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Case Records of the Massachusetts General Hospital
Case 40-2011 — A 52-Year-Old Man with Weakness, Infections, and Enlarged Adrenal Glands
Presentation of Case. Dr. Liana K. Billings (Medicine): A 52-year-old man was admitted to this hospital because of weakness and swelling in his legs. The patient had been in his usual health until 9 months earlier, when leg edema and weakness developed, associated with weight gain. His physician…
- CME
Clinical Problem-Solving
A Bird's-Eye View of Fever
Foreword. In this Journal feature, information about a real patient is presented in stages (boldface type) to an expert clinician, who responds to the information, sharing his or her reasoning with the reader (regular type). The authors' commentary follows. Stage. A 78-year-old man presented to his…
Correspondence
Drugs and Pheochromocytoma — Don't Be Fooled by Every Elevated Metanephrine
To the Editor: A 51-year-old woman presented to our clinic in April 2010 with a 10-year history of hypertension and anxiety. The patient was concerned about pheochromocytoma because her identical twin sister had died at the age of 50 from metastatic pheochromocytoma. Her nephew and two grandsons…
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Original Article
Genetic Variant of the Scavenger Receptor BI in Humans
A low plasma level of high-density lipoprotein (HDL) cholesterol is a strong risk factor for cardiovascular disease. This explains the interest in the development of HDL cholesterol–increasing drugs to reduce atherosclerosis. To develop such drugs, in-depth knowledge of human HDL metabolism is…
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In a family with high HDL, a genetic mutation was identified. In addition to higher HDL levels, carriers had reduced cholesterol efflux from macrophages, impaired platelet function, and attenuated adrenal steroidogenesis. No significant difference was seen in the carotid artery intima–media thickness.
Images in Clinical Medicine
Auricular Cartilage Calcification and Adrenal Insufficiency
Figure 1.
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Case Records of the Massachusetts General Hospital
Case 14-2010 — A 54-Year-Old Woman with Dizziness and Falls
Presentation of Case. Dr. Emily P. Zeitler (Medicine): A 54-year-old woman was admitted to this hospital because of episodes of dizziness resulting in falls. Approximately 2 months earlier, while walking to work, the patient had the sudden onset of dizziness and the sensation of falling to the left,…
- CME
A 54-year-old woman was admitted to this hospital because of 2 months of episodes of dizziness resulting in falls, which occurred only when standing and were associated with diaphoresis, weakness in the legs, and palpitations. She had a history of borderline hypertension and atrial fibrillation. Physical and neurologic examinations were normal. Orthostatic vital signs showed decreased blood pressure and increased heart rate on standing. Symptoms persisted despite treatment with meclizine, metoprolol, fluid administration, and fludrocortisone. A diagnostic test result was received.
Case Records of the Massachusetts General Hospital
Case 13-2010 — An 18.5-Month-Old Girl with Watery Diarrhea and Poor Weight Gain
Presentation of Case. Dr. Sara V. Bates (Pediatric Service): An 18.5-month-old girl was seen in the pediatric gastroenterology clinic of this hospital because of watery diarrhea and poor weight gain. The patient was born to a multigravida mother after a full-term gestation. She was breast-fed for…
An 18.5-month-old girl was seen in the pediatric gastroenterology clinic of this hospital because of watery diarrhea and poor weight gain. The child had been healthy until 12 months of age, when chronic watery diarrhea developed. Six months later, her weight had decreased to the fourth percentile for her age. Extensive studies of stool, ultrasonography of the abdomen, and upper and lower endoscopic examinations were normal. A sweat test was interpreted as borderline. A diagnostic test result was received.
Review Article
Drug Therapy: Oral Phosphate Binders in Patients with Kidney Failure
Hyperphosphatemia, a nearly universal complication of kidney failure, is accompanied by hypocalcemia and low serum levels of vitamin D. Without treatment, these deficiencies usually lead to severe secondary hyperparathyroidism, which in turn leads to painful fractures, brown tumors, and generalized…
- CME
Hyperphosphatemia, which is nearly universal in kidney failure, is accompanied by low serum levels of vitamin D and hypocalcemia. Without treatment, severe secondary hyperparathyroidism occurs, which may result in painful fractures, brown tumors, and generalized osteopenia. This article reviews the rationale for treatment with oral phosphate binders, discusses evidence supporting the use of available agents, and suggests an approach for clinical practice.
Clinical Practice
The Incidentally Discovered Adrenal Mass
Foreword. This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author's clinical recommendations. Stage. A 68-year-old…
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A 68-year-old woman is incidentally found to have a left adrenal mass, 2.8 cm in diameter, on abdominal computed tomography that was ordered to evaluate right lower abdominal discomfort (which has since resolved). Her medical history is notable only for hypertension that has been well controlled with hydrochlorothiazide, at a dose of 25 mg daily. She reports no sweating, palpitations, headache, weight gain, or proximal muscle weakness. Her physical examination is unremarkable. How should she be evaluated?
