A Case of Cerebral Venous Sinus Thrombosis Presenting with Delirium

A 73-year-old woman with no history of headache, seizure and trauma was admitted to the emergency department complaining about fever, vomiting and delirium for 3 days. She was lethargic upon admission and her blood pressure (BP) was recorded as 140/90 mm/Hg, her pulse rate (PR) as 75 beat/min and oral temperature as 38 °C. No localizing findings were observed in neurological examinations.  Laboratory findings were as follows:  White Blood Cell (WBC) count: 7,000/mm3, Hemoglobin: 13 g/dl, Platelet count: 300000. Lumbar CSF, blood and urine cultures were found to be negative for infections. Brain Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) were also performed. MRI showed filling defects in the left transverse sinus, the jugular bulb and the internal jugular vein. Moreover, hyper-intense signal was observed in the left temporal lobe (T1 sequence) suggesting hemorrhagic venous infarction (Figure1). The obtained results were confirmed by Magnetic Resonance Venography (MRV) of the brain (Figure2). The patient underwent anticoagulation therapy using LMWH and she was? hydrated using physiologic solution. The patient’s symptoms disappeared and she was then followed up regularly

Necrotizing Fasciitis in a Patient with Diabetes Mellitus

Case presentation: A 46-year-old man was admitted to the emergency department with complaints of fever and skin lesions in the right leg since 3 days before. Moreover, he revealed a history of 5 years of poorly controlled diabetes mellitus despite being on oral medication. On physical examination, he was oriented and the following vital signs were observed: blood pressure: 80/60 mmHg; pulse rate: 90 beats/min; respiratory rate: 18 breaths/min; and oral temperature: 38 °C. Two large erythematous lesions with central necrosis in the upper segment of the right leg were noticed. Further examination revealed crepitation of the same right leg segment. Laboratory findings revealed the following: white blood cell (WBC) count, 17,000/mm3; hemoglobin, 15 g/dl; sodium, 125 meq/l; potassium, 3.8 meq/l; blood glucose, 400 mg/dl; blood urea nitrogen, 45 mg/dl; creatinine, 2.4 mg/dl; and bicarbonate,13 meq/l. Plain X-ray of right leg revealed gas formation in the soft tissues, which was a diagnostic criterion for necrotizing fasciitis (Figure 1). The patient was treated immediately with intravenous fluid, broad spectrum empiric antibiotics (meropenem plus vancomycin), and insulin infusion; moreover, urgent surgical consultation was requested. He underwent emergency debridement within few hours of hospitalization

A 10-year-old Male with Osteogenesis Imperfecta; Zebra Lines

Case presentation: A 10-year-old male who was a known case of osteogenesis imperfecta was referred to our clinic for follow up. He had osteogenesis imperfecta since birth with multiple fractures. He was treated with pamidronate every 3 months. He did not have a new fracture after treatment. Hand radiography showed multiple metaphyseal bands, called zebra lines, parallel to the growth plate. Learning points: Osteogenesis imperfecta is a congenital disorder due to a mutation in the CoL1A1 or CoL1A2 gene. It is often called brittle bone disease. The incidence of osteogenesis imperfecta is 1 in 10000–20000 birth. These patients are often characterized by multiple fractures with minimal or no trauma, skeletal deformity, and short stature. Radiological findings show generalized osteopenia, skeletal deformity, and bone fractures. The bisphosphonates are analogs of pyrophosphate that inhibit osteoclast activity. Pamidronate increased bone mineral density, decreased bone fracture rate, decreased pain, and improved the functional ability (3). Radiography findings after treatment with bisphosphonate showed dens metaphyseal lines in the long bones, so-called zebra lines. These lines were parallel to the growth plate. Each line corresponded to one intravenous treatment course. The bone growth rate and the time gap between two treatment courses were determined from the space between two zebra lines

