BackgroundHepatitis B and C cause significant morbidity and mortality worldwide. Little is known about the existence of hepatitis B and C among high risk groups of the Pakistani population. The present study was conducted to determine the prevalence of Hepatitis B and C in high risk groups, their comparison and the possible mode of acquisition by obtaining the history of exposure to known risk factors.MethodsThis cross sectional study was carried out in Karachi, from January 2007 to June 2008.HBsAg and Anti HCV screening was carried out in blood samples collected from four vulnerable or at risk groups which included injecting drug users (IDUs), prisoners, security personnel and health care workers (HCWs). Demographic information was recorded and the possible mode of acquisition was assessed by detailed interview. Logistic regression analysis was conducted using the STATA software.ResultsWe screened 4202 subjects, of these, 681 individuals were reactive either with hepatitis B or C. One hundred and thirty three (3.17%) were hepatitis B reactive and 548 (13.0%) were diagnosed with hepatitis C. After adjusting for age, security personnel, prisoners and IV drug users were 5, 3 and 6 times more likely to be hepatitis B reactive respectively as compared to the health care workers. IDUs were 46 times more likely to be hepatitis C positive compared with health care workers.ConclusionThe prevalence of hepatitis B and C was considerably higher in IDUs, prisoners and security personnel compared to HCWs group. Hepatitis C is more prevalent than hepatitis B in all these risk groups. Prevalence of hepatitis C increased with the increase in age. Use of unsterilized syringes, used syringes, body piercing and illicit sexual relations were found to be important associated risk factors for higher prevalence of Hepatitis B and C in these groups.

Paroxysmal Nocturnal Hemoglobinuria (PNH) is a rare type of acquired hemolytic anemia that is frequently associated with thrombophilia. It may rarely present with cerebral venous sinus thrombosis, which manifests clinically with signs of raised intracranial pressure and requires lifelong anticoagulation therapy. One such rare presentation was seen in a 28 years old male who had history of recurrent episodes of passing red colored urine and this time presented with severe headache. He was diagnosed to have cerebral venous sinus thrombosis and on further workup was found to be suffering from PNH.

ObjectiveTo study frequency and associated factors for care giving among elderly patients visiting a teaching hospital in Karachi, Pakistan.MethodologyA cross sectional questionnaire-based study was conducted at the Community Health Centre (CHC), Aga Khan University Hospital (AKUH) Karachi, Pakistan from September to November 2009. All individuals, visiting the CHC and aged 65 years or above were interviewed after taking written informed consent.ResultsA total of 400 elderly completed the interview. Majority were females, 65–69 years age, More than half of the individuals ie: 227 (85%) had received Care Giver experience for assistance and among these 195(72%) had care provided by an immediate family member. A large proportion of them stated that their Care Givers managed to provide less than four hours in a day for care giving. Around 37% showed substantial improvement in their relationship with the care givers. About 70% of the respondents stated that the care provided by the Care Giver improved their quality of life.ConclusionElderly care is provided by majority of the family members resulting in increased satisfaction level, however small number still not satisfied due to unfulfilled need of these older people. This demands that efforts should be made to strengthen the family support by increasing awareness regarding elderly care and arranging support system by the government.

