Challenges and Uncertainties in the Diagnosis of Cardiac Amyloidosis: A Case Report.

Amyloidosis is the condition when starch-like misfolded proteins form insoluble fibrils that deposit in tissues and cause dysfunction. Cardiac amyloidosis occurs due to the deposition of amyloid fibrils at the cardiac level and is an important cause of heart failure. This case reveals a patient with significant heart failure and arrhythmia, which later on turned out to be caused by cardiac amyloidosis. While regarded as a rare disease in practice, in retrospect, there are a lot of signs and imaging indicators, particularly in echocardiography that warrant an investigation of cardiac amyloidosis. In this case review, red flags in echocardiography that should endorse further testing for underlying cardiac amyloidosis are highlighted.

Recurrent Hypoglycemia in Diabetic Patient With Hypopituitarism: The Houssay Phenomenon.

The association of treatment of diabetes mellitus and hypoglycemia is well described in the literature. However, the association of recurrent hypoglycemia in diabetic patients with hypopituitarism has been rarely described. This phenomenon, called Houssay phenomenon, usually occurs in individuals with a long diabetes evolution. It is caused by the failure of counter-regulatory hormones produced by the anterior pituitary gland to correct hypoglycemia. We describe this phenomenon in an elderly female known with type 2 diabetes mellitus taking insulin and oral diabetes medications. Workup showed partially empty sella on pituitary imaging. Hormonal assessment showed very low morning cortisol, low adrenocorticotropin hormone (ACTH) and zero response to synacthen. Loss of these counter-regulatory hormones leads to hypoglycemia (Houssay phenomenon). Hypopituitarism has several causes, including pituitary adenoma and traumatic brain injury as common causes among the others. In our reported case, we correlate our patient's condition to Houssay phenomenon, for the implication of refractory hypoglycemic episodes and cortisol deficiency, all of which are the consequences of hypopituitarism. Clinicians should be aware of the link between diabetes and hypopituitarism to avoid deleterious consequences of hypoglycemia.

Graves' Disease Presenting as Urticaria.

Graves' disease (GD) is an autoimmune disease that is characterized by the presence of antibodies targeting the thyroid gland. Commonly, the disease presents with symptoms of thyrotoxicosis such as sweating, tremors, and weight loss; less frequently, patients with GD might also have urticaria. Urticaria is clinically defined as the presence of wheals, angioedema, or both. While its pathophysiology is not completely understood, urticaria is believed to be an immune-mediated response activating mast cells, leading to the release of histamine and cytokines. Although the association between urticaria and GD is well established, it is uncommon for GD patients to present with urticaria as their sole complaint. In this paper, we present a case of a previously healthy patient who originally presented to the dermatology clinic with urticaria alone; however, she developed thyrotoxic symptoms soon after. Furthermore, her treatment was complicated by developing an allergic reaction to carbimazole.