Mitral valve chord rupture in a pregnant patient with uncontrolled hyperthyroidism.

Summary: Graves' disease can have multiple cardiac manifestations. A rare complication is that of severe mitral regurgitation secondary to mitral valve chordae rupture, due to both compromise of valve integrity by deposition of glycosaminoglycans and the hemodynamic stresses of thyrotoxicosis. Pregnancy, with its related hemodynamic changes, is another setting in which mitral valve chordae rupture has occasionally been documented. We present a unique case of a 36-year-old female with uncontrolled Graves' disease who presented during pregnancy at 13 weeks gestation with atrial flutter and features of congestive heart failure. Echocardiogram found severe mitral regurgitation secondary to a ruptured mitral chord. She was treated conservatively with diuresis and ultimately delivered her baby without complication at 28 weeks when she had preterm premature rupture of membranes. She is currently on methimazole and propranolol and pending definitive management of her Graves' disease. This represents not only a rare cardiac complication in a patient with Graves' disease but also is the first in the literature, to our knowledge, which describes this complication in a pregnant patient with Graves' disease. Learning points: Thyroid disease can have multiple effects on the heart through hemodynamic and structural changes and can result in heart failure, arrhythmias, valvular disease, and pulmonary hypertension. Graves' disease can cause glycosaminoglycan deposition in valvular tissue resulting in fragile leaflets that can rupture with little stress. Pregnancy and thyrotoxicosis have similar hemodynamic consequences with increased cardiac output and reduced systemic vascular resistance. Be vigilant in those with hyperthyroidism with a new murmur or features of acute heart failure, as a ruptured valve chord can result in increased morbidity and mortality if not recognized and addressed quickly.

Tumor-Induced Hypoglycemia: An Unusual Case Report and Review of Literature.

OBJECTIVE: To describe a rare case of pheochromocytoma presenting with hypoglycemia. METHODS: We describe a rare case of pheochromocytoma presenting with a hypoglycemic seizure. Our article includes our differentials, work up, and management. RESULTS: Our patient had non-islet-cell tumor hypoglycemia that was non-insulin mediated, as noted by low insulin levels. His hypoglycemia was likely multifactorial and mediated by different mechanisms. We describe the rare case and review the causes of tumor-induced hypoglycemia. CONCLUSION: Pheochromocytomas can rarely present with hypoglycemia and are associated with a poor prognosis.

Insulin Use and Poor COVID-19 Outcomes among Diabetes Patients: Association Not Necessarily Causation.

Our study looked at the relationship between insulin use and clinical outcomes in COVID-19. A response to our article, written by Dr. Chia Sing Kow and Dr. Syed Shahzad Hasan raised a few questions. They mentioned our use of hemoglobin A1c may be inaccurate as the patients in our study had high rates of CKD or ESRD which could alter the hemoglobin A1c levels. However due to the limitations of our patient population and perhaps in a lot of other sample populations in the real-world setting, it was the most feasible way to represent glucose control.The writers also suggested that the use of metformin, a potential confounder, was also not adjusted for. This should be considered in future research but addition of too many variables in a regression model may lead to less reliability of results for our study.The letter writers also suggested that the results of our paper may lead to misinterpretation by readers and may influence providers to not use insulin therapy for their patients when necessary due to fear of worse outcomes in the setting of COVID-19. We reiterated that it is very important that the data not be misinterpreted, and that nowhere in our paper did we imply or suggest that patients who need insulin therapy to treat their diabetes should not receive proper therapy due to the association we delineated in our paper. Instead, more careful surveillance of patients with advanced diabetes is needed especially when admitted with COVID-19.

Acute hypertensive crisis due to newly diagnosed pheochromocytoma in the ninth decade of life: an unusual presentation.

The patient is an 85-year-old man with multiple comorbidities, including hypertension and coronary artery disease with recent myocardial infarction who underwent cardiac catheterisation. During the procedure, the patient developed profound hypertensive crisis with flash pulmonary oedema, requiring significant intervention for blood pressure (BP) control. His crisis was also marked by wide excursions in his BP. The patient was found to have a large left adrenal mass measuring 9.4×8.7×8.1 cm, with biochemical testing confirming the suspicion of pheochromocytoma. Alpha-blockade was started prior to availability of lab results due to high index of suspicion. Surgical removal, the mainstay of treatment, has yet to transpire as he has no family, and due to his underlying dementia, he was not felt to have capacity for decision-making at the time of diagnosis. The case elucidates the vast presentations of this tumour, the means of diagnosis and the difficulties of treatment.

