that this represents the first such reported example.

We have described an unusual case of multifocal eosinophilic granuloma ("Hand-Schueller-Christian disease") in a middle-aged woman. The case underscores the varied and subtle nature of the disease presentation and the extent to which many organ systems may become involved. Unusual features of her case include atypical bone roentgenograms, cutaneous anergy, panhypopituitarism and evidence of diffuse central nervous system dysfunction. Several features of multifocal eosinophilic granuloma present in the older age group are different from those presenting in children and young adults. Finally, multifocal eosinophilic granuloma may present all the clinical and laboratory features of a progressive, chronic disease.