Frequent Monitoring of Blood Glucose Levels via a Remote Patient Monitoring System Helps Improve Glycemic Control.

OBJECTIVE: This study aimed to evaluate the effectiveness of the Vivovitals diabetes platform in improving glycemic control and reducing hemoglobin A1c (HbA1c) levels in patients with uncontrolled type 2 diabetes mellitus by providing more accessible and direct patient care under the monitoring and oversight of their physician. METHODS: This 12-week, prospective, pragmatic, single-center, double-arm study assessed the impact of the Vivovitals diabetes platform on glycemic control in 78 adults aged ≥18 years with HbA1c levels of ≥7.5% (58 mmol/mol) at baseline. The participants were randomized into 2 groups. The control group received usual clinical care, whereas the intervention group was provided with a smartphone-linked telehealth application, a preconfigured glucometer, and access to a glycemic reading diary. The blood glucose levels of the intervention group were transmitted to the providers daily. Patients whose blood glucose level was <70 mg/dL or >180mg/dL were contacted, and modifications were made to their diet and medication. The 2 groups were compared at the baseline and at 12 weeks using nonparametric tests, with P <.05 considered statistically significant. RESULTS: Over 12 weeks, the average HbA1c level in the control group reduced by 0.474% (P = .533; 95% CI, -0.425 to -0.523), whereas the average HbA1c level in the intervention group reduced by 1.70% (P = .002; 95% CI, -1.02 to -2.39). The estimated treatment difference was expressed using Cohen d, which yielded 0.62. After 12 weeks, the HbA1c values between the control and intervention groups were statistically significant (P = .001). CONCLUSION: The use of the Vivovitals platform may help to improve glycemic control among individuals with type 2 diabetes mellitus.

HASHIMOTO THYROIDITIS NOT ASSOCIATED WITH VITAMIN D DEFICIENCY.

OBJECTIVE: Vitamin D deficiency is associated with several autoimmune diseases. This study assessed whether vitamin D deficiency is associated with Hashimoto thyroiditis (HT). METHODS: Two groups of patients were selected for which serum 25-hydroxyvitamin D (25(OH)D) levels had been measured: (1) a study group of patients diagnosed with HT as indicated by thyroid antibodies, and (2) a healthy control group. Each group was separated by sex and then controlled for age and body mass index (BMI). Groups' mean 25(OH)D levels were compared by analysis of variance (ANOVA), and percent frequencies of vitamin D sufficiency, insufficiency, and deficiency were compared with a Z-test. The correlations between 25(OH)D levels and thyroid antibodies and thyroid-stimulating hormone (TSH) levels were also tested. RESULTS: The mean 25(OH)D levels for the HT and control groups were significantly different in females (30.75 vs. 27.56 ng/mL, respectively) but not in males (14.24 vs. 13.26 ng/mL). HT females had a higher rate of vitamin D sufficiency (51.7% vs. 31.1%) and a lower rate of insufficiency (48.3% vs. 68.9%) relative to control females. No such differences were found in the male groups. None of the females were vitamin D deficient, but almost all males were. A significant (P = .016) positive correlation (rs = 0.436) between 25(OH)D and TPOAb was observed in males. CONCLUSION: HT is not associated with higher rates of vitamin D deficiency relative to a control group. ABBREVIATIONS: BMI = body mass index HT = Hashimoto thyroiditis 25(OH)D = 25-hydroxyvitamin D TgAb = thyroglobulin antibody TSH = thyroid-stimulating hormone TPOAb = thyroid-peroxidase antibody VDR = Vitamin D receptor.

A Case Report of Systemic Allergic Reaction to the Dual Glucose-Dependent Insulinotropic Polypeptide/Glucagon-Like Peptide-1 Receptor Agonist Tirzepatide.

This report examines a case of systemic hypersensitivity to tirzepatide in a patient with type 2 diabetes. Tirzepatide (Mounjaro®), a dual agonist of glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) receptor, has recently gained FDA approval. Additionally, a literature review was conducted to summarize recent research on tirzepatide's effectiveness and safety. A 67-year-old woman, previously treated with basal insulin, metformin, and semaglutide (a GLP-1 agonist), experienced severe disseminated pruritus and a generalized urticarial rash after her first dose of tirzepatide. This reaction, which subsided with antihistamines, raises questions about possible immunoglobulin E-mediated hypersensitivity. The report highlights the need for increased vigilance regarding allergic reactions to new diabetes medications, particularly in the context of GIP/GLP-1 receptor agonists.

