Pseudo-pheochromocytoma due to obstructive sleep apnea: a case report

SUMMARY

Obstructive sleep apnea (OSA) is a condition of intermittent nocturnal upper airway obstruction. OSA increases sympathetic drive which may result in clinical and biochemical features suggestive of pheochromocytoma. We present the case of a 65-year-old male with a 2.9-cm left adrenal incidentaloma on CT, hypertension, symptoms of headache, anxiety and diaphoresis, and persistently elevated 24-h urine norepinephrine (initially 818 nmol/day (89-470)) and normetanephrine (initially 11.2 µmol/day (0.6-2.7)). He was started on prazosin and underwent left adrenalectomy. Pathology revealed an adrenal corticoadenoma with no evidence of pheochromocytoma. Over the next 2 years, urine norepinephrine and normetanephrine remained significantly elevated with no MIBG avid disease. Years later, he was diagnosed with severe OSA and treated with continuous positive airway pressure. Urine testing done once OSA was well controlled revealed complete normalization of urine norepinephrine and normetanephrine with substantial symptom improvement. It was concluded that the patient never had a pheochromocytoma but rather an adrenal adenoma with biochemistry and symptoms suggestive of pheochromocytoma due to untreated severe OSA. Pseudo-pheochromocytoma is a rare presentation of OSA and should be considered on the differential of elevated urine catecholamines and metanephrines in the right clinical setting.

LEARNING POINTS

Obstructive sleep apnea (OSA) is a common condition among adults. OSA may rarely present as pseudo-pheochromocytoma with symptoms of pallor, palpitations, perspiration, headache, or anxiety. OSA should be considered on the differential of elevated urine catecholamines and metanephrines, especially in patients with negative metaiodobenzylguanidine (MIBG) scan results.

Thyroid Doses to French Polynesians Resulting from Atmospheric Nuclear Weapons Tests: Estimates Based on Radiation Measurements and Population Lifestyle Data

Thyroid doses were estimated for the subjects of a population-based case-control study of thyroid cancer in a population exposed to fallout after atmospheric nuclear weapons tests conducted in French Polynesia between 1966 and 1974. Thyroid doses due to (1) intake of I and of short-lived radioiodine isotopes (I, I, I) and Te, (2) external irradiation from gamma-emitting radionuclides deposited on the ground, and (3) ingestion of long-lived Cs with foodstuffs were reconstructed for each study subject. The dosimetry model that had been used in 2008 in Phase I of the study was substantially improved with (1) results of radiation monitoring of the environment and foodstuffs, which became available in 2013 for public access, and (2) historical data on population lifestyle related to the period of the tests, which were collected in 2016-2017 using focus-group discussions and key informant interviews. The mean thyroid dose among the study subjects was found to be around 5 mGy while the highest dose was estimated to be around 36 mGy. Doses from I intake ranged up to 27 mGy, while those from intake of short-lived iodine isotopes (I, I, I) and Te ranged up to 14 mGy. Thyroid doses from external exposure ranged up to 6 mGy, and those from internal exposure due to Cs ingestion did not exceed 1 mGy. Intake of I was found to be the main pathway for thyroid exposure accounting for 72% of the total dose. Results of this study are being used to evaluate the risk of thyroid cancer among the subjects of the epidemiologic study of thyroid cancer among French Polynesians.

Ground deposition of radionuclides in French Polynesia resulting from atmospheric nuclear weapons tests at Mururoa and Fangataufa atolls

