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Six interesting cases presented at Endocrine Clinical Meeting held at BIDE.

Byline: Dr. Musarrat Riaz

Case based clinical meetings are a regular feature of Pakistan Endocrine Society, Karachi chapter long before its inception. It all started with a handful of practicing endocrinologists of the city with their trainees as monthly endocrine Journal Club. Over the years it has evolved in a very organized learning experience where people who attend these meetings have a chance to share and learn from the experiences of other fellow endocrinologists. The current meeting was held at Baqai Institute of Diabetology and Endocrinology (BIDE) in which six interesting cases were presented by endocrine fellows being trained in different institutions of Karachi followed by interactive discussion.

The first case was presented by Dr. Nadeem Naeem from BIDE of a 17-year-old female who presented with primary amenorrhea. Physical examination was unremarkable with proper secondary sexual characteristics development. Breast development was also normal. Her hormonal profile including FSH, LH, serum Testosterone, prolactin, TSH, 17 OH progesterone were all in normal range. Ultrasound of pelvis shows normal ovaries but small hypo plastic uterus. MRI was done which confirmed the findings plus also revealed vaginal atresia and malrotation of right kidney which leads to the diagnosis of Mayer-Rokitansky-Kster-Hauser (MRKH)syndrome. It is a disorder that occurs in females and mainly affects the reproductive system. This condition causes the vagina and uterus to be underdeveloped or absent, although external genitalia are normal.

Case presentation was followed by discussion and although not much is available as far as treatment is considered, Psychological counselling is very important and should be offered to every patient.

The second case was presented by Dr. Tayyaba Jamil from National Institute of Diabetes and Endocrine (NIDE). She presented a case of Turner syndrome with co-existing MRKH Syndrome. The 19 year old female presented with short stature and primary amenorrhea and during the work up turner plus MRKH was diagnosed. Dr. Najmul Islam from AKUH opined that a second opinion from a radiologist should be sought by reviewing the MRI films as it is very unusual to have both these conditions together. Few cases reported in the literature were also discussed. Practical problems in managing these cases were also highlighted during discussion.

Third case was presented by Dr. Shair Zaman from BIDE regarding diabetic foot. The patient presented with ischemic foot ulcer plus ischemic heart disease with three vessel disease. He was managed conservatively with antibiotics, offloading, metabolic control and good podiatry because angiography of limb was not recommended before first addressing the heart issue. However, the patient responded well because of the development of collateral blood vessels and the take home message was that sometimes simple measures can also contribute in overall healing of diabetic foot lesions. At this point use of latest mobile technology in the form of Whats App group to obtain expert opinions involving diabetologists, interventional cardiologists, general surgeons and vascular surgeons to name a few were also highlighted.

The next case was presented by Dr. Sumerah Jabeen from AKUH. The 40 years old patient presented with recurrent episodes of hypoglycemia and weight gain. Initially he was thought to have some underlying psychiatric illness which was not proved. Later his blood tests revealed hypoglycemia with low levels of serum insulin and C peptide levels. Use of oral hypoglycemic agents was ruled out. Ultrasound as well as CT scan of abdomen was reported to be normal. As it was an unusual presentation no definite diagnosis could be made. Differential diagnosis of recurrent hypoglycemia was discussed. Further work up and plan of management was also discussed.

Dr. Sidra Mumtaz from JPMC presented a case of pheochromocytoma. The unusual presentation was absence of hypertension in this case. Differential diagnosis as well as management plans for this particular patient was discussed in detail. It was observed that usual protocols for surgical removal of this tumor may need to be altered with full back up support in case of any hypertensive crises if the need arises.

Final presentation was made by Dr. Saima Ghaus from MIDEM. She presented two cases of increased TSH levels during ART procedures. Prof. Tasnim Ahsan was of the opinion that management of raised TSH levels during assisted reproductive techniques is different and most of the time it is transient and no change in dose alteration of thyroxine is required. She discussed the various physiological reasons for this high TSH and therefore should be managed differently as compared to normal pregnancy.

All the case presentations generated interactive discussions which was a good learning experience for students, trainees and fellows.
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Title Annotation:Baqai Institute of Diabetology and Endocrinology
Author:Riaz, Musarrat
Publication:Pulse International
Geographic Code:9PAKI
Date:Jun 30, 2018
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