ABSTRACT
SUMMARY: Hypothyroidism is a common medical condition and is often easily managed with excellent outcomes, when treated adequately. Compliance with levothyroxine (LT4) therapy is often compromised because of the need for a daily and lasting schedule. Overt rhabdomyolysis due to under-treatment or non-compliance is a rare occurrence. We report a case of rhabdomyolysis leading to acute kidney injury (AKI) on chronic kidney disease (CKD) requiring hemodialysis (HD) in a 68-year-old Caucasian male due to non-compliance with levothyroxine (LT4) therapy. Our patient 'ran out of levothyroxine' for approximately 4 weeks and developed gradually progressive muscle pain. The diagnosis of severe AKI due to rhabdomyolysis was made based on oliguria, elevated creatinine kinase (CK), and renal failure. Resuming the home dose of LT4 failed to correct CK levels, and there was a progressive decline in renal function. Although increasing doses of LT4 and three cycles of HD improved CK levels, they remained above baseline at the time of discharge. The patient recovered gradually and required HD for 4 weeks. CK levels normalized at 6 weeks. Through this case report, we highlight that non-compliance with LT4 therapy can lead to life-threatening complications such as renal failure and hence the need to educate patients on the significance of compliance with LT4 therapy should be addressed. LEARNING POINTS: Non-compliance to levothyroxine therapy is common and can lead to serious complications, including rhabdomyolysis. Rhabdomyolysis is an uncommon presentation of hypothyroidism and severe rhabdomyolysis can result in renal failure requiring hemodialysis. Rhabdomyolysis associated with hypothyroidism can be further exacerbated by concomitant use of statins.
ABSTRACT
BACKGROUND: Smoking is one of the most important yet modifiable risk factors for incidence, morbidity, recurrence and mortality from Pulmonary Koch's or tuberculosis. This study attempted to demonstrate the association between smoking and recurrence risk of Pulmonary Koch's in Pakistani male population. METHODS: This case control study was conducted at Federal Government Tuberculosis Hospital, Rawalpindi from 2015 to 2016. It included 332 study participants; 166 recurrent cases of Pulmonary Tuberculosis within two years of completion of Anti-tuberculous therapy (ATT) and 166 non-recurrent controls. Smoking status of all study participants was assessed. RESULTS: Amongst 166 cases of recurrence, 75 (63.6%) had continued smoking after ATT compared to 43 (36.4%) controls who continued smoking (p-value 0.00, OR=2.35, 95% CI=1.48 to 3.74, NNH=4.75). Highly statistically significant associations of recurrence were observed with smoking>10 years (p-value 0.00, OR=3.67, CI=1.55-8.71 NNH=4.75) and if ever smoked in life (p-value 0.00, OR=2.05, CI=1.32-3.19, NNH=5.61). Mean duration of smoking in cases (12.37±8.72 years) was statistically different from controls (9.54±7.01 years), with p-value of 0.04. CONCLUSIONS: There is strong association of recurrence of Pulmonary Kochs with continuation of smoking within 2 years of completion of ATT, with ever smoking in life and smoking >10 years in life.
