Osteoporosis is common disorder of elderly population all over the world as well as in India. The presence of osteoporosis predicts fracture risk. Fragility fracture has marked morbidity as well as mortality. Thus, osteoporosis has marked therapeutic and economic implications. Osteoporosis is defined by low bone mineral density (BMD). The gold-standard method to assess BMD is dual X-ray absorptiometry (DXA). In India, hologic and lunar machines are most commonly used to measure BMD; these machines have their own normative data from which patients BMD is compared and results are generated. As per recommendations, all postmenopausal women and men above 70 years need BMD estimation other than quite a few other specific indications as well. With increasing life expectancy, increased awareness of osteoporosis, and availability of DXA machines, there is flooding of requests for BMD estimation. In view of all this, it becomes imperative on part of physicians, orthopedicians, rheumatologists, and endocrinologists alike to be fully aware about pitfalls in BMD assessment by DXA and interpretation of BMD reports.

Thyroid hormone (TH) is known to have many beneficial effects on vital organs, but its extrapolation to be used therapeutically has been restricted by the fact that it does have concurrent adverse effects. Recent finding of various thyroid hormone receptors (TR) isoforms and their differential pattern of tissue distribution has regained interest in possible use of TH analogues in therapeutics. These findings were followed by search of compounds with isoform-specific or tissue-specific action on TR. Studying the structure-activity relationship of TR led to the development of compounds like GC1 and KB141, which preferentially act on the β1 isoform of TR. More recently, eprotirome was developed and has been studied in humans. It has shown to be effective in dyslipidemia by the lipid-lowering action of TH in the liver and also in obesity. Another compound, 3,5-diiodothyropropionic acid (DITPA), binds to both α- and β-type TRs with relatively low affinity and has been shown to be effective in heart failure (HF). In postinfarction models of HF and in a pilot clinical study, DITPA increased cardiac performance without affecting the heart rate. TR antagonists like NH3 can be used in thyrotoxicosis and cardiac arrhythmias. However, further larger clinical trials on some of these promising compounds and development of newer compounds with increased selectivity is required to achieve higher precision of action and avoid adverse effects seen with TH.

Thyroid ultrasonography has established itself as a popular and useful tool in the evaluation and management of thyroid disorders. Advanced ultrasound techniques in thyroid imaging have not only fascinated the radiologists but also attracted the surgeons and endocrinologists who are using these techniques in their daily clinical and operative practice. This review provides an overview of indications for ultrasound in various thyroid diseases, describes characteristic ultrasound findings in these diseases, and illustrates major diagnostic pitfalls of thyroid ultrasound.

Thyroidectomy is the most common endocrine surgical procedure being carried out throughout the world. Besides, many patients who have deranged thyroid physiology, namely hyperthyroidism and hypothyroidism, have to undergo various elective and emergency surgical procedures at some stage of their life. The attending anesthesiologist has to face numerous daunting tasks while administering anesthesia to such patients. The challenging scenarios can be encountered at any stage, be it preoperative, intra-op or postoperative period. Preoperatively, deranged thyroid physiology warrants optimal preparation, while anticipated difficult airway due to enlarged thyroid gland further adds to the anesthetic challenges. Cardiac complications are equally challenging as also the presence of various co-morbidities which make the task of anesthesiologist extremely difficult. Thyroid storm can occur during intra-op and post-op period in inadequately prepared surgical patients. Postoperatively, numerous complications can develop that include hemorrhage, laryngeal edema, nerve palsies, tracheomalacia, hypocalcemic tetany, pneumothorax, etc., The present review aims at an in-depth analysis of potential risk factors and challenges during administration of anesthesia and possible complications in patients with thyroid disease.

Endocrine surgeries have been on the rise for the last few years. During surgery, endocrine disorders present unique challenges to the endocrinologist and to the attending anesthesiologist. The endocrine, electrolyte and metabolic disturbances resulting from such disorders can have a profound effect on the normal human physiological milieu. Surgery of parathyroid glands is no exception and is associated with a multiple challenges during pre-, intra-, and post-operative period. Pre-op examination and optimization is essential so as to prevent any intra-op or post-op complications. The most striking electrolyte disturbance during parathyroid surgery is the imbalance of calcium levels in the body and the main emphasis during the entire peri-operative period revolves around the maintenance of normal serum calcium levels. The present article review in depth the various anesthetic considerations and implications during parathyroid surgery with an emphasis on pre-op preparation for elective and emergency surgery.

