Recurrent hypokalemia in an adult male: A case report on gitelman’s syndrome

Introduction@#Gitelman Syndrome (GS), a rare autosomal recessive inherited disorder, is frequently unrecognized in the clinical setting. GS typically manifests with severe hypokalemia with debilitating and potentially fatal consequences if untreated. As of writing, confirmatory genetic assays are currently unavailable in the country, and the diagnosis of GS is primarily based on several biochemical laboratory tests. This results in the difficulty with prompt diagnosis of GS in the locality.@*Case@#We present a 52-year-old male who came in with chronic, intermittent paraparesis associated with persistent hypokalemia. A diagnosis of GS was made biochemically based on renal wasting of potassium and magnesium, hypocalciuria, and metabolic alkalosis. Electrolyte correction with lifelong supplementation, and administration of Spironolactone resulted in the resolution of bilateral leg weakness. Electrolyte levels were maintained within normal limits in the outpatient setting.@*Conclusion@#GS is an uncommon potentially debilitating disorder that may lead to problematic, potentially fatal consequences to electrolyte abnormalities if left untreated. The lack of awareness and consequent delay in the diagnosis, and the unavailability of confirmatory genetic testing remains a clinical challenge. Timely recognition and initiation of treatment leads to early control of electrolyte levels, and better prognosis.

Normotensive pheochromocytoma presenting as adrenal incidentaloma: A case report

Background@#Pheochromocytomas are rare catecholamine-secreting tumors that usually present with hypertension and palpitations. However, a subset of pheochromocytoma patients is asymptomatic, presenting as adrenal incidentaloma on imaging.@*Case@#We present a case of a 32-year-old normotensive female who presented with a right suprarenal mass on abdominal ultrasound. Diagnosis of pheochromocytoma was made after biochemical testing revealed elevated 24- hour urine metanephrine of 1.96 mg/24hrs (NV:0-1 mg/24hrs) and epinephrine of 129 mcg/24hrs (NV: 2-24 mcg/24hrs). In addition, plasma chromogranin A was elevated at 225.38 ng/ml (NV:<100 ng/ml). CT scan of the abdomen showed a 3.0 x 4.0 x 3.0 cm heterogeneous well-circumscribed right adrenal mass, with 87Hu on contrast, an absolute washout of 21%, and a relative washout of 13% on a delayed scan. After adequate preoperative medical therapy with an alpha-adrenergic blocker, a right laparoscopic adrenalectomy was done, with histopathologic confirmation of pheochromocytoma. Repeat 24-hour urine metanephrine measurements done on multiple follow-ups after surgery were normal.@*Conclusion@#Asymptomatic pheochromocytoma should be included in the differential diagnoses of adrenal incidentalomas. As in our case, patients with normotension and adrenal incidentalomas should still undergo biochemical workup to rule out the presence of pheochromocytoma. Long-term complications from chronic exposure to high catecholamine levels lead to significant adverse cardiovascular effects. Early detection, adequate perioperative preparation, and timely surgical intervention can prevent a potential catastrophe.

Idiopathic Pyoderma Gangrenosum a rare cause of Ulcerative lesion in the leg: A case report

Background@#Pyoderma gangrenosum is a rare ulcerative skin disease that can present as an ulcerative skin disease with the prominence of pain. The pathogenesis may be related to disruptions in the immune pathways. Targeted therapy is lacking and current treatment is largely empirical and consists of corticosteroids and cyclosporine first line. Early recognition can improve clinical outcomes.@*Case@#This case is a 67-year-old male diabetic who was admitted for a progressive ulcerative lesion on the right leg. Arterial Doppler studies and CT angiogram of the right lower extremity were normal. Blood and deep wound cultures of the lesion showed Klebsiella pneumoniae and Pseudomonas aeruginosa. Multiple antibiotic regimens were given with no improvement of the ulcerating lesions of the leg. Pain on the lesion remained persistent. The tissue biopsy of the lesion taken during debridement revealed that it was a pyoderma gangrenosum with dystrophic sclerosis. Oral prednisone at 1 mg/kg was added to the regimen which improved pain but the lesion did not improve. The persistence of the pain and progression to sepsis during the hospital course prompted the decision to do an above-knee amputation of the right leg. He was discharged improved.@*Conclusion@#Pyoderma gangrenosum is a rare non-infectious cause of an ulcerative lesion in the lower extremity. Diabetes is a strong risk factor for this disease. The course is prolonged with the possibility of secondary infections. Upon histopathologic confirmation, an anti-inflammatory regimen could help improve outcomes.