Insulin Use, Diabetes Control, and Outcomes in Patients with COVID-19.

Background: The novel coronavirus (SARS CoV-2) has caused significant morbidity and mortality in patients with diabetes. However, the effects of diabetes control including insulin use remain uncertain in terms of clinical outcomes of patients with COVID-19.Methods: In this single-center, retrospective observational study, all adult patients admitted to Einstein Medical Center, Philadelphia, from March 1 through April 24, 2020 with a diagnosis of COVID-19 and diabetes were included. Demographic, clinical and laboratory data, insulin dose at home and at the hospital, other anti-hyperglycemic agents use, and outcomes were obtained. Multivariate logistic regression was used to evaluate the factors associated with diabetes control and mortality.Results: Patients who used insulin at home had higher mortality compared to those who did not (35% vs 18% p = .015), this was true even after adjustment for demographics, comorbidities and a1c OR 2.65 95% CI (1.23-5.71) p = .013. However, the mean a1c and the median home requirements of insulin did not significantly differ among patients who died compared to the ones that survived. Patients who died had significantly higher inpatient insulin requirements (highest day insulin requirement recorded in units during hospitalization) 36 (11-86) vs 21 (8-52) p = .043 despite similar baseline a1c and steroid doses received. After adjusting for demographics, comorbidities and a1c, peak insulin requirements remained significantly associated with inpatient mortality OR 1.022 95% CI (1.00-1.04) p = .044.Conclusion: Among diabetic patients infected with COVID-19, insulin therapy at home was significantly independently associated with increased mortality. Peak daily inpatient insulin requirements was also independently associated with increased inpatient mortality.

The relationship between diabetes and clinical outcomes in COVID-19: a single-center retrospective analysis.

AIMS: Coronavirus disease 19 (COVID-19) has become a pandemic. Diabetic patients tend to have poorer outcomes and more severe disease (Kumar et al. in Diabetes Metab Syndr 14(4):535-545, 2020. https://doi.org/10.1016/j.dsx.2020.04.044 ). However, the vast majority of studies are representative of Asian and Caucasian population and fewer represent an African-American population. METHODS: In this single-center, retrospective observational study, we included all adult patients (> 18 years old) admitted to Einstein Medical Center, Philadelphia, with a diagnosis of COVID-19. Patients were classified according to having a known diagnosis of diabetes mellitus. Demographic and clinical data, comorbidities, outcomes and laboratory findings were obtained. RESULTS: Our sample included a total of 355 patients. 70% were African-American, and 47% had diabetes. Patients with diabetes had higher peak inflammatory markers like CRP 184 (111-258) versus 142 (65-229) p = 0.012 and peak LDH 560 (384-758) versus 499 (324-655) p = 0.017. The need for RRT/HD was significantly higher in patients with diabetes (21% vs 11% p = 0.013) as well as the need for vasopressors (28% vs 18% p = 0.023). Only age was found to be an independent predictor of mortality. We found no significant differences in inpatient mortality p = 0.856, need for RRT/HD p = 0.429, need for intubation p = 1.000 and need for vasopressors p = 0.471 in African-Americans with diabetes when compared to non-African-Americans. CONCLUSIONS: Our study demonstrates that patients with COVID-19 and diabetes tend to have more severe disease and poorer clinical outcomes. African-American patients with diabetes did not differ in outcomes or disease severity when compared to non-African-American patients.

An academic community hospital experience using commercially available molecular testing in the management of indeterminate thyroid nodules.

INTRODUCTION: Molecular thyroid testing is increasingly being used to further stratify risk of malignancy in cytologically indeterminate thyroid nodules. We report our experience using three commercially available tests in a community hospital setting. MATERIALS AND METHODS: All molecular test reports (Afirma, ThyroSeqV2, and ThyGENX/ThyraMIR) on thyroid nodules from Einstein Medical Center, Philadelphia, between April 2014 to March 2017 were compared with follow-up surgical results as part of a quality assurance exercise. Slides and records of disparities were reviewed. RESULTS: Ninety-five thyroid nodules with molecular testing were identified with surgical follow up available on 19. No benign Afirma results had surgical follow-up. All 7 suspicious Afirma results had surgery, with 3 being benign on follow-up. Ten ThyroseqV2 tested nodules had follow-up surgery and included 2 papillary carcinomas following a completely negative result and another papillary carcinoma following over expression of the NIS gene reported as likely benign. One case with a TP53 mutation was benign on follow-up total thyroidectomy. Follow-up on 1 NRAS point mutation by ThyGenX/ThyraMIR was confirmed malignant although the microRNA portion of the test was negative. CONCLUSIONS: Quality assurance review refined our utilization practices as we better appreciated the limitations of molecular testing and use relative to other factors in managing indeterminate thyroid nodules.