Efficacy of Levothyroxine Sodium Soft Gelatin Capsules in Thyroidectomized Patients Taking Proton Pump Inhibitors: An Open-Label Study.

Background: Treatment with proton pump inhibitors (PPIs) and antacids affects the gastrointestinal absorption of levothyroxine sodium (LT4) tablets. Patients with hypothyroidism taking LT4 and PPIs or antacids, thus, require appropriate monitoring. The objective of this study was to determine whether a soft gelatin capsule of LT4 (Tirosint®) would obviate the effect of PPIs on LT4 absorption. The objective was achieved by assessing the effects of a switch from a conventional LT4 tablet form to the same dose as soft capsules in thyroidectomized patients on treatment with LT4 and PPIs. Methods: Patients with history of hypothyroidism due to total thyroidectomy on stable treatment with LT4 tablets, and with gastrointestinal disease treated with PPIs, were switched to a 12-week treatment with Tirosint at the same dose of the LT4 tablets, while maintaining treatment with PPIs. Serum thyrotropin (TSH) levels were the primary endpoint of the study. Secondary efficacy endpoints were: serum levels of free thyroxine (fT4), total thyroxine (TT4), free triiodothyronine (fT3), total triiodothyronine (TT3), creatine-phosphokinase (CPK), sex-hormone binding globulin, ferritin, angiotensin converting enzyme, and a lipid panel. Results: Forty-seven patients (36 females and 11 males, mean age 55.4 years) were enrolled and 45 of them completed the study (2 patients withdrew consent). During treatment with Tirosint, mean TSH levels demonstrated a statistically significant decrease (mean changes from baseline: -0.32 mIU/L at week 6 and -0.68 mIU/L at week 12) and concomitant increases in thyroid hormone (TH) levels from baseline to week 12, which were statistically significant for fT3 and TT3 (mean changes from baseline: 0.26 pmol/L and 0.10 nmol/L, respectively). Significant decreases of serum low-density lipoprotein, total cholesterol, and CPK levels were observed at week 12. No signs/symptoms arose during the study that could be specifically correlated to either hypo- or hyperthyroidism. Conclusions: In thyroidectomized patients taking PPIs and replacement LT4, a switch from conventional LT4 tablets to LT4 soft capsules at the same dose was associated with a significant decrease in TSH and increase in TH, indicating that LT4 absorption may be less affected by PPIs when given in the form of soft capsules. Clinical Trial Registration: NCT03094416.

Anti-hyperglycemic Medication Compliance: A Quality Assurance Project.

In order to determine the prevalence of adherence among diabetes patients treated at Queens Hospital Center's Diabetes Clinic and to determine barriers preventing adherence, 50 patients were asked a series of questions regarding their medication intake. The majority of patients reported that they understood the self-management steps that were necessary in order to control their diabetes. However, 30% of the interviewed patients with type 1 or type 2 diabetes reported that they missed a dose of their diabetes medication on at least one day in the last month. Forgetting and lifestyle inconveniences were the two most frequently reported reasons for non-adherence. Side effects and problems with the pharmacy or insurance were also significant reasons for non-adherence. Adherence can potentially be increased by combining new forms of treatment and increasing educational reinforcement.

Maculopapular Exanthema After the Second Dose of Evolocumab.

Evolocumab is a relatively new monoclonal antibody designed to decrease low-density lipoproteins via the inhibition of proprotein convertase subtilisin/kexin type 9 (PCSK9). It is used alone or in combination with other lipid-lowering agents. Evolocumab was associated with adverse events of skin rashes in clinical trials. We describe a rare case of maculopapular exanthema in a female patient with hyperlipidemia, which was treated with evolocumab. The patient was a 60-year-old female with hyperlipidemia who experienced a maculopapular rash after she was administered the second dose of evolocumab subcutaneously. The rash occurred on her torso and upper extremities and was associated with pruritus and mild wheezing. The hypersensitivity reaction was treated with antihistamines and with the discontinuation of evolocumab. The skin eruption cleared within 10 days. In conclusion, medical professionals should be aware of evolocumab skin hypersensitivity reactions, which could demand the cessation of the evolocumab treatment.

