Prolonged coma resulting from massive levothyroxine overdose and the utility of N-terminal prohormone brain natriuretic peptide (NT-proBNP).

INTRODUCTION: Levothyroxine overdose rarely results in systemic toxicity. We report a case of intentional levothyroxine overdose with a delayed onset coma and delirium lasting two weeks. CASE SUMMARY: A 72-year-old female ingested 12 mg levothyroxine. Initially, she was drowsy but quickly recovered and was well for the following two days. On day-3 post-overdose her mental state gradually deteriorated. She presented to the hospital with agitation, confusion and dyspnoea. Initial vital signs: P128 bpm, BP132/67 mmHg, temperature 38 °C and SpO2 97%RA. Features suggesting thyroid storm were present: fever >38 °C, tachycardia and persistent coma. Serum T4 and T3 were >150 pmol/L (normal: 8-16) and >30.8 pmol/L (normal: 3.2-6.1), respectively. These remained elevated for 11 days. She was treated with propranolol, propylthiouracil and cholestyramine. She remained intubated for two weeks without sedation. Her conscious state improved on day-13, coinciding with normalisation of serum T4. Normal cognition was regained four days later. N-terminal pro-brain natriuretic peptide (NT ProBNP) concentration was increased during coma and peaked 2 days prior to Glasgow Coma Score improving. DISCUSSION: Our case demonstrates features of thyrotoxicosis and thyroid storm with coma after massive levothyroxine overdose. Coma was associated with an increase in NT-proBNP concentration. This may be a potential marker for brain injury and recovery.

Coffee Intake Is Associated with a Lower Liver Stiffness in Patients with Non-Alcoholic Fatty Liver Disease, Hepatitis C, and Hepatitis B.

There is emerging evidence for the positive effects or benefits of coffee in patients with liver disease. We conducted a retrospective cross-sectional study on patients with non-alcoholic fatty liver disease (NAFLD), hepatitis C virus (HCV), and hepatitis B virus (HBV) infection to determine the effects of coffee intake on a non-invasive marker of liver fibrosis: liver stiffness assessed by transient elastography (TE). We assessed coffee and tea intake and measured TE in 1018 patients with NAFLD, HCV, and HBV (155 with NAFLD, 378 with HCV and 485 with HBV). Univariate and multivariate regression models were performed taking into account potential confounders. Liver stiffness was higher in males compared to females (p < 0.05). Patients with HBV had lower liver stiffness than those with HCV and NAFLD. After adjustment for age, gender, smoking, alcohol consumption, M or XL probe, and disease state (NAFLD, HCV, and HBV status), those who drank 2 or more cups of coffee per day had a lower liver stiffness (p = 0.044). Tea consumption had no effect (p = 0.9). Coffee consumption decreases liver stiffness, which may indicate less fibrosis and inflammation, independent of disease state. This study adds further evidence to the notion of coffee maybe beneficial in patients with liver disease.