Pleural effusion due to lymphangiomatosis and the role of sirolimus: A case report.

Introduction: Lymphangiomatosis is a rare abnormal proliferation of lymphatic vessels involving multiple organs like the brain, lung, heart, spleen, liver, and bones. Lymphangiomas constitute 5.6% of all benign tumors in infancy and adulthood. Case presentation: We report a case of a young lady who presented with constitutional symptoms and progressive dyspnea. Her medical history is significant for muco-cutaneous albinism, diffuse hemangiomas of the bone and viscera, and consumptive coagulopathy status post-splenectomy. After initial investigations, she was found to have right-sided pleural effusion. Pleural fluid analysis indicated chylothorax. She had multiple drainages of the pleural fluid done, and afterward, ligation of the right thoracic duct was performed with a trial of sirolimus, which improved her chylothorax. Clinical discussion: Several case reports have reported positive outcomes with sirolimus in the treatment of lymphangiomatosis. However, larger controlled studies are needed to confirm these findings. Conclusion: Sirolimus is promising as a medical treatment for diffuse pulmonary lymphangiomatosis.

Papillary Thyroid Cancer With Pituitary Gland Metastasis: A Unique Encounter.

The pituitary gland is a rare metastatic site, and thyroid cancer (TC) metastasis to the pituitary gland is immensely uncommon. We report the case of a 45-year-old male in whom pituitary metastasis (PM) discovery during the immediate postoperative period complicated the management of papillary thyroid cancer (PTC). His postoperative magnetic resonance imaging (MRI) of the pituitary lesion showed a progression in size with persistent optic nerve compression. The critical location of the pituitary lesion and the rapid progression dictated the treatment course. The pituitary lesion was non-iodine avid, and thus we opted for external beam radiation therapy (EBRT). He received 1,200 centigray (cGy) with Gamma knife radiosurgery with steroid cover. In our case, the aggressive histological and clinical variant of PTC consisted of multiple metastatic sites involving large volume pulmonary, skeletal, and chest wall lesions coupled with crucial macro metastatic pituitary mass. The patient was offered radioactive iodine to treat other iodine avid metastases in the lungs and bones and was also offered EBRT to target skeletal lesions. Systemic treatment with tyrosine kinase inhibitor was also discussed with the patient. Our case encourages clinicians to exercise vigilance and a high index of suspicion for PM when a patient with any pre-existing cancer presents with visual disturbance, cranial nerve deficit, or symptoms suggestive of hormonal deficiency. It also highlights the importance of involving endocrinologists before performing any surgery on the endocrine organs to ascertain the integrity of the endocrine function of the glands.

Antithyroid Drugs in the Management of Graves' Disease: A Friend and Foe.

Graves' disease is an autoimmune condition in which the patient develops autoantibodies that stimulate the thyroid gland, leading to thyrotoxicosis. We report the case of a 29-year-old female who presented one month postpartum with typical symptoms and signs of thyrotoxicosis. Biochemical and radiological investigations confirmed thyrotoxicosis due to Graves' disease. She received methimazole (MMI) treatment, leading to an allergic reaction in the form of a generalized rash on the body precluding its use. We later started the treatment with propylthiouracil, which she initially tolerated well. During her treatment, she became pregnant and delivered a baby girl by cesarean section at 37 weeks of gestation. The baby developed neonatal thyrotoxicosis due to the transplacental transmission of maternal thyrotropin receptor antibodies. Thyrotoxicosis was short-lived, without consequences, and treated with antithyroid drugs. Three months after delivery, thyroid hormone levels rose considerably, requiring higher doses of propylthiouracil, which resulted in severe hepatic dysfunction, and therefore we stopped the therapy. We admitted her to the hospital for rapid correction of thyroid hormones using steroids, supersaturated potassium iodide, and cholestyramine before she underwent a total thyroidectomy. Our case highlights the challenges the patients and clinicians can face while managing Graves' disease. We discuss the role of a multidisciplinary team approach to care and the options available for treatment in such difficult situations.

A Case of Disseminated Herpes Zoster With Polyneuropathy Following the Third Dose of the Pfizer-BioNTech Vaccine.

