We aimed to describe congenital keratoglobus with blue sclera in two siblings with overlapping Marshall/Stickler phenotype. Two sisters (ages four and six) with bilateral high astigmatism were evaluated by slit-lamp microscopy. Corneal topography and pachymetry maps were also obtained. Slit-lamp examination revealed that both corneas were globular in shape with peripheral corneal thinning. Pachymetry maps showed diffuse corneal thinning. Two siblings had in common the features of keratoglobus, blue sclera, atypical face, hearing loss, and hypermobile joints. We tentatively diagnosed the sisters as having an overlapping Marshall-Stickler phenotype based on clinical and radiological findings. Marshall-Stickler syndrome may exist in the differential diagnosis of keratoglobus with blue sclera.

Age-related macular degeneration (AMD) is a leading cause of blindness in developed countries. The ARMS2 gene has been found to be associated with AMD. Currently, intravitreal ranibizumab (IVR) treatment is one of the widely used treatments for neovascular AMD. The aim of this study was to investigate the association between the genotype of ARMS2 rs10490924 polymorphism and IVR treatment responsiveness in patients with neovascular AMD. The study included 39 patients with advanced neovascular AMD (patient group) and 250 healthy individuals with exome sequencing data (control group). The patient group was divided into three subgroups: GG (N = 10), TG (N = 14), and TT (N = 15). Before IVR treatment, all patients had intraretinal or subretinal fluid or both. They received three monthly IVR-injection treatments. One month after the third injection, the patients were evaluated as either "responders" or "non-responders" based on the presence or absence of intraretinal or subretinal fluid or both. The patient subgroups TG and TT had an 8.56- and 39-fold higher risk of AMD, respectively, than patient subgroup GG had. The allele frequency was 0.537 and 0.10 in the patient and control groups, respectively. Within the patient subgroup TT, there was a significant difference between the "responders" and "non-responders" (P = 0.025). In conclusion, in neovascular AMD patients undergoing IVR treatment, TT genotype tended to be a better predictor of good short-term treatment response, compared to the GG and TG genotypes. Further studies using confirmed genetic biomarkers for individualized optimal treatments are required.

PURPOSE:To evaluate the efficacy of intravitreal ranibizumab (IVR) combined with posterior sub-Tenon injection of triamcinolone acetonide (STTA) for treatment of diabetic macular edema (DME) with serous retinal detachment (SRD).METHODS:Eighty-five eyes of 65 patients with DME and SRD were enrolled in this retrospective study. Fifty-eight eyes were treated with IVR and STTA (combined group), whereas 27 eyes were treated with pro re nata (PRN) IVR (control group). The combined group patients received a single and the control group patients received mean 1.29 ± 0.46 injections and followed for 3 months. The primary outcome measures were change in central macular thickness (CMT) and best corrected visual acuity (BCVA). The secondary outcome measure was the complication rate.RESULTS:In the combined group, mean initial CMT was 543.9 ± 133.5 μm. Macular thickness was significantly reduced both after 1 month (334 ± 88 μm; P < 0.001) and after 3 months (387.6 ± 131.9 μm; P < 0.001) of treatment. At the 3-month follow-up, BCVA improved in 37.2% of the eyes. Complications were drug reflux at the time of STTA injection, elevation of intraocular pressure, and migration of hard exudates to the fovea. The decrease in CMT was statistically significant in the combined group in the first month, but not in the third month compared with the control group. The improvement in BCVA was not statistically significant between the 2 groups both after the first and third months. SRD disappeared with a higher rate with the combined therapy in the first month.CONCLUSION:IVR and STTA seem to be effective in improving BCVA in DME with SRD.

AIM:The aim of this study was to determine the relationship between biochemical parameters, parathyroid adenoma volume, and bone mineral density with respect to intact parathyroid hormone (iPTH) levels in patients with primary hyperparathyroidism.METHODS:Data were collected retrospectively from patients with primary hyperparathyroidism who were diagnosed and followed in our clinic between 2005 and 2008. Forty-eight (female/male=42/6) patients with a mean age of 52.8±13.1 years were enrolled into the study.RESULTS:Bone pain was the most common presenting feature, seen in 41.7% of patients, while 29.1% of patients were asymptomatic. The mean serum calcium and iPTH concentrations were 2.9±0.6 mmol/L and 657.1±682 ng/L, respectively. The mean total Z/T scores of dual-energy X-ray absorptiometry (DEXA) scan at the femur and lumbar spine were -0.4±1.6/-1.0±1.7 and -1.4±1.6/-2.2±1.5, respectively. Preoperative iPTH levels were correlated with serum phosphate (r=-0.412, P=0.005), alkaline phosphatase (r=0.698, P=0.0001), and femur (r=-0.402, P=0.020) and lumbar spine total Z scores (r=-0.441, P=0.013), whereas parathyroid adenoma volume was correlated with iPTH (r=0.367, P=0.036) and alkaline phosphatase (r=0.570, P=0.001). There was no correlation between iPTH, serum calcium levels and total T scores at the femur and lumbar spine. After excluding patients with 25-OHD insufficiency, there was still no correlation between serum iPTH and calcium levels. Parathyroid adenoma volume, serum iPTH and calcium levels were also not different between patients with and without 25-OHD insufficiency.CONCLUSION:These results suggest that serum iPTH level may be useful in predicting parathyroid adenoma volume and it is also well correlated with femur and lumbar spine Z scores.