The association between COVID-19 and type 1 diabetes mellitus: A systematic review.

BACKGROUND: /Aim: Various reports of the occurrence of type 1 diabetes mellitus (T1DM) in patients with COVID-19 have been published, denoting an association between both diseases. Therefore, we conducted this systematic review to summarize the prevalence of T1DM in COVID-19 patients and to identify the clinical presentations and outcomes in this patient population. MATERIALS AND METHODS: Up to 10/27/2020, Medline, Embase, cochrane and google scholar databases were searched for original studies investigating the association between COVID-19 and T1DM. A manual search was conducted to identify missing studies. The quality of included studies was analyzed by the National Institute of Health (NIH) risk of bias tool. Outcomes included length of hospital stay, hospitalization, intensive care unit (ICU) admission, diabetic ketoacidosis (DKA), severe hypoglycemia, and death. RESULTS: Fifteen studies were included in the qualitative analysis. Included studies reported data of both adult and pediatric patients. The prevalence of T1DM in COVID-19 patients ranged from 0.15% to 28.98%, while the rate of COVID-19 in patients with T1DM ranged from 0% to 16.67%. Dry cough, nausea, vomiting, fever and elevated blood glucose levels were the most commonly reported presentations. The investigated outcomes varied widely among studied populations. CONCLUSIONS: The prevalence of T1DM in patients with COVID-19 ranged from 0.15% to 28.98%. The most common presentation of COVID-19 in patients with T1DM included fever, dry cough, nausea and vomiting, elevated blood glucose and diabetic ketoacidosis. The outcomes of COVID-19 in terms of length of hospital stay, hospitalization, ICU admission, DKA rate, and severe hypoglycemia were reported variably in included studies. Due to the heterogeneous study populations and the presence of many limitations, more studies are still warranted to reach a definitive conclusion.

New-Onset Diabetes in the Setting of Beta-Cell Dysfunction in a Young Patient With COVID-19 Infection.

Reciprocal relationships between viral illness and chronic diseases have been established. Such relationships augment one another and increase the potential harm. The coronavirus 2019 pandemic proved that the most vulnerable populations are the ones with underlying chronic diseases, especially diabetes mellitus. As new data are evolving, viral illnesses, like COVID-19, have been speculated to potentially induce diabetes mellitus. Here we report a 20-year-old male with no past medical history who presented with polyuria, polydipsia, and dry mouth. He was found to have significant hyperglycemia. He had COVID-19-like symptoms a few weeks prior to admission and was tested positive for COVID-19, but the symptoms had resolved prior to his presentation. He was managed with intravenous fluids (IVFs), electrolytes replacement, and insulin. He was diagnosed with new-onset diabetes mellitus likely secondary to a recent COVID-19 infection and was discharged home on insulin, oral antidiabetic medications, and outpatient follow-up with primary care clinic and endocrinology clinic.

Diabetes Mellitus and COVID-19: Review Article.

BACKGROUND AND AIMS: We aim to cover most of the current evidence on the mutual effect of diabetes & COVID-19 infection on each other and the management of the COVID-19 patients with diabetes. METHODS: We utilized databases to review the current evidence related to diabetes mellitus and COVID-19. RESULTS: We discussed the most recent evidence of diabetes milieus and COVID-19 regarding risk factors, management, complications, and telemedicine. CONCLUSION: Diabetes mellitus is associated with a significant risk of complications, extended hospital stays, and mortality in COVID-19 infected patients.

A Study of Artificial Sweeteners and Thyroid Cancer Risk.

BACKGROUND: In recent decades, data from certain observational studies have stirred controversy over artificial sweeteners by linking them with certain malignancies. As the incidences of artificial sweetener consumption and thyroid cancer are both increasing, our study aimed to determine any possible association between them. METHODS: This retrospective observational study enrolled 50 patients (group 1) with proven diagnosis of well-differentiated thyroid cancer (WDTC) and 50 control subjects (group 2) diagnosed as having benign thyroid nodule by fine-needle aspiration. The survey questionnaire included the total amount and duration of intake of artificial sweeteners. RESULTS: Increased consumption of artificial sweeteners was noted in group 1 as compared to group 2, which was statistically significant (76% vs. 24%, P < 0.01). This study suggested that the use of an average of four packets (4 g) per day of artificial sweetener for an average duration of 5 years is associated with WDTC. CONCLUSIONS: Our study emphasizes the significance of artificial sweetener consumption as a potential risk factor for WDTC and increase in public awareness regarding this association if other studies in future report similar findings.

