The COVID-19 pandemic has recently spread worldwide, presenting primarily in the form of pneumonia or other respiratory disease. In addition, gastrointestinal manifestations have increasingly been reported as one of the extrapulmonary features of the virus. We report two cases of SARS-CoV-2 infection complicated by paralytic ileus. The first patient was a 33-year-old man who was hospitalized with severe COVID-19 pneumonia requiring ventilator support and intensive care. He developed large bowel dilatation and perforation of the mid-transverse colon, and underwent laparotomy and colonic resection. Histopathology of the resected bowel specimen showed acute inflammation, necrosis, and hemorrhage, supporting a role for COVID-19-induced micro-thrombosis leading to perforation. The second patient was a 33-year-old man who had severe COVID-19 pneumonia, renal failure, and acute pancreatitis. His hospital course was complicated with paralytic ileus, and he improved with conservative management. Both cases were observed to have elevated liver transaminases, which is consistent with other studies. Several authors have postulated that the angiotensin-converting enzyme 2 receptors, the host receptors for COVID-19, that are present on enterocytes in both the small and large bowel might mediate viral entry and resultant inflammation. This is a potential mechanism of paralytic ileus in cases of severe COVID-19 infection. Recognizing paralytic ileus as a possible complication necessitates timely diagnosis and management.

The central location, the size, and instability of saddle pulmonary embolism (PE) have raised considerable concerns regarding its hemodynamic consequences and the optimal management approach. Sparse and conflicting reports have addressed these concerns in the past. We aimed to evaluate the clinical presentation, hemodynamic and echocardiographic effects, as well as the outcomes of saddle PE, and compare the results with those of non-saddle type. This was a retrospective study of 432 adult patients with saddle and non-saddle PE. Overall, 432 patients were diagnosed with PE by computed tomography pulmonary angiography (CTPA). Seventy-three (16.9%) had saddle PE, and 359 had non-saddle PE. Compared to those with non-saddle PE, patients with saddle PE presented more frequently with tachycardia (68.5% vs. 46.2%, P = .001), and tachypnea (58.9% vs. 42.1%, P = .009) on admission, required more frequent intensive care unit (ICU) admissions (45.8% vs. 26.6%, P = .001) and thrombolysis/thrombectomy use (19.1% vs. 6.7%, P = .001), and were at more risk of developing decompensation and cardiac arrest after their initial admission (15.3% vs. 5.9%, P = .006). On echocardiography, right ventricular (RV) enlargement (60% vs. 31.1%, P = .000), RV dysfunction (45.8% vs. 22%, P = .000), and RV systolic pressure (RVSP) of greater than 40 mmHg (61.5% vs. 39.2%, P = .003) were significantly more observed with saddle PE. The two groups did not differ concerning the rates of hypotension (17.8% vs. 18.7%, P = .864) and hypoxemia (41.1% vs. 34.3%, P = .336) on admission and mortality rates. A logistic regression model indicated that the use of oral contraceptive pills (OCP), RVSP > 40 mmHg, and development of hypotension and decompensation following admission were associated with an increased likelihood of having saddle embolus. Saddle PE accounts for a higher proportion among all PE cases than previously reported. Patients with saddle PE tend to present more frequently with adverse hemodynamic and echocardiographic changes and decompensate after their initial presentation. OCP use, development of hypotension, and decompensation following admission and RVSP > 40 mmHg are significant predictors of saddle PE. These characteristics should not be overlooked when managing patients with saddle PE.

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Background: Type 2 diabetes mellitus has been found to be associated with 25(OH)D (vitamin D) deficiency. The aim of this study was to the prevalence of vitamin D deficiency in T2DM patients in Qatar and the correlation between vitamin D deficiency and other variables such as dyslipidemia and glycemic control and microalbuminuria. Methods: This retrospective cross-sectional analytical study was carried out at the Hamad General Hospital medical outpatient clinic, in which adult patients (? 18 years) with type 2 DM were involved, between January 1, 2018, and July 31, 2018. Ethical approval was obtained from medical research committee.  Results: We recruited 400 subjects with type 2 diabetes mellitus. Their mean age was 58.97±10.32 years and the majority were women (52.0%) and Arabs (69.5%). The mean duration of type 2 diabetes diagnosis was 14.94±8.99 years and mean. The prevalence of vitamin D deficiency was 29.5%. A comparison between vitamin D deficiency and non-vitamin D deficiency groups, showed a statistically significant difference in terms of fasting blood sugar (P<0.001), random blood sugar (P<0.001), HBA1c (P<0.001), total cholesterol (P=0.001), LDL (C) (P=0.004), HDL (C) (P<0.001), triglyceride (P<0.001), and Urinary Albumin Excretion Rate (P=0.007). Data analysis showed that a significant negative correlation was found between vitamin D level and fasting blood sugar (r= -0.208, P<0.001), random blood sugar (r= -0.20, P<0.001), HBA1c (r= -0.260, P<0.001), total cholesterol (r= -0.218, P<0.001), LDL (C) (r= -0.176, P=0.004), triglyceride (r= -0.342, P<0.001), and Urinary Albumin Excretion Rate (r= -0.184, P=0.007). Conclusion: Our study showed a significant correlation between vitamin D deficiency and the poor control of T2DM, dyslipidemia, and microalbuminuria. The results emphasize the importance of monitoring vitamin D status in high-risk populations.