Fever and Flank Pain in a Diabetic Woman; a Case of Emphysematous Pyelonephritis

Case presentation: A 55–year-old diabetic woman presented to the emergency department with a complaint of nausea, vomiting, right upper abdominal pain, and fever with chills since 10 days. She revealed a 10-year history of poorly controlled diabetes on oral agent and kidney stones. On examination, the patient was found to be febrile (39 ℃) with tenderness in the right renal angle. Laboratory data has revealed the following findings: blood sugar (BS: 480 mg/dl), HbA1C: 13%, complete blood count (white blood cells (WBC): 13,900; polymorphonuclear leukocytes (PMN): 80%; lymphocytes: 18%; hemoglobin: 12 g/dl; and platelet: 118,000), blood urea nitrogen (BUN): 79 mg/dl, creatinine (Cr): 2.3 mg/dl, and erythrocyte sedimentation rate (ESR): 103 mm in 1 h. The urine analysis revealed 12–13 WBCs, 7–8 red blood cells (RBCs), and several bacteria. Urgent ultrasound indicated a heterogeneous mass in with focal echoes suggesting intraparenchymal gas, along with gross hydronephrosis and numerous stones, in the right kidney. The patient was treated with hydration, insulin, and intravenous imipenem 500 mg twice daily (adjusted with her creatinine). After 48 h, blood culture report was negative, whereas urine culture revealed presence of imipenem sensitive Citrobacter. Computed tomography (CT) scan without contrast indicated an enlarged, edematous right kidney with multiple air bubbles and air fluid levels. Based on the clinical and radiological findings, diagnosis was confirmed and right urgent nephrectomy was performed after 36 h of admission. The histopathology of the removed kidney revealed acute or chronic inflammation and necrosis, extending to the perinephric fat. The patient was discharged without any major complication after a 14-day hospital stay. Learning points: Emphysematous pyelonephritis (EPN) is an acute, severe, and gas producing necrotizing bacterial infection that affects the renal parenchymal and surrounding tissues. The predisposing factors include: diabetes mellitus, urinary tract obstructions, and immune incompetence. Diabetes mellitus is the most commonly associated factor and up to 90% of the patients report uncontrolled diabetes mellitus. Bilateral renal involvement and obstruction has been observed in 5% and 30% of the patients, respectively. The most common pathogen causing EPN is Escherichia coli. Other pathogens have been reported including Klebsiella pneumoniae, Proteus mirabilis, and Pseudomonas aeruginosa. Several factors contribute in the pathogenesis of EPN including high levels of glucose inside the tissues, gas forming bacterial infection, impaired vascular blood supply, reduced host immunity, and obstruction in the urinary system. Clinical manifestations are similar to acute pyelonephritis, including fever, nausea, vomiting, and flank pain; however, often they do not respond to the medical treatment. Laboratory investigations often reveal leukocytosis with a shift to the left, thrombocytopenia, and elevation of the serum creatinine levels. As aforementioned, urine analysis reveals WBCs, RBCs, and several bacteria. The diagnosis is confirmed by radiological imaging. A plain abdominal X-ray can be more specific than the ultrasound, indicating the presence of gas in the kidney. The gold standard is abdominal CT scan that reveals the presence of gas and obstruction in the urinary tract systems. Treatment should commence with fluid resuscitation, antibiotic therapy, and control of blood sugar and electrolytes. Percutaneous drainage or DJ-stenting is recommended in the patients with urinary tract obstruction. If the aforementioned measures fail, then emergency nephrectomy should be considered

