Risk Factors for Fragility Fractures in Chronic Lymphocytic Leukemia.

Abnormal bone health and fragility fractures (FF) are more common in patients with chronic lymphocytic leukemia (CLL). We hypothesize that there may be risk factors in CLL patients with osteoporosis that increase the risk of FFs. We conducted a cohort study encompassing all patients diagnosed with CLL from January 1, 2000, to July 31, 2020, utilizing International Classification of Diseases (ICD) codes related to abnormal bone health (osteopenia, osteoporosis, and/or presence of FF) within a single tertiary care institution. Of the 89 patients included, 55 (62%) were female with a mean age of 68 ± 11 years at cohort entry. Fifty-nine (66%) had at least one FF present (pFF) and 30 (34%) did not have an FF (nFF). There were no differences in IGHV (Immunoglobulin heavy chain variable region gene) mutation status, chromosomal abnormalities, or the presence of a complex karyotype. The spine accounted for 81% of identified FF. T-score <-2.5 was more common in those without FF (pFF 38% vs. nFF 71%, P = 0.02). DXA evaluation was not conducted for 36 (40%) individuals within the cohort. Risk factors for fragility fractures included male sex (relative risk [RR] 8.1, 95% confidence interval [CI] 2.1-31.7), diabetes mellitus (RR 1.4, 95% CI 1.04-1.8), smoking (RR 1.3, 95% CI 1.02-1.8), Rai stage >0 (RR 1.4, 95% CI 1.04-1.9), and T-score >-2.5 (RR 1.8, 95% CI 1.1-3.1). There is a high frequency of vertebral FFs in people with CLL despite T-scores not being in the osteoporotic range. Increased awareness to screen and treat vertebral FFs in people with CLL is needed.

Graves' Disease With Initial Presentation of Thyrotoxic Periodic Paralysis.

Graves' disease is a common cause of hyperthyroidism. However, thyrotoxic periodic paralysis (TPP) is a rare complication of Graves' disease and is characterized by episodes of muscle weakness and hypokalemia in the setting of thyrotoxicosis. Episodic weakness and paralysis can be the first manifestation of Graves' disease with TPP despite lacking classic symptoms of hyperthyroidism and can be precipitated by risk factors such as a high carbohydrate diet and strenuous exercise. Although TPP is reversible with correction of hypokalemia and thyrotoxicosis, its uncommon presentation can lead to delay in diagnosis and treatment. Here, we describe a case of a 24-year-old Thai male who presented with proximal muscle weakness that progressed to frequent falls and inability to ambulate over the course of three days. He was found to have severe hypokalemia and diagnosed with TPP from underlying Graves' disease. He was treated with cautious replacement of potassium, a beta blocker, and methimazole to reverse thyrotoxicosis. He regained his ability to ambulate, and his weakness resolved after hypokalemia was corrected. He did not have a reoccurrence of muscle weakness the following 12 months after discharge by continuing treatment with methimazole. The varied clinical manifestations of TPP can make diagnosis challenging, but early recognition and treatment can prevent severe complications of this potentially life-threatening condition.

Utilization of bilateral percutaneous microwave ablation of the adrenal glands in ectopic Cushing's syndrome.

Ectopic Cushing's syndrome (CS) is rare and difficult to cure when the source is elusive. Medical management is complex and often times contraindicated in the medically complex patient. We present a complicated case of ectopic CS where bilateral percutaneous microwave ablation (MWA) of the adrenal glands successfully cured hypercortisolism when surgery and medical therapies were contraindicated. A 71-year-old male was diagnosed with ectopic CS after adrenocorticotropic hormone-dependent hypercortisolism persisted after hypophysectomy despite a positive gradient of >3 on inferior petrosal sinus sampling. An ectopic source was not identified. Surgery and medical therapies were contraindicated due to comorbidities and drug interactions. Bilateral MWA of the adrenal glands was performed. Postprocedurally cortisol levels declined and the patient was clinically adrenally insufficient at 6 months. Bilateral MWA of the adrenal glands can prove to be an effective treatment option for ectopic CS when surgical resection and medical therapies are ineffective or contraindicated.

Case report: Pulmonary sequestration in an adult.

Pulmonary sequestration is a rare congenital malformation that is uncommonly diagnosed during adulthood. Pulmonary sequestrations can manifest with variable presentations. It can remain asymptomatic or present with more severe symptoms such as hemoptysis and recurrent pneumonia. Diagnosis can be confirmed with computed tomography angiogram or angiography. Treatment with embolization of the afferent artery and surgical removal of the pulmonary sequestration generally has good outcomes. We report a case of a 43-year-old man who presented with recurrent pneumonia and left-sided back pain and was eventually diagnosed with pulmonary sequestration.