Normal Complete Blood Count Research Articles

Analysis of associated risk factors among recurrent cutaneous leishmaniasis patients: A cross-sectional study in Khyber Pakhtunkhwa, Pakistan

BackgroundLeishmaniasis is the second and fourth highest cause of mortality and morbidity respectively among all tropical diseases. Recurrence in the onset of leishmaniasis is a major problem that needs to be addressed to reduce the case fatality rate and ensure timely clinical intervention. Here we are investigating the association of risk factors with recurrent cutaneous leishmaniasis to address this issue. Material and methodsPatients received by Nasser Ullah Khan Babar Hospital in Peshawar, Pakistan from March 2019 to July 2020 were enrolled in this study. Those patients who developed symptoms after completion of treatment were included in Group-A while those who had atypical scars like leishmaniasis but were negative for cutaneous leishmaniasis were included in the comparison group tagged as Group B. All those individuals who had completed six weeks of treatment for CL but had normal complete blood counts (CBC) were included to avoid other underlying immunological pathologies, while we excluded those participants who had co-morbidities like diabetes, liver disease, cardiac disease, and pregnant and lactating women through their history Association was tested between Group-A and Group-B with other explanatory variables through chi-square test. The regression model was proposed to determine the predictors. ResultA total of 48 participants of both sexes were included in the study with a mean age of 32.2 ± 15.10. The data suggest that females are overrepresented among the patients with recurrent leishmaniasis [21(53.8 %,); p = 0.07]. Compared to patients; healthy participants had a higher proportion of adults (19–59 years) versus adolescents (13–18 years) [26(66.7 %) vs 07(17.9), p = 0.004]. Multivariate logistic regression analysis shows that females are 2.1 times more prone to infections among cases as compared to healthy individuals [unadjusted OR 2.20, 95 % confidence interval (CI) 1.5–10.6, p = 0.02; adjusted OR 2.1, 95 % CI 1.50–10.69, p = 0.02]. We propose that patients receiving intradermal were less likely to be infected as compared to those receiving intralesional injections [unadjusted OR 0.07.0, 95 % confidence interval (CI) 1.18–3.37, p = 0.03; adjusted OR 0.06, 95 % CI 1.18–3.38, p = 0.03]. ConclusionOld age (adults) and sex (females) were the strongest predictors to be associated with recurrent leishmaniasis. Similarly, the choice of intradermal as compared to intralesional injection and the prolonged treatment duration were strongly associated with greater chances of recurrence.

Case 302: Supratentorial Lymphocytic Inflammation with Parenchymal Perivascular Enhancement Responsive to Steroids.

Part one of this case appeared 4 months previously and may contain larger images. A 21-year-old immunocompetent man who was a long-term resident of Qatar presented to the emergency department with recurrent episodes of unprovoked generalized tonic-clonic seizures lasting 2-3 minutes that spontaneously resolved and were associated with postictal confusion. The patient also had progressive mild diplopia, intermittent dizziness, and numbness in the left arm over the course of 3 months. The patient did not have any other systemic symptoms or chronic medical diseases. He did not have any history of intake of illicit drugs, supplements, or regular medications; he had not received any recent vaccinations; and he had not undergone any surgical procedures. He had no history of travel. At presentation, vital signs were normal. Neurologic examination showed mild left homonymous hemianopia, normal gait with no cerebellar signs, and preserved sensations, power, tone, and reflexes in all four limbs. An electroencephalogram showed no epileptiform discharges. Chest CT and extensive laboratory work-up, including viral, fungal, bacterial, and parasite work-up, thyroid function tests, and immunologic blood tests yielded normal results. Those included normal complete and differential blood counts and normal serum chemistry. Serum analysis was negative for antinuclear antibody, Sjögren syndrome antigens A and B, cytoplasmic antineutrophil cvtoplasmic antibody, and paraneoplastic profile. Serum evaluation was also negative for human immunodeficiency virus type 1 and type 2 RNA, and Brucella, Schistosoma, and toxoplasma antibodies. Venereal Disease Research Laboratory (VDRL) and rapid plasma regain (RPR) test results were negative. Cerebrospinal fluid (CSF) analysis revealed clear fluid and normal pressure and biochemistry, except for elevated protein concentration (0.48 g/L) (normal range, 0.15-0.45 g/L). There were 43 leukocytes/µL (99% lymphocytes) (normal range, 0-5 leukocytes/µL; lymphocytes range, 40%-80%), with no atypical or malignant cells. CSF Gram staining, acid-fast staining, cryptococcal antigen, varicella-zoster virus polymerase chain reaction (PCR), herpes simplex virus PCR, VDRL, and RPR test results were negative. CSF cultures did not show any evidence of growth of bacteria, fungi, or acid-fast bacillus. CSF flow cytometry did not show a monoclonal lymphoid population. No CSF oligoclonal bands were detected. Conventional brain MRI with intravenous administration of contrast material and perfusion study were performed and included different sequences (Figs 1-3).

