Severe rhabdomyolysis and acute renal failure secondary to the use of simvastatin in undiagnosed hypothyroidism.

A 52-year-old Indian woman with underlying diabetes mellitus, hyperlipidemia and undiagnosed hypothyroidism presented with generalized musculoskeletal pain and oliguria for three days. The patient was taking 80 mg of simvastatin (initiated 20 days before) after cardiac catheterization for an inferior myocardial infarction. Laboratory evaluation revealed the following serum levels: creatine kinase, 81,660 U/L; aspartate aminotransferase, 2,497 U/L; alanine aminotransferase, 1,304 U/L; blood urea nitrogen, 88 mg/dL; creatinine, 5.1 mg/dL; free thyroxine (FT(4)), 12.6 Pmol/L and thyroid stimulating hormone, 22.7 uIU/L. Simvastatin was discontinued and the patient was administered forced alkaline diuresis. Her hypothyroidism was treated with thyroxine, which was continued after discharge. Her renal function recovered within two months. This case report discusses the higher incidence of rhabdomyolysis in patients with undiagnosed hypothyroidism receiving large doses of simvastatin.

Outcome of thyrotoxicosis treatment with 3 different modalities.

OBJECTIVE: To assess the efficacy of 3 different treatment modalities for thyrotoxicosis and a comparison of their cost effectiveness. METHODS: The case records of 100 patients treated for thyrotoxicosis at King Khalid National Guard Hospital in Jeddah were reviewed, during the period January 1992 through to January 2000. Their various treatments and responses were recorded as well as their thyriometabolic status, one year following the last treatment. The treatment consisted of an average of 9 months of antithyroid medication, thyroidectomy or treatment with radioactive iodide. Cure was defined as a patient being euthyroid or hypothyroid for a minimum period of at least one year. Cost-effectiveness was calculated as the total cost of treating the patient in a specific treatment modality, divided by those who were considered to be cured. RESULTS: For the remainder, the cost could not be definitively determined. The mean age was 41+/- 15.7 years, with female to male ratio of 6:1. Grave's disease was the underlying cause in 76% of cases, toxic multinodular goiter in 13% and toxic nodule in 1%. Ninety-one patients, who were treated with anti-thyroid medication for an average of 9 months, had a success rate of 11%. The success rate with surgery was 54.5%, while of 68 patients treated with radioactive iodide 65 (96%) were cured. Radioactive iodide was the most cost effective modality of treatment costing 1700 Saudi Riyals, followed by surgery at 40,000 Saudi Riyals. Medical treatment was the most expensive at 135,000 Saudi Riyals per cure. CONCLUSION: A treatment of thyrotoxicosis with radioactive iodine is much more efficacious than medical or surgical modalities. Furthermore, it is by far the most cost effective and has no harmful effects.

Profile of stroke in a teaching university hospital in the western region.

OBJECTIVE: An epidemiological study of stroke on patients admitted at King Abdul Aziz University hospital to determine the pattern of stroke, clinical presentation, risk factors and the outcome of the stroke in Saudis and non Saudis. METHODS: Case records of patients admitted with stroke between (January 1997 to January 2000) at King Abdul Aziz University Hospital which is a teaching hospital affiliated to Ministry of Education, provides health care to multinational population of mixed socioeconomic status. The diagnosis was established by radiological assessment either by computerized tomography scan or magnetic resonance imaging. Pattern of stroke, clinical presentations, risk factors and the outcome of stroke and other relevant data were documented. RESULTS: A total of 71 patients were admitted with stroke during the period of the study with incidence of 3% of total admission to the medical unit. The mean age was 63 years with male: female ratio of 3.4:1. Cerebral infarction was recorded in 80% of the cases. The most common presentation of stroke in Saudis were ischamic in 77% and hemorrhagic in 20.5%. Where as in non-Saudis, it was 85% and 7%. Intra cerebral hemorrhage was recorded in 15% of patients, while the subaraichnoid hemorrhage only in 1%. Ruptured aneurysm diagnosed by cerebral angiogram attributed to the cause of subarachnoid hemorrhage. Hypertension was the most important risk factor for ischamic and hemorrhagic stroke, as other risk factors were hyperlipidemia, diabetes mellitus, ischemic heart disease, atrial fibrillation and smoking. Death was the eventual outcome of stoke in 31% of patients, septicemia contributed to 35% of deaths, 77% of cerebral stokes were treated with aspirin, only 2 cases were treated by ticlopdine. Average hospital stay was 63 days, while 6 patients stayed longer than 600 days. CONCLUSION: Stroke is a common neurological problem among patients admitted at King Abdul Aziz University Hospital and the pattern of stroke is similar to those reported from other parts of Saudi Arabia and other Arab countries. There was a high incidence of thrombotic stroke in our study. Hemorrhage was rare in our study especially subarachniod hemorrhage. Hypertension was the most common risk factor, so emphasis should be made on strict control of blood pressure in the community to reduce the incidence of stroke. Since long hospital stay was observed in our study, we recommend establishment of more nursing homes and rehabilitation centers for stoke patients aiming to decrease the burden on the teaching hospital.