Insulin resistance (IR) is one of the common features of the polycystic ovary syndrome (PCOS), and recent studies indicate the possible role of vitamin D in the pathogenesis of IR and glucose metabolism. Aim of this study was aimed to determine the effect of vitamin D replacement therapy on glucose metabolism, insulin, and androgen levels in obese, insulin-resistant women with PCOS. Eleven women with PCOS were included in the study. Mean age of the patients was 23.6±5.7 yr, body mass index 33.9±5.1 kg/m2. Six patients (54.5%) had acantosis nigricans and 10 (90.9%) oligoamenorrhea. The mean Ferriman Gallwey score was 14.1 ±4.6. Only 2 women were within the normal limits of vitamin D levels as >20 ng/ml. Three weeks after the administration of the single dose of 300,000 units of vitamin D3 orally, 25-hydroxyvitamin D3 significantly increased from 16.9±16 ng/ml to 37.1 ±14.6 ng/ml (p: 0.027) and only 2 women were detected to have vitamin D3 levels <20 ng/ml. Although glucose and insulin levels were decreased non-significantly, homeostasis model assesment (HOMA)-IR significantly decreased from 4.41 ±1.38 to 3.67±1.48 (p: 0.043). No significant alterations were witnessed at the levels of DHEAS, total and free testosterone, androstenedione. No correlation was found between vitamin D with HOMA and other hormonal parameters. In conclusion, women with PCOS have mostly insufficient vitamin D levels, and vitamin D replacement therapy may have a benefical effect on IR in obese women with PCOS.

Combinations of insulin and oral antidiabetic drugs (OAD) are often prescribed instead of insulin alone. In this study, the effects of insulin glargine (IG) in combination with repaglinide or acarbose on glycemic parameters were investigated. Obese Type 2 diabetic patients with fasting blood glucose (FBG) levels ≥ mmol/l and hemoglobin glycated (A1C) ≥9% under maximal OAD combination therapy were enrolled. Previous therapies were discontinued, and patients were randomized into 2 groups. The combinations of IG and repaglinide were administered to group 1, and of IG and acarbose to group 2 for 13 weeks. Twenty patients in group 1 and 18 patients in group 2 completed the study. A1C levels were significantly decreased from 10.9±1.4% to 7.7±1.1% in group 1 and 11.0±1.4% to 8.1±1.4% in group 2. FBG levels were significantly decreased from 11.9±2.7 to 7.1 ±2.3 mmol/l in group 1 and 11.1 ±2.5 to 6.8±1.4 mmol/l in group 2. Post-prandial glucose levels were significantly decreased from 15.3±3.8 to 10.3±3.0 mmol/l in group 1 and 14.0±3.1 to 8.9±2.2 mmol/l in group 2. Intergroup comparisons indicated no significant differences. More weight gain was detected in group 1, compared to the baseline. Syptomatic hypoglycemia incidence was similar in both groups. Severe hypoglycemic attacks were seen in two patients in group 1. Flatulance incidence was higher in acarbose group. Conclusively, repaglinide and acarbose were equally effective when combined with IG for obese Type 2 diabetic patients controlled inadequately with OAD alone. Furthermore, acarbose seems to have advantages over repaglinide concerning weight gain and severe hypoglycemic attacks.

Internal Medicine JournalVolume 39, Issue 12 p. e5-e7 Suicide attempt of a physician with 3600 units of insulin and rapid onset acute hepatitis M. Guclu, M. Guclu Department of Endocrinology and Metabolism, School of Medicine, Uludag University, Bursa, TurkeySearch for more papers by this authorC. Ersoy, C. Ersoy Department of Endocrinology and Metabolism, School of Medicine, Uludag University, Bursa, TurkeySearch for more papers by this authorS. Imamoglu, S. Imamoglu Department of Endocrinology and Metabolism, School of Medicine, Uludag University, Bursa, TurkeySearch for more papers by this author M. Guclu, M. Guclu Department of Endocrinology and Metabolism, School of Medicine, Uludag University, Bursa, TurkeySearch for more papers by this authorC. Ersoy, C. Ersoy Department of Endocrinology and Metabolism, School of Medicine, Uludag University, Bursa, TurkeySearch for more papers by this authorS. Imamoglu, S. Imamoglu Department of Endocrinology and Metabolism, School of Medicine, Uludag University, Bursa, TurkeySearch for more papers by this author First published: 30 December 2009 https://doi.org/10.1111/j.1445-5994.2009.02090.xCitations: 7Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume39, Issue12December 2009Pages e5-e7 RelatedInformation

Papillary thyroid carcinoma is one of the differentiated cancers of the thyroid. Hypothyroidism occuring after total thyroidectomy and ablative dose of radioactive iodine should be treated with L-thyroxine to prevent clinical symptoms and signs of hypothyroidism and occasional tumor growth. A 50-year-old female patient with a history of total thyroidectomy 15 years ago due to papillary thyroid carcinoma with capsule invasion followed by ablative dose of radioactive iodine and received no hormone replacement treatment from then-on since she was lost to follow-up was admitted with dyspnea on excursion and chest pain. Although she had laboratory findings of hypothyroidism, there was no remarkable clinical sign or symptom related to hypothyroidism other than isolated pericardial effusion. Her thyroglobulin (Tg) level was low but a halo image was observed in the pericardiac region with no other activity in the rest of the body in I131 scan. Differential diagnosis indicated that isolated pericardial effusion was due to hypothyroidism rather than recurrence of the papillary thyroid carcinoma. The importance of thyroid status evaluation in suspected individuals for the differential diagnosis of complications due to the recurrence of the underlying thyroid cancer or hypothyroidism and the reliability of Tg to rule out metastasis in cases with a false positive I131 scan are discussed on behalf of our case in the view of the literature.