This paper presents the results of the first comprehensive estimation of the ground deposition density of radionuclides in French Polynesia resulting from the 41 atmospheric nuclear weapons tests that were conducted between 1966 and 1974 at Mururoa and Fangataufa. For each test, the deposition density at the time of arrival of fallout was estimated for 33 radionuclides either from measurements of total ground deposition or from measurements of total beta-concentration in filtered air and exposure rate at different locations in French Polynesia. The results of the measurements were mainly taken from reports that were recently de-classified by the French Ministry of Defense. The highest total deposition densities in inhabited islands and atolls occurred in Gambier: 6.1 × 10⁷ Bq m^-2 after test Aldébaran conducted on 2 July 1966 and 9.2 × 10⁶ Bq m^-2 after test Phoebé conducted on 8 August 1971. Next was Tureia with deposition densities of 1.6 × 10⁷ Bq m^-2 after test Arcturus of 2 July 1967 and 1.2 × 10⁷ Bq m^-2 after test Encelade of 12 June 1971. In Tahiti, the most populated island in French Polynesia, major fallout occurred after tests Centaure of 17 July 1974 (3.4 × 10⁶ Bq m^-2), Sirius of 4 October 1966 (4.4 × 10⁵ Bq m^-2) and Arcturus of 2 July 1967 (1.1 × 10⁵ Bq m^-2); these three tests contributed about 94% to the total deposition density of radioactive fallout in Tahiti from all 41 tests and around 85% of the ¹³¹I deposition density. The results of this study are being used to reconstruct the radiation dose to the thyroid gland for the 950 subjects of a case-control study of thyroid cancer among French Polynesians exposed as children and adolescents to fallout from the atmospheric nuclear weapons tests conducted in 1966-1974.

Prévention de la propagation de la Covid-19 en Polynésie française

La Polynésie française est une collectivité d’outre-mer de la République française regroupant 118 îles. Située en plein océan Pacifique, elle a dû relever un défi majeur pour freiner l’entrée du virus Sars-CoV-2, tout en assurant la continuité des soins auprès de sa population répartie sur ses cinq archipels. Le risque d’infection à Covid-19 chez la femme enceinte a constitué une forte préoccupation, notamment en raison du taux élevé d’obésité sur le territoire.

and Coxiella burnetii in Tahiti, French Polynesia

BACKGROUND

In the Pacific islands countries and territories, very little is known about the incidence of infectious diseases due to zoonotic pathogens. To our knowledge, human infections due to Rickettsia spp., Coxiella burnetii, Ehrlichia spp. and Bartonella spp. have never been reported in French Polynesia; and infections due to C. burnetti have been reported worldwide except in New Zealand. To evaluate the prevalence of this disease, we conducted a serosurvey among French Polynesian blood donors.

METHODS

The presence of immunoglobulin G antibodies against R. felis, R. typhi, R. conorii, C. burnetii, B. henselae, B. quintana, and E. chaffeensis was evaluated by indirect immunofluorescence assay in sera from 472 French Polynesian blood donors collected from 2011 to 2013. In addition, 178 ticks and 36 cat fleas collected in French Polynesia were also collected and tested by polymerase chain reaction to detect Rickettsia spp., B. henselae and Ehrlichia spp.

RESULTS

None of the blood donors had antibodies at a significant level against Rickettsia spp., Coxiella burnetii, Ehrlichia spp. and Bartonella spp. All tested ticks and cat fleas were PCR-negative for Rickettsia spp., B. henselae, and Ehrlichia spp.

CONCLUSION

We cannot conclude that these pathogens are absent in French Polynesia but, if present, their prevalence is probably very low. C. burnetii has been reported worldwide except in New Zealand. It may also be absent from French Polynesia.

Estimation of population size and dispersal of Aedes polynesiensis on Toamaro motu, French Polynesia

Mark-release-recapture methods were used to compare Aedes polynesiensis Marks adult numbers and dispersal between dry and wet seasons in a closed population on a small island (motu) in French Polynesia. Females were more than three times more common during wet (December 2008) than dry (May 2007) season samplings although high numbers of vectors were collected during both seasons. Lincoln-Petersen estimates for Ae. polynesiensis females on the motu were 6,055 per hectare for the dry season and 18,860 per hectare for the wet season. Marked females dispersed rapidly to all parts of the motu and survived until recaptures on days 1-5 after release. Males were not adequately sampled using human sentinels or Biogent Sentinel traps.

