Hypothyroidism associated with therapy for multi-drug-resistant tuberculosis in Australia.

BACKGROUND: Reports from resource-poor countries have associated thionamide- and para-aminosalicylate sodium (PAS)-based treatment of multi-drug-resistant tuberculosis (MDR-TB) with the development of hypothyroidism. AIM: To identify predictors and assess the cumulative proportions of hypothyroidism in patients treated for MDR-TB with these agents in Australia. METHODS: Retrospective multicentre study of MDR-TB patients from five academic centres covering tuberculosis (TB) services in Victoria, Australia. Patients were identified using each centre's pharmacy department and cross checked with the Victorian Tuberculosis Program. Hypothyroidism was categorised as subclinical if the thyroid-stimulating hormone was elevated and as overt if free thyroxine (fT4) was additionally reduced on two separate occasions. Our main outcome measured was the cumulative proportion of hypothyroidism (at 5 years from treatment initiation). RESULTS: Of the 29 cases available for analysis, the cumulative proportion of hypothyroidism at 5 years was 37% (95% confidence interval (CI): 0-57.8%). Eight of the nine affected cases developed hypothyroidism within the first 12 months of treatment. Hypothyroidism was marginally (P = 0.06) associated with higher prothionamide/PAS dosing and was reversible with cessation of the anti-tuberculosis medication. CONCLUSIONS: Prothionamide/PAS treatment-associated hypothyroidism is common in MDR-TB patients in Australia, emphasising the importance of regular thyroid function monitoring during this treatment. Thyroid hormone replacement, if initiated, may not need to be continued after MDR-TB treatment is completed.

Insulinoma presenting with post-prandial hypoglycaemia following fundoplication.

Insulinomas are rare neuroendocrine tumours that classically present with fasting hypoglycaemia. This case report discusses an uncommon and challenging case of insulinoma soon after upper gastrointestinal surgery. A 63-year-old man presented with 6 months of post-prandial hypoglycaemia beginning after a laparoscopic revision of Toupet fundoplication. Hyperinsulinaemic hypoglycaemia was confirmed during a spontaneous episode and in a mixed-meal test. Localisation studies including magnetic resonance imaging (MRI), endoscopic ultrasound (EUS) and gallium dotatate positron emission tomography (68Ga Dotatate PET) were consistent with a small insulinoma in the mid-body of the pancreas. The lesion was excised and histopathology was confirmed a localised well-differentiated neuroendocrine pancreatic neoplasm. There have been no significant episodes of hypoglycaemia since. This case highlights several key points. Insulinoma should be sought in proven post-prandial hyperinsulinaemic hypoglycaemia - even in the absence of fasting hypoglycaemia. The use of nuclear imaging targeting somatostatin and GLP1 receptors has improved accuracy of localisation. Despite these advances, accurate surgical resection can remain challenging. LEARNING POINTS: Hypoglycaemia is defined by Whipple's triad and can be provoked by fasting or mixed-meal tests.Although uncommon, insulinomas can present with post-prandial hypoglycaemia.In hypoglycaemia following gastrointestinal surgery (i.e. bariatric surgery or less commonly Nissen fundoplication) dumping syndrome or non-insulinoma pancreatogenous hypoglycaemia syndrome (NIPHS) should be considered.Improved imaging techniques including MRI, endoscopic ultrasound and functional nuclear medicine scans aid localisation of insulinomas.Despite advances in imaging and surgical techniques, accurate resection of insulinomas remains challenging.

The use of 8-cm 22G Seldinger catheters for intravenous access in children with cystic fibrosis.

PURPOSE: Long intravenous catheters are an effective and economical choice of vascular access for intravenous antibiotic therapy in children with cystic fibrosis (CF). This prospective audit assesses the use of Vygon Leaderflex 22G × 8 cm catheters in an Australian tertiary centre. Key outcomes included catheter lifespan, ability to complete antibiotic therapy and complication rates. METHODS: All paediatric patients admitted with infective exacerbations of CF lung disease for 18 months between 2012 and 2013 were prospectively included. Data were analysed using t-tests and Fisher exact test. RESULTS: A total of 40 successful catheter insertions for 20 patients during 32 admissions were identified. The mean duration of the catheters was 10.08 days (median 9.5, SD=5.0). Of the 32 admissions, antibiotic therapy was completed with long catheters in 78% of cases (n=25) and with a single catheter in 48% (n=19). Rates of local complications were high, but there were no serious adverse outcomes. CONCLUSION: Although limited by a small sample size, the results from this study are promising and suggest that 8 cm long catheters are a safe, effective and economical alternative to peripherally inserted central catheters (PICCs) in treating pulmonary exacerbations in children with CF.