100年度秋季會

中 華 民 國內 分泌 暨 糖 尿病 學 會 100 年 度 秋 季 學 術 研 討 會

中華民國內分泌暨糖尿病學會 100 年度秋季學術研討會 日期：民國 100 年 9 月 24 日(星期六)中午 12:40-17:20 地點：高雄醫學大學附設中和紀念醫院 6 樓啟川大樓

節目總表 Time

第一講堂

第一會議室

中庭廣場

報到

12:10 12:40~ 1:20

Luncheon Symposium MSD

Luncheon Symposium BMS/AZ

1:25 ~ 1:30

Opening

1:30~3:30

Symposiums for 2011 update DM guideline in Taiwan

1:30 ~ 2:00

Special Lecture 1

2:00 ~ 2:30

Special Lecture 2

2:30 ~ 3:00

Special Lecture 3

3:00 ~ 3:30

Panel Discussion

3:30 ~ 3:50

Tea Break

3:50 ~ 5:20

Oral Presentation

Poster Presentation 大會晚宴：Novartis 贊助

6:00 ~ 8:30

6:00-6:40 演講

6:40-8:30 晚宴＆頒獎

金典酒店 38 樓珍鑽廳

9

會場平面圖

會場平面圖

10

中 華 民 國內 分泌 暨 糖 尿病 學 會 100 年 度 秋 季 學 術 研 討 會

September 24, 2011 【第一講堂】

Special Lecture 主持人：辛錫璋

1:30 ~ 2:00

SL1 CKD management for DM patients 黃尚志 高雄醫學大學附設醫院腎臟內科

主持人：許惠恒 2:00 ~ 2:30

SL2 Update CVD issues for DM patients 葉宏一 台北馬偕紀念醫院內科部

主持人：莊立民 2:30 ~ 3:00

SL3 Bariatric surgery for DM patients 庄 強 敏盛綜合醫院新陳代謝科

Luncheon Symposium September 24, 2011 【第一會議室】 12:40 ~ 1:20

主持人：莊立民、林興中、劉瑞川、王佩文

LS 2012 DM Guideline in Taiwan 張恬君 台大醫院內科

11

節目表

September 24, 2011 【第一講堂】 12:40 ~ 1:20

主持人：許惠恒、辛錫璋

LS A Decade of Progress in Managing T2DM: Navigating Current Evidence of Changing Treatment Paradigm and Oral Pharmacotherpay 陳榮福 高雄長庚紀念醫院

September 24, 2011 【第一講堂】

Oral Presentation 主持人：張恬君

3:50~3:55

OP1

HLA-DRB1 基因與兒童期的格瑞夫茲氏病: 個案對照和以 家族為基礎的研究 1,2,9 李燕晉， 1 黃琪鈺， 3,4 羅福松， 1 丁瑋信， 5 林昭旭， 1 吳怡磊，6 李欣蓉，7 洪禎鎂，8 詹佳蓉，1 鄭弼文，2 林瓊玲 馬偕紀念醫院，1 小兒科部; 馬偕紀念醫院淡水院區，2 醫學研 究部; 長庚紀念醫院，3 兒童內科; 長庚大學，4 醫學院; 馬偕 紀念醫院新竹分院， 5 小兒科; 財團法人天主教聖馬爾定醫 院，6 小兒科; 國泰綜合醫院新竹分院，7 小兒科; 沙鹿童綜合 醫院，8 兒童醫學部; 台北醫學大學，9 小兒科部

3:55~4:00

OP2

自我血糖監測於第 1 型糖尿病病人成果 方淑音，徐慧君，李洮俊 李洮俊診所

主持人：蕭璧容 4:00~4:05

OP3

北台灣糖尿病敗血症住院經驗 黃瑞助 長庚紀念醫院內科部新陳代謝科

12

中 華 民 國內 分泌 暨 糖 尿病 學 會 100 年 度 秋 季 學 術 研 討 會

4:05~4:10

OP4

白蛋白尿是第二型糖尿病男性病患性功能障礙的一個獨立危 險因子 1 鍾明憲，2 莊燿吉，2,3 王佩文，1 李偉嘉，3 陳窗達，4 張學文， 5 楊崑德，6Michael B.Chancellor，2 劉瑞川 1 高雄長庚紀念醫院暨長庚大學醫學系外科部泌尿科，2 高雄長 庚紀念醫院暨長庚大學醫學系內科部新陳代謝科，3 高雄長庚 紀念醫院暨長庚大學醫學系核子醫學部，4 國立中山大學生物 科學系，5 彰化秀傳醫院醫學研究部，6 密西根州皇家橡樹鎮威 廉寶蒙特醫院泌尿部

主持人：黃建寧 4:10~4:15

OP5

以腎功能變化重新訂立糖尿病診斷基準 1 梁文偉 苗栗大千醫院

4:15~4:20

OP6

血糖正常和高血糖者的腎功能變化 1 梁文偉 苗栗大千醫院

主持人：江怡德 4:20~4:25

OP7

空腹血糖不良族群健康促進計畫─區域醫院經驗 1 曾士婷，1 劉文華，1 黃淑君，1 蘇筱芬 光田綜合醫院 1

4:25~4:30

OP8

南台灣某榮民醫院糖尿病共同照護計畫門診病人代謝指標改 善之研究 1 郝立智，2 田凱仁，3 趙海倫，1 洪靜如，4 周福星，5 吳達仁， 6 趙建剛，7 奚明德，8 柴國樑，9 葛光中，10 馬瀰嘉 1 永康榮民醫院內科部新陳代謝科，2 台南奇美醫院內科部新陳 代謝科，3 中華醫事科技大學醫管系，4 國立成功大學資訊管理 學系，5 成功大學附設醫院內科部新陳代謝科，6 玉里榮民醫院 精神部，7 永康榮民醫院病理檢驗科，8 永康榮民醫院內科部， 9

屏東龍泉榮民醫院院本部，10 國立成功大學統計學系 13

節目表

主持人：陳涵栩 胰臟脂肪浸潤與代謝症候群之相關性分析 吳婉禎，王治元 臺大醫院內科部代謝內分泌科

4:30~4:35

OP9

4:35~4:40

OP10 臂踝脈波傳遞速度預測第二型糖尿病患腎絲球過濾率進展： 某中部區域醫院一年追蹤研究 1 沈宜靜，1 林建良，1 鮑卓璨，2 許惠恒 1 行政院衛生署台中醫院內科部新陳代謝科，2 台中榮民總醫院 內科部新陳代謝科 評分

4:40~5:20

September 24, 2011 【中庭廣場】

Poster Presentation 主持人：李弘元

3:50~3:55

PP1

C 型肝炎患者經過干擾素治療後發生胰島素依賴型糖尿病的 病例報告及後續追蹤 1 林昆德，1 何俊緯，1 周炳全，1 蕭璧容，1 辛錫璋 1 高雄醫學大學附設中和紀念醫院新陳代謝內分泌科

3:55~4:00

PP2

一個甲狀腺正能的個體表現出極高游離型 T4 與正常促甲狀 腺激素值 1 曾怡菁，1 林立偉，1 翁瑄甫，1 黃千玲，1, 2 許重輝 1

臺北醫學大學-北醫附設醫院-內科部-內分泌新陳代謝科 2 臺北醫學大學-北醫附設醫院-核子醫學科

14

中 華 民 國內 分泌 暨 糖 尿病 學 會 100 年 度 秋 季 學 術 研 討 會

主持人：施翔蓉 4:00~4:05

PP3

一雄性素分泌型腎上腺皮質癌病例報告 1 劉如玫，1 陳華芬，2 陳沛輝 1 亞東紀念醫院內科部新陳代謝科 2 亞東紀念醫院外科部泌尿科

4:05~4:10

PP4

以明顯頸部腫瘤及嚴重骨骼肌肉症狀表現之原發性副甲狀腺 機能亢進 1 曾睿玉，1 洪晧彰，1 歐弘毅，2 洪崇傑，1 吳達仁 1 國立成功大學醫學院附設醫院內科部內分泌新陳代謝科 2

國立成功大學醫學院附設醫院外科部內分泌外科

主持人：朱志勳 4:10~4:15

PP5

以黃疸為最初表現症狀的葛雷夫氏病合併甲狀腺風暴 1 洪薇雯，1 林昆德，1 林幸宜，1 辛錫璋，1 蕭璧容 1 高雄醫學大學附設中和紀念醫院內科部內分泌新陳代謝科

4:15~4:20

PP6

以嚴重低血糖和高血鈣表現之多發性內分泌腫瘤第一型：案 例報告 1 薛又毓，1 洪晧彰，1 歐弘毅，1 吳達仁，2 黃士銘 1 國立成功大學醫學院附設醫院內科部內分泌新陳代謝科 2 國立成功大學附設醫院斗六分院外科部

主持人：謝靜容 4:20~4:25

PP7

正常血鈣型原發性副甲狀腺功能亢進合併骨質缺乏 1 白蕙菁，2 王治元 1 亞東紀念醫院內科部新陳代謝科 2 台灣大學附設醫院內科部

4:25~4:30

PP8

合併甲狀腺濾泡腺、瘤腺癌與乳突癌的臨床病例分析 1 姜和均，1 蕭璧容，1 林昆德，1 洪薇雯，1 辛錫璋 1 高雄醫學大學附設醫院內分泌新陳代謝內科 15

節目表

主持人：張道明 4:30~4:35

PP9

合併葛瑞夫茲氏病與淋巴球性腦垂腺炎之案例報告 1 陳愛華，1 曾芬郁 1 台大醫院內科部內分泌及新陳代謝科

4:35~4:40

PP10

自體免疫性胃炎和胃泌素瘤的鑑別診斷 1 蔡明潔，1 王朝弘，2 王蒼恩，3 陳繼寬，1 簡銘男 1 馬偕紀念醫院內科部內分泌既新陳代謝科，2 馬偕紀念醫院內 科部肝膽腸胃科，3 馬偕紀念醫院病理科

主持人：陳沛隆 4:40~4:45

PP11

胰島素自體免疫症候群---個案報告 1,2 林亮羽，1 陳柏儒，3 張錦文，1,2 葉振聲 1 台北榮民總醫院新陳代謝科，2 國立陽明大學醫學院， 3 國軍高雄總醫院內科部

4:45~4:50

PP12

異位縱膈腔副甲狀腺腺瘤：案例報告 1 龔芳平，1 吳達仁，2 陳雅萍，3 賴吾為，4 黃士銘 1 國立成功大學醫學院附設醫院內科部內分泌新陳代謝科， 2 血液腫瘤科，3 外科部胸腔外科，4 一般外科

4:50~5:20

評分

16

中 華 民 國內 分泌 暨 糖 尿病 學 會 100 年 度 秋 季 學 術 研 討 會

SL1 CKD management for DM patients Shang-Jyh Hwang, M.D. Faculty of Medicine & Renal Care, College of Medicine, Kaohsiung Medical University; Nephrology Division, Department of Medicine, KMU Hospital, Kaohsiung, Taiwan.

