Use of a Continuous Glucose Monitoring System in High-Risk Hospitalized Noncritically Ill Patients With Diabetes After Cardiac Surgery and During Their Transition of Care From the Intensive Care Unit During COVID-19: A Pilot Study.

OBJECTIVE: Continuous glucose monitoring (CGM) has demonstrated benefits in managing inpatient diabetes. We initiated this single-arm pilot feasibility study during the COVID-19 pandemic in 11 patients with diabetes to determine the feasibility and accuracy of real-time CGM in patients who underwent cardiac surgery and whose care was being transitioned from the intensive care unit. METHODS: A Clarke error grid analysis was used to compare CGM and point-of-care measurements. The mean absolute relative difference (MARD) of the paired measurements was calculated to assess the accuracy of CGM for glucose measurements during the first 24 hours on CGM, the remaining time on CGM, and for different chronic kidney disease (CKD) strata. RESULTS: Overall MARD between point-of-care and CGM measurements was 14.80%. MARD for patients without CKD IV and V with an estimated glomerular filtration rate (eGFR) of ≥20 mL/min/1.73 m2 was 12.13%. Overall, 97% of the CGM values were within the no-risk zone of the Clarke error grid analysis. For the first 24 hours, a sensitivity analysis of the overall MARD for all patients and those with an eGFR of ≥20 mL/min/1.73 m2 was 15.42% ± 14.44% and 12.80% ± 7.85%, respectively. Beyond the first 24 hours, overall MARD for all patients and those with an eGFR of ≥20 mL/min/1.73 m2 was 14.54% ± 13.21% and 11.86% ± 7.64%, respectively. CONCLUSION: CGM has shown great promise in optimizing inpatient diabetes management in the noncritical care setting and after the transition of care from the intensive care unit with high clinical reliability and accuracy. More studies are needed to further assess CGM in patients with advanced CKD.

A Rare Case of Addison's Disease Presenting With Intermittent Pancytopenia and Cardiac Tamponade.

OBJECTIVE: To report the first case, to our knowledge, of intermittent pancytopenia and cardiac tamponade occurring together in association with Autoimmune Addison's Disease (AAD). METHODS: A 21 year-old woman presented on three different occasions with multiple complaints. Her evaluation was significant for intermittent pancytopenia (white blood cell, 1.3-3.0 × 103/µL [normal 4.5-11 × 103]; hemoglobin, 8.8-9.6 g/dL [11-16]; and platelets, 102-117 × 103/µL [150-400 × 103/µL]) and pericardial effusion with cardiac tamponade. Further investigation including a morning serum cortisol level of 0.6 µg/dL (5.27-22.45 µg/dL), adrenocorticotropic hormone level of 1027 pg/mL (normal 6-50 pg/mL), and positive 21-hydroxylase antibodies confirmed the diagnosis of primary adrenal insufficiency due to AAD. Treatment with steroids resulted in prompt hemodynamic recovery with normalization of all blood cell lines. RESULTS: The diagnosis of AAD is often delayed or overlooked. Pancytopenia occurring in AAD is most likely due to either marrow suppression in the setting of acute illness and exacerbated by hypoadrenalism or possibly an autoimmune-mediated marrow reaction. Pericarditis with cardiac tamponade has been described in AAD occurring in the setting of polyglandular autoimmune syndrome type II. The pathogenesis involves autoimmune inflammation of the pericardium, which precipitates an acute inflammatory reaction and rapid fluid accumulation. CONCLUSION: Pericarditis with cardiac tamponade and intermittent neutropenia may be rare manifestations of an Addisonian crisis.

Manifestations of thyroid disease post COVID-19 illness: Report of Hashimoto thyroiditis, Graves' disease, and subacute thyroiditis.

OBJECTIVE: We present three cases of thyroid dysfunction such as Hashimoto thyroiditis, Graves' disease and subacute thyroiditis which developed few weeks after resolution of acute phase of COVID -19 infection in patients with no prior thyroid disease. METHODS: We discuss clinical presentation, diagnostic evaluation and subsequent management and follow-up in three patients. RESULTS: All three patients tested positive for COVID-19 infection prior to diagnosis. Patient 1. A 38-year-old female developed hypothyroidism 6 weeks after COVID-19 infection, confirmed by TSH 136 mIU/L (range 0.34-5.6), free T4 level 0.2 ng/dL (range 0.93-1.7). Patient 2. A 33-year-old female developed Graves' disease 8 weeks after COVID-19 infection, with a TSH <0.01 mIU/L (range 0.4-4.5), Free T4 2.1 ng/dl (range 0.8-1.8), total T3 216 ng/dl (range 76-181), elevated TSI 309 (normal <140). A 24-h thyroid uptake was calculated at 47.1% (normal values between 8% and 35). Patient responded favorably to methimazole 10 mg in few weeks. Patient 3. A 41-year old healthy female developed thyroiditis at 6 weeks after COVID-19 infection, with a TSH 0.01 mIU/L and free T4 1.9 ng/dL accompanied by low 24-h thyroid uptake, calculated at 0.09%. Three weeks later, she developed hypothyroidism, with a TSH 67.04 mIU/L and free T4 0.4 ng/dl. CONCLUSION: The temporal relationship between COVID-19 infection in the patients described here raises the question of possible effects of COVID-19 on the immune system and the thyroid gland.

A rare case of herniated duplex collecting system causing obstructive uropathy.

BACKGROUND: An inguinal hernia is the protrusion of intraabdominal organs through an opening in the abdominal wall. Structures such as small and large intestines are commonly contained within inguinal hernias. However, uretero-inguinal hernia of the native collecting system is an extremely rarely reported entity. If unrecognized, acute kidney injury due to obstructive uropathy or serious intraprocedural ureteral injuries during hernia repair can occur. A duplex collecting system is a congenital kidney anomaly with an incidence of 0.8%. A uretero-inguinal hernia involving duplicated ureters has not been previously described in literature. Here we report a case of obstructive uropathy secondary to uretero-inguinal hernia involving duplicated ureters. CASE PRESENTATION: A 78-year-old male known to have a left sided inguinal hernia presented to the Emergency department with two weeks of intermittent suprapubic tenderness, dysuria, frequency, urgency, frothy urine as well as nausea and vomiting. Workup on admission revealed an elevated creatinine of 2.8 mg/dl. CT imaging revealed duplicated left sided ureters with left inguinal hernia containing the ureters. There was cystic ureteral dilation within the herniation sac as well as moderate left hydroureteronephrosis. Patient had an elective inguinal hernia repair with left ureteral stent placement. Following the surgery, he had recovery of kidney function to the previous baseline serum creatinine of 1.5 mg/dl. CONCLUSION: A duplex collecting system arises when two ureteral buds are formed during fetal development. However, diagnosis can be made in rare instances during adulthood when duplex collecting systems are usually found incidentally. Uretero-inguinal hernias have been reported as a common complication of renal transplant. However, uretero-inguinal hernias in native kidneys are considered an uncommon finding, especially with a duplex collecting system. When patients present with herniation and acute kidney injury, it is important to rule out the possibility of uretero-inguinal hernia to minimize complications such as obstructive uropathy and kidney failure. CT scan providing cross-sectional imaging is the ideal modality for identification of the site and etiology of urinary tract obstruction and site of herniation. If during imaging, an obstructive uropathy is observed, a nephroureteral stent or nephrostomy tube can be inserted to protect the ureter as well as relieve the obstruction, respectively.