Objective:To determine the prevalence of microalbuminuria and its association with hypertension and other diabetic complications among Type-2 diabetic patients attending at Aga Khan University Hospital Karachi.Methods:1280 Type-2 diabetes patients who visited the outpatient department of Aga Khan University Hospital from September 2014 to August 2016 were included in the study. Microalbuminuria was diagnosed if spot urinary microalbumin excretion was confirmed to be more than 20mg/l. Hypertension was diagnosed if BP >140/90 or already on antihypertensive medications. Other demographic, clinical and laboratory data were also recorded.Results:Microalbuminuria was diagnosed in 404(31.56%) patients and among these albuminuric patients 335(82.9%) had hypertension. They were also dyslipidemic, having raised triglyceride levels, lower HDL levels, with more prevalence of background diabetic retinopathy and peripheral neuropathy. They also showed higher HbA1C levels and longer duration of diabetes.Conclusion:The prevalence of the microalbuminuria in our patients with Type-2 diabetes is 31.56% and is not only an early sign of diabetic nephropathy but also a host of other diabetic complications and should be dealt early with strict control of their hyperglycemia and hypertension to help prevent the future complications.

BackgroundLymphomas are cancers that arise from the white blood cells and have been traditionally divided into two large subtypes: Hodgkin and non-Hodgkin lymphoma. B-cell lymphoma is the most common subtype of non-Hodgkin lymphoma; almost 85% of patients with lymphoma have this variant. Lymphomas can potentially arise from any lymphoid tissue located in the body; however, primary adrenal non-Hodgkin lymphoma is extremely rare. We report the history, examination findings, and laboratory results of a 50-year-old man diagnosed with a primary left adrenal diffuse large B-cell lymphoma.Case presentationA 50-year-old Pakistani man presented to our hospital with progressively increasing pain and fullness in the left upper quadrant of his abdomen, generalized weakness, easy fatigability, and decreased appetite of 1.5 months’ duration. On examination, he had a blood pressure of 140/80 mmHg with no postural drop, a pulse rate of 106 beats/minute, and no fever. His past medical history was significant for pulmonary tuberculosis 2 years earlier, for which he received antituberculous therapy. Computed tomography revealed a heterogeneous enhancing soft tissue density mass in the left adrenal gland. It measured 7.1 × 5.6 × 9.5 cm. Further laboratory workup revealed the following levels: sodium 135 mEq/L, potassium 4.5 mEq/L, lactate dehydrogenase 905 IU/L, renin 364 IU/ml, aldosterone 5.79 ng/dl, dehydroepiandrosterone sulfate 79.20 μg/dl, urinary vanillylmandelic acid 6.4 mg/24 hours, and a low-dose overnight dexamethasone suppression test result of 3.20 μg/dl. The patient underwent left adrenalectomy. Histopathological test results showed a diffuse large B-cell lymphoma. Immunohistochemical stains were strongly positive for CD20 and negative for CD3, CD5, CD10, and cyclin D1. The patient’s Ki-67 (Mib-1) index was approximately 80%. He received a total of six cycles of cyclophosphamide, doxorubicin, vincristine, and prednisone chemotherapy (rituximab was not given, owing to financial constraints) and was routinely followed pre- and postchemotherapy at our hematology clinic with complete blood count and serum lactate dehydrogenase evaluations. The patient responded to chemotherapy and is currently doing well.ConclusionsPrimary adrenal lymphoma is an extremely rare but rapidly progressive disease. It generally carries a poor prognosis, partly because an optimal treatment protocol has not yet been established. Further studies with larger sample sizes are needed to establish the best treatment option and increase overall survival.