Taiwan has the highest incident and prevalent rates of ESRD (dialysis) for years. DM and old age groups are two major parts of ESRD patients. Diabetic ESRD constituted 40% of incident dialysis patients. Mortality and progression into end-stage renal disease are the two most important outcomes of chronic kidney disease, especially in patients of diabetic nephropathy. Both are not only conditions miserable to patients and family members, but also devastating and costive to the medical system. Thus, the main goals of CKD management

include

preventing

early

death,

slowing

the

progression,

and

preventing/managing the complications, which are applicable to diabetic patients. The initiating mechanisms of renal injuries in diabetes might involve various progressive mechanisms, including hyperfiltration, advanced glycosylated end-products injury, glomerular hypertension and protienuria, inflammation and cytokines activation, and etc.

However, screening of urinary microabuminuria is the most sensitive and effective way for detection of DMN and for subsequent preventive measures.

Strategy to retard the progression includes different aspects, from lifestyle modification, pharmacological treatment for underlying diseases, controls of blood pressure, glucose, and lipids, avoidance of nephrotoxic agents, to dietary management.

However, patient compliance and the method for delivery of these measures are critical determinants for the successful treatment of CKD. Despites of a more rapid speed of renal function deterioration in diabetic patients with nephropathy, if the BP, sugar, and lipid could be tightly controlled through optimal ways and the diet is modified to low protein and low salt, slow progression could be anticipated.

Following the DM prevention project in 1990, Taiwan launched series of CKD prevention projects since 2001. Nephrologists, nursing educators, and renal dietitians are the three major core members as in DM care. This integrated care team not only took care of renal and nutritional problems, but also concerned the personal and socio-family 17

摘要

problems of CKD patients. It markedly improved the compliance of patients in every aspect. It demonstrates that CKD stage 3B-5 patients who received integrated renal care had better quality of care, slower rate of GFR deterioration and into dialysis, better preparations at time of dialysis initiation, better survival after dialysis, and less medical expenses over the periods. From 2011, CKD stage 1-3A patients, including DM patients, were also covered by another program.

18

中 華 民 國內 分泌 暨 糖 尿病 學 會 100 年 度 秋 季 學 術 研 討 會

SL2 Update CVD issues for DM patients 葉宏一 馬偕醫學院 醫學系 教授兼主任 馬偕紀念醫院 內科部 副主任 Diabetes has been considered an coronary heart disease risk equivalent. However, how to alleviate the risk associated with diabetes is a challenge. In high CV risk patients, previous studies had shown that RAS blockers were cardio-protective. Whether such beneficial effects exist in patients at pre or early stage of diabetes were examined in 2 clinical trials named NAVIGATOR and ROADMAP, the results of which have been published recently. In NAVIGATOR study, valsartan group was found superior to the placebo group in delaying the onset of diabetes in individuals with impaired glucose tolerance. In ROADMAP study, olmesartan was found superior to the placebo group in reducing

the

occurrence

of

microalbuminuria

in

diabetic

patients

without

microalbuminuria. However, both studies failed to show cardio-protective, though blood pressure is lowered more in the ARB group. In ROADMAP the CV event rate is even higher in participants taking olmesartan. These results indicate that, in patients with pre or early stage of DM, early exposure to ARB treatment is not recommended for all patients.

On the other hand, pioglitazone, an oral hypoglycemic agent known to reduce CV events in diabetic patients with macrovascular disease, was recently reported to increase the risk of urinary bladder cancer and was withdrawn from the market in France and Germany.

Although no such action was taken in Taiwan, the balance between CV benefit and cancer risk should be properly weighted. All the 3 studies and related literatures will be reviewed in this talk.

19

摘要

SL3 Bariatric surgery for DM patients 庄 強 敏盛綜合醫院新陳代謝科 背景： 1995 年 Dr. Pories 在 Annals of Surgery 發表了有關胃繞道手術使 146 位第二型糖 尿病病患中之 121 位(82.9%)脫離了糖尿病，開啟了醫學界有關糖尿病減重手術的相 關研究。根據 Dr. Buchwald 於 2004 年發表在 JAMA 的統合分析，減重手術可以使糖 尿病的緩解率達到 76.8%，同時血壓及血脂數值也得到大幅的改善。在 Swedish Obese Subjects 的研究中，更進一步顯示減重手術能減少肥胖病患長期的死亡率。而且一些 研究也顯示，減重手術治療糖尿病是符合成本效益的。因此，近年來有關糖尿病減 重手術治療成為醫學界的熱門。在台灣本土的資料也顯示，減重手術對糖尿病的緩 解率也有六到九成。 減重手術的術式： 非侵襲性的手術方式有胃內水球、十二指腸及空腸袖狀管等。侵襲性的手術方 式包括有限制型（restrictive type） ，如：胃束帶手術和胃縮小手術，以及吸收不良型 （malabsorptive type） ，如：膽胰分流併十二指腸轉位手術，及混合型（mixed type）， 如：胃繞道手術，目前以胃繞道手術及胃束帶手術為糖尿病減重手術之主流。不同 的術式對緩解糖尿病的成功率不同，而手術的風險及術後所衍生的健康問題也有所 不同。胃繞道手術比胃束帶手術及胃縮小手術對緩解糖尿病的成功率較高，但是術 後營養素之缺乏（如：鐵、鈣及多種維他命等）也較明顯，因此長期的追蹤及足夠 的營養補充是很重要的。 糖尿病緩解的機轉及影響的因素： 糖尿病的緩解率與病患之肥胖程度、糖尿病病史的長短、胰島細胞分泌胰島素 的殘存功能等因素有關。通常 BMI 較大者，糖尿病病史較短者，以及殘存胰島素分 泌功能較佳者其效果較好。使糖尿病緩解的確切機轉目前仍不清楚，以胃繞道手術 而言，目前認為可能的機轉包括下列四項：第一是飲食限制伴隨體重下降的效果， 第二是 Ghrelin 減少的效果，第三是十二指腸(上腸道)隔絕的效果，第四是下腸道荷 爾蒙（如：GLP-1,PYY 等）上升的效果，再由上述四個因素來改善胰島素之阻抗性， 20

中 華 民 國內 分泌 暨 糖 尿病 學 會 100 年 度 秋 季 學 術 研 討 會

以及增加胰島細胞分泌胰島素之能力。 哪些糖尿病病患適合採取手術治療？ 傳統上是依據美國 NIH 的建議針對 BMI≧35Kg/m2 的第二型糖尿病患者可考慮 手術。但一些研究發現對 BMI＜35Kg/m2 的第二型糖尿病患者，手術治療也能獲得 某種程度的效果。而今年國際糖尿病聯盟提出對 BMI 在 30~35kg/m2 而且血糖控制不 佳的第二型糖尿病患者，手術治療也是可以考慮的，甚至在亞洲族群可能可以把標 準再降低 2.5Kg/m2。除了 BMI 之外，還需要考量病患之年齡及其身體健康狀況（與 手術風險有關） ，病患糖尿病病史之長短及殘存胰島細胞功能，病患對手術的期待和 意願，以及手術後病患是否能遵從醫囑作長期的追踨和營養素補充等。 減重手術之健保規範： 健保局目前對減重手術之規範只有提到早期使用之胃隔間術，其他術式則未闡 明，但一般仍以此條件作申報之標準。另外，目前減重手術幾乎都使用內視鏡手術 方式，而內視鏡耗材之費用則需病患自費。 健保規範：實施胃隔間術(gastric partition)應符合下列各項條件： 1. BMI(body mass index)身體質量指數≧40kg／m2；BMI≧35kg／m2，合併有高 危險性併發症(如：糖尿病、高血壓、呼吸暫停症候群等)。 2. (1)經運動及飲食控制在半年以上。(2)年齡在 18~55 歲間。(3)無其它內分泌疾 病引起之病態肥胖。(4)無酗酒、嗑藥及其它精神疾病。(5)精神狀態健全，經 由精神科專科醫師會診認定無異常。 手術的風險與併發症： 根據國外之報告，與減重手術相關之三十天內死亡率為 0.1-0.3%，其中胃繞道 手術之死亡率約 0.5%，胃束帶手術約為 0.1%。其他的併發症，包括：縫合處之滲漏、 傷口感染、出血、急性阻塞、潰瘍、傾倒症候群(dumping syndrome) 、低血糖，以 及心臟和肺部疾患等。另外，長期營養素之缺乏（如：鐵、葉酸、鈣和多種維他命 等）可能引起貧血、骨質疏鬆及神經病變等併發症。 糖尿病減重手術的照顧： 可以預期的是糖尿病患接受手術治療的個案會越來越多，對這些患者手術前的 評估、手術期間的照顧及手術後的長期追蹤是很重要的健康問題，必須要有跨領域 的團隊彼此合作來完成。一般來說，手術前的評估包括：先排除一些內分泌疾病引 起之肥胖（如：甲狀腺功能低下，庫欣氏症及多囊性卵巢症候群等） ，由外科醫師、 21

