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The best PC games this week include daylight horror and dark dating-sims
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We continue this month's spooky month with a new batch PC titles that will get your pulse racing. Horror can take many forms, and gaming allows for interconnections with other genres, creating truly unique experiences.
This week's PC game picks are filled with dating sims that offer wild twists and turns, managing eldritch abominations for a mega-corporation, tearing up your environments as you explore a dark cave, or navigating through a world filled with abnormal sights and foes.
There's plenty to choose from and explore within these atypical options, so be sure to check out at least one of them this weekend and have a blast. These games can all be completed in less than ten minutes so you can fit in several gaming sessions.
Hatoful Boyfriend
(Image credit: Epic Games).
A dating sim with pigeon lovers could be so much fun, heartwarming and emotionally satisfying. Yes, that's right. Hatoful Boyfriend lets you play as a human girl who enters an all-bird highschool. Your job is to love one of the birds to avoid an unfortunate ending.
You will need to navigate through hostile and fascinating environments with your best friend, who may also be your love interest. The story and characters are incredible, and the story writing is so good that it puts most romance dating sim visual novels to shame.
The game is well aware of how ridiculous the premise is but still plays it straight and treats every character with due respect, fleshing out their arcs and backgrounds to the point that you genuinely forget they're birds. And it's not afraid to delve into dark and mature subject matter either, handling those topics with as much sharp wit and deftness as any other aspects of the game.
Take a look at Hatoful Boyfriend on steam
Sucker for Love
(Image credit: DreadXP)
Another dating-sim visual novel with a bizarre premise that somehow works, Sucker for Love sees you as a handsome guy who is the king of monsterf**kers. And this title is earned as he's literally summoning Cthulhu so he can give them a smooch! He summons essentially a female Cthulhu named Ln'eta, and from there comes a love affair that literally ends the world.
You can then play two more routes with two cosmic horror cuties. These three routes are very charming, with great character development. The visuals and writing both expertly balance the difficult line between black humor or disturbing horror.
Each route also has its own unique gameplay style that compliments the characters and story and separates from the first girl Ln'eta's spell-casting style game mechanics. It's a well-paced title with simple yet addictive gameplay and it never overstays its welcome. Even more amazing is the fact that you actually care about each woman you love. This is remarkable considering they can change reality in a split second.
Take a look at Steam: Sucker for Love
Monster Management Simulation| Monster Management Simulation
(Image credit: ProjectMoon)
If you're a fan of SCP Foundation, Warehouse 13, Cabin in the Woods, and similar media, this monster-management simulation is absolutely the game for you. You are an L corporation manager and you have to keep the evil eldritch beings inside cells.
Each monster requires different energy sources. This energy can then be stored and sold to the public. These monsters will invariably cause contamination and havoc. You need to redirect your subordinates to corral them and re-contain their families, often at the expense of their lives.
The game is addictive and intense. Your subordinates will be able to delegate monsters for you to take care of. This allows you to maximize energy collection while maintaining calm and compliant behavior. The best part is that you are able to access all the information about each one as you care. And that's not even touching all the drama going on with the protagonist and the other characters in the game.
Take a look at Lobotomy Corporation on Steam
(Image credit: Nolla Games)
While plenty of realistic 3D titles offer destructible environments, the same can't be said for 2D pixel-based games. That is, until Noita. Noita is a roguelite magical action game where "every pixel is physically simulated," according to the description.
This allows you to affect and destroy every part of your environment with magic spells. The magic can also be combined to create spells that have unique properties and interact with the environment. This procedurally generated world gives you more play options.
The idea of a pixel world that can be broken down and molded as you please is such a fantastic concept that it's mind-blowing that no one has come up with it before. This is the game for you if you're looking for a fun, sandbox-style game that you can play as you like.
Take a look at Noita on Steam
Hylics
(Image credit: Mason Lindroth)
Hylics is an excellent example of daylight horror, with freakish and weird visuals, and even more bizarre dialogue that's actually procedurally generated, all tucked away in a world with terrifying environments and enemies.
It also boasts some surprisingly deep RPG mechanics, with the gesture system being one of the most unique and downright imaginative gameplay systems we've seen. It's all complemented by the Claymation style graphics, which are all hand-animated and applied on RPG Maker of all engines.
And unlike nearly any other RPG, Hylics is at most a five-hour game, which means you can beat it and collect all the collectibles/spells/equipment in a single session. It's a wonderfully bizarre and entertaining ride if you're in the mood for something very different from your usual horror fare.
Tags: DarkdatingsimsDaylightGamesHorrorIncludeWeeks
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As of mid-November, the Sioux County Regional Airport is open for business. Hundreds from the surrounding communities gathered for the ribbon-cutting ceremony to celebrate the completion of this regional transportation hub. This nearly $32 million new airport is located on a 493-acre site about half way between Orange City and Sioux Center. The airport offers a 5,500-foot runway that can serve business jets, terminal, multiple hangers, safety approach lighting, weather observation station and much more.
North West REC secured $300,000 through the USDA Rural Economic Development Loan & Grant (REDL&G) program to support this project. North West REC added a $60,000 match plus $150,000 from their Revolving Loan Fund. The loan will be repaid into the existing Revolving Loan Fund to support future projects.


