Today during Hillcrest morning report, Dr. Randall Blankers, one of our phenomenal PGY-2’s, shared the case of a middle-aged man with uncontrolled type 2 diabetes on insulin and SGLT-2 inhibitors who presented with acute onset of vomiting and diffuse abdominal pain. He was found to have mild hyperglycemia, a combined ketoacidosis and metabolic alkalosis, and an acute kidney injury and was ultimately diagnosed with euglycemic diabetic ketoacidosis (eDKA). Because of the patient’s combined ketoacidosis and metabolic alkalosis from profuse vomiting, his serum bicarbonate and venous pH were both within normal limits, which initially obfuscated the patient’s underlying diagnosis.
With the help of our amazing endocrinologist, Dr. Kristen Kulasa, we discussed the pathophysiology of eDKA in the setting of SGLT-2 inhibitor use, which involves glycosuria, decreased insulin secretion, increased counterregulatory hormones, and increased ketogenesis. We also reviewed other benefits and complications of SGLT-2 inhibitor use. Patients on SGLT-2 inhibitors should be counseled on “sick day” rules, or when their SGLT-2 inhibitor should be held.
Thank you, Dr. Kulasa and Dr. Blankers, for sharing this illuminating case!
Medical Spanish Word of the Day: el goteo (o la infusión) de insulina = insulin drip
Dear Residents, Please join us for our Endocrinology Interest Group on Thursday 11/12 from 5:30pm-6:30pm via Zoom (information below). Thank you to Sophie Cannon and Dr. Santos for setting this up! Sincerely, Your Chiefs
Our own Dr. Jeremy Pettus gave an outstanding Grand Rounds this morning entitled “Moving Beyond Insulin Therapy: Novel Approaches to Treating Type 1 Diabetes.” Dr. Pettus described many of the issues related to patients’ management of Type 1 Diabetes (T1DM). These included the requirement of frequent testing, the dangers of insulin overdose and the need for constant vigilance, which can be overwhelming even in the most adherent patients.
The early diagnosis of T1DM has improved over the past several years and with that, new avenues for treatments, such as immunotherpaies have arisen. Recently, the use of teplizumab was shown to delay the development of T1DM by two years and is on track to be approved by the FDA later this year.
Dr. Pettus went through his experience with managing his own T1DM and the impact of improved technology and treatments. The current continuous glucose monitors have had the biggest impact on day-to-day management, as they do not require calibration, so do not require finger sticks. Now, in combination with insulin pumps, the “artificial pancreas” can be a reality with a closed loop system.
Glucagon receptor antagonists have also been shown to have significant improvement on glucose management and prevention of DKA.
Today, with the expert assistance of Dr. Trish Santos, we discussed a case of a middle-aged man with a history of pituitary tumor resection who presented to the hospital with a LUE abscess and osteomyelitis requiring surgical intervention. In the setting of his PSH and his upcoming procedure, we decided to investigate the possibility of hypopituitarism, given the concern for hypocortisolism and hypothyroidism. Our patient was found to have panhypopituitarism, leading to a great discussion with Dr. Santos! Please see below for some of the highlights!
We were lead today through some interesting high yield Osteoporosis learning objectives by our RACE track resident Dr. Kusuma Pokala and endocrinologist Dr. Gina Woods. Our residents took on the challenge of teaching each other and we took our newfound knowledge through a Jeopardy game to solidify this information! We then learned about common dermatologic conditions that general internists may encounter with the help of Drs. Natasha Carter, Laura Romero and Joyce Yuan. Thank you all for helping our residents with our virtual learning experiences!
