Endocrinology

An 18-month-old girl was noted to have somatic overgrowth, macroglossia, macrostomia, fading telangiectatic nevi over the glabella and eyelids, vertical creases on the earlobes, a short nose with anteverted nares, and a long philtrum. She also had an ejection systolic murmur best heard at the left mid- and upper sternal border, compatible with an atrial septal defect.

A 13-year-old girl was notably short and had short fourth metacarpals and metatarsals. She was very mildly mentally retarded.

A 49-year-old woman noticed a growing lesion near the inner corner of her left upper eyelid. The lesion had become conspicuous because of its size and color; the patient wanted it removed.

Type 2 diabetes was recently diagnosed in a 59-year-old woman whose vision in both eyes had been impaired for about 1 month. She had experienced fatigue and malaise for 4 to 6 weeks but had delayed seeking medical care.

A 40-year-old woman with a history of amenorrhea complained of recent headaches and galactorrhea for the last 6 months. A neurologic work-up revealed bitemporal hemianopia, and a radiograph of the skull suggested an enlarged sella turcica. A large pituitary adenoma disclosed by an MRI and a serum prolactin level of 360 µg/L led to a diagnosis of prolactinoma.

Congenital adrenal hyperplasia is an autosomal recessive disorder. Deficiency of 21-hydroxylase accounts for 95% of all cases.

An obese 52-year-old woman with a 5-year history of type II diabetes mellitus had odynophagia and dysphagia for several days. She described the sensation as food “sticking” in her chest. She also complained of vaginal itching, polyuria, and polydipsia. The only remarkable finding on physical examination was candidal vaginitis. The patient did not smoke cigarettes or drink alcoholic beverages, and there was no history of recent weight loss.

Affected infants present shortly after birth with a large bowel obstruction secondary to transient dysmotility in the descending colon. Although the cause is unknown, immaturity of the colonic myenteric plexuses has been demonstrated in some cases. More than 50% of affected infants are born to mothers with diabetes. Other predisposing factors include hypoglycemia and sepsis.

A 57-year-old man with a history of venous stasis leg ulceration wondered about the “white spots” on his leg.

This 56-year-old man presented with a swollen face and puffy eyelids. He recently had an ear, nose, and throat evaluation for persistent hoarseness, and the findings were normal. The patient complained that he has had difficulty in lifting his head for about 4 years and was treated by a chiropractor but obtained no relief.

For 2 months, a 31-year-old woman had had dyspnea and dull, continuous retrosternal pain. She was admitted to the hospital, and a helical CT scan of the thorax identified a saddle pulmonary embolism. An ultrasonogram revealed deep venous thrombosis (DVT) in the left leg. Intravenous heparin was given; the patient was discharged, and warfarin was prescribed.

A 7-year-old boy presented with two testicles on the left side of the scrotum. The superior one was half the size of the inferior one, which measured 2 × 1 cm. The testicle on the right side measured 2 × 1 cm. Surgical exploration was done, and the atrophic left supernumerary testicle shown in the photo was removed. Biopsy specimens taken from the remaining testicle were normal.

This 15-year-old boy presented with a 3-year history of gradual, bilateral breast enlargement. He was otherwise healthy and showed normal pubertal development.

The significant palmar erythema seen on the hands of a 60-year-old man with alcoholic cirrhosis is a sign of underlying chronic liver failure.

A 55-year-old woman, who had fairly well-controlled type 2 diabetes for 15 years, noticed a slow, progressive decrease in the visual acuity of her right eye during the past 6 to 8 weeks.

A mass in the neck of a 65-year-old woman had grown slowly and progressively during the last 5 years. The patient was otherwise asymptomatic; in particular, there was no heat or cold intolerance, irritability, weight loss, increased appetite, palpitations, lethargy, constipation, dysphagia, or dyspnea.

A healthy 31-year-old man was referred to a dermatologist with a diagnosis of tinea versicolor that did not respond to oral ketoconazole and topical selenium sulfide.