Musculoskeletal involvement in childhood leukemia: Characteristics and survival outcomes

Background Childhood leukemia with musculoskeletal (MSK) involvement mimics various conditions, which consequently leads to diagnostic delays. The clinical implication of MSK involvement in this disease on survival outcomes is inconclusive. This study aimed to compare characteristics and survival outcomes between MSK and non-MSK involvement in childhood leukemia.MethodsThe medical records of children newly diagnosed with acute leukemia of an age under 15 years were retrospectively reviewed. Two-to-one nearest-neighbor propensity score-matching was performed to obtain matched groups with and without MSK involvement. The Kaplan–Meier method and log-rank test were then used to assess the effect of MSK involvement on survival outcomes.ResultsOf 1042 childhood leukemia cases, 81 (7.8%) children had MSK involvement at initial presentation. MSK involvement was more likely in children with acute lymphoblastic leukemia than acute myeloid leukemia (p < 0.05). Hematologic abnormalities were less frequent in the MSK involvement group (p < 0.05). The absence of peripheral blast cells was significantly higher in the MSK involvement group (17.3% vs 9.6%, p = 0.04). Normal complete blood counts with absence of peripheral blast cells were found 2.5% of the children with MSK involvement. By propensity score-matching for comparable risk groups of children with and without MSK involvement, the 5-year overall survival was not significantly different (48.2% vs 57.4%, respectively, p = 0.22), nor was event-free survival (43.3% vs 51.8%, respectively, p = 0.31).ConclusionChildhood leukemia with MSK involvement had the characteristics of minimal or absent hematologic abnormalities and peripheral blast counts.

Osteoid Osteoma of the Talus Misdiagnosed with Juvenile Idiopathic Arthritis: A Case Report

Osteoid osteoma is a primary benign bone tumor that consists of a central area (nidus), surrounded by sclerotic bone. The most relevant symptom is pain that increases during the night and improves after salicylates or nonsteroidal anti-inflammatory drug administration. Osteoid osteoma is frequently misdiagnosed because it mimics juvenile idiopathic arthritis, bone infection, or malignancy. A 14-year-old girl presented to our department with a history of chronic pain in her left ankle. Juvenile idiopathic arthritis was diagnosed and anti-inflammatory treatment was prescribed. Because of persistence of ankle pain, the patient underwent further examinations, in particular, bone scintigraphy and computed tomography. As a result, osteoid osteoma of the talar neck was diagnosed. The patient underwent surgical treatment and her condition improved. Osteoid osteoma should also be considered in patients with chronic ankle pain to avoid misdiagnosis and start adequate treatment. This condition should be suspected in a patient with chronic bone pain and normal complete blood count and inflammatory parameters.

Evaluation of the growth response to growth hormone therapy in short children with normal growth hormone secretion

Introduction The availability of biosynthetic growth hormone (GH) ensures that children who are deficient can have replacement therapy, but it has also created the opportunity to treat children who are short but do not have a deficiency. The target height of children with short stature who have normal GH secretion, idiopathic short stature (ISS), without treatment, fails to reach their midparental potential. GH therapy for these children has resulted in variable height outcomes. While some children reached or exceeded genetic target height, others did not have a favorable response. Aim The aim of this study was to report the outcome of the children with ISS who had initial height standard deviation score (HtSDS) (Z score) less than −2, with normal stimulated GH levels (&gt;10 μg/l), after treatment with biosynthetic GH for at least 1 year. Patients and methods This retrospective study included 20 children with ISS, with initial HTSDS less than −2, normal stimulated GH levels (&gt;10 μg/l), who were treated with rhGH (0.04 mg/kg/day) for at least 1 year. None had any other systemic or endocrine disorder. All had normal complete blood count, liver, and renal functions. Results Twenty children (15 males and five females) with ISS, aged between 4.3 and 13.8 years (mean=9.88±2.62 years), who had mean peak GH=15.58±6.95 μg, were studied. All received GH treatment (average GH dose was 0.04 mg/kg/day) for a mean duration=2.49±1.61 years. The mean midparental HtSDS (MPHSDS) was −1.23±0.57. Their bone age did not differ significantly compared with their chronological age (the mean difference=−0.13±0.67 years). The mean HSDS before treatment was −2.34±0.41 and after 1 year of GH treatment was −1.83±0.48. This gave a gain of an average of 0.5 SD. At the last visit (after a mean of 2.5 years), the HtSDS −1.57±0.55 SD with a gain of 0.77±0.14 SD versus before treatment. The difference between children HtSDS compared with their MPHSDS was −1.08 SD before treatment that was changed to −0.3 SD at the last visit. The increment in HSDS was positively correlated with the duration of rhGH therapy (r=0.82, P=0.01) and negatively correlated with age at the start of treatment (r=−0.54, P=0.01). Conclusion Growth hormone therapy that benefits short children with normal growth hormone secretion achieves near-normal HSDS and approaches MPHSDS.