Osteoporosis has traditionally been considered a disorder of postmenopausal women, but low bone mass and accelerated bone loss can also occur early in life causing premenopausal osteoporosis. There are a few risk factors that increase a woman's risk of premenopausal osteoporosis, including drugs, hormonal and nutritional factors, and physical in-activity, which need to be identified and managed accordingly. Lifestyle modification is of importance in preventing progressive bone loss in premenopausal women and should be actively encouraged.

A number of drugs have been advocated for the medical management of Cushing's syndrome but few have gained widespread acceptance. The most reliably effective agents are metyrapone and ketoconazole as monotherapy, or in combination. Cabergoline may be of value in a minority of patients but pasireotide is a more reliable and effective agent that lowers cortisol secretion in the great majority of patients, although only normalises UFC in a minority. The potential for combination of an agent that blocks adrenal steroidogenesis with inhibition of ACTH secretion by pasireotide needs to be explored.

Basal insulin have been developed over the years. In recent times newer analogues have been added to the armanentarium for diabetes therapy. This review specifically reviews the current status of different basal insulins

Objective: The objective of this study was to optimize dose of levothyroxine (LT4) based on lean body mass (LBM) in young athyrotic patients with differentiated carcinoma of thyroid (DCT) which has not been properly addressed in Bangladesh before. Materials and Methods: Sixty patients with DCT (age, range: 20-39 years) having total thyroidectomy followed by radioiodine ablative therapy (RIT) and 23 euthyroid volunteers were recruited. Clinical, biochemical parameters were obtained from all patients after 2 months of RIT and on LT4 replacement at a dose of 200 μg/day as first follow up visit and also from control subjects. Then 60 patients were divided into two groups consisting of 30 patients each. Patients of Group-I received LT4 replacement based on LBM measured by dual energy X-ray absorptiometry (DXA) and Group-II continued LT4 replacement in conventional dose. Patients of both groups were assessed again for same parameters at 6 to 12 months at the second visit. Results: Optimized dose of LT4 based on LBM by DXA (131 ±23 μg/day) significantly reduced thyroid hormones and kept thyroid stimulating hormone (TSH) in expected levels in patients of Group-I at the second visit compared to patients of Group-II who continued conventional LT4 dose (200 μg/day). Hyperthyroid symptom scale (HSS) was significantly reduced to 2 ± 1 in patients of Group-I but not in patients of Group-II, HSS, 8 ±1 ( P < 0.001). Conclusion: Optimization of LT4 dose based on LBM can avoid chronic exposure of mild excess of thyroid hormone in young patients with low risk DCT.

Aim and Objectives: 1. To assess the iodine nutritional status in patients with goiter by measuring urinary iodine excretion. 2. To compare the iodine nutritional status with the thyroid function and correlate with the type of thyroid disease. Study Design: Case control study. Materials and Methods: Three hundred patients with goiter and one hundred euthyroid healthy non-goitrous volunteers were included in this study. Results and Conclusions: All patients had elevated urinary iodine suggesting excess iodine intake and absence of iodine deficiency. Complications known to be associated with excess iodine, viz., benign goiter (35%), iodine-induced hyperthyroidism or thyrotoxicosis (34%), thyroiditis (16%) and cancer of thyroid (15%) have been observed in this study. Therefore, continued supplementation of edible salt fortified with iodine should be monitored carefully, and supplementation programs should be tailored to the particular region.

