Severe hyponatremia due to surreptitious water intoxication in a hospitalized patient.

Hyponatremia is a common electrolyte abnormality among hospitalized patients and often present as first sign of other underlying medical conditions. Severe hyponatremia can be life threatening and requires prompt diagnosis and treatment. We present a case of refractory hyponatremia that was a diagnostic challenge requiring a prolonged hospitalization. Diagnosis of primary polydipsia was ultimately suspected due to improbable 24-h urine studies and confirmed through complete removal of free water access in the form of disconnecting the bathroom faucet in the patient's hospital room. Diagnosis and management of primary polydipsia is further discussed.

Side Effects of the Sinopharm/BBIBP COVID-19 Vaccine among Iranian Healthcare Workers: A Gender Assessment

Background: Since the outbreak of COVID-19, vaccination has been considered as an important measure against it. Side effects have always been an inseparable component of vaccination, which in this study, Sinopharm vaccine, its side effects and the differences of their manifestation amongst men and women have been investigated. Objective(s): This study aimed to compare the side effects of the Sinopharm vaccine among men and women working in some medical centers in Tehran, Iran. Method(s): This cross-sectional descriptive-analytical study on 890 healthcare workers of 7 medical centers in Tehran within 2 months, from late June to late August 2021. The samples were selected by the complete enumeration method, and the required data were collected using a questionnaire. Only those who received the Sinopharm vaccine at least 10 days before the study were included. Result(s): Of 890 participants, 22.96% and 77.30% were women and men, respectively, and 65.8% of women and 78.1% of men were in the age range of 20-29 years. It was revealed that 74.75% of women and 26.16% of men had at least one side effect. The incidence of at least one side effect was significantly higher in women than in men (P<0.001). It was also found that 12 side effects were significantly higher in women than in men. Most men and women had side effects within the first 24 h after vaccination. There was no significant difference in taking therapeutic measures to reduce or minimize the post-vaccination complications between men and women;however, 9.4% of men and 27.2% of women reported a decline in their ability to perform daily activities as they were unable to do their everyday tasks the day after vaccination which was significantly different between the two groups (P<0.001). Conclusion(s): The results showed that the occurrence rate of side effects after receiving the Sinopharm vaccine was significantly higher in women than in men. Moreover, women were significantly less able to perform daily routines than men.Copyright © 2022, Author(s).

An Overview About Pediatric Type 1 Diabetes Mellitus

Background: Diabetes mellitus (DM) represents one of the most common metabolic diseases in the world, with rising prevalence in recent decades. Most cases are generally classified into two major pathophysiological categories: type 1 diabetes mellitus (DM1), which progresses with absolute insulin deficiency and can be identified by genetic and pancreatic islet autoimmunity markers, and type 2 diabetes mellitus (DM2), which is the most prevalent form and involves a combination of resistance to the action of insulin with an insufficient compensatory response of insulin secretion. In the last two decades, in parallel with the increase in childhood obesity, there has also been an increase in the incidence of DM2 in young people in some populations. Other forms of diabetes may affect children and adolescents, such as monogenic diabetes (neonatal diabetes, MODY – maturity onset diabetes of the young, mitochondrial diabetes, and lipoatrophic diabetes), diabetes secondary to other pancreatic diseases, endocrinopathies, infections and cytotoxic drugs, and diabetes related to certain genetic syndromes, which may involve different treatments and prognoses. DM1 is considered an immuno-mediated disease that develops as a result of gradual destruction of insulin-producing pancreatic beta cells that eventually results in their total loss and complete dependence on exogenous insulin. Clinical presentation can occur at any age, but most patients will be diagnosed before the age of 30 years

Socio-economic Barriers to Care and Medical Complexity Leading to a 5-year Diagnostic Delay of Untreated Chronic Diabetes Insipidus and Rapidly Progressive Puberty in a 10-year-old Venezuelan Immigrant

