Clinical Pearls from JCM Case Reports Lecture

Introduction

• Host: Bill Young (Editor-in-Chief)
• Co-Chair: Dr. Adina Turku (Deputy Editor)
• Format: Three short presentations (~7 minutes each) followed by Q&A and expert discussion.

Presentation 1: GnRH Analogues in Female Androgen Excess

Presenter: Dr. Lauren Doyle

• Background:
  • Completed Internal Medicine Residency in the US.
  • Moving to Endocrine Fellowship.
• Title: Clinical utility of GnRH analogues in female androgen excess.
• Conflicts of Interest: Off-label use of medications discussed.

Key Concepts:

• GnRH analog testing principle:
  • Ovarian-derived androgen excess controlled by HPG axis.
  • Adrenal androgen excess not controlled by HPG axis.
• Administration: 3mg triptorelin IM.
• Results:
  • Initial receptor binding leads to downregulation and reduction of testosterone after 28 days.

Case Studies:

Case 1: 68-Year-Old Woman

• History: 3-4 years of facial hirsutism, vocal deepening, genitalia changes.
• Biochemistry: Elevated testosterone, suppressed gonadotropins.
• Findings:
  • Normal adrenal imaging, large ovarian tumor identified.
  • GnRH analogue test: Full suppression of testosterone.
• Outcome: Benign ovarian steroid cell tumor diagnosed post-surgery.

Case 2: 67-Year-Old Woman

• History: 15 years of hirsutism, frontal hair thinning.
• Biochemistry: Testosterone mildly elevated (2.5).
• Findings: Identified adrenal myelolipoma; likely benign ovarian hyperthecosis.
• Outcome: Continued therapy with GnRH analog; declined surgical intervention.

Case 3: 25-Year-Old Woman

• History: Significant hirsutism, secondary amenorrhea, juvenile dermatomyositis.
• Biochemistry: Elevated LH/FSH ratio, high testosterone and hyperinsulinemia.
• Findings: No identifiable source; GnRH analogue resulted in suppression of testosterone and symptom relief.
• Outcome: Surgical intervention planned due to adverse effects from treatment.

Take-Home Messages:

• GnRH analogues can be useful for diagnosing and managing benign ovarian androgen excess.
• Potential to reduce reliance on invasive procedures.
• Careful case selection is crucial to avoid overlooking malignancy.

Q&A Session

• Queries about imaging techniques and GnRH analog response in different scenarios.

Presentation 2: Molar Pregnancy-Induced Hyperthyroidism

Presenter: Dr. Lauren Walish

• Case Summary: 32-year-old female, 10 weeks pregnant, presented with severe nausea.
• Findings:
  • Beta HCG levels extremely high (420 million).
  • Thyroid profile indicates hyperthyroidism.
• Management:
  • Urgent laparoscopic evacuation of molar pregnancy;
  • Post-operative care included PTU & beta blockers.
• Outcome:
  • Normalized thyroid function, follow-up required due to rising beta HCG levels.

Learning Points:

• Recognize link between gestational trophoblastic disease and hyperthyroidism.
• Multidisciplinary approach is essential for patient safety.

Q&A Session

• Discussion on PTU management and follow-up protocols post-molar evacuation.

Presentation 3: Type B Insulin Resistance Syndrome

Presenter: Dr. Salman Bot

• Case Summary: 59-year-old female with SLE and diabetes presented with hypoglycemia.
• Findings:
  • Elevated insulin levels; fasting tests confirmed insulin resistance.
  • Biochemical evaluation pointed to Type B insulin resistance syndrome.
• Management:
  • Dietary modifications and cessation of insulin therapy.
• Outcome: Improved glycemic control without medication.

Learning Points:

• Type B insulin resistance syndrome shows unique characteristics in demographics and lab results.
• Anti-insulin receptor antibodies confirm diagnosis.

Expert Discussions

• Dr. Francis Hayes discussed the utility of GnRH analogues, testing protocols, and the importance of imaging.
• Dr. Elizabeth Pierce emphasized the urgency in managing hyperthyroidism in pregnancy.
• Dr. David Delesio commented on the rarity and significance of Type B insulin resistance syndrome and its implications in research.

Conclusion

• Continued collaboration and knowledge sharing through case reports is vital in advancing endocrinology.