Nonclassic Congenital Adrenal Hyperplasia Metabolic Resolution Post Roux-en-Y Gastric Bypass and Associated Weight Loss.

Nonclassic congenital adrenal hyperplasia (NCCAH) is characterized by mild cortisol deficiency, excess androgens and adrenocorticotropin (ACTH) production, and often with various features of dysmetabolic syndrome. Elective bariatric surgery is one of the most effective long-term management strategies for severe obesity. Our case presents a 34-year-old woman with symptomatic NCCAH and class III obesity who status post Roux-en-Y gastric bypass (RYGB) had significant weight loss with metabolic resolution of NCCAH, and no longer required glucocorticoid (GC) therapy. At 11 months post operation and off GC therapy, she had a weight deficit of approximately 160 pounds (72.57 kg) with continued metabolic resolution of NCCAH markers including ACTH, 17-hydroxyprogesterone, and androstenedione. Presently, GC therapy remains one of the few available treatments for symptomatic NCCAH; however, long-term GC therapy has the potential for various complications and side effects. Our case presents elective bariatric surgery as a potential and unique treatment option for patients with NCCAH with associated class III obesity. The exact pathophysiologic basis for this effect and its potential role in long-term management of appropriate NCCAH patients requires further study.

Fahr Syndrome Secondary to Pseudohypoparathyroidism.

Fahr syndrome is a rare neurologic disorder, usually affecting young and middle-aged adults, that can present with symptoms ranging from extrapyramidal to neuropsychiatric abnormalities. Pseudohypoparathyroidism (PHP), characterized by parathyroid hormone (PTH)-resistance or PTH-unresponsiveness at target organs, is associated with Fahr syndrome and typically presents with hypocalcemia. The following case presents a 39-year-old-woman with PHP complicated by symptomatic hypocalcemia, hypokalemia, and movement disturbances, who had computed tomography imaging showing basal ganglia calcifications consistent with Fahr syndrome. She initially presented with headache and was hospitalized for hypertensive emergency and severe hypocalcemia. Examination, including the neurologic examination, was unrevealing aside from hypertension and central adiposity. Laboratory tests were consistent with PHP, showing hypocalcemia with elevated PTH, and negative for hyperaldosteronism. Management of hypocalcemia consisted of intravenous calcium infusion, oral calcium carbonate, oral vitamin D3, and oral calcitriol. Patients with severe hypocalcemia and elevated PTH who present with new neurological symptoms despite normal general neurologic examination may warrant consideration for brain imaging to evaluate for Fahr syndrome. Further investigations are necessary to determine the prevalence of Fahr syndrome and hypokalemia in patients with PHP, explore if these findings are significantly associated with PHP-1b subtype, and ultimately inform potential new screening pathways for these patients.

A Case of Hypoglycemia With Concomitant Use of a Sulfonylurea and Clopidogrel.

Hypoglycemia secondary to sulfonylureas and clopidogrel have been independently described in the literature. However, there has been minimal investigation into the risk of clopidogrel-induced hypoglycemia in the setting of long-term or concomitant sulfonylurea use in patients with Type 2 diabetes mellitus. We present a case of a patient with diabetes well managed on glimepiride (second-generation sulfonylurea) for more than 10 years who presented with an episode of hypoglycemia shortly after initiation of clopidogrel for peripheral vascular disease.

A Rare Case of Renal Sarcoidosis.

