Isoniazid Induced Unilateral Gynecomastia: A Rare Case Report

Gynecomastia refers to glandular enlargement of male breast. It can be physiological, pathological, pharmacological and idiopathic. The present case report describes a case of isoniazid induced gynecomastia. Keywords: Gynecomastia, antitubercular treatment (ATT), isoniazid.

Giant torus mandibularis causing submandibular duct obstruction and sialadenitis

Torus mandibularis is a benign osseous overgrowth arising from the lingual surface of the mandible. It is a common, incidental finding on imaging due to its relatively high prevalence. In the majority of cases, mandibular tori are asymptomatic. We report a novel presentation of a giant torus mandibularis causing bilateral obstruction of the submandibular ducts and consequent sialadenitis. Our patient presented with progressive pain centered in the floor of his mouth and had bilateral submandibular glandular enlargement on exam. Computed tomography showed a giant right torus mandibularis, which was causing obstruction and dilation of the bilateral submandibular ducts. Although conservative management was attempted, he ultimately underwent surgical resection of his torus with symptomatic improvement. This patient highlights a novel complication of torus mandibularis and illustrates successful treatment. Though not previously described, this complication may be underreported and should be considered in the appropriate clinical setting.

Clinical features and outcomes from the Singapore Sjögren's syndrome study

Objective To study the clinical features, treatment and outcomes of primary Sjögren's Syndrome (pSS) in a Singapore cohort from an outpatient rheumatology clinic. Methods Computerised Physician Order entry records of patients who fulfilled the 2016 ACR-EULAR classification criteria for pSS between 1993 and 2013 were retrospectively analysed. Results There were 102 patients, of which 96 (94.1%) were females, and 91 (89.2%) Chinese. Mean age at diagnosis was 49.3 ± 11.8 years, mean disease duration was 9.0 ± 4.6 years. The most common manifestations were keratoconjunctivitis sicca (99.0%), xerostomia (96.1%), arthralgia/arthritis (56.9%). Exocrine glandular enlargement comprised parotidomegaly (28, 27.5%), with concurrent submandibular and lacrimal gland enlargement in one. The nervous system (15.7%) was the most commonly affected internal organ, with peripheral nervous system (peripheral neuropathy, mononeuritis multiplex) involvement more common than central. Hydroxychloroquine was most frequently used (88.2%), followed by methotrexate (7.8%) and azathioprine (6.9%). Pulsed intravenous (IV) methylprednisolone 500 mg/day for 3 days was used in 5 patients followed by oral (4) or IV cyclophosphamide (1) for cardiomyopathy and interstitial lung disease (1), and neurological involvement (4). These comprised neuromyelitis optica, transverse myelopathy, cranial neuropathy, mononeuritis multiplex and/or peripheral neuropathy alone or in combination. Intravenous immunoglobulins (2.0%) was used for sensory neuropathy and mononeuritis multiplex; rituximab (1.0%) in 1 patient for treatment of non-Hodgkin’s B-cell lymphoma. There were no deaths. Conclusion Musculoskeletal manifestations were common, with the nervous system (peripheral more than central) the most common internal organ involved. Lymphoma was uncommon despite up to one-third of the cohort developing glandular enlargement.

Diagnosis

Clinically, a diffuse, firm goiter with pyramidal lobe enlargement, and without signs of thyrotoxicosis, should suggest the diagnosis of Hashimoto's thyroiditis (HT). The association of goiter with hypothyroidism is almost diagnostic. The thyroid stimulating hormone (TSH) is the sensitive marker of hypothyroidism and diagnosis of subclinical hypothyroidism. Thyroid perioxidase antibodies (TPO-Ab) and, less frequently, thyroglobulin antibodies (Tg-Ab) are elevated in the serum of patients with HT. Ultrasound may display an enlarged gland with normal texture, focal, or diffuse glandular enlargement with coarse, heterogenous, and hypo-echoic pattern, or a suggestion of multiple ill-defined micro-nodules. Color Doppler shows extensive hyper-vascularity. Histologically, the thyroid gland shows diffuse lymphocytic and plasma cell infiltration with formation of lymphoid follicles. Atrophy of the thyroid parenchyma is usually evident. It also reveals scant colloid, and a few epithelial cells, which may show Hurthle cell change. This chapter explores the diagnosis of Hashimoto's disease.

