The effect of wet-cupping therapy (hijama) in modulating autoimmune activity of Hashimoto's thyroiditis: A pilot controlled study.

OBJECTIVES: To investigate the possible effects of wet-cupping therapy (hijama) on autoimmune activity and thyroid hormonal profiles of Hashimoto's disease (HD) patients. METHODS: A prospective pilot controlled trial was carried out among adult females following HD at the Endocrinology Clinic of King Abdulaziz University Hospital, Jeddah, Saudi Arabia, from February 2014 until March 2017. A total of 13 patients (intervention group) underwent 3 hijama sessions at 3-week interval with a 6-month follow-up. Blood tests were carried out for both pre- and post-hijama, including: thyroid peroxidase antibody (TPO), thyroglobulin antibody (TG), thyroid stimulating hormone (TSH), thyroxine-4 (T4), and prolactin. Control group included 13 randomly selected HD patients following usual care with 2 consecutive measurements of TPO and TG at 2-3 months interval. RESULTS: Changes in anti-TPO and anti-TG showed a decrease in hijama group versus an increase in control group, and intervention group comparison was statistically significant. On a fixed thyroxine supplement for each patient, significant decrease in levels of anti-TPO, anti-TG, TSH, prolactin, and erythrocyte sedi-mentation rate (ESR) occurred. CONCLUSION: These findings are presumptive to the efficacy of hijama on the pathogenesis of HD in modulating the immune inflammatory process demonstrated by the reduction in ESR, TPO, and TSH levels on a fixed thyroxin supplementation dose, along with patient-reported clinical improvement and positive changes in ultrasound including regaining of gland physiological size, echogenicity, and vascularity.

Childhood nephrolithiasis and nephrocalcinosis caused by metabolic diseases and renal tubulopathy: A retrospective study from 2 tertiary centers.

OBJECTIVES: To study childhood nephrolithiasis and nephrocalcinosis caused by metabolic disorders, distal renal tubular acidosis (dRTA), and familial hypomagnesemia, hypercalciuria, and nephrocalcinosis (FHHNC). METHODS: We retrospectively evaluated 86 children presented over 10 years (2011-2021), with nephrolithiasis (89%) and nephrocalcinosis (11%) caused by metabolic disorders (62%), FHHNC (21%), and dRTA (17%). RESULTS: The mean age at discovery was 72.7 months. The underlying metabolic etiologies included hyperoxaluria (38%), cystinuria (32%), hypercalciuria (24%), and hyperuricosuria (6%). Genetic testing was carried out for 23 patients. Hyperoxaluria was typically treated medically (75%). However, the majority progressed to end-stage kidney disease (ESKD). Most children with cystinuria, hypercalciuria, and hyperuricosuria required medical and surgical intervention. Patients with FHHNC typically presented with nephrocalcinosis. Genetic testing revealed Claudin-16 mutations in 7 children. Patients often progressed to stage II-IV chronic kidney disease (61%) and ESKD (6%). Patients with dRTA typically presented with nephrocalcinosis (80%), as well as poor weight gain and failure to thrive (86%), and medical treatment included sodium bicarbonate and potassium replacement. Despite nephrocalcinosis progression, most patients had normal renal function (53%), although the remaining 47% progressed to chronic kidney disease (none reached ESKD). CONCLUSION: Childhood nephrolithiasis is mainly related to metabolic disorders and is associated with poor renal outcomes. Nephrocalcinosis and nephrolithiasis have poor outcomes when associated with FHHNC, while nephrocalcinosis associated with dRTA has relatively good renal outcomes.

Factors That Influence Mortality in Critically Ill Patients with SARS-CoV-2 Infection: A Multicenter Study in the Kingdom of Saudi Arabia.

BACKGROUND: SARS-CoV-2 infection has a high mortality rate and continues to be a global threat, which warrants the identification of all mortality risk factors in critically ill patients. METHODS: This is a retrospective multicenter cohort study conducted in five hospitals in the Kingdom of Saudi Arabia (KSA). We enrolled patients with confirmed SARS-COV-2 infection admitted to any of the intensive care units from the five hospitals between March 2020 and July 2020, corresponding to the peak of recorded COVID-19 cases in the KSA. RESULTS: In total, 229 critically ill patients with confirmed SARS-CoV-2 infection were included in the study. The presenting symptoms and signs of patients who died during hospitalization were not significantly different from those observed among patients who survived. The baseline comorbidities that were significantly associated with in-hospital mortality were diabetes (62% vs. 48% among patients who died and survived (p = 0.046)), underlying cardiac disease (38% vs. 19% (p = 0.001)), and underlying kidney disease (32% vs. 12% (p < 0.001)). CONCLUSION: In our cohort, the baseline comorbidities that were significantly associated with in-hospital mortality were diabetes, underlying cardiac disease, and underlying kidney disease. Additionally, the factors that independently influenced mortality among critically ill COVID-19 patients were high Activated Partial Thromboplastin Time (aPTT )and international normalization ratio (INR), acidosis, and high ferritin.

