Atypical Presentation of Hashimoto’s Disease in an Adolescent: Thyroid-Associated Ophthalmopathy

Hashitoxicosis is generally differentiated from Graves’ hyperthyroidism by its shorter course and absence of ophthalmopathy. In this case report, we describe an adolescent girl who presented with significant clinical findings of hyperthyroidism, a diffuse goiter with homogenously increased uptake in scintigraphy, and with ocular findings of ophthalmopathy. The thyroid stimulating hormone receptor antibody test was positive, and the family history revealed thyroid-associated ophthalmopathy. Clinical findings supported the diagnosis of Hashimoto’s disease (HD) in the follow-up period. Radioactive iodine uptake investigation was found to be a reliable method for differential diagnosis. Attention was drawn to the rarity of pediatric cases of HD who present with ophthalmopathy.     

The effect of local corticosteroid injection on F-wave conduction velocity and sympathetic skin response in carpal tunnel syndrome

The aim of this study was to evaluate the efficacy of steroid injection for the treatment of the carpal tunnel syndrome (CTS), with F-wave parameters and sympathetic skin response (SSR). Seventeen hands of 10 women patients were treated with local steroid injection with 2-month follow-up. All patients underwent single injection into the carpal tunnel. Response to injection was measured nerve conduction studies (NCSs), median nerve F waves, and SSR before and after treatment. To determine the normal values, 42 hands of 21 healthy women were also studied. There was a significant improvement of sensory and motor nerve conduction values when compared to baseline values (P < 0.01). At the end of follow-up period, the median sensory distal latency and the sensory latency differences between the median and the ulnar nerve were improved 35 and 65%, respectively. The maximum, mean F-wave amplitudes and chronodispersion showed a slight improvement with respect to baseline values and controls, but statistical significance was not achieved after treatment. Although no statistically significant improvements were observed in SSR parameters, slightly decreased amplitudes and increased habituation of SSR were noted at the end of the treatment. The present study shows that the local steroid injection results in improvement in NCSs values, but the F-wave parameters were not effectual in short-term outcome of CTS treatment. These findings suggest that the sensory latency differences between the median and the ulnar wrist-to-digit 4 are better parameters in the median nerve recovery after treatment than the median sensory distal latency. Furthermore, the SSR does not seem to be a sensitive method in follow-up of CTS treatment.     

DRESS syndrome with fatal results induced by sodium valproate in a patient with brucellosis and a positive cytoplasmic antineutrophilic cytoplasmic antibody test result

DRESS syndrome is a life-threatening adverse reaction characterized by skin rashes, fever, leukocytosis with eosinophilia or atypical lymphocytosis, lymph node enlargement, and liver or renal dysfunctions. DRESS syndrome related to valproic acid use is very rarely observed. We present a case of DRESS syndrome induced by sodium valproate, which developed and progressed fatally in a brucellosis patient with a positive c-ANCA test. A 19-year-old female patient presented with fever, cough, jaundice, and rash all over her body. Brucella Coombs test was positive at 1:1280 titers, and the Rose Bengal test was also positive. The involuntary movements were thought to be due to chorea, and the patient was started on sodium valproate 500 mg 2*1, as well as streptomycin 1?g flk 1*1 and tetradox capsules 2*1 for the brucellosis and was discharged. DRESS syndrome was suspected in the patient, and she was taken off sodium valproate and tetradox; N-acetylcysteine, ceftriaxon, prednizolone, and support treatment were started. When sodium valproate is used on its own, it carries no risk of inducing DRESS syndrome. However, in the case presented, another co-morbidity such as brucellosis and c-ANCA positivity was present. We believe that the presence of further co morbidity not yet reported in literature is important from the perspective of the risk of valproate-induced DRESS syndrome. Therefore, if sodium valproate treatment is to be started in patients, especially those with co morbidity, they must be closely monitored with clinical and laboratory observations. At the slightest suspicion of DRESS syndrome, all medication should be ceased immediately and the patient should be placed under continuous observation.     

Does preoperative total parenteral nutrition in patients with ulcerative colitis produce better outcomes?

