Complete recovery after glucocorticoid replacement therapy in a case of primary adrenal insufficiency caused by adrenal tuberculosis infection.

Summary: Symptoms of primary adrenal insufficiency (PAI) are commonly nonspecific, causing the disease to be misdiagnosed or often delayed, and patients may present to the hospital with a life-threatening crisis. Previous case reports have documented that patients in this condition often require lifelong glucocorticoid replacement therapy. This study aimed to present a noteworthy outcome of PAI caused by adrenal tuberculosis infection, demonstrating complete recovery after six months of glucocorticoid replacement therapy. A 38-year-old Indonesian man presented to the endocrinology clinic in a tertiary hospital with a chief complaint of epigastric pain. The patient experienced nausea, vomiting, loss of consciousness, weight loss, excessive sweat, decreased appetite, weakness, and dizziness in the past 2 weeks. Laboratory examinations revealed hyponatremia, elevated adrenocorticotropic hormone, and suppressed morning plasma cortisol level. A non-contrast-enhanced abdominal MRI showed unilateral right-side adrenal enlargement and calcification. The patient's Mantoux test was positive. Corticosteroids and anti-tuberculosis therapy were administered. After 6 months, hydrocortisone was discontinued due to the patient's good clinical condition and normal morning plasma cortisol levels. After a 1-year follow-up, the patient remained asymptomatic with normal cortisol levels. We hypothesized several reasons for this unique outcome: (i) the patient was relatively young compared to previous cases, suggesting an adequate immune system may play a role; (ii) despite a 1-month delay in diagnosis and treatment, the absence of skin hyperpigmentation suggested an acute presentation, potentially contributing to the favorable outcome; and (iii) the absence of comorbidities potentially positively impacted the patient's outcome. Learning points: Symptoms of adrenal insufficiency are often nonspecific and may only become apparent once significant damage has occurred to the adrenal gland. Clinical adjustments and a comprehensive understanding of epidemiological knowledge are necessary for diagnosing patients with endocrine diseases in limited-resource settings. Complete recovery in primary adrenal insufficiency caused by tuberculosis infection might be due to younger age, acute presentation, and absence of comorbidities.

A case report of a successful alternative regiment therapy for toxoplasma encephalitis in AIDS patients.

Introduction: AIDS patients are more susceptible to opportunistic diseases, such as toxoplasma encephalitis, because of weakened immune systems. Toxoplasma encephalitis manifests as a severe neurological crisis in HIV patients. The standard initial treatments are sulfadiazine and pyrimethamine. This case presents an HIV patient treated with an alternative regimen for toxoplasma encephalitis. Case description: A young Acehnese man, 32 years old, arrived at the emergency unit after complaining of a general seizure 2 hours before arrival. He has a history of a two-week fever and white patches on his tongue and oral cavity. The result of the HIV test was positive, and after a thorough examination, he was diagnosed with toxoplasma encephalitis. The patient was given cotrimoxazole 960 mg twice daily and clindamycin 600 mg four times daily as an alternative treatment. Clinical improvement was reported after six weeks of therapy. Conclusion: A case of toxoplasma encephalitis was reported. The first-line treatment for toxoplasma encephalitis is pyrimethamine and sulfadiazine; however, the patient was treated with cotrimoxazole and clindamycin as an alternative treatment. Clinical improvement was used to assess the success of therapy. Cotrimoxazole and clindamycin can be utilized as alternative regiment therapy if the first-line treatment option is unavailable.

Current Insights into Cellular Determinants of Peritoneal Fibrosis in Peritoneal Dialysis: A Narrative Review.