I have updated Sparrow with a fresh batch of clothes. All great items for the fall and winter ahead. I hope you find something you like! Let me know if you have any questions and click here to view the items.


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Home › Pink #7 - Nancy Hart Capturing the Tories
Pink #7 - Nancy Hart Capturing the Tories
"When a band of Tories visited Nancy they were so intent upon their dinner that their removed guns escaped notice. Until suddenly every Tory sprang up. As one stepped forward she seized a musket, fired, and he fell dead. She aimed again. Each now feared to move. Her husband arrived and they were captured."
During the American Revolution, Nancy Hart became known for her work in opposing the Tories, English soldiers, and British sympathizers. Living on the Broad River frontier (in what is now Elbert County), Hart's life has inspired local folklore. Accounts describe her as six feet tall, with red hair, a scarred face, and crossed eyes. She was known for her temper and fearless spirit. For most of the war, she cared for her children while her husband served in the Georgia militia under Elijah Clarke. She sometimes disguised herself as a man and served as a spy for the patriots. One story of Hart's courage occurred when six Tories came to her cabin and demanded information about a patriot leader. Not convinced when she denied any knowledge of the man's location, one of the Tories killed her prized turkey and ordered her to cook it for them. As she served the Tories their dinner, she passed between them and their weapons, passing the weapons one by one to her daughter waiting outside. Her daughter signaled the neighbors. When one of the soldiers noticed that she was removing the weapons and tried to stop her, Hart shot him and one other. She kept the others captive until her husband and the other men arrived. The remaining Tories were hanged. (In 1912 workmen discovered a row of six skeletons buried three feet underground near the site of the old Hart cabin, seeming to substantiate this story.)
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Comme un bateau, la mer en moins est un film français, réalisé par Dominique Ladoge et sorti en 1992.

Le scénario, autobiographique, est écrit par le réalisateur, puis publié en 1992 aux éditions Gallimard dans la collection Pages Blanches. C'était son premier roman, se sera aussi son premier long métrage. Initialement destiné à la télévision et tourné en super , le film obtiendra, après tournage, l'agrément cinématographique. Il recevra plusieurs prix dans des festivals internationaux tels  que Cannes, Berlin et Toronto. Sa diffusion en télévision intervient sur la chaîne Antenne 2 (dans la série Les Mercredis de la vie) début . Il sera rediffusé par la chaîne Arte en .

Synopsis
Fin des années 1960, Fabien, 11 ans, vit dans une caravane avec sa mère et son père qui doit plusieurs fois par an suivre les chantiers de construction où il travaille. Fabien avait tissé des liens d'amitié dans une école du sud de la France, mais en cours d'année, il doit suivre ses parents dans une autre région.