Aim: To study the efficacy of endonasal endoscopic orbital decompression in cases of Graves' orbitopathy. Material and Methods: A total of 24 orbits in 12 patients underwent endoscopic orbital decompression for graves orbitopathy in the period between October 2002 and December 2010. Indications for surgery included proptosis, corneal exposure, keratitis, and compressive optic neuropathy. Decompression was accomplished by the removal of the medial and part of inferior wall of the orbit and slitting of the orbital periosteum. Pre and postoperative exophthalmometry measurements and visual acuity were recorded and compared. Results: A mean orbital regression of 3.70 mm was noted following endoscopic decompression. The visual acuity improved significantly in one of two eyes decompressed for failing visual acuity secondary to optic nerve compression. Transient diplopia was invariable following surgery but resolved over the next 8 weeks. One case manifested unilateral frontal sinus obstruction symptoms 4 months postoperatively and responded to medical therapy. Conclusion: Endonasal endoscopic orbital decompression provides for an effective, safe, and minimally invasive treatment for proptosis and visual loss of Graves Orbitopathy. Long-term problems with diplopia were not noted in the endonasal endoscopic approach for orbital decompression.

Introduction: Cardiovascular system is rich in thyroid hormone receptors and is one of the major sites of action for thyroid hormones. However, the effect of subclinical hypothyroidism (SCH) on atherosclerosis has not been cleared yet. Materials and Methods: SCH is defined as high thyroid-stimulating hormone (TSH) levels in the presence of normal serum T4 and T3 levels. A total of 32 patients with SCH and 29 controls were included in the study. Carotid intima-media thickness, flow-mediated dilatation, and aortic distensibility were compared between the groups. Results: FMD was lower in patients with SCH than in controls. GTN-induced vasodilatation was similar in the patients with SCH and controls. There was no statistically significant difference between the patients with SCH and controls with respect to CIMT and aortic distensibility. Conclusion: SCH is associated with endothelial dysfunction as established by FMD. Inconsistent results of CIMT and aortic stiffness can be explained by these parameters being measures of structural changes whereas FMD is a dynamic measure that reflects the impact of both acute and chronic influences on endothelial function.

Background: Iodine-rich diet is necessary for proper thyroid gland function. Subclinical hypothyroidism (SCH) is associated with serious complications. Substantial numbers of patients have risk of SCH getting converted into primary hypothyroidism. Objectives: The objectives of the present study are to survey dietary iodine intake pattern in ethnic population of Kashmir and to study the prevalence of SCH. Materials and Methods: A retrospective, cross-sectional referral hospital study was conducted. Sample size comprised of 2550 patients who were referred to Department of Biochemistry, Government Medical college, Srinagar diagnostic laboratory from OPD and IPD of associated SMHS hospital. Assessment of thyroid function over a period of one year from March 2010 to March 2011 in the serum has been performed by electro-chemiluminescence immunoassay method on "ECLIA 2010" fully automatic analyzer. Interview cum questionnaire methods were used to record the patient history and dietary iodine intake pattern. Iodine status of these patients was assessed by measuring urinary iodine excretion. Results: Total patients were 2550 comprising of 44.6% males and 56.4% females. Subjects with elevated and normal thyroid stimulating hormone (TSH) levels in the serum were 30.51 and 69.4% respectively. About 550 patients (21.56%) had subclinical hypothyroidism which includes both males and females. Prevalence of SCH was more in females (81.8%) than in males (18.2%). Most of the patients presenting with SCH were in the age group of 20-65 years. Conclusion: The percentage of SCH amongst the study sample patients was 21.56%, which is much higher as compared to other parts of the world. The highest percentage of SCH was found in females (81.8%) as compared to males (18.2%). On the basis of the present study, we suggest that routine screening of selected populations, especially women between 20 and 65 years of age, may be advocated. Further community level awareness programs need to be organized wherein people in mountainous valley of Kashmir are motivated to take salt in iodized form and diet rich in iodine to ensure proper thyroid gland functioning.

