A case report of thyroid-associated Orbitopathy with elevated TPO antibodies.

BACKGROUND: Thyroid associated orbitopathy (TAO) is defined as an immune mediated inflammatory process affecting the extraocular muscles, connective and adipose tissue of uncertain etiopathogenesis. TAO are classically described in Grave's disease (GD) however it may occur in euthyroid and hypothyroid patients. Those patients usually test positive for Thyroid Stimulating Hormone receptor antibodies (TRAb). For instance, only few cases of severe Hashimoto's thyroiditis (HT) associated orbitopathy with negative TRAb are reported to date. CASE PRESENTATION: Herewith we report a rare case of a middle-aged female who presented with bilateral progressive upper and lower palpebral edema and a unilateral marked proptosis associated with asthenia, headache and decrease in visual acuity. Biological investigation was notable for high levels of anti-thyroid peroxidase antibodies (Anti-TPO) in an otherwise euthyroid patient with negative TRAb. Orbital Magnetic resonance imaging revealed edema of the extraocular muscles and inflammation of periorbital soft tissue. The patient received a treatment with intravenous methylprednisolone followed by oral treatment with prednisone. This regimen was both effective and safe with minimal metabolic side effects in our patient. CONCLUSION: Minor ocular manifestations of HT are common; however, severe sight threatening ophtalmopathy in the absence of TRAb is rare. Multiple differential diagnosis should be considered and investigated before diagnosing this rare entity. Management of similar cases is currently based on reports and no clear guidelines have been elaborated, corticosteroids is the mainstream of treatment with a potential benefit of selenium supplementation in mild to moderate cases.

Infected diabetic ulcers, when to amputate.

INTRODUCTION: In 2030 diabetes will cause one amputation every 20 seconds. Currently 10 to 20% of all diabetic patients develop infected foot ulcers that recur 40% of the time within one year, even when adequately treated by antibiotics, angioplasty or bypass. Therefore, factors other than infection and peripheral artery disease must be incriminated in wound healing in diabetic patients. The identification of those factors is the subject of our study. METHODOLOGY: A retrospective study done at CHU-NDS (Centre Hospitalier Notre Dame De Secours) included all patients with infected diabetic ulcers between 2012 and 2017. Age was recorded as well as: gender, HbA1c (Hemoglobin A1c), coronary heart disease, antihypertension treatment, creatinine, CRP (C reactive protein), ejection fraction, total cholesterol level and previous amputations. All our patients were followed by an infectious disease specialist, an orthopedist and a vascular surgeon. RESULTS: 139 diabetic ulcers in total were recorded; 83 were infected and 36 underwent amputation (25.9%). Amongst the amputated patients, 25 were males, 22 were > 65YO, 14 had HbA1c > 8,31 had CAD, 23 had previous amputations, 25 had CRP > 80, 14 had an EF < 50% and 17 were treated by dihydropyridine. CONCLUSIONS: We concluded that HbA1c > 8%, coronary heart disease, ejection fraction < 50%, CRP above 80 mg/L, as well as history of previous amputations were risk factors for amputation. Moreover, patients treated with dihydropyridine calcium channel blockers showed less ulcer prevalence and less amputation procedures.

Brucella endocarditis: diagnostic challenges.

INTRODUCTION: Brucellosis is a multisystemic infectious disease, which can manifest as endocarditis. Diagnosis can be challenging. CASE PRESENTATION: An 80-year-old male patient presented with fever 38.5 °C, cough and progressive shortness of breath of 14 days. History of Brucellosis 18 months earlier inadequately treated. Physical examination showed a mid-frequency mitral and aortic murmur. Brucella serologies and blood cultures were positive. He was discharged on Doxycycline and Rifampicin for 3 months and was lost to follow up. Four months later, he presented for recurrent fever. Physical examination showed a radiating heart murmur. Blood cultures were negative; however, blocking antibodies were 1/2560. Echocardiography showed calcified aortic stenosis. TEE showed an abscess formation at the level of the non-coronary cusp. Ceftriaxone 3g IV q24h, gentamicin 80mg IV q8h, doxycycline 100mg po q12h and trimethoprim-sulfamethoxazole 160/800 mg po q12h were initiated (shortage of rifampicin). Aortic bio-prosthesis was successfully inserted, one week after initiating antibiotics. Intraoperative cultures were negative. He was discharged 18 days following surgery on doxycycline 100 mg po q12h, and rifampicin 900mg po q24h and ciprofloxacin 500mg po q 12h for 3 more months, with twice a month follow up. DISCUSSION: Endocarditis is one of the most lethal complication of Brucellosis. Early diagnosis and effective medical and surgical management are essential.