摘要

新陳代謝科醫師與精神科醫師評估該病患是否適合手術治療，由心臟科醫師、胸腔 科醫師及麻醉科醫師評估手術風險，個案管理師向病患說明手術相關的問題、手術 前後的注意事項與長期照顧的細節。手術期間的照顧除了一般減重手術須注意的事 項外，還需要特別注重的是監測血糖、足夠的輸液補充及使用適量的胰島素。手術 後須注意可能的併發症，如：出血、急性阻塞及縫合處滲漏等引起之症狀；專門的 營養師給予病患飲食的指導，一般都需從使用流質食物開始，並注意“少量多餐，細 嚼慢嚥＂的原則；手術後患者作長期的鐵、鈣、葉酸及多種維他命等之補充是很重 要的。 結語： 總言之，糖尿病手術治療有不錯的效果，但也有其風險及併發症，要能為病患 帶來最大的益處，必需要有專業且有經驗的外科醫師，加上多科合作團隊的協助， 在手術前後為病患提供仔細的評估及適切的照顧，並作長期的追蹤，而病患本身也 需要對此有清楚的認知和良好的配合度。

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OP1 THE HLA-DRB1 GENE AND GRAVES DISEASE IN CHILDREN: CASE-CONTROL AND FAMILY-BASED STUDIES 1,2,9

YJ LEE, 1CY HUANG, 3,4FS LO, 1WH TING, 5CH LIN, 1YL WU, 6HJ LI, 7CM HUNG, 8 CJ CHAN, 1BW CHENG, 2CL LIN 1 Department of Pediatrics, Mackay Memorial Hospital; 2Department of Medical Research, Mackay Memorial Hospital Tamsui District; 3Department of Pediatrics, Chang Gung Memorial Hospital; 4Department of College of Medicine, Chang Gung University; 5

Department of Pediatrics, Mackay Memorial Hospital HsinChu Branch; 6Department of Pediatrics, St. Martin De Porres Hospital; 7Department of Pediatrics, Cathay General Hospital, Hsinchu Branch; 8Department of Pediatrics, Tungs' Taichung MetroHarbor

Hospital; 9Department of Pediatrics, Taipei Medical University Objective: Graves disease (GD) is an autoimmune thyroid disease with female preponderance and a wide range of ages at onset. Human leukocyte antigen (HLA) complex plays a primary role in the susceptibility to GD. We investigated the genetic association between HLA-DRB1 and Taiwanese children with GD. Design: Case-control and family-based studies with a candidate gene approach.

Patients and measurements: The study subjects consisted of 186 unrelated children (155 girls, 31 boys) with GD, 539 healthy controls, 90 trios of affected patients and their parents, and 102 trios of non-affected siblings and their parents. All were Taiwanese. We performed genotyping for HLA-DRB1 alleles by polymerase chain reaction and sequence-based typing assays.

Statistical analysis: In case-control study, difference in the frequencies of DRB1 alleles between patients and controls were compared using the chi-squared test with Yates' correction and Fisher's exact test where appropriate (one expected number <5). In family-based study, Transmission disequilibrium test (TDT) was used. The odds ratio (OR) and 95% confidence intervals (95% CI) for each allele were calculated. The Bonferroni inequality method, Pc = 1 – (1-P)n, was used for multiple comparisons where Pc is the corrected P value, P the uncorrected value, and n the number of comparisons. Pc values of less than 0.05 were considered statistically significant.

23

摘要

Results: DRB1*09:01 was positively associated with GD (OR = 2.71, 95% CI 2.07-3.56, Pc =3.1 × 10-12) while DRB1*12:02 was negatively associated with GD (OR = 0.31, 95% CI 0.17-0.54, Pc =2.8 × 10-4). Transmission/Disequilibrium test (TDT) confirmed that DRB1*09:01 was in linkage with GD and conferred susceptibility of it (OR = 2.94, 95% CI 1.79-5.69, Pc = 9.0 × 10-4) but DRB1*12:02 rendered prevention against GD (OR = 0.22, 95% CI 0.04-0.47, Pc =0.01). Comparison of transmitted and non-transmitted counts between patients and non-affected siblings excluded the possibility of segregation distortion (P = 0.0006). The findings were similar in females when stratified by gender.

Conclusions: Our

results

demonstrated

that

HLA-DRB1*09:01

confers

susceptibility to GD and DRB1*12:02 exerts protection against GD development in Taiwanese children and both alleles are in linkage with GD. These findings may only be observed in children with GD patients.

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OP2 THE VALUE OF SMBG IN TYPE 1 DIABETIC PATIENTS SU-YIN FANG, HUI-CHUN HSU, YAU-JIUNN LEE Lee's Endocrinology Clinic Background: To improve glycemic control, the Bureau of National Health Insurance has reimbursed the blood glucose test strips to encourage type 1 diabetic patients for increasing SMBG frequency. The aim of this study is to reveal the effect of SMBG to glycemic control in type 1 diabetic patients for past 1 year.

Methods: Type 1 diabetic patients who have followed up in Lee’s Endocrinology Clinic were included in this study. These patients were prescribed with 100 blood test strips every month and their A1C was checked for every 3 month. All of their SMBG data were downloaded from Accu-Chek® Performa.

Results: A total of 35 (M/F:11/24) type 1 diabetic patients were included in this study.

Their mean age was 33.2 ± 13.6 yrs, diabetes disease duration was 13.1 ± 6.6 yrs and baseline A1C was 7.9 ± 2.7%. During the 1-year period, the weekly SMBG frequency was 18.6 ± 9.0. After 1 year of management, we didn’t find significant reduction in A1C (7.9 ± 1.9%) and the differences between subsequent A1C was not correlated with weekly SMBG frequency (r=0.006, p=0.963). However, we found the mean A1C level was negatively correlated with diabetic disease duration (r=-0.574; p=0.001). By using median mean A1C, we stratified these patients into two groups with mean A1C 7.0±0.7% and 9.5 ± 1.8%, respectively; we surprising found both groups had similar glucose variability estimated by coefficient of variation (49.9% vs. 51.1%; p=0.640).

Conclusion: For type 1 diabetic patients, our result suggested that SMBG is not helpful in improving glycemic control. Instead, our result hinted that the glycemic control may be improved by the experiences patients learned during increased disease duration.

However, we should also aware of significant glucose variability in type 1 diabetic patients, even in those with optimal glycemic control.

25

摘要

OP3 THE EXPERIENCE OF HOSPITALIZED INDIVIDUALS WITH TYPE 2 DIABETES MELLITUS AND SEPSIS IN NORTHERN TAIWAN JUI-CHU HUANG Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital Objectives: Increased population with type 2 diabetes mellitus (T2DM) makes global impacts, especially the in-patient service. Not increased mortality among individuals with T2DM and sepsis was reconfirmed with less acute lung injury of 24-year follow-up in United States. We aimed to describe the experience in Northern Taiwan.

Methods: Using the Taiwan Chang Gung Memorial Hospital In-patient Diabetes Registry, hospitalized individuals with T2DM from 2001 to 2008 were integrated with sepsis proved by behaviors of physician. The subgroup with bacteremia was analyzed the age, gender, length of hospital stay, failed organs, complications, comorbidities and overall mortality.

Results: Over half of hospitalized individuals with T2DM got suspicion sepsis (65.7%, n=68159). But the subgroup with bacteremia was 4.8% (n=5832), and its overall mortality was 16.6%. The most common bacteria is Escherichia coli, which infected individuals with more urogenital tract sourced, female dominant, less respiratory failure and less overall mortality as 5%.

Conclusions: The less detections of bacteremia and significant variations of mortality between common bacteria made the need of demographic monitor for remodeling clinical practice.

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中 華 民 國內 分泌 暨 糖 尿病 學 會 100 年 度 秋 季 學 術 研 討 會

OP4 ALBUMINURIA IS AN INDEPENDENT RISK FACTOR OF ERECTILE DYSFUNCTION IN MEN WITH TYPE 2 DIABETES 1

MIN-SHEN CHUNG, 2YAO-CHI CHUANG, 2,3PEI-WEN WANG, 1WEI-CHIA LEE, 3 CHUNG-DAR CHEN, 4HSUEH-WEN CHANG, 5KUENDER D. YANG, 6MICHAEL B. CHANCELLOR, 2RUE-TSUAN LIU 1 Division of Urology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taiwan;2Division of Metabolism, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taiwan;3Department of Nuclear Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taiwan;4Department of Biological Sciences, National Sun Yat-Sen University, Kaohsiung, Taiwan;5Department of Medical Research, Show Chwan Memorial Hospital, Changhua, Taiwan;6Department of Urology, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan Introduction: Erectile dysfunction (ED) is a frequent comorbidity in diabetic men, and is frequently overlooked in routine clinical evaluation. Albuminuria is a marker of endothelial dysfunction and may link to ED. Aim: The study evaluated the association of albuminuria, and risk factors of ED in men with type 2 diabetes at a dedicated diabetic center.

Methods: The diagnosis of ED was based on a self –administered questionnaire containing Sexual Health Inventory for Men. Urinary albumin excretion rate was determined by urine albumin-to-creatinine ratio (UACR) in spot urine.

Main Outcome Measures: The clinical variables, and diabetes associated complications to risk of ED were evaluated.