Background. Screening for thyroid autoimmunity in patients with chronic idiopathic urticaria (CIU) is generally recommended. However, there are not yet sufficient data as to whether levothyroxine treatment is beneficial for the clinical symptoms of CIU in patients with thyroid autoimmunity.Aim. We investigated the effect of levothyroxine treatment on clinical symptoms and serum tumour necrosis factor (TNF)-alpha, interleukin (IL)-10 and interferon (IFN)-gamma levels in euthyroid patients with CIU and thyroid autoimmunity.Methods. In total, 15 patients with CIU and positive thyroid autoantibodies were randomized to receive either levothyroxine plus 5 mg/day desloratadine (suppression group, n = 8) or 5 mg/day desloratadine alone (control group, n = 7) for 12 weeks. Clinical symptoms of CIU, thyroid hormone levels, thyroid antibodies and serum cytokine levels were assessed at baseline and after the treatment.Results. There were significant improvements in pruritus score and severity of weals in both groups compared with baseline values, but when the two groups were compared, there was no significant difference in the patients' clinical symptoms. Thyroid antibody titres were not different according to intragroup and intergroup analysis. In the suppression group, serum IFN-gamma and TNF-alpha levels were increased after treatment with levothyroxine compared with baseline values and there was a borderline statistical significance (P = 0.05 for both).Conclusions. These results suggest that levothyroxine treatment is not a reasonable option in euthyroid patients with CIU and thyroid autoimmunity. Augmentation of cytokine production after levothyroxine treatment seems to be related to the immunomodulatory effects of TSH-suppressive treatment.

Ghrelin, a potent gut-brain orexigenic peptide, has a role in stimulation of food intake and long-term regulation of body weight. Metformin and pioglitazone treatment have different effects on body weight. This discrepancy might be related with the effect of these two drugs on plasma ghrelin levels. We investigated the effect of these two drugs on post-prandial acylated and total ghrelin levels in patients with type 2 diabetes. Eleven patients treated with diet, 12 patients treated with 850 mg/day metformin monotherapy and 12 patients treated with 30 mg/day pioglitazone monotherapy for at least 6 months were enrolled in the study. Plasma acylated and total ghrelin levels were investigated at baseline and at the 60 (th), 120 (th), 180 (th), 240 (th) minutes after a mixed meal test. There were no differences between groups in any of baseline metabolic and anthropometric parameters, including acylated and total ghrelin levels. Acylated and total ghrelin concentrations were suppressed similarly after food consumption, and we could not determine any significant difference between the groups at any time interval. A prolonged postprandial suppression of acylated ghrelin concentrations was observed in the pioglitazone treatment group compared with baseline values. In conclusion, total and acylated ghrelin levels after a mixed meal test were similar in type 2 diabetic patients treated with metformin, pioglitazone or diet therapy alone. These results suggest that changes in body weight during metformin and pioglitazone treatment are not associated with plasma ghrelin levels.

Aim: Autoimmune disorders are considered to be associated with a Th1 immune response whereas allergic diseases with a Th2 response. Studies mainly performed on children revealed conflicting results regarding the association of atopy/allergic disease and autoimmune disorders. Therefore, we aimed to investigate the prevalence of allergic diseases in adult Type 1 diabetic patients. Methods: Eighty-nine Type 1 diabetic patients and 64 controls were enrolled into the study. Skin-prick test and European Community Respiratory Health Survey questionnaire were performed on all cases. Patients who gave at least one positive answer to questions about asthma in the questionnaire underwent pulmonary function test and methacholine challenge test. Results: Patients’ mean age were similar in diabetic patients and controls (28.2±8.9 and 28.1±5.2 yr; respectively). In skin-prick test. the rate of positive response to at least one allergen was not significantly different in diabetes (29.2%) and in the control group (31.3%). In European Community Respiratory Health Survey questionnaire, diabetic patients waked up by an attack of cough more than controls did. The rate of physician-diagnosed asthma was similar in both groups. There was no difference between the 2 groups based on the answers of other questions about asthma and other allergic diseases such as allergic rhinitis, eczema, and drug allergy. Conclusion: We found that atopy frequencies were similar in an adult population of Type 1 diabetic patients and controls. Although asthmatic symptom prevalence is increased in diabetic patients, the incidence of current asthma was similar in both groups.

AIM:To determine if therapeutic management programmes for type 2 diabetes that include self-monitoring of blood glucose (SMBG) result in greater reductions in glycated haemoglobin (HbA1c) compared with programmes without SMBG in non-insulin requiring patients. METHODS:Multicentre, randomized, parallel-group trial. A total of 610 patients were randomized to SMBG or non-SMBG groups. Patients in both groups received the same oral antidiabetic therapy using a gliclazide modified release (MR)-based regimen for 27 weeks. The primary efficacy end-point was the difference between groups in HbA1c at the end of observation. RESULTS:A total of 610 patients were randomized: 311 to the SMBG group and 299 to the non-SMBG group. HbA1c decreased from 8.12 to 6.95% in the SMBG group and from 8.12 to 7.20% in the non-SMBG group; between-group difference was 0.25% (95% CI: 0.06, 1.03; p = 0.0097). Symptoms suggestive of mild to moderate hypoglycaemia was the most commonly reported adverse event, reported by 27 (8.7%) and 21 (7.0%) patients in the SMBG and non-SMBG groups, respectively; the incidence of symptomatic hypoglycaemia was lower in the SMBG group. CONCLUSION:In patients with type 2 diabetes, the application of SMBG as an adjunct to oral antidiabetic agent therapy results in further reductions in HbA1c.