Cette fois, il se retrouve dans le Nord, un choc pour ce garçon qui s'était habitué à la chaleur et la beauté des paysages du sud. Il arrive dans une école où il est le nouveau, tout de suite remarqué par son accent. Quand la bande des élèves dominants de la classe s'aperçoit qu'il vit dans une caravane, il est encore plus rejeté, traité de romanichel. Il subit des brimades, on lui vole ses affaires. Le maître ne le soutient pas, prenant ses actes de rébellion pour des actes d'indiscipline.

Dans l'univers morne des corons et des mineurs au chômage, il rencontre une bande de jeunes garçon, vrais gitans avec qui il fraternise bien que restant pour eux un gadjo. Réprimandé par son père pour sa conduite problématique à l'école, fuguant certains soirs avec les gitans, il se retrouve en plein désarroi et, après une nouvelle bagarre avec les durs de l'école, il fomente une vengeance par laquelle il retrouvera sa dignité.

Fiche technique
 Titre : Comme un bateau, la mer en moins
 Réalisation : Dominique Ladoge
 Scénario : Dominique Ladoge
 Photographie : Étienne Fauduet
 Montage : Didier Ranz
 Ingénieur du son : Jean-Louis Ducarme
 Mixage : Gérard Lamps
 Musique : Michel Cœuriot
 Production : Belbo films, Jacques Fansten
 Pays d'origine :
 Langue : français
 Format : Couleurs  - Super 16 mm - 1,66:1 - Mono
 Genre : drame
 Durée : 91 minutes

Distribution
Mathias Le Ny : Fabien
Patrick Fierry : père de Fabien
Alexandra Vandernoot : mère de Fabien
Jean-Pierre Bisson : l'instituteur, monsieur Burgère
Jérémie Semonin : Karl, copain de Fabien
Jean-Sébastien Peru : Étienne, bande des durs
Vincent Klingbeil : Philippe, bande des durs
Jacques Brillet de Cande : Eddy, bande des durs
Jeffrey Ribier : José, jeune gitan
Manuel Miguez : Faro, jeune gitan
Liliane Ledun : directrice de l'école
Stéphane Shandor : Jules Karchewski, mineur à la retraite
Sabine Leroc : Pauline, amie de Fabien

Distinctions
Prix spécial du Jury du Festival Cannes Junior (1993)
Grand Prix Festival International Londonderry 1993
BAILLARD D'OR du meilleur scénario et Prix de la meilleure première œuvre de la Confédération Internationale des Cinémas d'Art et d'Essai -
Festival International de Namur 1992
Prix du jury CINEMAGIC Belfast 1993
Prix UNICEF Festival International de Berlin 1993
Grand Prix - Prix du meilleur acteur - Prix du meilleur réalisateur - Prix spécial du Jury Jeunesse Festival International de Poznan (Pologne) 1994
Sélection officielle au Festival International du Film pour Enfants de Tel-Aviv 1993
Selection officielle au Festival International de Toronto (Canada) 1992

Autour du film
 Les extérieurs sont tournés au lycée Notre-Dame de Messine à Mons (Belgique) et dans la commune de Wallers.

Notes et références

Liens externes

Film français sorti en 1992
Film dramatique français
Film sur l'enfance
Film sur le harcèlement scolaire
Film tourné dans le département du Nord
Premier long métrage sorti en 1992