Paraparesis in a young adult: A case report on Neurofibromatosis-2

Background@#Neurofibromatosis-2 (NF2) is a rare neurocutaneous syndrome that typically presents with hearing loss, tinnitus, or weakness associated with few subcutaneous nodules. In contrast to neurofibromatosis-1 (NF1), NF2 presents clinically with more central lesions rather than peripheral lesions. The presence of bilateral vestibular schwannomas through imaging studies distinguishes NF2 from other neurocutaneous syndromes.@*Case@#This is a case of an 18-year-old male who presented with lower paraparesis with associated hearing loss, cataract, and a few subcutaneous nodules. Centrally located lesions were suspected, thus brain and spine magnetic resonance imaging (MRI) were done revealing bilateral vestibular schwannomas and spine neurofibromas. The patient and family were advised for tumor surveillance, and apprised of surgical intervention once with brainstem compression symptoms.@*Conclusion@#NF2 is a rare debilitating disease that may lead to multiple neurologic deficits. The absence of recommended medical treatment and the multifocality of the tumors leave surgical resection a high-risk treatment option. Early recognition by tumor surveillance may give patients with NF2 a better prognosis and survivability.

Degree Of burnout and its association with depression, anxiety and stress among health care workers in a tertiary hospital in Mandaue City during the COVID-19 pandemic

Background@#On top of adjusting to the societal shifts and emotional stressors faced by everyone, health care workers are also confronted by stressors such as an increased risk of exposure, extreme workloads, moral dilemmas, and a dynamic practice environment that differs greatly from what was familiar. These can lead to burnout, a state of physical, emotional, and mental exhaustion that results from long-term involvement in work situations that are emotionally demanding. @*General Objective@#This is a descriptive cross-sectional study that intends to measure the degree of burnout and determine its association with depression, anxiety, and stress among health care workers in Chong Hua Hospital Mandaue during the COVID-19 pandemic. @*Methodology@#The data collection process entailed the researchers’ physical and online administration of a questionnaire which included the health care workers’ socio-demographic data and questions lifted from both the Copenhagen Burnout Inventory (CBI) and Depression, Anxiety, Stress Scales (DASS) 42-item. Also included was an open-ended questionnaire to enumerate outbreak-specific contributors to burnout. @*Results@#222 health care workers were surveyed. Almost half (98, 44.2%) of the health care workers registered moderate to high overall burnout scores on the CBI but none of them had severe burnout. The degree of burnout was determined to be moderately associated with all three negative emotional states using the Cramer’s V coefficient: depression (V = .448), anxiety (V = .378), and stress (V = .415). The foremost factor identified to be a contributor to burnout was the high workload which was exacerbated by the onset of the pandemic. @*Conclusion@#The study showed that burnout and the negative psychological states of depression, anxiety, and stress, are prevalent in health care providers with results comparable to other global studies. The contributors to burnout identified by the respondents were either present pre-pandemic but were aggravated by it and those which were outbreak-specific.

Complete reversal of severe pulmonary artery hypertension after antiretroviral treatment in a 43-year-old newly diagnosed HIV-infected male: A case report