Influence of mercury exposure on blood pressure, resting heart rate and heart rate variability in French Polynesians: a cross-sectional study

BACKGROUND

Populations which diet is rich in seafood are highly exposed to contaminants such as mercury, which could affect cardiovascular risk factors

OBJECTIVE

To assess the associations between mercury and blood pressure (BP), resting heart rate (HR) and HR variability (HRV) among French Polynesians

METHODS

Data were collected among 180 adults (≥ 18 years) and 101 teenagers (12-17 years). HRV was measured using a two-hour ambulatory electrocardiogram (Holter) and BP was measured using a standardized protocol. The association between mercury and HRV and BP parameters was studied using analysis of variance (ANOVA) and analysis of covariance (ANCOVA) RESULTS: Among teenagers, the high frequency (HF) decreased between the 2nd and 3rd tertile (380 vs. 204 ms2, p = 0.03) and a similar pattern was observed for the square root of the mean squared differences of successive R-R intervals (rMSSD) (43 vs. 30 ms, p = 0.005) after adjusting for confounders. In addition, the ratio low/high frequency (LF/HF) increased between the 2nd and 3rd tertile (2.3 vs. 3.0, p = 0.04). Among adults, the standard deviation of R-R intervals (SDNN) tended to decrease between the 1st and 2nd tertile (84 vs. 75 ms, p = 0.069) after adjusting for confounders. Furthermore, diastolic BP tended to increase between the 2nd and 3rd tertile (86 vs. 91 mm Hg, p = 0.09). No significant difference was observed in resting HR or pulse pressure (PP) CONCLUSIONS: Mercury was associated with decreased HRV among French Polynesian teenagers while no significant association was observed with resting HR, BP, or PP among teenagers or adults.

Thyroid cancer following nuclear tests in French Polynesia

BACKGROUND

Between 1966 and 1974, France conducted 41 atmospheric nuclear tests in Polynesia, but their potential health effects have not previously been investigated.

METHODS

In a case-control study, we compared the radiation exposure of almost all the French Polynesians diagnosed with differentiated thyroid carcinoma between 1981 and 2003 (n=229) to the exposure of 373 French Polynesian control individuals without cancer from the general population. Radiation exposures were estimated using measurements after the nuclear tests, age at time of each test, residential and dietary information.

RESULTS

The average thyroid dose before 15 years of age was about 1.8 mGy, and 5% of the cases and 3% of the controls received a dose above 10 mGy. Despite this low level of dose, and after adjusting for ethnic group, level of education, body surface area, family history of thyroid cancer and number of pregnancies for women, we observed an increasing risk (P=0.04) of thyroid cancer with increasing thyroid dose received before age of 15 years, which remained after excluding non-aggressive differentiated thyroid micro-carcinomas. This increase of risk per unit of thyroid radiation dose was higher (P=0.03) in women who later experienced four or more pregnancies than among other women.

CONCLUSION

The risk estimate is low, but is based on limited exposure data. The release of information on exposure, currently classified, would greatly improve the reliability of the risk estimation.

Extensive clonality and strong differentiation in the insular pacific tree Santalum insulare: implications for its conservation

BACKGROUND AND AIMS

The impact of evolutionary forces on insular systems is particularly exacerbated by the remoteness of islands, strong founder effects, small population size and the influence of biotic and abiotic factors. Patterns of molecular diversity were analysed in an island system with Santalum insulare, a sandalwood species endemic to eastern Polynesia. The aims were to evaluate clonality and to study the genetic diversity and structure of this species, in order to understand the evolutionary process and to define a conservation strategy.

METHODS

Eight nuclear microsatellites were used to investigate clonality, genetic variation and structure of the French Polynesian sandalwood populations found on ten islands distributed over three archipelagos.

KEY RESULTS

It was found that 58 % of the 384 trees analysed were clones. The real size of the populations is thus dramatically reduced, with sometimes only one genet producing ramets by root suckering. The diversity parameters were low for islands (n(A) = 1.5-5.0; H(E) = 0.28-0.49). No departure from Hardy-Weinberg proportion was observed except within Tahiti island, where a significant excess of homozygotes was noted in the highland population. Genetic structure was characterized by high levels of differentiation between archipelagos (27 % of the total variation) and islands (F(ST) = 0.50). The neighbour-joining tree did not discriminate the three archipelagos but separated the Society archipelago from the other two.

CONCLUSIONS

This study shows that clonality is a frequent phenomenon in S. insulare. The genetic diversity within populations is lower than the values assessed in species distributed on the mainland, as a consequence of insularity. But this can also be explained by the overexploitation of sandalwood. The differentiation between archipelagos and islands within archipelagos is very high because of the limited gene flow due to oceanic barriers. Delineation of evolutionary significant units and principles for population management are proposed based on this molecular analysis.