Today, med/peds PGY-3 Kevin Yang presented a great case of a patient with subacute fatigue & weakness and recent falls found to have hyponatremia and relative hyperkalemia in the setting of vomiting. In the setting of HIV/AIDS (CD4 58, VL 10k), we acknowledged that the differential is very broad. However, the presentation suggested possible adrenal insufficiency, and the patient was quickly diagnosed with an AM cortisol <0.2. This allowed us the opportunity to review differentiation, between primary, secondary, and tertiary adrenal insufficiency, diagnostic work-up and next steps for this patient. Furthermore, his HIV/AIDS diagnosis prompted us to discuss adrenal dysfunction in this particular patient population. Adrenal insufficiency has historically been known as the most common endocrinopathy associated with HIV/AIDS, usually in the context of an opportunistic infection such as CMV or MAC. Patients with HIV/AIDS typically have higher cortisol levels than patients without HIV/AIDS, though many have subclinical adrenal dysfunction and lower reserve. Thank you to Dr. Gigi Blanchard for her insights into the case!
Don’t forget about non-HIV/AIDS diagnoses in patients with AIDS.
Use the cosyntropin test and ACTH level to diagnose and differentiate between primary and secondary adrenal insufficiency which have different etiologies and treatment.
Be aware of the effects of ARVs, particularly protease inhibitors, have on exogenous steroid use (even inhaled or nasal steroids!) and other metabolic processes leading to lipodystrophy, hyperglycemia, etc.
Today our very own APD and endocrinologist extraordinaire Dr. Trish Santos presented an amazing talk on “Glucose Monitoring for the Internist: A Growth Mindset.”
We started with a discussion of the history of glucose monitoring since the 1950s into the current state of continuous glucose monitors (CGMs). This lead to a review of the use of hemoglobin A1c as a screening and monitoring tool for diabetes mellitus. Dr. Santos highlighted that the A1c is especially helpful from a population level and for predicting microvascular damage, but has some issues for individual patients. Current assays have a margin of error of 0.5%, and with data provided by CGM, it has been shown that the previous assumed fasting blood glucose (BG) levels may not actually reflect the true range of daily glucose variability in an individual. We reviewed some of this variability by looking at two patient examples and also discussed some of the reasons for variability in hemoglobin A1c.
We then started discussing the role of self-monitored blood glucose (SMBG) checks, which really only seems to have a role in patients on insulin therapy. Dr. Santos highlighted many of the challenges that patients face when using SMBG, which can be extensive! In addition to the challenges, we also discussed that the SMBG can give people false assurance about the true value of BG levels – it is not the gold standard for BG levels (plasma BG is the gold standard)!
Dr. Santos then completed her talk with a discussion of the CGM specifically. The CGM has 3 components: a subcutaneous glucose sensor, a transmitter, and a receiver (usually via a smart phone/device). Between devices, the mean absolute relative difference (MARD) is used, which assesses the accuracy between devices for BG monitoring. Dr. Santos then reviewed the most common devices available for our patients, with some important distinctions and caveats between devices (check out the summary table below). We discussed that the likely future of CGM will be an implantable sensing device that lasts for up to 90 days (newly available at UCSD)! Finally, we reviewed how CGMs can be used for data acquisition and for therapeutic intervention for type 2 diabetics. The use of CGM has been shown to improve both average BG levels and has lead to improved patient satisfaction as well! We are also slowly working on how to utilize the data provided by these devices, which is an ongoing, but exciting prospect!
Today we went over a case of a young man who happens to be a body builder who presents with bilateral breast enlargement, or gynecomastia.
We went over the common causes of gynecomastia, which may be transient and not require work up in teenage boys, but is concerning if persistent when older. In this patient we were initially concerned that his use of supplements for his work-outs or his use of marijuana might be causing suppression of endogenous testosterone. We reviewed the necessity of doing a thorough physical exam to check for any evidence of systemic illnesses such as thyrotoxicosis, cirrhosis or kidney disease, evidence of hypogonadism or testicular malignancy and most importantly a systematic breast exam (See following AFP article for excellent review: https://www.aafp.org/afp/2012/0401/p716.html).