@#<p style="text-align: justify;"><strong>Background:</strong> Human Immunodeficiency Virus (HIV) infection can be complicated by pulmonary arterial hypertension (PAH-HIV) wherein it can occur in approximately 0.5% of HIV patients. The benefit of ART in treating PAH-HIV is unclear in this population. Data on its safety, efficacy, and effect on the progression of PAH are conflicting and limited. In this case report, improvement in PAH was noted after ART was started.</p><p style="text-align: justify;"><strong>Case:</strong> A 43-year-old, male, patient with no comorbidities, consulted due to a five-month history of progressive dyspnea, body malaise as well as weight loss. The patient is heterosexual with multiple sexual partners, an injection drug user, and was previously worked up for HIV, Hepatitis B, and C with unremarkable results. Initially managed as a case of Pneumonia but on CT scan was found to have a suprahilar mass which showed chronic granulomatous features. The positive GeneXpert confirms Pulmonary Tuberculosis (PTB). However, dyspnea was noted to progress thus 2D echocardiography was done which revealed severe pulmonary arterial hypertension with normal left ventricular function. Rescreening for HIV turned out positive thus started on anti-retroviral therapy (ART) with a noted improvement of symptoms as well as improvement and eventual normalization in pulmonary artery pressure. One year after initial diagnosis, undetectable viral load for HIV and Hepatitis C were noted along with improvement in CD4 count.</p><p style="text-align: justify;"><strong>Conclusion:</strong> This is a rare case of severe pulmonary hypertension as an initial presentation for HIV infection. The approach to patients with incidental PAH may include work-up for HIV especially when risk factors are present. ART treatment may provide a favorable therapeutic option if initiated early.</p>

Metastatic Follicular Thyroid Cancer to the Scapula with Rotator Cuff Muscles involvement: A case report

Background@#Follicular carcinomas occur frequently in women beyond the 5th decade of life as a slow-growing thyroid nodule. They are known to invade locally and metastasize distantly. Common sites for distant metastases are lungs and bones. The bones often involved are axial skeleton such as vertebrae, sternum, and skull. Metastasis to scapula is an infrequent presentation and skeletal muscle metastasis is extremely rare.@*Methods@#Case Report@*Results@#We present a case of metastatic follicular thyroid carcinoma that manifested as a large scapular mass on the right shoulder of a 65-year-old female patient. MRI of the right shoulder revealed a large lobulated mass with central necrosis and non-delineation of the 4 rotator cuff muscles. Biopsy of the scapular mass revealed an invasive metastatic follicular carcinoma. A thyroid ultrasound showed a significant right thyroid nodule. The patient underwent total thyroidectomy and subsequent right total scapulectomy with biceps tendon transplantation attached to the clavicle. Histopathologic reports from both operations are consistent with invasive follicular thyroid carcinoma. The patient underwent radioiodine therapy. Follow-up showed no evidence of any functioning metastasis.@*Conclusion@#Soft tissue metastasis is an uncommon initial presentation of follicular thyroid carcinoma. Synchronous metastasis to the bone and soft tissue particularly on the right scapula and surrounding muscles is a rare occurrence that warrants this report.

Tuberculous Laryngitis mimicking as Fungal Laryngitis: A case report

@#Tuberculous laryngitis was considered common during pre-antibiotic area but after the effective antitubercular medication, the incidence of laryngeal tuberculosis had decreased to less than one percent2. Clinical presentation is mostly unclear but usually presents with odynophagia, cough, hoarseness of voice and frequently confused with other diseases, more importantly fungal laryngitis. This is a case of a diagnostic dilemma of an immunocompetent 55-year-old male presenting with odynophagia, dysphagia and hoarseness of voice that was initially managed as a case of fungal laryngitis due to history of prolonged use of dexamethasone and findings of leukoplakia in laryngoscopy. Despite adequate time for treatment, no significant improvement was noted. Acid fast bacilli microscopy tested negative. A previous history of pulmonary tuberculosis treatment and chest radiographs revealing fibrosis on both upper lungs puts tuberculous laryngitis as one of the differentials. Sputum GeneXpert/RIF taken and tested positive, hence lead to the diagnosis of tuberculous laryngitis. Guideline-based quadruple anti-tubercular therapy started and had showed a positive response. Laryngeal tuberculosis (LTB) requires a high index of suspicion since it mimics various laryngeal diseases such as fungal laryngitis or malignancy. Clinicians should always be aware of the atypical clinical features of laryngeal tuberculosis and the possibility of primary laryngeal tuberculosis, for early diagnosis and prompt treatment, thus preventing morbid complications. A positive mycobacterial culture along with a typical histopathological appearance remain the cornerstone of diagnosis, but sputum AFB in microscopy and GeneXpert/RIF must not be ignored as these can be cost-effective diagnostic alternatives.