Objective: To determine 7-9 am serum cortisol less than 5mcg/dl is an independent reliable confirmatory test for the diagnosis of primary adrenal insufficiency (PAI). Methods: A total of 164 patients who visited the outpatient or inpatient department of Aga Khan University Hospital from June 2011 to June 2017 were included for the study. All those patients whose levels came out less than 5mcg/dl were recruited for the study and they all underwent SST. Other demographic and laboratory data were also recorded. Results: The sensitivity of morning cortisol for diagnosis of PAI is 100% if levels are <1mcg/dl and decreases to 71.88% if levels are up to 5mcg/dl. Conclusion: Morning cortisol is sensitive enough as an alternative to SST if levels are <1mcg/dl (100%). However, if the levels are increased from >1mcg/dl to <5 mcg/dl, the sensitivity decreases gradually from 98% to 71%. doi: https://doi.org/10.12669/pjms.35.5.1208 How to cite this:Ulhaq I, Ahmad T, Khoja A, Islam N. Morning cortisol as an alternative to Short Synecthan test for the diagnosis of primary adrenal insufficiency. Pak J Med Sci. 2019;35(5):---------. doi: https://doi.org/10.12669/pjms.35.5.1208 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The incidence and clinical characteristics of malignant lymphomas (ML), the most common tumors encountered in the Middle East, vary in different regions. [1][2][3][4][5] This retrospective study analyzed histologically confirmed cases of malignant lymphoma seen in King Fahd Specialist Hospital (KFSH) during an eight-year period (01/01/87 to 31/12/94). The results were compared with data from other regions of the Kingdom and the Middle East. KFSH is a 570-bed regional referral hospital of Al-Qassim region and the majority of malignant disease patients of the region are referred here for further management. Patients and MethodsThe records of 160 consecutive patients of histologically confirmed lymphoma, seen in KFSH between 01/01/87 and 31/12/94, were reviewed. There were 145 Saudis and 15 non-Saudi patients. Twenty-one patients (nine Saudis and 12 non-Saudis) did not have either enough clinical details or pathological material available for inclusion in the study.The patient's age, sex, site of initial presentation and symptoms with duration were all noted. The majority of the patients had undergone a complete staging workup, including hemogram, liver function tests, chest x-ray, abdominal ultrasonography, CT scan of the chest and abdomen, as well as bone marrow examination. Laparotomy was not carried out for staging purposes.Patients were staged according to the Ann Arbor classification. 6 B symptoms were defined as weight loss >10% over six months prior the admission and/or unexplained fever with temperature >38°C and/or night sweats. The histopathology of Hodgkin disease (HD) was classified according to the Rye scheme of classification 7 and that of non-Hodgkin lymphoma (NHL) according to Rappaport 8 and the working formulation. 9 The results were compared by r-test and contingency tables were analyzed by χ 2 test with Yale's correction. ResultsOut of the total of 139 cases included in this study (136 Saudis, three non-Saudis), 87 (62.6%) patients had NHL and 52 had HD (37.4%).Age distribution: Shown in Figures 1 and 2. The age ranged from two to 99 years. The mean age for HD was lower than for NHL (27.9±21.2 years versus 46.8±27.60 years, t=2.3, P<0.05). Patients with the nodular sclerosis (NS) type of HD presented at an earlier age than other types of HD (mean age 21±13.5 versus 33.7±24.9 years, t=2.3, P<0.05).Sex ratio: The male to female ratio of 60:27 (2.2:1) in NHL was higher than 33:19 (1.7:1) in HD (χ 2 =0.23, P>0.5). The NS type of HD was more common in females with a male to female ratio of 1:1.3 (χ 2 =6.33, P<0.05). Histological types: Tables 1 and 2 show the age-related histological types of HD and NHL. In HD, lymphocytic predominant (LP) and NS were more common (57.7%) than mixed cellularity (MC) and lymphocytic depletion (LD) combined (42.3). The majority of NHLs were aggressive lymphomas (Table 3).Presenting symptoms: Awareness of a peripheral Jump was the most common symptom with which our patients presented (93/139, 66.9%), being more common in HD (47/52, 90.4%) than in NHL (46/87, 52.9%) (χ 2...

We present three patients with brain abscesses who also had pulmonary arteriovenous malformations (AVMs). All patients had hereditary haemorrhagic telangiectasia (Osler's Disease). It is probable that the lung AVMs contributed to the development of the brain abscesses by allowing bacteria easier access to the systemic circulation through a right to left pulmonary vascular shunt, bypassing the filtering action of the pulmonary capillaries. In addition, one patient required a period of postoperative ventilation using PEEP, which may have exacerbated the shunt through the lung AVM and led to difficulty in weaning her from the ventilator.