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[This corrects the article DOI: 10.1016/j.aed.2025.03.011.].
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This consensus statement provides evidence-based visual guidance in graphic algorithms and a summary of evidence and considerations to assist health care professionals with the diagnosis and management of adults with prediabetes and diabetes mellitus in shared decision making to improve care. The American Association of Clinical Endocrinology (AACE) selected a task force of medical experts to update the 2023 AACE Comprehensive Type 2 Diabetes Management Algorithm and align this algorithm update with related AACE clinical guidance. This algorithm for management of adults with type 2 diabetes (T2D) includes 11 sections: (1) Principles for the Management of Adults With T2D; (2) Prediabetes Algorithm (3) Diabetes Classification Algorithm (new); (4) Atherosclerotic Cardiovascular Disease Risk Reduction Algorithm: Dyslipidemia; (5) Atherosclerotic Cardiovascular Disease Risk Reduction Algorithm: Hypertension; (6) Comorbidities- and Complications-Centric Glycemic Control Algorithm; (7) Glucose-Centric Glycemic Control Algorithm; (8) Initiating and Titrating Insulin Algorithm; (9) Profiles of Pharmacotherapy for T2D; (10) Profiles of Pharmacotherapy for Obesity; and (11) Vaccine Recommendations for Adults With T2D. This 2026 update emphasizes lifestyle modification and treatment of overweight/obesity as key pillars in the management of prediabetes and T2D. It also provides guidance on the management of atherosclerotic risk factors of dyslipidemia and hypertension. A new algorithm was added to ensure that other causes and classes of diabetes are considered beyond T2D. There continues to be an emphasis on a complications- and comorbidities-centric approach, beyond glucose levels, to frame decisions regarding first-line and subsequent pharmacological choices for treating adults with T2D.
Laparoscopic sleeve gastrectomy/duodenojejunal bypass (LSG/DJB) aids weight loss and improves type 2 diabetes mellitus (T2DM) in patients with obesity. Herein, we present a 1-year longitudinal evaluation using continuous glucose monitoring (CGM), bioelectrical impedance analysis (BIA), and computed tomography (CT) fat scans after LSG/DJB in a patient with obesity and T2DM. Our patient was a 33-year-old female with obesity and T2DM who had been treated with intensive insulin therapy (50 units/d) before LSG/DJB. Preoperatively, the patient had uncontrolled diabetes, with a fasting blood glucose level of 252 mg/dL and HbA1c of 10.0%. Moreover, the CGM showed 1%, 99%, and 0% time-in range (TIR), time-above range, and time-below range, respectively. LSG/DJB significantly increased the 3-, 6-, and 12-month TIR to 96%, 93%, and 89%, respectively, and decreased the time-above range to 4%, 7%, and 11%, respectively, indicating high-dose insulin withdrawal and complete diabetes remission. Twelve months post-LSG/DJB, effective abdominal fat mass loss was observed on CT. Furthermore, both FM and the percentage of fat mass were reduced, and muscle mass was maintained according to the BIA. Effective weight loss, abdominal FM loss, and complete diabetes remission were observed after LSG/DJB, according to BIA and CT. The significant increase in TIR suggests that this therapeutic approach may improve the prognosis of patients with T2DM and obesity. CGM, BIA, and CT fat scans are highly useful for the long-term management of obesity and diabetes after LSG/DJB surgery.
Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a rare congenital anomaly characterized by agenesis or hypoplasia of the uterus and upper vagina in phenotypically normal females. Although patients with MRKH syndrome typically exhibit normal secondary sexual development, associations with extragenital anomalies and metabolic conditions such as diabetes mellitus have been increasingly reported. A female patient initially presented at the age of 15 (currently 19 year old) with primary amenorrhea and absence of secondary sexual characteristics. Initial laboratory evaluation showed elevated follicle-stimulating hormone (FSH) and thyroid-stimulating hormone (TSH) levels, while thyroid antibodies and prolactin were within normal limits. Pelvic magnetic resonance imaging revealed poorly visualized ovaries, a hypoplastic or absent uterus and upper vagina, and urinary tract anomalies including a duplicated right ureter. One year later, she developed symptoms suggestive of diabetes mellitus and was found to have elevated random and fasting blood glucose levels. Her mother had been diagnosed with type 2 diabetes mellitus prior to conception. The patient was referred to endocrinology to evaluate the possibility of monogenic diabetes. The constellation of uterovaginal aplasia, renal anomalies, and endocrine dysfunction raises clinical suspicion of an expanded phenotypic spectrum or a potential overlap syndrome, such as Müllerian duct aplasia, renal dysplasia, and cervicothoracic somite anomalies (Reference ranges: FSH: 3-10 mIU/mL in follicular phase; TSH: 0.4-4.0 μIU/mL). This case highlights the importance of comprehensive systemic evaluation in patients with MRKH syndrome, especially when extragenital anomalies or metabolic abnormalities such as diabetes mellitus coexist. Early recognition and multidisciplinary management are essential for optimal care and may provide valuable insights into potentially shared developmental and genetic pathways.
Early-onset type 2 diabetes (T2D) is an emerging public health concern. Despite its rising burden, national data on the prevalence and risk factors in Bangladesh remain scarce. This study aimed to estimate the prevalence of early-onset T2D and identify risk factors among young people in Bangladesh. This nationwide, population-based survey encompassed 2,300 young people-adolescents (10-18 years) and young adults (19-34 years)-from rural and urban sites across 8 divisions of Bangladesh using multistage random sampling in 2024. Glycemic status (by oral glucose tolerance test except in pre-existing diabetes mellitus), fasting lipid profile, sociodemographics, lifestyle, anthropometry, and blood pressure were assessed. Glucose was measured by the glucose-oxidase method, and lipids by the enzymatic method. Prevalence of early-onset T2D and prediabetes was 4.5% (104/2,300) and 18.4% (423/2,300), respectively. Among those with diabetes, 66.3% (69/104) were newly diagnosed. Diabetes prevalence was higher in young adults (89/1,182; 7.5%) than in adolescents (15/1,118; 1.3%), and in urban residents (65/1,079; 6.0%) than in rural residents (39/1,221; 3.2%) (P < .05 for both). Higher odds for diabetes were linked with suboptimal physical activity (odds ratio [OR] 2.0, 95% CI: 1.1-4.0), smokeless tobacco use (OR 2.6, 95% CI: 1.4-4.9), central obesity (OR 2.0, 95% CI: 1.3-3.3), hypertension (OR 3.3, 95% CI: 1.6-6.7), and hypertriglyceridemia (OR 2.9, 95% CI: 1.8-4.5). Early-onset T2D affects 4.5% of young people in Bangladesh, whereas 18.4% have prediabetes. Prevalence is higher in young adults and urban residents. Suboptimal physical activity, smokeless tobacco use, central obesity, hypertension, and hypertriglyceridemia are key risk factors.
Diabetes mellitus (DM) arises from insufficiencies in insulin secretion and action. The pancreatic α-amylase enzyme is involved in starch metabolism and influences glycated hemoglobin (HbA1c) level. The current study examines relationships between blood glucose level, α-amylase activity, HbA1c, and several trace elements (Cu, Zn, and Mg). Eighteen healthy control subjects and 31 patients with type 2 diabetes from both genders were recruited for this study. The enzymatic colorimetric method was used to assess serum glucose levels and α-amylase activity. The boronate affinity method and atomic absorption spectroscopy were used to measure HbA1c and trace elements, respectively. In comparison to the control group, the diabetes groups' mean levels of α-amylase were slightly higher. The Cu level was significantly increased (P < 0.05) in the patient group, whereas Zn and Mg levels did not change significantly. HbA1c demonstrated a significant negative correlation (r = -0.394, P < 0.05) with α-amylase in patients with diabetes. The α-amylase also exhibited a negative correlation with glucose level in these patients. Cu level increased in hyperglycemia, and α-amylase negatively correlated with Cu. The diabetes group's HbA1c and Zn levels were inversely correlated, which suggests that uncontrolled DM causes a reduction in Zn levels. Cu and Mg correlated positively with HbA1c in healthy people but not in people with diabetes. As the enzyme α-amylase correlated with HbA1c and glucose levels, it may serve as a supplementary marker of pancreatic exocrine involvement in patients with diabetes, but its predictive or diagnostic utility remains unproven. The pathophysiology of DM is complicated by altered trace element levels.