Peritoneal fibrosis is the final process of progressive changes in the peritoneal membrane due to chronic inflammation and infection. It is one of the main causes of discontinuation of peritoneal dialysis (PD), apart from peritonitis and cardiovascular complications. Over time, morphological changes occur in the peritoneal membranes of patients who use PD. Of those are mesothelial-to-mesenchymal transition (MMT), neoangiogenesis, sub-mesothelial fibrosis, and hyalinizing vasculopathy. Several key molecules are involved in the complex pathophysiology of peritoneal fibrosis, including advanced glycosylation end products (AGEs), transforming growth factor beta (TGF-ß), and vascular endothelial growth factor (VEGF). This narrative review will first discuss the physiology of the peritoneum and PD. Next, the multifaceted pathophysiology of peritoneal fibrosis, including the effects of hyperglycemia and diabetes mellitus on the peritoneal membrane, and the promising biomarkers of peritoneal fibrosis will be reviewed. Finally, the current and future management of peritoneal fibrosis will be discussed, including the potential benefits of new-generation glucose-lowering medications to prevent or slow down the progression of peritoneal fibrosis.

Complexity of diagnosis and management of a giant thyroid nodule: A case report and a concise literature.

It is crucial for doctors to decide whether a thyroid nodule is benign or malignant when a patient presents with one, as it will significantly impact how the patient is managed in the future. However, it is not as straightforward to determine between the two; even a physical examination, thyroid function test, ultrasonography, and biopsy have been well performed. It can be more stressful if a patient has an increased risk of malignancy, such as age (below 20- and above 60-year-old), solid nodule, rapid growth, hoarseness, lymphadenopathy, and microcalcifications on the ultrasonography. The aim of this case was to present the management of a giant thyroid nodule with malignancy presentation and a benign biopsy finding. A 41-year-old male complained of a palpable neck mass, hoarseness, and dysphagia. The thyroid function test was normal. Ultrasonography revealed suspicion of malignancy with category 4 of American College of Radiology-Thyroid Imaging Reporting and Data System (ACR-TIRADS). The biopsy revealed follicular neoplasm, and was classified as Bethesda IV. The patient underwent a total thyroidectomy due to the large tumor size and symptoms. Histopathological findings post-surgery revealed a follicular thyroid adenoma. This case highlights a complex diagnosis and management of follicular thyroid neoplasm due to their potential for both benign and malignant. Comprehensive pre- and post-operative care is essential to determine the nature of nodules. Post-operative follow-up care might improve the patient's outcome and prevent complications.

Normal intellectual ability and hyperprolactinemia as unique clinical manifestations of congenital hypothyroidism: A case report and review of hypotheses.

Congenital hypothyroidism is the deficiency of thyroid hormone in infants and hyperprolactinemia is frequently observed. Previously reported cases typically involve intellectual disability, highlighting this particular unique case report to the first reported patient demonstrating normal intellectual ability despite experiencing growth and gonad dysfunction. This study aims to present a case and review medical hypotheses related to the patient's condition. A 19-year-old female presented with a chief complaint of irregular menstruation for up to 40 days or not occurring at all. The patient experienced the first menstruation at the age of 16 years old. The patient's height was 133 cm, body weight 40 kg, and body mass index 22.61 kg/m2; other family members were normal. Physical examination showed no abnormalities, and laboratory examination showed suppressed serum free T4 (FT4) level (6.41 pmol/L), elevated thyroid stimulating hormone (TSH) level (333.700 µIU/mL), and elevated prolactin hormone level (32.03 ng/mL). Ultrasound of the thyroid gland found hypoplasia of the left and right thyroid glands. The patient was a college student enrolled in a public national university and had never complained about academic performance throughout the patient's education. The patient was diagnosed with congenital hypothyroidism and hyperprolactinemia. The patient was administered up to 100 µg daily of oral levothyroxine, which improved the patient's menstrual cycles. The patient's delayed diagnosis may be attributed to central congenital hypothyroidism being underdiagnosed. We hypothesized that thyroid-releasing hormone receptor (TRHR) gene mutation might contribute to the underlying cause of hyperprolactinemia and normal intellectual ability of the patient. Further study on the significance of TRHR gene mutations in congenital hypothyroidism is required to improve diagnosis and treatment.

