Advanced heart failure patients commonly suffer from ventricular arrhythmias which can be managed by antiarrhythmic drugs like mexiletine. These ventricular arrhythmias can be complicated by illicit drug use which alter outcomes and can potentially impact the patient-physician relationship through countertransference. However, mexiletine can lead to false positive urine drug screen testing for amphetamine, and these false-positive urine drug screen test results can affect the decision-making process. Health care providers should be aware of this fact and should either use confirmatory testing or look for confounding compounds in patients who deny using illicit substances and have a positive urine drug screen. Our patient is 64 years old who arrived at the emergency department after experiencing a shock by his intracardiac defibrillator. The patient tested positive for amphetamine on his urine drug screen and was later ruled out by confirmatory quantitative testing.
Introduction: The use of the 250μg cosyntropin dose or otherwise called high-dose ACTH test is the gold standard test for diagnosis of primary adrenal insufficiency. The 1μg dose test or the low-dose test is mostly reserved for diagnosis of secondary adrenal insufficiency. Careful consideration of the results produced during the diagnostic process is imperative to avoid mislabeling of patients with a disease that requires lifelong treatment. Case Report: This is the case of a 45-year-old female with a history of asthma and psoriasis who presented with emesis. Home medications included monthly TNF-alpha inhibitor injections for psoriasis, triamcinolone acetonide topical spray and budesonide-formoterol inhaler. On admission, she also had nausea, chills and diaphoresis, as well as palpitations, lightheadedness, and shortness of breath. When she arrived at the ER, vitals were remarkable for low blood pressure. Labs were unremarkable except for CMP concerning for anion gap metabolic acidosis, hyponatremia, and hypokalemia. A random serum cortisol was 6.4 mcg/dL, which was relatively low. ACTH was within normal range. Due to concern for adrenal insufficiency, a 1μg cosyntropin test was performed which showed a peak cortisol concentration of less than 18 mcg/dL. As the response was assessed as suboptimal, endocrinology was consulted to offer a treatment plan for steroids. However, the test was repeated using the gold standard 250μg cosyntropin dose and the patient then showed an adequate response and she was not started on steroids. Conclusions: This is a case that demonstrates how the 250 μg ACTH or high-dose stimulation test should be used for diagnosis of primary adrenal insufficiency (AI), as it is the gold standard. The 1 μg ACTH or low-dose stimulation test can be used for diagnosis of primary AI but only when the high dose test is not available. On the other hand, the 1 μg ACTH stimulation test has been shown to be more sensitive than the 250 μg test in diagnosing secondary adrenal insufficiency. When using the most appropriate test correctly, the clinician can only then offer the patient the best treatment strategies. Our patient did not require chronic replacement therapy. The steroids in this case could have harmed the patient as chronic administration could cause adrenal gland suppression.
Introduction - COVID-19 pandemic hit the world in 2019 and with its advent, began a race against time to curtail its destructive aftermath, which finally seemed plausible with effective vaccination. Malaise, fatigue, dizziness are the most commonly reported side effects of the vaccine. We present a series of two cases which shed light on such symptoms which often remain camouflaged under the background of expectation while indeed, may be linked to biochemical alterations in thyroid functioning causing a state of thyroid dysregulation - a syndrome of vaccine induced mild, self-limiting thyroiditis. Case presentation - Two healthy females presented with mild, non-specific symptoms of fatigue and dizziness days to weeks after receiving SARS-CoV-2 mRNA (severe acute respiratory syndrome coronavirus 2 messenger ribonucleic acid) vaccination. Lab work showed hyperthyroidism. They did not exhibit other clinical signs of overt hyperthyroidism. They were managed conservatively with serial hormonal measurements which stabilized over the next couple of months. Case 1 A 44 year old female presented for an annual visit and reported fatigue and dizziness for 2-3 days. TSH (thyroid stimulating hormone) was <0. 010 (normal 0.27 - 4.20 uIU/ml). She had received the SARS-CoV-2 mRNA vaccine 4 weeks earlier. TSH was repeated in 10 days and remained suppressed at <0. 010 while Free T4 was elevated at 1.92 (normal 0.5-1.6 ng/dL). At Endocrinologist appointment six weeks later TSH normalized at 3.734 and free T4 was low at 0.50. She was advised conservative management. Repeat lab testing in 6 week showed a return to euthyroid state. Case 2 A 29 year old female presented with dizziness and increased sweating. TSH was <0. 005 (normal 0.27 - 4.20 uIU/ml) and freeT4 2.62 (normal 0.5-1.6 ng/dL). She had received the SARS-CoV-2 mRNA vaccine 2.5 weeks earlier. Tests after one month: TSH 0. 013 and free T4 1. 06. ESR was 1 (normal 0-20 mm/hr). Labs showed a promising trend towards euthyroid state as the TSH had become detectable and the free T4 had normalized, and thus, she was recommended conservative management with repeat laboratory testing in 4-6 weeks. Discussion - Post-vaccination nonspecific, often overlooked, symptoms can stem from underlying biochemical abnormalities induced by the vaccines and their interactions with the thyroid gland. Due to the covert nature of these derangements owing to their co-incidentally similar symptomatology and occurrence immediately following vaccination, there is very limited data available on this topic. There is a need to detect, report and investigate this phenomenon to formulate monitoring guidelines, identify certain populations at risk and most importantly, investigate the effects of multiple vaccinations in a series, which is likely on the horizon given the trajectory of SARS-CoV-2 illness, as it can have a huge impact on the burden of thyroid disease in the general population. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.
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