Results: Of 666 type 2 diabetes receiving the questionnaire, 455 patients completed the questionnaire. Among them, 82.0%, 28.1%, and 35.8% reported having ED, severe ED, and albuminuria, respectively. The UACR level was significantly higher in ED (0.20± 0.83) and severe ED (0.34±1.18) groups compared to non ED group (0.07± 0.33). The presence of albuminuria adjusted for age and duration of diabetes was significantly associated with ED (OR=2.76), and macroalbuminuria has stronger impact (OR= 4.49) 27

摘要

than microalbuminuria (OR= 2.48). The other associated risk factors included hypertension, higher level of systolic BP, lower level of serum hemoglobin, and estimated glomerular filtration rate. The presence of retinopathy, neuropathy, insulin therapy, using calcium channel blocker and higher level of HbA1c further correlated with severe ED. Total testosterone level, hsCRP level, and the presence of metabolic syndrome were not risk factors. The 211 nonrespondents to the questionnaire had similar or worse risk profiles compared to the patients with ED. Conclusion: Albuminuria is an important independent risk factor of ED in diabetic men after adjustment of age and DM duration. Identification and control of albuminuria, and other associated risk factors might play a role in early treatment or prevention of ED.

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OP5 NEW CUTOFF POINT TO DIAGNOSE DIABETES MELLITUS ACCORDING TO RENAL FUNCTION CHANGE DATA 1

WEN WEI LIANG Dachien Hospital Background: Diabetes mellitus is diagnosed as fasting plasma glucose (FPG) larger or equal to 126 mg/dl. The incidence of retinopathy increases above an FPG of ≥126 mg/dl. The cut-off point was base on the relationship between fasting plasma glucose and diabetic retinopathy. Diabetes may induce retinopathy, nephropathy and other complications. The study was designed to define the cut-off point according to the renal function deterioration or new-onset proteinuria.

Method: We collected data from the people who visited our hospital for health examinations at least twice with over three years between 06/2002 and 12/2010. We excluded the people with a history of diabetes mellitus at first examination. There are 3252 people in the study. I use the renal function deteriorations (GFR decrease over 3, 5, 10 mL/min/1.73 m2 per year) and new-onset proteinuria as targets. GFR (glomerular filtration rate) was calculated by Modification of Diet in Renal Disease formula. I use the fasting plasma glucose to predict these targets. We use the receiver operating characteristic (ROC) curve to calculate the cutoff point for diabetes. .

Results: The mean duration between two health examinations are 5.30±1.46 years.

According to the data of the ROC curve, the FPG cutoff point is 91 mg/dl, 89 mg/dl, 135 mg/dl according to eGFR decrease over 3, 5, 10 mL/min/1.73 m2 per year. The area under ROC curve are 0.576, 0.567, 0.582 according to eGFR decrease over 3, 5, 10 mL/min/1.73 m2 per year. The FPG cutoff point is 94 mg/dl according to new-onset proteinuria..

Conclusion: The cutoff points of diabetes to predict renal function deterioration or new-onset are lower than present definitions. So in some people with impaired fasting glucose should accept the regular renal function follow up.

29

摘要

OP6 RENAL FUNCTION CHANGE IN PEOPLE WITH EUGLYCEMIA AND HYPERGLYCEMIA 1

WEN WEI LIANG Dachien Hospital BACKGROUND: Diabetic patients have a higher prevalence of kidney disease.

Some diabetic patients have kidney disease or proteinuria at the time of diabetes diagnosis.

Diabetes mellitus is diagnosed as fasting plasma glucose (FPG) larger or equal to 126 mg/dl. This study aimed to investigate the relationship between reduced glomerular filtration rate (GFR) and fasting plasma glucose level.

METHODS: We collected data from the people who visited our hospital for health examinations at least twice with over three years between 06/2002 and 12/2010. We excluded the people with a history of diabetes mellitus at first examination. There are 3252 people in the study. I calculate the mean yearly GFR change in serial glucose range (FPG<80, 80-99, 100-119, 120-139,140-159,160-179,over 180mg/dl). We calculate the mean yearly GFR change. We compare the difference between FPG<80 mg/dl amd other groups. GFR was calculated by Modification of Diet in Renal Disease formula.

RESULTS: The mean duration between two health examinations are 5.30±1.46 years.

The mean yearly GFR change is 0.017, -0.130, -0.171, -0.462, 0.738, -1.421, -1.642 mL/min/1.73/m2 per year from lowest glucose range to highest glucose range. Comparing the different groups, all other groups showed the mean yearly GFR reductions are more than groups with FPG<80mg/dl. However, only groups with 160-179 and over 180mg/dl showed the significant change.(p= 0.006 and < 0.001).

CONCLUSIONS: A yearly GFR reduction increase with glucose increase. Patient with higher glucose level had more rapid GFR decrease. In patient with euglycemia or ifg, the yearly GFR reduction also increase with glucose. The significant GFR reduction was found when the fasting plasma glucose over 160mg/dl.

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中 華 民 國內 分泌 暨 糖 尿病 學 會 100 年 度 秋 季 學 術 研 討 會

OP7 THE HEALTH PROMOTION PROGRAM FOR PATIENTS WITH IMPAIRED FASTING GLUCOSE IN A REGIONAL HOSPITAL 1

S-T TSENG, 1B-H LOW, 1S-C HUANG, 1H-F SU Kuang Tien General Hospital1 Introduction: The prevalence of diabetes increased over the past decade in Taiwan.

Prevention is a corner stone of strategies to reduce the diabetes burden. There have been several randomized controlled trials revealed that type 2 diabetes can be prevented or delayed through therapeutic lifestyle modification. But application the evidence into clinical practice in Taiwan would be a challenge.

Methods: This study was conducted in a regional hospital in Taichung since 2008.

The participants with impaired fasting glucose were identified through health physical check-up which is covered by National Health Insurance. The intervention included four individual sessions of consultation about principles of healthy life style which focused on weight reduction and increased physical activity (aerobic and strength training exercise), limit dietary fat and saturated fat and increased intake of dietary fiber. The participants followed up every 3 months with total 6 months duration. Main outcomes include changes in weight, waist circumference, physical activity, blood pressure, fasting plasma glucose (FPG), hemoglobin A1c, lipids, medication use.

Results: A total of 45 participants with a mean age of 55.32 years were enrolled. The mean weight change and reduction of body mass index after 6 months intervention were -1.38±3.13 kg, -0.50±1.17 kg/m2 respectively. However, blood pressure, FPG, hemoglobin A1c, total cholesterol, triglyceride, and high density lipoprotein did not change significantly.

Conclusions: Progressive weight reduction is noted during the follow-up period. Due to small number of this study subjects, FBS and other biochemistry profile did not change significantly.

31

摘要

OP8 METABOLIC OUTCOME FOR DIABETES SHARED CARE PROGRAM OUTPATIENTS IN A VETERANS HOSPITAL OF SOUTHERN TAIWAN 1

LYH-JYH HAO, 2KAI-JEN TIEN, 3HAILUN CHAO, 1CHING-JU HONG, 4FU-SHINE CHOU, 5TA-JEN WU, 6JIANG-KANG CHAO, 7MING-DER SHI, 8KUO-LIANG CHAI, 9 KUANG-CHUNG KO, 10MI-CHIA MA 1 Division of Endocrinology and Metabolism, Department of Internal Medicine, Yongkang Veterans Hospital, Yongkang, Taiwan.2Division of Endocrinology and Metabolism, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan.3Department of Health Care Administration, Chung Hwa University of Medical Technology, Tainan, Taiwan.4Institute of Information Management, National Cheng Kung University, Tainan, Taiwan.5Division of Endocrinology and Metabolism, Department of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan.6Department of Psychiatry, Yuli Veterans Hospital, Hualien, Taiwan.7Department of Pathology and Laboratory Medicine, Yongkang Veterans Hospital, Yongkang, Taiwan.8Division of Gastroenterology, Department of Internal Medicine, Yongkang Veterans Hospital, Yongkang, Taiwan.9Department of Administration, Longcyuan Veterans Hospital, Pingtung, Taiwan.10Department of Statistics, National Cheng Kung University, Tainan, Taiwan.

Background: To evaluate the metabolic outcomes of Diabetes Shared Care Program (DSCP) for type 2 diabetes after completion of 1 and 3-year of intervention.

Methods: Total 162 type 2 diabetes (average age 67.14 years old with 62.35% male and 37.65% female) in 2004 were referred to the diabetes educator for the program.

Parameters related to diabetes among these patients were inquired, and biochemical data were compared before and after the DSCP. Differences in the before and after management data were compared by using SPSS 12.0 software.

Results: DSCP did increase patient number in achieving the glycated hemoglobin (A1C), BP and LDL-C target levels. These patients have 3.1% emergency utilization rates and 1.9% hospitalization utilization rates and significant improvement in diastolic blood pressure (DBP), BW, fasting plasma glucose (FPG), A1C levels

after

one year, and significant improvement in systolic blood pressure (SBP), DBP, BW, total 32

中 華 民 國內 分泌 暨 糖 尿病 學 會 100 年 度 秋 季 學 術 研 討 會

cholesterol, HDL-C, LDL-C levels after three years. But only 4.84% and 8.87% met all the ABC target values after the 1 and 3-year intervention, respectively.

Conclusion: DSCP should be offered as close to the time of diagnosis, and directed towards patients with high baseline A1C, SBP, DBP, LDL-C, low baseline HDL-C levels.

Further public health efforts are needed to control risk factors for vascular disease among diabetes.

