Eosinophilic Granulomatosis With Polyangiitis Presenting With Purpura, Mononeuritis Multiplex, and Cerebral Infarction.

We present a case of a 52-year-old woman who had transient speech impediment and progressive numbness, weakness, and a purpuric rash affecting her limbs, with severe joint pains. Because she had a chest infection two weeks prior, her clinical presentation gave rise to a suspicion of post-infective vasculitis or post-infective polyneuritis. Further investigation proved this to be eosinophilic granulomatosis with polyangiitis (EGPA) presenting with purpura, mononeuritis multiplex, and cerebral infarction. Treatment with glucocorticoids and cyclophosphamide led to rapid remission. This case highlights the potential difficulty in diagnosing EGPA because of its multiple clinical manifestations and emphasizes the importance of a thorough review of the past medical history.

A Re-audit of the Management of Diabetic Ketoacidosis (DKA): The Importance of the Seven-Day Working Inpatient Diabetes Specialist Nurse Service.

Background Diabetic ketoacidosis (DKA) is a life-threatening metabolic emergency due to insulin deficiency in patients with diabetes mellitus. The United Kingdom national survey and local audits of the management of DKA have revealed several areas of suboptimal care, and room for improvement, necessitating the need for intensified education, updating local guidelines, and increased recruitment of seven-day working inpatient diabetes specialist nurses. Therefore, this project aimed to re-audit our adherence to the DKA treatment guidelines. Methodology A retrospective re-audit examining patient admissions with DKA between October 2022 and September 2023. A list of 18 standards/criteria, adopted from the Joint British Diabetes Society (JBDS) DKA treatment guidelines was used for this re-audit. Results were compared with that of the previous audit. Results We had 126 patients admitted with DKA between October 2022 and September 2023. There were 62 males and 64 females with an average (range) age of 46.5 (19-92) years. Eighty percent had type 1 diabetes, and common precipitating factors for admission included infection and poor adherence to insulin treatment. The median (IQR) length of hospital stay was 2.1 (1.0-5.1) days. Compared to the previous audit, improvements occurred in 11 of 18 standards/criteria. This included timely commencement of intravenous fluids and fixed-rate insulin, commencing glucose infusion to prevent hypoglycemia, potassium replacement, continuation of long-acting insulin during treatment, timely conversion to variable-rate insulin infusion, and conversion to the usual subcutaneous insulin regimen. Additionally, 124 patients (98.4%) were reviewed at least once by the inpatient diabetes specialist nurses (DSN) during their admission. Complications of treatment, namely, iatrogenic hypoglycemia and transient hypokalemia occurred in 13 (10.3%) and 40 (31.7%) patient admissions, respectively. Conclusions This re-audit demonstrated improved adherence to the guidelines during several steps in the management of DKA. It also demonstrated room for improvement regarding other aspects of care. The importance of continued education, accurate documentation, and the presence of seven-day working inpatient DSN cover cannot be overemphasized.

Acyclovir-Induced Nephrotoxicity and Neurotoxicity: A Report of Two Cases.

Acyclovir is a widely used antiviral agent used to treat viral meningitis. Although well tolerated, on rare occasions, it can cause severe nephrotoxicity and neurotoxicity. It is recommended that the dose of intravenous acyclovir be calculated based on the ideal body weight for height rather than the actual weight in obese patients to avoid excessive dosage. We report two patients who developed severe acute kidney injury and neurological symptoms while on intravenous acyclovir therapy. The first patient was a 57-year-old obese woman known to have epilepsy who received a dose of intravenous acyclovir based on her actual weight of 80 kg and subsequently developed acyclovir-induced nephrotoxicity and increased seizure activity. The second patient was a 60-year-old, slightly overweight, man, who received a dose of intravenous acyclovir based on his actual weight of 80 kg and subsequently developed both acyclovir-induced nephrotoxicity and possible neurotoxicity. No other cause for the deterioration in renal function or neurological symptoms was identified, and there was rapid recovery within three days of stopping acyclovir therapy. This case report emphasizes the importance of monitoring renal function while patients are on intravenous acyclovir therapy and highlights the fact that even non-obese, overweight patients are at risk of toxicity when their actual body weight instead of their ideal body weight for height is used for intravenous acyclovir dose calculation.