Nocardia species are aerobic and saprophytic actinomycetes found all around the world. They invade the human body from the environment via trauma and the respiratory tract, and cause cutaneous, pulmonary, and systemic nocardiosis in humans. There is no age, ethnic group, or geographic variation in nocardiosis caused by the different Nocardia species, and the male to female ratio for infection is 3 to 1.1McNeil M.M. Brown J.M. The medically important aerobic actinomycetes. Epidemiology and microbiology.Clin Microbiol Rev. 1994; 7: 357-417Crossref PubMed Scopus (562) Google Scholar Nocardiosis is a rare infection and almost half of all cases are immunocompromised subjects.2Hidri N. Farina C. Boiron P. İnci R. Nocardia and human nocardiosis.Turkish J Infect. 2001; 15: 1-13Google Scholar, 3Auzary C. Du Boutin L.T. Wechsler B. Chollet P. Piette J.C. Disseminated nocardiosis presenting as a flare of Behçet's disease.Rheumatology (Oxford). 2001; 40: 949-952Crossref PubMed Scopus (8) Google Scholar, 4Korkmaz C. Aydınlı A. Erol N. Yıldırım N. Akgün Y. İnci R. et al.Widespread nocardiosis in two patients with Behçet's disease.Clin Exp Rheumatol. 2001; 19: 462-469Google Scholar, 5Pamuk G.E. Pamuk O.N. Tabak F. Mert A. Öztürk R. Aktuğlu Y. Systemic Nocardia infection in a patient with Behçet's disease.Rheumatol. 2001; 40: 597-599Crossref PubMed Scopus (11) Google Scholar, 6Leong K.P. Tee N.W. Yap W.M. Chee T.S. Koh E.T. Nocardiosis in patients with systemic lupus erythematosus. The Singapore lupus study group.J Rheumatol. 2000; 27: 1306-1312PubMed Google Scholar, 7Saubolle M.A. Susland D. Nocardiosis. Review of clinical and laboratory experience.J Clin Microbiol. 2003; 41: 4497-4501Crossref PubMed Scopus (310) Google Scholar The taxonomy of Nocardia species is a complex issue and more than 30 different species have been reported to date.8Brown-Elliot B.A. Clinical and laboratory features of the Nocardia spp based on current molecular taxonomy.Clin Microbiol Rev. 2006; 19: 259-282Crossref PubMed Scopus (756) Google Scholar The morphologic and phenotypic characterization of these species is difficult and time-consuming, hence they have been grouped mainly on the basis of their pattern of drug resistance (types I–VI). Nocardia asteroides drug pattern type VI has recently been identified as Nocardia cyriacigeorgica by use of the 16S rRNA gene amplification method. Therefore, N. cyriacigeorgica is not really a new species, but a new name given to a relatively common species.9Roth A. Andrees S. Reiner M.K. Harmsen D. Mauch H. Phylogeny of the genus Nocardia based on reassessed 16S rRNA gene sequences reveals underspeciation and division of strains classified as Nocardia asteroides into three established species and two unnamed taxons.J Clin Microbiol. 2003; 41: 851-856Crossref PubMed Scopus (160) Google Scholar, 10Conville P.S. Fischer S.H. Cartwright C.P. Witebsky F.G. Identification of Nocardia species by restriction endonuclease analysis of an amplified portion of 16S rRNA gene.J Clin Microbiol. 2007; 45: 1146-1151Crossref PubMed Scopus (41) Google Scholar This bacterium was originally described by Yassin et al. with the name N. cyriacigeorgici;11Yassin A.F. Rainey F.A. Steiner U. Nocardia cyriacigeorgici sp.nov.Int J Syst Evol Microbiol. 2001; 51: 1419-1423Crossref PubMed Scopus (26) Google Scholar its name was subsequently changed to N. cyriacigeorgica. Few invasive forms of Nocardia species have been reported in the literature.12Ansari S.R. Han X.Y. O’Brien S. Safdar A. Nocardia veterana bloodstream infection in a patient with cancer and a summary of reported cases.Int J Infect Dis. 2006; 10: 483-486Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar, 13Fux C. Bodmer T. Ziswiler H.R. Leib S.L. Nocardia cyriacigeorgici: first report of invasive human infection.Dtsch Med Wochenschr. 2003; 128: 1038-1041Crossref PubMed Scopus (12) Google Scholar, 14van Dam A.P. Pruijm M.T. Harinck B.I. Gelinck L.B. Kuijper E.J. Pneumonia involving Aspergillus and Rhizopus spp after a near-drowning incident with subsequent Nocardia cyriacigeorgici and N. farcinica coinfection as a late complication.Eur J Clin Microbiol Infect Dis. 2005; 24: 61-64Crossref PubMed Scopus (34) Google Scholar, 15Barnaud G. Deschamps C. Manceron V. Mortier E. Laurent F. Bert F. et al.Brain abscess caused by Nocardia cyriacigeorgica in a patient with human immunodeficiency virus infection.J Clin Microbiol. 2005; 43: 4895-4897Crossref PubMed Scopus (47) Google Scholar, 16Elsayed S. Kealey A. Coffin C.S. Read R. Megran D. Zhang K. Nocardia cyriacigeorgica septicemia.J Clin Microbiol. 2006; 44: 280-282Crossref PubMed Scopus (32) Google Scholar, 17Alp E. Yıldız O. Bilgehan A. Sumerkan B. Sari I. Koc K. et al.Disseminated nocardiosis due to unusual species: two case reports.Scand J Infect Dis. 2006; 38: 545-548Crossref PubMed Scopus (20) Google Scholar, 18Arslan U. Tuncer I. Uysal E.B. Inci R. Pleuropulmonary and soft tissue Nocardia cyriacigeorgici infection in a patient with Behcet's disease.Saudi Med J. 2007; 28: 1435-1437PubMed Google Scholar, 19Muñoz J. Mirelis B. Aragón L.M. Gutiérrez N. Sánchez F. Español M. et al.Clinical and microbiological features of nocardiosis 1997–2003.J Med Microbiol. 2007; 56: 545-550Crossref PubMed Scopus (120) Google Scholar, 20Kageyama A. Yazawa K. Ishikawa J. Hotta K. Nishimura K. Mikami Y. Nocardial infections in Japan from 1992 to 2001, including the first report of infection by Nocardia transvelensis.Eur J Epidemiol. 2004; 19: 383-389Crossref PubMed Scopus (103) Google Scholar, 21Kageyama A. Hoshino Y. Yazawa K. Poonwan N. Takeshita N. Maki S. et al.Nocardia cyriacigeorgica is a significant pathogen for nocardiosis in Japan and Thailand.Mycopathologia. 2005; 160: 15-19Crossref PubMed Scopus (18) Google Scholar, 22Poonwan N. Mekha N. Yazawa K. Thunyaharn S. Yamaka A. Mikami Y. Characterization of clinical isolates of pathogenic Nocardia strains and related actinomycetes in Thailand from 1996–2003.Mycopathologia. 2005; 159: 361-368Crossref PubMed Scopus (33) Google Scholar The case described herein is the first in the literature involving pulmonary N. cyriacigeorgica infection in an immunocompromised patient with Basedow–Graves disease. We also review the previously reported cases of N. cyriacigeorgica infections in humans. The case was a 37-year-old man who was started on propylthiouracil treatment, 450 mg daily, for treatment of Basedow–Graves disease. After approximately one year, an orbital computerized tomography (CT) scan was performed, and findings resembling a thyroid orbitopathy were found. He was started on methylprednisolone treatment, 96 mg daily, which was gradually tapered and ceased a month later; he developed diabetes mellitus secondary to corticosteroid treatment, which was controlled with appropriate diet and gliclazide treatment. In July 2003 following consultation at the ophthalmology department, methylprednisolone treatment, 48 mg daily, was started once more. In September 2003, while under the corticosteroid treatment, he was admitted to our hospital with complaints of lethargy, weight loss, muscle weakness, dyspnea, cough, hemoptysis, blurred and double vision, pain in the eye, generalized itching, and papular lesions on his upper trunk. On physical examination, crackles were detected in the basal segments of both lungs. Exophthalmia was detected in both eyes, diffuse and bilateral enlargement of the thyroid gland was noted, and muscle weakness was present in the lower extremities. A posteroanterior chest X-ray showed multiple sharp-edged homogenous masses as large as 6 cm