Pituitary Macroprolactinoma with Mildly Elevated Serum Prolactin: Hook Effect

A 45-year-old man was admitted in our department with complaints of severe headache for over 6 months period. He also suffered from several problems such as visual field defect, decreased energy and libido, body hair loss, cold intolerance, decreased appetite and dry skin. On physical examination, he was afebrile: BP (blood pressure): 110/70 mm/Hg, PR (pulse rate) :65 beat/min, BMI (body mass index): 24. He had no terminal hair on face or chest and subcutaneous adipose tissue mass had been decreased substantially. Laboratory tests revealed; Hb: 12 g/dL (N: 14–17 g/dL), Total testosterone: 1.2 ng/mL (N:–-10 ng/mL), Luteinizing hormone (LH):3.3MIU/mL (N:1–8 MIU/mL), Follicle Stimulating hormone (FSH):1.3 MIU/mL (N:1–7 MIU/mL), T4:3.4 micg/dL (N:4–12 micg/dL), TSH:0.6 MIU/mL (N:0.5–5 MIU/mL), Prolactin:100 ng/mL (2–24 ng/mL), serum cortisol:6 MIU/mL (N:4–21 MIU/mL), IGF1:162 ng/mL (50–245). Pituitary MRI showed macroadenoma (29*16*14 mm) in left side of sella turcica which bulged to suprasellar cistern with pressure effect on left optic nerve (Figure 1, 2). Visual field examination revealed mild temporal hemianopia. These findings are consistent with macroadenoma and mild prolactin elevation. We also observed a discrepancy between pituitary tumor size and prolactin level. The correct estimate of serum prolactin was obtained after serial dilutional measurement. Serum prolactin after dilution was 6470 ng/mL. With these findings pituitary macroadenoma was diagnosed and treatment with cabergoline (dopamine agonist) 0.5 mg/week was started. After one month follow-up he had no symptoms, visual field defect was improved and pituitary MRI showed significant shrinkage of tumor

Coronavirus Disease (COVID-19): 10 Questions and Discussion Points for Diabetes and COVID-19

The COVID-19 pandemic is now an international concern. COVID-19 is first reported in Wuhan, China on 31 December 2019 and affects different people in different ways. Evidence suggests that people with underlying disease are at higher risk for more severe disease. People with diabetes are not only more likely than the general population to have COVID-19 but also they are among those high-risk categories that can have serious illness if they get the virus

Pituitary Macroprolactinoma with Mildly Elevated Serum Prolactin: Hook Effect

A 45-year-old man was admitted in our department with complaints of severe headache for over 6 months period. He also suffered from several problems such as visual field defect, decreased energy and libido, body hair loss, cold intolerance, decreased appetite and dry skin. On physical examination, he was afebrile: BP (blood pressure): 110/70 mm/Hg, PR (pulse rate) :65 beat/min, BMI (body mass index): 24. He had no terminal hair on face or chest and subcutaneous adipose tissue mass had been decreased substantially. Laboratory tests revealed; Hb: 12 g/dL (N: 14–17 g/dL), Total testosterone: 1.2 ng/mL (N:–-10 ng/mL), Luteinizing hormone (LH):3.3MIU/mL (N:1–8 MIU/mL), Follicle Stimulating hormone (FSH):1.3 MIU/mL (N:1–7 MIU/mL), T4:3.4 micg/dL (N:4–12 micg/dL), TSH:0.6 MIU/mL (N:0.5–5 MIU/mL), Prolactin:100 ng/mL (2–24 ng/mL), serum cortisol:6 MIU/mL (N:4–21 MIU/mL), IGF1:162 ng/mL (50–245). Pituitary MRI showed macroadenoma (29*16*14 mm) in left side of sella turcica which bulged to suprasellar cistern with pressure effect on left optic nerve (Figure 1, 2). Visual field examination revealed mild temporal hemianopia. These findings are consistent with macroadenoma and mild prolactin elevation. We also observed a discrepancy between pituitary tumor size and prolactin level. The correct estimate of serum prolactin was obtained after serial dilutional measurement. Serum prolactin after dilution was 6470 ng/mL. With these findings pituitary macroadenoma was diagnosed and treatment with cabergoline (dopamine agonist) 0.5 mg/week was started. After one month follow-up he had no symptoms, visual field defect was improved and pituitary MRI showed significant shrinkage of tumor