Schmidt's syndrome in a Saudi family.

We present 3 patients from a Saudi family who are presented with polyglandular autoimmune syndrome type 2. They have Addison's disease with either autoimmune thyroid disease or insulin dependent diabetic mellitus. Although this syndrome is rare, the incidence among Saudi Arabia or the Arab population is not known.

Profile of stroke in a teaching university hospital in the western region.

OBJECTIVE: An epidemiological study of stroke on patients admitted at King Abdul Aziz University hospital to determine the pattern of stroke, clinical presentation, risk factors and the outcome of the stroke in Saudis and non Saudis. METHODS: Case records of patients admitted with stroke between (January 1997 to January 2000) at King Abdul Aziz University Hospital which is a teaching hospital affiliated to Ministry of Education, provides health care to multinational population of mixed socioeconomic status. The diagnosis was established by radiological assessment either by computerized tomography scan or magnetic resonance imaging. Pattern of stroke, clinical presentations, risk factors and the outcome of stroke and other relevant data were documented. RESULTS: A total of 71 patients were admitted with stroke during the period of the study with incidence of 3% of total admission to the medical unit. The mean age was 63 years with male: female ratio of 3.4:1. Cerebral infarction was recorded in 80% of the cases. The most common presentation of stroke in Saudis were ischemic in 77% and hemorrhagic in 20.5%. Where as in non-Saudis, it was 85% and 7%. Intra cerebral hemorrhage was recorded in 15% of patients, while the subaraichnoid hemorrhage only in 1%. Ruptured aneurysm diagnosed by cerebral angiogram attributed to the cause of subarachnoid hemorrhage. Hypertension was the most important risk factor for ischemic and hemorrhagic stroke, as other risk factors were hyperlipidemia, diabetes mellitus, ischemic heart disease, atrial fibrillation and smoking. Death was the eventual outcome of stoke in 31% of patients, septicemia contributed to 35% of deaths, 77% of cerebral stokes were treated with aspirin, only 2 cases were treated by ticlopdine. Average hospital stay was 63 days, while 6 patients stayed longer than 600 days. CONCLUSION: Stroke is a common neurological problem among patients admitted at King Abdul Aziz University Hospital and the pattern of stroke is similar to those reported from other parts of Saudi Arabia and other Arab countries. There was a high incidence of thrombotic stroke in our study. Hemorrhage was rare in our study especially subarachniod hemorrhage. Hypertension was the most common risk factor, so emphasis should be made on strict control of blood pressure in the community to reduce the incidence of stroke. Since long hospital stay was observed in our study, we recommend establishment of more nursing homes and rehabilitation centers for stoke patients aiming to decrease the burden on the teaching hospital.

Diabetic foot: presentation and treatment.

OBJECTIVE: The aim of this study is to determine the mode of presentation, medical and surgical treatment in diabetic foot. METHODS: Medical notes of 34 diabetic patients admitted to King Abdulaziz University Hospital in Jeddah from June 1997 to June 1999 with diabetic foot were studied retrospectively. Collection of demographic data, mode of presentation, investigations, medical treatment (antibiotics cover) and surgical treatment has been studied. Data of those patients were collected for gender, age, duration of diabetes, mode of presentation, presence of peripheral neuropathy, peripheral vascular disease and other complications, precipitating factors, concurrent medical illness (ischemic heart disease, hypertension, chronic renal failure, and retinopathy), microbial flora, medical treatment by antibiotics, surgical treatment, and duration of hospital stay RESULTS: Majority of patients were male above 50 years, mean age 59 +\- 9.6, 29 male, 47% Saudi, 65% diabetic patients, their blood sugar were controlled by oral hypoglycemic drugs. However only 29% were on insulin. History of trauma preceding infection was present in 20%. Peripheral neuropathy was the main precipitating factor in 94%, as well the presence of peripheral vascular disease in 50%. Smoking was found in 44% patients. Foot ulcer was the most common type of presentation in 59% of patients, 65% of these patients need debridement. However 8 patients had major amputation. Proteus and pseudomonas were the most common organisms isolated. The mean hospital stay was 21.44 +\- 17.7 days. CONCLUSION: Diabetic foot sepsis is a common health problem presented in Saudi Arabia particularly among men, peripheral neuropathy, as well poor glycemic control are the most common precipitating factors. Foot infection is usually poly-microbial. Most of these patients required debridement, however 8 (23.5%) of them, ended up having major limb amputation.

Hypercalcemia due to parathyroid adenoma.

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