A Case of Pseudogout Following Zoledronic Acid Administration.

Calcium pyrophosphate dihydrate (CPPD) deposition in the joints, often referred to as pseudogout, can lead to debilitating arthritis. Rare cases of pseudogout associated with bisphosphonate therapy have been reported in the literature, although the mechanism for this remains unclear. We report a case of a 53-year-old female who developed an acute pseudogout attack following administration of zoledronic acid for treatment of osteoporosis.

Management of Cardiogenic Shock due to Thyrotoxicosis: A Systematic Literature Review.

BACKGROUND: A grave complication of thyrotoxicosis, or thyroid storm, is the development of heart failure and cardiomyopathy. Recognizing this condition is imperative in preventing further left ventricular dysfunction and cardiogenic shock. This manuscript aims to review the literature on cardiogenic shock associated with thyrotoxicosis and present management recommendations on this rare condition. METHODS: A literature search was performed in December of 2018, using the PubMed medical search engine. A systematic search was carried out using the keywords Thyroid Storm AND Cardiogenic Shock and Thyrotoxicosis AND Shock. MANAGEMENT: Decrease of thyroid hormone levels using therapeutic plasma exchange LV Unloading and ventilation by Impella and Extracorporeal Mechanical Ventilation (ECMO). CONCLUSION: Patients presenting with thyroid storm-induced shock may not be suitable candidates for traditional management with ß -adrenergic blockers (ß-blockers). The use of ß-blockers could exasperate their condition. Through extensive literature review on this rare condition, the most effective management was found to be therapeutic plasma exchange in order to decrease thyroid hormone levels, which have direct toxic effect on the heart. Furthermore, the use of ECMO and Impella is advised to reduce pressure on the heart and ensure the patient's organs are well oxygenated and perfused while the left ventricle is recovering.

HEMOGLOBIN WAYNE VARIANT INTERFERING WITH HEMOGLOBIN A1C MEASUREMENT.

OBJECTIVE: To describe the effect of hemoglobin Wayne variant on hemoglobin A1c (A1c) accuracy and to stress the importance of patient-physician communication and trust. METHODS: We present the clinical history and laboratory findings of 2 patients, with a review of related literature. RESULTS: Two older patients were diagnosed with diabetes mellitus (DM) and suffered from frequent hypoglycemia resulting from titrating their diabetes medications based on an extremely elevated A1c (>11% [97 mmol/mol]) obtained through high-performance liquid chromatography. Discrepancies were noticed between their blood glucose logs and their A1c results. Ultimately, both were found to have heterogenous hemoglobin Wayne variant by hemoglobin electrophoresis. Repeat immunoassay found the A1c to be very low, in the 5 to 6.2% (31 to 44 mmol/mol) range. One of the patients did not even meet diagnostic criteria for DM. CONCLUSION: A1c testing is susceptible to misinterpretation due to multiple interfering factors. Hemoglobin variants should be considered as a differential when there are discrepancies between A1c and blood glucose levels. Trust between the patient and the physician is essential in raising clinical suspicion and avoiding potentially lethal outcomes.

Challenges in the diagnostic work-up and management of patients with subclinical Cushing's syndrome and bilateral adrenal masses.

OBJECTIVE: To review the challenges encountered in the diagnostic work-up and management of patients with subclinical Cushing's syndrome (SCS) and bilateral adrenal masses to aid in the case description of a patient with SCS and adrenocorticotropic hormone (ACTH)-independent macronodular adrenal hyperplasia (AIMAH). METHODS: We describe our experience managing a patient with AIMAH and SCS. This case report is followed by an extensive review of the literature regarding differential diagnoses, work-up including adrenal venous sampling (AVS), and treatment of SCS with bilateral adrenal masses. RESULTS: A 51-year-old female who was diagnosed with recent onset hypertension and diabetes mellitus type 2 was evaluated for adrenal masses discovered incidentally on computed tomography (CT). She did not have any Cushingoid features. Magnetic resonance imaging (MRI) of abdomen was performed for further evaluation. Hormonal evaluation came back consistent with SCS. The AVS results were consistent with bilateral autonomous cortisol hypersecretion without lateralization. Collectively, the findings favored the diagnosis of bilateral AIMAH. A left adrenalectomy was performed, and the patient's clinical response was favorable with improvement in blood pressure (BP) accompanied by significant weight loss. Follow-up hormonal testing for autonomous cortisol hypersecretion was within the target range. CONCLUSIONS: AIMAH is a rare cause of SCS. AVS is a useful diagnostic tool that helps localize the source of autonomous cortisol hypersecretion in ACTH-independent SCS with bilateral adrenal masses, especially if radiological features are inconclusive. Patients undergoing unilateral adrenalectomy should be followed for monitoring of clinical response, as well as progression of AIMAH in the contralateral adrenal gland.