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Introduction. As opposed to secreting tumours, non-functioning pituitary adenomas are usually diagnosed at a later stage, when they are large enough to cause symptoms due to mass effect rather than because their associated endocrine dysfunction. We aim to introduce a case report with limited therapy options. Case presentation. We present the case of a 69 year-old male patient with a history of stroke, atrial fibrillation and type 2 diabetes, who was initially admitted to the neurology department three years ago for frontal headaches and visual disturbances. The MRI (magnetic resonance imaging) exam revealed a 15.4/26.7/19.5 mm sellar mass, with suprasellar and parasellar extension, minimal optic chiasm compression and pituitary stalk deviation. Initial pituitary hormone profile showed central hypogonadism and mild hyperprolactinemia. The patient underwent neurosurgery evaluation but at that point transsphenoidal surgery was contraindicated due to severe cardiovascular comorbidities and the patient was referred to the endocrinology department for further follow-up, where he presented a year later, after worsening of symptoms. The MRI revealed tumour enlargement (18.5/28/24.6 mm) and stationary hormonal profile. The diagnosis of nonfunctioning pituitary macroadenoma was once again confirmed, cabergoline was initiated as adjuvant therapy since surgery was still contraindicated because high cardiovascular risk. Stereotactic radiation was not an option due to tumour proximity to the optic chiasm, therefore the patient underwent conventional radiotherapy. Evaluation after 3 months showed stationary clinical picture while MRI scan 3 months revealed a mild tumour growth (4 mm in all diameters). Further cabergoline therapy 2 mg/week was prescribed and the patient needs carefull monitorization for worsening of symptoms and hypopituitarism. Conclusion. Surgery is the mainstay of therapy in case of large nonfunctioning pituitary macroadenomas. If contraindicated, the available options include radiotherapy and medical therapy like cabergoline, with varying results, mostly suboptimal. [ABSTRACT FROM AUTHOR]

Non-functioning pituitary adenoma is one of the most common endocrine tumour with a benign pattern in the majority of cases. We present the case of a 69 years old female admitted on endocrinology department for visual field defects, dizziness, memory disorder, bradylalia, bradypsychia. During medical examination, the patient presented a sincopal event, with abundant sweating and temporo-spatial disorientation. Magnetic Resonance Imaging revealed a pituitary macroadenoma of 23/33.3/37 mm with two spherical lesions overlapped ("snow man" shape), with mass effect on the cavernous sinuses extending to the posterior wall of the left sphenoid sinus. Visual field examination showed significant narrowing to both eyes. The hormonal profile revealed gonadotropic insufficiency and low Insulin-like Growth Factor 1 with normal prolactin and cortisol levels. Thyroid hormonal evaluation highlighted primary hypothyroidism due autoimmune thyroiditis. Two weeks later, adenomectomy was performed by supraorbital craniotomy. After discharge, she received the thyroid hormone replacement therapy initiated preoperatively and specific therapy for associated pathology: diabetes mellitus type 2, osteoporosis, and hyperlipidemia. Pituitary surgery is the first line treatment for the majority of patients with symptomatic endocrine-inactive adenomas. Further multidisciplinary close check-up is periodically recomended. [ABSTRACT FROM AUTHOR]

Riedel's thyroiditis is a fibrous invasive type of chronic thyroiditis with a benign pattern which is characterized by a dense fibrotic and inflammatory process that invades the thyroid gland and adjacent structures of the neck Our purpose is to introduce such a rare case with challenges of rapid diagnosis associating severe local complications which required thyroid surgery. A 71-yearold female patient was admitted because of developing a neck mass in association with dysphagia and weight loss. Thyroid enlargement, especially of the right lobe, had a woody consistency. Ultrasound showed an asymmetric enlargement, with absent vascular flow. Normal thyroid function associated positive anti-thyroperoxidase antibodies. The diagnosis of Hashimoto's thyroiditis was confirmed but the clinical evaluation (a large compressive goiter) raised the suspicion of a thyroid malignancy. Fine needle aspiration provided unsatisfactory tissue sample because of the fibrous consistency. Due to the persistent aggravating compressive symptoms emergency thyroidectomy was performed. The pathologic report showed: chronic Hashimoto thyroiditis with an extensive fibrous tissue transformation of the right lobe, chronic inflammatory and sclerosing pattern suggestive for Riedel's thyroiditis. The postoperative evolution had no complications, levothyroxine substitution was initiated, and the pain and dysphagia completely disappeared. Clinical presentation of Riedel's thyroiditis, a rare thyroid condition, mimics practically any other thyroid pathologies, especially sub-acute thyroiditis and malignancy. The differential diagnosis is essential for the treatment plan since missing the diagnosis may be fatal. Atypical cases which rapidly developing compressive symptoms require lifesaving surgery. [ABSTRACT FROM AUTHOR]