Neurosarcoidosis-associated central diabetes insipidus masked by adrenal insufficiency.

Central diabetes insipidus (CDI) is an infrequent complication of neurosarcoidosis (NS). Its presentation may be masked by adrenal insufficiency (AI) and uncovered by subsequent steroid replacement. A 45-year-old woman with a history of NS presented 2 weeks after abrupt cessation of prednisone with nausea, vomiting, decreased oral intake and confusion. She was diagnosed with secondary AI and intravenous hydrocortisone was promptly begun. Over the next few days, however, the patient developed severe thirst and polyuria exceeding 6 L of urine per day, accompanied by hypernatraemia and hypo-osmolar urine. She was presumed to have CDI due to NS, and intranasal desmopressin was administered. This eventually normalised her urine output and serum sodium. The patient was discharged improved on intranasal desmopressin and oral prednisone. AI may mask the manifestation of CDI because low serum cortisol impairs renal-free water clearance. Steroid replacement reverses this process and unmasks an underlying CDI.

Methimazole-induced cholestatic jaundice in an elderly hyperthyroid patient.

BACKGROUND: Hyperthyroidism is a common disease in the elderly. Antithyroid medications such as methimazole are one of the few treatment options. CASE SUMMARY: A 76-year-old white woman presented to the clinic with a 1-week history of fatigue, sleepiness, 7-pound weight loss, and tachycardia. Her blood work showed low levels of thyroid-stimulating hormone and high levels of free thyroxine. Due to persistence of her symptoms, she was hospitalized and started on methimazole 10 mg TID. Six weeks after receiving methimazole for the treatment of hyperthyroidism, she had severe jaundice and itching. Results of her liver function tests showed elevation of her alkaline phosphatase and liver transaminase levels, as well as hyperbilirubinemia, formed mainly of the conjugated fraction. Methimazole-induced cholestatic jaundice was diagnosed. Her symptoms gradually improved after discontinuation of the medication, and plasma bilirubin levels were near normal after 8 weeks without methimazole. CONCLUSIONS: We report here a probable association between methimazole use and severe cholestatic jaundice in an elderly hyperthyroid patient. The patient's jaundice was reversed after drug discontinuation.

Bone mineral density screening: assessment of influence on prevention and treatment of osteoporosis.

OBJECTIVE: To assess the effect of bone mineral density (BMD) screening on the decision to initiate preventive or therapeutic measures for osteoporosis. METHODS: We offered low-cost BMD screening by dual-energy x-ray absorptiometry of the lumbar spine and proximal femur in conjunction with National Osteoporosis Week. In an effort to assess whether the availability of the BMD measurements resulted in any medical action by the participants of the screening, we conducted a retrospective telephone survey 9 to 12 months after the screening. RESULTS: In response to a newspaper promotion, 350 subjects underwent BMD screening during a 3- to 4-month period. Of these 332 female and 18 male participants, 83% were Caucasian, 10% were Asian, 5% were Hispanic, and 2% were African American. The mean age was 60 +/- 11 years (range, 29 to 93). Osteoporosis (T-score > or = -2.5) was present in 24% and osteopenia (T-score of -1 to -2.49) in 47% of the subjects. A report was sent to the participant and, if requested, also to a specified physician. Of the 350 participants, 249 (238 women and 11 men) responded to the telephone survey. Of these respondents, 63% had sought medical consultation after the BMD screening. Results of the BMD study led to an increase in calcium intake in 32% of female respondents (48% of those with osteoporosis). After BMD measurement, use of osteoporosis therapy approved by the US Food and Drug Administration increased from 38% to 78% of those with osteoporosis. CONCLUSION: These results suggest that low-cost BMD screening is highly effective in increasing awareness of osteoporosis, prompting medical consultation, and initiating measures for prevention and treatment of osteoporosis.