Hb Kirikiriroa [α57(E6)Gly→Cys; HBA1: c.172G>T]: A Novel Unstable α-Globin Variant with Oxidized Derivatives Interfering with Hb A1c

We report the identification of a novel hemoglobin (Hb) variant [α57(E6)Gly→Cys; HBA1: c.172G>T], to be referred to as Hb Kirikiriroa. The variant was detected in five subjects from two families, with familial relationship established between the families following diagnosis. A persistently elevated Hb A1c over a 1-year period prompted hemoglobinopathy screening in an adolescent male of New Zealand (NZ) European descent (case 1). Capillary electrophoresis (CE) revealed the variant was negatively charged and susceptible to oxidation, with multiple abnormal peaks detected (0.4–5.1% total Hb). Hb A1c analysis by cation exchange high performance liquid chromatography (HPLC) was the first indication of the variant in a pregnant female of NZ European descent (case 2). Cases 1 and 2 had normal complete blood counts. Isopropanol stability testing provided evidence the variant was unstable. We herein describe the characterization of Hb Kirikiriroa and clinical significance of the variant for interference with Hb A1c analysis by CE and cation exchange HPLC.

Inflammation is associated with impairment of oxidative status, carbohydrate and lipid metabolism in type 2 diabetes complicated by non-alcoholic fatty liver disease.

Non-alcoholic fatty liver disease (NAFLD) is accompanied by inflammation and impairment of the lipid metabolism. In addition, NAFLD is one of the major complications of type 2 diabetes associated with oxidative stress. Based on this, we evaluated the tumor necrosis factor alpha (TNF-α), nuclear factor κB (NF-κB), oxidative status rates, and analyzed its correlation with carbohydrate and lipid metabolism in patients with NAFLD and type 2 diabetes. A case-control study included 63 participants with NAFLD developing in patients with type 2 diabetes, and 65 healthy volunteers with a normal complete blood count and blood biochemical profile. The following parameters and states were assessed during the study: glycaemia, insulin resistance, lipid levels, liver tests, intensity of free radical induced oxidation, antioxidant enzymes, TNF-α and NF-κB level. Free radical induced oxidation was significantly elevated (P<0.001), total antioxidant activity was significantly decreased (P<0.001) and associated with insulin resistance (P=0.019) and lipid metabolism shifts (P<0.05) in patients with NAFLD and type 2 diabetes. Such patients had showed impaired functioning of antioxidant system (P<0.001), inhibition of NADPH-generating enzymes activity (P<0.001), increased levels of TNF-α (P<0.001) and NF-κB (P=0.019) correlated with the severity of hyperglycemia (P<0.05), concentration of reduced glutathione (P=0.005) and total cholesterol (P=0.016). The increase of free radical induced oxidation, TNF-α and NF-κB levels, and depletion of the antioxidant system seems to be the key factors of the development of NAFLD in patients with type 2 diabetes.

Case 302.

History A 21-year-old immunocompetent man who was a long-term resident of Qatar presented to the emergency department with recurrent episodes of unprovoked generalized tonic-clonic seizures lasting 2-3 minutes that spontaneously resolved and were associated with postictal confusion. The patient also had progressive mild diplopia, intermittent dizziness, and numbness in the left arm over the course of 3 months. The patient did not have any other systemic symptoms or chronic medical diseases. He did not have any history of intake of illicit drugs, supplements, or regular medications; he had not received any recent vaccinations; and he had not undergone any surgical procedures. He had no history of travel. At presentation, vital signs were normal. Neurologic examination showed mild left homonymous hemianopia, normal gait with no cerebellar signs, and preserved sensations, power, tone, and reflexes in all four limbs. An electroencephalogram showed no epileptiform discharges. Chest CT and extensive laboratory work-up, including viral, fungal, bacterial, and parasite work-up, thyroid function tests, and immunologic blood tests yielded normal results. Those included normal complete and differential blood counts and normal serum chemistry. Serum analysis was negative for antinuclear antibody, Sjögren syndrome antigens A and B, cytoplasmic antineutrophil cvtoplasmic antibody, and paraneoplastic profile. Serum evaluation was also negative for human immunodeficiency virus type 1 and type 2 RNA, and Brucella, Schistosoma, and toxoplasma antibodies. Venereal Disease Research Laboratory (VDRL) and rapid plasma regain (RPR) test results were negative. Cerebrospinal fluid (CSF) analysis revealed clear fluid and normal pressure and biochemistry, except for elevated protein concentration (0.48 g/L) (normal range, 0.15-0.45 g/L). There were 43 leukocytes/µL (99% lymphocytes) (normal range, 0-5 leukocytes/µL; lymphocytes range, 40%-80%), with no atypical or malignant cells. CSF Gram staining, acid-fast staining, cryptococcal antigen, varicella-zoster virus polymerase chain reaction (PCR), herpes simplex virus PCR, VDRL, and RPR test results were negative. CSF cultures did not show any evidence of growth of bacteria, fungi, or acid-fast bacillus. CSF flow cytometry did not show a monoclonal lymphoid population. No CSF oligoclonal bands were detected. Conventional brain MRI with intravenous administration of contrast material and a perfusion study were performed and included different sequences (Figs 1-3).

