Hyperglycemia Associated With Raynaud Phenomenon and Liver Dysfunction After COVID-19 Vaccination in Type 1 Diabetes Mellitus.

Background/Objective: The association of COVID-19 vaccinations and the changes in glycemic control remains debatable. We report a case of a patient with type 1 diabetes mellitus (DM) with previously well-controlled glucose on a hybrid closed-loop insulin pump who developed significant glucose variation, new onset Raynaud phenomenon, and liver dysfunction after the vaccination. Case Report: A 33-year-old man with type 1 DM since the age of 5 years was on an insulin pump for 17 years. He had a reasonable controlled glucose level with a hemoglobin A1c level of 6.8% (51 mmol/mol). Three days after he received the COVID-19 vaccination, his glucose level started to fluctuate in the range of 46 to 378 mg/dL with 3.5 times higher total daily insulin requirement. The patient developed white-pale cold hands, weight gain, fatigue, and liver dysfunction. Computed tomography of the abdomen revealed mild hepatomegaly, and laboratory workup was negative for hepatitis. One month later, his glucose level became better controlled, and his liver function improved. Continuous glucose monitoring revealed that his glucose profile returned to baseline after 6 weeks. Discussion: COVID-19 vaccination resulted in significant glucose variation and fluctuations in this patient. It could be explained by the vaccine-induced immune response causing an increase in insulin resistance, such as in adipose tissue and muscle cells. Immune stimulation could have also caused the abnormal liver function and explain his new onset Raynaud phenomenon. Conclusion: We described, for the first time, the long-term continuous glucose monitoring glucose profile with a hybrid closed-loop system in type 1 DM after COVID-19 vaccination. Clinicians need to keep alert to glycemic excursion and side effects after immunization in type 1 DM.

A Thyrotoxicosis Surprise: Jod-Basedow Phenomenon Following IV Contrast Administration.

Jod-Basedow phenomenon (JBP) is a rare thyrotoxic condition due to increased exogenous iodine exposure, also known as iodine-induced hyperthyroidism (IIH). Historically JBP was typically seen in iodine-deficient patients when exposed to increased amounts of iodine. However, in today's era, the most common cause of JBP is exposure to iodinated contrast media commonly used in various radiological examinations and interventional procedures, resulting in massive iodine exposure. Patients with normal thyroid function usually experience no ill effects. There has been increasing use of iodinated contrast in imaging and procedures over recent decades. Deposition of iodine in the thyroid in a person with normal functioning thyroid glands would usually be autoregulated and inhibited by the Wolff Chaikoff effect. However, a small albeit a significant portion of patients, particularly those with pre-existing thyroid conditions, can escape this auto-regulatory effect and be subject to life-threatening conditions, such as arrhythmias, heart failure, pulmonary arterial hypertension, cerebrovascular and pulmonary embolism, and cardiomyopathy. We present a case of a 59-year-old female with pre-existing goiter who presented with altered mentation and seizures, requiring endotracheal intubation for airway protection. She underwent a CT angiogram of the head and neck for a suspected stroke, receiving iodinated IV contrast in the process. Thyroid function tests on admission showed a thyroid-stimulating hormone (TSH) of 0.974 mIU/L (reference range 0.465-4.650 mIU/L) and free T4 of 0.46 ng/dL (reference range 0.75-2.19 ng/dL). The ensuing ICU course was complicated by thyrotoxicosis eight days after contrast administration with a surge of free T4 from 0.46 ng/dL on admission to 4.07 ng/dL and a TSH suppression to <0.015 mIU/L. She subsequently required three sessions of emergent plasmapheresis to remove excess free T4 before undergoing partial thyroidectomy and cardiac catheterization. Iodine-induced hyperthyroidism solidifies the need for awareness of a potential JBP following contrast administration, especially in an aging population and undiagnosed thyroid conditions, and timely diagnosis and intervention can greatly influence outcomes.

THYROID NODULE LOCATION ON ULTRASONOGRAPHY AS A PREDICTOR OF MALIGNANCY.

OBJECTIVE: The diagnostic capacity of ultrasonography (US) for differentiating between malignant and benign thyroid nodules is crucial in preventing unnecessary invasive procedures. This is the first study to evaluate whether thyroid nodule location on US has predictive value for malignancy. METHODS: We retrospectively reviewed data from 219 patients with thyroid nodules who underwent fine-needle aspiration biopsy in 1 year. Patients' demographics as well as nodule's laterality, polarity, morphology, and multinodularity were analyzed. All malignant lesions were confirmed by surgical pathology. RESULTS: The majority of the patients were female (86.2%). Nodules were evenly distributed between the right lobe (46.3%) and left lobe (49.5%). Eight nodules (4.2%) were located in the isthmus. Most nodules (79.3%) were located in the lower pole, while 9.6% were located in the upper pole and 6.9% in the middle pole. Seventy-five patients (39.9%) had multiple nodules. Fourteen nodules were malignant, representing a prevalence of 7.4%. A significantly higher frequency of malignancy was observed in upper pole (22.2%) compared to lower pole (4.7%) and middle pole (15.4%). A multiple logistic regression model confirmed such association after adjusting for age, body mass index, multinodularity, and laterality. The odds of malignancy in the upper pole were 4 times higher than other locations (odds ratio, 4.6; P = .03). CONCLUSION: Our study is the first showing that thyroid nodules located in the upper pole can be considered as having higher risk for malignancy. It may enhance the predictive value of malignancy if it is included in thyroid nodule ultrasound classification guidelines. ABBREVIATIONS: AACE = American Association of Clinical Endocrinologists; ATA = American Thyroid Association; BMI = body mass index; FNA = fine-needle aspiration; TMS = total malignancy score; TTW = taller than wide; US = ultrasonography.

Association of lower serum cholesterol levels with higher risk of osteoporosis in type 2 diabetes.

OBJECTIVE: To determine whether a correlation exists between bone mineral density and circulating lipoprotein levels and whether these variables are independently associated with osteoporosis in patients with type 2 diabetes. METHODS: In a cross-sectional analysis, 159 patients with type 2 diabetes were compared with 70 patients without diabetes selected from an outpatient endocrinology clinic in a tertiary care institute during a 1-year period. Variables were gathered through history, physical examination, and laboratory findings, including blood chemistry studies and dual-energy x-ray absorptiometry. RESULTS: Of the 229 study patients, 86 (37.6%) had osteoporosis. In the patients with diabetes, the mean +/- SD of age, weight, total cholesterol, and low-density lipoprotein (LDL) cholesterol in those with and without osteoporosis was 72.3 +/- 10.4 years versus 63.6 +/- 11.0 years, 74.2 +/- 14.4 kg versus 83.7 +/- 15.5 kg, 178.4 +/- 33.7 mg/dL versus 194.1 +/- 33.9 mg/dL, and 100.0 +/- 27.1 mg/dL versus 114.2 +/- 30.2 mg/dL, respectively (P<0.01 for all variables). After adjustment for other variables, multiple logistic regression analysis showed that the presence of diabetes was associated with a lower risk of osteoporosis. Similarly, older age and lower body weight, LDL levels, and serum calcium levels were independently associated with lumbar spine osteoporosis in patients with diabetes, in comparison with older age and lower weight in patients without diabetes. Lower weight and older age were associated with femoral neck and total hip osteoporosis in patients with diabetes, in comparison with only older age in patients without diabetes. CONCLUSION: The presence of type 2 diabetes is associated with a lower risk of osteoporosis. In patients with type 2 diabetes, a lower LDL level is more likely to be associated with osteoporosis at the lumbar spine.