Introduction: Germ cell tumors, including germinomas, account for 10% of pediatric chronic Diabetes Insipidus (DI) cases. Delays in diagnosis of germinomas are generally longer than six months, however, no reported cases of suprasellar germinomas causing chronic DI and precocious puberty have been known to exceed a 5-year delay in both treatment of DI symptoms and a definitive diagnosis. Case Description: A 10-year-old Hispanic male presented with a 5-year history of polydipsia and polyuria. He underwent evaluation in Venezuela, where DI was reportedly 'ruled out';however, no head MRI was performed. After two years in the US struggling to acquire insurance, he presented to his pediatrician with worsening symptoms. A head MRI, ordered to evaluate dilute high-volume urine output, revealed a suprasellar mass. He was admitted for diagnostic evaluation and met the criteria for DI. Notably, he had an elevated Beta-Human Chorionic Gonadotropin (B-HCG) level. Biopsy confirmed the diagnosis of a Central Nervous System (CNS) germinoma. He was treated with DDAVP and proton therapy with subsequent remission of his tumor. Discussion: Throughout the patient's disease course, there were multiple delays in seeking and receiving care. These include a 5-year delay in seeking care despite worsening symptoms, a one-month delay in completing a 24-hour urine collection, a one-month delay in consulting pediatric nephrology, and another month delay before completing a retroperitoneal ultrasound. Multiple medical and socio-economic factors led to these delays. The patient did not present with symptoms more typical of CNS Germinomas like headaches, nausea, and vomiting. He had no visual disturbances despite mass effect on his optic chiasm. His increased stretched penis length and Tanner staging, which were identified later in his disease course, were contradicted by his pre-pubertal testicular volume and bone age. The patient is from a Spanishspeaking/Limited English Proficiency (SSLEP) household. While Spanish interpreters were present at each appointment, the language barrier proved to be a consistent issue. Initially, the child's mother indicated that the diagnosis of DI was 'ruled out' in Venezuela. In reality, the recommended imaging was never performed. Mychart messages left by his father further highlighted communication difficulties. Without access to an interpreter, he was forced to use broken English to relay his concerns. These frantic messages indicated misunderstandings regarding scheduling with various services and completing vital labs. Care only proceeded after significant physician intervention. Poverty in Venezuela, lack of insurance, and anxiety regarding COVID-19 also contributed to these delays. Conclusion: To our knowledge, this is the first case report of a pediatric patient presenting with a 5-year history of untreated polyuria and polydipsia due to undiagnosed DI with a B-HCG secreting CNS germinoma, without spinal metastasis. This study also illustrates the importance of supporting SSLEP families as they grapple with the complicated process of navigating our healthcare system. Sagittal T1 post gadolinium contrast image (A) and axial T2 FLAIR image (B) show an enigmatic, homogeneous, briskly enhancing mass in the suprasellar cistern (red arrow) with mass effect on the optic chiasm which is displaced upward and anteriorly (green arrow).

An Unusual Case of Autoantibody-Negative KetosisProne Diabetes (KPD) Secondary to Marked Insulin Resistance

KPD is classically regarded as an atypical form of diabetes caused by near-complete beta-cell failure. A 37-year-old Egyptian man (BMI: 27.7 Kg/m2) presented with hyperglycemia (362 mg/dL) and DKA (arterial pH 7.20, ketonemia 5.0 mmol/L, ketonuria 80 mg/dL) . He was afebrile, with recent polyuria, polydipsia and weight loss. HbA1c was 107 mmol/mol (11.9%) and blood tests excluded diabetes secondary to endocrinopathies. SARS-CoV-2 RT-PCR test was negative. IV insulin infusion (0.1 IU/kg/h) and IV fluid therapy were started. He was shortly transitioned to a sc basal-bolus insulin regimen (0.7 IU/kg/day) . Mixed-meal tolerance test (MMTT) revealed a peak 120-min stimulated C-peptide of 12.3 ng/mL, suggesting marked insulin resistance. Islet autoantibodies (ICA, IAA, GADA, IA-2A, ZnT8A) and insulin receptor autoantibodies (IgG/IgM) were negative. HLA genotyping detected the following haplotypes: DRB1∗01, ∗04;DQA1∗01:01P, ∗03:01P;DQB1∗03:02P, ∗05:01P. Insulin dose was gradually reduced and insulin therapy was discontinued after 4 months in favor of metformin (2550 mg/day) plus sc semaglutide (up to 1 mg/week) . After one year, MMTT revealed a peak 60-min stimulated C-peptide of 8.25 ng/mL. During the 18-month follow-up period, fasting capillary beta-hydroxybutyrate values were <0.2 mmol/L and HbA1c remained <48 mmol/mol (<6.5%) , indicating disease remission. This case suggests the existence of an autoantibody-negative KPD subtype driven by marked insulin resistance rather than by insulinopenia.

