Unique Presentation of Thyrotoxic Periodic Paralysis With Urticarial Dermographia.

Thyrotoxic periodic paralysis (TPP) is an acute complication of hyperthyroidism. Thyrotoxic periodic paralysis is treatable, and the management consists of potassium correction, beta-blockers, and antithyroid drug (ATD) therapy. While TPP is well described in the literature, we describe a case of TPP with urticarial dermographia (UD) that resolved with a short course of antihistamines while continuing ATD therapy. To the best of our knowledge, this is the first reported case of UD after methimazole (MMI) therapy in a TPP patient. A 25-year-old Cambodian active duty male with no significant past medical history presented to the emergency department with acute loss of lower extremity muscle tone with hypokalemia in the setting of previously undiagnosed Graves' disease (GD). He was started on MMI but within 2 weeks developed a rash consistent with UD. This was successfully treated with a second-generation antihistamine while continuing his MMI. Thyrotoxic periodic paralysis is primarily treated by controlling the underlying thyroid disease causing paralysis. Methimazole is commonly chosen as a treatment due to its rapid efficacy and long duration of action. However, adverse effects like UD can occur. Current recommendations are that minor cutaneous reactions can be treated with antihistamines for the management of Graves' disease. However, this case and others show that even moderate reactions can be managed in this manner. In a patient with TPP with UD after treatment with MMI, it is reasonable to attempt a trial of antihistamine before changing to another ATD.

False elevations in urinary metanephrines: under-recognised pitfall with 24-hour urinary volume collection.

One pitfall in 24-hour urine collection is the input of incorrect urinary volume by the reference laboratory. This may lead to an incorrect diagnosis of pheochromocytoma or paraganglioma. A 48-year-old African-American woman was seen in the clinic for an elevated 24-hour urine metanephrine screen during workup for secondary hypertension. Urine volume was found to be incorrectly inputted by the lab as 9750 mL rather than 975 mL. The urinary metanephrines were then recalculated and the 24-hour urinary metanephrines resulted within normal limits. This case highlights this unique and potentially under-recognised error in testing with 24-hour urine volume collection.

ADULT OSTEOPOROSIS WITH A HISTORY OF CHILDHOOD-ONSET FRACTURE DUE TO AN LRP5 RECEPTOR VARIANT MUTATION.

OBJECTIVE: This case highlights the value of genetic screening for idiopathic osteoporosis with recurrent fractures. METHODS: Case report and review of the literature. RESULTS: A 52-year-old Caucasian female with idiopathic osteoporosis with recurrent fractures was identified with a heterozygous low-density lipoprotein receptor related protein 5 (LRP5) mutation. CONCLUSION: This case highlights the variability in clinical expression of LRP5 polymorphisms and suggests that standard treatment in cases of recurrent fracture may be ineffective.

Successful treatment of a patient with statin-induced myopathy and myotonic dystrophy type II with proprotein convertase subtilisin/kexin type 9 inhibitor, alirocumab (Praluent).

Presently there are limited treatment options for hypercholesterolemia in patients with statin intolerance and myotonic dystrophy. A 74 year-old male presented to endocrine clinic with hypercholesterolemia (serum LDL-C 210 mg/dL), hypogonadism, insulin-controlled type 2 diabetes mellitus, and minimally elevated serum creatine kinase (CK) levels (184 U/L, ref. range 38-174). Shortly after simvastatin treatment, patient developed severe myalgias in the proximal lower and upper extremities; and serum CK increased to 317 U/L. Subsequently patient was treated with various statins including rosuvastatin with similar outcomes. Patient was also treated with bile acid binding resin and ezetimibe without improvement. At this time, a diagnosis of myotonic dystrophy type 2 was confirmed. Patient was then treated with alirocumab, a PCSK9 inhibitor 75 mg subcutaneously every 2 weeks with significant improvement in LDL-C (90 mg/dL) and myalgias. In conclusion, PCSK9 inhibitors such as alirocumab may be an excellent lipid lowering agent in patients with statin intolerance and myotonic dystrophy.

Calcium maelstrom: recalcitrant hypocalcaemia following rapid correction of thyrotoxicosis, exacerbated by pregnancy.

A 29-year-old pregnant woman with Graves' disease presented with severe persistent hypocalcaemia after thyroidectomy. Six months prior to presentation she was diagnosed with Graves' disease and remained uncontrolled with methimazole. She was confirmed pregnant prior to radioactive iodine ablation (RAI), and underwent total thyroidectomy during her second trimester. After surgery, continuous intravenous calcium infusion was required until delivery of the fetus allowed discontinuation at postoperative day 18, despite oral calcium and calcitriol administration. A total of 38 g of oral and 7.5 g of intravenous elemental calcium was administered. We report an unusual case of recalcitrant hypocalcaemia thought to be due to a combination of postoperative hypoparathyroidism, combined with thyrotoxic osteodystrophy and pregnancy, after surgical correction of Graves' disease. Increased vigilance and early calcium supplementation should be a priority in the management of these patients.

High altitude illnesses in Hawai'i.

High Altitude Headache (HAH), Acute Mountain Sickness (AMS), and High Altitude Cerebral Edema (HACE) are all high altitude related illnesses in order of severity from the mildly symptomatic to the potentially life-threatening. High altitude illnesses occur when travelers ascend to high altitudes too rapidly, which does not allow enough time for the body to adjust. Slow graded ascent to the desired altitude and termination of ascent if AMS symptoms present are keys to illness prevention. Early recognition and rapid intervention of AMS can halt progression to HACE. Pharmacologic prophylaxis with acetazolamide is a proven method of prevention and treatment of high altitude illness. If prevention fails then treatment modalities include supplemental oxygen, supportive therapy, hyperbaric treatment, and dexamethasone. Given the multitude of visitors to the mountains of Hawai'i, high altitude illness will continue to persist as a prevalent local condition. This paper will emphasize the prevention and early diagnosis of AMS so that the illness does not progress to HACE.

Actinomyces naeslundii and Eikenella corrodens as rare causes of liver abscesses.

A 48-year-old man with an unremarkable medical history was admitted with vague conditions of fever, chills, myalgias and malaise. Physical examination was remarkable for only scleral icterus. Laboratory evaluation revealed elevated aminotransferases, alkaline phosphatase and bilirubin. Imaging demonstrated two masses in the right lobe of his liver, which were ultimately drained and cultures demonstrated Actinomyces and Eikenella. He continued to have fever on broad-spectrum antibiotics until catheter drainage of the abscesses was performed. He was eventually discharged in improved condition on amoxicillin-clavulanate. His aminotransferases, alkaline phosphatase and bilirubin continued to improve and he remained afebrile and asymptomatic. A repeat CT 2 months after discharge demonstrated resolution of the abscesses. Actinomyces and Eikenella are rare causes of liver abscesses and treatment requires drainage and an extended course of antibiotics. The polymicrobial character typical of liver abscesses makes antibiotic therapy challenging when cultures reveal rare organisms such as Actinomyces and Eikenella.