Nonadherence to insulin therapy remains a major challenge to achieving optimal glycemic control, leading to complications and increased health care costs. Despite accessible insulin therapy in tertiary hospitals, barriers such as injection fear, complex regimens, inadequate storage, stigma, and limited health literacy contribute to poor adherence. Evidence on determinants of insulin nonadherence in tertiary care settings in India remains limited. This study aimed to determine the prevalence and predictors of insulin nonadherence among adults with diabetes mellitus. A cross-sectional survey was conducted from February to July 2025 among adults (≥18 years) with type 1 or type 2 diabetes mellitus receiving insulin therapy for at least 6 months, selected using a consecutive sampling technique. The 8-item Morisky Medication Adherence Scale assessed adherence; scores <6 indicated nonadherence. Data were analyzed using SPSS version 29, and binary logistic regression identified independent predictors. Of 402 participants, 36.8% were nonadherent. Independent predictors of nonadherence included upper-middle socioeconomic status (adjusted odds ratio [AOR] 2.11; 95% CI 1.07-4.15; P = 0.031), type 2 diabetes (AOR 2.23; 95% CI 1.20-4.14; P = 0.011), lack of insulin storage (AOR 4.72; 95% CI 2.28-9.76; P < 0.001), polypharmacy (AOR 4.00; 95% CI 0.99-16.14; P = 0.046), and poor lifestyle adherence (AOR 1.62; 95% CI 0.95-2.77; P = 0.047). Primary education was associated with lower odds of nonadherence (AOR 0.26; 95% CI 0.08-0.83; P = 0.023). Over one-third of patients were nonadherent to insulin therapy. Findings highlight the need for focused educational support, behavioral counseling, and structural solutions such as improved storage provisions to enhance adherence and metabolic outcomes.
To investigate the remission rate and metabolic outcomes under the Diabetes Reversal Clinic with multidisciplinary management. Patients with type 2 diabetes who visited the Diabetes Reversal Clinic from April 2022 to December 2024 were enrolled. Baseline characteristics and metabolic indicators were recorded. Participants received comprehensive multidisciplinary management including personalized treatment plans, structured lifestyle modification, continuous glucose monitoring, and traditional Chinese medicine as adjunctive therapy. After 6 months, the remission rate, the rate of target glycated hemoglobin A1c < 53 mmol/mol (7.0%), and changes of metabolic indicators in patients were analyzed. Our major results found that, among 171 patients with type 2 diabetes who were followed for more than 6 months, 50 (29.24%) patients achieved remission and 149 (87.13%) patients achieved the target of glycated hemoglobin A1c < 53 mmol/mol (7.0%). At the end of 2022, 2023, and 2024, the annual diabetes remission rate reached 6.12% (6/98), 16.78% (25/149), and 16.24% (19/117), respectively. The multidisciplinary management significantly decreased body mass index, waist circumference, waist-to-height ratio, fasting blood glucose, glycated hemoglobin A1c, and homeostasis model assessment of insulin resistance, while significantly increasing high-density lipoprotein cholesterol (all P < 0.05). A diabetes remission rate of 29.24% and a target rate of 87.13% were obtained after 6 months of multidisciplinary management among patients with type 2 diabetes in the Diabetes Reversal Clinic. Our findings suggest that the multidisciplinary management model employed in the Diabetes Reversal Clinic is superior to conventional management in general outpatient clinics for promoting diabetes remission and metabolic reversal.