redpajama_set_name: RedPajamaWikipedia


But it's also eerily familiar.
Protesters shout slogans and wave Turkish national flags in front of the Dutch consulate in Istanbul. March 12, 2017.
ISTANBUL ― Flying back to Istanbul after a warm week in Britain ― where it felt liberating to be away from the constant political chatter back home ― I came to the shocking realization that the Netherlands, of all things, had been dominating Turkey's news cycle in my absence.
In Germany, and now in the Netherlands, Turkish politicians who support Turkish President Recep Tayyip Erdoğan's proposal for an executive presidency in the upcoming April referendum, had been barred from organizing public rallies for Turks there who can vote, I learned.
'Turks are ugly, regressive and violent; they are rapists and murderers; they need to be stopped.' This is the message spreading in Europe nowadays.
At the time, I was unprepared for the ominous power of identity politics, ready to prove to my European hosts that I was not a barbarian but a civilized young man from Turkey. The same was not expected from students who didn't come from Muslim-majority countries.
I am not a conservative, but reading about the recent violent events against conservative Turks there ― the Dutch police had attacked those who came to the Turkish consulate in Rotterdam to support a conservative Turkish politician ― deeply unsettled me.
I came across an article about a video of a group of men in Switzerland dressed as terrifying Ottoman Turks ― they had thick beards and fezzes on their heads, the piece reported. Marching like Death Troopers, with the Turkish president representing a kind of Darth Vader, they seemed to scream, "Turks are ugly, regressive and violent; they are rapists and murderers; they need to be stopped." This is the message spreading in Europe nowadays ― a new ghost set to haunt the continent even more than it already has. While the tone in Switzerland wasn't as harsh toward Turkey as Germany or the Netherlands on rallies, this footage, which I cannot verify but which was spread around on social media here, was shocking for many Turks. But for me, this terrifying bogeyman seemed eerily familiar.
Riot police stand guard during clashes with demonstrators near the Turkish consulate in Rotterdam, Netherlands. March 12, 2017.
I don't like murderers, but I don't like European politicians telling me I will be perceived as one of those nasty people if I act too Turkish, for that is clearly the sentiment, part of a larger anti-Muslim sentiment, being disseminated from cities across Europe these days.
Thanks to the rise of right-wing politics, the most liberal countries in the continent have changed beyond return.
In the Netherlands, where I was a graduate student a decade ago, I had once taken much pleasure in being away from the kind of nationalism that had been brewing up in Turkey back then. As someone deeply weary of jingoism and the political rhetoric of patriotism, I had long disliked Turkish identity politics. And yet, it was also in the Netherlands that I'd realized the uncannily inescapable power of national and religious identity ― of the misery of being pigeonholed into categories inside which I couldn't help but appear to Europeans.
I don't like murderers, but I don't like European politicians telling me I will be perceived as one of those nasty people if I act too Turkish.
On the day I arrived in Amsterdam in 2004, a Dutch-Moroccan extremist had cut the throat of filmmaker Theo van Gogh near Oosterpark, a public park located a few hundred meters away from my apartment. I had had little idea then but I would have no other choice but to experience my new city under the shadow of that murder.
As my plane flew over the Rhine, I remembered that day ― November 2, 2004 ― when I headed out with my flatmate and a graduate student I had just met. There was outrage on the Amsterdam street ― a feeling equally intense to that produced by the assassination, in 2002, of Pim Fortuyn, a politician who held anti-Islam views similar to those of Theo van Gogh and Geert Wilders.
In the liberal capital of Europe, Fortuyn's assassination, the first in Dutch history in centuries, had sent shockwaves. The killing of van Gogh in 2004 rekindled that feeling with a fervor. That was understandable. When someone is assassinated in a park of your city, you are perfectly entitled to be outraged. But then again, ideology cunningly makes use of such feelings. And so it did in Amsterdam from my first day there.
People watch a TV broadcast near to the crime scene where Dutch filmmaker Theo van Gogh was killed in Amsterdam. Nov. 2, 2004.
A war had been waged against liberal values by "barbarians," locals whispered to each other, and that needed to be answered with equal ferocity ― for people like now-far-right candidate Geert Wilders, but also for mainstream politicians, this sense of outrage would turn into an opportunity. Despite Wilders' defeat by incumbent Prime Minister Mark Rutte in this week's elections, mainstream Dutch politics had already turned right-wing and anti-Islam back then, thanks to the instrumentalization of that 2004 murder. The fact that Wilders' party came in second shows it's still a contender.
That night, we had made our way to an avant garde bar. We were full of hopes and dreams. We talked about Jacques Derrida and wanted to explore minds as curious as ours ― I wanted to discover new views and face new ideas. Instead, I was lectured by a group of old local hippies at the bar about the beauty of freedom in Europe. Learning that I was coming from Turkey, they instructed me to tell my "Muslim countrymen" about the importance of Enlightenment.