Sarcoidosis is a multisystem granulomatous disorder characterized by non-caseating granulomas in multiple organs. It most commonly involves lungs and it is very rare to find isolated cases affecting other organ systems with no associated pulmonary findings. We hereby present a case of a young 30-year-old male who was referred to the hospital by his primary medical doctor due to right eye pain secondary to iritis and acute kidney injury (AKI). His initial laboratory studies revealed anemia, AKI, mild hypercalcemia, and the urinary analysis revealed proteinuria. Imaging studies were negative and a kidney biopsy was performed and showed results from the biopsy that revealed diffuse tubulointerstitial disease with early fibrosis, widespread moderate inflammation, multifocal tubulitis, and focal aggregate of epithelioid cells suggestive of granuloma consistent with sarcoidosis. The patient was treated with prednisone. Renal involvement of sarcoidosis is extremely rare (around 0.7%). It has a wide spectrum of presentation including abnormal calcium metabolism, nephrolithiasis, nephrocalcinosis, and acute tubulointerstitial nephritis with or without granulomas. This is a unique case as it shows renal sarcoidosis without coexisting pulmonary finding of hilar lymphadenopathy on chest X-ray. There are very few reported cases of renal sarcoidosis in the literature and this case can add to the pool of those cases. It also emphasizes the need for urgent renal biopsy in the settings of AKI associated with mild to moderate proteinuria. Lack of availability of comprehensive research on the disease may lead to misdiagnosis and delay in treatment.

A Rare Case of Hypoparathyroidism and Myxedema Coma in a Patient With Diamond-Blackfan Anemia.

Diamond-Blackfan anemia (DBA) is a rare genetic condition that presents due to bone marrow failure caused by a dysfunction in ribosomal biogenesis and function. The patients would often require chronic transfusions as treatment, which puts them at high risk for the development of secondary hemochromatosis. This secondary hemochromatosis results in endocrinopathies due to iron deposition into the endocrine glands. We present an interesting case report of a female patient with multiple endocrinopathies due to secondary hemochromatosis resulting from chronic transfusion therapy. Her endocrinopathies included hypothyroidism complicated by myxedema coma and, interestingly, hypoparathyroidism, which has seldom been reported in DBA patients. Early diagnosis and precise treatment of life-threatening conditions like myxedema coma in DBA patients can avoid morbidity and mortality.

A Case of Rheumatoid Arthritis-Associated Interstitial Lung Disease - An Unfortunate Complication of Untreated Rheumatoid Arthritis!

Rheumatoid arthritis-associated interstitial lung disease (RA-ILD) is a rare extraarticular manifestation of the systemic autoimmune disease rheumatoid arthritis. RA-ILD is one of the leading causes of morbidity and mortality in patients with rheumatoid arthritis. It is more commonly seen in patients with risk factors, which include male sex, severe rheumatoid arthritis, and smoking. The presentation depends on the extent of the underlying pathology. Patients can remain asymptomatic for extended periods of time and progressively develop symptoms such as shortness of breath on exertion and a nonproductive cough. The diagnosis is made using a combination of clinical presentation, pulmonary function testing, and imaging. It is difficult for a practitioner to distinguish the presentation of interstitial lung disease from other causes and RA-ILD. However, it is extremely important to differentiate them due to the differences in management. The treatment usually involves a multidisciplinary team guided approach towards treating the underlying rheumatoid arthritis. Asymptomatic patients are managed by observation, while symptomatic patients are managed with glucocorticoids and immunosuppressants. Accurate and early treatment can lead to an improvement in a patient's symptoms and significantly improve their quality of life. We present an interesting case of a female with a long-standing history of rheumatoid arthritis not on any treatment presenting to the ED with exertional shortness of breath, dry cough, and abdominal distension.

Clinical, Radiological, and Molecular Findings of Acute Encephalitis in a COVID-19 Patient: A Rare Case Report.

We report a case of encephalitis in a young male patient with severe coronavirus disease 2019 (COVID-19) who initially presented with typical symptoms of fever, dry cough, and shortness of breath but later on developed acute respiratory distress syndrome and required mechanical ventilation. Two days post-extubation, the patient developed new-onset generalized tonic-clonic seizures and confusion. MRI of the brain was done and it showed an abnormal signal in the bilateral medial cortical frontal region. His cerebral spinal fluid (CSF) analysis revealed a characteristic picture of a viral infection with a high white blood cell count and normal glucose and protein levels. After ruling out all common causes of viral encephalitis such as herpes simplex virus (HSV) and based on the review of available literature regarding the neurological manifestations of COVID-19, this case was labeled as acute viral encephalitis secondary to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

Euglycemic Diabetic Ketoacidosis With Sodium-Glucose Cotransporter-2 Inhibitor Use Post-Bariatric Surgery: A Brief Review of the Literature.