P046 Tofacitinib Induced Resolution of Severe Colitis and Reactive Atypia in an Adolescent Patient With IBD.

Tofacitinib is an anti-JAK/STAT small molecule approved for treatment of adults (but not children and adolescents) with moderate to severe ulcerative colitis. Data is limited in children and teens although two major centers have shown efficacy as both mono- and dual - combination therapy using tofacitinib in pediatric patients refractory to anti-TNF agents. We present a 16-year-old female diagnosed with inflammatory ileocolonic Crohn's disease without upper gastrointestinal involvement after presenting with several months of abdominal pain, diarrhea, and unintentional weight loss. Laboratory evaluation was notable for normal inflammatory markers, albumin and complete blood count and an elevated stool lactoferrin. Initial endoscopic evaluation revealed moderate to severe pancolitis and patchy ileitis; biopsies noted mild chronic active ileitis and moderate to severe chronic active pancolitis without dysplastic or atypical changes. She was started on infliximab for induction and maintenance therapy and dosage was increased due to suboptimal levels and marginal symptomatic improvement. However, despite increased dosing plus a course of budesonide (Uceris), she had minimal improvement in her symptoms and ongoing elevation of her lactoferrin. Given an equivocal result on a Clostridium difficile testing (GDH antigen positive only), she was started on oral vancomycin which resulted in mild improvement, but not resolution, of diarrhea and abdominal pain. This was continued after completion of a 14-day course (and subsequent negative testing) due to increased stool frequency with discontinuation of the medication and improvement with reinitiating it. She had severe pancolitis (Mayo 2 - 3) but normal TI on repeat colonoscopy 5 months after diagnosis. Biopsies (reviewed by a panel of adult GI pathologists) were notable for reactive atypia with features concerning for early dysplasia in the ascending and descending colon. Due to disease severity and rapid progression plus histologic changes concerning for possible dysplasia despite optimized therapy with infliximab and repeat negative C. difficile testing, she was started on tofacitinib 10 mg twice daily along with oral vancomycin. She had complete resolution of diarrhea, abdominal pain, and early satiety within a week; repeat fecal lactoferrin was negative (<30). She underwent repeat colonoscopy with chromoendoscopy 5 months after initiation of tofacitinib which revealed mild acute ileitis but no active colonic inflammation, atypia or dysplasia. This is the first report to our knowledge that an adolescent patient with colonic predominant Crohn's disease has complete resolution of atypia and possible early dysplasia with tofacitinib therapy.

NCMP-17. BEWARE: ALL POSTERIOR FOSSA MASSES IN CHILDREN ARE NOT BRAIN TUMORS

Abstract INTRODUCTION Isolated Myeloid sarcoma (MS) of the central nervous system (CNS-MS) is a very rare presentation of Acute Myeloid Leukemia (AML). A 10-year-old boy with a two-week history of intermittent headaches was referred to the emergency department (ED) by an optometrist for evaluation of bilateral papilledema. Physical examination in the ED confirmed the presence of papilledema with no other abnormal neurologic findings. Emergent MRI of the brain showed an avidly homogeneously enhancing extra-axial dural based mass in the right posterior fossa measuring 4.8 cm (AP) x 3.2 cm (CC) x 4.6cm (T), with significant mass effect and peri-tumoral vasogenic edema. Neuro-surgery consultation was obtained and complete blood count (CBC) was normal except for the presence of 13% blasts with occasional Auer rods seen on the peripheral blood smear. Bone marrow aspirate demonstrated 56% myeloblasts; A diagnosis of AML with CNS-MS (CNS-3c) was made and the initial lumbar puncture (LP) was deferred due to the risk of CNS herniation. Induction chemotherapy was initiated as per protocol. A CT scan done two weeks later showed complete resolution of the intracranial mass. DISCUSSION The incidental finding of papilledema, with imaging to investigate the intracranial pathology revealed a large posterior fossa mass in our patient. However, the atypical features of the mass (dural based extra-axial location; extensive infiltration into adjacent structures) and the finding of blasts with Auer rods in peripheral blood helped us to diagnose CNS-MS, and avoided an extensive neurosurgical procedure and a delay in definitive therapy. Our patient had a normal CBC and the review of the peripheral blood film by an experienced Hematologist was very crucial in making a clinical diagnosis of MS. CONCLUSION Myeloid sarcomas should be considered in the differential diagnosis of an intracranial mass, particularly when accompanied by abnormal findings in the CBC.

