An Unusual Presentation of Subacute Thyroiditis As Pyrexia of Unknown Origin With Normal Thyroid Functions.

Subacute thyroiditis is a rare condition believed as immune-mediated inflammation of the thyroid gland that frequently manifests after a viral upper respiratory tract infection. A 52-year-old South-Asian female patient presented to Same Day Emergency Care (SDEC) with feeling unwell and sore throat. Moreover, she reported low-grade fever, fatigue, headache, and breathlessness on exertion for the past five weeks. She had a past medical history of gastroesophageal reflux disease. She had no associated cough, rigors, chills, urinary symptoms, night sweats, or weight loss. There was no history of recent travel abroad. On examination, she was tachycardic; however, there was no lymphadenopathy, palpable thyroid gland, skin rash, or signs of infective endocarditis. Routine blood analysis showed elevated erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and normal white blood cell count. Her thyroid stimulating hormone (TSH) was normal. Chest X-ray and echocardiogram were unremarkable. She was prescribed clarithromycin with no effect. After inconclusive results of the routine investigation and no response to antibiotics, a computed tomography (CT) scan of the thorax, abdomen, and pelvis (TAP) was performed, which revealed a thickened thyroid isthmus. Positron Emission Tomography (PET) scan revealed bulky appearances of the thyroid gland with diffuse increased uptake suggestive of thyroiditis. Prednisolone 30mg daily was prescribed, which was later reduced by 5mg weekly for six weeks. The patient showed improvement in symptoms, and normal ESR and CRP were achieved.

Resistant type 2 amiodarone-induced thyrotoxicosis responsive to cholestyramine as an adjunctive therapy.

Amiodarone is a class 3 antiarrhythmic drug which may be associated with thyroid dysfunction. Amiodarone-induced thyrotoxicosis (AIT) is classified as type 1 (AIT 1; which may develop in the presence of latent autoimmune hyperthyroid condition) or type 2 (AIT 2; which develops in an apparently normal thyroid resulting from destructive thyroiditis). AIT 1 routinely requires treatment with thionamides, whereas AIT 2 is treated with steroids. Resistance to the conventional treatment of hyperthyroidism is not commonly found in clinical practice. This report discusses a case of AIT 2 resistant to conventional treatment. Despite being on high doses of carbimazole and steroids (prednisolone), the patient remained thyrotoxic. Cholestyramine, a bile salt sequestrant, was used as an adjunctive therapy resulting in significant clinical and biochemical improvement. The patient subsequently became euthyroid and is being followed up in endocrine clinic.

A Breath Close To Death: A Case Report Of Idiosyncratic Reaction To Welding Fumes.

A 39-year-old gentleman presented to emergency department with a few hours' history of acute shortness of breath, cough and haemoptysis that developed whilst welding a steel tank in a closed container. He was welder by profession for thirteen years with no significant past medical history. The arterial blood gas showed severe oxygenation impairment and he was intubated for mechanical ventilation. The radiographs showed bilateral widespread interstitial shadowing. The echocardiography showed normal heart and ruled out cardiogenic pulmonary oedemic. The microbiological investigations were all normal. He was treated as Acute Respiratory Distress Syndrome (ARDS) secondary to exposure to welding metal fumes in a closed container. He was given limited tidal volume invasive ventilation, extubated successfully after twelve days, transferred to respiratory ward for rehabilitation and discharged few days later. Exposure to welding metal fumes at work place is a major occupational health hazard worldwide. It can cause ARDS and other respiratory illnesses such as bronchitis, metal fumes fever and chronic pneumonitis. The pathogenesis of ARDS due to welding metal fumes involves direct inhalational injury and/or immune system dysfunction. Welding metal fumes related ARDS remains the diagnosis of exclusion and all other causes must be ruled out. The key to treatment is ventilation support with early endotracheal intubation. Appropriate precautionary measures are advised to avoid occupational health hazards in welding profession.