Therapeutic Plasma Exchange in Refractory Atrial Fibrillation Secondary to a Thyroid Storm.

Thyrotoxic crisis (thyroid storm) is a severe form of hyperthyroidism. It has a wide range of symptoms, including cardiovascular manifestations that can be life-threatening and require prompt management. Cardiac manifestations of thyroid storm include hypertension, tachycardia, congestive heart failure, cardiac ischemia, and atrial fibrillation. Standard therapeutic approaches of thyroid storm are based on the use of thionamides, corticosteroids, and nonselective beta-blockers to inhibit thyroid hormone synthesis and release while also blocking thyroxin's peripheral effects. This approach is an effective measure in the management of these manifestations. However, when a patient fails to respond to conventional therapy, or there is end organ damage and surgery is not feasible, therapeutic plasma exchange (TPE) is a life-saving measure. Here, we report a case of a 27-year-old female who is known to have hyperthyroidism, but she was not compliant with her medication. She presented with symptoms of hyperthyroidism and was found to have a thyroid storm with refractory atrial fibrillation. Despite the effort to control her symptoms, she developed cardiac arrest, and after 15 minutes of cardiopulmonary resuscitation, she was revived. Amiodarone, beta-blockers, and cardioversion failed to improve the patient's status, and her condition deteriorated. So, we decided to use TPE, and she received three sessions in total. After the first session of TPE, her rhythm converted to sinus rhythm, and her heart rate was controlled to less than 100 beats per minute. She showed dramatic improvement clinically and biochemically. In conclusion, cardiac complications are potentially lethal complications of thyroid storm. Prompt restoration of a normal thyroid state can reverse these complications. When conventional therapy fails to ameliorate symptoms or organ deterioration is rapid and severe, TPE can be a safe and effective measure.

Thyroid Storm in a Patient With Alemtuzumab-Induced Graves' Disease: A Case Report.

Thyroid storm (TS) is a rare and life-threatening medical emergency, most commonly caused by Graves' disease (GD). GD can be induced by immune reconstitution therapy (IRT) such as alemtuzumab (ALZ), a humanized monoclonal antibody against CD52, which is shown to be effective in the treatment of relapsing-remitting multiple sclerosis (RRMS). Here, we present a rare case of TS developing in a 39-year-old female with ALZ-induced GD, managed with antithyroid medication followed by thyroidectomy. There is some evidence that ALZ-induced GD may behave less aggressively than conventional GD. However, physicians should be aware that severe thyrotoxicosis and thyroid storm can happen, which requires prompt recognition and aggressive therapy.

Graves' Ophthalmopathy in the Setting of Primary Hypothyroidism.

Graves' ophthalmopathy (GO) is commonly associated with hyperthyroidism secondary to Graves' disease (GD). Although rare, there have been case reports of it occurring in patients who are hypothyroid with underlying Hashimoto's thyroiditis (HT), as well as in euthyroid patients. Below, we describe a case of GO developing in a patient who has hypothyroidism secondary to HT successfully treated with high-dose steroids. We present a case of a 53-year-old female known to have primary hypothyroidism (Hashimoto's thyroiditis) diagnosed at the age of 39 years and has been on levothyroxine since diagnosis. She presented to our endocrine clinic complaining of new-onset diplopia and periorbital swelling for five months. There is no previous hyperthyroid state or radioactive iodine therapy. Examination showed left-sided upper and lower eyelid swelling, limited abduction with diplopia, and mild punctate keratopathy. Laboratory investigation revealed positive thyroid-stimulating immunoglobulin of 500 IU/mL (normal value: <140 IU/mL) with thyroid-stimulating hormone (TSH) and free thyroxine (FT4) in the euthyroid range. She was found to have a small heterogeneous thyroid gland on ultrasound suggestive of atrophic thyroiditis, and magnetic resonance imaging (MRI) of the orbits demonstrated bilateral ocular proptosis with extraocular muscle enlargement. The patient was diagnosed with active moderate-severe isolated GO with a background of HT, clinically and biochemically euthyroid on levothyroxine. She was referred to an ophthalmologist and was started on a course of high-dose oral prednisone tapered over three months, which was followed by oral selenium and botox injections to both medial recti muscles. Graves' ophthalmopathy is an uncommon presentation in hypothyroid and euthyroid patients but should be considered in the differential diagnosis. The incidence varies between studies from 2% to 7.5%. Awareness of this clinical presentation is important, as early detection and treatment can prevent visual complications. To date, there are no clear guidelines on how to treat GO with underlying HT. Treating our patient with high-dose steroids extrapolated from treating GO secondary to GD showed significant improvement in her symptoms.

The potential role of adjunctive ascorbic acid in the prevention of colistin-induced nephrotoxicity in critically ill patients: A retrospective study.

