Considering the role of endothelin-1 (ET-1) in tissue remodeling and fibrosis during the development of scleroderma as well as the effect of α-Klotho in pathogenesis of calcinosis and/or endothelial cell injury and its correlation with severity of disease, this study aimed to evaluate serum ET-1, α-Klotho and 25(OH) vitamin D levels in patients with limited and diffuse scleroderma compared to healthy subjects. In this cross-sectional study, 60 scleroderma patients according to the ACR/EULAR 2013 criteria and 60 age- and sex-matched healthy controls were included. In patients, clinical examination was performed and Medsger severity scale was assessed. Serum ET-1, soluble α-Klotho and 25(OH)D levels were measured using ELISA kits. The mean ± SD age of patients and controls was 46.2 ± 9.6 and 47.2 ± 7.0 years, respectively. Compared to healthy controls, serum ET-1 was significantly higher in SSc patients (p = 0.001); whilst serum α-Klotho and 25(OH)D were significantly lower in patients (p = 0.001). The most common organs involved in patients were skin, lung, peripheral vascular and gastrointestinal system and the severity of involvement was mainly mild and/or moderate. There were no significant differences in serum ET-1 and α-Klotho levels according to the severity of different organ involvement (p > 0.05). There was no significant correlation between presence or absence of calcinosis and negative or positivity of auto-antibodies with ET-1, α-Klotho and 25(OH)D levels. Although our study revealed higher serum ET-1 and lower serum α-Klotho levels in SSc patients compared to healthy controls, there were not any significant correlations between their serum levels with severity of organ involvement.

Factitious disorder is a psychologic problem which may cause symptoms of a disease which is non-compliance with patient physical exam. Some cases of brittle diabetes are because of underlying psychologic disorder such as factitious disorder or Munchausen syndrome. In this paper a 17-years old female is presented with factitious hyperglycemia and DKA-like symptoms such as nausea, vomiting and severe abdominal pain. Finally with subtle monitoring it was found that the cause of patient's hyperglycemia despite high dose insulin prescription was impregnating her finger into the date palm in the context of the factitious disorder. The patient had different deceptive behaviors depending on the method of treatment. She used every trick to mislead the medical team. In Munchausen syndrome, patient is unaware of his problem that mimic an episode of diabetic ketoacidosis. Thus psychotherapy is the main treatment of this factitious hyperglycemia. The main aim of this report is consideration of factitious hyperglycemia in patients with brittle diabetes mellitus.

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This bronchoscopic method is minimally invasive, without surgery, anesthesia and hospital admission, the least complication and morbidity as well as is cost benefit in comparison with surgery.