Background COVID-19 infection affects multiple organ systems including the endocrine system. Its effect on thyroid function has been reported in multiple studies and one of them observed overt thyrotoxicosis in 10.8% of COVID-19 hospitalized patients associated with higher mortality and longer hospital stays. There is paucity of data on the impact of COVID-19 in patients with pre-existing hyperthyroidism, with only few case reports highlighting the clinical course of such patients. We report a young woman diagnosed with Graves’ disease (GD) who was admitted 4 weeks later with thyroid storm precipitated by COVID-19. Case An 18 year old woman presented to the Emergency Room (ER) with fatigue, palpitations, diaphoresis, and diarrhea for 2 weeks. She had sinus tachycardia with heart rate (HR) of 118 beats per minute (bpm). She had diffuse thyromegaly and fine tremors on exam. TSH was < 0.01 uIU/mL and free Thyroxine (FT4) >8 ng/dL. Thyroid Stimulating Immunoglobulin (TSI) was elevated consistent with GD. She was admitted and treated with intravenous fluids (IV), propranolol and methimazole with significant improvement. She was discharged on methimazole and propranolol. FT4 improved to 3.31 ng/dL 3 weeks later with 100% medication compliance. A week later, patient visited ER due to sore throat, left earache, and dry cough. Influenza PCR and COVID-19 nasal antigen tests were negative, and patient was discharged on amoxicillin-clavulanate for suspected otitis media and acute pharyngitis. Her symptoms worsened over the next few days and she was admitted again with nausea, vomiting, anxiety, palpitations, dyspnea and diarrhea. She was febrile to 101F, HR 135 bpm with agitation and reduced concentration. Burch-Wartofsky score was 65, highly suggestive of thyroid storm. FT4 was elevated at 4.46 ng/dL. COVID-19 PCR was positive. She was treated with propylthiouracil, propranolol and IV hydrocortisone with gradual improvement in symptoms. She was discharged on methimazole, propranolol and prednisone 10 mg for 10 days. Due to worsening hyperthyroid symptoms and rise in FT4, 1 week after stopping prednisone, it was restarted, and an urgent out-patient surgical referral was placed. She was advised to repeat thyroid labs in 1 week. Conclusion Thyroid storm is a rare, life-threatening endocrine emergency with a mortality rate of 10-30% that demands prompt recognition and timely intervention. Our case highlights that there must be a high index of suspicion for COVID-19 with worsening hyperthyroidism in patients with GD who are compliant with anti-thyroid medication especially if they have upper or lower respiratory tract symptoms. Patients with GD should be closely monitored during COVID-19 infection for development of thyroid storm. Early initiation of steroids might be considered with worsening thyroid function despite normal respiratory status to counteract inflammatory thyroiditis. Further studies will be useful to see the effect of COVID-19 infection in patients with GD. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Introduction Magnesium plays a role in production, release, and end-organ responsiveness of parathyroid hormone (PTH) and calcium homeostasis. Hypomagnesemia has been well documented to cause hypocalcemia by impaired secretion of PTH or PTH resistance. Iatrogenic hypermagnesemia in pregnant patients receiving intravenous magnesium for suppression of premature labor and pre-eclampsia is an uncommon cause of hypocalcemia. We are reporting a case of symptomatic hypocalcemia caused by iatrogenic hypermagnesemia in post-partum mother, who had high PTH in contrast to previous case reports. CaseA 28-year-old G4P1122 female, postpartum day 16 was admitted for headache, slurred speech, and vomiting. She was found to have elevated blood pressures and was started on IV magnesium for postpartum preeclampsia. On her first day, she received a 4g bolus of magnesium sulfate followed by 2g as maintenance for seizure prophylaxis. The following morning, the patient awoke complaining of numbness/tingling in both arms and twitching in her face and eyelids. Later that day, she had developed bilateral spontaneous carpopedal spasm as well. Labs drawn at that time revealed ionized calcium 0.78mmol/L (1.18-1.32 mmol/L), corrected calcium 7.42mg/dL (8.5-10.1), vitamin D 25-OH 45ng/mL (30-100), PTH 149.1pg/mL (18.5-88), phosphorus 2.9mg/dL (2.3-4.6), GFR116mL/min (>60) and magnesium 3.5mg/dL (1.4-2.2). Patient was started on IV calcium gluconate infusion along with calcium carbonate 1g QID and vitamin D3 5000 units daily. By the evening of the second day, patient's carpopedal spasm and paresthesia completely resolved. Repeat labs demonstrated improved ionized calcium of 1.17mmol/L (1.18-1.32), corrected calcium of 9.78mg/dL (8.5-10.1), and magnesium of 1.5mg/dL (1.4-2.2). Patient was discharged on calcium carbonate 1g TID and Vitamin D3 5000 units daily. Patient self-discontinued calcium and vitamin D supplementation a week after discharge. Repeat labs one week later showed normal corrected calcium, magnesium, and PTH levels. Conclusion Our patient developed transient, symptomatic hypocalcemia with elevated PTH secondary to iatrogenic hypermagnesemia, which improved with intravenous calcium. Hypomagnesemia is a known cause of hypocalcemia, but hypermagnesemia is a significantly less recognized etiology. Hypermagnesemia can cause low PTH due to activation of calcium sensing receptors resulting in inhibition of PTH secretion. Hypermagnesemia can also blunt the peripheral effect of PTH and promote hypercalciuria. Previous studies showed PTH can peak by the end of magnesium infusion but still result in hypocalcemia, although this is an uncommon clinical presentation. Our case highlights this aspect of elevated PTH after the completion of IV Magnesium infusion but still unable to correct hypocalcemia due to PTH resistance from hypermagnesemia. This calls attention to another underrecognized sequalae of hypermagnesemia: blunting of peripheral tissues response to PTH. Clinicians should be aware of development of hypocalcemia with both hypo- and hypermagnesemia as well as the underlying pathophysiology. Presentation: No date and time listed