Background: Thyroid dysfunction is a common occurrence in pregnancy and affects both maternal and fetal outcomes. There are limited data on prevalence of hypothyroidism during pregnancy from India. Therefore, this study was designed to evaluate the prevalence of thyroid dysfunction especially hypothyroidism during first trimester in a large public hospital in North India. Materials and Methods: All the consecutive first trimester pregnant women attending Lok Nayak and Kasturba Hospitals were enrolled in the study after institutional ethics approval and consent from the study subjects. The pregnant women with diagnosed thyroid disease and on thyroid medications were excluded from the study. Morning samples of study participants were analyzed for thyroid hormone profile which included free T3, free T4, TSH, and TPO Ab. In addition, all study participants were tested for CBC, LFT, KFT, and lipid profile. Results: A total of 1000 women were enrolled for this prospective observational study. The mean (SD) age of study subjects was 25.6 (11.1) years, and mean (SD) gestational age was 10.3 (3.4) weeks. One hundred and forty-three (14.3%) subjects had TSH values more than 4.5 mIU/L above the cutoff used for definition of hypothyroidism. Out of these, 135 had normal free T4 and therefore labeled as subclinical hypothyroidism and 7 had low free T4 suggestive of overt hypothyroidism. TPO Ab was positive in 68 (6.82%) of total, 25 (18.5%) of subclinical and 5 (71%) of overt hypothyroid patients. Conclusion: Hypothyroidism, especially subclinical, is common in North Indian women during first trimester. Further countrywide studies are needed to evaluate the prevalence and etiology of hypothyroidism to prevent maternal and fetal adverse effects of hypothyroidism in India.

Objective: Alteration in thyroid hormones are seen in critically ill patients admitted to intensive care units. Our objective was to study the thyroid hormone profile, prolactin and, glycosylated hemoglobin (HbA1c) at admission and analyze their correlation with mortality. Materials and Methods: In this single centre, prospective, observational study, 100 consecutive patients (52M; 48F) admitted to medical ICU irrespective of diagnosis were included. Patients with previous thyroid disorders and drugs affecting thyroid function were excluded. All participants underwent complete physical examination and a single fasting blood sample obtained at admission was analyzed for total triiodothyronine (T3), total thyroxine (T4), thyroid stimulating hormone (TSH), HbA1c, and prolactin. The patients were divided into two groups: Group 1 - survivors (discharged from the hospital) and Group 2 - nonsurvivors (patients succumbed to their illness inside the hospital). The data were analyzed by appropriate statistical methods and a P-value of <0.05 was considered significant. Results: The mean age of the participants was 58.7 ± 16.9 years and the mean duration of ICU stay was 3.3 ± 3.1 days. A total of 64 patients survived, whereas remaining 36 succumbed to their illness. The baseline demographic profile was comparable between survivors and nonsurvivors. Nonsurvivors had low T3 when compared with survivors (49.1 ± 32.7 vs. 66.2 ± 30.1, P = 0.0044). There was no significant difference observed between survivors and nonsurvivors with respect to T4, TSH, HbA1c, and prolactin. Conclusion: Our study showed that low T3 is an important marker of mortality in critically ill patients. Admission HbA1c, prolactin, T4, and TSH did not vary between survivors and nonsurvivors.

Objective: The cross-sectional study was carried out to assess the iodine status of pregnant women, using median urinary iodine concentration (MUI) as the measure of outcome, to document the impact of advancing gestation on the MUI in normal pregnancy. Materials and Methods: The present study assessed the MUI in casual urine samples from 50 pregnant subjects of each trimester and 50 age-matched non-pregnant controls. Results: The median (range) of urinary iodine concentration (UIC) in pregnant women was 304 (102-859) μg/L and only 2% of the subjects had prevalence of values under 150 μg/L (iodine insufficiency). With regard to the study cohort, median (range) UIC in the first, second, and third trimesters was 285 (102-457), 318 (102-805), and 304 (172-859) μg/L, respectively. Differences between the first, second, and third trimesters were not statistically significant. The MUI in the controls (305 μg/L) was not statistically different from the study cohort. Conclusion: The pregnant women had no iodine deficiency, rather had high median urinary iodine concentrations indicating more than adequate iodine intake. Larger community-based studies are required in iodine-sufficient populations, to establish gestation-appropriate reference ranges for UIC in pregnancy.

Objective: To study pregnancy outcomes in relation to thyroid peroxidase antibody (TPOAb) status with optimum thyroxine replacement for subclinical hypothyroidism. Materials and Methods: Ninety-eight women with subclinical hypothyroidism were followed up until the end of their pregnancy. TPO antibody status was performed for 59 women (positive 20, negative 39). Levothyroxine was supplemented to maintain TSH between 0.3-3 mIU/l in all patients, irrespective of TPOAb status. Pregnancy outcomes were noted as pregnancy-induced hypertension (PIH), antepartum or postpartum hemorrhage, preterm delivery, and spontaneous abortion. Outcomes were compared between 3 groups as per TPO antibody status (positive, negative, and undetermined), which were matched for age and gestational period. Results: Thyroid autoimmunity was noted in 34% of women screened for TPO antibody. A total of 11 adverse pregnancy outcomes were recorded (4 spontaneous abortions, 4 preterm deliveries, 3 PIH) with no significant difference between the groups. Conclusion: Adverse pregnancy outcomes were not different in the 3 groups with adequate thyroxine replacement for pregnant women with subclinical hypothyroidism targeting TSH in euthyroid range, irrespective of thyroid autoimmunity status.