Diabetes insipidus following neurosurgery at a university hospital in Western Saudi Arabia.

OBJECTIVES: To review the incidence, spectrum of clinical manifestation, course, risk factors, as well as treatment of diabetes insipidus (DI) following neurosurgery of the pituitary gland. METHODS: The files of 24 patients that underwent neurosurgery for sellar lesions, or tumor near the hypothalamus or pituitary gland at the Department of Neurosurgery, King Abdulaziz University Hospital, Jeddah, Kingdom of Saudi Arabia were retrospectively reviewed between January 2011 to December 2014. A total of 24 patients were studied, and were divided into 2 groups namely; DI and non-DI. Patient characteristics were studied using descriptive statistics. The differences in proportion between the 2 groups were found out using Z-test for proportion in 2 populations. The mean differences in the hormonal abnormalities for the 2 groups were assessed using independent t-test. All statistics are considered statistically significant when p less than 0.05. RESULTS: During hospitalization, 13 (54.2%) out of 24 patient that underwent neurosurgery had manifestations of DI, which was transient in 5 (38.8%) and permanent in 8 (61.2%). The DI subgroup contained higher prevalence of prolactinoma, craniopharyngioma, pre-operative panhypopituitarism, and macroadenoma in MRI imaging and transphenoidal surgery. Furthermore, urine osmolality was significantly lower in the DI group post-operatively with a significant p=0.023. It was recognized that the permanent DI documented more significant numbers than other studies. CONCLUSION: In our study group, it was recognized that permanent DI meant that our patients needed desmopressin for more than 3 months, which documented a more significant number than other studies.

Thyroid function status and its impact on clinical outcome in patients admitted to critical care.

OBJECTIVE: To analyze alterations in thyroid function and the correlation between results of thyroid function test and mortality in medical and surgical intensive care unit (ICU) patients. It also aimed to evaluate the effect of thyroid dysfunction in ICU patients and their need for mechanical ventilation (MV). METHODS: A single-center, prospective, observational study was conducted on patients admitted to medical and surgical ICU between 2013-2014.. Clinical and paraclinical findings (free triiodothyronine, free thyroxine and thyroid stimulating hormone) were documented for all patients. Regression analysis and chi-square were used for death and MV outcome variables. RESULTS: We included 502 patients. Of these, 340 (67.7%) were admitted to the medical ICU. Results of thyroid function tests were normal in 320 (64%) and 162 (32.3%) medical and surgical ICU patients, respectively. Euthyroid sick syndrome (ESS) was documented in 86 patients (17%). Mortality was twice higher among surgical ICU patients with ESS compared to those with normal thyroid function (p=0.085), which is not statistically significant. Based on thyroid function status, no differences in the risk to be mechanically ventilated was found between medical or surgical ICU patients. CONCLUSION: There is a significant association between ESS and mortality in ICU patients. Future studies should determine whether abnormal thyroid function increases the risk for MV in ICU patients.

Brown tumor in a patient with ectopic mediastinal parathyroid adenoma: A case report.

Brown tumors are uncommon focal giant-cell lesions that arise as a direct result of the effect of parathyroid hormone on bone tissue in some patients that have hyperparathyroidism. Primary hyperparathyroidism could be caused by ectopic mediastinal parathyroid adenomas. The occurrence of lesions is explainable on embryologic basis. We present a 55-year-old Saudi woman with a rare case of brown tumor of the maxilla due to ectopic mediastinal parathyroid adenoma.

Severe rhabdomyolysis and acute renal failure secondary to use of simvastatin in undiagnosed hypothyroidism.

A 52-year-old Indian woman with underlying diabetes mellitus and hyperlipidemia, presented with generalized musculoskeletal pain and oliguria for three days. The patient was taking 80 mg of simvastatin initiated 20 days earlier after cardiac catheterization for an inferior myocardial infarction. Laboratory investigations revealed the following serum levels: creatine kinase 81,620 U/L, aspartate aminotransferase 2497 U/L, alanine aminotransferase 1304 U/L, blood urea nitrogen 21.7 mmol/L, creatinine 447 micromol/L, Free T4 12.6 pmol/L, and thyroid stimulating hormone (TSH) 22.7 microIU/L. Simvastatin was discontinued and the patient received forced alkaline diuresis. Her hypothyroidism was treated with thyroxin, which was continued upon discharge, and her renal function recovered within two months. This case report discusses the incidence of rhabdomyolysis in a patient with primary hypothyroidism receiving large doses of simvastatin.