Endocrine morbidities are a vast panel of conditions; the most frequent diseases in daily endocrine practice are typically thyroid nodules or primary osteoporosis. We aim to introduce two cases who underlined a hematologic malignancy in association with apparently low risk endocrine conditions involving thyroid, respective osteoporosis field. A 24-year female is admitted for anterior cervical lumps which she self-detected one month ago. Normal thyroid blood assays are associated with neck ultrasound anomalies as: 2 thyroid nodules of 0.5/0.3 cm, respective of 0.5/0.2 cm; 5 left cervical lumps (largest at supraclavicle level of 1.5/ 0.7/1.5 cm); 4 right lateral cervical lymph nodes; multiple similar lesions were also revealed at others neck areas - largest at submandible level of 1.3/0.9/1.2 cm (right), respective 1.1/0.9/2.4 cm (left). Evaluation at oto-rhino- laringology, infectious disease was unrevealing; diagnosis of stage IIA Hodgkin lymphoma was established starting from ganglion biopsy. This is 78-year female, admitted for evaluation of bone loss under densumab for the latest year after a decade history of bisphosphonates. Secondary causes of osteoporosis or hypovitaminosis D were ruled out; computed tomography detected a small adrenal incidentaloma, whole body bone scintigrame did not reveal metastasis while flow cytometry of peripheral lymphocytes identified B monoclonal lymphocytosis/chronic lymphatic leukaemia with B cell starting from a mild elevation of white blood cells in routine hemogram. Behind classical endocrine conditions as goitre or osteoporosis, severe diagnosis might be found in situations as associated cervical nodes involvement, respective non-response to specific anti-osteoporotic therapy if active case finding strategies in a multidisciplinary manner are performed. [ABSTRACT FROM AUTHOR]

Adrenoleukodystrophy (ALD) is a genetically determined disorder, with recessively X-linked inheritance, manifested by: progressive cerebral demyelination, primary adrenocortical failure and testicular impairment. The affected gene is ABCD1, which codes for a peroxisomal membrane protein implicated in the beta-oxidation of very long-chain saturated fatty acids (VLCFA). In affected patients VLCFA are accumulating within the cells, primarily in the nervous system white matter, in the adrenal cortex and in testis. Three mean phenotypes of ALD are described: the childhood cerebral form (CCALD) the most severe, adrenomyeloneuropathy with adult onset (AMN) and isolated adrenal failure (Addison-only). We present the case of a male patient diagnosed with: Addison's disease at age 7, hypergonadotropic hypogonadism and AMN at age 21, showing the diagnostic and therapeutic difficulties in the context of our country. The diagnosis of ALD is based on the determination of VLCFA in plasma and is confirmed by molecular genetic testing of the ABCD1 gene locus, both not available in Romania. Concerning the treatment, besides hormonal replacement therapy, the options in order to prevent the occurrence and progression of neurological symptoms are limited: Lorenzo's oil is used therapeutically to normalize VLCFA but its impact upon neurological disorders is largely debated; hematopoietic stem cell transplantation is shown to be beneficial in mild CCALD, but this effect was not proved for AMN; gene therapy showed good results in experimental animal studies and seems to be a promising perspective for the future, but none are at that time available in Romania. [ABSTRACT FROM AUTHOR]

We introduce a challenging inter-disciplinary case involving a female of 66 years old with Schmidt's syndrome and renal deterioration (diagnosis of chronic thyroiditis- related hypothyroidism at age of 56 in association with tubule-interstitial nephritis- associated renal failure at age of 66 followed, 4 months later, by an adrenal crisis as onset of Addison's disease). This exceptional rare situation involves: very late onset of second autoimmune disease (during the seventh decade of life) which is diagnosed using extreme elevation of Adrenocorticotropic Hormone (30 times above normal); the association with vitamin D deficiency (which may be due to general lack in menopausal population, cortex renal disturbances or malabsorption); a potential third autoimmune component of the syndrome involving the kidney is found in this case which is atypical in adults forms of type II polyglandular syndrome and it increases the severity of prognosis. [ABSTRACT FROM AUTHOR]

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Ectopic Cushing syndrome or ectopic ACTH (Adrenocorticotropic Hormone) syndrome, a rare but severe condition, is due to a non-pituitary ACTH excess or exceptionally a non-hypothalamic CRH (Corticotropin - Releasing Hormone) hyper-production, usually due to a neoplasia which may be of endocrine or nonendocrine origin. Our objective is to introduce a brief literature regarding ectopic Cushing syndrome based on five micro-chapters: clinical evaluation, lab tests, imaging assays, therapy options and as discussions – the current limits of the topic. This actually comes with a twist in every aspect since a lot of data are yet to be clarify about this complex medical entity. Clinical presentation may be suggestive for Cushing syndrome but a few characteristics are more frequently seen as hyperpigmentation, rapid onset up even becoming an endocrine emergency, male preponderance, potential weight loss instead of weight gain, as oppose to Cushing disease or adrenal Cushing syndrome. Hypokalaemia is a hallmark of this particular situation. Additional tests are necessary to identify the source of ACTH excess and this twist is necessary in addition to traditional suppression tests for glucocorticoid axes. Some authors describe another twist in recognition of syndrome presentation: that actually there are two subtypes – one caused by a very aggressive tumour with rapid evolution and another with a lent slope of clinical features appearance caused by a occult neoplasm. Another twist is the fact that, in cases without a clear tumour origin, bilateral adrenal removal is actually necessary until adequate identification of source is done (if ever). Overall, a complex multidisciplinary team is necessary, the prompt recognition and therapy is life saving and numerous limits of both diagnosis and management are still a matter of debate [ABSTRACT FROM AUTHOR]