Autoimmune Thyroiditis with Hypothyroidism Induced by Sugar Substitutes.

The use of sugar substitutes (artificial sweeteners or non-nutritive sweeteners) has increased dramatically in the past few decades. They have been used as a substitute for sucrose (table sugar) in various diet-related disorders. Their excessive use has been linked to hyperphagia and obesity-related disorders. Hashimoto's thyroiditis (chronic autoimmune thyroiditis) is a disease that involves the immune-mediated destruction of the thyroid gland, gradually leading to its failure. Animal studies report that artificial sweeteners affect the immune system. Moreover, animal studies show that sucralose diminishes the thyroid axis activity. We are presenting the case of a 52-year-old female with autoimmune thyroiditis with hypothyroidism (Hashimoto's thyroiditis) induced by an excessive intake of beverages containing non-nutritive sweeteners. She was ruled out for any other autoimmune disorder. The association between Hashimoto's thyroiditis and the excessive consumption of sugar substitutes is shown by the quick return of thyroid stimulating hormone and antibody levels to normal after eliminating the use of sugar substitutes. Thus, it suggests that the sugar substitutes were the culprit in the development of Hashimoto's thyroiditis in our patient.

Adult-onset Still's Disease in a Female Patient with Schizophrenia: A Case Report and Literature Review.

Adult-onset Still's disease (AOSD) is a rare diagnosis. In small percentage of cases, AOSD is associated with other autoimmune diseases including schizophrenia. Despite the lack of sufficient studies, both conditions may share similar autoimmune pathogenic pathways. Herein we describe a 36-year-old woman with the past medical history of schizophrenia who presented with spiking fevers, arthralgia, evanescent rash and pleural chest pain. She reported developing these symptoms a while after poor compliance with her antipsychotic medication. On admission, physical examination was remarkable for high-grade fever, maculopapular rash, oligo arthralgia, hepatomegaly and lymphadenopathy. Laboratory investigation revealed leukocytosis with neutrophilia and markedly elevated ferritin. The patient met four out of four major, and three out of five minor Yamaguchi criteria for AOSD. The patient started on therapy with corticosteroid. Soon after, her symptoms resolved and most of her biochemical markers went back to normal. We review the literature on co-existence of AOSD with other autoimmune diseases, we also discuss that there may be a correlation between ceasing antipsychotic medication (with known immunomodulatory effect) in a schizophrenic patient and triggering an auto-inflammatory process such as AOSD in a susceptible host. In addition, we discussed the possible similar autoimmune pathway of schizophrenia to pathogenesis of AOSD.

Acute Liver Injury Induced by Sitagliptin: Report of Two Cases and Review of Literature.

We present two cases of acute liver injury associated with sitagliptin. The first case was a 58-year-old male with a history of poorly controlled type 2 diabetes mellitus and hyperlipidemia. Sitagliptin was added for better control of diabetes. After initiation of sitagliptin, the patient's serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels increased gradually over a period of six months. The second case was a 44-year-old female with type 2 diabetes mellitus, and she experienced a more than ten-fold elevation in ALT and AST levels after starting sitagliptin therapy. Both patients did not have any history of alcohol abuse, acetaminophen use, or chronic liver disease. In the literature review, the reported magnitude of liver enzyme derangement with sitagliptin is generally mild and transient (two-fold upper limit of normal). We believed that the acute derangement of ALT and AST in our patients was due to sitagliptin since the ALT and AST normalized shortly after sitagliptin was discontinued and remained at baseline after resuming all other medications. Further research is needed to understand the mechanism of dipeptidyl peptidase 4 (DPP-4) inhibitors associated liver injury.

Hyperprolactinemia with Galactorrhea Due to Subclinical Hypothyroidism: A Case Report and Review of Literature.

Hyperprolactinemia is a common finding in primary hypothyroidism, but increased prolactin in the setting of subclinical hypothyroidism (SCH) has been scarcely reported in the literature. This is a rare case of hyperprolactinemia due to SCH that resolved with thyroid hormone replacement therapy. The patient was not on any medications known to cause hyperprolactinemia but she was using isoniazid for her latent tuberculosis. Isoniazid therapy may explain breast pain, but there is no reported relationship between isoniazid use causing subclinical hypothyroidism and hyperprolactinemia. A literature review reveals that few cases of galactorrhea associated with subclinical hypothyroidism have been reported. Similar to the reported cases in the literature, our patient's thyroid stimulating hormone (TSH) and prolactin levels returned to normal with levothyroxine therapy.

Graves' Disease Presenting as Painful Goiter: A Case Report and Review of the Literature.

A painful and tender thyroid gland is a rare phenomenon in Graves' disease. We present a case of 31-years-old Guyanese female who was admitted to the hospital with complaints of neck pain for the past few days. She also reported increase appetite for a few weeks; she did not have palpitations, heat intolerance, or muscle weakness. The presence of hyperthyroidism with elevated TSI suggested that the patient had Graves' disease. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were within normal limit, thus the diagnosis of thyroiditis was effectively ruled out. This is a rare case of a painful and tender thyroid gland in Graves' disease without the evidence of sub-acute thyroiditis.