Background Drug induced liver injury (DILI) is a rising morbidity amongst patients with COVID-19 clinical syndrome. The updated RUCAM causality assessment scale is validated for use in the general population, but its utility for causality determination in cohorts of patients with COVID-19 and DILI remains uncertain. Methods This retrospective study was comprised of COVID-19 patients presenting with suspected DILI to the emergency department of Weill Cornell medicine-affiliated Hamad General Hospital, Doha, Qatar. All cases that met the inclusion criteria were comparatively adjudicated by two independent rating pairs (2 clinical pharmacist and 2 physicians) utilizing the updated RUCAM scale to assess the likelihood of DILI. Results A total of 72 patients (mean age 48.96 (SD ± 10.21) years) were examined for the determination of DILI causality. The majority had probability likelihood of “possible” or “probable” by the updated RUCAM scale. Azithromycin was the most commonly reported drug as a cause of DILI. The median R-ratio was 4.74 which correspond to a mixed liver injury phenotype. The overall Krippendorf’s kappa was 0.52; with an intraclass correlation coefficient (ICC) of 0.79 (IQR 0.72–0.85). The proportion of exact pairwise agreement and disagreement between the rating pairs were 64.4%, kappa 0.269 (ICC 0.28 [0.18, 0.40]) and kappa 0.45 (ICC 0.43 [0.29–0.57]), respectively. Conclusion In a cohort of patients with COVID-19 clinical syndrome, we found the updated RUCAM scale to be useful in establishing “possible” or “probable” DILI likelihood as evident by the respective kappa values; this results if validated by larger sample sized studies will extend the clinical application of this universal tool for adjudication of DILI.

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

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Thyrotoxic periodic paralysis (TPP) is a rare disease seen predominantly in men of Asian origin. It should be considered in the differential diagnosis of patients with acute onset of weakness, and it is reversible after the correction of serum potassium. TPP can rarely be the initial presentation of Graves' disease.

Polycythemia vera (PV) is a myeloid stem cell disorder characterized by excess red cell mass. The two major complications of PV are thrombosis and bleeding. Atrial fibrillation is a potentially devastating condition that can complicate the course of PV. We describe a case of a 65-year-old woman with PV who presented with new-onset atrial fibrillation. The atrial fibrillation was aborted successfully, and the patient was started on oral anticoagulation with rivaroxaban. PV with atrial fibrillation poses a challenge in management due to the risk of thrombosis and bleeding. Despite the lack of standard recommendations or guidelines, this case highlights that oral anticoagulation therapy can be safe and convenient for such patients.

Insulinomas are rare functioning neuroendocrine (NEN) tumors. Up to 10% of insulinomas are associated with multiple endocrine neoplasia 1 (MEN1). Most of the tumors present with symptomatic hypoglycemia. Several non-invasive and invasive techniques are used to localize the lesion. We present a case of insulinoma How to cite this article: Umer W, Mohammed AS, Khan AA, Saddique MU, Zahid M. A case report of insulinoma presenting with seizures and localized on endoscopic ultrasound.

Insulinomas are rare functioning neuroendocrine tumors. Up to 10% of insulinomas are associated with multiple endocrine neoplasia 1 . Several non-invasive and invasive techniques are used to localize the lesion. We present a case of insulinoma presenting with seizures episode , with negative non-invasive imaging results ,diagnosed with endoscopic ultrasound.