Subacute thyroiditis in Western Saudi Arabia.

OBJECTIVES: The aim of this study is to assess the clinical presentation of 23 patients with subacute thyroiditis (SAT) and the diagnostic value of radionuclear scan. METHODS: This is a cohort study, which consists of 23 patients with a suspected diagnosis of subacute thyroiditis. The study was carried out in the Endocrinology Clinic, King Abdul-Aziz University Hospital, Jeddah, Kingdom of Saudi Arabia between July 2002 and July 2004. Medical charts including age, gender, clinical presentation, systemic symptoms and clinical examination of the thyroid gland were reviewed. Laboratory data included white blood count and its differential count, erythrocyte sedimentation rate (ESR), thyroid function test and thyroid antibodies. The radionuclear scan results were also noted. The mode of therapy provided to patients and the outcome of the treatment during a follow up period of 2 years was reported. RESULTS: Twenty-three adult patients with subacute thyroiditis (15 females and 8 males with a female to male ratio of 1.9:1) were reviewed over a 2-year period. The mean age was 35.8+/-9.2 years. Eighteen patients (78%) had an upper respiratory tract infection at the initial clinical presentation. Twenty patients (87%) visited an Ear, Nose and Throat specialist for sore throat and abnormal sensation in the throat at least 2 weeks before presentation to the endocrinologist. Two patients were admitted to a medical unit with a diagnosis of fever of unknown origin for 4 weeks. All patients had an elevated free thyroxine (35.7+/-19.8 pmol/L) and suppressed thyroid stimulating hormone (TSH) (0.043+/-0.065 IU). The radionuclear san showed either no uptake at all in 12 patients or minimal uptake in 11 patients (0.32+/-0.55%). Eight patients (35%) received prednisolone therapy alone with an average dose of 30-40 mg daily for 7-8 days; 7 patients (30%) were treated with non-steroidal anti-inflammatory drugs (NSAIDs) only. Eight (35%) patients were treated with both NSAIDs and corticosteroids. Hypothyroidism, with elevated TSH, was observed in 6 (26%) of our patients with positive thyroid antibodies during the first 6 months of follow up. There were no reported cases of recurrent or permanent hypothyroidism in our cohort study. CONCLUSION: Subacute thyroiditis is an uncommon disease that should be considered in the differential diagnosis of acute anterior neck pain, sore throat and fever especially in patients who do not respond to treatment. In the clinical setting, radioiodine uptake can help exclude other diseases, confirm the diagnosis and expedite the initiation of appropriate therapy to relieve symptoms.

Multinodular goiter management in Western Saudi Arabia.

OBJECTIVE: The aim of this study was to provide epidemiological data and summarize the different modalities of management of multinodular goiters (MNG) in the Western Province of Saudi Arabia (KSA). METHODS: A total of 135 patients had MNG, which were diagnosed by ultrasonography at King Abdul-Aziz University Hospital in Jeddah, KSA between January 2003 and June 2004. The data collected includes the age, gender, physical examination of the thyroid gland (trifluorothymidine, free thyroxine, free triiodothyronine, thyroid stimulating hormone), ultrasonographic findings and Tc99 radioiodine nuclear scan of the thyroid gland, fine needle aspiration (FNA) of the gland and antithyroid antibodies. The study group was divided according to the thyroid status: nontoxic euthyroid MNG, hypothyroid MNG and toxic hyperthyroid MNG. The management of MNGs according to the patients' clinical presentations and thyroid status was reviewed. RESULTS: The mean age was 39 +/- 12.66 years with a range of 10-79 years. Forty-two patients (31%), with no history of thyroid cancer, had ultrasoundguided FNA; 41 (97.6%) of the FNAs were benign. One FNA (2.3%) was positive for papillary carcinoma in a 56-year-old female patient. Thyroid antibodies (anti-microsomal antibodies and anti-thymoglobulin antibodies) were measured in 50 patients (37%). Thirty-one (62%) were positive, 11 (35%) of which were positive in patients with documented hypothyroidism. All patients with hypothyroidism were treated with levothyroxine; however, only 25.6% with euthyroid MNG were treated with suppressive doses of levothyroxine. Twelve patients (44.4%) with toxic MNG were treated with antithyroid medications. Radioiodine therapy was not given to any patient with nontoxic MNG; however, 48% of those with hyperthyroid MNG received radioactive iodine treatment. Surgery was carried out in 25.6% of patients with euthyroid nontoxic MNG, and in 11 patients with toxic MNG. Nearly half of those with nontoxic MNG (46.5%) and 14.8% of those with a subclinical hyperthyroid MNG refrained from any therapy. They were followed-up by their clinician in the outpatient clinic. CONCLUSION: Serum thyroid stimulating hormone levels, ultrasound and fine needle biopsy were the cornerstones of the diagnostic evaluation of patients with MNG. Review of the management of these patients was comparable to that found in the literature. The treatment strategy was similar to the recommendations by the American Thyroid Society; however, radioactive iodine treatment was not used as a treatment for patients with nontoxic goiters.

