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Insulin-induced hypoglycaemia causes similar degrees of significant hypokalaemia in patients with normal pituitary function and in those with GH deficiency, either alone or in combination with other pituitary hormone deficiencies. Therefore, insulin-induced hypoglycaemia does not appear to be associated with any greater risk of hypokalaemia in hypopituitary adults with GHD compared to those with normal anterior pituitary function.

We describe the case of a 30-year-old female patient with a 7-year history of multiple sclerosis, who presented with an 18-month history of secondary amenorrhoea and vague symptoms which included poor sleep and impaired concentration. Endocrine investigations revealed hypogonadotrophic hypogonadism and GH deficiency, a probable consequence of a hypothalamic plaque. This is the first report of hypogonadotrophic hypogonadism and GH deficiency occurring in conjunction with multiple sclerosis. As such, it should raise suspicion of endocrine dysfunction occurring in a condition with such a vast spectrum of disability as multiple sclerosis.

INTRODUCTION:The "tree-in-bud" sign consists of multiple pulmonary nodules centered in the secondary lobule without involvement of the subpleural lung, in a linear branching pattern arising from a common stalk. It can indicate the presence of mucus, fluid, and/or pus in the bronchioles, most commonly due to acute infection or aspiration. Such findings are rarely attributed to malignancy. Lung adenocarcinoma has a varied appearance on CT that can range from ground glass nodules to cavitating lesions or lobar consolidations. Here we present the case of a former smoker with persistent dry cough and tree-in-bud sign on CT, who was ultimately diagnosed with lung adenocarcinoma. CASE PRESENTATION:A 69-year-old female former smoker with alcoholic cirrhosis and mild COPD presented to her primary care physician for evaluation of persistent cough following a viral illness. Initial chest x-ray was consistent with a right lower lobe pneumonia, for which a 5 day course of azithromycin was prescribed. Symptoms persisted and serial radiography did not show improvement, prompting a non-contrast CT chest. The chest imaging revealed multiple tree-in-bud opacities and a right lower lobe consolidation and no mediastinal lymphadenopathy. Referral to pulmonology was made and her antibiotics were changed for suspected chronic aspiration. Subsequent CT scan showed progression of infiltrates to the right upper lobe. The decision was made to pursue bronchoscopy with BAL and TBBx BAL cultures were negative, however transbronchial biopsy was positive for mucinous adenocarcinoma. PET scan noted metastatic lesions in the contralateral lung and pleura consistent with stage IV disease. The patient declined systemic chemotherapy in favor of hospice.DISCUSSION: Adenocarcinoma is now the most common type of primary lung cancer. Early diagnosis is crucial given its propensity for aerogenic dissemination, however, most patients present with advanced disease. Surgical resection of early-stage disease offers a 5-year survival of over 70%. Targeted molecular therapies have been shown to improve the response rate but with a higher rate of adverse events. Platinum-based chemotherapy, for those patients without treatable oncogenic alterations, offers a 1-year survival rate of 30-40%.CONCLUSIONS: This case report demonstrates that lung cancer can present with atypical radiographic findings, and the astute clinician should remain vigilant for lung cancer when encountering tree-in-bud opacities.

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