Background: Pheochromocytomas and paragangliomas (PPGLs) are rare neuroendocrine tumours arising from the adrenal medulla or from paravertebral ganglia of the sympathetic chain(1). The tumours commonly produce one or more catecholamines: epinephrine, norepinephrine, and dopamine leading to a classic triad of presentation with pounding headache, profuse sweating, and palpitations occurs in spells; However, one in 10 patients may be completely asymptomatic and the diagnosis of PPGL is frequently missed(2). Care Report: A 29 years old African female presented with one-month history of throbbing headache, palpitations, profuse sweating, and unintentional weight loss. Her previous medical history and family history was unremarkable. She was found to have accelerated hypertension and a small lacunar infarct and some suspected subarachnoid hemorrhage on MRI head but was clinically silent. Investigation for secondary causes of hypertension revealed high metanephrine in urine and her imaging showed giant adrenal mass suggestive of pheochromocytoma. CT Abdomen of large left adrenal necrotic solid mass lesion with heterogenous enhancement of its solid components measuring 6.5 x 6.1 x 7 cm in maximum AP, TR and CC dimensions respectively. She was scheduled for open resection and left adrenalectomy after approximatly10 day and was treated with high-sodium diet, alpha blockers, and beta blockers perioperatively. Histopathology examination revealed Pheochromocytoma measuring 8 x 7 x 5 cm with diffuse growth &gt;10% of tumor volume with central necrosis; PASS =4, which has malignant potential. She recovered well post operatively and required no further antihypertensive therapy or hormonal replacement, follow up hormonal profile and imaging with Iodine-123 metaiodobenzylguanidine (MIBG) scintigraphy were negative for remnants or metastasis, further evaluation with gallium DOTATATE PET CT and molecular genetic testing was considered, but it was not available. Conclusion: Pheochromocytoma is a rare cause of secondary hypertension with a variable clinical presentation. Episodes of tumoral catecholamine release, are thought to be responsible for the high prevalence of cardiovascular emergencies, such as myocardial infarction, heart failure, and stroke as a complication of hypertensive crisis. Timely diagnosis and treatment are crucial to prevent life-threatening complications.

Background: Hypopituitarism refers to complete or partial insufficiency of pituitary hormone secretion and patients require lifelong hormone replacement. Those with ACTH deficiency rely on exogenous glucocorticoids and at times of intercurrent illness require stress doses to prevent an adrenal crisis. The benefits and adverse effects of corticosteroids for treatment of COVID-19 pneumonia are currently under investigation. We report our experience in a patient with COVID-19 pneumonia who received high dose corticosteroids for panhypopituitarism. Clinical Case: A 51-year-old man presented with one-week history of fever and generalized weakness. He had been diagnosed with a non-functional pituitary macro-adenoma causing panhypopituitarism 1 year ago when he developed generalized tonic-clonic seizures. He underwent trans-sphenoidal resection of the pituitary adenoma. However, he then discontinued his hormonal therapy and was lost to follow up. He had postural hypotension but was not tachypneic or hypoxemic. He tested positive for COVID-19 and chest x-ray showed prominent bilateral broncho-vascular markings; he was hospitalized as mild COVID-19 pneumonia. Laboratory investigations revealed secondary adrenal insufficiency, secondary hypothyroidism and hypogonadotropic hypogonadism. MRI of the pituitary now showed persistence of the pituitary macroadenoma, measuring 3.5 x 3.7 x 2.4 cm in dimensions, causing sellar obliteration and left cavernous sinus invasion. Treatment with stress dose steroids, Hydrocortisone 50 mg 4 times daily was initiated, followed by thyroid hormone replacement with Levothyroxine 125 mcg daily. He also received antivirals and supportive care for COVID-19, guided by local hospital protocol. After significant clinical improvement, steroids were tapered down and he was discharged on a maintenance dose of 20 mg hydrocortisone per day in divided doses. The patient was stable at outpatient follow up after one month. He was started on testosterone replacement for erectile dysfunction due to hypogonadotropic hypogonadism. He was offered surgery for complete resection of the residual pituitary adenoma, but he declined and preferred to continue medical therapy. Conclusion: Hypopituitarism is associated with significant morbidity and premature mortality, a key risk factor being cortisol deficiency. Adrenal crisis is a life-threatening medical emergency and remains an important cause of death in patients with adrenal insufficiency. These patients are also vulnerable to develop severe complications from COVID-19 infection due to the absence of normal cortisol responses to stress. Despite receiving stress dose corticosteroids, this high-risk patient recovered from COVID-19 pneumonia without complications. These findings support the use of corticosteroids when necessary for treatment of coexisting conditions in patients with COVID-19.