The management of hypothyroidism has evolved over time as the development of new guidelines and formulations of thyroid hormone have become available. A survey of American Association of Clinical Endocrinology members in the United States examining the treatment of hypothyroidism, including questions about initial choice of therapy, use of liothyronine (LT3)-containing regimens, and use of thyroid hormones in hypothyroid and non-hypothyroid patients. Survey links were opened by 387 of 4000 potential respondents and completed by 299 (7%). Respondents unanimously cited levothyroxine (LT4) as the initial treatment choice for hypothyroidism. Forty-seven percent indicated they would use thyroid hormones in patients with euthyroidism with infertility and elevated thyroid antibodies, with smaller numbers for goiter, depression, hypercholesterolemia, fatigue, and obesity. About 60% would consider combination LT4/LT3 in a patient with euthyroidism who does not feel well on treatment or has persistent symptoms. In contrast, a much smaller minority (16% for LT4/LT3 and 5% for desiccated thyroid extract) used such regimens to manage their own hypothyroidism. Persistent symptoms in treated patients with a normal TSH were most often attributed to psychosocial factors, unrealistic patient expectations, and comorbidities. Significant associations were identified between respondent demographics and treatment choices, most notably age, practice setting, and volume of patients with hypothyroidism. LT4 monotherapy is overwhelmingly employed as first line therapy for hypothyroidism by U.S. clinicians. However, the high usage of thyroid hormones for patients whose symptoms were considered to be unrelated to hypothyroidism is at odds with current international guidelines for the management of hypothyroidism.
To compare glycemic control and metabolic outcomes between multiple daily injections (MDIs) and continuous subcutaneous insulin infusion (CSII) in pediatric type 1 diabetes mellitus. Searches were conducted in PubMed MEDLINE, Web of Science, Scopus, CNKI, CINAHL, Cochrane, and EMBASE on 02/2025. A systematic review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Outcomes included HbA1c levels, total daily dose, diabetic ketoacidosis, hypoglycemia events, body mass index change, and adverse events. Statistical analysis was performed using R version 3.4.3. Eighteen randomized controlled trials (1229 participants) were analyzed. CSII compared to MDI significantly reduced HbA1c (MD = -0.37%; 95% CI: -0.62 to -0.12; P < 0.01; I2 = 86.6%), adverse events (relative risk [RR]: 1.45; 95% CI: 1.10 to 1.90; P < 0.01; I2 = 0.0%), and increased body mass index (MD = 0.43; 95% CI: 0.31 to 0.55; P < 0.01; I2 = 0.0%). No significant differences were found for insulin requirement (MD = -0.08 U/kg/d; P = 0.14), severe hypoglycemia (RR = 1.09; P = 0.73), or diabetic ketoacidosis (RR = 1.40; P = 0.43). Trial sequential analysis for HbA1c reduction indicated conclusive evidence, while for insulin requirements, it remains inconclusive due to insufficient sample size. Our meta-analysis confirms CSII achieves superior HbA1c reduction versus MDI in pediatric type 1 diabetes, as supported by trial sequential analysis. However, evidence for insulin requirements remains inconclusive, highlighting the need for larger trials and personalized treatment considering patient preferences and accessibility.
Recent observational studies report conflicting evidence on whether semaglutide use is associated with non-arteritic anterior ischemic optic neuropathy (NAION). This systematic review synthesizes available evidence and critically evaluates bias and confounding. PubMed, Embase, and the Cochrane Library were searched through December 2025 for observational studies assessing semaglutide and NAION. Two reviewers independently screened records, extracted data, and assessed study quality using the Newcastle-Ottawa Scale. Owing to substantial clinical and methodological heterogeneity, results were synthesized narratively. Nine large retrospective cohort studies, encompassing more than 3 million patients, and one major regulatory review were included. Findings were sharply divided. Four studies reported statistically significant increased risk, with hazard ratios ranging from 1.76 to 4.28. Four studies found no significant association, while one suggested a protective effect (odds ratio 0.36). All studies were of moderate quality and exhibited high risk of bias in cohort comparability. Notably, studies using broad or untreated comparators consistently reported elevated risk, whereas studies employing active comparators with similar metabolic risk profiles generally found no association. Current evidence does not support a causal relationship between semaglutide and NAION. The divergent findings are most plausibly explained by confounding by indication: patients prescribed semaglutide tend to have more severe diabetes, obesity, and cardiovascular disease, all independent risk factors for NAION. Even under the highest reported relative risk estimates, the absolute risk remains very low and is outweighed by well-established cardiovascular and renal benefits of semaglutide. Definitive clarification will require prospective studies with standardized ophthalmologic adjudication and measurement.
