A Case Series of Statin-Induced Necrotizing Autoimmune Myopathy.

The use of statins has been increasing over the past decade for the primary and secondary prevention of cardiovascular disease worldwide. Subsequently, various side effects have also been unfolding. Muscle-related side effects secondary to statins range from myalgia to rhabdomyolysis and need close monitoring for early detection. Statin-induced necrotizing autoimmune myopathy (SINAM) in particular is unique given its pathophysiology, trigger factor, genetic predisposition, and aggressive management strategy. We present two cases of SINAM and discuss the clinical aspects of diagnosis, investigation, and management. Statin-induced necrotizing autoimmune myopathy usually presents with proximal myopathy along with increased creatinine kinase (CK) levels which do not resolve with only statin discontinuation. Diagnosis should be made with biopsy and 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) antibody detection. The investigation should also be directed to rule out other etiology of proximal myopathy. In most cases, rechallenge with a statin is unsuccessful and immunosuppressive treatment is essential.

A Case of Adrenal Insufficiency Diagnosed Using Optimal Dosing of Cosyntropin During Stimulation Testing.

BACKGROUND This case report illustrates the difficulties that arise during diagnosis of adrenal insufficiency, especially in the general medicine setting. Symptoms can often be nonspecific, and when a serum cortisol level is checked, further difficulty exists as to how to interpret the results. The 250-µg cosyntropin dose or 1-µg dose are available for use in the diagnosis of adrenal insufficiency, but each test has its own indications, which will be discussed. CASE REPORT A 45-year-old woman presented with nausea, emesis, chills, and diaphoresis, symptoms that concerning for adrenal insufficiency. Her random serum cortisol levels were relatively low. Her ACTH levels were within normal range. She received additional testing with the ACTH stimulation test using both the 1-µg and the 250-µg dose. The 1-µg test was performed in the evening and showed an inadequate adrenal response. The 250-µg dose test, which is the criterion standard, was performed the following morning and excluded adrenal insufficiency. CONCLUSIONS With the use of the high-dose ACTH stimulation test performed in the early morning, this patient was able to avoid lifelong steroid replacement therapy that could potentially suppress the hypothalamic-pituitary-adrenal (HPA) axis, which of itself can lead to adrenal insufficiency. Careful consideration is needed in choosing the right modalities for diagnosis of adrenal insufficiency.

Type 2 diabetes is associated with increased risk of critical respiratory illness in patients COVID-19 in a community hospital.

BACKGROUND: Type 2 diabetes (T2D) is the leading non-communicable disease worldwide and is associated with several microvascular and macrovascular complications. Individuals with T2D are more prone to acquiring selected types of infections and are more susceptible to complications due to these infections. This study aimed to evaluate the relationship between T2D and COVID-19 in the community setting. METHODS: This was a single-center retrospective analysis that included 147 adult patients with laboratory-confirmed COVID-19 admitted to a community hospital. Demographics, medical history, symptoms and signs, laboratory findings, complications during the hospital course, and treatments were collected and analyzed. The Kaplan-Meier method was used to describe the probability of intubation in patients with T2D as compared with patients without T2D. The hazard ratio for intubation in the survival analysis was estimated using a bivariable Cox proportional-hazards model. RESULTS: Of 147 patients, 73 (49.7%) had a history of T2D. Patients with T2D had higher requirement of ICU admission (31.5% vs 12.2%; p = .004), higher incidence of ARDS (35.6% vs 16.2%, p = .007), higher rates of intubation (32.9% vs 12.2%, p = .003), and higher use neuromuscular blocking agents (23.3% vs 9.5%, p = .02). In the survival analysis at 28 days of follow-up, patients with T2D showed an increased hazard for intubation (HR 3.00; 95% CI, 1.39 to 6.46). CONCLUSION: In our patient population, patients with COVID-19 and T2D showed significantly higher ARDS incidence and intubation rates. The survival analysis also showed that after 28 days of follow-up, patients with T2D presented an increased risk for shorter time to intubation.

SARS-CoV2 and Co-Infections: A Review of Two Cases.

COVID-19 infection caused by SARS-CoV2 virus is an acute respiratory illness which was declared as a pandemic by the World Health Organization. Usually, SARS-CoV2 infects independently and can cause spectrum of disease ranging from mild illness to severe progressive pneumonia, multiorgan dysfunction, and death; however, co-infections with other respiratory pathogens have been noted. Here, we present 2 fatal cases with co-infection, one with parainfluenza-4 virus and other co-infection/secondary infection with Streptococcus pneumoniae bacteria. Further studies are needed to study the effect of co-infections on morbidity and mortality of patients and establish the outcome of such infections.