Key words: diabetes mellitus, diabetes mellitus educator, diabetes shared care

33

program

摘要

OP9 FATTY PANCREASE IS STRONGLY ASSOCIATED WITH METABOLIC SYNDROME: CORRELATION BETWEEN FATTY PANCREAS AND METABOLIC PARAMETERS WAN-CHEN WU, CHIH-YUAN WANG Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taiwan, R.O.C. Fatty liver has been reported to be associated with insulin resistance, dyslipidemia, and obesity, and is considered as a phenotype of metabolic syndrome. However, the clinical significance of fatty pancreas remained to be determined. Ogilvie first described fatty infiltration of the pancreas in 1993 when he found 17% pancreatic fat in obese cadavers as compared with 9% in lean ones. Animal studies presented that pancreatic steatosis caused anomalies of the pancreas islet cells leading to hyperglycemia. Several studies have attempted to further evaluate this entity. Autopsy and abdominal ultrasonography series have suggested that fatty pancreas is associated with age, overweight, and body fat before. More recent studies have demonstrated additional possible associations for fatty pancreas including male gender, age older than 60 years, hypertension, hepatic steatosis, alcohol use, increased body mass index (BMI), impaired insulin secretion, insulin resistance, visceral fat, triglyceride, alanine aminotransferase (ALT), beta-cell dysfunction, and diabetes. Prior report showed fatty pancreas had a strong association with frequency of metabolic syndrome, and correlation with a number of the parameters of metabolic syndrome. The aim of this study was to investigate the associated factors and clinical implications of fatty pancreas. We retrospectively enrolled all individuals who had a health check-up at National Taiwan University Hospital Health Management Center from January 1st, 2009 to March, 31st, 2009, and total 557 consecutive patients were included in this study. Fatty pancreas was diagnosed by trans-abdominal ultrasonographic findings. 72 patients (30 men and 42 women) were diagnosed with fatty pancreas, and defined as the study group. The remainders (485 patients, with 285 men and 200 women) were defined as control group. Various demographic and metabolic risk factors were assessed. Demographic and metabolic 34

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parameters associated with fatty pancreas include age, BMI, abdominal girth/height, abdominal girth in both genders, fasting blood sugar, postprandial blood sugar, HbA1c, total cholesterol, triglyceride, LDL-C, systolic blood pressure, and platelet count.

Interestingly, in the present study, serum amylase level was lower in fatty pancreas group than control group (93.25±26.64 v.s. 102.30±36.19, p=0.04), which was contrast to the results of the previous studies. Fatty pancreas is a risk factor of metabolic syndrome or another manifestation of metabolic syndrome. Further investigation is needed to clarify their correlation.

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OP10 BRACHIAL-ANKLE PULSE WAVE VELOCITY PREDICTS PROGRESSION OF ESTIMATED GLOMERULAR FILTRATION RATE AMONG PATIENTS WITH TYPE 2 DIABETES: ONE YEAR FOLLOW-UP 1

yi-Jing Sheen, 1jainn-Liang Lin, 1cho-Tsan Bau, 2wayne Huey-Herng Sheu 1 Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Hospital Department of Health, Executive Yuan, Taiwan, R.O.C.; 2Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taiwan, R.O.C. Aims: It is well known that peripheral arterial disease is associated with chronic kidney disease in patients with type 2 diabetes.

We evaluated the clinical variables and

the indexes of peripheral artery disease related to the progression of estimated glomerular filtration rate (eGFR) in type 2 diabetic outpatients.

Methods: A total of 625 (male/female: 315/310) subjects with mean age of 63.7 ± 11.6 years (mean ± SD), baseline eGFR 89.06 ± 29.82 mL/min/1.73 m2 were enrolled from Oct 2008 to Dec 2009.

Baseline clinical information plus ankle brachial index

(ABI), toe-brachial index (TBI) and brachial-ankle Pulse Wave Velocity (ba-PWV) (by Colin VP 1000) were collected.

Patients were enrolled for having at least two additional

eGFR data which obtained at the 6th ± one month and the 12th ± one month. Patients with the history of stroke, end stage renal disease, malignancy, acute myocardial infarction or amputation were excluded.

The eGFR were calculated by the Modification of Diet in

Renal Disease Study equation.

Results: Among studies subjects, 133 patients (21.3%) experienced continuously worsened eGFR progression (the progressively worsen lower eGFR values were detected both at the 6th ± one month and the 12th ± one month), while the rest of them (n=492) did not get worse continually during the observation period.

Higher systolic blood pressure,

higher glycosylated haemoglobin (HbA1C) level and higher ba-PWV value at the baseline were independent predictors of worsened eGFR progression during the one year observation. Since diabetic cardiovascular and renal complications share common risk 36

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factors, we calculated the cardiovascular risk score by Framingham-Wilson equation, and the score associated with continuous eGFR progression significantly (p=0.007).

Receiver operating characteristic (ROC) curve of these factors in predicting eGFR worsened progression were constructed, and the area under curve were calculated and resulted that: systolic blood pressure (0.596), HbA1C (0.574), ba-PWV (0.601) and Framingham-Wilson risk score (0.575).

Conclusions: In addition to the traditional risk factors, such as systolic pressure、 HbA1C and Framingham-Wilson score, the ba-PWV value significantly predicted worsened eGFR progression among type 2 diabetes.

This non invasive examination may

assist in the early detection of CKD progression among patients with type 2 diabetes.

Keywords: Type 2 diabetes, brachial-ankle Pulse Wave Velocity (ba-PWV), estimated glomerular filtration rate (eGFR)

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PP1 PEGYLATED INTERFERON-Α INDUCED AUTOIMMUNE DIABETES, DIABETIC KETOACIDOSIS—A CASE REPORT AND FOLLOW UP 1

KUN-DER LIN, 1CHUN-WEI HO, 1PING-CHUAN CHOU, 1PI-JUNG HSIAO, 1 SHYI-JANG SHIN 1 Division of Endocrinology and Metabolism, Kaohsiung Medical University Hospital, Kaohsiung Medical University Brief history: A 54 y/o female had chronic hepatitis C infection with abnormal liver function. She received pegylated interferon-α (IFN-α) plus ribavirin therapy since March 22, 2010 to Aug 4, 2010. She did not have family history about diabetes and her OGTT screen test before IFN-α use was within normal range.

She suffered from abdominal pain on Aug 2, 2010 and went to our ER for help.

Diabetic ketoacidosis was diagnosed which blood glucose was up to 760 mg/dL and HbA1c level was 10.5%. Elevated lipase level up to 133 mg/dL was also noted. After admission and insulin therapy, her general condition was stable. However, she had primary OAD failure after insulin pump was discontinued; so, she received basal-bolus insulin therapy after discharge. During the OPD following up, she had good blood glucose control and her HbA1c was down to 6.3%.

After 10 months following up, she ever suffered from hypoglycemia episodes especially in recent 3 months. The daily insulin dosage was tapered down from 46U/day to 38U/day and still tapering down according her SMBG. We had followed her C-peptide levels and elevated C-peptide level was noted on 2011-6-11.

Lab examination: Before IFN therapy (2010-2-23): Fasting plasma glucose 93 mg/dL, OGTT test PC 2 hours: 121 mg/dL, HbA1c 5.2%. AST: 161 mg/dL, ALT: 231 mg/dL and Cr 0.63 mg/dL. The serum GAD-ab before IFN therapy was 193.3 U/ml which was checked on 2010-8-27 during admission.

When DKA attack (2010-6-7): sugar 760 mg/dL, vein GAS PH 7.075, HCO3- 4.2 mMol/L, and blood ketone body was 3.3. GAD-Ab was > 300 and followed serum GAD-ab was 1689.3 U/ml after one week. Fasting serum C-peptide level was undetectable.

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After basal-bolus insulin therapy for 10 months, the C-peptide was 0.48 ng/ml on 2011-6-11. The following C-peptide was 0.64 ng/ml on 2011-7-30.

Discussion: Chronic hepatitis C infection has the association with development of diabetes mellitus and the prevalence of type 2 DM was found to be significantly higher in a cohort of IFN-α naïve HCV patients compared with patients suffering from other chronic liver disease and general population. Interferon induced type 1 diabetes had been reported in many country, too. However, the linkage of the GAD-ab after IFN therapy and type 1 diabetes was not clear.

In this case, we demonstrate the strong linkage about the GAD-ab and the β-cell failure after IFN therapy. Furthermore, after the basal-bolus insulin therapy and supportive care, the β-cell function was partially recovered. The daily insulin amount also reduced while C-peptide was elevated.

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PP2 AN EUTHYROID SUBJECT PRESENTED WITH EXTREMELY HIGH SERUM FREE THYROXIN AND NORMAL TSH LEVEL 1

YI-CHING TSENG, 1LI-WEI LIN, 1SHUEN-FU WENG, 1CHEN-LING HUANG, 1, 2 CHUNG-HUEI HSU 1 Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Medical University Hospital 2

Department of Nuclear Medicine, Taipei Medical University Hospital Introduction: Immunoassays are common ways to measure circulating thyroid

hormones. Interferences of the assay by non-hormonal or hormonal factors have been documented. The result obtained from the influences may cause data misinterpretation and lead to inappropriate treatment. All medical practitioners have to pay attention to those conditions possibly interfere in an assay system while there is great inconsistency between laboratory and clinical findings.

Case report: A 63-yr-old woman visited our hospital on account of easy nervousness and occasional hand tremor. She has hypertension been treated with angiotensin II receptor blocking and calcium blocking agents. Her serum free T4 (FT4) test using an equilibrium one-step radioimmunoassay (RIA) kit (125I-labeled FT4 analog competes with FT4 in the patient’s sampling for sites on tube-coated anti-rabbit antibody) revealed extremely high concentration (18 ng/dL), but serum TSH and T3 levels were normal. The same specimen and another blood sample collected several days later were repeatedly measured. The results were similar. The results of dilution tests for evaluating validation of the assay were disappointed. Due to curious discrepancy between laboratory and clinical findings, we rechecked the serum samples with two different assays’ kits, including a two-steps pre-incubation anti-sheep RIA kit and a chemiluminescence immunoassay kit. The results were within normal range of approximate 0.5-2.5 ng/dL. We got conclusion that the patient was in euthyroidism.