Severe hypernatremia in soft drink ketoacidosis and hyperglycemic hyperosmolar state at the onset of type 2 diabetes mellitus: a case series of three adolescents

Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are diabetic emergencies. Some patients with a hyperglycemic crisis can present with an overlap of DKA and HHS. The coexistence of DKA and HHS is associated with higher mortality than in isolated DKA and HHS. In addition, electrolyte derangements caused by global electrolyte imbalance are associated with potentially life-threatening complications. Here, we describe three cases of mixed DKA and HHS with severe hypernatremia at the onset of type 2 diabetes mellitus. All patients had extreme hyperglycemia and hyperosmolarity with acidosis at the onset of diabetes mellitus. They consumed 2 to 3 L/d of high-carbohydrate drinks prior to admission to relieve thirst. They showed severe hypernatremia with renal impairment. Two patients recovered completely without any complications, while one died. Severe hypernatremia with mixed DKA and HHS is rare. However, it may be associated with excess carbohydrate beverage consumption. Reduced physical activity during the COVID19 pandemic and unhealthy eating behaviors worsened the initial presentation of diabetes mellitus. We highlight the impact of lifestyle factors on mixed DKA and HHS.

EKG changes in severe hypercalcemia mimicking Brugada's syndrome

Case Report A 62-year-old Caucasian, female patient with history of celiac disease and chronic pain s/p spinal cord stimulator presented to our institution to follow up on abnormal lab findings. The patient presented to her PCP with complaints of worsening weakness, nausea, vomiting, constipation, polydipsia, and occasional palpitations. Labs resulted a severely elevated serum calcium level (17 mg/dL), increased BUN (32), and elevated Cr (1.8) indicating acute kidney injury. Full workup was initiated. Vitamin D, 25-Hydroxy level returned greater than 209 and PTH resulted in a normal range of 22. Detailed history revealed that the patient was taking 50,000 units of vitamin D3 by mouth six times/ week for six months. Fear surrounding the current COVID- 19 pandemic prompted the exorbitant intake of vitamin D supplementation in hopes of immune improvement. Bisphosphonate were contraindicated due to AKI.Volume expansion with normal saline and calcitonin successfully decreased the patient's serum calcium. Discussion The diagnostic criteria for reversible Brugada pattern, recently classified as Brugada phenocopy, includes four mandatory components. Primarily, an ECG tracing delineating type 1 or type 2 Brugada morphology. Secondarily, the presence of an underlying condition that is identifiable and reversible. Third, complete resolution of the ECG pattern upon elimination or correction of the underlying condition. Fourth, a low probability for Brugada syndrome determined by the lack of symptoms, clinical history, and family history. Our patient experienced severe hypercalcemia with palpitations that prompted an ECG. The abnormal ECG produced was read independently by two interventional cardiologists and a cardiac electrophysiologist who all concluded the ST segment and T wave deviations were consistent with Brugada pattern type 1. Importantly, the ECG was compared to one from a year prior which showed a normal rate and rhythm. There was complete resolution on repeat ECG once serum calcium was returned to reference range. The patient did not experience Brugada specific symptoms of syncope, seizures, nocturnal agonal breathing, or sudden cardiac death. No family history suggested Brugada syndrome or cardiac issues. Electronic medical record documentation tracked over the last 5 years showed no concerns for prior arrhythmias or syncope. Additionally, the patient does not fit the epidemiological profile of a male of Southeast Asian decent which is classically associated with Brugada syndrome. To our knowledge, this is the first documented presentation of Brugada phenocopy induced by severe hypercalcemia secondary to vitamin D toxicity. Conclusion Although the mechanism is not completely understood, severe hypercalcemia can cause a reversible type 1 Brugada pattern on ECG. Careful consideration of vitamin supplementation must be discussed with patients to avoid potentially fatal cardiac outcomes.