A new cannula for suction removal of parenchymal tissue of gynaecomastia

Background: There are various surgical techniques that are available for surgical management of gynecomastia. The aim of the study was to evaluate the cosmetic results and patient satisfaction of a combined liposuction with excision for gynecomastia.Methods: Clinical records of patients affected by gynecomastia referred to our department between between 2015 and 2018 were analyzed, total of 23 patients were included in the study.Results: Overall 23 patients underwent surgery for gynecomastia in the study period, a total of 42 breasts were operated as most of the cases were bilateral in nature. 19 patients had bilateral presentation while 4 patients had unilateral presentation. 35 breasts (80%) were operated with a combined liposuction and excision. Liposuction addresses the fatty gynecomastia whereas open excision is used to remove the glandular enlargement. Four patients underwent excision alone as these patients had a firm retro-areolar lump that was suspicious for malignancy. Another four patients underwent liposuction alone.Conclusions: Surgery is the main stay of management of gynecomastia. Liposuction with excision has had the best outcome with good cosmetic results, acceptable complication rates and good patient satisfaction.

Glandular Enlargement

Glandular enlargement in the mediastinum is usually due to hyperplasia of thymus in the anterior mediastinum or thyroid enlargement with intramediastinal growth. Thymic enlargement is typically due to rebound hyperplasia associated with chemotherapy, radiation therapy, and stresses. Rebound thymic hyperplasia manifests as diffuse, symmetric enlargement of the thymus. MRI may be helpful in distinguishing thymic hyperplasia from neoplastic involvement of the thymus, as the former lose signal on opposed-phase T1-weighted MR imaging. Thyroid goiters may originate in the neck and migrate into the mediastinum or arise from an ectopic focus of mediastinal thyroid tissue. Goiters manifest as mediastinal masses that are similar in appearance to the thyroid gland, with intrinsic hyperdensity, hyperenhancement, foci of calcification and cystic change.

Lymphocytic hypophysitis

✓ A case of lymphocytic hypophysitis is described in a patient presenting with panhypopituitarism 8 years after her last childbirth. The patient developed headache, vomiting, and diplopia (due to palsy of the right lateral rectus muscle) 7 months after delivery of her last baby. The diplopia disappeared after a few days with symptomatic treatment, and the headache and vomiting decreased in intensity with analgesic therapy. Eight years later the patient developed symptoms suggestive of hypoadrenalism, hypothyroidism, and amenorrhea. Investigations revealed panhypopituitarism with a pituitary mass lesion. Repeat evaluation 1 year later demonstrated no change in the size of the pituitary gland. The patient underwent transsphenoidal surgery with a provisional diagnosis of pituitary adenoma. Histological examination of the resected gland revealed evidence of lymphocytic hypophysitis. Symptoms suggestive of a pituitary mass lesion were noted during the peripartum period, but features of hypopituitarism developed much later. Such a long latent period has not been reported before. This report also highlights the fact that glandular enlargement may persist for many years after the onset of lymphocytic hypophysitis.

METABOLISM OF TESTOSTERONE BY FOREHEAD SKIN OF THE ROEBUCK (CAPREOLUS CAPREOLUS)

Roebucks have a specialized region of skin on the forehead which contains sebaceous and apocrine glands that produce secretions used in territorial marking. These glands enlarge during the breeding season and regress after the rut as the testes regress. The metabolism of testosterone by this forehead skin in vitro was studied in two captive roebucks over the period of glandular enlargement and subsequent regression, and compared with that of dorsal skin. In May, June and July, both areas of skin actively metabolized testosterone and the metabolites detected were androstenedione, androstanedione, dihydrotestosterone, epiandrosterone, androsterone and 5α-androstanediols. There were no major differences in testosterone metabolism between the two body sites, although dorsal skin appeared to be more active in total metabolism than forehead skin. There was a peak in the extent of metabolism in June/July, with a subsequent gradual decline to December. The decline in metabolism occurred at a time when the associated glands were still enlarged, which suggests that the availability of androgen to the skin glands is determined not only by the amount of testosterone in the circulation, but also by a decrease in the metabolizing capacity of the tissue.

Synergistic autonomic nervous regulation of accelerated salivary gland growth in rats

Within 8 days after a submandibular salivary gland is deprived of its parasympathetic nervous innervation, the gland undergoes a marked reduction in weight. After either sympathectomy or parasympathectomy, the increase in gland weight which usually follows incisor amputation or dietary pancreatin is partially inhibited. The gland weight response to these two stimuli is completely inhibited after combined sympathectomy and parasympathectomy. In contrast, the response of the glands to isoproterenol is not dependent upon nervous innervation since administration of the drug still causes glandular enlargement after partial or complete denervation. Compensatory growth of the remaining submandibular gland after removal of one gland and ligation of the ducts of the parotid glands is partially inhibited by section of either nervous branch alone and almost entirely inhibited after complete denervation. A small but definite compensatory response still occurs after complete denervation indicating that humoral as well as nervous factors may be involved in this response. In hypophysectomized rats the response of the submandibular glands to growth hormone administration is not impaired by partial or complete autonomic denervation, indicating that nervous factors do not have a role in this effect of growth hormone.