Chronic fatigue syndrome and neurally mediated hypotension.
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Fatigue Syndrome, Chronic↗
Biomedical subjects
D C Klonoff
Publications and source records attributed to D C Klonoff.
Hypoglycemia following inadvertent and factitious sulfonylurea overdosages.
OBJECTIVE: To recognize unreported sulfonylurea overdosages in hypoglycemic patients. CASES: We describe three patients with hypoglycemia due to inadvertent (in two patients) and factitious (in one patient) sulfonylurea overdosages. We review the world literature and summarize 43 previously published cases of inadvertently administered and 23 previously published cases of factitiously self-administered sulfonylurea overdosages with hypoglycemia. RESULTS: An inadvertently administered fulsonylurea overdosage usually occurred when a sulfonylurea was accidentally substituted for an intended medication with a similar generic or trade name. Features of the patients with a factitiously self-administered sulfonylurea overdosage included: 1) a history of the patient or patient's spouse having a medical job or sulfonylurea-treated diabetes mellitus; 2) an unusual affect or psychiatric history; 3) an abrupt onset of severe symptoms without previous milder symptoms; and 4) an absent hypoglycemic or hyperinsulinemic response to provocative testing. These features are not typical for an insulinoma. CONCLUSIONS: When a hypoglycemic patient denies antidiabetic medication use, we recommend sequentially performing: 1) a thorough pill inspection; 2) an interview for recently altered pill appearances; 3) a measurement of serum insulin and C-peptide levels during hypoglycemia; and 4) a blood or urine sulfonylurea screen. Discovery of an unreported sulfonylurea overdosage can eliminate the need to search for an insulinoma and prevent further overdosages from occurring.
Adult↗
Chronic fatigue syndrome.
Chronic fatigue syndrome (CFS) is defined by symptoms and diagnosed without any objective diagnostic tests. Risk factors for developing CFS may include infection, psychiatric disorders, and allergies. Modest dysfunction of multiple organ systems, including the immune, central nervous, endocrine, and muscular systems, have been identified in cases of CFS. Symptoms of various organic, psychiatric, and poorly understood disorders overlap those of CFS. There is no known cure for CFS; however, exercise, counseling, and medications may provide symptomatic relief.
Depression↗
Acute water intoxication as a complication of urine drug testing in the workplace.
Urine drug testing is now mandatory in many industries. We report the first case, to our knowledge, of an adverse consequence of drug testing in the workplace: acute water intoxication. We discuss normal water metabolism and the adverse effects of water loading and impaired renal function on free water clearance. We present a literature review of seven other cases of acute voluntary water intoxication in patients without chronic psychiatric or neurologic illness. For workers undergoing urine drug testing we conclude that risk factors for acute water intoxication include (1) intake of more than 1 L of water and (2) impaired urine dilution. In a recently drug-tested worker, symptoms of cerebral dysfunction should suggest the possibility of water intoxication.
Acute Disease↗
Insulinomas associated with multiple endocrine neoplasia type I: the need for a different surgical approach.
Insulinomas are usually solitary (greater than 90%) benign pancreatic tumors readily cured by enucleation or resection. To determine whether the 4% of insulinomas associated with multiple endocrine neoplasia type 1 (MEN-I) require a different surgical approach, we analyzed our experience in seven patients with MEN-I insulinomas treated during the past 28 years at the University of California, San Francisco, and 53 patients reported in the English literature. We found: (1) MEN-I insulinomas were associated with an antecedent history of other endocrinopathy or a family history of MEN-I in six of our seven patients, allowing preoperative identification of these patients. (2) All seven of our patients had hyperparathyroidism and four had pituitary tumors. Overall 83.6% of patients had hyperparathyroidism and 45.4% had pituitary tumors. (3) In our patients, MEN-I insulinomas were usually multiple (median 3; range 1 to 14). Overall, 76.3% of patients had multiple islet cell tumors. (4) Distal subtotal pancreatectomy with enucleation of any tumors identified in the head of the gland was done in five of our patients. Four are now normoglycemic and one is diabetic. Enucleation alone failed in one patient. The seventh patient was diagnosed at autopsy. Because the diagnosis of MEN-I can generally be made, preoperative strategy can address the unique pathologic features of insulinomas associated with MEN-I. The tumors are usually multiple, so local resection will fail. We recommend subtotal pancreatectomy in addition to enucleation of tumors in the head of the pancreas.
