Introduction: The development of Glucagon like peptide-1 (GLP-1) receptors agonists represents an important advancement in the management of type 2 diabetes. The long-acting GLP-1 receptor agonists improve glycemic control, promote weight loss. Anaphylaxis to GLP-1 receptor agonists and mainly Dulaglutide is a rare but serious side effect. We report a patient with Type 2 DM who was recently started on Dulaglutide and started to experience systemic hypersensitivity reactions that required discontinuing the medication and inpatient hospitalization. Case: A 53-Year-old Caucasian female with past medical history of type 2 DM on Metformin presented to the ED with sudden onset of sporadic itchy rash on the lip and chin associated with lip swelling within one hour of her first injection of Dulaglutide. She denied difficulty breathing, rash or pruritus on any other part of the body. She denied any food allergies. The patient used two tablets of Oral Diphenhydramine 25 mg with minimal improvement in her symptoms which warrant her to come to the ED. On arrival, she was Afebrile with a HR 97 beats/minute, a BP of 105/58 mm of Hg and a RR of 17 breaths/minute. The rash was blotchy, non- tender, more evident on the upper lip as compared to the lower lip. Lab results showed WBC count of 11 k/uL with basophils of 2% and HbA1c 8.6%. She was treated for her allergic reaction with Intramuscular injection of Epinephrine 0.3mg, Intravenous Dexamethasone 6mg and Intravenous Diphenhydramine 25mg. She was then transferred to the observation unit for monitoring. Her home metformin 500mg two times a day was continued. After 48 hours, the patient’s symptoms were improved and she was discharged home. She was advised to follow up with her PCP and endocrinologist and stop Dulaglutide. Discussion: GLP-1 receptor agonists are commonly used currently in the management of DM due to their beneficial effect in controlling blood glucose as compared to other diabetic medications. Rarely, a potentially life-threatening reaction, such as anaphylactic reactions have been documented with GLP-1 receptor agonist. Systemic allergic reaction to GLP-1 Agonist Exenatide has been reported in the literature. Our patient had anaphylactic reaction after using Dulaglutide. The mechanism of action of anaphylaxis in GLP-1 receptor agonists is thought to be related to IgE mediated and the immune response was demonstrated by basophil activation.
Introduction Myxedema coma is a rare presentation of severe hypothyroidism. The low incidence of this life-threatening disease may be attributed to easy availability of TSH testing and thyroid hormone replacement therapy. Well documented cases of thyroiditis and thyrotoxicosis due to SARS-CoV-2 are now available in medical literature. Additionally, COVID-19 pandemic has also caused higher rates of non-compliance with medications and appointments. This has resulted in higher rates of exacerbations of most chronic illnesses, including thyroid diseases. We present a case of myxedema coma and subsequent iatrogenic hyperthyroidism during the COVID-19 pandemic. Clinical Case 57-year-old male with paroxysmal atrial fibrillation, CHF, CKD stage IV, type 2 diabetes mellitus, hypertension, and post ablative hypothyroidism was found unresponsive at home. Initial vitals were temperature 95.1F, HR 52 beats per minute, RR 14 breaths per min, BP 90/62 mmHg, and glucose 68 mg/dL. There was no evidence of goiter, and he had generalized edema. Initial labs showed hyponatremia, elevated CPK, TSH 111uIU/mL (0.27-4.2 uIU/mL) and free T4 was <0.1 ng/dL (0.93-1.7 ng/dL). He was intubated, needed vasopressor support, and was treated with empiric antibiotics. He was diagnosed with myxedema coma which was treated with 200 mcg IV levothyroxine, and stress dose hydrocortisone. He was extubated on day 4 of hospital admission after which oral levothyroxine 275 mcg daily was initiated, and steroids were tapered off. Patient's pharmacy confirmed that Levothyroxine was not last filled more than eight months ago. Patient was hospitalized 3 weeks later for pneumonia and Levothyroxine dose was further increased to 300 mcg due to persistently elevated TSH levels. Three months later, patient was admitted for Atrial fibrillation in rapid ventricular response with difficult to control tachycardia. His TSH was 0.01 uIU/mL and thyroxine of 1.93 ng/dL despite not taking any medication for 2 weeks. He admitted to not following up with endocrinologist due to the surge in COVID-19 cases. Dose of levothyroxine was decreased to weight-based dose of 225 mcg, and patient discharged with instructions to repeat labs in 6 weeks and follow up with a clinical provider. Conclusion This case highlights the consequences of under and over replacement of thyroid hormone. Viral illnesses including SARS-CoV-2 can precipitate myxedema coma in patients with severe hypothyroidism. A high index of suspicion is needed to treat this disease in a timely manner. Providers must make allowances for the limitations in our system to function in a pandemic. Prescribing extra medication refills and offering virtual medicine appointments may help lower hospitalizations. Also, understanding the effect of non-thyroidal illness on thyroid function tests and knowing that TSH takes six weeks to normalize after starting/ adjusting thyroid hormone dose will avoid premature adjustment in hormone doses. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.
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