Sodium-glucose cotransporter-2 (SGLT-2) inhibitors are antihyperglycemic drugs that are currently being recommended as second-line therapy for patients with diabetes mellitus. SGLT-2 Inhibitors function by inhibiting renal cotransporters, which reduces the reabsorption of glucose in the kidney, ultimately decreasing the concentration of glucose in the body. They have gained popularity in recent years due to their protective effects on the heart and kidneys - both organ systems that diabetes mellitus has shown to have a deleterious effect on. However, despite their growing fame, they have been found to increase the risk of euglycemic diabetic ketoacidosis (DKA). Euglycemic DKA is particularly dangerous as there is a chance that it can be missed by clinicians due to glucose levels generally being less than 200 mg/dL. There is an increasing body of literature detailing cases of euglycemic DKA after bariatric surgery. We present a brief review of the literature regarding this important side effect of SGLT-2 inhibitors seen in patients after bariatric surgery.

Cytomegalovirus Hepatitis in an Immunocompetent Patient: A Cause of Fever of Unknown Origin.

Acute hepatitis is most often self-resolving and a benign condition that rarely requires any anti-viral drugs. In immunocompromised patients (HIV-infected patients and transplant recipients), the morbidity and mortality associated with cytomegalovirus (CMV) infection have been extensively reported in the medical literature. We are describing a rare case of acute severe cytomegalovirus hepatitis in an immunocompetent host. In immunocompetent individuals, in most cases, it causes a subclinical infection and hence doesn't require an anti-viral agent for treatment. Our patient was unique because it presented with clinically severe hepatitis and was uncharacteristically treated with the use of antiviral medications.

A Literature Review on Thyrotoxic Periodic Paralysis.

Thyrotoxic periodic paralysis (TPP) is a rare disease of the muscles that presents with painless weakness of the muscles. The patients usually have hypokalemia and hyperthyroidism with elevations in the level of triiodothyronine (T3) and thyroxine (T4). The muscle weakness is usually transient, and the patients in many cases suffer from recurrent episodes of muscle paralysis. This flaccid muscle paralysis predominantly affects the proximal and lower extremities group of muscles more than the distal and upper extremity muscles. This condition is one of the drastic complications of Graves's disease and, unfortunately, may require admission and treatment in the critical care units. It is often not recognized during the initial attack in the American population as the prevalence is very low among the Caucasian population and people from North America. However, while the prevalence is extremely low in the Caucasian population, it is known to be 10 times more common among the Asian population when compared with the Caucasian population. Furthermore, while the diseases of the thyroid gland are more common in females, this rare disease predominantly affects male sex. It is treated by reversing the hypokalemia, which can in itself prove to be fatal if not corrected quickly, and this is followed by treatment to restore the euthyroid state. A literature review on this reversible cause of muscle weakness is very important to better understand this disease.

Miliary Tuberculosis in a Young Patient? Let's Not Forget the Lung Adenocarcinoma!

Lung cancer is one of the most common cancers diagnosed every year and accounts for a major percentage of cancer incidence and mortality annually, especially in men. Lung adenocarcinoma is a subtype of non-small cell lung cancer (NSCLC), which is the most common type of lung cancer found in smokers and nonsmokers alike. It is known to have diverse CT chest findings ranging from: ground-glass opacities (GGOs) with partially solid nodules, to single or multiple solid nodules that can be either central or peripheral, to thin-walled cystic lesions. Lesions are usually solitary but may be multifocal. Rarely, these lesions can be calcified or demonstrate cavitation, which can make it difficult to distinguish from an infectious disease like tuberculosis, pneumonia, or even fungal infections. Here, we present a case of a 36-year-old Asian male with no significant past medical history, except a 16-pack-year smoking history and recent deployment to Afghanistan, that initially presented with a chief complaint of cough of three-week duration. His CT scan showed innumerable bilateral pulmonary nodules within both lung fields with a miliary type appearance that ultimately turned out to be adenocarcinoma.