Continuous Glucose Monitoring Versus Self-monitoring of Blood Glucose in Type 2 Diabetes Mellitus: A Systematic Review with Meta-analysis.

Every eleventh adult has diabetes, and every third has prediabetes. Over 95% of diabetics are of type 2. It is well established that diabetes doubles the risk of heart disease and stroke apart from increasing the risk of microvascular complications. Hence, strict glycemic control is necessary. However, it increases the risk of hypoglycemia, especially in patients with longstanding diabetes. Continuous glucose monitors (CGM) use a sensor to continuously measure the glucose levels in the interstitial fluid every 10 seconds and gives out mean values every five minutes. CGMs are emerging tools in the management of type 2 diabetes. The prime objective of this review is to find out if there is enough supporting evidence, suggesting that continuous glucose monitoring is more effective than self-monitoring of blood glucose (SMBG) in type 2 diabetes. We conducted a systematic literature search in Medline (PubMed) looking for any studies addressing our objective. It is observed that there is a varying level of evidence supporting that employing a CGM can reduce glycated hemoglobin (HbA1c), hypoglycemic events, and increase patient satisfaction. However, some studies reported no significant benefits. This systematic review with meta-analysis concludes that the use of CGM in type 2 diabetes mellitus (T2DM) is beneficial, as it significantly reduces HbA1c compared to the usual method of SMBG. The pooled mean difference in HbA1c was -0.25 (-0.45, -0.06) and statistically significant (at p = 0.01) when comparing CGM to SMBG.

Effect of High-dose Biotin on Thyroid Function Tests: Case Report and Literature Review.

Biotin is a readily available supplement that is part of the B-complex vitamins. It is an essential co-factor for five carboxylases involved in fatty acid synthesis and energy production. The recommended daily intake (RDI) of biotin ranges from 30 to 70 mcg per day. At high doses (10,000 times RDI), biotin improves clinical outcomes and quality of life in patients with progressive multiple sclerosis (MS). It has been reported to cause interference in immunoassays resulting in abnormal thyroid function tests. Hereby we are describing the case of a patient having MS who was on high-dose biotin, seen in the clinic for a follow-up visit with thyroid function tests suggestive of Graves' disease with no signs and symptoms of hyperthyroidism and completely normal physical examination. In the case we have described, the laboratory measurements suggestive of thyrotoxicosis were attributed to interference of the patient's high-dose biotin treatment with the biotin-streptavidin chemistry of the immunoassays. We observed normalization of the thyroid stimulating hormone (TSH) and free T4 measurements when the patient withheld biotin for a week. As our case illustrates, early consideration of biotin interference minimizes unnecessary repeat laboratory studies. As trials in MS are progressing, we expect to see more patients on high-dose biotin treatment with spurious laboratory measurements. Therefore, we advise careful history taking and close communication with the laboratory when the clinical picture does not match with the laboratory results.

Prolonged Duration of Hashitoxicosis in a Patient with Hashimoto's Thyroiditis: A Case Report and Review of Literature.

Hashitoxicosis is the initial hyperthyroid phase of patients with Hashimoto's thyroiditis and, usually, this phase lasts for one to two months. We report a case of a 21-year-old male who had Hashitoxicosis of two years duration before converting to Hashimoto's hypothyroidism. He initially presented with complaints of increased appetite, heat intolerance, fatigue, and sweating. On a physical exam, he had mild exophthalmos with lid lag and a fine tremor in the hands. Thyroid function tests also confirmed that the patient had hyperthyroidism. Thyroglobulin antibody and thyroid peroxidase antibody were both positive. He also had mildly elevated thyroid-stimulating immunoglobulin (TSI) but decreased radioactive iodine uptake scan. Based on the clinical presentation and biochemical test, a diagnosis of Hashitoxicosis was made. This hyperthyroid phase lasted for a period of two years. The patient eventually developed hypothyroidism suggesting that Hashimoto's thyroiditis was the most likely diagnosis. He was started on levothyroxine replacement therapy and remained euthyroid on levothyroxine since that day. The initial presentation mimicked Grave's disease, but with decreased radioiodine uptake, despite the high TSI level, leading us to treat him medically and not with radioactive iodine therapy. The patient was thus spared unnecessary radioactive iodine therapy (RAI) therapy.