Background: Permanent hypocalcaemia following thyroidectomy causes considerable morbidity. This prospective observational study aims to define the factors likely to predict hypocalcaemia following total thyroidectomy. Materials and Methods: Patients who were subjected to total thyroidectomy during January 2005 to December 2009 were followed up for a minimum period of 1 year. Efficacy of an intraoperative parathyroid hormone assay to predict hypocalcaemia was validated. Results: Overall incidence of hypocalcaemia was 23.6% ( n = 190) and that of permanent hypocalcaemia was 1.61% ( n = 13). Onset was delayed up to 3 ^rd postoperative day in 13 patients. Hypocalcaemia was significantly associated with thyroidectomy for Grave's Disease ( P = 0.001), Hashimoto's thyroiditis ( P = 0.003), and with incidental parathyroidectomy ( P = 0.006). The intraoperative assay of parathyroid hormone showed low sensitivity (0.5) and satisfactory specificity (0.9) in predicting hypocalcemia. Conclusion: Hypocalcemia could manifest late in the immediate postoperative period and this may explain latent hypocalcemia. High incidence of hypocalcaemia noted in Grave's Disease could be due to the autoimmunity since same feature was noted associated with Hashimoto's thyroiditis and the incidence of hypocalcaemia was not high in the subgroup with toxic nodular goiter. The incidence of hypocalcemia was not affected by age or sex.

Context: Polycystic ovarian syndrome (PCOS), the most common endocrinopathy of women in the reproductive age group seems to be adversely affected by associated thyroid dysfunction. Both pose independent risks of ovarian failure and pregnancy related complications. Aims: The present study from Eastern India is, therefore, aimed to investigate the prevalence and etiology of different thyroid disorders in PCOS subjects. Settings and Design: Cross-sectional hospital based survey-single centre observational case-control study. Materials and Methods: This prospective single-center study recruited 106 female patients with hypertrichosis and menstrual abnormality among which 80 patients were defined as having PCOS according to the revised 2003 Rotterdam criteria and comprised the study population. Another 80 age-matched female subjects were studied as the control population. Thyroid function and morphology were evaluated by measurement of serum thyroid stimulating hormone (TSH), free thyroxine levels (free T3 and free T4), anti-thyroperoxidase antibody (anti-TPO Ab), clinical examination and ultrasound (USG) of thyroid gland. Statistical Analysis Used: It was done by Student's t-test and Chi-square test using appropriate software (SPSS version 19). Results: This case-control study revealed statistically significant higher prevalence of autoimmune thyroiditis, detected in 18 patients (22.5% vs. 1.25% of control) as evidenced by raised anti-TPO antibody levels (means 28.037 ± 9.138 and 25.72 ± 8.27 respectively; P = 0.035). PCOS patients were found to have higher mean TSH level than that of the control group (4.547 ± 2.66 and 2.67 ± 3.11 respectively; P value < 0.05). There was high prevalence of goiter among PCOS patients (27.5% vs. 7.5% of control, P value < 0.001). On thyroid USG a significantly higher percentage of PCOS patients (12.5%; controls 2.5%) had hypoechoic USG pattern also compatible with the diagnosis of autoimmune thyroiditis. Conclusions: High prevalence of thyroid disorders in PCOS patients thus points towards the importance of early correction of hypothyroidism in the management of infertility associated with PCOS.