Thyrotoxic Muscle Paralysis as a Rare Cause of Reversible Muscle Weakness: A Case Report.

Thyrotoxic periodic paralysis is a clinical condition characterized by muscle weakness in patients with underlying hyperthyroidism. It is usually more commonly seen in patients of Asian origin and has a predisposition for the male population (unlike other thyroid disorders which commonly affect the female population). Findings are more overt in patients who have subclinical hyperthyroidism and there is a risk of them remaining untreated. The symptoms can range from mild muscle weakness to total paralysis. The muscles affected predominantly are the proximal and lower extremities group of muscles. Thyrotoxic muscle paralysis can be precipitated by hyperinsulinemic states such as after heavy meals, physical exertion, obesity, stress, and certain medications like high-dose steroids, antiretrovirals, and interferon therapy. The acute intervention usually revolves around the replenishment of patient's potassium stores followed by maintenance therapy with anti-thyroid medications. We present a case of a Chinese adolescent who presented to us with lower muscle weakness and underlying subclinical hyperthyroidism. It's important for clinicians to be familiar with this disease entity and include it in their differentials whenever a patient with muscle weakness presents. The treatment is simple and can result in rapid improvement of symptoms and should be initiated quickly.

Rare Case of Iatrogenic Myocardial Infarction Induced by Use of Pyridostigmine.

Myasthenia gravis is an auto-immune disease that results in muscle weakness caused by antibodies released against acetylcholine receptors at the presynaptic membrane. Treatment options include acetylcholinesterase medications that cause a wide range of side-effects by increasing the concentration of acetylcholine at the synaptic cleft. One peculiar side effect seen is the precipitation of myocardial infarction caused by an excess of acetylcholine especially among elderly females. We present an interesting case of an 88-year-old female with a history of lung cancer newly diagnosed with paraneoplastic myasthenia gravis, started on treatment with prednisone 40 mg daily, and pyridostigmine 60 mg every six hours. She initially showed remarkable improvement in symptoms within a few hours, however, one day later, the patient developed sudden onset of chest pain radiating towards her left arm. A 12-lead electrocardiogram (EKG) showed diffuse ST-elevation in anterior leads and cardiac enzymes were found to be elevated. Pyridostigmine was stopped and the patient was started on heparin. The patient underwent cardiac catheterization which showed 50% stenosis in the right coronary artery (RCA) and 70% in the left anterior descending artery (LAD). The patient was monitored in the cardiac care unit (CCU) for 24 hours and later on discharged home on oral prednisone. It is a common practice to start treatment with anti-cholinesterase medications in newly diagnosed patients of myasthenia gravis, however, these medications can precipitate myocardial ischemia by coronary vasogenic spasm or by their arrhythmogenic effect. It is important to be aware of these outcomes while starting patients on these medications.

COVID-19 Induced Myocarditis: A Rare Cause of Heart Failure.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing lung injury has been well documented in the literature recently. They do so primarily by binding to the membrane-bound form of angiotensin-converting enzyme 2 (ACE-2) receptors. However, since these receptors are also expressed in the heart and blood vessels, coronavirus can also cause damage to these organs by binding to the ACE-2 receptors. A typical case of coronavirus disease 2019 (COVID-19) usually presents with respiratory symptoms like cough and shortness of breath accompanied by fever. The literature regarding this pandemic has been growing and now we know very well that the effect of this deadly virus is not restricted to the lungs alone. It can, unfortunately, cause various other complications ranging from neurological damage to even myocardial injury in rare cases. We present an interesting case of a 40-year-old male patient who presented to us with shortness of breath. When further investigated, the patient was found to have a new onset of heart failure secondary to COVID-19 induced myocarditis.