in diameter resembling metastases, with heterogeneous increment in density in the lung parenchyma. In laboratory evaluation his leukocyte count was 12.8 × 109/l with 90% neutrophils in the differential count, C-reactive protein level was 9.62 mg/dl, and blood glucose level was 319 mg/dl. On the second day, he had a fever of 39.0 °C. In the chest CT, diffuse consolidations and calcifications were detected in the lung parenchyma. His blood glucose was regulated with insulin treatment. Following consultation with the infectious diseases department and after obtaining a sputum specimen, cefepime 2 g iv every 12 hours, amikacin 1000 mg iv/day, trimethoprim–sulfamethoxazole (TMP–SMX 80/400 mg) four tablets every 12 hours po, and amphotericin B deoxycholate 1 mg/kg/day iv were started. Direct microscopic examination of the sputum with modified Ziehl–Neelsen stain showed many branching acid-fast bacilli (Figure 1). Sputum cultures performed on four occasions grew Nocardia spp, Candida spp, and Aspergillus fumigatus. Antibiotic susceptibility testing with the E-test revealed resistance to TMP–SMX (minimum inhibitory concentration (MIC) ≥0.064 mg/l) and his serum aspergillus galactomannan test was found to be negative; TMP–SMX and amphotericin B treatments were ceased and vancomycin was added. Following the determination of Nocardia spp as the causative agent this was changed to imipenem 500 mg iv (MIC 0.125 mg/l) every 6 hours for 5 days, but unfortunately the patient died. Although many attempts at treatment were undertaken, the patient's situation deteriorated. He died 30 days after hospitalization due to acute circulatory failure and disseminated infection that did not respond to medical treatment. Our case was a male patient with an immunocompromising condition (Basedow–Graves disease), long-term and high dose corticosteroid usage, and resultant diabetes mellitus. Mootsikapun et al. reported four cases with diabetes mellitus and one case with Graves disease among their 70 cases of nocardiosis,23Mootsikapun P. Intarapoka B. Liawnoraset W. Nocardiosis in Srinagarind Hospital, Thailand: review of 70 cases from 1996–2001.Int J Infect Dis. 2004; 9: 154-158Abstract Full Text Full Text PDF Scopus (69) Google Scholar but there were no data on the species names of the bacteria. Our patient's symptoms, physical examination, and radiological findings were in concordance with the symptoms and findings of pulmonary nocardiosis reported in the literature. A summary of reported nocardiosis cases with N. cyriacigeorgica as the etiologic agent is shown in Table 1.Table 1Summary of reported cases of Nocardia cyriacigeorgica infection (adapted from Ansari et al.12Ansari S.R. Han X.Y. O’Brien S. Safdar A. Nocardia veterana bloodstream infection in a patient with cancer and a summary of reported cases.Int J Infect Dis. 2006; 10: 483-486Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar)ReferenceAge (years), sexUnderlying disease and concurrent infectionsSystemic corticosteroid useInfection siteCulture samplesTreatmentInfection outcomeYassin et al.11Yassin A.F. Rainey F.A. Steiner U. Nocardia cyriacigeorgici sp.nov.Int J Syst Evol Microbiol. 2001; 51: 1419-1423Crossref PubMed Scopus (26) Google ScholarNAChronic bronchitisNANABronchial secretionNANAFux et al.13Fux C. Bodmer T. Ziswiler H.R. Leib S.L. Nocardia cyriacigeorgici: first report of invasive human infection.Dtsch Med Wochenschr. 2003; 128: 1038-1041Crossref PubMed Scopus (12) Google Scholar59, MRAYes + methotrexate, mycophenolateMultifocal brain abscessesAbscess fluidMeropenem + amikacin + ceftriaxone, TMP–SMXResolvedvan Dam et al.14van Dam A.P. Pruijm M.T. Harinck B.I. Gelinck L.B. Kuijper E.J. Pneumonia involving Aspergillus and Rhizopus spp after a near-drowning incident with subsequent Nocardia cyriacigeorgici and N. farcinica coinfection as a late complication.Eur J Clin Microbiol Infect Dis. 2005; 24: 61-64Crossref PubMed Scopus (34) Google Scholar22, MFungal pneumonia + N. farcinicaNoLungBALMeropenem + amikacin, TMP–SMXImprovedBarnaud et al.15Barnaud G. Deschamps C. Manceron V. Mortier E. Laurent F. Bert F. et al.Brain abscess caused by Nocardia cyriacigeorgica in a patient with human immunodeficiency virus infection.J Clin Microbiol. 2005; 43: 4895-4897Crossref PubMed Scopus (47) Google Scholar33, FHIV infectionNoBrain abscessBALAmoxicillin + minocycline + TMP–SMXImprovedElsayed et al.16Elsayed S. Kealey A. Coffin C.S. Read R. Megran D. Zhang K. Nocardia cyriacigeorgica septicemia.J Clin Microbiol. 2006; 44: 280-282Crossref PubMed Scopus (32) Google Scholar69, FDiabetes mellitus, chronic lymphocytic leukemiaNALung, CNS, RAMBlood, adrenal biopsy specimenMeropenem, TMP–SMXResolved47, FFollicular non-Hodgkin lymphoma, ASCTNALungBloodMeropenem, TMP–SMXResolved (died from aspergillosis)Alp et al.17Alp E. Yıldız O. Bilgehan A. Sumerkan B. Sari I. Koc K. et al.Disseminated nocardiosis due to unusual species: two case reports.Scand J Infect Dis. 2006; 38: 545-548Crossref PubMed Scopus (20) Google Scholar72, MNoNoMultiple intracranial abscessesSputum, abscess materialCeftriaxone + amikacinImprovedArslan et al.18Arslan U. Tuncer I. Uysal E.B. Inci R. Pleuropulmonary and soft tissue Nocardia cyriacigeorgici infection in a patient with Behcet's disease.Saudi Med J. 2007; 28: 1435-1437PubMed Google Scholar25, MBehcet's diseaseYesLung, STAAbscess materialCefoperazoneDied (from pulmonary embolism)Muñoz et al.19Muñoz J. Mirelis B. Aragón L.M. Gutiérrez N. Sánchez F. Español M. et al.Clinical and microbiological features of nocardiosis 1997–2003.J Med Microbiol. 2007; 56: 545-550Crossref PubMed Scopus (120) Google Scholar74, MCOPDYesLungNASulfadiazineSurvived58, MHeart transplant, diabetesYesLungNATMP–SMXSurvived44, FCOPD, RAYesLungNATMP–SMXSurvived71, FCOPD, lymphomaYesLungNATMP–SMXDied76, MCOPDNoLungNATMP–SMXSurvived79, MCOPDNoLungNACo-amoxiclavSurvivedNA, not available; M, male; F, female; RA, rheumatoid arthritis; TMP–SMX, trimethoprim–sulfamethoxazole; BAL, bronchoalveolar lavage; CNS, central nervous system; RAM, right adrenal mass; ASCT, allogeneic stem cell transplant; STA, soft tissue abscess; COPD, chronic obstructive pulmonary disease. Open table in a new tab NA, not available; M, male; F, female; RA, rheumatoid arthritis; TMP–SMX, trimethoprim–sulfamethoxazole; BAL, bronchoalveolar lavage; CNS, central nervous system; RAM, right adrenal mass; ASCT, allogeneic stem cell transplant; STA, soft tissue abscess; COPD, chronic obstructive pulmonary disease. Kageyama et al. reported 31 cases affected by N. cyriacigeorgica in Japan,20Kageyama A. Yazawa K. Ishikawa J. Hotta K. Nishimura K. Mikami Y. Nocardial infections in Japan from 1992 to 2001, including the first report of infection by Nocardia transvelensis.Eur J Epidemiol. 2004; 19: 383-389Crossref PubMed Scopus (103) Google Scholar and in another report by the same author, 27 cases – 19 in Japan and eight in Thailand.21Kageyama A. Hoshino Y. Yazawa K. Poonwan N. Takeshita N. Maki S. et al.Nocardia cyriacigeorgica is a significant pathogen for nocardiosis in Japan and Thailand.Mycopathologia. 2005; 160: 15-19Crossref PubMed Scopus (18) Google Scholar Poonwan et al. reported 13 strains of N. cyriacigeorgica in Thailand.22Poonwan N. Mekha N. Yazawa K. Thunyaharn S. Yamaka A. Mikami Y. Characterization of clinical isolates of pathogenic Nocardia strains and related actinomycetes in Thailand from 1996–2003.Mycopathologia. 