Determination of reference ranges for automated erythrocyte and reticulocyte parameters in healthy adults

Abstract Objectives Recent advances in hematology analyzers have enabled to improve the reliability in the results and also provided additional hematological parameters. In the present study, we aimed to determine the reference ranges for automated erythrocyte and reticulocyte parameters in healthy individuals on Sysmex XN 1000 hematology analyzer. Methods One hundred and thirty-three subjects with normal physical examination and complete blood count results within the reference ranges were included in the study. Venous blood samples collected in tubes containing K2-EDTA were analyzed on Sysmex XN-1000. The references intervals for IRF, RBC He, Ret He, LFR, MFR, HFR, Delta He, Micro R, Macro R, Hypo He and Hyper He were determined according to CLSI EP28-A3c. Results The reference ranges of the parameters were estimated with 90% confidence intervals. The reference ranges were 3.4–17% for IRF, 26.9–32.8 pg for Ret-He, 25.2–30.5 pg for RBC-He and 0.5–3.7 pg for delta-He. Gender specific reference ranges were calculated for of Ret-He (male (M): 26.8–32.9 pg, female (F): 23.9–33.6 pg), RBC-He (M: 26.3–30.8 pg, F: 25.3–30.5 pg) and delta-He (M: 0.5–3.7 pg, F: 0.3–3.7 pg). Conclusions The new reticulocyte and erythrocyte parameters may be conveniently used in clinical diagnosis and follow-up of patients, as they offer reliable, automated and cheap results. Each laboratory is recommended to determine its own reference intervals considering the differences like the instrument used and population studied.

SPONTANEOUS CORONARY ARTERY DISSECTION: A RARE SEQUELA OF COVID-19

TOPIC: Cardiovascular Disease TYPE: Fellow Case Reports INTRODUCTION: Spontaneous coronary artery dissection (SCAD) is a rare coronary event, mostly associated with autoimmune and inflammatory conditions. We share a case report of a patient admitted to the Creighton University Medical Center, Omaha, Nebraska with the clinical presentation and diagnostics suggestive of SCAD after coronavirus disease 2019 (COVID-19). CASE PRESENTATION: A 43-year-old caucasian woman with a history of atrial fibrillation (AF) during pregnancy, was brought to the hospital after she had a syncopal episode due to ventricular fibrillation (VF) leading to cardiac arrest requiring defibrillation on site. She had been tested positive for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) by PCR with mild symptoms, about 12 weeks prior to this episode and she recovered within a week after self-quarantine at home. In the emergency room, she had AF with a rapid ventricular response, hypothermia, bilateral decreased breath sounds, a non-tender abdomen, and equal pulses. She required endotracheal intubation for airway protection. Her initial laboratory studies revealed normal complete blood counts, CRP 71.2 mg/L, and initial Troponin I 2.55 ng/mL (with a peak of 21 ng/mL). Subsequently, she progressed to refractory cardiogenic shock necessitating four vasopressor agents. A transthoracic echocardiogram revealed a left ventricular ejection fraction of 20% with new-onset global hypokinesis and myocardial wall thickness. The coronary angiogram revealed SCAD in the left circumflex artery. An Impella device was placed for cardiovascular support initially, but she ultimately required Veno-arterial (VA) ECMO. She was also given pulse dose IV methylprednisone due to concerns for myocarditis as a late inflammatory sequela of COVID-19. She was managed conservatively without coronary intervention. The follow-up TTE one week later showed improvement in her LVEF to 60%. DISCUSSION: SCAD should be kept in the differential diagnosis in the patients who have COVID-19 infections within the past 2-12 weeks and noted to have symptoms of an acute coronary syndrome (ACS) or new-onset cardiac arrhythmias. So far there are very few reported cases of SCAD after COVID-19, all having a variable clinical course (1–3). Overall, SCAD is an underreported coronary event and has a prevalence of around 4%, mostly associated with autoimmune and inflammatory diseases. Various mechanisms of SCAD have been proposed including infection-related endothelial dysfunction and intra-plaque hemorrhage leading to an intra-adventitial hematoma, followed by longitudinal spread along the coronary artery and eventually dissection. Even though SCAD can be due to other contributory factors in critical illness, however, the association of SCAD with COVID-19 needs to be further elaborated. CONCLUSIONS: COVID-19 may lead to various cardiovascular disorders ranging from ACS to SCAD and management protocols need further research. REFERENCE #1: Kumar K, Vogt JC, Divanji PH, Cigarroa JE. Spontaneous coronary artery dissection of the left anterior descending artery in a patient with COVID-19 infection. Catheter Cardiovasc Interv [Internet] 2021;97(2). Available from: https://onlinelibrary.wiley.com/doi/10.1002/ccd.28960 REFERENCE #2: Aparisi Á, Ybarra-Falcón C, García-Granja PE, Uribarri A, Gutiérrez, and H, Amat-Santos IJ. COVID-19 and spontaneous coronary artery dissection: causality? REC Interv Cardiol (English Ed [Internet] 2021;Available from: https://www.recintervcardiol.org/en/?option=com_content&view=article&id=548&catid=41 REFERENCE #3: Shojaei F, Habibi Z, Goudarzi S, et al. COVID-19: A double threat to takotsubo cardiomyopathy and spontaneous coronary artery dissection? Med Hypotheses [Internet] 2021;146:110410. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0306987720333016 DISCLOSURES: No relevant relationships by Faran Ahmad, source=Web Response No relevant relationships by Arslan Ahmed, source=Web Response No relevant relationships by Austin Loranger, source=Web Response Speaker/Speaker's Bureau relationship with Boehringer Ingelheim Pharmaceuticals, Inc. Please note: $5001 - $20000 by Doug Moore, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Genentech Please note: $1001 - $5000 by Doug Moore, source=Web Response, value=Honoraria No relevant relationships by Sanu Rajendraprasad, source=Web Response No relevant relationships by Renuga Vivekanandan, source=Web Response