Adult-onset Still's Disease in a Female Patient with Schizophrenia: A Case Report and Literature Review.

Adult-onset Still's disease (AOSD) is a rare diagnosis. In small percentage of cases, AOSD is associated with other autoimmune diseases including schizophrenia. Despite the lack of sufficient studies, both conditions may share similar autoimmune pathogenic pathways. Herein we describe a 36-year-old woman with the past medical history of schizophrenia who presented with spiking fevers, arthralgia, evanescent rash and pleural chest pain. She reported developing these symptoms a while after poor compliance with her antipsychotic medication. On admission, physical examination was remarkable for high-grade fever, maculopapular rash, oligo arthralgia, hepatomegaly and lymphadenopathy. Laboratory investigation revealed leukocytosis with neutrophilia and markedly elevated ferritin. The patient met four out of four major, and three out of five minor Yamaguchi criteria for AOSD. The patient started on therapy with corticosteroid. Soon after, her symptoms resolved and most of her biochemical markers went back to normal. We review the literature on co-existence of AOSD with other autoimmune diseases, we also discuss that there may be a correlation between ceasing antipsychotic medication (with known immunomodulatory effect) in a schizophrenic patient and triggering an auto-inflammatory process such as AOSD in a susceptible host. In addition, we discussed the possible similar autoimmune pathway of schizophrenia to pathogenesis of AOSD.

Malignant Hypertension in Association with Low Estrogen Dose Oral Contraceptives: Case Report and Review of Literature.

Malignant hypertension (MH) has been described in association with high-dose (50 - 100 mcg) estrogen oral contraceptive pills (OCPs). Although the rise in blood pressure (BP) is usually mild, some women will have a more significant increase in BP, and hypertensive emergencies may very rarely occur. We present a 21-year-old Caucasian female with a past medical history of fibromyalgia and family history of hypertension (both grandparents) who was admitted with a three-day history of headache and blurring of vision in her left eye with a BP of 210/150. Her medications, which were continued on admission, included tramadol, 100 mg twice daily (bid), and low-dose estrogen OCP. During the hospital course, she received different antihypertensive medications and her hypertension was controlled. A diagnosis of MH due to OCP was made. All antihypertensive medications were stopped, except metoprolol, and the patient was discharged home on metoprolol with a BP of 107/55 mmHg. On follow-up in the medical clinic three months later, her visual disturbances had completely resolved and her BP was 98/56 mmHg.  One-third of patients aged 15 - 44 years old who develop MH are likely to be on high-dose estrogen OCP. As far as we know, our case is the third documented case of MH occurring in patients on low-dose estrogen OCP. Chronic use of oral contraceptives will slightly increase the systemic BP in most women. It is advisable to avoid OCP in high-risk patients and do regular BP checks on patients on OCP. In patients presenting with hypertension or MH while on OCP, the OCP should be discontinued.

Improvement of Chronic Idiopathic Urticaria With Levothyroxine: A Case Report and Review of Literature.

There is an increased association between chronic urticaria (CU) and thyroid autoantibodies. We presented a case of a patient suffering from CU and newly diagnosed Hashimoto's thyroiditis in which levothyroxine therapy completely resolved the symptoms of urticaria. A 58-year-old female with a past medical history of recurrent urticaria presented with complaints of fatigue and weight gain. Laboratory investigations showed a high thyroid stimulating hormone (TSH) level and a low free thyroxine (T4) level. She had elevated levels of antithyroid peroxidase (anti-TPO) and anti-thyroglobulin antibodies (anti-TG). She was diagnosed as a case of Hashimoto's thyroiditis and started on levothyroxine therapy. She noticed that her uncontrolled recurrent urticaria started to get better and after a few months of therapy, she stopped taking her topical ointments and antihistamines. The reason for the association between positive serological tests for thyroid autoimmunity and CU is unclear. The resolution of chronic urticaria with levothyroxine in our patient with Hashimoto's thyroiditis suggests a common underlying mechanism between the two pathologies.

A Rare Case Report of Extra-adrenal Pheochromocytoma with Normal Blood Pressure: Is that Possible?