2005; 159: 361-368Crossref PubMed Scopus (33) Google Scholar There were no data in these reports on the clinical features of the cases, hence these series could not be detailed in Table 1; we recommend the readers to see original reports for further details.20Kageyama A. Yazawa K. Ishikawa J. Hotta K. Nishimura K. Mikami Y. Nocardial infections in Japan from 1992 to 2001, including the first report of infection by Nocardia transvelensis.Eur J Epidemiol. 2004; 19: 383-389Crossref PubMed Scopus (103) Google Scholar, 21Kageyama A. Hoshino Y. Yazawa K. Poonwan N. Takeshita N. Maki S. et al.Nocardia cyriacigeorgica is a significant pathogen for nocardiosis in Japan and Thailand.Mycopathologia. 2005; 160: 15-19Crossref PubMed Scopus (18) Google Scholar, 22Poonwan N. Mekha N. Yazawa K. Thunyaharn S. Yamaka A. Mikami Y. Characterization of clinical isolates of pathogenic Nocardia strains and related actinomycetes in Thailand from 1996–2003.Mycopathologia. 2005; 159: 361-368Crossref PubMed Scopus (33) Google Scholar In terms of geographical distribution, N. cyriacigeorgica seems to be predominant in Asian and European countries, as reported cases have come from Japan, Thailand, Turkey, Germany, and Spain.9Roth A. Andrees S. Reiner M.K. Harmsen D. Mauch H. Phylogeny of the genus Nocardia based on reassessed 16S rRNA gene sequences reveals underspeciation and division of strains classified as Nocardia asteroides into three established species and two unnamed taxons.J Clin Microbiol. 2003; 41: 851-856Crossref PubMed Scopus (160) Google Scholar, 13Fux C. Bodmer T. Ziswiler H.R. Leib S.L. Nocardia cyriacigeorgici: first report of invasive human infection.Dtsch Med Wochenschr. 2003; 128: 1038-1041Crossref PubMed Scopus (12) Google Scholar, 14van Dam A.P. Pruijm M.T. Harinck B.I. Gelinck L.B. Kuijper E.J. Pneumonia involving Aspergillus and Rhizopus spp after a near-drowning incident with subsequent Nocardia cyriacigeorgici and N. farcinica coinfection as a late complication.Eur J Clin Microbiol Infect Dis. 2005; 24: 61-64Crossref PubMed Scopus (34) Google Scholar, 15Barnaud G. Deschamps C. Manceron V. Mortier E. Laurent F. Bert F. et al.Brain abscess caused by Nocardia cyriacigeorgica in a patient with human immunodeficiency virus infection.J Clin Microbiol. 2005; 43: 4895-4897Crossref PubMed Scopus (47) Google Scholar, 16Elsayed S. Kealey A. Coffin C.S. Read R. Megran D. Zhang K. Nocardia cyriacigeorgica septicemia.J Clin Microbiol. 2006; 44: 280-282Crossref PubMed Scopus (32) Google Scholar, 17Alp E. Yıldız O. Bilgehan A. Sumerkan B. Sari I. Koc K. et al.Disseminated nocardiosis due to unusual species: two case reports.Scand J Infect Dis. 2006; 38: 545-548Crossref PubMed Scopus (20) Google Scholar, 18Arslan U. Tuncer I. Uysal E.B. Inci R. Pleuropulmonary and soft tissue Nocardia cyriacigeorgici infection in a patient with Behcet's disease.Saudi Med J. 2007; 28: 1435-1437PubMed Google Scholar, 19Muñoz J. Mirelis B. Aragón L.M. Gutiérrez N. Sánchez F. Español M. et al.Clinical and microbiological features of nocardiosis 1997–2003.J Med Microbiol. 2007; 56: 545-550Crossref PubMed Scopus (120) Google Scholar, 20Kageyama A. Yazawa K. Ishikawa J. Hotta K. Nishimura K. Mikami Y. Nocardial infections in Japan from 1992 to 2001, including the first report of infection by Nocardia transvelensis.Eur J Epidemiol. 2004; 19: 383-389Crossref PubMed Scopus (103) Google Scholar, 21Kageyama A. Hoshino Y. Yazawa K. Poonwan N. Takeshita N. Maki S. et al.Nocardia cyriacigeorgica is a significant pathogen for nocardiosis in Japan and Thailand.Mycopathologia. 2005; 160: 15-19Crossref PubMed Scopus (18) Google Scholar, 22Poonwan N. Mekha N. Yazawa K. Thunyaharn S. Yamaka A. Mikami Y. Characterization of clinical isolates of pathogenic Nocardia strains and related actinomycetes in Thailand from 1996–2003.Mycopathologia. 2005; 159: 361-368Crossref PubMed Scopus (33) Google Scholar, 23Mootsikapun P. Intarapoka B. Liawnoraset W. Nocardiosis in Srinagarind Hospital, Thailand: review of 70 cases from 1996–2001.Int J Infect Dis. 2004; 9: 154-158Abstract Full Text Full Text PDF Scopus (69) Google Scholar In the literature, all reported cases have had the invasive disease, and there is only one case report on this bacterium in a cat with cutaneous infection.24Malik R. Krockenberger M.B. O’Brien C.R. White J.D. Foster D. Tisdall P.L. et al.Nocardia infections in cats: a retrospective multi-institutional study of 17 cases.Aust Vet J. 2006; 84: 235-245Crossref PubMed Scopus (41) Google Scholar In our patient, after finding branching acid-fast bacilli on direct microscopy, sputum samples were cultured in blood agar, chocolate agar, and Sabouraud's dextrose agar, and incubated for 2–4 weeks. The diagnosis of Nocardia was obtained from our laboratory; the identification of N. cyriacigeorgica was performed by P. Boiron in the Mycology Laboratory of Claude Bernard University using the 16S rRNA gene amplification method.9Roth A. Andrees S. Reiner M.K. Harmsen D. Mauch H. Phylogeny of the genus Nocardia based on reassessed 16S rRNA gene sequences reveals underspeciation and division of strains classified as Nocardia asteroides into three established species and two unnamed taxons.J Clin Microbiol. 2003; 41: 851-856Crossref PubMed Scopus (160) Google Scholar, 25Couble A. Rodriguez-Nava V. Perouse de Montclos M. Boiron P. Laurent F. Direct detection of Nocardia spp in clinical specimens by a rapid molecular method.J Clin Microbiol. 2005; 43: 1921-1924Crossref PubMed Scopus (66) Google Scholar A total of 85 N. cyriacigeorgica cases have been reported to date for which 27 of the infections have been located in the lung, three in the brain, and one in the eye; the infection sites of the remaining 54 cases were not identified in the reports. According to Kageyama et al., the combination of an aminoglycoside with imipenem acts synergistically.20Kageyama A. Yazawa K. Ishikawa J. Hotta K. Nishimura K. Mikami Y. Nocardial infections in Japan from 1992 to 2001, including the first report of infection by Nocardia transvelensis.Eur J Epidemiol. 2004; 19: 383-389Crossref PubMed Scopus (103) Google Scholar In the literature, most of the improved or resolved cases were treated with meropenem, amikacin, or ceftriaxone combination and oral TMP–SMX as maintenance therapy (Table 1); it appears that the most convenient combination is meropenem + amikacin. It should be noted that this bacterium is resistant to beta-lactams, ciprofloxacin, and some macrolides.26Glupczynski Y. Berhin C. Janssens M. Wauters G. Determination of antimicrobial susceptibility patterns of Nocardia spp from clinical specimens by Etest.Clin Microbiol Infect. 2006; 12: 905-912Crossref PubMed Scopus (89) Google Scholar Our patient received a combination of cefepime, amikacin, and imipenem according to antibiogram test results. However, since he was seriously immunodeficient and diabetic due to long-term corticosteroid therapy, the condition resulted in death. In conclusion, N. cyriacigeorgica has the potential to cause invasive infections in immunocompromised patients. Nocardia infections should be borne in mind in all cases with the probability of immune system derangement and should be differentiated from other fungal and mycobacterial infections and malignancies as quickly as possible and treated promptly with aggressive combination protocols. The authors are indebted to Professor Patrick Boiron from Mycology Laboratory of Claude Bernard University, France, and Professor Ramazan Inci from the Mycology Laboratory of Ege University School of Medicine, Izmir, Turkey, for their contributions in identifying Nocardia cyriacigeorgica. Financial support: No financial support was given for this report. Conflict of interest: No conflict of interest to declare.