SARS-CoV-2 pandemic resulted in the fast development of new vaccines, which helped contain the pandemic, but some adverse events started to rise. Recently, post-administration of mRNA-based vaccines, varicella-zoster virus (VZV) reactivation was reported. We report a case of disseminated herpes zoster with polyneuropathy and cerebrospinal fluid (CSF) findings following the Pfizer-BioNTechvaccine. Our observation aims to increase clinicians' awareness of a possible relationship between herpes zoster reactivation and SARS-CoV-2 vaccines.

The short synacthen test: Variations in methodology and protocols in KSA.

Objectives: This study aimed to compare the current Kingdom-wide practice with our prior institutional study on use of the short synacthen test (SST), and to determine whether physician specialty or grade is associated with a tendency toward using a particular protocol. Method: We surveyed clinicians registered with the Saudi Medical Council to determine the different SST protocols used within KSA. Results: We received 162 responses, 66 (41%) from endocrinologists and the remainder from internists. A total of 61 (38%) respondents were consultants, whereas the rest were non-consultant grade. The clinicians indicated metabolic derangements, such as hypotension (78%), hyponatremia (65%), hypoglycemia (59%), and hyperkalemia (54%), as the main reasons for performing the test. Most clinicians used the SST protocol, which measures baseline serum cortisol (90%) and ACTH (78%) on the test day. A total of 75% of the physicians measured both the 30- and 60-minute serum cortisol after ACTH injection. Of these clinicians, 13% reported that the cortisol levels were below the pass threshold at 30 min but reached the pass threshold only at 60 min. The SST was normal 90% of the time when performed. A total of 93% of the clinicians considered a stimulated cortisol level of 550 nmol/L to be the threshold for normal adrenal function. Conclusion: The survey confirms that 60-min serum cortisol should be part of the SST protocol to avoid false-positive results. Moreover, clinicians should consider other causes of these metabolic derangements before requesting a SST, particularly in patients with a low pretest probability.

A Hybrid Virtual Fracture Clinic is Safe and Efficacious in the COVID-19 Era: Stay at Home and Save Lives.

Introduction The coronavirus disease 2019 (COVID-19) pandemic necessitated a change in the manner outpatient fracture clinics are conducted due to the need to reduce footfall in hospitals. While studies regarding virtual fracture clinics have shown these to be useful and effective, they focus exclusively on remote consultations. However, our service was bespoke to the patient - either a face-to-face, a telephone consultation or both, depending on patient need - a 'hybrid virtual fracture clinic' (HVFC). We report patient satisfaction and outcomes with this service from the first wave of the pandemic. Methods We retrospectively interviewed patients who availed of the HVFC service at our institution during the first two weeks of national lockdown in England from March 23 to April 5, 2020. The number and type of consultations, patient vulnerability to COVID-19, and type of management (surgical vs non-surgical) were among the factors taken into consideration. Patient experience was assessed using the Net Promoter Score (NPS), Customer Effort Score (CES), and Customer Satisfaction Score (CSS) on a scale of 0-10. Patient-reported outcomes were assessed using the EuroQol-5D-5L score (including EQ Visual Analogue Scale {EQ-VAS} scoring on a scale of 0-100). Results The mean overall NPS, CES, and CSS for the service were 7.32, 7.24, and 7.49, respectively. The mean self-reported EQ-VAS rating was 77.5. Of 442 consultations, 246 were conducted virtually; 10% were face-to-face, 29% virtual, and 61% were hybrid consultations. The HVFC resulted in a 55.65% reduction in footfall. Statistical analysis showed no significant difference across any outcome measure when compared between hybrid, virtual, and face-to-face consultations. Patients vulnerable to COVID-19 and those who did not require surgery tended to report better overall scores. Conclusion Our study indicates that the HVFC format can reduce patient footfall significantly (>50%) while providing effective and satisfactory outpatient care. There appears to be no difference in patient-reported outcomes between face-to-face consultations and hybrid or virtual consultations. Patients would recommend HVFC to family and friends, found it was easy to use, and reported good satisfaction with the service.