The COVID-19 infection impacts endocrine tissues, and various thyroid disorders have been reported in affected patients. Subacute thyroiditis (SAT), a self-limited inflammatory thyroid condition, is associated with viral respiratory tract infections. Studies have suggested a link between COVID-19 and SAT. Our study expands on this by examining differences in SAT severity before and after COVID-19. A retrospective cohort study analyzed SAT cases at an outpatient Ontario endocrinology clinic. Cases were identified as pre-Covid (December 2015 - April 2019) or post-Covid (December 2019 - April 2023). Patient charts were screened for diagnostic characteristics of SAT and relevant lab data, including thyroid-stimulating hormone (TSH), free thyroxine (FT4), and free triiodothyronine (FT3). From 436 pre-Covid and 629 post-Covid cases, 32 and 37 met the inclusion criteria. Our study showed no difference between incidence of SAT cases post-Covid versus pre-Covid. However, post-Covid, more patients had severe SAT, defined as values of FT4 and FT3 >30% above their upper normal range and TSH >10, (FT4 37.8 ∓ 6.7 vs 50.9 ∓ 23.5 [P = 0.05]; FT3 9.6 ∓ 2.2 vs 18.6 ∓ 10.9 [P = 0.02]). No significant differences were identified in median TSH levels during hyperthyroid phase (P = 0.12). In the hypothyroid phase, median TSH values were significantly higher post-Covid (P = 0.0046). Low FT4 values also showed significance (P = 0.001). Our study shows SAT incidence was similar pre- and post-COVID-19. Severity of the SAT disease course was amplified after the onset of the COVID-19 pandemic, with a significant elevation in FT4 and FT3 levels during hyperthyroidism and higher TSH during hypothyroidism in the post-Covid cohort.
We assessed the impact of adding subcutaneous basal insulin to hybrid closed-loop insulin pump therapy on diabetic ketoacidosis (DKA) rates and glycemic outcomes in adults with type 1 diabetes (T1D) and recurrent DKA. We conducted a retrospective review of electronic health records from adults with T1D and recurrent DKA who received concurrent treatment with subcutaneous basal insulin and hybrid closed-loop insulin pump therapy at an academic health system in the United States. We performed an as-treated analysis using descriptive statistics. Our cohort included 5 adults (3 women, 2 men; mean age 39.4 ± 10.8 years) with T1D and recurrent DKA. Due to elevated DKA risk, all 5 adults were initiated on once-daily subcutaneous basal insulin (degludec or glargine, mean dose 0.14 units/kg/d, range 0.07-0.22 units/kg/d) in addition to insulin pump therapy (Omnipod 5 with automated insulin delivery). Mean HbA1c decreased from 9.3% (79 mmol/mol) (days -360 to -1) to 8.2% (66 mmol/mol) (days 0 to 360) following the intervention. The frequency of DKA-related hospitalizations decreased from a mean of 2.0 events per person (days -360 to -1) to 0.75 events per person (days 0 to 360). One individual discontinued subcutaneous basal insulin due to recurrent level 1 hypoglycemia. Adding once-daily subcutaneous basal insulin to hybrid closed-loop therapy may have the potential to reduce DKA-related hospitalizations and improve glycemic outcomes in adults with T1D and recurrent DKA. However, given this was a retrospective study with a small cohort, further research is needed to rigorously evaluate this approach.
Maturity Onset Diabetes in the Young (MODY) is the most common form of monogenic diabetes caused by various single gene mutations. We present a patient with presumed type 2 diabetes mellitus (T2DM), ultimately diagnosed with MODY due to heterozygous Wolfram Syndrome 1 (WFS1) gene mutation. Our patient was diagnosed with T2DM at age 22 and treated with oral medications and lifestyle modifications. At age 45, patient's HbA1c was 11.4% (reference <5.7%) on metformin XR 1000 mg twice daily. Additional testing (serum glucose 216 mg/dL [reference: 70-125 mg/dL], C-peptide level 2.18 ng/mL [reference 0.78-5.19 ng/mL], undetectable glutamic acid decarboxylase antibody 65 [GAD-65] [reference: 0.0-5.0 IU/mL], undetectable IgG Islet Cell cytoplasmic antibody [reference: <1:4]) ruled out type 1 diabetes mellitus (T1DM). Due to family history of diabetes and normal body mass index (BMI) 23.2 kg/m2, MODY testing was done. This revealed one variant of uncertain significance in the WFS1 gene (NM_006005.3:c.2026C > T; p.Arg676Cys; heterozygous) not previously described in literature. MODY is a known but uncommon cause of diabetes in young adults. While mutations in HNF1A, GCK, and HNF4A are commonly associated with MODY, rare mutations such as the WFS1 gene mutation should be considered. Our patient's WFS1 mutation (NM_006005.3:c.2026C > T; p.Arg676Cys; heterozygous) has not been reported in literature. Young adults with family history of diabetes and normal BMI should be evaluated for MODY when diagnosed with diabetes. A complete mutation panel for MODY should be done to evaluate for lesser-known mutations such as the WFS1 gene mutation.