A Fish Farmer's Encounter With Leptospirosis: A Case Report.

Leptospirosis is a zoonotic infection primarily caused by bacteria of the genus Leptospira. This infectious disease mainly occurs through direct contact with infected animals or indirect contact via contaminated soil or water. While the incidence rate of leptospirosis in the developing world is as high as 100 cases per 100,000 population, the incidence rate in the United Kingdom is low (0.14 cases per 100,000 population). We present a 56-year-old male fish farmer who presented to the emergency department with a history of intense thigh pain and sudden inability to mobilise following a week-long period of a flu-like illness, characterised by worsening myalgia localised to the inner thighs, fever, and episodes of passing dark red urine. Initial investigations demonstrated acute renal impairment, hepatitis, thrombocytopenia, mild rhabdomyolysis and raised inflammatory markers. With a suspected diagnosis of leptospirosis after a detailed clinical history and preliminary blood tests, treatment was immediately commenced with intravenous antibiotics, intravenous rehydration and vigilant monitoring of urinary output. The patient's condition rapidly improved and the diagnosis was later confirmed by a positive Leptospira polymerase chain reaction (PCR) report and serology. We believe prompt treatment prevented deterioration in this case. The aim of this case report is to highlight the importance of a detailed clinical history, with a particular focus on occupational exposure, especially in the developed world. Additionally, a low clinical threshold for leptospirosis is imperative, as rapid clinical deterioration can happen if no immediate medical intervention is performed.

Interpretation and Misinterpretation of Medical Abbreviations Found in Patient Medical Records: A Cross-Sectional Survey.

Introduction  Medical abbreviations are used in patient medical records across all departments within the hospital setting and upon discharge. Abbreviations can have more than one contradictory or ambiguous definition, which can result in errors in communication due to misunderstanding or misinterpretation. Modern patient care is multidisciplinary, so there should be no room for ambiguity in patient medical records. Therefore, the aim of this survey was to assess individual interpretations and misinterpretations of a list of medical abbreviations found in patient medical records, and thereby increase awareness of the growing use of non-standard abbreviations.  Materials and methods  In this cross-sectional survey, anonymized questionnaires containing a list of 20 abbreviations were given to a convenience sample of consultant physicians, doctors-in-training, and nurses, all of whom are involved in the day-to-day use of patient medical records. Volunteers were asked to define each abbreviation in full. A provided definition was either the intended definition (given a score of one) or completely different in terms of text and meaning (alternative definition). The intended definitions, alternative definitions, and number of abbreviations that were defined by at least 50% of volunteers were collated. Abbreviations that had more than 50% of volunteers providing the intended definition, were regarded as "generally accepted" abbreviations. Volunteers were assured that this was not a test of knowledge and that questionnaires were completely anonymized.  Results  In total, 46 volunteers completed questionnaires. Volunteers consisted of 15 nurses, 15 doctors-in-training, and 16 consultant physicians. The number of volunteers who provided the intended definition for each abbreviation ranged from zero to 87%, depending on the abbreviation. Only four out of 20 abbreviations (20%) had more than 50% of volunteers providing the intended definition and thus regarded as "generally accepted". The maximum score achieved among the volunteers was 12 out of 20 (60%), and the minimum score achieved was 2 out of 20 (10%). The overall mean score achieved by the volunteers was 6.39 out of 20 (32%). Only one-quarter of the volunteers achieved a score above 50%. Additionally, 75% of the abbreviations had one or more (one to seven) alternative definitions.  Conclusions  This survey demonstrated that non-standard medical abbreviations used in patient medical records were being misunderstood or misinterpreted. A majority of abbreviations were not recognized among user groups. Additionally, three-quarters of abbreviations had one or more alternative definitions. Healthcare institutions should encourage the reporting of errors arising from the usage of abbreviations, and introduce initiatives to discourage the use of non-standard abbreviations in patient medical records.

