Publications by authors named "Annalisa Montebello"

12 Publications

  • Page 1 of 1

Neurosyphilis in a suspected case of giant cell arteritis.

BMJ Case Rep 2021 Sep 8;14(9). Epub 2021 Sep 8.

Diabetes and Endocrinology, Mater Dei Hospital, Msida, Malta.

A 67-year-old man had a few month history of deteriorating visual acuity. He had originally presented to ophthalmology with right-sided visual blurring. This subsequently progressed to involve the left eye. At this point, he was empirically treated with high-dose glucocorticoids, both orally and intravenously, with the suspicion that giant cell arteritis was causing acute visual deterioration of his left eye. Unfortunately, his symptoms did not improve. During an admission to hospital for a pneumonia, he underwent further investigations for this bilateral visual loss. He was diagnosed with left neuroretinitis and right vitritis. A thorough workup revealed positive syphilis serology and cerebrospinal fluid was positive on venereal disease research laboratory testing. He was diagnosed and treated for neurosyphilis with intravenous benzylpenicillin 4 million units 4 hourly for 14 days. His left-sided vision improved but he still suffers from severe visual impairment in his right eye.
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http://dx.doi.org/10.1136/bcr-2021-242733DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8438723PMC
September 2021

Biochemically silent phaeochromocytoma presenting with non-specific loin pain.

BMJ Case Rep 2021 Aug 16;14(8). Epub 2021 Aug 16.

Department of Diabetes and Endocrinology, Mater Dei Hospital, Msida, Malta.

A 55-year-old woman presented with a 4-month history of right-sided non-specific loin pain and 6 kg weight loss. A CT scan of the abdomen and pelvis showed an incidental 4.5 cm right-sided adrenal lesion which was not typical of an adrenal adenoma. This was further confirmed on MRI of the adrenals. Biochemical investigations to investigate for a functional adrenal lesion included serum catecholamines and metanephrines, an aldosterone to renin ratio and an overnight dexamethasone suppression test. These were all negative. A laparoscopic adrenalectomy was performed in view of the large size of the lesion. Histology was consistent with a phaeochromocytoma, which confirmed the diagnosis of a non-secreting phaeochromocytoma. Non-secreting phaeochromocytomas are rare and usually found in patients with known genetic mutations. Adrenal lesions not related to any mutations similar to our case are even rarer and reported even less in the literature.
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http://dx.doi.org/10.1136/bcr-2021-244258DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8370509PMC
August 2021

Recurrent Graves' disease post SARS-CoV-2 infection.

BMJ Case Rep 2021 Aug 6;14(8). Epub 2021 Aug 6.

Diabetes and Endocrinology, Mater Dei Hospital, Msida, Malta

A 22-year-old woman was diagnosed with thyrotoxicosis 8 weeks after the diagnosis of a mild COVID-19 infection. She had reported significant unexplained weight loss after testing positive for COVID-19, but failed to seek medical attention. She recovered well from COVID-19, but presented to the emergency department with worsening symptoms of thyrotoxicosis after 2 months. In view of her known history of previously treated Graves' disease, a recurrence of Graves' thyrotoxicosis was suspected. A positive thyroid stimulating hormone receptor antibody confirmed the diagnosis. She was started on carbimazole and propranolol treatment with significant improvement of her symptoms.
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http://dx.doi.org/10.1136/bcr-2021-244714DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8351485PMC
August 2021

Hypercalcaemia due to ovarian small cell carcinoma of the hypercalcaemic type.

BMJ Case Rep 2021 Jul 30;14(7). Epub 2021 Jul 30.

Department of Diabetes and Endocrinology, Mater Dei Hospital, L-Imsida, Malta.

A 37-year-old woman presented with a few days' history of lower abdominal pain and an incidental finding of hypercalcaemia. A thorough workup ensued, and the cause was found to be an exceptionally rare ovarian tumour-ovarian small cell carcinoma of the hypercalcaemic type. Acute treatment of hypercalcaemia consisted of aggressive intravenous fluids and bisphosphonates. She underwent surgery to remove the tumour and is currently receiving systemic platinum/etoposide chemotherapy combination to be followed by pelvic radiotherapy. This case highlights the wide range of differential diagnosis for hypercalcaemia and the importance of a stepwise and thorough approach during investigations. We discuss the pathophysiology of malignancy-related hypercalcaemia, focusing especially on parathyroid hormone-related peptide-associated hypercalcaemia.
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http://dx.doi.org/10.1136/bcr-2021-243571DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8327804PMC
July 2021

Para-adrenal schwannoma mimicking a giant adrenal lesion.