Lung nodules are often incidentally discovered on lung imaging and can be solitary, which makes them suspicious for tumors, or multiple, which can be suggestive of an infectious process. A bronchial carcinoid is a rare pulmonary neoplasm, representing 1.2% of all primary pulmonary tumors. We report a case of incidentally discovered multiple lung nodules in an asymptomatic human immunodeficiency virus (HIV) patient, which turned out to be a tumor, necessitating the need for keeping a broad differential, a high degree of clinical suspicion, and long-term follow-up for the optimal management of the patient.

Introduction Parathyroid crisis is a serious, life-threatening complication of primary hyperparathyroidism (PHPT) which causes severe symptomatic hypercalcemia and affects multiple organ systems. PHPT is far less common in children and young adults, but they are frequently symptomatic often with kidney and skeletal involvement. We report a case of young adult who presents with severe symptomatic hypercalcemia with classical skeletal findings. Case A 23-year-old man with past medical history of autism spectrum disorder and obesity presented with extreme fatigue, malaise, epigastric pain, nausea and vomiting for 5 days. Patient also reported diffuse bilateral lower extremity pain for 1 year with weakness and difficulty in ambulation for 1 month. He did not see any provider in the last 2 years. He was not on any prescription or over the counter medications. He was found to have severe hypercalcemia with corrected calcium of 14.7 mg/dL, low phosphorus 1.6 mg/dL, low 25 hydroxy vitamin D <4 ng/mL, very high parathyroid hormone (PTH) 1859 pg/mL and high alkaline phosphatase 1167 U/L. No prior history of hypercalcemia. No family history of hypercalcemia, thyroid cancer, pheochromocytoma, pituitary or pancreatic tumor. CT abdomen was performed on admission due to severe gastrointestinal symptoms which revealed left nephrolithiasis, sclerotic changes in the end plates of the spines and multiple lucent lesions throughout femoral necks, symphysis pubis, and sacroiliac joints. It also showed chronic rib fractures. Knee x ray showed bilateral extensive sub-periosteal, sub-tendinous and subligamentous bony resorption and brown tumors. Patient was treated with aggressive intravenous (IV) hydration, calcitonin and IV pamidronate with gradual improvement in serum calcium. Thyroid ultrasound showed left inferior 3.2 cm mass suspicious for parathyroid adenoma. Surgical team was consulted. Patient underwent left inferior parathyroidectomy along with left hemithyroidectomy due to concern for parathyroid cancer. Surgical pathology showed parathyroid adenoma. Patient required aggressive calcium supplementation, along with vitamin D, calcitriol and magnesium to prevent severe hypocalcemia and hungry bone syndrome. He recovered well and was discharged with outpatient follow up. Conclusion Our case highlights that parathyroid crisis is a serious endocrine emergency associated with significant morbidity and urgent surgical intervention after stabilizing serum calcium level leads to a favorable outcome. The finding of parathyroid adenoma is interesting because the constellation of severe skeletal involvement, nephrolithiasis and significantly elevated PTH and calcium in our patient was concerning for parathyroid carcinoma. Clinicians should consider both in patients with severe hypercalcemia and PTH more than 5 times upper limit of normal. The characteristic finding of osteitis fibrosa cystica in our case is rare in United States and is seen in <2% of patients with PHPT due to routine biochemical screening leading to early diagnosis of asymptomatic cases. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

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