Transient Thyroiditis Followed by Exacerbation of Hypothyroidism After Immune Checkpoint Inhibitor Therapy (Nivolumab and Ipilimumab) in a Patient With Pre-existing Autoimmune Hypothyroidism: A Case Report.

Treatment with immune checkpoint inhibitors has improved the prognosis of solid tumors. However, immune-related adverse events (IRAEs), including exacerbation of pre-existing autoimmune disease, are common and have become more frequent with combination therapy. The literature is scanty regarding reports of the use of combination immune checkpoint therapy in patients with pre-existing autoimmune hypothyroidism. We report a case of a man with a history of hypothyroidism, who developed transient thyroiditis, characterized by a thyrotoxic phase followed by a severe hypothyroid phase soon after receiving combination therapy (nivolumab and ipilimumab) for the treatment of a malignant pleural mesothelioma. He had been on a stable low dose of levothyroxine for 12 years prior to this episode. His levothyroxine requirement markedly increased soon after the episode of immune checkpoint inhibitor-induced thyroiditis. Immune checkpoint inhibitors can cause destructive thyroiditis followed by exacerbation of hypothyroidism in patients with pre-existing autoimmune hypothyroidism, such that patients end up on a higher dose of levothyroxine. This case will add to the growing literature regarding thyroid IRAEs associated with the use of immune checkpoint inhibitors in patients with pre-existing autoimmune thyroid disease.

Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) Complicated by Generalized Tonic-Clonic Seizures After a Course of Antibiotics: A Case Report.

Nitrofurantoin and cephalexin are commonly used antibiotics for treating urinary tract infections. Hyponatremia secondary to syndrome of inappropriate antidiuretic hormone secretion (SIADH) has been reported as a rare side effect of nitrofurantoin but has never been a reported side effect of cephalexin. We report a case of a 48-year-old female who developed severe hyponatremia complicated by generalized tonic-clonic seizures after a course of antibiotics (nitrofurantoin followed by cephalexin) used for treating a urinary tract infection. She presented to the emergency department with a one-week history of dizziness, nausea, fatigue, and listlessness. She also had a two-week history of persistent urinary frequency despite completing a course of nitrofurantoin followed by a course of cephalexin. While in the emergency department waiting room, she had two episodes of generalized tonic-clonic seizures. Immediate post-ictal blood test results revealed severe hyponatremia and lactic acidosis. Results were consistent with severe SIADH and she was subsequently managed with hypertonic saline and fluid restriction. She was discharged after 48 hours of admission when her serum sodium levels normalized. Though we believe that nitrofurantoin was the culprit drug, we still asked the patient to avoid future use of both nitrofurantoin and cephalexin. Healthcare providers need to be aware of antibiotic-induced SIADH when assessing patients with hyponatremia.

A Young Female With Medium-Chain Acyl-CoA Dehydrogenase Deficiency (MCADD): A Case Report.

Medium-chain acyl-CoA dehydrogenase (MCAD) deficiency (MCADD) is a rare autosomal recessive inborn error of mitochondrial fatty acid oxidation. MCAD is essential for fatty acid ß-oxidation during hepatic ketogenesis, which provides a major source of energy once hepatic glycogen stores are exhausted during extended fasting and periods of increased energy demand. The inability to metabolize these fatty acids results in hypoketotic hypoglycemia and the accumulation of toxic partially metabolized fatty acids. Intercurrent infection, extended fasting, excessive alcohol intake, vomiting, or diarrhea can lead to serious illness, including encephalopathy and even sudden death. Young people with MCADD are followed up on a regular basis by their metabolic disease specialist, and they are informed about risk factors as they advance through adolescence and adulthood. They should also carry along a written emergency management plan and relevant contact numbers. We describe a case of a 17-year-old female who attended her local emergency care center complaining of severe abdominal pain, vomiting, muscle ache, and poor oral intake. She was known to have MCADD; however, her emergency care plan had a date from eight years ago. She made a rapid recovery after receiving intravenous glucose and other therapies. The patient's concerns and knowledge about MCADD were not fully appreciated at the initial stage due to the rare nature of the disease. This in combination with the absence of current notes on the system, an emergency care plan dated from eight years ago, and the need to obtain specialist advice led to a slight delay in commencing specific therapy. This case report serves as a reminder of the emergency presentation of young people with MCADD, emphasizing the importance of effective communication between the patient, their parents, and the treating clinicians, obtaining the emergency care plan and recommendations, and communicating with the metabolic disease specialist.