Extra-adrenal pheochromocytoma is uncommon and usually secreting nor-epinephrine. We are presenting a possible case of extra-adrenal pheochromocytoma in a 68-year-old male who was admitted to Queens Hospital Center complaining of shortness of breath for two days. Physical examination was unremarkable except tachycardia. Ventilation/perfusion (V/Q) scan showed the intermediate probability for pulmonary thromboembolism. Computed tomography (CT) chest confirmed the presence of old embolism and showed the 1.1 cm nodule in the left upper lobe. He suddenly collapsed and went into cardio-respiratory failure and attempts to resuscitate were futile. Results for pheochromocytoma workup received after the patient has passed away and it showed elevated levels of 24-hour urine metanephrine, normetanephrine, and Vanillylmandelic acid (VMA). In our patient, CT abdomen did not identify any mass in the adrenal gland or at the bifurcation of the aorta. The extra-adrenal tumor can secrete enough epinephrine to negate the hypertensive effect of norepinephrine. The clinician should be aware of the possibility that tachycardia could be a presenting symptom in pheochromocytoma although the patient is normotensive.

Thrombotic Thrombocytopenic Purpura Associated with Dermatomyositis.

Dermatomyositis and thrombotic thrombocytopenic purpura (TTP) are both rare diseases. TTP is a blood abnormality in which blood clots form in blood vessels leading to fatal outcomes. Dermatomyositis is an inflammatory myopathy which causes a distinctive skin rash and muscle weakness. We are hereby presenting the case of a 27-year-old female who presented with characteristic skin findings on the face pathognomic of dermatomyositis and further investigation revealed that she had underlying TTP.

Brachydactyly Mental Retardation Syndrome Diagnosed in Adulthood.

Brachydactyly mental retardation syndrome (BDMR) is due to a rare, small chromosomal deletion of 2q37, and manifests with variable signs and symptoms in people who live with it. BDMR could be misdiagnosed as Albright hereditary osteodystrophy (AHO), because it presents with lack of hormone resistance to parathyroid hormone (PTH) and similar skeletal and craniofacial abnormalities; however, BDMR is far rarer and can present with a different phenotype. In some cases, BDMR patients exhibit malformations of the internal organs, which could cause life-threatening health issues. Associations have also been made between this chromosomal deletion and autism as well. We here report a case of BDMR with an AHO-like phenotype: mild mental retardation, along with normal calcium, phosphate, and PTH levels. Since our patient had a normal biochemical test, we considered pseudopseudohypoparathyroidism (PPHP) as the diagnosis and genetic testing was performed. Karyotype analysis showed deletion of the long q-arm of chromosome 2 in all analyzed cells-46 XX, del (2)(q37.1), which was consistent with BDMR. This deletion is a loss of around 100 genes that can present itself in various ways neurologically and physiologically, depending on the genes lost. However, because patients experience a range of symptoms such as autism, seizures, heart defects, brachydactyly, there could be unforeseen complications with BDMR. Therefore, we postulate that it is necessary to consider a diagnosis of BDMR in adults with AHO-like phenotype and normal calcium metabolism.

Autoimmune Thyroiditis with Hypothyroidism Induced by Sugar Substitutes.

The use of sugar substitutes (artificial sweeteners or non-nutritive sweeteners) has increased dramatically in the past few decades. They have been used as a substitute for sucrose (table sugar) in various diet-related disorders. Their excessive use has been linked to hyperphagia and obesity-related disorders. Hashimoto's thyroiditis (chronic autoimmune thyroiditis) is a disease that involves the immune-mediated destruction of the thyroid gland, gradually leading to its failure. Animal studies report that artificial sweeteners affect the immune system. Moreover, animal studies show that sucralose diminishes the thyroid axis activity. We are presenting the case of a 52-year-old female with autoimmune thyroiditis with hypothyroidism (Hashimoto's thyroiditis) induced by an excessive intake of beverages containing non-nutritive sweeteners. She was ruled out for any other autoimmune disorder. The association between Hashimoto's thyroiditis and the excessive consumption of sugar substitutes is shown by the quick return of thyroid stimulating hormone and antibody levels to normal after eliminating the use of sugar substitutes. Thus, it suggests that the sugar substitutes were the culprit in the development of Hashimoto's thyroiditis in our patient.