Pancreatitis as the first manifestation of multiple endocrine neoplasia type 2A

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Abstract

Multiple endocrine neoplasia type 2A (MEN2A) is an autosomal dominant inherited condition that predisposes to the triad of medullary thyroid cancer (MTC), pheochromocytoma (Pheo), and primary hyperparathyroidism (PHT). Nearly 100% of MEN2A are associated with germ line mutation of the RET proto-oncogene (RET), and DNA-based RET genotype analysis is now considered essential for earlier diagnosis. The first manifestation of MEN2A is most often due to MTC, and less frequently to Pheo. Rarely, MEN2A is recognized during the search for PHT associated conditions. Most patients with primary hyperparathyroidism are asymptomatic, and the focus of the presentation may be the side effects of chronic hypercalcemia, osteoporosis, renal lithiasis, peptic ulcer disease, and hypertension. Hypercalcemic pancreatitis is rare, being an uncommon first manifestation of PHT. Here, we report on a patient who presented recurrent pancreatitis as the first manifestation of MEN2A. In the present case, prompt sequential dosage of calcium, diagnosis of PHT, and genetic analysis would have resulted in pancreatitis prevention and early MEN2A management.

Translated abstract

Neoplasia endócrina múltipla do tipo 2 (NEM2A) é uma síndrome genética com herança autossômica dominante, que predispõe à tríade de carcinoma medular de tireóide (CMT), feocromocitoma (Feo) e hiperparatireoidismo primário (HPP). Aproximadamente 100% dos casos de NEM2A estão associados a mutações germinativas do protooncogene RET (RET), e a análise molecular do RET é atualmente considerada essencial para diagnóstico precoce. A primeira manifestação da NEM2A é geralmente em decorrência de CMT, e menos freqüentemente devido ao Feo. Raramente, a NEM2A é descoberta durante investigação para condições associadas ao HPP. A maioria dos pacientes com HPP é oligossintomática e a apresentação ocorre devido a sintomas relacionados à hipercalcemia, à osteoporose, à dispepsia, à hipertensão ou à litíase renal. A pancreatite hipercalcêmica é rara, sendo uma manifestação incomum do HPP. Este artigo relata um caso de paciente que apresentou pancreatite recorrente como primeira manifestação de NEM2A. Neste caso, abordagem seqüencial com determinação do cálcio sérico, diagnóstico de HPP e análise genética poderiam ter resultado prevenção de pancreatite e manejo precoce da NEM2A.

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Most cited references 15

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The phenotypes associated with ret mutations in the multiple endocrine neoplasia type 2 syndrome.

B A Ponder (1999)

Different specific mutations in the ret tyrosine kinase give rise to different clinical types of the inherited cancer syndrome multiple endocrine neoplasia type 2 (MEN 2). The explanation for these genotype-phenotype correlations is not yet certain. Several lines of evidence suggest that they result either from different levels of RET activation induced by different mutations or, in one class of mutation, possibly from altered substrate specificity of the RET tyrosine kinase. ret is expressed during development in a lineage of neuroectodermal cells that gives rise to the thyroid C cells and the adrenal medulla, which are involved in tumor formation in MEN 2. ret is also expressed in the enteric autonomic nervous system. Inactivating mutations of ret lead to Hirschsprung's disease, a congenital absence or maldevelopment of the enteric plexuses, whereas activating mutations in one variety of the MEN 2 syndrome lead to their overgrowth. The range of phenotypic expression seen in families with different ret mutations and the variation within families with the same mutation provide a potentially interesting and tractable system for the analysis of both the relationship between phenotype and genotype and the effects of modifier genes.