A 46-year-old man with diabetes presented for evaluation of gradual fingernail deterioration, which had failed to respond to several courses of griseofulvin and a recent 3-month course of daily terbinafine. The patient-who worked as a bartender-was otherwise healthy.

A 68-year-old woman was referred from an acute care clinic for evaluation of a persistent cellulitis. Ten days before, erythematous, pruritic plaques developed on her ankles; these slowly enlarged, and pustules formed. The patient denied fever or chills. Her past medical history was unremarkable, and conjugated estrogen, medroxyprogesterone acetate tablets, and multivitamins were the only medications and nutritional supplements she was taking.

This contorted hand of a 49-year-old man demonstrates Dupuytren's contracture, a disorder first described by Baron Guillaume Dupuytren in 1831. Although the condition may occur as a completely independent abnormality, it is commonly associated with chronic liver disease, diabetes mellitus, epilepsy, palmar fasciitis, carpal tunnel syndrome, rheumatoid arthritis, pulmonary tuberculosis, and alcoholism. This patient had a history of alcohol abuse.

A 30-year-old woman was brought to the hospital with syncope, bradycardia, and hypotension. For the past 6 years, she had vomited after eating meals and after occasional episodes of binge eating.

Highly pruritic, 2- to 4-mm, papular lesions with central ulceration erupted on the back of a 66-year-old woman. She had had 2 similar outbreaks in the past. The patient was taking conjugated estrogens, alprazolam, and alendronate.

After this 9-year-old boy complained of “growing too fast” during the past 1 to 2 years, his parents sought medical advice. He had no significant past medical history.

Three years ago, the young man pictured here was told that he might have acromegaly, but he ignored this warning. Now, at age 32, he consulted an endocrinologist because he realized his facial features and voice were becoming increasingly coarse. Soft-tissue swelling of his hands was also noted.

A 70-year-old man was brought from a nursing home to the emergency department with abdominal distention and vomiting of recent onset and a 2-day history of fever and abdominal pain. The patient had chronic obstructive pulmonary disease, type 2 diabetes mellitus, and hypertension. His gastric feeding tube, which had been placed via percutaneous endoscopic gastrostomy, was blocked.

A 32-year-old woman with insulin-dependent diabetes noted a painful erosion at the site of "the rose tattoo," which she had gotten 5 days before.

Abstract: Tuberculous meningitis has several different clinical presentations, including an acute meningitic syndrome simulating pyogenic meningitis, status epilepticus, stroke syndrome, and movement disorders. Cranial nerve palsies and seizures occur in about one third of patients, and vision loss is reported by almost 50%. The cerebrospinal fluid (CSF) typically shows moderately elevated levels of lymphocytes and protein and low levels of glucose. The demonstration of acid-fast bacilli in the CSF smear or Mycobacterium tuberculosis in culture confirms the diagnosis. CNS tuberculosis may also manifest as intracranial tuberculomas. The characteristic CT and MRI finding is a nodular enhancing lesion with a central hypointensity. Antituberculosis treatment should be initiated promptly when either tuberculous meningitis or tuberculoma is suspected. (J Respir Dis. 2005;26(9):392-400)

A 55-year-old man complains of fatigue. Although he sleeps 8 hours every night, he has to push himself to perform his usual daily activities. He has also experienced loss of libido and episodic impotence, which he ascribes to the fatigue.

Scaling patches that resist antifungals; an outbreak of red papules; a velvety,hyperpigmented rash--can you identify the disorders pictured here?

ABSTRACT: The management of chronic daily headache is difficult and complex. Those affected have a sensitive nervous system, and their predisposition for a low tolerance to sensory stimuli appears to be inherited. Under appropriate conditions, the equilibrium or balance between bombardment from painful stimuli and the regulatory systems that inhibit those stimuli is disrupted, allowing painful stimuli to become manifest at a greater intensity than in the nonmigraineur. Successful management depends on close adherence to nonpharmacologic approaches and pharmacologic regimens that desensitize the system and restore equilibrium. Comorbid conditions must be identified and treated as well.