Background. To evaluate the obesity status, factors and comorbidities related to it in three district municipalities (DM) that compose city center of Bursa with inhabitants of different socioeconomic status.Methods. A total of 1632 inhabitants greater than or equal to 18 years of age were interviewed. The number of sample in each DM was obtained proportional to their populations by stratified sampling method. Among 1632, a total of 1543 subjects were included by random sampling and a questionnaire was filled in including demographic, social and behavioral features.Results. The participants living in DM with the highest socioeconomical status (SES) score and level of education had the lowest body mass index (BMI) and body fat percentage (%BF) compared to other DMs. The lowest obesity prevalence (30.8% vs. 36.4% and 39.3%) in that DM was possibly due to younger age, lower female ratio, more active professional, higher percentage of smoking, more consumption of vegetables, olive or corn oil, and less carbohydrate. For the evaluation of the factors that may influence obesity risk, we investigated the effects of these factors in men and women separately with logistic regression model. Sedentary life style and dyslipidemia (DL) in men, being unemployed, having lower level of education and having hypertension (HT) in women and familial obesity in both gender were found to be related to increased obesity risk.Conclusions. The prevalence of obesity in Bursa is increasing although inhabitants are taking some precautions parallel to their socioeconomical and educational levels. Obesity is becoming a more alarming public health problem in Bursa and Turkey like in most other parts of the world, which forces us to invent new prevention policies. Besides, the results of our study highlight the fact that especially female education requires more attention for decreasing obesity prevalence in coming generations. (C) 2004 The Institute For Cancer Prevention and Elsevier Inc. All rights reserved.