Background and Objectives: The complications of type 2 diabetes mellitus (T2DM) can occur in some organs, such as the heart, blood vessels, eyes, kidneys, and nerves. Stroke, one of such complications, is increasing every year. This study aims to investigate the prevalence of and risk factors for stroke among T2DM patients in Qatar. Methods: This was a secondary post hoc analysis of collected data from our previous study titled “Association of Vitamin D deficiency with dyslipidemia, glycemic control, and microalbuminuria in patients with T2DM in Qatar.” Results: The prevalence of stroke among our patients was 3.8%. A comparison between stroke and no-stroke groups showed a significant association between stroke and other diseases, namely, chronic kidney diseases (CKD) (p=0.007), coronary artery disease (CAD) (p=0.010), peripheral vascular disease (PVD) (p<0.001), retinopathy (p=0.044), prolonged duration of diabetes mellitus (DM) (p=0.041), glycated hemoglobin (HbA1c) (p=0.006), and a high serum creatinine level (p=0.003). In the multivariate analysis, we identified the following variables as independent risk factors for stroke in patients with T2DM: male gender, CKD, CAD, PVD, high HbA1c, a high creatinine level, and prolonged duration of DM. Conclusion: The prevalence of stroke among T2DM patients in Qatar was around 3.8%. The main risk factors were male gender, CKD, CAD, PVD, high HbA1c, prolonged duration of DM, and a high level of creatinine.

Background: The Coronavirus disease 2019 (COVID-19) pandemic impacted health care systems in all countries, including Qatar. Hamad Medical Corporation (HMC); In compliance with recommendations, suspended all non-urgent procedures, including thyroid fine needle aspiration biopsies (FNAB). Thyroid nodules are second most common cause of referral to HMC endocrine clinic. FNABs are gold standard to differentiate benign from malignant nodules.1- 2 Methods: Our approach includes a teleconsultation to obtain patient’s history and risk factors. Reviewing neck ultrasound (US), obtaining a calcitonin level if indicated, considering comorbidities associated with a high risk of COVID-19 morbidity and mortality.3 Results: We developed a pathway triaging thyroid (FNAB) to:1-Urgent: patients at higher risk of aggressive thyroid malignancy. Benefits of early detection and treatment outweigh the risk of COVID-19 exposure.4 FNAB should not be delayed.2-Semi-urgent: patients at low risk for COVID-19 and high suspicion thyroid nodules, but no evidence that early detection improves survival2, FNAB may be delayed up to 12 months.3-Non-urgent: patients with asymptomatic nodules that have low or intermediate suspicion US pattern.2 Also, includes nodules with ATA high suspicion US pattern in pregnant women and patients at high risk for COVID-19. The risks outweigh the benefits. FNAB should be delayed until outbreak is controlled.4 When urgent FNAB is indicated, safety of patients and medical staff needs to be addressed.5 We recommend testing patient for COVID-19 before FNAB, utilizing US guidance with rapid on-site adequacy evaluation in all cases. Cervical lymph node FNAB with TG washout should be done if indicated. The patient should wear a mask. All medical staff involved should wear personal protective equipment (PPE). The operator should wear N95 mask and face shield. The patient should be informed about cytopathology results via telemedicine. Conclusion: Triaging thyroid (FNAB) during the COVID-19 pandemic should be based on nodule characteristics and risk of COVID-19 morbidity and mortality. Our group recommends deferring FNAB for asymptomatic patients.4FNAB should not be delayed in selected patients who benefit from early detection and intervention. Table1: Triage of Thyroid fine needle aspiration biopsies (FNAB). ATA: American thyroid association. US: ultrasound.