Pattern of thyroid malignancy at a University Hospital in Western Saudi Arabia.

OBJECTIVE: The aim is to study the incidence of thyroid cancer in surgically treated nodular thyroid disease, clinicopathological characteristics and treatment results. METHODS: A retrospective review of 45 patients with thyroid malignancy at King Abdul-Aziz University Hospital, Jeddah, Kingdom of Saudi Arabia during a 3-years period between January 2000 through to December 2003 was carried out. Analysis of clinicopathologic characteristics, age correlation to different risk factors, outcome of surgery and radioiodine treatment. RESULTS: A total of 120 thyroidectomies were performed during the 3-years period, January 2000 through to December 2003 at King Abdul-Aziz University Hospital. Forty-five (37.5%) patients had histopathology confirmed diagnosis of thyroid cancer. Eighty-two point two percent cases of papillary carcinoma, 4.4% follicular type and 6.7% anaplastic and medullary carcinoma of thyroid. Mean age was 40.5 +/- 14.8 years. Male preponderance was seen in this study with males: female's ratio is 1.1:1. Nodular goiter was the most frequent presentation, observed in 30 (66.7%) cases. Fine needle aspiration cytology was suggestive of malignancy in 76% of cases. Ninety-seven patients with papillary carcinoma received ablative dose of radioiodine with average dose of 100-200 mCi. One female patient with follicular carcinoma of thyroid with bone, lung, and brain metastases received 4 doses of radioiodine with total dose of 800 mCi. Mortality rate was (2.2%), one patient died of complication of invasive anaplastic carcinoma with invasion of the trachea. CONCLUSION: There is a lot of controversy regarding thyroid malignancy investigations and management. We recommend that thyroid cancer patients should be treated by a team of endocrinologist, pathologist, experience thyroid surgeon, nuclear medicine and external radiotherapy physician to achieve an optimum care and good prognosis.

Bacteremia and septicemia in diabetic patients in Western Saudi Arabia.

OBJECTIVE: The present study aims to define the pattern of bacteremia with clinical sepsis in diabetic patients at King Abdul-Aziz University Hospital (KAUH), Jeddah, Kingdom of Saudi Arabia (KSA), in relation to the type of infection, microbial pattern, source, complication, outcome, and the risk factors associated with high mortality. METHODS: Retrospective study of adult diabetic patients with bacteremia and septicemia admitted to KAUH during a 2 years period between January 2000 through to December 2002 was carried out. RESULTS: A total of 4850 blood culture were submitted to the Microbiology Laboratory of KAUH over a 2 years period. Two hundred and ninety (6%) cases had positive blood cultures, 70 were diabetic patients with an incidence rate of 24% with p-value of 0.043 which is statically significant. Urinary tract infection was the most common source of bacteremia in our study group with Escherichia coli as the most frequent organism in 62%. Mortality rate was 44%. Old age was an important risk factors for high mortality with p-value 0.011, which is statically significant. Other risk factors included comorbidity associated with diabetes, septic shock, mechanical ventilation and disseminated intravascular coagulation. CONCLUSION: Increase age was one of the important risk factors for high mortality rate in our study group. Good empiric antibiotics coverage should be instituted early in high risk groups.

Tender neck in a diabetic patient.

A 45-year-old Indian patient with a history of type 2 diabetes mellitus presented with history of pain in the left side of the neck associated with sore throat of one month duration. The diagnosis of subacute granulomatous thyroiditis (de Quervains thyroiditis) was made which was confirmed radiologically by depressed radioactive iodine uptake. The patient showed marked clinical response and improvement within 24 hours on anti-inflammatory drugs and corticosteroid.

Clinical pattern of systemic lupus erythematosus in Western Saudi Arabia.