BMJ Case Rep 2021 Jul 20;14(7). Epub 2021 Jul 20.

Diabetes and Endocrinology, Mater Dei Hospital, Msida, Malta.

A 57-year-old man was incidentally diagnosed with a 7 cm left-sided retroperitoneal mass. The mass was presumed to be arising from the left adrenal gland on a CT scan of the adrenal glands. Thus, a thorough workup ensued, looking into the possible functionality of the lesion. All investigations resulted in the negative. Subsequently, the patient was referred for surgery to fully characterise the tumour. Histology proved that the lesion was a benign retroperitoneal schwannoma with no relation to the adrenal gland.
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http://dx.doi.org/10.1136/bcr-2021-243652DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8292798PMC
July 2021

Large cell neuroendocrine carcinoma arising from the anterior mediastinum.

BMJ Case Rep 2021 May 25;14(5). Epub 2021 May 25.

Gastroenterology, Mater Dei Hospital, Msida, Malta.

Anterior mediastinal large cell neuroendocrine carcinomas (LCNECs) are extremely rare, extremely aggressive malignancies that carry a dismal prognosis. We discuss a woman aged 60 years who presented with a 2-month history of recurrent severe constant epigastric pain. Abdominal examination revealed massive hepatomegaly and a CT scan of the liver confirmed coarse liver lesions. Histology from a liver biopsy was consistent with a large cell (non-small cell) neuroendocrine carcinoma. A CT scan of the chest showed a large anterior mediastinal mass unrelated to the lung, suggesting that the anterior mediastinum was the primary origin of the tumour. The patient was planned to receive platinum/etoposide chemotherapy for a metastatic mediastinal large cell neuroendocrine carcinoma. Unfortunately, her health deteriorated, and she was unfit to undergo any further treatment. She was treated palliatively and died 2 months after the diagnosis.
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http://dx.doi.org/10.1136/bcr-2020-240453DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8154970PMC
May 2021

Ectopic ACTH secretion from a metastatic gastric carcinoma with neuroendocrine component.

BMJ Case Rep 2021 May 6;14(5). Epub 2021 May 6.

Department of Diabetes and Endocrinology, Mater Dei Hospital, Msida, Malta.

An elderly gentleman was admitted to hospital with severe hypokalaemia of 1.75mmol/L. A background of a recently diagnosed metastatic gastric carcinoma with a neuroendocrine component pointed towards the diagnosis of ectopic ACTH secretion causing this dangerous electrolyte imbalance. He was treated with aggressive potassium supplementation and the adrenal steroid synthesis blocker metyrapone to acutely control his Cushing's syndrome. Chemotherapy consisting of carboplatin/etoposide combination was initiated but unfortunately the patients' health deteriorated, and he died three months after his initial diagnosis. This case highlights the accelerated presentation of hypercortisolism due to ectopic ACTH secretion. It discusses the classification of neuroendocrine tumours and their varied prognosis depending on the underlying tumour grade. It emphasises the importance of having a multidisciplinary team to be able to care for two underlying pathologies simultaneously: both the severe hypercortisolism and his metastatic gastric tumour.
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http://dx.doi.org/10.1136/bcr-2020-240290DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8103837PMC
May 2021

Cotrimoxazole-induced hyperkalaemia in a patient with known hypoaldosteronism.

BMJ Case Rep 2021 Mar 4;14(3). Epub 2021 Mar 4.

Department of Diabetes and Endocrinology, Mater Dei Hospital, Msida, Malta.

A70-year-old man, with established hypoadrenalism due to a previous bilateral adrenalectomy, was admitted with recurrent episodes of postural dizziness and presyncope. He had been discharged from hospital 3 weeks earlier on a 1-month course of cotrimoxazole following a diagnosis of prostatitis. His electrolytes on admission showed new onset hyponatraemia and hyperkalaemia.His usual glucocorticoid replacement dose was doubled in view of a presumed diagnosis of hypocortisolaemia. However, the hyperkalaemia persisted. On rereviewing his treatment, we suspected a possible diagnosis of cotrimoxazole-induced hyperkalaemia. Cotrimoxazole was stopped and ciprofloxacin started instead. His fludrocortisone replacement was doubled for 3 days after stopping treatment to decrease his postural symptoms. His postural symptoms improved, his serum potassium decreased to normal levels and he was safely discharged.It is essential to remember that cotrimoxazole, a commonly used antibiotic, can induce a potentially fatal hyperkalaemia especially in patients with known hypoadrenalism.
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http://dx.doi.org/10.1136/bcr-2020-239543DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7934741PMC
March 2021

Pre-eclampsia complicated by severe hyponatraemia.