B rown tumors are locally destructive bone lesions caused by rapid osteoclastic bone resorption due to severe hyperparathyroidism1. For years, brown tumors have been considered to be characteristic of primary hyperparathyroidism. However, brown tumors also have been reported to occur in patients with severe hyperparathyroidism secondary to chronic renal failure2-4, especially those on long-term hemo-dialysis. Hypocalcemia, hyperphosphatemia, and vitamin-D deficiency are the basic characteristics of chronic renal failure associated with secondary hyperparathyroidism. Fig. 1 Photograph of the lesion at presentation. The appearance of brown tumor lesions in a patient with secondary hyperparathyroidism due to malabsorption has been reported5; but, to our knowledge, there are no reported cases of a patient in whom brown tumor developed secondary to osteomalacia due to inadequate sunlight exposure and dietary vitamin-D deficiency. Our patient was informed that data concerning the case would be submitted for publication. A twenty-eight-year-old woman who had been in purdah (no skin exposed in public except the hands and face) since she was thirteen years old presented with a 4 × 3-cm painful mass in the region of the fourth metacarpal of the right hand without redness or warmth (Fig. 1). Her hand movement was extremely restricted. Radiographs revealed an expansile lytic lesion …

Brown tumor is an important but rare complication of primary hyperparathyroidism. It is seen in approximately 1% of the cases. Common involvement areas are long bones, ribs, hand, skull, pelvic bones, and mandible. The maxillary sinus is a rare involvement site. Patellar bone involvement has not been reported. Because brown tumor and giant cell tumor have similar histopathologic findings, the differential diagnosis is important. We present a patient with ectopic parathyroid adenoma with multiple brown tumors located in uncommon areas such as the maxillary sinus and patella. A 54-year-old female patient was operated on 3 times for the suspicion of osteal giant cell tumor. After admission, the diagnosis of primary hyperparathyroidism was suggested by the clinical history. This was confirmed by biochemical, radiologic, and histopathologic determinations. Excision of an ectopic parathyroid adenoma normalized the metabolic status. The unusual brown tumor localizations were important in the differential diagnosis of lytic skeletal lesions.

Objective: To examine serum leptin concentrations in obese and lean patients with polycystic ovary syndrome (PCOS) to assess whether the changes in leptin levels are due to obesity or hormonal alterations.Design: Controlled clinical study.Setting: Academic research environment.Patient(s): Obese and lean women with PCOS.Intervention(s): Blood samples were collected before and after food consumption.Main Outcome Measure(s): Serum leptin and insulin levels.Result(s): Serum leptin concentrations were significantly correlated with body mass index (r = 0.649) and also with HOMA (r = 0.535). However, after controlling for body mass index in a partial correlation analysis, no significant correlation was found between serum leptin levels and HOMA or hyperinsulinemia. While lean patients with PCOS had a significant correlation between leptin concentrations and obesity parameters, they did not show any significant correlation with insulin resistance parameters.Conclusion(s): Although leptin concentrations in women with PCOS correlate with insulin resistance/hyperinsulinemia, this is related only to obesity. (C) 2004 by American Society for Reproductive Medicine.