Challenging Thyroid Storm in Pregnancy, Case Report

Background: Thyroid storm is a rare complication of hyperthyroidism. It can lead to life-threatening complications such as Arrhythmias, multiorgan failure and disseminated intravascular coagulation (DIC) (1). In pregnant patients can cause spontaneous abortions, fetal demise (2). Aggressive treatment under critical care settings is needed. Clinical Case: We report a case of 24-year-old Indian female twelve weeks pregnant; background of Graves’ disease for five years, was on carbimazole but she discontinued since she became pregnant. Presented to Hamad general hospital with nausea, vomiting and altered mental status for one day. She was afebrile, normotensive, tachypneic, tachycardiac with heart rate of 150bpm, and confused. Investigations showed supraventricular tachycardia aborted by adenosine and amiodarone, TSH was < 0.01mIU/l(0.3-4.2) and FT4> 100 pmol/L(11.6-21.9),normal baseline liver function and complete blood counts. In the emergency department, she was managed for thyroid storm with hydrocortisone, propranolol, propylthiouracil (PTU), iodine solution and cholestyramine. Then suddenly she deteriorated requiring intubation and vasopressor support under care of Medical Intensive Care Unit (MICU) progressed to multiorgan failure; acute liver injury, acute kidney injury and DIC. So, PTU was stopped and started on plasma exchange followed by total thyroidectomy and tracheostomy. US pelvis showed nonviable fetus, so dilation and curettage were done by obstetric team. Afterwards, she markedly improved except her conscious level and kidney function which required Hemodialysis. MRI brain showed small subdural hematoma treated conservatively and Wernicke encephalopathy treated with thiamine with substantial response and spontaneously breathing. Post thyroidectomy she required calcium supplementation and levothyroxine, liver function and coagulation parameters back to baseline. Conclusion: Thyroid storm in pregnancy is a medical emergency with high mortality rate, it needs high index of suspicion and early aggressive management by a multidisciplinary team. Plasmapheresis may be considered for challenging cases as a bridge for definitive therapy. Thyroidectomy may be the only option in selected cases like our case.

Non-Fasting Hypoglycemia Secondary to Opioid Induced Adrenal Insufficiency: A Case Report