Adolescent↗
Hyperprolactinemia in a patient with a pituitary and an ovarian dermoid tumor: case report.
A patient with galactorrhea, amenorrhea, and hyperprolactinemia caused by a dermoid tumor of the pituitary gland is presented. The patient had a prior history of an ovarian dermoid tumor. The pathology of dermoid tumors is discussed along with the management of pituitary tumor-associated hyperprolactinemia. This is the first reported case of an intracranial and an ovarian dermoid tumor occurring in the same patient.
Adult↗
Stroke associated with cocaine use.
We describe eight patients in whom cocaine use was related to stroke and review 39 cases from the literature. Among these 47 patients the mean (+/- SD) age was 32.5 +/- 12.1 years; 76% (34/45) were men. Stroke followed cocaine use by inhalation, intranasal, intravenous, and intramuscular routes. Intracranial aneurysms or arteriovenous malformations were present in 17 of 32 patients studied angiographically or at autopsy; cerebral vasculitis was present in two patients. Cerebral infarction occurred in 10 patients (22%), intracerebral hemorrhage in 22 (49%), and subarachnoid hemorrhage in 13 (29%). These data indicate that (1) the apparent incidence of stroke related to cocaine use is increasing; (2) cocaine-associated stroke occurs primarily in young adults; (3) stroke may follow any route of cocaine administration; (4) stroke after cocaine use is frequently associated with intracranial aneurysms and arteriovenous malformations; and (5) in cocaine-associated stroke, the frequency of intracranial hemorrhage exceeds that of cerebral infarction.
Adult↗
Association of hyperinsulinemia with chlorpropamide toxicity.
Clinical and metabolic features of chlorpropamide toxicity are described in two patients with diabetes mellitus and accidental chlorpropamide overdosage. Elevated serum insulin levels were found during hypoglycemia in both patients. The world's literature was reviewed for other cases of chlorpropamide toxicity in which insulin levels have been measured during hypoglycemia. A consistent feature of chlorpropamide toxicity is hyperinsulinemia. It is concluded that stimulation of the pancreatic beta cells during chlorpropamide toxicity leads to hyperinsulinemia and hypoglycemia.
Aged↗
Cryptosporidial and cytomegaloviral hepatitis and cholecystitis.
We describe an immunosuppressed patient with enteric cryptosporidiosis who developed combined cryptosporidial and cytomegaloviral hepatitis and cholecystitis as well as Enterobacter cloacae cholecystitis. To our knowledge, the presence of Cryptosporidium in a liver biopsy specimen has not previously been reported.
Acquired Immunodeficiency Syndrome↗
The thyroid nodule.
Solitary cold thyroid nodules occur in approximately 4% to 7% of adults. The diagnostic workup should be designed to predict the likelihood of malignancy. The presence of risk factors for carcinoma raises the index of suspicion and should prompt consideration of surgical excision of the nodule. An orderly sequence of diagnostic tests should be performed in every patient with a thyroid nodule, and additional special tests may be needed under specified clinical circumstances. With careful selection high risk patients can be referred for neck exploration and low risk patients can be followed without operation.
Adenocarcinoma↗
Macroamylasemia and other immunoglobulin-complexed enzyme disorders.
Macroamylase is a circulating complex of immunoglobulin linked to normal amylase in most cases. Its physical properties are heterogeneous, but its large size impairs renal filtration. Macroamylasemia usually causes hyperamylasemia and an amylase clearance:creatinine clearance (C(AM):C(CR)) ratio of less than 1 percent. Macroamylasemia occurs in 2.5 percent of hyperamylasemic patients, and 1 percent of apparently healthy subjects with normal amylase levels. It often accompanies diseases of aberrant immunity or conditions in which pancreatitis must be ruled out. This disorder should be considered in a patient with asymptomatic hyperamylasemia because its detection can obviate a prolonged diagnostic workup. The condition requires no treatment and may be transient. Macroamylasemia is one of several immunoglobulin-complexed enzyme (ICE) disorders. MacroLDemia, an ICE disorder of lactate dehydrogenase (LD), shares features with macroamylasemia. These and other ICE disorders appear to represent nonspecific dysproteinemic responses to disease.
Adolescent↗