Discussion: RIA based on an immunochemical reaction, competitive binding between labeled antigen and unlabeled antigen (standard solution and samples) to small amount of specific antibody. Validation of an immunoassay should be non-interference of 40

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the measured serum sample to the assay system. The interfered factors include non-hormonal effects such as chemicals, anticoagulant, proteins, lipidemia, bilirubin, or hemolysis and hormonal effects such as heterophile antibody or heterogeneity of labeled and measured hormones. In this test, we suppose that (1) plasma protein(s) bind to the labeled antigen, (2) endogenous heterophile antibodies bind the labeled antigen or bind to and occupy the tube-coated antibody, or (3) low affinity of labeled antigen to antibody in the assay system resulted in low bound-form labeled antigen (4) heterogeneity of labeled-analog and measured hormones or (5) dissociation of T4 to FT4 in the assay system.

Hence, falsely higher FT4 in the sample was detected.

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PP3 A CASE REPORT OF ANDROGEN PRODUCING ADRENOCORTICAL CARCINOMA 1

JU-MEI LIU, 1HUA-FEN CHEN, 2PEI-HWEI CHAN 1 Division of Endocrinology and Metabolism, Department of Internal Medicine, Far Eastern Memorial Hospital, Taiwan, ROC 2 Division of Urology, Department of Surgery, Far Eastern Memorial Hospital, Taiwan, ROC Case report: The 47 year-old female sustained early menopause with elevated testosterone at age of 43. She did not pay attention to it at that time. However frontal baldness, and excess hairs at the chin had developed since 6 months ago. She denied abdominal pain, deepening of voice, or easily bruising but increased body weight by 5kg in one year was found. She visited doctors on 2011/4. Series assessment of endocrine parameters revealed elevated testosterone (236ng/dl) and DHEA-S (1122ug/dl) without ovarian tumors on sonogram, which was suggestive of adrenal hyperandrogenism. Adrenal CT presented a 6.6 cm left adrenal mass with the characteristic of heterogeneity, and a high attenuation value before enhancement and lower rapidity of washout of contrast medium, and therefore a malignant adrenal tumor was highly suspected. Hence she underwent left adrenalectomy on 2011/5/26. The pathologic report demonstrated left adrenocortical carcinoma.

Discussion: Hirsutism is defined as excessive terminal hair that appears in a male pattern in women. Hirsutism results from an interaction between the androgen level and the sensitivity of the hair follicle to androgen. Hyperandrogenism indicates the further hormonal analyses including pituitary, thyroid, adrenal gland, and ovary diseases.

Hyperandrogenism is most often caused by the polycystic ovary syndrome (PCOS).

However, elevated DHEA-S without ovarian lesions on sonogram can exclude PCOS or ovarian tumors, and then adrenal source should be considered. Image study of adrenal gland can help us to differentiate adenoma from non-adenoma. All patients with a functional adrenal tumor need to undergo surgical intervention for the histopathological diagnosis.

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Adrenocortical carcinoma (ACC) is a rare malignant tumor. 87% ACC is functional tumors, in which the incidence of cortisol producing carcinoma is 63%, whereas the androgen producing ACC is 15 %. Symptoms may result from hormonal oversecretion, the mass effect or/and metastases. Complete tumor removal offered the best chance for long-term survival. Despite tumor resection for cure, most patients will develop local recurrence or distant metastases in 5 years. Some studies have shown that Mitotane therapy may provide benefits for recurrence-free survival. Chemotherapies and radiation therapy are regarded as of limited benefit. Most of all, when surgical removal of the tumor is not feasible, the patients with ACC have an extremely poor prognosis. The estimated 5year survival rate is less than 30%.

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PP4 PRIMARY HYPERPARATHYROIDISM WITH PRESENTATION OF PALPABLE NECK MASS AND SEVERE MUSCULOSKELETAL SYMPTOMS 1

JUEI-YU TSENG, 1HAO-CHANG HUNG, 1HORNG-YIH OU, 2CHUNG-JYE HUNG, 1 TA-JEN WU 1 Division of Endocrinology and Metabolism, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan, R.O.C. 2 Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan, R.O.C. Introduction: About 75-80% of cases are accidentally diagnosed as asymptomatic primary hyperparathyroidism during biochemistry evaluation. We report a case of primary hyperparathyroidism with severe musculoskeletal symptoms.

Case report: This 23-year-old female was admitted due to bilateral flank dull pain without radiation for one month. The pain exacerbated on motion, and relieved when rest that made her lie in bed most of the time in this period.. She denied fever, chills, nausea/vomiting, abdominal pain, constipation, or polyuria. The pain persisted despite analgesia, so she came to our emergency room. Past history revealed that the patient ever received ESWL for renal stone. Hypercalcemia was noted incidentally five years ago with elevated iPTH (307pg/ml). However, parathyroid echo showed no mass and Tc-99m sestamibi scan revealed no evidence of adenoma or hyperplasia. She then lost follow-up.

On physical examination, one palpable mass, 3x2 cm, over left neck was noted.

Diffuse tenderness over bilateral flank was noted, but there was no local heat, erythema or swelling. Lab data revealed WBC: 5900, Hb: 14.7 g/dL, BUN: 4 mg/dl, creatinine: 0.3mg/dl, sodium: 141mmol/L, potassium: 3.4mmol/L, calcium: 13.2 mg/dl, phosphate: 2.0mg/dL, CK: 24U/L, LDH: 138U/L and iPTH: 2497 pg/ml. Urine routine showed RBC: 38/LPF, WBC: 1/LPF and no bacteria. Thyroid and parathyroid sonography revealed a left parathyroid adenoma, about 3cm. Parathyroid Sestamibi

scan revealed one left upper

adenoma. T score of bone mineral density of lumbar spine(L1~L4) is -5.5. Spine X-ray showed fusion of the collapsed T6 and T7 vertebral bodies and compression fracture of 44

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T11. Other lab data was unremarkable. Abdominal echo revealed only left renal stone.

Parathyroidectomy and left thyroid lobectomy were done smoothly. During operation, one

2.1x1.8x1.4cm left upper parathyroid adenoma was noted, which was homogenous

and well circumscribed. Pathology showed parathyroid adenoma with atypical features.

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PP5 JAUNDICE AS THE INNITIAL PRESENTATION OF GRAVES’ DISEASE COMPLICATED WITH TYROID STORM 1

W-W HUNG, 1K-D LIN, 1H-Y LIN, 1S-J SHIN, 1P-J HSIAO 1 Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University INTRODUCTION: Jaundice, a rare symptom of hyperthyroidism per se, can also be due to the side effect of anti-thyroid drugs. Other causes of jaundice unrelated to thyroid disease include autoimmune hepatitis, viral hepatitis, alcohol abuse, sepsis, cholangitis, or as a side effect of certain medications. Here we report a patient of Graves’ disease presented with jaundice and discuss the treatment dilemma.

CASE REPORT: We reported a 53-year-old female without any underlying disease who was referred to our outpatient department due to recent onset of exertional dyspnea while mountain-climbing and unexplained jaundice noted by local physician. Blood tests confirmed hyperbilirubinemia and hyperthyroidism with positive TSH-receptor antibody, and chest X-ray showed massive amount of right pleural effusion. Due to unexplained jaundice and right pleural effusion, she was admitted for further survey. During hospitalization, thoracentesis proved transudate. Electrocardiogram revealed atrial fibrillation (Af) with rapid ventricular rate (RVR) which persisted during admission.

Cardiac echo showed left ventricular systolic dysfunction and valvular heart disease. Thus chronic Af with congestive heart failure (CHF) was impressed. Besides, a series of exams had performed to find out the cause of jaundice. Abdominal computed tomography showed small liver cyst and mild ascites without liver cirrhosis. Hepatitis markers and anti-nuclear antibody were all negative. As for her medications, digitalis and beta-blocker were added first for CHF and Af with RVR. Then steroid was given for Graves’ disease with thyroid storm. After survey completed, methimazole was prescribed to treat the newly-onset thyrotoxicosis because the cause of jaundice was attributed to hyperthyroidism per se.

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CONCLUSION: In patients with Graves’ disease complicated with thyroid storm, jaundice is a rare but possible presentation. Before the prompt treatment for thyroid storm with anti-thyroid drugs which may worsen hyperbilirubinemia, it’s essential to exclude other causes of jaundice unrelated to thyroid disease.

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PP6 MULTIPLE ENDOCRINE NEOPLASIA TYPE 1 PRESENTED AS SEVERE HYPOGLYCEMIA AND HYPERCALCEMIA : A CASE REPORT 1

YOU-YU HSUEH, 1HAO-CHANG HUNG, 1HORNG-YIH OU, 1TA-JEN WU, 2 SHIH-MING HUANG 1 Division of Endocrinology and Metabolism, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan, R.O.C. 2 Department of Surgery, Dou-Liou Branch, National Cheng Kung University Hospital Introduction: The association of parathyroid, enteropancreatic endocrine and pituitary neoplasia is called multiple endocrine neoplasia type 1 (MEN-1). We report a case of MEN-1 with the presentation of severe hypoglycemia.and hypercalcemia Case Report: A 68-year-old female presented to emergency room with acute loss of consciousness. Hypoglycemia (11.5 mg/dL) was noted, and the consciousness recovered after glucose supplement. The laboratory surveys showed the insulin level of 26 uU/ml (normal reference 0-22 uU/ml) and c-peptide level of 12.9 uU/ml (normal reference 0.9-7.1uU/ml) when the plasma glucose level was 36mg/dL. Abdominal magnetic resonance imaging (MRI) found one nodule, 1cm, at the pancreatic head and two nodules, 1cm, at pancreatic tail. Intra-arterial calcium stimulation test with hepatic venous sampling showed insulin gradients on calcium stimulation to the splenic artery and gastroduodenal artery. Besides, hypercalcemia (12.5 mg/dL) with high iPTH (186.8 pg/ml) was also noted.