Recurrent Gestational Thrombocytopenia Affecting Four Consecutive Pregnancies: A Case Report.

Gestational thrombocytopenia is the commonest cause of thrombocytopenia in pregnancy, accounting for 70-80% of cases. It is a benign condition that recovers completely in the postpartum period. Although the cause is not fully understood, it is thought that pregnancy-related hemodilution and increased platelet consumption play a significant contributory role. Several life-threatening causes of thrombocytopenia in pregnancy make up the remaining 20-30% of cases. There are reports of recurrence of GT in women, but not many case reports document more than three consecutive episodes. We present a case of a young woman who had gestational thrombocytopenia during the third trimester of her four consecutive pregnancies, followed by complete recovery after each pregnancy. We ruled out other sinister and life-threatening causes of thrombocytopenia in pregnancy. During her four consecutive pregnancies, her platelet count fell below normal at the beginning of the third trimester, with a nadir towards the end. The other hematological indices, generally used as markers of hemodilution, remained in the normal pregnancy-specific reference range during each of her four pregnancies. This case argues against pregnancy-related hemodilution being a major factor in gestational thrombocytopenia. A systematic approach is paramount when differentiating the several causes of thrombocytopenia in pregnancy.

A Case of Recurrent Gestational Hypokalemia Due to an Exaggerated Physiological Response to Pregnancy: The Importance of Using Pregnancy-Specific Reference Ranges.

Hypokalemia in pregnancy can occur secondary to hemodilution of pregnancy, physiological changes during pregnancy, or other pathological conditions. It should be investigated the same way as in non-pregnancy with particular emphasis on the importance of using pregnancy-specific reference ranges when interpreting clinical laboratory test results. Here, we present a case of a woman who had late-trimester gestational hypokalemia requiring potassium supplementation affecting four consecutive pregnancies. We thought that there was accompanying hypomagnesemia and hypobicarbonatemia in previous pregnancies, so we suspected a form of renal tubular dysfunction exacerbated by pregnancy. Subsequent investigation and the use of pregnancy-specific reference ranges revealed that this was an exaggerated physiological response to pregnancy.

Variability, Validity and Operator Reliability of Three Ultrasound Systems for Measuring Tissue Stiffness: A Phantom Study.

Introduction Ultrasound elastography is a method of measuring soft tissue stiffness to detect the presence of pathology. There are several ultrasound elastography devices on the market. The aim of this study was twofold. Firstly, to determine the validity of three different ultrasound systems used to measure tissue stiffness. Secondly, to determine the operator reliability and repeatability when using these three systems. Materials and methods Two observers undertook multiple stiffness measurements from a phantom model using three different ultrasound systems; the LOGIQ E9, the Aixplorer, and the Acuson S2000. The phantom model had four cylindrical-shaped inclusions (Type 1-4) of increasing stiffness values and diameter embedded within. The background phantom stiffness was fixed. The mean, standard deviation, and coefficient of variation (CV) were calculated from measured stiffness readings per diameter per inclusion. Intra-observer variability was assessed. The validity of the measured stiffness value was assessed by calculating the difference between the measured elasticities and actual phantom elasticities. Bland-Altman plots with limits of agreement were used to display the inter-observer agreement. The intraclass correlation coefficients (ICC) were used to measure intra-observer, inter-observer, and inter-system reliability. Results Each observer undertook 1020 measurements. All three systems generally underestimated the stiffness values for the inclusions; the higher the actual stiffness value, the more significant the underestimation. The percentage difference between measured stiffness and actual stiffness varied from -79.1% to 12.7%. The intra-observer variability was generally less than 5% for observers using the LOGIQ E9 and the Aixplorer systems but more than 10% over the stiffer inclusions (Types 3 and 4) for the Acuson system. There was 'almost perfect' intra-observer reliability and repeatability for both the LOGIQ E9 and the Aixplorer systems; this was 'moderate' for the Acuson system over specific inclusions. For all systems, there was 'almost perfect' inter-observer reliability and repeatability between Observer A and Observer B. The inter-system reliability and repeatability were 'almost perfect' between the LOGIQ E9 system and the Aixplorer system but 'poor' and 'moderate' when the Acuson system was matched with the LOGIQ E9 system and the Aixplorer system, respectively. Conclusion This study has demonstrated that the Acuson, LOGIQ E9, and Aixplorer ultrasound systems have low variability, high reproducibility, and good intra-observer and inter-observer reliability when used to measure tissue stiffness. However, they all underestimated the stiffness values during this in vitro study. This study also revealed that not all ultrasound systems are comparable when measuring tissue stiffness, with some having better inter-system reliability than others. Ongoing standardization of technology is required at the manufacturer level.

