We present this case to increase the awareness of this complication for patients during the peri-transplant period. As it is difficult to predict which patients will develop pituitary apoplexy, careful attention to clinical symptoms in thrombocytopenic PSCT patients should prompt immediate supportive care to avoid fatal complications.
Introduction:The ongoing COVID-19 pandemic has been devastating the United States since early 2020. As time went on, its extrapulmonary manifestations became further elucidated. Here we present a case of suspected thyroiditis from COVID-19 or intravenous (IV) contrast. Case Description: 34 year old man with schizoaffective disorder, bowel obstruction with subsequent colectomy and colostomy, and recent COVID-19 ICU admission in May 2020 presents in July with fevers and chills from group home. Patient had no history of lithium or amiodarone use. He did have a CT abdomen with IV contrast in May. He had symptoms of increased output from the colostomy and abdominal discomfort but denied any symptoms of neck pain, dysphagia, dysphonia, heat intolerance, palpitations, or tremors. On admission, the patient received an abdominal CT scan with intravenous contrast for his gastrointestinal symptoms which was unremarkable. Lab studies showed TSH < 0.10 mU/L(0.27 e 42 mU/L), TT3 108 ng/dl(80-200 ng/dl), and FT4 3.21 ng/ dl(0.7-1.8 ng/dl). Thyroid ultrasound found no evidence of nodules. Burch Wartofsky score was 60 from temperature of 102.9 ºF, sinus tachycardia to 130 beats/min and mild abdominal discomfort with increased output from colostomy. Though the Burch Wartofsky score was suggestive of thyroid storm, his FT4 was not severely elevated, therefore he was started on methimazole 20 mg daily with metoprolol tartrate 12.5 mg twice a day. TSH receptor antibody and thyroid stimulating immunoglobulin came back negative. Given high suspicion for thyroiditis from either COVID-19 or IV contrast, methimazole was discontinued. Patient was subsequently discharged on metoprolol tartrate 12.5 mg twice a day. His follow up labs in September during an admission for aspiration pneumonia revealed TSH < 0.10 mU/L(0.27 e 4.2 mU/L), TT3 67.9 ng/dl(80-200 ng/dl), and FT4 1.28 ng/dl(0.7-1.8 ng/dl) suggesting resolving thyroiditis. Discussion: There are a handful of cases of subacute thyroiditis caused by COVID-19 viral infection described in literature. Our patient's thyroiditis is further complicated by recent IV contrast use, which is commonly used. Both IV contrast and COVID-19 can cause thyroiditis, though post-viral thyroiditis typically presents with anterior neck pain. Treatment options have beta blockers in common but painless thyroiditis from IV contrast usually does not require prednisone or nonsteroidal anti-inflammatory drugs. Our case helps raise the awareness of COVID-19 and IV contrast as possible causes of thyrotoxicosis during this pandemic. Thyroiditis should always be part of the differential in the workup of thyrotoxicosis in a patient recently diagnosed with COVID-19 in the last couple of months.
Adrenal incidentalomas, masses noted on imaging done for other purposes, are common with 10-15% presenting as bilateral adrenal masses. These cases can be challenging as the differential diagnosis is broad including metastatic disease, primary adrenal lymphoma (PAL), or infection, often requiring a biopsy if initial biochemical workup is unrevealing. Case description, laboratory and radiologic imaging studies and discussion of literature. A 62 year old Korean woman presents with altered mental status and fevers. She was found to have bilateral adrenal incidentalomas and retained acupuncture needles. Adrenal workup did not show biochemical evidence of hormonal excess. Infectious workup was unrevealing as was a metal/toxin work up due to retained acupuncture needles. Fevers and episodes of hypotension persisted which prevented the patient from obtaining an adrenal biopsy. Bone marrow biopsy was obtained for pancytopenia and revealed B cell lymphoma with large cell morphology and few histiocytes with hemophagocytosis, raising concern for lymphoma induced hemophagocytic lymphohistiocytosis (HLH). Primary adrenal lymphoma (PAL) associated with HLH was highly suspected in our patient given the large 7 cm bilateral adrenal masses and bone marrow biopsy findings of lymphoma. Patient was treated for diffuse large B cell lymphoma (DLBCL) with clinical improvement. PAL is a rare but aggressive lymphoma with few reported cases. It should be considered in the differential for both unilateral and bilateral adrenal masses. An early diagnosis is crucial as the main treatment is chemotherapy rather than surgery and it confers a significant survival benefit.
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