Refractory Thyroid Storm Due to Graves Disease in a Patient With Thymic Lymphoepithelial Carcinoma.

Thyroid storm is a life-threatening endocrine emergency that warrants early clinical recognition and aggressive intervention. We present a 64-year-old female with no known history of thyroid disease, who presented to her primary care physician with dyspnea on exertion and was found to have an anterior mediastinal mass. She had elective thymectomy. Pathology confirmed thymic lymphoepithelial carcinoma. Postoperatively, she developed altered mental status, fever, and atrial fibrillation with marked elevation of thyroid hormones, consistent with thyroid storm. She decompensated rapidly and was treated aggressively with standard therapies for thyroid storm, including beta-blockers, methimazole, cholestyramine, steroids, and iodine, with poor response. The patient eventually underwent 4 sessions of therapeutic plasma exchange (TPE) with marked improvement in her symptoms. This case reports a possible association between thymic lymphoepithelial carcinoma and Graves disease and highlights the utility of TPE in cases of severe thyroid storm that are refractory to traditional treatments. We learn from this case that evaluating thyroid function tests in patients with thymic or mediastinal masses before surgery might be helpful. TPE should be considered in patients with thyroid storm refractory to traditional therapies.

Association of electrocardiographic and echocardiographic variables with neurological outcomes after ischemic Stroke.

Background: Cardiac dysfunction is often seen following neurological injury. Data regarding cardiac involvement after ischemic stroke is sparse. We investigated the association of electrocardiographic (ECG) and echocardiographic variables with neurological outcomes after an acute ischemic stroke. Methods: We retrospectively collected baseline characteristics, stroke location, National Institute of Health Stroke Scale (NIHSS) at the time of admission, acute reperfusion treatment, ECG parameters, and echocardiographic data on 174 patients admitted with acute ischemic stroke. Outcomes of the stroke were based on cerebral performance category (CPC) with a CPC score of 1-2 indicating a good outcome and a CPC score of 3-5 indicating a poor outcome. Results: Older age (75.31 ± 11.89 vs. 65.16 ± 15.87, p < 0.001, OR = 1.04, 95 % CI 1.01-1.07), higher heart rate (80.63 ± 18.69 vs. 74.45 ± 17.17 bpm, p = 0.024, OR = 1.02, 95 % CI 1.00-1.05) longer QTc interval (461.69 ± 39.94 vs. 450.75 ± 35.24, p = 0.024, OR = 1.01, 95 % CI 0.99-1.02), NIHSS score (60.9 % vs. 17.8 %, p < 0.001, OR = 14.90, 95 % CI 3.83-69.5), and thrombolysis (15 % vs. 5 %, p = 0.049, OR = 0.55, 95 % CI 0.10-2.55) were associated with poor neurological outcomes. However, when adjusted for age and NIHSS, heart rate and QTc were no longer statistically significant. None of the other ECG and echocardiographic variables were associated neurological outcomes. Conclusions: Elevated heart rate and longer QTc intervals may potentially predict poor neurological outcomes. Further studies are needed for validation and possible integration of these variables in outcome predicting models.

Calcium use during cardiac arrest: A systematic review.

Introduction: Calcium use during cardiac arrest has conflicting results in terms of efficacy. Therefore, we performed a systematic review evaluating the role of calcium administration in cardiac arrest. Methods: We searched PubMed, Cochrane, and EMBASE for studies comparing calcium administration versus no calcium administration during cardiac arrest. The study was prospectively registered in PROSPERO (CRD42022316641) adhering to PRISMA guideline recommendations. The primary outcome was return of spontaneous circulation (ROSC) or survival at one hour. The secondary outcomes included survival to discharge or at 30 days, and favorable neurologic outcomes at 30 and 90 days. We planned to perform a random-effects meta-analysis of low risk of bias studies. We evaluated risk of bias with RoB-2 and ROBINS-I. Results: We identified 1,921 articles and included ten studies with 2509 patients. We were not able to perform a meta-analysis with low-risk of bias studies as only one study was found to be at low-risk of bias. However, for the primary outcome, the three RCTs included showed no benefit with calcium administration during cardiac arrest for ROSC. For the secondary outcomes, based on the most recent study and lower risk of bias, there was a neutral effect for survival to discharge or at 30 days and neurologic outcomes at 30 days. However, there was unfavorable neurologic outcomes at 90 days. Conclusion: Based on our results, calcium administration in cardiac arrests shows no benefit and can cause harm. Further studies on this matter are likely not advisable.

Triple Tick Attack.

Tick-borne diseases are frequently seen in tick-inhabited areas. Lyme disease is the most common tick-borne illness. However, patients with co-infections can present with nonspecific symptoms, which can make the diagnosis far more challenging. We present a case of triple infection with babesiosis, Lyme disease, and anaplasmosis treated with antibiotics and red blood cell (RBC) exchange (erythrocytapheresis). A 74-year-old, avid female gardener presented with one week of progressive dyspnea, cough with mucoid expectoration, and fatigue. On presentation, she was afebrile, hypotensive, and tachycardic. General examination was significant for altered mental status, dyspnea, pallor, and peripheral edema. Lung examination was remarkable for bibasilar crackles. Pertinent laboratory findings were significant for hemolytic anemia and thrombocytopenia. A peripheral blood smear revealed the presence of intracytoplasmic parasites consistent with Babesia. The patient was started on azithromycin and atovaquone. Doxycycline was added empirically for Lyme disease, which was later confirmed by serology. In addition, Anaplasma titers were also positive. Further investigation revealed that the parasitic load was 9.04%, and RBC exchange (erythrocytapheresis) was performed for severe babesiosis. Repeat laboratory tests demonstrated an inadequate reduction in parasitic load (6.54%), requiring a second round of RBC exchange. Antimicrobials were changed to clindamycin, quinine, and doxycycline for a total of 14 days. There was an improvement in the patient's anemia and thrombocytopenia along with clinical improvement.

Mitral stenosis due to rheumatic heart disease - A rare cause of massive hemoptysis.

Severe mitral valve stenosis caused by rheumatic heart disease presenting initially as massive hemoptysis has become a rare occurrence in contemporary western medicine. Massive hemoptysis can be due to multiple disease processes including airway diseases such as bronchiectasis, pulmonary parenchymal disease of infectious or autoimmune etiology, pulmonary AVM's, hematologic disorders, and numerous drugs and iatrogenic injuries. It is less associated with congestion from rheumatic heart disease due to the earlier detection and subsequent management of cardiac valve disease preventing the sequela of more severe disease. We describe a case of a 59 year-old woman with hemoptysis, who was found to have severe mitral stenosis consistent with rheumatic heart disease. We demonstrate the appearance of pulmonary venous congestion can be seen on bronchoscopic examination in severe mitral stenosis and discuss the significance of the Wilkins score to help guide management.

Autosplenectomy Causing Catastrophic Pneumococcal Meningitis in a Patient with Lupus/Antiphospholipid Antibody Syndrome.

We present the case ofa26-year-old female who presented to the hospital with pneumococcal meningitis. A review of her records showed atrophic spleen, and a hypercoagulable workup was positive for Systemic Lupus Erythematous (SLE)/Antiphospholipid Antibody Syndrome (APS). An autosplenectomy from thrombotic occlusion of the splenic artery made her susceptible to pneumococcal meningitis. Autoimmune conditions, particularly SLE and APS, are important causes of hypercoagulable states in a young population, and earlier detection of these conditions and appropriate treatment helps to decrease morbidity and mortality among these patients.