Purpose

Malnutrition is a frequent problem in patients with ulcerative colitis (UC) leading to increased postoperative complication rates. Preoperative total parenteral nutrition (TPN) has been shown to reduce complications in some subgroups of patients, but has not been studied in UC. We investigated the impact of preoperative TPN on postoperative complication rates in patients undergoing surgery for UC.

Methods

This paper is a review of 235 patients who underwent surgery for UC; 56 received preoperative TPN and 179 did not. Postoperative complication rates were compared.

Results

Both had similar rates of anastomotic leak (5.4 vs. 2.8?%, p?=?0.356), infection (12.5 vs. 20.1?%, p?=?0.199), ileus/bowel obstruction (21.4 vs. 15.6?%, p?=?0.315), cardiac complications (3.6 vs. 0?%, p?=?0.056), wound dehiscence (3.6 vs. 1.7?%, p?=?0.595), reoperation (10.7 vs. 3.9?%, p?=?0.086), and death (1.8 vs. 0?%, p?=?0.238). The TPN group was more malnourished (albumin 2.49 vs. 3.45, p?<?0.001), more often on steroids (83.9 vs. 57.5?%, p?<?0.001), had more emergent surgery (10.7 vs. 3.4?%, p?=?0.029), more severe colitis (89.3 vs. 65.9?%, p?=?0.001), and lower Surgical Apgar Score (6.15 vs. 6.57, p?=?0.033). After controlling for these with logistic regression, the TPN group still had higher complication rates (OR 2.32, p?=?0.04). When line infections were excluded, TPN did not significantly affect outcomes (OR 1.5, p?=?0.311)

Conclusion

There were no differences in postoperative complications when line infections were excluded. Our data does not support routine preoperative TPN in patients with UC. However, it may lead to equal surgical outcomes in the sickest and most malnourished patients at the cost of line-related morbidity.     

Chronic inflammatory demyelinating polyradiculoneuropathy associated intracranial hypertension

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an acquired immune-mediated demyelinating neuropathy. In this report, we detail the course of a 58-year-old male patient who had headache and double vision followed by progressive paresthesia and difficulty in walking. The patient had bilateral papilledema and mild leg weakness, absent ankle jerks and loss of sensation in distal parts of his lower and upper extremities. His electromyography (EMG) was concordant with CIDP and lumbar puncture revealed high opening pressure. The polyradiculoneuropathy as well as the papilledema and elevated cerebrospinal fluid (CSF) pressure improved under steroids. The improvement in intracranial hypertension (IHT) and papilledema under steroid treatment suggests that the IHT in this patient might be associated with CIDP.     

Can dynamic and static pupillary responses be used as an indicator of autonomic dysfunction in patients with obstructive sleep apnea syndrome?

Purpose

We aimed to reveal whether static and dynamic pupillary responses can be used for the detection of autonomic nervous system (ANS) dysfunction in patients with obstructive sleep apnea syndrome (OSAS).

Methods

We included in this study patients with OSAS, who were divided into three groups according to the apnea–hypopnea index (AHI) (group 1, mild [n?=?20]; group 2, moderate [n?=?20]; and group 3, severe [n?=?20]), and healthy controls (group 4, n?=?20). Pupillary responses were measured using a pupillometry system.

Results

Static (mesopic PD, P?=?0.0019; low photopic PD, P?=?0.001) and dynamic pupil responses (resting diameter, P?=?0.004; amplitude of pupil contraction, P?<?0.001; duration of pupil contraction, P?=?0.022; velocity of pupil contraction, P?=?0.001; and velocity of pupil dilation, P?=?0.012) were affected in patients with different OSAS severities. Also, AHI was negatively correlated with mesopic PD (P?=?0.008), low photopic PD (P?=?0.003), resting diameter (P?=?0.001), amplitude of pupil contraction (P?<?0.001), duration of pupil contraction (P?=?0.011), velocity of pupil contraction (P?<?0.001), and velocity of pupil dilation (P?=?0.001).

Conclusion

We detected pupil responses innervated by the ANS were affected in the OSAS patients. This effect was more significant in the severe OSAS patients. Therefore, the pupillometry system can be an easily applicable, noninvasive method to detect ANS dysfunction in the OSA patients.