His labs revealed a normal testosterone level but suppressed LH and FSH, raising the suspicion for unreported injected anabolic steroid use. Medical management currently consists of the use of SERMs (Tamoxifen and raloxifen) vs surgery for management of gynecomastia. Lastly we reviewed the risk of breast cancer in men.
We were fortunate to have Dr. Trish Santos there to give us her insight into the work-up and management of these patients! Thank you, Dr. Santos!
Remember that gynecomastia is ductal proliferation of breast tissue in men, usually caused by an imbalance of estrogen to androgen ratio. Check for exogenous culprits such as steroids, opioids, medications such as spironolactone, endogenous sources such as testicular and adrenal tumors, and remember that for obese patients and those with systemic illness there can also be increase aromatization of estrogen to testosterone peripherally.
Currently treatment with SERMs and/or surgery are the main treatment options for gynecomastia.
Breast cancer in men is likely under detected, as it is not routinely screened but should be considered in patients with a strong family hx, it usually presents as a painless lump, as invasive ductal carcinoma is the most common form.
Today our amazing 2nd year resident Sharon Choi lead us through a case of a middle aged man who presented with subacute bilateral pitting edema that was refractory to diuretics. On exam he was tachycardic to 120s and mildly diaphoretic. He underwent a thorough work-up and was found to have normal cardiac, kidney function, and liver function but interestingly had an undetectable TSH. On further history taking, he did note that he had been losing some weight and reported heat intolerance and was found to have an elevated T3 and T4.
Our wards team was able to review and show off their accumulated knowledge regarding the illness script for hyperthyroidism and we discussed how this patient fit some symptoms but not all of typical findings.
We went on to discuss what further testing could be done to delineate the different etiologies of hyperthyroidism and the treatment options.
Thanks for a great case, Dr. Choi!
Remember that there are two big pathophysiologic mechanisms for hyperthyroidism: a) increased production of endogenous hormone (Autoimmune thyroid disease like Graves disease/Autonomous thyroid tissue) and b) inflammation and destruction of thyroid tissue with release of preformed hormone into the circulation or an extrathyroidal source of thyroid hormone (Thyroiditis/exogenous thyroid hormone intake/ectopic hyperthyroidism).
Pretibial myxedema is nonpitting, involves colloid deposition and is a manifestation of Graves disease; pitting edema is atypical clinical finding in thyroid disease.
Treat hyperthyroidism with medications that suppress thyroid hormone synthesis (first line is methimazole, except in pregnant patients then use PTU). Radioactive iodine ablative therapy or surgery are more definitive therapies but will often result in need for post-therapy thyroid hormone replacement.
Today our fantastic R2 Mitra Jamshidian presented a puzzling case of young man with history of HIV/AIDS sent to the emergency department for hypercalcemia of 20mg/dL!.
Our team brainstormed a list of causes for hypercalcemia and considered additional causes specific to a patient with HIV including Cryptococcus, TB, MAC, M. bovis and (case reported) PCP. Patients with HIV are also at elevated risk for all types of cancers, so we also considered malignancies, especially lymphoma in a patient with AIDS.
Our young patient was found to have low PTH and low Vitamin D levels. He then underwent extensive workup for possible infections and cancer. Eventually, his PTHrP returned elevated and biopsy of an anal ulcer revealed Plasmablastic Lymphoma. Normally lymphomas cause elevated calcium through increased 1,25OH Vitamin D but can cause hypercalcemia through other mechanisms.
Thank you Dr. Blanchard for your expertise! Stay tuned for future morning reports on managing hypercalcemia.
Take Home Points: – Workup of hypercalcemia in patients with HIV should go beyond the “traditional workup” with PTH, Vitamin D levels (25OH and 1,25OH Vitamin D) and include a specific focus on opportunistic infections (Cryptococcus, TB, MAC, M bovis, PCP) and malignancies – Patients with HIV are at higher risk for all types of malignancies, including AIDS defining malignancies such as primary CNS lymphoma, Kaposi Sarcoma, Cervical Cancer. Lymphomas of all types are an important consideration!