Complications and specific considerations in managing newly diagnosed DKA with COVID-19;Challenges in managing DKA with COVID-19 infection

Introduction: New cases of type 1 diabetes (T1D) remain commonly found in Indonesia. One of the most typical presenting symptoms is diabetic ketoacidosis (DKA);approximately 71% of all cases. There has been several reports of the negative association between type 2 diabetes (T2D) and Coronavirus disease (COVID-19) cases in adults, but T1D and COVID-19 cases in children are still scantily studied. Mortality of COVID-19 pediatric case could reach higher than 50% in children below 5 years old. Objectives: Early detection and prompt treatment for DKA, T1D and COVID-19 should be emphasized. Methods: This case described new-onset T1D presented with DKA and severe COVID-19 infection. Results: 7-year-old boy was presented with altered consciousness, epigastric pain, dehydration, dyspnea, history of nocturnal enuresis, polydipsia, and polyphagia. Random blood glucose (BG) was 516 mg/dL, blood ketone 5.2 mmol/L, A1c 15%, pH 6.932, pCO2 16 mmHg, pO2 153.8 mmHg, base excess-26.5 mmol/L, HCO3 3.4 mmol/L, and positive polymerase chain reaction COVID-19 with E gene Cq of 30.66. The patient was treated in isolation PICU as severe DKA with hypovolemic shock and confirmed COVID-19 case;received fluid resuscitation, intravenous insulin with saline and dextrose infusion and remdesivir. The patient had recurring hyponatremia, hyperkalemia, hypophosphatemia, increased coagulation markers, and had catecholamine-resistant shock, and received hydrocortisone from 2 mg/kg/day and subsequently titrated. The patient regained consciousness on the 2nd day of admission, and were stable on the 5th day of admission. The patient's condition improved on day 6 of admission and insulin and hydrocortisone were weaned. COVID-19 PCR test yielded negative result on day 9 of admission. Conclusions: The COVID-19 pandemic presents additional unwanted complications in both clinical and non-clinical aspects of DKA and T1D management. Special considerations should be highlighted considering the comorbidities and medications given in addition to the treatment for DKA.

Concomitant presence of COVID-19 infection and inaugural diabetic ketoacidosis in children and adolescents

Introduction: The COVID-19 pandemic, which has left its mark all over the world, has led to a decrease in the addressability to health care professionals, due to people's fear of becoming infected with COVID-19. This delays a correct diagnosis that can have lifethreatening consequences. Objectives: To establish if type 1 diabetes is triggered by COVID-19 Methods: We will present 3 cases pf type 1 diabetes at onset with ketoacidosis, triggered by the COVID-19 infection, diagnosed between December 2020 and April 2021. The diagnosis of SARSCoV2 infection was established based on RT-PCR (a reversetranscription polymerase-chain-reaction) positive for SARS-CoV2. Results: Case 1: 14 years old, boy, presented with Kussmaul breathing, abdominal pain, polyuria, polydipsia, weight loss (5 kg in 2 weeks), fever (38 C). The laboratory test showed a bicarbonate: 5 mEq/L, pH: 7.08, alkaline reserve: 6 mmol/l, glucose: 454 mg/dl, HbA1c: 14.5%. Case 2: 7 years old, boy presented with Kussmaul breathing, shock hypovolemic, hypotensive (Blood pressure 60/30 mmHg), fever, tachypnea, polyuria, polydipsia. The laboratory test showed a bicarbonate: 3 mEq/L, pH: 6,95, alkaline reserve: 2 mmol/l, glucose: 567 mg/dl, HbA1c: 12.6 %. Case 3: 10 years old, boy presented with similar clinical findings. The laboratory test showed a bicarbonate: 5 mEq/L, pH: 6,90, alkaline reserve: 3 mmol/l, glucose: 457 mg/dl, HbA1c: 16.6 %. All patients received treatment according to the diabetic ketoacidosis protocol treatment and switched to basal-bolus insulin treatment after an average of 48 hours. In all 3 cases the SARS-CoV2 infection was mild, with no changes in the lungs (lung x-rays being within normal limits). Conclusions: Due to the general fear of appearing in a hospital during the COVID-19 pandemic, there are delays in the diagnosis of lifethreatening conditions, such as ketoacidosis. The link between SARSCoV2 infection and type 1 diabetes in children and adolescents remains unknown and further studies are needed to gather more data.

Type 1 diabetic manifestations in a young man triggered by COVID-19.

COVID-19 could potentially lead to the progression of the course of undiagnosed type 1 diabetes in an infected individuals.