Abstract Background: A patient on chronic methadone therapy presented following a suicide attempt, was noted to have recurrent episodes of non-fasting symptomatic hypoglycemia and was diagnosed with opioid induced adrenal insufficiency (OIAI). Opioid induced endocrinopathies are underappreciated, particularly in the midst of a growing opioid epidemic in the United States. We believe this is the first reported clinical case of OIAI associated with non-fasting hypoglycemia. Clinical Case: A 33-year-old female with history of depression and heroine abuse on methadone therapy presented after a suicide attempt by methadone overdose. Home medications included 170mg of methadone daily for the past 5 years. She was afebrile, heart rate of 68, blood pressure 102/72, respiratory rate of 10, oxygen saturation 92%. On exam she was lethargic with altered mental status and had pinpoint pupils. Labs showed a normal complete blood count and metabolic panel. Urine toxicology was positive for methadone. Clinical picture improved temporarily after Narcan administration however 1 hour later she was confused again, with a fingerstick glucose of 50mg/dL and she was admitted to ICU for monitoring. In the ICU she continued to be lethargic with dizziness, nausea and headaches. She continued to have approximately 4 spontaneous episodes of hypoglycemia per day, despite having a good appetite and increased parenteral glucose administration. Blood pressure continued to be marginal, ranging from 85–100/50–60. There was no obvious source of infection. Urine sulfonylurea screen was negative. Investigations showed a morning cortisol of 2.23 ug/dL. A 250 µg ACTH stimulation test showed an inadequate response. The am basal plasma cortisol was 2.25 ug/dL with 15.28 ug/dL and 15.13 ug/dL at 30 and 60 minutes respectively (6.20–19.40ug/dL). She was diagnosed with hypoglycemia secondary to OIAI. Given the patient’s critical condition she was initially started on stress dose of hydrocortisone 80mg every 8 hours. Attempts to down titrate the methadone dose were unsuccessful. Patient’s symptoms improved and hypoglycemia subsided. She was discharged home on hydrocortisone 10mg qam &amp; 5 mg qpm and she was continued on Methadone 170mg daily. Conclusion: OIAI is an under-recognized clinical entity with potentially serious adverse outcomes. Currently, 3% to 4% of US adults receive long-term opioid treatment. OIAI is present in 9—29% of individuals on chronic opioids. Opioids act through suppression of the HPA axis, primarily at the level of the hypothalamus, mediated through either delta or kappa receptors leading to a decrease in ACTH and cortisol secretion. Management should include decreasing and ideally discontinue opioids, along with glucocorticoid replacement until documented recovery of the HPA axis. Reference: Reference: (1)Donegan, Diane et al. Opioid-Induced Adrenal Insufficiency. Mayo Clin. Proc. 2018 93(7), 937–944.

Pseudopheochromocytoma as a Presentation of Amyotrophic Lateral Sclerosis

Introduction: Pseudopheochromocytoma presents as paroxysmal events of hypertension and other noradrenergic symptoms similar to pheochromocytoma (PCC) but do not meet tumoral diagnosis. Case Report: A 70-year-old Caucasian male with history of gastroesophageal reflux disease (GERD) and Barrett’s esophagus presented to the Emergency Department with fatigue, shortness of breath, palpitations, and fasciculations in the anterior chest wall. He reported recent diagnosis of PCC. Patient had episodes of non-exertional palpitations, diaphoresis, dizziness, facial flushing, and facial involuntary movement along with self-monitored average blood pressure (ABP) of 160/100 mmHg and heart rate (HR) of 90 beats per minute (bpm). Spells occurred 2 to 3 times per month at first, later increased. Between episodes self-monitored ABP was 120/70 mmHg and HR of 50 bpm and asymptomatic. He reported unintentional weight loss of 40 pounds in the same interval and newly muscle weakness that he attributed to weight loss and malnutrition. Patient had no remarkable past medical history. Medications included coq10 enzyme, glucosamine, flax seed oil, primrose oil and recently added doxazosin 1 mg tab per day. Evaluation revealed a cachectic patient (body mass index 17.46 k/m2) with normal vital signs, otherwise unremarkable physical exam except for diffuse fasciculations in chest and upper extremities. Outpatient work up included normal complete blood count, comprehensive metabolic panel, drug screening, thyroid function test. He had elevated free plasma metanephrine (FPM) of 73 pg/mL (< 57 pg/mL), free plasma normetanephrine (FPN) of 487 pg/mL (<148 pg/mL), before doxazosin. Repeated FPM of 55 pg/mL (< 57 pg/mL), FPN of 347 pg/mL (<148 pg/mL). The 24-hour urine for metanephrine was normal with total metanephrine of 157 ug/d (55-320 ug/d) and normetanephrine 432 ug/d (114-865 ug/d) with a creatinine of 900 mg/dL (800-2100 mg/d). He also had outpatient computed tomography (CT) scan of thorax, abdomen, and pelvis that was normal. Positron emission tomography CT scan did not reveal any tumors. Our initial suspicion, later confirmed with electromyography, was a neurodegenerative disease with motor neuron dysfunction. Patient was diagnosed with Amyotrophic Lateral Sclerosis (ALS) and started in riluzole with improvement of spells. Since, his muscle weakness progressed, he now requires noninvasive ventilation. Discussion: Pseudopheochromocytoma is an idiopathic disease that mimics catecholamine-secreting PCC and needs adequate and complete evaluation. Catecholamine levels can be affected by illness, stress, medications, and sample collection. In the case presented, the patient’s muscular weakness and fasciculations was caused by ALS. Neurodegenerative diseases such as ALS can cause a central nervous system stress response, consequently causing elevated norepinephrine levels.

Small Bowel Hemolymphangioma Treated by Polypectomy in a Pediatric Patient with Cystic Fibrosis

Small Bowel Hemolymphangioma Treated by Polypectomy in a Pediatric Patient with Cystic Fibrosis

Analysis of the Nutritional Status in Homeless People in Poland Based on the Selected Biochemical Parameters.