BMJ Case Rep 2020 Dec 31;13(12). Epub 2020 Dec 31.

Department of Diabetes and Endocrinology, Mater Dei Hospital, Msida, Malta.

A 41-year-old woman was diagnosed with pre-eclampsia at 35 weeks gestation. She was treated with antihypertensives but, unfortunately, her condition became complicated by severe hyponatraemia. Her sodium levels rapidly dropped to 125 mmol/L. The cause for the hyponatraemia was the syndrome of inappropriate antidiuretic hormone secretion. She was initially managed with fluid restriction, but an emergency caesarean section was necessary in view of fetal distress. Her sodium levels returned to normal within 48 hours of delivery.Pre-eclampsia is rarely associated with hyponatraemia. A low maternal sodium level further increases the mother's risk for seizures during this state. Additionally, the fetal sodium rapidly equilibrates to the mother's and may result in fetal tachycardia, jaundice and polyhdraminios. All these factors may necessitate an emergency fetal delivery.
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http://dx.doi.org/10.1136/bcr-2020-237827DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7780503PMC
December 2020

Adrenal medullary hyperplasia mimicking pheochromocytoma.

BMJ Case Rep 2020 Sep 22;13(9). Epub 2020 Sep 22.

Diabetes and Endocrinology Department, Mater Dei Hospital, Msida, Malta.

A 59-year-old woman, a known case of hypertension, was incidentally diagnosed with a large right-sided adrenal mass. Investigations for a functional adrenal lesion resulted in very high preoperative norepinephrine levels. A right adrenalectomy was performed. Histology showed adrenal medullary hyperplasia (AMH). AMH is a rare diagnosis and its incidence is poorly documented in the literature. This is a benign entity which resembles pheochromocytoma (PCC) in both clinical and biochemical manner. AMH is usually bilateral and may occur in isolation or in association with PCC. In fact, some authors consider it to be a precursor to PCC. Thus, these patients need long-term follow-up in view of the risk of development of PCC later.
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http://dx.doi.org/10.1136/bcr-2020-236209DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7509954PMC
September 2020

Isolated second-phase diabetes insipidus post-transsphenoidal surgery.

BMJ Case Rep 2020 Jun 30;13(6). Epub 2020 Jun 30.

Department of Diabetes and Endocrinology, Mater Dei Hospital, Msida, Malta.

A 57-year-old woman presented with severe lethargy, dizziness and nausea 1 week after transsphenoidal resection of a growth hormone secreting pituitary adenoma. She was found to have severe hyponatremia of 115 mmol/L. Importantly, she was neurologically intact and clinically euvolaemic. Her fluid intake was restricted and her sodium levels increased to 131 mmol/L over 4 days. She made a full recovery.She was diagnosed with isolated second-phase diabetes insipidus, a state of symptomatic hypoosmolar hyponatremia that usually occurs 7-10 days after transsphenoidal surgery. The sodium levels improve with fluid restriction.
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http://dx.doi.org/10.1136/bcr-2020-235499DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7328762PMC
June 2020

Benign cystic mediastinal teratoma presenting as a massive pleural effusion in a 17-year-old boy.

BMJ Case Rep 2017 Jan 10;2017. Epub 2017 Jan 10.

Department of Medicine, Mater Dei Hospital, Malta, Msida, Malta.

Mediastinal teratomas are a rare, albeit an important differential diagnosis of anterior/middle mediastinal masses in young adults and various atypical presentations have been reported. The authors report a case of a 17-year-old boy who presented with a 2-month history of worsening shortness of breath and pleuritic chest pain. A massive left-sided pleural fluid collection was seen on a chest radiograph (CXR). The pleural fluid was drained and a CT Thorax confirmed the presence of a cystic mass. Following re-accumulation of the fluid, thoracotomy was performed and a benign mediastinal teratoma excised. The patient remained well with no evidence of recurrence on follow-up CXRs a year post operatively.
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http://dx.doi.org/10.1136/bcr-2016-217439DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5256584PMC
January 2017
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