The parathyroid echo and parathyroid Sestamibi scan suspected parathyroid lesions near the left lower and right upper thyroid. Pituitary function showed normal and brain MRI did not reveal any pituitary tumor.

The patient underwent total parathyroidectomy with autotranplantion in forarm first and 28 days later, pancreatic head tumor enucleation, distal pancreatectomy and splenectomy were done.

The pathology revealed parathyroid hyperplasia and malignant

insulinoma with soft tissue metastasis.

Conclusion: MEN-1 is a malignant potential multiple endocrine disorder especially for enteropancreatic lesions.

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PP7 NORMOCALCEMIC PRIMARY HYPERPARATHYROIDISM WITH OSTEOPENIA 1

HUI-CHING PAI, 2CHIH-YUAN WANG 1 Division of Endocrinology and Metabolism, Department of Internal Medicine, Far-Eastern Memorial Hospital, Taipei, Taiwan, R.O.C. 2 Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, R.O.C. A 52 year-old male with osteopenia history for 20 years visited endocrinologic OPD for the evaluation of left neck mass. Thyroid function tests showed euthyroidism and negative anti-thyroglobulin and anti-TPO antibodies. Thyroid sonography presented left nodular goiter and a retro-thyroid hypoechoic lesion over right thyroid which was suspected as a parathyroid adenoma. Fine needle aspiration cytology over the right retro-thyroid lesion was suggestive of parathyroid tissue. However, a faint hot spot was noted at left inferior thyroid bed on Tc-99m MIBI scan. After series laboratory assessment, normocalcemic primary hyperparathyroidism was diagnosed. Left thyroidectomy and right inferior parathyroidectomy were performed and parathyroid adenoma was confirmed.

Normocalcemic primary hyperparathyroidism (PHPT) is thought to represent the mildest form of parathyroid autonomy, and a large Swedish study suggested it may account for as much as 27.5% of all PHPT. Although normocalcemic PHPT was recognized 30 years ago, the natural history and consequences have not well understood.

This is mainly because the diagnosis is confounded by the many secondary causes of hyperparathyroidism, and patients are asymptomatic.

A recent proposal has suggested that normocalcemic PHPT represents an early manifestation of symptomatic PHPT. The pathophysiology and natural history of normocalcemic PHPT, present evidence indicates that it may have significant long-term renal and skeletal sequelae. When managing individual patients with normocalcemic PHPT, treatment with parathyroidectomy should be considered when there is evidence of deteriorating skeletal or renal disease.

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PP8 ANALYSIS OF THE CLINICAL CHARACTERISTICS OF PATIENTS CONCOMITANT WITH FOLLICULAR NEOPLASM AND THYROID PAPILLARY CARCINOMA 1

H-J JIANG, 1P-J HSIAO, 1K-D LIN, 1W-W HUNG, 1S-J SHIN 1 Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Medical University Hospital. Kaohsiung Medical University, Taiwan, R.O.C. Follicular cell origin of thyroid accounts for the majority (~95%) of all thyroid cancers. However, it is clinically uncommon for patients concomitant with follicular neoplasm and papillary carcinoma (PTC). The molecular mechanisms of the oncogenesis for follicular neoplasm and papillary carcinoma are essentially different. Follicular neoplasms, including follicular adenoma (FTA) or carcinoma (FTC), carry either a RAS mutation or PAX8/PPARγ rearrangement in almost 80% of cases. The majority (~75%) of PTC is reported to have RET/PTC, BRAF gene alterations. There is also some different decision making of surgical exploration for these two conditions. Therefore, pre-operative diagnosis seems challenging for clinician.

From our clinic, we have collected 12 patients coexistent with follicular neoplasm and PTC. There were 4 males and 8 females, age ranged from 33 to 59 years old.

Combination of the pathology included: one patient was diagnosed with toxic adenoma but microPTC occurred 2 years later after I131 therapy, 2 patients coexistent with FTC and PTC, 2 patients with lymphocytic thyroiditis, 2 patients coexistent with FTA, PTC and small nodular goiter. Concomitant with follicular neoplasm and microPTC in contralateral lobes were found in 9 patients (75%), including multifocal microPTC in 3 patients.

Pre-operational cytologic diagnosis of dominant follicular neoplasm was found in 7 cases.

In contrast, 2 patients with dominant PTC and small FTA were found after total thyroidectomy. Frozen section to prove PTC was the main reason for total thyroidectomy in 11 patients and hemithyroidectomy was done in one case of FTA coexistent with ipsilateral microPTC. The diverse manifestation of the follicular neoplasm concomitant with PTC is present in clinical reality. It means the different somatic mutations may occur at the same time in 50

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one patient. As there is high frequency of the follicular neoplasm concomitant with microPTC in contralateral lobes, we suggest the cytologic proof or frozen section within operation is necessary to make an adequate surgical exploration if the dominant follicular neoplasm coexisted with small irregular margined nodules.

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PP9 A 37-YEAR-OLD MALE WITH GRAVES’ DISEASE AND LYMPHOCYTIC HYPOPHYSITIS 1

AI-HUA CHEN, 1FEN-YU TSENG 1 Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taiwan, R.O.C. In this case report, we presented a case with Graves’ disease and lymphocytic hypophysitis developing clinical symptoms in the same period. He had symptoms of hyperthyroidism and general malaise, nausea, vomiting, polyuria and headache for 4 months. Lab data showed hypogonadotropic hypogonadism, hyperthyroidism with low TSH level, hypoadrenalism and hyperprolactinemia. Central DI was diagnosed by water deprivation test. Pituitary MRI showed symmetric enlarged, strong homogenous enhanced pituitary with enlarged stalk. Lymphocytic hypophysitis was diagnosed. We gave him high dose steroid therapy. Followed pituitary MRI showed decreased size of stalk and pituitary gland. His symptoms improved also. To our knowledge, only few cases were reported to have both Graves’ disease and lymphocytic hypophysitis. None of them developed clinical symptoms in the same period.

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PP10 AUTOIMMUNE GASTRITIS MIMICING GASTRINOMA 1

MING-CHIEH TSAI, 1CHAO-HUNG WANG, 2TSANG-EN WANG, 3CHI-KUAN CHEN, 1MING-NAN CHIEN 1 Division of Endocrinology and Metabolism, Department of Internal Medicine, Mackay Memory Hospital, R.O.C.; 2Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mackay Memory Hospital, R.O.C.; 3Department of Pathology, Mackay Memory Hospital, R.O.C. Objective: Autoimmune gastritis was a common autoimmune disease in general population but increased prevalence 3-5 fold in endocrine organ-specific autoimmune disease, included Type 1 diabetes mellitus, Hashimoto’s thyroiditis, Graves’ disease, Addison’s disease and autoimmune polyglandular syndrome types II and III1. One of the characteristic of autoimmune gastritis was hypergastrinemia. Gastrinoma was a functional neuroendocrine tumor with hypergastrinemia and easily accompanied with diarrhea and diffused ulcer over stomach, duodenal and intestine, which called Zollinger-Ellison syndrome.

When a patient with hypergastrinemia, the differential diagnosed includs gastrinoma, chronic atrophic gastritis type A (autoimmune gastritis related), chronic atrophic gastritis type B (Helicobacter pylori related) and chronic antisecretory agent related (H2 receptor antagonist and proton pump inhibitors)2. We present a case of a 39 years old male with autoimmune gastritis mimic gastrinoma in below article.

Method: A 39 years old male was a patient with Grave’s disease (anti-TSH receptor antibody: 55.03%, anti-microsomal antibody 1:256000) received subtotal thyroidectomy when he was 23 years old in 1984. He needed Levothyroxin sodium 50mcg per day since May, 2008. He suffered diabetes ketoacidosis at 32 years old. The examination of glutamic acid decarboxylase antibodies showed 16.46 U/mL (reference < 1.0 U/mL). He had received Glucagon Test with C-peptide at 0 minute revealed 0.13 ng/ml ( 1.06-3.53 ng/mL) and C-peptide at 6 minutes revealed 0.45ng/mL (1.06-3.53 ng/mL). Under the Anti-GAD antibody and Glucagon test were both positive, the patient was diagnosed with Type 1 Diabetes Mellitus at 32 years old. He visited our outpatient clinic regular since 2003 for 53

摘要

the treatment of Type1 Diabetes Mellitus with Insulin glargine 26 units.

This time, he was admitted in our Endocrinology ward for nausea and vomiting more frequently for 1 week. He had chronic diarrhea 3~6 times per day in recently 3 years accompanied with nausea, vomiting, mild abdominal dull pain and fluctuant value of glucose. His stool starch, fat and trypsin were all positive. His esophagogastroduodenoscopy, colonoscopy and abdominal computer tomography all had no specific finding, but double contrast gastrointestinal radiography showed persistent distention and poor peristalsis of stomach with much food debris and contrast retention causing limited small bowel opacification.

Blood test gave a value for Gastrin of 3152 pg/mL (target value 13-115 pg/mL). We stopped his proton pump inhibitors immediately. The value of gastrin in his blood was still 2002 pg/ml 2 months later. The patient received small bowel enteroscopy and gastritis and duodenitis was noted without gastric ulcer, duodenal ulcer and mass lesion. The value of gastrin was still 1876 pg/mL 6 months later. Due to the abnormal gastrin level, the patient received somatostatin receptor scintigraphy but no specific lesion or mass was noted.