Co-incidence of COVID-19 and hepatocellular carcinoma during pregnancy: Double punches to disease severity and mortality?

Hepatocellular carcinoma (HCC), a considerable leading cause of cancer-related deaths worldwide, is the most common primary liver cancer with poor prognosis and outcome. Many advances in prevention, screening, and new technologies in diagnostics and therapy have been achieved, but its incidence and mortality remain increasing. Co-infection of another viral disease in HCC patients with pregnancy might exacerbate the condition and double the mortality rate. The aim of this case report was to describe the co-infection of coronavirus disease 2019 (COVID-19) in an HCC patient during pregnancy. A 26-year-old woman with 16-17 weeks of gestation was admitted to Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia with shortness of breath. The patient also reported that the abdomen expanded rapidly in the last three weeks, followed by severe pain and collateral vein appearance. Laboratory findings revealed anemia, leukocytosis, HBsAg reactive, hypoalbuminemia, hyperbilirubinemia, elevated liver enzymes, increased alpha-fetoprotein (AFP), and cancer antigen 125 (CA-125). Ultrasonography indicated gestation with a single fetus, an enlarged liver with a 9.9 × 9.4 cm nodule, and massive ascites. The patient was also RT-PCR-confirmed COVID-19. On day 8 of hospitalization, the patient suddenly reported severe abdominal pain. Ultrasonography revealed fetal distress immediately followed by fetal death. Adequate management of cancer pain, continuous evacuation of ascites, and other supportive care could not save the patient who died on the day 17 of hospitalization. In this case, we found no proof that the patient experienced cirrhosis prior to HCC. Pregnancy through hormonal alteration is thought to be the aggravating factor that accelerates the progression of pre-existing liver disease into carcinoma and infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) worsened the outcome in this patient.

Comparative analysis of accuracy between fine-needle aspiration biopsy and postoperative histopathology for detecting large thyroid nodules: A retrospective observational study.

To avoid unnecessary surgeries, ultrasound-guided fine-needle aspiration biopsy (FNAB) is an effective and reliable procedure for the preoperative evaluation of thyroid nodules. However, there have been only a limited number of studies exploring the ability of preoperative FNAB to distinguish malignancy compared to postoperative histopathology in thyroid nodules larger than 4 cm. The aim of this study was to investigate the diagnostic accuracy of FNAB compared to postoperative histopathology in distinguishing malignancy in thyroid nodules larger than 4 cm. A single-center retrospective observational study was conducted at Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia, between January 2014 and December 2018. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy were calculated. A total of 83 patients were included in the study. The results showed that preoperative FNAB may have the ability to distinguish malignancy compared to postoperative histopathology. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy were 42.85%, 98.38%, 90.00%, 83.56%, and 84.33%, respectively. These data suggested that ultrasound-guided preoperative FNAB is a reliable diagnostic tool in the preoperative evaluation of thyroid nodules larger than 4 cm, but it has limited capability in distinguishing malignancies. In conclusion, although FNAB may be useful in reducing unnecessary surgeries, histopathology remains the preferred method for confirming malignancy in thyroid nodules.

Severe hypocalcemia as a cause of transient ischemic attack? A debatable case and evidence from literature.