OBJECTIVE: The aim of this study is to demonstrate the clinical laboratory, treatment and course of systemic lupus erythematosus (SLE). METHODS: A total of 65 patients with positive double strand antibodies were collected at the Immunology Laboratory of King Abdul-Aziz University Hospital, Jeddah, Kingdom of Saudi Arabia over a 2 year period between January 2000 and December 2001. The data included personal data, clinical manifestations, laboratory, results, and different modalities of treatment and outcome of treatment. Group results were presented as median +/- standard deviation or as a percentage. RESULTS: Sixty-five patients with SLE were included in the study. The female to male ratio was 5.5:1. Median age of 23+/-11.33 years. Seventy percent had a multiple system involvement, 60% presented with arthralgia or arthritis and 55.4% had lupus nephrites, proved by kidney biopsy in 22 patients. Most were treated by intermittent cycolphoamide and steroids with an excellent outcome. Laboratory results and modalities of treatment were similar to previous results. Male SLE is more common in our study group with serious organ damage. Our mortality rate was 3% only. CONCLUSION: Systemic lupus erythematosus presentation is similar to pervious studies and it is more common in male. Lupus nephritis is a common prevention with excellent outcome.

The spectrum of tuberculosis among patients of the King Abdul Aziz Unveristy Hospital, Jeddah, Saudi Arabia.

A retrospective study, reviewing the medical records of 157 patients with a final diagnosis of tuberculosis on discharge, was conducted at King Abdul Aziz University Hospital during the period July 1999 to July 2001. The data included demographic characteristics, the spectrum of clinical presentations, diagnostic methods, and the outcome of treatment. A total of 157 patients were admitted with tuberculosis; their median age was 33(+/- 15.33) years. Fifty-seven (36%) were Saudis and 100 (64%) were non-Saudis. Pulmonary tuberculosis and pleural effusion were the commonest presentations (37.6%). Diagnosis was confirmed in most cases by either a positive sputum smear for AFB or by pleural biopsy; in five patients the diagnosis was made on clinical grounds and pleural fluid analysis. There was a wide spectrum of extra-pulmonary tuberculosis, diagnosed histologically except in five cases, in which treatment was started empirically based on high clinical suspicion and a strongly positive tuberculin test.

Precipitating factors for diabetic ketoacidosis.

OBJECTIVE: The aim of this study is to identify the precipitating factors from a medical and social point of view, in addition to discussing some clinical and laboratory aspects of diabetic ketoacidosis. METHODS: Sixty-eight patients were admitted to King Abdulaziz University Hospital, Jeddah, Kingdom of Saudi Arabia, over a 2 year period, (April 1999 through to April 2001). Diagnosis of diabetic ketoacidosis was based on: clinical features, serum sugar >12 mmol/L with ketonuria, bicarbonate and base deficit. RESULTS: The mean age was 22.5 years (0.5-87) years with a male to female ratio of 1.4:1. Poor compliance to continue the treatment and infection were the most common precipitating factors being responsible for 54.4% and 28% cases. A low mortality rate of 2.9% in our study compared favorably with other studies, which contributed to a high level of medical care in King Abdulaziz University Hospital. CONCLUSION: Diabetic ketoacidosis is a fatal complication among our diabetic patients. Implementing a patient education program to increase awareness of the disease is the most important step in the prevention of this complication. The authorities should ensure availability of insulin to all patients, either free or at lower prices. The role of cultured and socioeconomic factors in aggravating or precipitating diabetic ketoacidosis should always be considered and where possible, eliminated

Profile of Diabetic Patients with End-stage Renal Failure Requiring Dialysis Treatment at the King Abdulaziz University Hospital, Jeddah.

The aim of this study was to know the characteristics and risk factors of 13 diabetic patients (8 males and 5 females) undergoing chronic hemodialysis (HD) at the King Abdulaziz University Hospital in Jeddah during the last one and half years. The 13 diabetic patients who were included in the study constituted 31% of the total patients on HD. The median age was 50.7 year (33-60 years) with M: F ratio of 1.6:1, and Saudi to non-Saudi ratio of 1:1.8. The mean duration of diabetes mellitus (DM) was 12.15 year (3-28 years). Almost half of these patients required HD within 10 years of diagnosis of diabetes. The mean age at starting HD was 46.9 year (33-59). All patients were hypertensive, and 46% were hyperlipidemic. History of smoking was present in 38.5% (5 patients, all men). Complications of diabetes were documented in almost all patients, proliferative retinopathy in 53.8%, bilateral cataract in 15.4%, while one patient had total blindness. There was clinical evidence of peripheral neuropathy and ischaemic heart disease in 30.4% of patients, whereas stroke and gangrenous foot were each seen in 7.7% of patients. Our brief report confirms that DM contributes significantly to end stage renal disease. This could be attributed to poor glycemic control, inadequate treatment of hypertension, high smoking rate and inadequate screening for micro-albuminuria.