Cure Rates After a Single Dose of Radioactive Iodine to Treat Hyperthyroidism: The Fixed-Dose Regimen.

Introduction Radioactive iodine (RAI) has been used to treat hyperthyroidism for more than 70 years. Cure rates after RAI therapy range between 80% and 100%, with some patients requiring two or more doses. There is continued debate over which dosing regimen is optimal. We evaluated our cure rates after giving a single dose of radioactive iodine to treat hyperthyroidism using the fixed-dose regimen as opposed to the calculated-dose regimen. Materials and methods We retrospectively reviewed the clinical records of patients who had received their first single dose of RAI between 2016 and 2021. The patients had clinical and biochemical assessments every six weeks until six months post-RAI therapy, then every three months thereafter, if still not cured. Patients were deemed cured if they developed persistent hypothyroidism or euthyroidism after a single dose of RAI. The data included baseline demographics, adverse events, and cure rates after RAI treatment. Results One hundred and thirty-eight patients received their first dose of RAI during the study period. Their mean ± standard deviation (SD) age was 56.9 ± 15.3 years, and there were 101 women and 37 men. The median duration of hyperthyroidism was 34 months, and 62% of the cases were affected by Graves' disease. A majority of patients (90%) were on an antithyroid drug prior to RAI therapy. The median (interquartile range) dose of RAI received by the group was 559 (546-577) megabecquerels (MBq). Four patients (2.9%) reported adverse events shortly after receiving RAI. Our overall cure rate was 87.7% amongst patients who received a single dose of RAI therapy. This number consisted of 96 patients (69.6%) who developed hypothyroidism and 25 patients (18.1%) who remained euthyroid. Our one-year cure rate was 84.1%. Further analysis revealed that women had a greater cure rate than men over the study period (92% vs 75.7%, p = 0.017).  Conclusion We have evaluated cure rates after a single dose of RAI therapy for the treatment of hyperthyroidism at our center. Our results are comparable to those reported at other centers using a similar dosing regimen.

Partial Remission of Diabetes in a Young Adult While Testing Positive for Several Islet Cell Autoantibodies: A Case Report, Literature Review, and Patient Perspective.

Type 1 diabetes is a chronic disease characterized by abnormal metabolism and hyperglycemia due to insulin deficiency. There is a rapid decline in insulin production due to autoimmune destruction of the pancreatic beta cells. Partial remission (honeymoon phase) of type 1 diabetes is common in children and young adults with newly diagnosed type 1 diabetes. There is temporary restoration of beta cell function such that little or no exogenous insulin is required. Stopping insulin therapy soon after an emergency admission requiring intravenous insulin and subsequent subcutaneous insulin therapy can be frightening for both patient and healthcare provider. Affected patients require education and support during this period. This report describes a case of a 28-year-old man who presented to the emergency department with features of type 1 diabetes and diabetic ketoacidosis. He was treated with intravenous fluids and intravenous insulin and discharged on a subcutaneous insulin regimen. Despite testing positive for several types of islet cell autoantibodies, the patient was able to stop insulin therapy within three months of diagnosis. The patient maintained a self-initiated low-carbohydrate diet, regular weight-reducing exercise, and normal glucose levels without the need for insulin therapy. The honeymoon phase of type 1 diabetes, latent autoimmune diabetes, and ketosis-prone type 2 diabetes are discussed as important differential diagnoses.