The aim of the study was to assess the nutritional status of adult homeless people using both anthropometric and biochemical measurements. The analysis comprised anthropometric indicators, i.e., body mass index and waist circumference, and the following biomarkers: red blood cells, hemoglobin, hematocrit, mean corpuscular volume, mean corpuscular hemoglobin concentration, mean corpuscular hemoglobin, white blood cells, complete lymphocyte count, neutrophils-to-lymphocytes ratio, platelets-to-lymphocytes ratio, platelets-to-leukocytes ratio, C reactive protein level, serum iron concentration, serum albumin concentration, total serum protein, fasting lipids and blood glucose level. There were representative Polish homeless people enrolled (n = 580). The analysis of the conducted studies proved that there is a greater frequency of overweight and obesity than underweight in the target population. The major problem was abdominal obesity that was present statistically more frequently in women than men (p < 0.001). In the majority of cases, homeless people were found to have normal complete blood count parameters. In obese people, there were statistically significant both elevated and decreased hematocrit levels, a significant decrease in red blood cells, elevated serum glucose, triglycerides and total protein level (p < 0.05). The presence of abdominal obesity, elevated glucose concentration, low-density lipoprotein cholesterol, and triglycerides, and decreased high-density lipoprotein cholesterol in serum together with smoking increase the risk of cardiovascular disease.

An Unusual Case of Meningitis in an Adolescent.

An Unusual Case of Meningitis in an Adolescent.

Screening of Biochemical Abnormalities in Suicide Attempters Irrespective of Psychiatric Diagnosis: A Cross-sectional Study

Introduction: Empirical studies have documented the impact of membrane cholesterol on serotonergic function which might influence the suicidality in various psychiatric disorders. Most studies in last two decades demonstrated low cholesterol as potential predictor of suicidality in depression but trends of metabolic disorders and current status of hypercholesterolemia and biochemical abnormalities in suicidal spectrum population is scarce. Aim: The present study was aimed to comprehensively evaluate the blood levels of cholesterol and other biochemical abnormalities (serum electrolytes, proteins, blood pH etc.,) irrespective of any psychiatric disorders in suicide attempters. Materials and Methods: A cross-sectional study was conducted on a total of 202 patients who visited our emergency hospital services with the suicidal attempt from 1st January 2019 till 31st December 2019 for a period of 12 Months. Blood evaluation and analysis were done on the same day of hospitalisation for complete blood counts, serum electrolytes, proteins and cholesterol levels. Clinical and standardised psychological evaluations for psychiatric diagnosis were performed. The results were analysed and compared using descriptive and inferential statistics based on SPSS software 21.01. Results: Out of 202 total suicide attempters, 120 (59.4%) were males and 82 (40.6%) were females with most patients 111 (54.9%) falling in the age range of 20-29; while 175 (86.6%) of patients had their first ever suicide or deliberate harm. A total of 169 (83.7%) of patients had normal complete blood counts but 106 (52.5%) showed acidic pH (&lt;7.3) while only 5 (2.5%) of the patients had alkalosis. Serum potassium was abnormal in 43 (21.3%) patients. Further serum chloride was deranged in 13(6.4%) while serum albumin was deranged in 17 (8.4%). About 27 (13.4%) found to have increased serum cholesterol and none of them had low cholesterol. Conclusion: Excessive and dampened reactivity of biomolecular parameters including hypercholesterolemia may modulate the neurobiological stress system associated with increased suicidality. This may be one of the predictors irrespective of the underlying psychiatric disorders.

Chronic hepatitis c and hereditary hemochromatosis: A case report

Introduction. Between 20 - 60% of patients with chronic hepatitis C present with elevated serum ferritin and iron, as well as increased transferrin saturation, yet without a significant liver iron burden. The objective of this article was to summarize current knowledge on interactions between hepatitis C virus infection and iron metabolism. Case Report. A 34-year-old female patient positive for hepatitis C virus genotype 3, underwent therapy of chronic hepatitis C with pegylated interferon/ribavirin. The therapy was discontinued after four weeks due to leukopenia, anemia and significantly increased ferritin levels. Liver biopsy (Perl?s stain) revealed iron deposition predominantly in periportal hepatocytes. The therapy of chronic hepatitis C was continued by direct-acting (sofosbuvir/antiviral/velpatasvir) drugs. During the course of the therapy, the patient presented with normal complete blood count, ferritin of 150 ?g/l, and ferremia at upper limit of normal. Twelve weeks after the end of the therapy, the patient showed a sustained virologic response. The additional diagnostics of hereditary hemochromatosis has been performed, and therapeutic phlebotomy procedures were initiated. Conclusion. In patients with chronic hepatitis C and significantly elevated serum ferritin and iron, the diagnosis should be extended to hereditary hemochromatosis.