Adrenal insufficiency (AI) is characterized by glucocorticoid deficiency, with symptoms such as fatigue and hypoglycemia. Since AI presents with various severities in actual clinical settings, its evaluation using endocrine stress tests also requires a graded and comprehensive interpretation. We aimed to classify AI severity in patients who underwent endocrine stress tests and analyze their clinical characteristics using real-world medical data. This cross-sectional study was conducted at Tokyo Rosai Hospital. Inpatients who underwent endocrine stress tests, including the insulin tolerance test, corticotropin-releasing hormone stimulation test, and standard-dose and low-dose corticotropin stimulation tests. Patients were classified into 3 groups based on hormone responses: overt AI, suspected early-stage AI, and normal adrenal function. Clinical characteristics, laboratory findings, and treatment interventions were analyzed across groups. The 104 patients (mean age: 46.4 ± 13.5 years, 18.9% male, body mass index: 24.3 ± 6.7) exhibited low cortisol levels and fatigue. Among 90 patients completing severity-classifying tests, 19 (21.1%) had overt AI, 38 (42.2%) had suspected early-stage AI, and 33 (36.7%) had normal adrenal function. Corticotropin-releasing hormone stimulation test results indicated varying pituitary-adrenal axis function based on AI severity. In routine care, a pragmatic classification combining stress tests can help stratify suspected cases. These findings underscore the importance of flexible and comprehensive interpretation of dynamic endocrine stress tests to detect diverse and subtle dysfunctions of the hypothalamic-pituitary-adrenal axis.
Severe pediatric hypothyroidism may cause growth failure and pituitary hyperplasia mimicking adenoma. Although thyroid nodules are rare in children, their malignancy risk is higher than in adults. We report a boy with severe hypothyroidism, growth failure, pituitary hyperplasia, and oncocytic thyroid carcinoma, underscoring the need for comprehensive evaluation. A 10-year-old boy presented with growth delay, height 105 cm (<1st percentile, -6.7 SD), and weight 21.2 kg (third percentile, -2.03 SD). Examination revealed pallor, dry skin, alopecia, Tanner stage I/I, and bitemporal hemianopsia. Laboratory results showed thyroid stimulating hormone >500 mIU/ml (reference 0.45-4.50 mIU/L), free thyroxine <0.30 ng/dl (reference 0.93-1.60 ng/dl), prolactin 102 ng/ml (reference 5-20 ng/ml), and insulin-like growth factor 1 of 8 ng/ml (reference 123-497 ng/ml). Pituitary magnetic resonance imaging demonstrated a homogeneous, isointense sellar lesion with optic chiasma displacement. Thyroid ultrasound showed a 43.9 mm hypoechoic nodule, and fine-needle aspiration classified it as Bethesda category IV. Total thyroidectomy confirmed encapsulated angioinvasive oncocytic carcinoma, followed by radioactive iodine therapy. With levothyroxine and growth hormone treatment, pituitary hyperplasia regressed, and height increased by 15 cm in 1 year. Pituitary hyperplasia secondary to hypothyroidism is reversible with levothyroxine and must be differentiated from adenomas to avoid unnecessary surgery. Oncocytic thyroid carcinoma is rare in children, and its coexistence with hypothyroidism is unusual. This case emphasizes the importance of thyroid function testing in children with growth failure and sellar lesions, and vigilance in evaluating pediatric thyroid nodules given their elevated risk of malignancy.