A Rare Case of Severe Hemolytic Anemia and Pulmonary Embolism Secondary to Mycoplasma pneumoniae Infection.

A 27-year-old woman was admitted with a history of dry cough, breathlessness, fever, lethargy, and nausea and vomiting. On examination, she was febrile, jaundiced, and hypoxic. Blood tests revealed severe leucocytosis and severe hemolytic anemia. The chest imaging demonstrated coexisting pneumonia and pulmonary embolism. An initial blood transfusion worsened the hemolytic anemia to the point that critical care review was required. Subsequent blood tests revealed cold agglutinin hemolytic anemia due to Mycoplasma pneumoniae infection. The patient's condition improved after receiving a warm-blood transfusion, antibiotics, and steroid therapy. The patient also received anticoagulant therapy for 6 months. Our case is unique in that the patient had very severe anemia and very severe leucocytosis, making us suspect a hematologic malignancy at initial presentation. This case emphasizes the importance of prompt evaluation of hemolytic anemia and the use of warm blood transfusion for cold agglutinin disease.

Correction: Atezolizumab-Induced Hypothyroidism in a Patient With Pre-existing Triiodothyronine (T3) Thyrotoxicosis Due to Graves' Disease: A Case Report and Literature Review.

[This corrects the article DOI: 10.7759/cureus.19736.].

Pyomyositis Affecting the Paraspinal and Iliacus Muscles in a Patient With Staphylococcus aureus Urinary Tract Infection.

We report a case of a 63-year-old man who presented with a four-day history of fever, night sweats, and left lower back pain, which radiated down to his left buttock and leg. He also had a short-lived episode of chest pain and breathlessness. He had a medical history of chronic back pain, which had been diagnosed as sciatica three years ago. Initial investigations revealed raised inflammatory markers due to a Staphylococcus aureus urinary tract infection. Despite treatment, his inflammatory markers did not improve and the left lower back pain persisted. A magnetic resonance imaging scan demonstrated features consistent with pyomyositis of the left lumbar erector spinae (paraspinal) and iliacus muscles. After prolonged antibiotic therapy, his symptoms completely resolved. Pyomyositis is a rare tropical infection of the skeletal muscles most commonly caused by Staphylococcus aureus. Risk factors include trauma and immunosuppression. This case highlights a nearly missed diagnosis of paraspinal and iliacus pyomyositis in patients with a background history of chronic lower back pain. Early diagnosis and treatment are pivotal in preventing serious complications such as septicemia and multi-organ failure.

Atezolizumab-Induced Hypothyroidism in a Patient With Pre-existing Triiodothyronine (T3) Thyrotoxicosis Due to Graves' Disease: A Case Report and Literature Review.

The use of immune checkpoint inhibitors has improved the management and prognosis of many solid tumors. Because of their mechanism of action, and as checks on the immune systems are reduced, immune-related adverse events are common, including the exacerbation of the pre-existing autoimmune disease. The literature is scanty regarding reports of the use of immune checkpoint inhibitors in patients with pre-existing Graves' disease. We report a case of a woman with pre-existing triiodothyronine (T3) thyrotoxicosis (hyperthyroidism) secondary to Graves' disease, who developed thyroiditis followed by severe hypothyroidism after receiving an immune checkpoint inhibitor (atezolizumab) for the treatment of small-cell lung cancer. She had been on an anti-thyroid drug for Graves' disease for two and a half years and was on the waiting list for a total thyroidectomy. However, the discovery of the severe hypothyroidism following atezolizumab-induced thyroiditis resulted in the need for long-term thyroid replacement therapy, and the planned surgery was no longer required. This case is one of the very few published reports of the use of atezolizumab in a patient with pre-existing Graves' disease, resulting in the conversion from pre-existing T3-thyrotoxicosis to overt hypothyroidism. A multidisciplinary team approach is required when using immune checkpoint inhibitors in patients with pre-existing Graves' disease or any other autoimmune disease.

