ABSTRACT
Background/Objective: Cushing syndrome (CS) is a prothrombotic state associated with an increased risk of postoperative venous thrombosis. We aim to present the case of a patient with Cushing disease who underwent pituitary surgery and subsequently developed acute lower extremity deep venous thromboses after anticoagulation was stopped. Case Report: We present the case of a 57-year-old woman who was admitted for intra-abdominal abscesses after a gastric bypass surgery and was found to have evidence of severe CS. Her 24-hour urinary free cortisol level was 898.6 µg/24 h. She was diagnosed with Cushing disease and underwent transsphenoidal resection of a pituitary adenoma, with an appropriate postoperative drop in the cortisol level. She received thromboprophylaxis during hospitalization; however, this was discontinued upon discharge, on postoperative day 9, because she was ambulating. Five days after hospital discharge and 14 days after her surgery, she developed left lower extremity edema and was found to have 4 deep venous thromboses. Discussion: As previously described, thrombotic risk can be elevated for at least 1 month after surgery for CS, and thromboprophylaxis can decrease this risk. Conclusion: This case highlights the need for clear recommendations for the duration of postoperative thromboprophylaxis in patients with CS. Clinicians should consider continuing thromboprophylaxis for at least 1 month after surgery for CS.
ABSTRACT
BACKGROUND: Inpatient falls are a patient safety concern. Limited data exist on the utility of head computed tomography (CT) for inpatient falls. The New Orleans Criteria (NOC) is a validated tool to determine the appropriateness of neuroimaging in the emergency department for falls with minor head injury. This study aimed to evaluate whether the NOC could be applied to inpatient falls. METHODS: This retrospective cohort study assessed 1 year of inpatient falls with injury at 5 inpatient facilities. Records were reviewed for demographic data, fall circumstances, laboratory results, components of the NOC, and head CT results. Cohorts included positive NOC (≥1 NOC finding) and negative NOC. Sensitivity and specificity were calculated for the NOC alone, NOC plus coagulopathy, and NOC or coagulopathy for acute intracranial process. RESULTS: Of 332 inpatient falls with injury, 188 (57%) received a head CT. Of the 250 (75.3%) NOC-positive cases, 159 (63.6%) received a head CT. Of all patients who received a head CT, 7 (2.1%) showed a significant acute intracranial process. The NOC was positive in 6 of the 7 cases (sensitivity 85.7% and specificity 23.8%); the other case had a significant coagulopathy. New Orleans Criteria or coagulopathy had 100% sensitivity and 23.4% specificity. CONCLUSIONS: Our findings show that use of the NOC to evaluate potential intracranial injury in inpatient falls is limited. Adding criteria to the NOC may improve its test characteristics, with a sensitivity of 100% for the NOC or coagulopathy, suggesting potential clinical utility.
ABSTRACT
Graves' disease may lead to hepatic dysfunction. This is due to the direct effect of increased circulation of thyroid hormones. Graves' disease is associated with other autoimmune diseases, including autoimmune hepatitis. We report four cases of a rare occurrence of both Graves' disease and autoimmune hepatitis. Two female patients underwent radioactive iodine ablation for Graves' disease. Both patients were diagnosed with autoimmune hepatitis with liver biopsy after liver enzymes worsened despite stable thyroid function. Both patients received steroid immunosuppression therapy for autoimmune hepatitis. The first patient improved with return of thyroid function and liver enzymes to normal whereas the second patient's liver disease progressed despite treatment and she eventually required liver transplant. A female patient with concomitantly diagnosed Graves' disease and autoimmune hepatitis was initially treated with steroids and anti-thyroid medication. She then underwent radioactive iodine ablation but ultimately required liver transplant. Another female patient received treatment with immunosuppression and anti-thyroid therapy. She eventually underwent radioactive iodine ablation with normalization of thyroid function and liver profile. This case series illustrates the diagnostic challenge to determine the cause of elevated liver enzymes in patients presenting with both Graves' disease and autoimmune hepatitis. A brief review of the literature on its clinical presentation and diagnosis is discussed.