Introduction: Normal pregnancy results in a number of important physiological and hormonal changes that alter thyroid function. In pregnancy, the thyroid gland being subjected to physiological stress undergoes several adaptations to maintain sufficient output of thyroid hormones for both mother and fetus. Consequently, pregnant women have been found to be particularly vulnerable to iodine deficiency disorders (IDD), and compromised iodine status during pregnancy has been found to affect the thyroid function and cognition in the neonates. Objectives: Two decades after successful universal salt iodization (USI) in the country, there is scarce data on the iodine status of the pregnant women and their neonates. This is more relevant in areas like Kashmir valley part of sub-Himalayan belt, an endemic region for IDD in the past.The objective was to estimate Urinary Iodine status in pregnant women, the most vulnerable population. Materials and Methods: We studied thyroid function [free T3 (FT3), T3, free T4 (FT4), T4, thyroid stimulating hormone (TSH)] and urinary iodine excretion (UIE) in the 1 ^st , 2 ^nd , and 3 ^rd trimesters and at early neonatal period in neonates in 81 mother-infant pairs (hypothyroid women on replacement) and compared them with 51 control mother-infant pairs (euthyroid). Results: Mean age of cases (29.42 + 3.56 years) was comparable to that of controls (29.87 + 3.37 years). The thyroid function evaluation done at baseline revealed the following: FT3 2.92 ± 0.76 versus 3.71 ± 0.54 pg/ml, T3 1.38 ± 0.37 versus 1.70 ± 0.35 ng/dl, FT4 1.22 ± 0.33 versus 1.52 ± 0.21 ng/dl, T4 9.54 ± 2.34 versus 13.55 ± 2.16 μg/dl, and TSH 7.92 ± 2.88 versus 4.14 ± 1.06 μIU/ml in cases versus controls ( P < 0.01), respectively. The 2 ^nd to 6 ^th day thyroid function of neonates born to case and control mothers revealed T3 of 1.46 ± 0.44 versus 1.48 ± 0.36 ng/dl, T4 of 12.92 ± 2.57 versus 11.76 ± 1.78 μg/dl, and TSH of 3.64 ± 1.92 versus 3.82 ± 1.45 μIU/ml, respectively. Discussion: UIE was similar (139.12 ± 20.75 vs. 143.78 ± 17.65 μg/l; P = 0.8), but TSH values were higher in cases (7.92 ± 2.88) as compared to controls (4.14 ± 1.06). Although UIE gradually declined from 1 ^st trimester to term, it remained in the sufficient range in both cases and controls. Thyroid function and UIE was similar in both case and control neonates. Conclusion: We conclude that pregnant Kashmiri women and their neonates are iodine sufficient, indicating successful salt iodization in the community. Large community-based studies on thyroid function, autoimmunity, malignancies, etc., are needed to see the long-term impact of iodization.

Primary hypothyroidism is a common endocrine diseases and in recent times with increased awareness of thyroid diseases among internists, gynecologists and primary care physicians the number of patients with thyroid dysfunction seems increasing. During Ramadan, often patients find it difficult to administer levothyroxine on empty stomach since they may not wake up so early, so in this article suggestion has been given to take it at bed time. We conducted a prospective observational study during this year's holy month of Ramadan on patients enrolled from our thyroid clinic who had hypothyroidism and decided to undertake fasting. Our aim was to study the impact of bed time levothyroxine on TSH (thyroid stimulating hormone) levels.

The parathyroid glands are now recognized as being essential for life. Their structure and function is well delineated, and their disease and dysfunction, well characterized. Diagnosis and management of parathyroid disease has improved in the past few decades. The path of parathyroid science, however, has been far from smooth. This paper describes the early history of parathyroid endocrinology. In doing so, it focuses on major events and discoveries, which improved the understanding and practice of our specialty. Contribution in anatomy, physiology, pathology, medicine, surgery and biochemistry are reviewed.

Pheochromocytoma is an uncommon cause of high blood pressure touching adults. The combination of severe hypertension in the triad of headache, sweating, and tachycardia should suggest this diagnosis; this clinical picture is similar to that of hyperthyroidism. We report the case of a 22-year-old patient with multiple pheochromocytoma associated with Graves' disease revealed by malignant hypertension and discussed the difficulties of the diagnosis and the treatment approach.