Wear a white mask and no European fears you ... But behind masks and the erasure of one's perceived self, lies the seeds of subjugation and self-denial.
It is a difficult task, for a liberal to understand his condescension towards the "regressive" people of the world. The liberal worldview smoothly provides the comforting bubble of opinion outside of which all seems barbaric.
In Amsterdam all was fine as long as I acted in a non-Turkish way and agreed to "de-Turkishize" my character. As an aspiring Oscar Wilde scholar and, like him, someone deeply suspicious of nationalism, that was easy.
But did I really want to hate my own past and memories and experiences? Just wear a white mask and no European fears you any longer. But behind masks and the erasure of one's perceived self, lies the seeds of subjugation and self-denial.
Kaya at a cafe in Amsterdam in 2004.
Politics is theater, and whilst talking about books in Britain, I had almost missed the biggest play on offer, I realized as the plane flew over Europe: Turkey's foreign minister had been banned from landing in the Netherlands, the Turkish minister of families stopped outside the door in the Turkish consulate in Rotterdam before reportedly being forced to spend about four hours in her car, and others.
This reminded me of how the Turk is a crucial character in the European psyche. While in Britain on my most recent trip, a local gentleman told me that his aunt used to warn him against becoming "a Turk" when he acted violently. The Turk: the darkest fear of the European, the age-old stereotype goes.
What is more surprising to me is how the most liberal friends I have on social media have started expressing views that are but an evolution of that stereotype so masterfully repurposed by right-wing politicians ― my friends consider themselves left wing and yet they openly confess to agreeing with the views of Wilders on Turks living in European Union countries.
The Turk is a crucial character in the European psyche ... the darkest fear of the European.
Reading about how a Dutch mayor said he'd given special forces the go ahead to open fire on the Turkish crowd in Rotterdam if they found it necessary and the protests in Istanbul where someone reportedly changed the Dutch flag at the consulate with the Turkish one, I was initially reminded of the protest culture in my homeland ― or rather its violent suppression by the Turkish state.
This was, after all, precisely the kind of reaction the Turkish police force had towards protesters at Gezi Park in Istanbul during 2013's environmentalist uprising. Young activists were killed, and fear and anxiety had dominated the public space. The authorities acted cowardly, as they often do, and young people were understandably furious. Officials ruthlessly burned the tents of young people whose ideals they failed to burn ― they live on.
People watching Turkey back then might have pointed at the violence in Gezi as yet another reason to brand us barbarians. But just as it wasn't fair to label me with this term back in 2004 as a student looking to get an education in the Netherlands, this label isn't fair here either.
Turkish police clash with anti-government protesters in Istanbul over the Gezi Park redevelopment project. June 22, 2013.
Turks like the novelist Orhan Pamuk or the filmmaker Nuri Bilge Ceylan have been inspiring youth all over the world because of their explorations of the Turkish psyche and the Anatolian heartland. They have challenged the stereotype of "the regressive Turkish culture," instead choosing to focus on exploring its intricacies. From contemporary artists like Deniz Tortum and Deniz Gamze Ergüven to musicians like Gaye Su Akyol, a new generation of creative Turks are also producing exciting artworks.
But why should I, a Turkish novelist, be forced to give examples of Nobelists, Palme d'Or winners and Academy Awards nominees to prove that Turks can be creative, worthwhile members of the international community? Citizens of only some nations are put in this unsettling position.
I'm afraid that the rise of this intensely creative new generation of Turks, as well as the existence of perfectly civilized Turkish citizens, will do little in combating the image of "the barbarian" that had long haunted the European psyche and made a comeback a decade ago. Having taken the shape of the fez-wearing Ottoman Turk, an image meant to terrify us and change our ways, this specter will prove ineffective in turning Turks, the majority of whom don't see their traditional culture as a form of barbarism, into something else ― it may even turn the Ottoman fez into a fashion item.
Despite Geert Wilders' defeat, I fear that the genie put out of the bottle by right-wing European politicians will continue haunting the continent.
As my plane started descending on Istanbul, I had the distinct memory of an Amsterdam coffeehouse by a canal that I used to frequent as a 23-year-old. With a cigarette in my hand, I would reflect on the kind of nationalism brewing in my homeland and believed, naively, that the laid-back streets of this city could provide an antidote, and a solution, to all that.
Despite Wilders' defeat, I fear that the genie put out of the bottle by right-wing European politicians will continue haunting the continent.
It was raining at Atatürk Airport when I touched ground, and the night seemed grim.