Hypocalcemia and transient ischemic attack (TIA) are different medical disorders; however, limited evidence suggests a possible link between the two. The underlying pathomechanisms by which hypocalcemia may cause cerebrovascular damage are difficult to comprehend. The aim of the study was to present an individual experiencing TIA that possibly due to severe hypocalcemia that associated with hypoparathyroidism after total thyroidectomy; and to explore the available evidence of its cause-effect relationship through available literature. A 68-year-old man presented to Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia with complaints of weakness, especially in the right limbs that had worsened in the last week. The patient experienced unconsciousness for an hour before the admission; disorientation and anterograde amnesia over the time of recovering of consciousness. Other complaints included frequent muscle cramps, numbness in both arms and legs, dizziness, swallowing difficulty, nausea, and vomiting. The patient had a history of total thyroidectomy for a large struma diffuse 18 years ago and was prescribed several medications. However, the patient was overwhelmed by forgetfulness which had become more frequent in recent months resulting in medication nonadherence. The vital sign was stable and Chovsteck's sign was positive. The Montreal Cognitive Assessment (MoCA) revealed impairment in the visuospatial/executive component and delayed memory. Laboratory tests revealed severe hypocalcemia, altered thyroid function, hypomagnesemia, elevated D-dimer and fibrinogen, and vitamin D deficiency. TIA and severe hypocalcemia were proposed as the diagnosis. Prompt initiation of appropriate treatment, including calcium supplementation, anticoagulation, and neuroprotective agents, led to significant clinical improvement. Evidence from available literature suggests that there is a possible link between severe hypocalcemia and TIA that occurred in this patient. However, more studies are warrant to establish this cause-effect relationship.

Association between depression and HbA1c levels in the elderly population with type 2 diabetes mellitus during COVID-19 pandemic.

Diabetes mellitus is a chronic progressive disease affecting the metabolic hormonal system and its prevalence in the elderly population is high. Depression is one of the psychiatric disorders in diabetic patients in particular during the coronavirus disease 2019 (COVID-19) pandemic. People with depression are more susceptible to leading an unhealthy lifestyle; therefore, depression and diabetes have a negative influence on life quality and aggravate complications and symptoms. The aim of this study was to determine the association between depression and hemoglobin A1c (HbA1c) levels in elderly with type 2 diabetes mellitus patients. A cross-sectional study was conducted where a total of 42 diabetic patients from the Puskesmas Belakang Padang, Batam of Indonesia was recruited. The HbA1c level, the main determinant of optimum glycemic control, was measured using ion-exchange high-performance liquid chromatography while the level of depression was assessed using Geriatric Depression Scale-15 (GDS-15). The association between depression and HbA1c levels was analyzed using the chi-squared test. Our study found that that 69% of the elderly with diabetes experienced a depression, classified as mild (40.5%), moderate (21.4%) and severe (7.1%). There were 61.9% of the subjects had poor HbA1c control. Our data suggested that the depression level was associated with HbA1c (p = 0.002). In conclusion, there is a significant association between depression and HbA1c levels in the elderly with type 2 diabetes mellitus.

The Differences in Perceptions of Interprofessional Education Among Health Profession Students: The Indonesian Experience.

PURPOSE: Interprofessional education (IPE) is defined as a practice of collaboration between two or more students from different health profession programs in which the students study with and about, and learn from, each other. IPE is an educational method that trains students to perform in terms of good communication and teamwork which will be useful for the implementation of interprofessional collaboration (IPC) at health-care facilities. The aim of this study is to identify the perceptions of medicine and health profession students on IPE at Universitas Syiah Kuala, Indonesia. MATERIALS AND METHODS: This study was conducted in five health profession programs at Universitas Syiah Kuala, Indonesia. Data were collected using a questionnaire which was then distributed to 286 students sampled with a stratified random sampling method. Analyses were conducted by using a univariate statistical analysis to observe students' perceptions of IPE. Students were considered to have a positive perception if their total score was above the median score. RESULTS: More than half of the students (51.4%) in this study had a positive perception toward IPE. However, upon exploration of students' perceptions separately for each study program, only a minority of medical students responded with a positive perception toward IPE (37%). In contrast, the majority of students from dentistry, psychology, nursing, and pharmacy study programs showed a positive perception of IPE, with the pharmacy study program being the program with the highest proportion of students who showed a positive perception (62.5%, 53.5%, 56.4%, and 75%, respectively). CONCLUSION: The majority of medical students show a negative perception toward IPE in contrast to students from other health profession programs at Universitas Syiah Kuala. The pharmacy study program shows the highest proportion of students with a positive perception among all other students.