Ethical challenges in gestational diabetes

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Effect of Juglans regia L. Ridge on Blood Lipids in Type 2 Diabetic Patients with Dyslipidemia: A Double-blind Placebo-Controlled Randomized Clinical Trial

Background: Dyslipidemia and diabetes mellitus are two important risk factors for coronary artery disease and stroke. Traditionally, herbal remedies like walnut were used to treat dyslipidemia. The study aimed to evaluate the effect of Juglans regia L. (J. regia L.) internal septum extract (ISE) on lipid profile of patients with type 2 diabetes. Methods: After preparing hydroalcoholic ISE, Folin-Ciocalteau (FC) and AlCl3 colorimetric methods were used to determine total phenolic content (TPC) and total flavonoid content (TFC), respectively. In a randomized, double-blind placebo-controlled trial, 86 diabetic patients with dyslipidemia were randomly divided into equal groups and received ISE or placebo capsules 1500 mg/day for 12 weeks. Lipid profile, LFT, SCr, urea, hemoglobin A1c (HbA1c), blood pressure (BP), weight, waist and waist to hip ratio (WHR) were determined at baseline and after 12 weeks. The paired sample t-test and independent sample t-test were performed to compare the differences within and among the groups, respectively. This study was registered in the Iranian registry of clinical trials (IRCT ID: IRCT20201227049850N1). Results: The mean (SD) of TPC and TFC were measured based on 74.57 (5.20) milligram gallic acid equivalent/gram of dry extract (mg GAE/g DE) and 14.11 (2.73) mg quercetin equivalent/g of DE (mg QE/g DE), respectively. During the trial, 26 patients lost follow-up, and the study continued with remaining 60 patients. After intervention, there were no significant differences in LDL-C (p=0.44), total cholesterol (TC) (p=0.42), high-density lipoprotein cholesterol (HDL-C) (p=0.99), triglyceride (TG) (p =0.32) and Lp(a) (p=0.55) between two groups. Moreover, no significant (p>0.05) changes were observed in HbA1c, LFT, SCr, urea, BP, weight, waist, and WHR among the groups after 12 weeks. Conclusion: Our findings showed J.regia L. ISE had no significant effect on lipid profile compared to placebo. Moreover, no adverse effect was observed on liver and kidney function tests

The hypoglycemic effects of Juglans regia L. internal septum in type 2 diabetic patients: A double-blind, randomized, placebo-controlled clinical trial

Introduction: The internal septum of J.regia is traditionally used to control diabetes, and its effectiveness has been shown in animal studies. Accordingly, human clinical trials are needed to confirm its effectiveness on hemoglobin A1c (HbA1c), fasting blood sugar (FBS), blood insulin level, and insulin resistance as a complementary for better control of type 2 diabetes. Methods: This study was a randomized, double-blinded, controlled trial. The lyophilized powder of extract of the internal septum of J.regia was used to fill the capsules. Sixty type 2 diabetic patients were randomly divided into two groups. 500 mg capsules three times daily before meal was added to their routine drug regimen, and HbA1c, FBS, and blood insulin level were checked at the baseline and after three months. Results: Sixty patients completed the study. The mean(±SD) age of patients was 49.1(10.2) and 50.9(12.7) years in the placebo and J.regia groups, respectively. We observed that J.regia internal septum increases the level of HbA1c by about 0.02 units, but this effect was not significant (MD=0.02,95%CI=-0.36 to 0.40, P=0.93). Regarding the impact of capsules on insulin level, it seems that J.regia-containing capsules can raise insulin level by one unit. However, it was not significant (MD=1.01,95%CI=-0.86 to 2.88, P=0.28). As for FBS, it can cause a decrease of four units, but this effect is also not significant (MD=-3.98,95%CI=-18.33 to 10.37, P=0.58). Conclusion: Based on our study, the internal septum of J.regia has no significant effect on HbA1c, FBS, and insulin resistance. Moreover, no specific adverse reaction was observed in any of the patients