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Reduces inflammation or swelling in the Body.
Benefits for frozen shoulders, sprains & Strains.


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Lymphadenitis x
Fatal squamous cell carcinoma from necrobiosis lipoidica diabeticorum in a diabetic patient
Yael Lefkovits and Amanda Adler
Necrobiosis lipoidica diabeticorum (NLD) is a chronic granulomatous dermatitis generally involving the anterior aspect of the shin, that arises in 0.3–1.2% of patients with diabetes mellitus (1). The lesions are often yellow or brown with telangiectatic plaque, a central area of atrophy and raised violaceous borders (2). Similar to other conditions with a high risk of scarring including burns, stasis ulcers and lupus vulgaris, NLD provides a favourable environment for squamous cell carcinoma (SCC) formation (3). A number of cases of SCC from NLD have been recorded (3, 4, 5); however, our search of the literature failed to identify any cases of either metastatic or fatal SCC which developed within an area of NLD. This article describes a patient with established type 1 diabetes mellitus who died from SCC which developed from an area of NLD present for over 10 years. Currently, there are a paucity of recommendations in the medical literature for screening people with NLD for the early diagnosis of SCC. We believe that clinicians should regard non-healing ulcers in the setting of NLD with a high index of clinical suspicion for SCC, and an early biopsy of such lesions should be recommended.
Non-healing, recalcitrant ulcers arising from necrobiosis lipoidica diabeticorum, which fail to heal by conservative measures, should be regarded with a high index of clinical suspicion for malignancy.
If squamous cell carcinoma is suspected, a biopsy should be performed as soon as possible to prevent metastatic spread, amputation or even death.
Our literature search failed to reveal specific recommendations for screening and follow-up of non-healing recalcitrant ulcers in the setting of necrobiosis lipoidica diabeticorum.
Further research is required in this field.
A unique case of ectopic Cushing's syndrome from a thymic neuroendocrine carcinoma
Lima Lawrence, Peng Zhang, Humberto Choi, Usman Ahmad, Valeria Arrossi, Andrei Purysko and Vinni Makin
Ectopic adrenocorticotropic hormone (ACTH) production leading to ectopic ACTH syndrome accounts for a small proportion of all Cushing's syndrome (CS) cases. Thymic neuroendocrine tumors are rare neoplasms that may secrete ACTH leading to rapid development of hypercortisolism causing electrolyte and metabolic abnormalities, uncontrolled hypertension and an increased risk for opportunistic infections. We present a unique case of a patient who presented with a mediastinal mass, revealed to be an ACTH-secreting thymic neuroendocrine tumor (NET) causing ectopic CS. As the diagnosis of CS from ectopic ACTH syndrome (EAS) remains challenging, we emphasize the necessity for high clinical suspicion in the appropriate setting, concordance between biochemical, imaging and pathology findings, along with continued vigilant monitoring for recurrence after definitive treatment.
Functional thymic neuroendocrine tumors are exceedingly rare.
Ectopic Cushing's syndrome secondary to thymic neuroendocrine tumors secreting ACTH present with features of hypercortisolism including electrolyte and metabolic abnormalities, uncontrolled hypertension and hyperglycemia, and opportunistic infections.
The ability to undergo surgery and completeness of resection are the strongest prognostic factors for improved overall survival; however, the recurrence rate remains high.
A high degree of initial clinical suspicion followed by vigilant monitoring is required for patients with this challenging disease.
Hamman's syndrome in diabetic ketoacidosis
Alexandra Rose Pain, Josh Pomroy and Andrea Benjamin
Hamman's syndrome (spontaneous subcutaneous emphysema and pneumomediastinum) is a rare complication of diabetic ketoacidosis (DKA), with a multifactorial etiology. Awareness of this syndrome is important: it is likely underdiagnosed as the main symptom of shortness of breath is often attributed to Kussmaul's breathing and the findings on chest radiograph can be subtle and easily missed. It is also important to be aware of and consider Boerhaave's syndrome as a differential diagnosis, a more serious condition with a 40% mortality rate when diagnosis is delayed. We present a case of pneumomediastinum, pneumopericardium, epidural emphysema and subcutaneous emphysema complicating DKA in an eighteen-year-old patient. We hope that increasing awareness of Hamman's syndrome, and how to distinguish it from Boerhaave's syndrome, will lead to better recognition and management of these syndromes in patients with diabetic ketoacidosis.