Blood test gave the value for Gastric parietal cell antibody of 160X (target <20X).

The value of hemoglobin was 10.9 g/dL (target 13~18 g/dL). The value of mean corpuscular volume was 86.4 Fl (target 80~98 fL). The value of Vitamin B 12 was 1248 pg/mL (target 200-950 pg/mL). Normocytic anemia without iron deficiency and pernicious anemia was noted. By gastric biopsy, no dysplasia, malignancy or Helicobacter pylori was seen but the parietal cell signals of gastric were detectable by indirect immunofluorescence technique (IIF), which confirmed a diagnosis of autoimmune gastritis and autoimmune polyglandular syndrome Type 3 variant.

Result and Discussion: Autoimmune gastritis was a common autoimmune disease.

The prevalence in the general population was 0.15-1 %1. The prevalence is 3-5 fold augmented in patients with autoimmune thyroid disease and Type 1 diabetes mellitus. The association between autoimmune gastritis with endocrine organ-specific autoimmune disease, included Hashimoto’s thyroiditis, Graves’ disease, Addison’s disease and autoimmune polyglandular syndrome types II and III were also well known.

The pathogenesis of autoimmune gastritis was CD4+ T cell recongnizing parietal cell H+/K+ ATPase. The characteristic of autoimmune gastritis included atrophic fundus and 54

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corpus, antrum spared, parietal cell antibody, hypochlorhydria, hypergastrinemia, pernicious anemia, iron deficiency anemia and increased chromogranin A levels. A patient with autoimmune gastritis might had high possibility of gastric adenocarcinoma, gastric carcinoid tumor and colon carcinoma . The value of gastrin, iron, vitamin B12 and a complete blood count should be followed up regularly at yearly intervals1, but regular gastroscopies and gastric biopsy were controversial.

Gastrinoma and insulinoma are the most common symptomatic and functional neuroendocrine tumor in pancreas3. A gastrin-secreting tumor or gastrinoma might be sporadically persistent or as part of the multiple endocrine neoplasia type 1 syndrome2.

The most characterized symptoms of gastrinoma were severe diarrhea and an aggressive form of peptic ulcer disease, which named the triad of Zollinger-Ellison syndrome when the patient was found with a non-βislet cell in pancreas. But there are around 7% of those with Zollinger-Ellison syndrome occurred diarrhea without obvious peptic ulcer. When a patient is found with gastrinoma, early excision of the tumor is indicated. The treatment and prognosis of autoimmune gastritis and gastrinoma were so different so a definite diagnosed of them was important.

Our patient visited our emergency department for chronic diarrhea 3-6 times per day for 3 years accompanied with mild dull abdominal pain, nausea, vomiting and fluctuant hyperglycemia and hypoglycemia alternative. He had no laxative agent abuse, sympathectomy, vagotomy or gastrectomy history. After gastroscopies, colonscopy, abdominal computer tomography and functional image study, he had poor peristalsis of stomach with much food debris and contrast retention causing limited small bowel opacification in upper gastrointestinal radiography. He had no colon cancer, lymphoma, villous adenoma, diverticulitis or colitis4.

Hypergastrinemia was noted in this patient. The patient’s gastric biopsy revealed no Helicobacter pylori infected. We stopped the proton pump inhibitory immediately but the value of gastrin persisted higher than normal range after 6 months later. Under the impression of gastrinoma, the patient received the enteroscopy and somatostatin receptor scintigraphy

but all

of

them were

obvious

negative

finding.

The possibility

of gastrinoma could be ruled out. The serum test of gastric parietal cell was positive and the cytoplasma of gastric parietal cell was noted with signal by indirect 55

摘要

immunofluorescence technique (IIF) under gastric biopsy, which confirmed a dianosis of autoimune gastritis.

Besides above techniques, the first important step to differential diagnosed of autoimmune gastritis and gastrinoma is whether the antral pH elevated higher than normal or not2. The gastric-secreting tumors and gastrinoma usually had the value of antral pH lower than 2. The chronic atrophic gastritis type A which occurred from autoimmune gastritis had a higher value of pH usually more than 2. We could use 24 hours gastric pH-metry to examed the level of antral pH. The gastric acid hypersecretion with basal acid output and maximal acid output were also performe. The patient with gastrinoma usually had the ratio of MAO (maximal acid output)/ BAO (basal acid output) below 0.6.

If all of above techniques could not imply which kind disease dose the patient have, somatostatin receptor scintigraphy in combination with selective arterial secretagogue (secretin or calcium) injection test was indicated. However, this kind of examination was more invasive than previous2.

Conclusion: Hypergastrinemia and diarrhea were the common characteristic of gastrinoma and autoimmune gastritis. Whether the patient had stomach, duodenal and intestine ulcer could not be the crucial point of the diagnosis. A carefully examination of the iron, vitamin B12, gastric parietal cell antibody and complete blood counts level in serum should be performed. The gastroscopy, colonscopy, abdominal computer tomography, functional upper gastrointestine radiography image and gastric biopsy were all important.

The value of antral pH could be detected by 24 hours gastric pH-metry. The ratio of MAO/BAO should also be calculated. And the latest and more invasive technique to defined diagnosed the disease the patient had was somatostatin receptor scintigraphy in combination with selective arterial secretagogue (secretin or calcium) injection test.

Because the treatment plan and prognosis of autoimmune gastritis and gastrinoma were so different, the carefully and defined diagnosed was so important.

Reference: (1) De Block CEM, De Leeuw IH, Van Gaal LF. Autoimmune gastritis in Type 1 Diabetes: A clinical oriented Review. JCEM 2008;93:363-371 (2) Orlando LA, Lenard L, Orlando RC. Chronic Hypergastrinemia: Causes and 56

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Consequences. Dig Dis Sci 2007;52:2482-2489 (3) Roy PK, Venzon DJ, Shojamanesh H, Abou-Saif A, Peghini P, Doppman JL, Gibril F, Jensen RT. Zollinger-Ellison Syndrome: Clinical Presentation in 261 Patients.

Medicine (Baltimore) 2002;79(6):379-411.

(4) Schiller LR. Diarrhea and Malabsorption in the Elderly. Gastroenterol Clin N Am 2009;38:481-502

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摘要

PP11 INSULIN AUTOIMMUNE SYNDROME---A CASE REPORT 1,2

LIANG-YU LIN, 1PO-JU CHEN, 3CHIN-WEN CHANG, 1,2TJIN-SHING JAP 1 Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.

2 School of Medicine, National Yang-Ming University, Taipei, Taiwan.

3 Department of Internal Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan Insulin autoimmune syndrome (IAS), or Hirata disease, is a rare cause of hypoglycemia characterized by the presence of insulin-binding autoantibodies and fasting or late postprandial hypoglycemia who have not been injected with insulin. Mostly, IAS patients have either an underlying autoimmune disorder or have previously been exposed to drugs containing a sulfhydryl group, such as methimazole. We report a 76-year-old male Chinese patient with prostate cancer with lung metastasis and coronary artery disease but no diabetes or exogenous insulin injection. He developed recurrent severe post-absorptive hypoglycemic coma with a high concentration of total serum immunoreactive insulin. Image study of pancreas was unremarkable and selective intra-arterial calcium stimulation with hepatic venous sampling for insulin failed to show a gradient, thus almost completely excluding the possibility of occult insulinoma or noninsulinoma pancreatogenous hypoglycemic syndrome. After the disclosure of a high titer of circulating insulin binding antibody, he was diagnosed with IAS and prescribed oral steroid for symptom relief.

Therefore, we recommend that insulin autoimmune

syndrome be one of the differential diagnosis in patient with hyperinsulinemic hypoglycemia.

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PP12 ECTOPIC MEDIASTINAL PARATHYROID ADENOMA MIMICKING METASTATIC MALIGNANCY: A CASE REPORT 1

FANG-PING KUNG, 1TA-JEN WU, 2YA-PING CHEN, 3WU-WEI LAI, 4SHI-MING HUANG 1 Division of Endocrinology and Metabolism,2Division of Hematology & Oncology,3Division of Chest Surgery, 4Division of General Surgery, National Cheng Kung University Hospital, Tainan, Taiwan A healthy 45-year-old woman presented with chronic left hip pain for 1 year. She did not report having nausea, vomiting, constipation, lethargy or body weight loss. Pelvic –X ray showed large irregular osteolytic lesion with cortical destruction over the left ilium.

Tc-99m MDP Whole body bone scan revealed increased radioactivity in right S-I joint, bilateral ilium and pubic bones. On magnetic resonance imaging, osseous metastases of unknown origin at pelvic bones with cortical destruction and soft tissue extension were suspected. A biopsy sample obtained from left ilium turned out to be osteitis fibrosa cystica, known as brown tumor. Laboratory tests revealed a serum calcium level of 12.4 mg per deciliter (normal range, 8.6 to 10.1 mg per deciliter), a serum phosphate level of 1.6 mg per deciliter (normal range, 2.5 to 4.5 mg per deciliter), and a serum parathyroid hormone level of 439 pmol per deciliter (normal range, 10 to 65).Tc-99m sestamibi parathyroid scan showed an ectopic hyperfunctioning parathyroid tissues in the anterior mediastinum. Computed tomographic imaging of the chest revealed anterior mediastinal soft tissue tumor. Thymectomy was performed and an intrathoracic parathyroid adenoma was removed. She was treated with calcium and vitamin D supplement for hungry bone syndrome following parathyroidectomy.

We reported a case of rarely seen ectopic parathyroid adenoma mimicking the presentation of metastatic bone tumor. The clinician should be highly alert to check phosphate, calcium and PTH levels in routine survey for multiple osteolytic lesions

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