Diabetes mellitus (DM) and thyroid dysfunction (TD) are common endocrine diseases that often coexist in clinical practice. Prevalence of TD in individuals with DM type 2 ranges from 9.9 to 48%. There are no screening guidelines for thyroid function in patients with DM type 2 as there are in patients with DM type 1. Our previous electronic medical record (EMR) included an aid that imported diabetes metrics, but the current system does not. A previous study at our institution revealed TSH screening rate to be 86.2% in DM type 1 patients. We examined the rate of screening for TD in patients with DM type 2 versus DM type 1 based on the general population guidelines, and we evaluated the effect of EMR aid versus no aid on screening rate. We also analyzed the underlying etiology of thyroid dysfunction in patients with DM type 2 found to have an abnormal TSH. We compared practice patterns with Centricity (EMR aid; from June 1, 2013 to May 30, 2016) and MedConnect (no EMR aid; from January 1, 2017 to December 31, 2019) in both primary care and endocrinology clinics in the MedStar hospital system in Baltimore, MD. A retrospective review was performed on 949 patient charts (MedConnect 498, Centricity 451). Inclusion criteria were DM type 2 diagnosis (ICD code E 11.0 to E 11.9) and age ≥18 years with at least one outpatient clinic visit. Baseline TSH was done in 551 of overall 949 patients (58.1%), with 249 of 451 (55.2%) in Centricity and 302 of 498 (60.4%) in MedConnect. This difference was not significant (P = 0.5). Of the total 551 patients with baseline TSH, 48 (8.7%) had abnormal TSH, of which 35 patients (11.5%) were in MedConnect and 13 (5.2%) were in Centricity (P = 0.01). Of the overall abnormal results, 35 patients (6.3%) had hypothyroidism, 10 (1.8%) had hyperthyroidism, 2 (0.4%) had subclinical hyperthyroidism, and 1 (0. 2%) had subclinical hypothyroidism results. Logistic regression analysis found that the adjusted odds of baseline TSH screening with endocrinologists was 1.54 times higher than with primary care physicians. No significant difference was found in TSH screening in patients with DM type 2 irrespective of EMR aid. A larger proportion of abnormal results were found in MedConnect than in Centricity. Endocrinologists ordered TSH screening more often than primary care physicians. The screening rate of TSH in patients with DM type 2 was lower than that found in our previous study of TSH screening in patients with DM type 1. This was expected as there are no current screening guidelines for TD specific to DM type 2 patients. Further studies are needed, and consideration should be given to screening all DM type 2 patients with symptoms. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
Linear IgA bullous dermatosis is a rare autoimmune blistering disease. Although multiple reports have documented drug exposure as a precipitating factor, formal studies validating the existence of drug-induced LABD are lacking. A 49-year-old man with history of intravenous drug use presented with left hip pain of 3 weeks duration after sustaining a fall. On presentation he was hemodynamically stable and physical examination was notable proximal left thigh tenderness with stiffness and limited range of movement. Laboratory diagnostics were remarkable for elevated inflammatory markers, with no evidence of leukocytosis. CT scan without contrast of the left lower extremity demonstrated severe left hip osteoarthritis without fracture or dislocation. The patient continued to experience severe pain, prompting incision and drainage of the left hip along with acetabuloplasty, removal of the femoral head, and stage I hip replacement with placement of prophylactic prosthetic cement spacer with vancomycin and tobramycin. Within 24 h of surgery, he developed multiple distinct maculopapular/bullous lesions of his torso and medial thigh that rapidly progressed. Punch biopsy was performed and due to involvement of ~ 20% body surface area, he was transferred to a tertiary center. H&E and immunostaining of the histological sample demonstrated linear IgA bullous disease mimicking Stevens-Johnson syndrome. The patient’s bullous lesions improved 2 weeks after discontinuation of vancomycin and initiation of therapy. This case demonstrates the importance of early recognition of the rare adverse effects of commonly used medications. Vancomycin is currently used more frequently given the recent rise in the prevalence of methicillin-resistant Staphylococcus aureus infection. Further studies are needed to understand the pathophysiology, genetic predisposition, and disease penetrance.
Acute psychotic symptoms in young patients are frequently attributed to toxic or infectious causes. After ruling out the most common causes, obtaining a firm diagnosis becomes challenging. In this case report, we present the case of a young woman who presented with acute psychosis after returning from a five-day vacation in Mexico. We treated this as a case of cerebral spinal fluid (CSF)-negative anti-N-methyl-Daspartate receptor (NMDAR) encephalitis, as testing for CSF-NMDA receptor IgG antibodies was negative, and the absence of anti-NMDAR IgG antibodies does not rule out this autoimmune encephalitis. Moreover, IV methylprednisolone remarkably improved our patient's mental status and behavior. Anti-NMDAR encephalitis manifests itself in a variety of ways. As a result, providers must maintain a high level of suspicion based on their clinical assessment, as delays in labs or failure to diagnose early based on the clinical presentation can lead to delays in treatment with which this severe immune-mediated paraneoplastic condition can quickly escalate and have worse consequences. We describe our thought process behind our clinical judgment toward this atypical scenario to contribute to identifying this condition early on in the complex clinical presentation.
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