Hamman's syndrome (spontaneous subcutaneous emphysema and pneumomediastinum) is a rare complication of DKA.
Presentation may be with chest or neck pain and shortness of breath, and signs are subcutaneous emphysema and Hamman's sign – a precordial crunching or popping sound during systole.
Boerhaave's syndrome should be considered as a differential diagnosis, especially in cases with severe vomiting.
The diagnosis of pneumomediastinum is made on chest radiograph, but a CT thorax with water-soluble oral contrast looking for contrast leak may be required if there is high clinical suspicion of Boerrhave's syndrome.
Hamman's syndrome has an excellent prognosis, self-resolving with the correction of the ketoacidosis in all published cases in the literature.
Ketosis-prone diabetes and SLE co-presenting in an African lady with previous gestational diabetes
S Hussain, S Keat and S V Gelding
We describe the case of an African woman who was diagnosed with ketosis-prone diabetes with diabetes-associated autoantibodies, after being admitted for diabetic ketoacidosis (DKA) precipitated by her first presentation of systemic lupus erythematosus (SLE). She had a seven-year history of recurrent gestational diabetes (GDM) not requiring insulin therapy, with return to normoglycaemia after each pregnancy. This might have suggested that she had now developed type 2 diabetes (T2D). However, the diagnosis of SLE prompted testing for an autoimmune aetiology for the diabetes, and she was found to have a very high titre of GAD antibodies. Typical type 1 diabetes (T1D) was thought unlikely due to the long preceding history of GDM. Latent autoimmune diabetes of adults (LADA) was considered, but ruled out as she required insulin therapy from diagnosis. The challenge of identifying the type of diabetes when clinical features overlap the various diabetes categories is discussed. This is the first report of autoimmune ketosis-prone diabetes (KPD) presenting with new onset of SLE.
DKA may be the first presentation of a multi-system condition and a precipitating cause should always be sought, particularly in women with a history of GDM or suspected T2D.
All women with GDM should undergo repeat glucose tolerance testing postpartum to exclude frank diabetes, even when post-delivery capillary blood glucose (CBG) tests are normal. They should also be advised to continue CBG monitoring during acute illness in case of new onset diabetes.
KPD comprises a spectrum of diabetes syndromes that present with DKA, but subsequently have a variable course depending on the presence or absence of beta cell failure and/or diabetes autoantibodies.
KPD should be considered in a patient with presumed T2D presenting with DKA, especially if there is a personal or family history of autoimmune diabetes.
LADA should be suspected in adults presumed to have T2D, who do not require insulin therapy for at least six months after diagnosis and have anti-GAD antibodies.
Patients with autoimmune diabetes have an increased risk of other autoimmune diseases and screening for thyroid, parietal cell, coeliac and antinuclear antibodies should be considered.
Diabetes insipidus and hypopituitarism in HIV: an unexpected cause
Carlos Tavares Bello, Francisco Sousa Santos, João Sequeira Duarte and Carlos Vasconcelos
Central diabetes insipidus (DI) is a rare clinical entity characterized by low circulating levels of antidiuretic hormone (ADH) presenting with polyuria and volume depletion. Pituitary surgery is the most common cause of central DI in adults. Pituitary and hypothalamic disease, particularly invasive neoplasms, rarely cause DI, being idiopathic cases responsible for the majority of non-surgical cases. HIV patients, especially those with poor virulogical control, are prone to the development of CNS neoplasms, particularly lymphomas. These neoplasms usually become manifest with mass effects and seizures. Central DI and hypopituitarism are uncommon initial manifestations of primary CNS lymphomas. The authors describe the case of 29-year-old female, HIV-positive patient whose CNS lymphoma presented with DI.
