Introduction:
There are variable complications of hyperthyroidism, including atrial fibrillation, heart failure, osteoporosis, and thyroid storm. One infrequent complication of hyperthyroidism is non-diabetic ketoacidosis (NDKA). To the best of our knowledge, our case is the third report of NDKA related to thyrotoxicosis.
Patient concern:
We describe a case of a 41-year-old African lady with no past medical history presented to our hospital with severe abdominal pain and vomiting for three weeks. This was associated with decreased appetite and weight loss.
Diagnosis:
Laboratory findings were significant for high anion gap metabolic acidosis, positive ketones in the urine, and high serum B-hydroxybutyrate. The blood glucose readings and HbA1c were within normal limits. Also, serum lactic acid and salicylate levels were within the normal range. The diagnosis of NDKA was made. Later, the thyroid functions test (TFT) confirmed the diagnosis of primary hyperthyroidism.
Intervention and outcomes:
The patient was managed initially with intravenous fluid and antiemetics. Then, she was started on propranolol and carbimazole. After which, her symptoms improved dramatically, and the metabolic acidosis (with serum ketones) were corrected within a few days of starting anti-thyroid medications.
Conclusion:
Despite its rarity, NDKA can be associated with severe thyrotoxicosis. Vigorous intravenous hydration and anti-thyroid medication are the mainstay treatment. TFT should be requested in a patient with unexplained NDKA
Cervical ribs are rare and usually asymptomatic. Occasionally, they can cause nerve impingements and compressive symptoms. In cervical ribs, osteomyelitis secondary to trauma is unheard of. We report such a case made more interesting by the familial presence of bilateral cervical ribs in two generations, indicating a familial origin.
BackgroundCervical ribs are a rare and usually asymptomatic occurrence. Most are identified incidentally by Roentgenogram (X-rays). However, occasionally they can cause nerve impingements and compressive symptoms. In cervical ribs, osteomyelitis secondary to trauma is unheard of. We report such a case made more interesting by the familial presence of bilateral cervical ribs in 2 generations. This indicates a possible familial origin. Case presentationA 26-year-old woman known to have fibromyalgia presented with left shoulder pain and fever episodes. She was recently discharged from intensive physiotherapy for fibromyalgia management, but the pain aggravated instead of getting better unilaterally in the left arm after discharge. Electric shock-like sensations and reduced strength accompanied this. An evaluation revealed leukocytosis and S. aureus positive blood and urine cultures along with bilateral complete cervical ribs showing pseudoarthrosis of anterior left cervical rib. A collection was noted in the left scalene muscle near the pseudoarthrosis accompanying focal edema suggesting osteomyelitis. Transthoracic echocardiogram (TTE) ruled out infective endocarditis. Thoracic surgery recommended conservative management, and appropriate antibiotics were given, which resulted in the negative culture on day 6. The patient was discharged on appropriate analgesia, and her pain was significantly improved on discharge.ConclusionsThis is the first reported case of osteomyelitis in the cervical rib. This report also highlights the possibility of cervical ribs having a familial origin. Additionally, as in our patient, certain exercises can be a risk factor for inducing TOS in patients with cervical rib.
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