Antithyroid medications are one of the treatment options for Graves' disease. Carbimazole is widely used as the drug of choice, except in pregnancy, where propythiouracil is preferred by many. It is generally well-tolerated. Its side-effects include allergy, upper gastrointestinal upset, a rare occurrence of granulocytosis, and others. Hepatitis is another rare, but serious side-effect. We report a healthy 30-year-old male patient with Graves' disease, who developed cholestatic jaundice after Carbimazole therapy for four months. He made a full recovery after the drug was discontinued. An idiosyncratic mechanism seemed likely.

Parathyroid carcinoma is a very rare cause of hyperparathyroidism. The diagnosis is usually established on histopathological grounds of capsular and vascular invasion, but a potential clue to the diagnosis is also offered by the severity of clinical profile, abrupt onset of symptoms, and a high degree of hypercalcemia and raised serum parathyroid hormone (PTH). We report a case of an elderly female with a prolonged history of generalized weakness and bone pain along with bilateral renal calculi, classical bony lesions, and a high serum calcium and PTH level who underwent a right inferior parathyroidectomy considering a parathyroid adenoma as our diagnosis. However, the biopsy report was consistent with a parathyroid carcinoma, and so, she was further subjected to an ipsilateral hemithyroidectomy as a completion procedure. So, we would like to emphasize that its preferable to have a high index of suspicion for parathyroid carcinoma when these clues are present, than to miss the opportunity for surgical cure in the first go by failing to consider it in the differential diagnosis.

Autoimmune endocrinopathies and, less commonly, thyroid autoimmune disease have been reported in patients with sarcoidosis. Similarities exist in the pathogenesis of these two conditions. Concomitant sarcoidosis in the thyroid gland in patients with Graves' disease may contribute to the resistance to antithyroid drugs and radioiodine therapy. We present the clinical, laboratory, imaging, and pathologic findings of a patient with Graves' disease who was unresponsive to medical management. This 37-year-old man presented with thyrotoxicosis. Thyroid hormone assays and ^99m Technitium findings were consistent with Graves' disease. He was also found to have hilar lymphadenopathy. Patient failed to achieve remission with high doses of antithyroid drugs and 2 sessions of radioiodine ablative therapy.Histopathology of lymph nodesdisclosed noncaseating granulomas, consistent with sarcoidosis. Patient's thyrotoxicosis subsided only following steroid administration. The histopathology of the thyroid gland on aspiration and the subsidence of symptoms with steroids reiterate the possibility of thyroid sarcoidosis. This diagnosis needs biopsy for confirmation, which our patient didn't consent for.

We describe here the case of an elderly female with severe osteoporosis, who presented with a worsening backache, following teriparatide treatment. She was subsequently diagnosed to have normocalcemic primary hyperparathyroidism. Before prescribing teriparatide, an appropriate endocrine evaluation must be undertaken by all healthcare physicians (serum intact parathyroid hormone (iPTH) level), despite having a normal serum calcium. Normocalcemic hyperparathyroidism should be considered as an important alternate cause for osteoporosis.

Propylthiouracil (PTU) is a common drug used in patients with hyperthyroidism. It may cause perinuclearantineutrophil cytoplasmic antibodies (p-ANCA) in few patients with Graves' disease. This antibody has been associated with different forms of vasculitis. We report a patient who presented with cutaneous manifestations of leukocytoclasticvasculitis with simultaneous development of p-ANCAs during PTU therapy for Graves' disease.

Ocular myasthenia gravis in conjunction with thyroid disorders, although rare, has been reported in the past. However, the similarity in the presentation of both the entities and the tendency of myasthenia gravis to get overlooked easily, even by experienced clinicians, necessitates a thorough knowledge, a strong consideration, and a vigilant approach, to aid in its diagnosis. We discuss a case of a female in a thyrotoxic state, with symptoms of ocular myasthenia gravis, and a brief overview of this entity.

Association of Grave's ophthalmopathy with hyperthyroidism is well known, and it has also been reported in euthyroid or hypothyroid autoimmune thyroiditis, which rarely requires treatment. Here, we report a case of bilaterally symmetrical severe corticosteroid-resistant hypothyroid Grave's ophthalmopathy successfully treated with rituximab.

Primary hyperparathyroidism (PHP) with pheochromocytoma and neurofibromatosis type 1 is a rare clinical association. We present a case of PHP and pheochromocytoma occurring in a 33-year-old male with familial cutaneous neurofibromatosis.