Primary hyperparathyroidism (PHPT) is present in up to 0.1% of the general population. The incidence is higher in women and increases with age. The majority of the cases is asymptomatic and up to 85% are due to single gland adenoma. Parathyroidectomy is the treatment of choice after localization of the hyperactive gland. Papillary Thyroid Carcinoma (PTC) is the most common cancer of the thyroid and constitutes more than 70% of thyroid malignancies. PTC can present as a single nodule or can be Multifocal. The incidence is higher in women. Early treatment favors a good prognosis. PTC with PHPT has been reported in 2.3-4.3% of patients undergoing surgery for PHPT. The coexistence of parathyroid adenoma and incidental PTC is thought to be rare. The mechanisms underlying the relationship between PHPT and PTC have not been established. We suggest a possible hypothesis for the relationship based on shared embryological origin and genes, high parathyroid hormone (PTH), low 1,25 hydroxy vitamin D, hypercalcemia resulting in high levels of angiogenic growth factors. This promotes the formation of parathyroid adenomas and papillary thyroid carcinoma. Presence of these two diseases can complicate patient management due to untreated hypercalcemia, unrecognized thyroid cancer and need for second surgery if not screened for both diseases carefully.

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Diabetes mellitus affects over 463 million individuals worldwide. Religious activities such as the Hajj pilgrimage have a major impact on patients with diabetes mellitus, including increasing the risk of hyperglycaemia and hypoglycaemia. This increased risk is due to dietary changes and intense physical activity during pilgrimage while being on antidiabetic medications. Approximately 20% of the pilgrims with underlying illnesses who visit Mecca are diabetic, and complications, such as diabetic ketoacidosis, nonketotic hyperosmolar state, and fatigue/unconsciousness due to hypoglycaemia, have been observed among these patients. Diabetic patients are also at a high risk for foot complications and infections. To avoid any aggravation of the diabetes, a complete biochemical evaluation of the patient must be conducted before Hajj, and the patients must be provided contextualized educational guidance to avert these potential health challenges. This counselling should include the importance of

Introduction:Thyroid hormone abnormalities and autoimmune diseases in general are associated with various haematological manifestations. Neutropenia is a well recognised side effect of anti-thyroid drugs(ATDs) . Case history:We present a 41 year old Nepalese lady who was referred by her GP with a three month history of weight loss, insomnia, irritability, sweating, palpitations, tiredness and proximal muscle weakness. Past medical history revealed pyelonephritis six months ago and recurrent ear infections. There were no other medical problems and she was not on any regular medications. Her English speaking was limited. Examination revealed diffusely enlarged thyroid gland without opthalmopathy. Laboratory investigations revealed hyperthyroidism with T4 of 64 mol/L (9-24 mol/L) T3 of 20 mol/L (3.5-6.5mol/L) and TSH 0f <0.03mol/L (1.5-5). Full blood count prior to commencement of any treatment revealed neutropenia with a neutrophil count of 0.7x 10 9 /L(3.5-7.5 0.7x 10 9) with normal cell counts in other cell lines. TSH receptor antibodies were elevated 6.5 (<0.4) suggestive of graves disease and technetium scan showed homogeneous uptake supporting this diagnosis. Haematology advice was sought to investigate neutropenia and it was decided to start on carbimazole 10mg with close monitoring of blood counts.