Cortisol production by hepatocellular carcinoma (HCC) has not been previously reported and dehydroepiandrosterone (DHEA) secretion by HCC is rare. We report a case of a 53-year-old woman admitted with dyspnoea and headache. Serum cortisol by immunoassay (IA) was 42.3 μg/dL, urine free cortisol (UFC) by liquid chromatography mass spectrometry (LC/MS/MS) was 106.1 μg/24 h, serum DHEA by LC/MS/MS was 4886 ng/mL, serum DHEA-S by LC/MS/MS was 4477 ng/mL and plasma adrenocorticotrophic hormone (ACTH) by IA was 10 pg/mL. CT showed likely HCC metastatic to the left adrenal gland, brain and lungs. Liver and adrenal gland biopsies confirmed HCC. ACTH tumour staining was negative. High serum and UFC levels and high serum DHEA and DHEA-S with low-normal plasma ACTH and negative tumour ACTH staining suggested ACTH-independent ectopic Cushing's syndrome (CS); cortisol and DHEA being likely secreted by the HCC. To the best of our knowledge, this is the first reported case of HCC associated with CS.
Insulin resistance is associated with a number of conditions, such as non-classic 21-hydroxylase deficiency and allied disorders. Serum vitamin D is often deficient/ insufficient in insulin resistant individuals. Disorders associated with insulin resistance are often mitigated in association with vitamin D repletion. Here we report a patient with type 2 diabetes mellitus, lower extremity infection, vitamin D insufficiency, and elevated unstimulated serum 17-OH-progesterone (17-OHP), which normalized during vitamin D repletion. Serum 25-OHvitamin D (25-OHD) rose by 32% while serum 17-OHP fell by 87% over the course of four weeks receiving 50,000 IU ergocalciferol orally weekly. Vitamin D repletion in this setting restored normal serum 25-OHD levels and was associated with normalization of elevated serum 17-OHP. Serum 25-OHD levels should be determined before commencing glucocorticoids or mineralocorticoids for the treatment of elevated serum 17-OHP in disorders like non-classic adrenal hyperplasia (NCAH) and levels of 17-OHP, should be re-measured when vitamin D levels are replete to determine whether glucocorticoid/ mineralocorticoid replacement is actually necessary.
A 71-year-old woman with type 2 diabetes mellitus, chronic kidney disease stage IV, primary hypothyroidism and osteoarthritis, whose prescribed treatment included miglitol 50 mg thrice daily with the first bite of meals, reported that she suffered visual hallucinations while taking miglitol, which resolved within a few days of stopping the drug. When she resumed miglitol, hallucinations recurred within a few days and again resolved within a few days of stopping the drug. To our knowledge, this is the first reported case of hallucinations associated with the use of an α-glucosidase inhibitor and highlights a previously unappreciated risk associated with the use of this generally quite benign drug class.
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