Perspective
Incidentalomas — Clinical Correlation and Translational Science Required
It should have been a moment of huge relief. The biopsy specimen of the temporal artery was positive. We had answered the riddle of the patient's year-long fatigue, limb pain, and turbine-like noises in his head. He had giant-cell arteritis — not cancer, as he had feared. His disease would…
Correspondence
Staphylococcal Sepsis in Children
To the Editor: The article by Adem and colleagues (Sept. 22 issue) described three patients with severe sepsis caused by Staphylococcus aureus who had, at autopsy, bilateral adrenal hemorrhage. Two of the patients had elevated serum cortisol levels. Is it possible that clinical deterioration was…
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Original Article
Brief Report: Staphylococcus aureus Sepsis and the Waterhouse–Friderichsen Syndrome in Children
Staphylococcus aureus is a ubiquitous bacterium that causes infection in all age groups. The increasing recognition of isolates circulating in the community that are resistant to methicillin has increased the level of concern about this important pathogen and perhaps has led to the identification…
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This report describes three young children who died with severe staphylococcal sepsis after a rapidly progressive course, with necrotizing pneumonitis, coagulopathy, and cardiovascular collapse. At autopsy, all three were found to have bilateral adrenal hemorrhage with infarction, known as the Waterhouse–Friderichsen syndrome. The findings in these three children are similar to those usually seen with fulminant meningococcemia.
Case Records of the Massachusetts General Hospital
Case 7-2005 — A 59-Year-Old Woman with an Incidentally Discovered Adrenal Nodule
Presentation of Case. A 59-year-old woman was seen in the clinic for evaluation of an adrenal mass. Two years earlier, she had undergone her first physical examination since childhood, having sought medical attention because of morning stiffness and polyarticular joint pain that she had had for…
A 59-year-old woman was incidentally found to have an adrenal cortical nodule on abdominal computed tomography for evaluation of a colovesical fistula. Two years earlier, she had been found to have mild hypertension, which proved difficult to control with antihypertensive medication. She was slightly obese. How should she be evaluated?
Case Records of the Massachusetts General Hospital
Case 35-2000 — An 82-Year-Old Woman with Bilateral Adrenal Masses and Low-Grade Fever
Presentation of Case. An 82-year-old woman was admitted to the ambulatory care center because of bilateral adrenal masses and low-grade fever. The patient had been in good health until five months earlier, when myalgia developed, with a vague headache and a temperature of 37.2°C. A physician…
Correspondence
Case 3-2000
To the Editor: The January 27 Case Record (Case 3-2000) concerned a patient who had systemic amyloidosis, AL type, with restrictive cardiomyopathy and multiple organ involvement. I wish to draw attention to amyloidosis of the adrenal glands, which Dr. DiSalvo mentioned briefly. Secondary…
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Case Records of the Massachusetts General Hospital
Case 15-1992 — A 23-Year-Old Woman with a Painful Mass in the Right Adrenal Region
Presentation or Case. A 23-year-old woman was admitted to the hospital because of the acute onset of abdominal pain. The patient was in excellent health until the morning of admission, when she was awakened from sleep in the early hours by a severe, constant pain in the right upper abdominal…
Original Article
Petrosal Sinus Sampling with and without Corticotropin-Releasing Hormone for the Differential Diagnosis of Cushing's Syndrome
SURGERY for Cushing's syndrome can cure hyper-cortisolism and preserve pituitary—adrenal function in most patients in whom a specific diagnosis is established. Current diagnostic tests, however, do not always distinguish clearly among the causes of the syndrome, and as a consequence, patients may…
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Correspondence
Hormonal Evaluation of Patients with an Incidentally Discovered Adrenal Mass
To the Editor: Ross and Aron (Nov. 15 issue) recommend that the 1-mg dexamethasone suppression test for evaluating incidentally discovered adrenal masses be abandoned because Cushing's syndrome is rare. Although the authors acknowledge the existence of subclinical autonomous cortisol secretion,…
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Case Records of the Massachusetts General Hospital
Case 49-1989 — A 71-Year-Old Man with Thrombocytopenia and Hypotension after Resection of a Colonic Carcinoma
Presentation of Case. A 71-year-old man was admitted to the hospital because of a colonic tumor. The patient was in a static state of health until two weeks earlier, when he noticed fresh blood in a stool. Examination revealed a positive test for occult blood on a stool specimen. A barium-enema…