Central diabetes insipidus has multiple causes and central nervous system lymphomas are not often considered in the differential diagnosis due to their low prevalence.
Accurate biochemical diagnosis should always be followed by etiological investigation.
The HIV population is at risk for many neoplasms, especially CNS lymphomas.
New-onset polyuria in an HIV-positive patient in the absence of focal neurological signs should raise the suspicion for a central nervous system process of neoplastic nature.
This clinical entity usually constitutes a therapeutical challenge, often requiring a multidisciplinary approach for optimal outcome.
ACTH-secreting medullary thyroid cancer: a case series
Ayanthi A Wijewardene, Sarah J Glastras, Diana L Learoyd, Bruce G Robinson and Venessa H M Tsang
Medullary thyroid cancer (MTC) is a rare neuroendocrine tumour that originates from the parafollicular cells of the thyroid gland. The most common presentation of MTC is with a single nodule; however, by the time of diagnosis, most have spread to the surrounding cervical lymph nodes. Cushing's syndrome is a rare complication of MTC and is due to ectopic adrenocorticotrophic hormone (ACTH) secretion by tumour cells. Cushing's syndrome presents a challenging diagnostic and management issue in patients with MTC. Tyrosine kinase inhibitors (TKI) previously used for the management of metastatic MTC have become an important therapeutic option for the management of ectopic ACTH in metastatic MTC. The article describes three cases of ectopic ACTH secretion in MTC and addresses the significant diagnostic and management challenges related to Cushing's syndrome in metastatic MTC.
Medullary thyroid cancer (MTC) is a rare neuroendocrine tumour.
Cushing's syndrome is a rare complication of MTC that has a significant impact on patients' morbidity and mortality.
Tyrosine kinase inhibitors (TKI) provide an important therapeutic option for the management of ectopic ACTH in metastatic MTC.
IgG4-related hypophysitis presenting as diabetes insipidus with tubulo-interstital nephritis and mediastinal lymphadenopathy
Rayna Patel, Waheed Mustafa, Michael T Sheaff and Sami Khan
IgG4-related disease (IgG4-RD) is a rare but increasingly recognised condition, emerging as a clinical entity following the observation of the associations of autoimmune pancreatitis. IgG4-RD is characterised by extensive infiltration of IgG4-positive plasma cells into multiple organs and raised serum IgG4 levels. Clinical manifestations of IgG4 disease classically include autoimmune pancreatitis, lacrimal or salivary gland infiltration (formerly known as Mikulicz disease) and retroperitoneal fibrosis. More rarely, IgG4 disease can cause pituitary hypophysitis. Although most frequently described in middle-aged males, the epidemiology and pathogenesis of the disease remain largely undefined. Nevertheless, an understanding of the wide variety of clinical manifestations of this multi-system condition is undeniably important given the often excellent outcomes following treatment. We describe an unusual presentation of IgG4 disease with isolated diabetes insipidus secondary to pituitary hypophysitis. The patient in question subsequently developed chest pain secondary to mediastinal lymphadenopathy and tubulo-interstitial nephritis leading to renal dysfunction. He was successfully treated with oral steroids and had regular follow-up, and remains well at follow-up 2 years later.
IgG4 disease, although rare, is increasing in prevalence largely due to increased recognition of its clinical manifestations, including autoimmune pancreatitis, lacrimal or salivary gland infiltration, retroperitoneal fibrosis and, more rarely, lymphocytic hypophysitis presenting as diabetes insipidus.
IgG4 disease is highly treatable, and symptoms may show complete resolution with administration of steroids, highlighting the importance of correct and timely diagnosis.
Causes of lymphocytic hypophysitis are varied and not distinguishable radiologically. Given the difficulty in biopsying the pituitary, careful attention must be paid to the systemic clinical presentation to provide clues as to the underlying disorder.