Gender-affirming hormone therapy (GAHT) improves psychological well-being in transfeminine individuals but may cause endocrine alterations, including hyperprolactinemia and, rarely, pituitary adenomas. We report the youngest known case of galactorrhea and pituitary microadenoma associated with unsupervised GAHT, highlighting multifactorial contributing factors. An 18-year-old transfeminine youth presented with galactorrhea while taking self-administered GAHT without medical supervision. Laboratory testing showed elevated prolactin, and magnetic resonance imaging revealed a pituitary microadenoma. Contributing factors included high-dose estradiol, cyproterone acetate, concomitant antiretroviral and antidepressant therapy, and frequent breast massage. This case highlights the endocrine vulnerability of adolescents using unsupervised GAHT. The combined effects of estrogen excess, antiandrogen therapy, serotonergic and dopaminergic modulation, and mechanical breast stimulation likely contributed to hyperprolactinemia. Limited pediatric data and lack of structured hormonal monitoring delayed diagnosis and optimal management. Multidisciplinary care integrating endocrine follow-up and mental health support is essential to ensure treatment safety. Unsupervised GAHT in adolescents can lead to significant endocrine complications through multifactorial mechanisms. Early recognition, structured monitoring, and coordinated multidisciplinary care are crucial to balance gender-affirming goals with patient safety.
Endocrine emergencies, although uncommon, are potentially life-threatening and require prompt diagnosis and timely intervention. Although diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are well described, data on nondiabetic endocrine emergencies remain limited, particularly from low-resource settings. This study aimed to evaluate spectrum, clinical characteristics, and outcomes of endocrine emergencies presenting to a tertiary care hospital in North India. A prospective observational study was conducted over 18 months at a tertiary care academic hospital in North India. Patients aged ≥12 years presenting to the emergency department with endocrine emergencies were included. Clinical details, biochemical parameters, and outcomes were systematically recorded and analyzed. A total of 212 patients were enrolled, with an incidence of 1.82 per 1000 emergency visits annually. DKA was the most frequent diagnosis (69.3%), followed by hypercalcemia (11.3%) and hypoglycemia (7.1%). HHS accounted for 3.8% of cases and had the highest mortality (50%). All patients with thyroid storm (n = 3) succumbed. Myxedema coma had a mortality rate of 33.3%. In DKA, older age, reduced estimated glomerular filtration rate, and higher plasma osmolality were associated with poor outcomes. In HHS, nonsurvivors had significantly higher osmolality (P = .029). DKA is common and treatable, whereas HHS and thyroid storm carry high mortality, warranting early recognition and aggressive management.
Internal carotid artery aneurysms are rare and can lead to hypopituitarism due to their mass effect. Hypopituitarism triggered by aneurysmal compression may persist, and postsurgical restoration of pituitary function is challenging, often necessitating long-term hormone replacement therapy. We herein report a case of hypopituitarism caused by intrasellar aneurysm. A 77-year-old female with history of left eye blindness, Hashimoto's thyroiditis, and chronic kidney disease presented with nausea, vomiting, malaise, and altered mental status. Physical examination was unremarkable with no visual field or neurologic deficits except for blindness in left eye. The patient was noted to have hyponatremia which prompted checking serum cortisol level and endocrinology consultation. Workup demonstrated secondary adrenal insufficiency with low cortisol and low adrenocorticotropic hormone, central hypogonadism, and secondary hypothyroidism with low serum thyroid-stimulating hormone and low free thyroxine level. Prolactin was mildly elevated, likely due to stalk effect. Imaging revealed 2.3 × 3.1 × 2.3 cm right cavernous carotid aneurysm in the sella extending into the suprasellar cistern. Hydrocortisone therapy was started, and levothyroxine dose was adjusted which improved her mental status. Subsequently, the patient underwent stent-assisted coil embolization after unsuccessful placement of a flow diversion device by neurosurgery. The patient continues to be on hormone replacement therapy. Close monitoring of pituitary hormones is required in the context of giant intrasellar aneurysms, given their potential to induce pituitary dysfunction through mass effect. Timely diagnosis and intervention are paramount to prevent fatal outcomes.