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To characterize a cohort of elderly men with prolactinomas and their response to treatment. We have identified 28 elderly men diagnosed after the age of 65 with prolactinomas at seven different endocrine clinics in Israel. A retrospective electronic chart review identified a control group of 76 younger men with macroprolactinomas treated in one of the centers. Mean age at diagnosis was 71.3 ± 5.6 (range 65–86) years, and current age 76.6 ± 7.5 years. Initial complaints leading to diagnosis included sexual dysfunction in 17 males (61%), headaches in two patients (7%), and visual abnormalities in two (7%). Three men presented with osteoporosis. Ten patients (36%) were diagnosed incidentally following brain imaging for unrelated reasons. Seventeen patients (61%) had macroadenoma, while eleven (39%) presented with a microadenoma or no visible adenoma. Mean prolactin (PRL) at presentation was 1594 (median 382; range 50–18,329) ng/ml. Testosterone was low in 21 men. Patients were treated with cabergoline (max dose, 1.1 ± 0.5 mg/week), except for one given bromocriptine; none required pituitary surgery or radiotherapy. Treatment normalized PRL in 24 patients, and in three men PRL suppressed to

Introduction: Hypophosphatasia (HPP) is a rare disease that cause osteomalacia and premature tooth loss due to abnormal bone mineralization. The clinical presentation ranges from severe neonatal and infantile HPP with a high morbidity and mortalilty to mild Adult HPP. The ranging spectrum is possibly due to autosomal recessive versus autosomal dominant missense mutations at the gene that encodes TNSALP. The hallmark of the disease is a low serum total alkaline phosphatase level (ALP). It is important to diagnose adult HPP particularly to refrain from treating with bone antiresorptive medications. Low levels of alkaline phosphatase generally are undectected in the adult population even in patients with osteoporosis and fractures. We describe a case of a woman with postmenopausal osteoporosis without fractures diagnosed with adult HPP. The clinical course and management is described below. Case Description: A 62 y.o. women was referred for evaluation and treatment of osteoporosis. She had no fractures, including during childhood, no history of premature deciduous teeth loss, dental problems or nephrolithiasis. No family history of osteoporosis or fractures. Menopause at age 48 without hormone replacement therapy. Evaluation for secondary causes of osteoporosis was normal including serum TSH, calcium, phosphate, PTH, 24 hours urinary calcium and vitamin D-25. ALP ranged from 33-40 U/L (nl 37-126) before therapy. She was treated with raloxifene for 2 years. Therapy was switched to alendronate due to a decrease in bone density. She subsequently treated with alendronate for 5 years until 5/2012. Due to a decrease in bone density alendronate therapy was reinstituted between Jan 2013-Jan 2016 but in spite of therapy and a CTX level of 333 pg/ml bone density in the spine decreased significantly. In view of the low ALP and decreasing bone density while on bisphosphonate and a high B6 level (B6= 37 nl: -27) a genetic test for HPP and a compound heterozygote mutation in ALPL gene was detected. Her daughter was also found to have low ALP and carries the same mutation. Bone density has been stable since bisphosphonate therapy was stopped (spine T -3.2, LT femoral neck T -2.9) CTX 360 pg/ml. Recently therapy with raloxifene was initiated in view of the low bone density and high risk of fractures. Conclusion: The proper diagnosis and management of patients with adult HPP is challenging because the diagnosis may be missed in patients with borderline low ALP and on the other hand the proper managent of osteoporosis in these patients is not known.

Central diabetes insipidus (CDI) is a rare heterogeneous condition with various underlying causes. This study sought to increase the still-limited data on the clinical characteristics and long-term course in adults diagnosed with CDI.Data on demographics, presentation, imaging findings, affected pituitary axes, treatment, and complications were collected retrospectively from the files of 70 adult patients with CDI followed at a referral endocrine clinic.Forty women and 30 men were included. Mean age was 46.8 ± 15 years at the time of this study and 29.3 ± 20 years at CDI diagnosis. Twenty-eight patients were diagnosed in childhood. Forty patients (57%) acquired CDI following surgery. Main sellar pathologies were: craniopharyngioma, 17 patients (11 diagnosed in childhood); Langerhans histiocytosis, 10 patients (5 diagnosed in childhood); 7 patients (all diagnosed as adults) had a growth hormone-secreting adenoma; 12 patients (17%; 6 diagnosed in childhood) had idiopathic CDI. At least one anterior pituitary axis was affected in 73% of the cohort: 59% had growth hormone deficiency, 56% hypogonadism, 55% central hypothyroidism, 44% adrenocorticotropic hormone-cortisol deficiency. Patients with postoperative/trauma CDI (n = 44) tended to have multiple anterior pituitary axes deficits compared to the nonsurgical group of patients. All patients were treated with vasopressin preparations, mostly nasal spray. Hyponatremia developed in 32 patients, more in women, and was severe (125 mEq/L) in 10 patients. Hypernatremia (150 mEq/L) was noticed in 5 patients. Overall, the calculated complication rate was 22 in 1,250 treatment-years.Most adult patients with CDI have anterior pituitary dysfunction. Stability is usually achieved with long-term treatment. Women were more susceptible to desmopressin complications, albeit with an overall relatively low complication rate.ACTH = adrenocorticotropic hormone CDI = central diabetes insipidus GH = growth hormone MRI = magnetic resonance imaging.

Context: There is no therapy for control of hypercalciuria in nonoperable patients with primary hyperparathyroidism (PHPT). Thiazides are used for idiopathic hypercalciuria but are avoided in PHPT to prevent exacerbating hypercalcemia. Nevertheless, several reports suggested that thiazides may be safe in patients with PHPT. Objective: To test the safety and efficacy of thiazides in PHPT. Design: Retrospective analysis of medical records. Setting: Endocrine clinic at a tertiary hospital. Patients: Fourteen male and 58 female patients with PHPT treated with thiazides. Interventions: Data were compared for each patient before and after thiazide administration. Main Outcome Measures: Effect of thiazide on urine and serum calcium levels. Results: Data are given as mean ± standard deviation. Treatment with hydrochlorothiazide 12.5 to 50 mg/d led to a decrease in mean levels of urine calcium (427 ± 174 mg/d to 251 ± 114 mg/d; P < 0.001) and parathyroid hormone (115 ± 57 ng/L to 74 ± 36 ng/L; P < 0.001), with no change in serum calcium level (10.7 ± 0.4 mg/dL off treatment, 10.5 ± 1.2 mg/dL on treatment, P = 0.4). Findings were consistent over all doses, with no difference in the extent of reduction in urine calcium level or change in serum calcium level by thiazide dose. Conclusion: Thiazides may be effective even at a dose of 12.5 mg/d and safe at doses of up to 50 mg/d for controlling hypercalciuria in patients with PHPT and may have an advantage in decreasing serum parathyroid hormone level. However, careful monitoring for hypercalcemia is required.