Background: Colistin is considered a valuable and last-resort therapeutic option for MDR gram-negative bacteria. Nephrotoxicity is the most clinically pertinent adverse effect of colistin. Vivo studies suggest that administering oxidative stress-reducing agents, such as ascorbic acid, is a promising strategy to overcome colistin-induced nephrotoxicity (CIN). However, limited clinical data explores the potential benefit of adjunctive ascorbic acid therapy for preventing CIN. Therefore, this study aims to assess the potential nephroprotective role of ascorbic acid as adjunctive therapy against CIN in critically ill patients. Method: This was a retrospective cohort study at King Abdulaziz Medical City (KAMC) for all critically ill adult patients who received IV colistin. Eligible patients were classified into two groups based on the ascorbic acid use as concomitant therapy within three days of colistin initiation. The primary outcome was CIN odds after colistin initiation, while the secondary outcomes were 30-day mortality, in-hospital mortality, ICU, and hospital LOS. Propensity score (PS) matching was used (1:1 ratio) based on the patient's age, SOFA score, and serum creatinine. Results: A total of 451 patients were screened for eligibility; 90 patients were included after propensity score matching based on the selected criteria. The odds of developing CIN after colistin initiation were similar between patients who received ascorbic acid (AA) as adjunctive therapy compared to patients who did not (OR (95 %CI): 0.83 (0.33, 2.10), p-value = 0.68). In addition, the 30-day mortality, in-hospital mortality, ICU, and hospital LOS were similar between the two groups. Conclusion: Adjunctive use of Ascorbic acid during colistin therapy was not associated with lower odds of CIN. Further studies with a larger sample size are required to confirm these findings.

Diabetic ketoacidosis precipitated by Coronavirus disease 2019 infection: Case series.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has evolved into a devastating pandemic since December 2019. Saudi Arabia's first case was reported in March 2020. Subsequently, some 220,000 cases and 2000 deaths were recorded through July 2020. COVID-19 infection aggravates glycemic control and provokes acute hyperglycemic crises, according to some reports. We made the same observations in some of our patients diagnosed with COVID-19. However, we are unaware of any reported cases of diabetic ketoacidosis (DKA) among COVID-19 patients in Saudi Arabia. OBJECTIVE: Highlighting the significance of hyperglycemia on COVID-19 patient outcomes. METHODS: Five patients with DKA were admitted and diagnosed with COVID-19 based on real-time reverse transcription-polymerase chain reaction assays. Electronic medical records were reviewed and informed consent was obtained before reporting the index cases. RESULTS: Five patients presenting with DKA complicating a concurrent COVID-19 infection were reported. Three were known to have preexisting diabetes and 2 had newly diagnosed diabetes based on significantly elevated glycated hemoglobin levels at admission. Four recovered and were discharged to their homes and 1 had a complicated course and died. CONCLUSIONS: Our cases demonstrate that COVID-19 infection can trigger DKA. DKA can occur among patients who are known to have diabetes mellitus or appears as a first presentation. Clinicians should be extremely careful in checking for admission hyperglycemia and closely monitor respiratory status during fluid resuscitation of COVID-19-related DKA. (Curr Ther Res Clin Exp. 2020; 81:XXX-XXX).

Saudi womens acceptance and attitudes towards companion support during labor: should we implement an antenatal awareness program?

BACKGROUND AND OBJECTIVES: Despite the known benefits of support during chilbirth, most hospitals in Saudi Arabia do not allow a companion during labor. This can be due to cultural beliefs among pregnant Saudi women. The aims of this study are to describe Saudi women's preferences towards supportive companions during labor and to explore their attitudes and knowledge about the importance of support during childbirth. DESIGN AND SETTING: Prospective cohort study conducted in three governmental tertiary hospitals within Riyadh. SUBJECTS AND METHODS: Women who consented were interviewed during their postpartum hospital stay using a validated standardized Arabic questionnaire. Participants were asked about their preferences and attitudes towards companions during childbirth, as well as about their knowledge on the importance of such support. RESULTS: Of 402 women who participated in the study, 182 women (45.3%) preferred the presence of a companion during childbirth and only 57 of all interviewed women (14.2%) had ever had a supportive companion during any of their previous childbirths. The mother (58%) or husband (51%) was the most preferred person as a childbirth companion. Age, level of educational, or antenatal, intrapartum or postpartum status had no impact on their decision. However, women who had some sort of antenatal educational classes and/or read educational material about childbirth were more likely to prefer support during labor. More than one-third of participants (35.9%) thought that having a companion as support during labor would not help, but the most common reason for not preferring to have a companion was their fear of being exposed most of the time to their companion (64.1%). CONCLUSIONS: A significant percentage of surveyed Saudi women preferred not to have a supportive companion during childbirth. The reason might be a lack of understanding of the positive role of a companion during childbirth or because of cultural beliefs. Education of women during their antenatal care about the importance and the implementation of such a practice are warranted.