Syndrome of Inappropriate Antidiuretic Hormone Secretion and Trimethoprim-Related Hyponatremia Following Transurethral Bladder Wall Biopsy.

Postoperative hyponatremia is common. It results from the physiological antidiuretic hormone (ADH) response to surgery and associated exacerbating factors. Common exacerbating factors include medications, excessive fluid administration, and syndrome of inappropriate antidiuretic hormone (SIADH) secretion. High-dose trimethoprim can cause transient salt-losing nephropathy, resulting in SIADH-like hyponatremia associated with hypovolemia, hyperkalemia, and metabolic acidosis. We present a patient who developed symptoms of vomiting, loss of appetite, fatigue, and abdominal discomfort six days after having a transurethral bladder wall biopsy. He had also started a course of trimethoprim two days prior to the onset of the symptoms. Initial investigations demonstrated severe hyponatremia, concentrated urine, and compensated metabolic acidosis. These results suggested postoperative SIADH possibly exacerbated by trimethoprim-related hyponatremia. Cautious IV normal sodium chloride infusion resulted in a rapid recovery. While raising the awareness of postoperative hyponatremia, this case also highlights the difficulty distinguishing between SIADH and trimethoprim-related hyponatremia.

Biochemical transition during triphasic postpartum thyroiditis: confusion with central hypothyroidism.

SUMMARY: Hypothyroidism occurring in the postpartum period can be due to pituitary or hypothalamic disease as in Sheehan's syndrome and postpartum autoimmune hypophysitis or due to a primary thyroid disease as in postpartum thyroiditis. It is important that the correct diagnosis is ascertained because hypothalamic or pituitary disorders are often associated with other pituitary hormone deficiencies, especially life-threatening adrenal insufficiency or adrenal crisis. A combination of various symptoms and biochemical markers, especially serum thyroid-stimulating hormone levels dictate the initial diagnostic pathway. We present a case of a woman who presented with a 2-month history of tiredness and neck discomfort following delivery. A thyroid function test demonstrated results, which we initially interpreted as central hypothyroidism. Follow-up results indicated that this was in fact the transition period between the thyrotoxic phase and hypothyroid phases of postpartum thyroiditis. This case highlights the potential for diagnostic confusion between central hypothyroidism and postpartum thyroiditis. LEARNING POINTS: Postpartum thyroiditis affects one in twenty mothers within 12 months of delivery. The majority of patients have transient thyrotoxicosis only, some have transient hypothyroidism only, and the rest has a triphasic pattern (thyrotoxic, hypothyroid then a euthyroid phase). During the transition from the thyrotoxic phase to hypothyroid phase, when serum TSH is still suppressed, the biochemical results can resemble that of central hypothyroidism. If central hypothyroidism is suspected, then urgent diagnostic investigations should be carried out along with the assessment of adrenal function. There is a potential for diagnostic confusion between postpartum central hypothyroidism and postpartum thyroiditis; however, the obstetric history, clinical symptoms, and signs (headaches, breastfeeding, goitre, etc.) and serum adrenocorticotropic levels should help with the differential diagnosis.

Subacute Thyroiditis After Receiving the Adenovirus-Vectored Vaccine for Coronavirus Disease (COVID-19).

Since the emergence of the coronavirus disease pandemic, several effective vaccines have been introduced. These vaccines work through several different immunogenic pathways to produce effective immunity. There have been a number of reports of patients developing subacute thyroiditis and thyroid dysfunction after receiving the coronavirus (COVID-19) vaccine. This paper presents a case of a female patient who developed subacute thyroiditis soon after receiving the adenovirus-vectored COVID-19 vaccine. The patient presented with severe neck pain and her blood results demonstrated an initial thyrotoxic phase followed by a hypothyroid phase. She had no past history of thyroiditis or thyroid dysfunction. Subacute thyroiditis occurring after COVID-19 vaccination is rare but also probably underreported. We hope that this case report not only contributes to the literature but also raises awareness of subacute thyroiditis occurring after receiving the COVID-19 vaccine.