David Bronsky

A CLINICAL STUDY OF THYROID STORM

Excerpt INTRODUCTION Thyroid storm or crisis is a severe, often fatal exacerbation of the manifestations of hyperthyroidism, which requires prompt recognition and energetic treatment if the patient...

Calcium and the electrocardiogram

Abstract The electrocardiograms of twenty-two patients with hypoparathyroidism were examined during hypocalcemia and compared to those obtained when normocalcemia was restored. Prolongation of the Q-oTc segment causing, thereby, prolongation of the Q-Tc interval was observed in almost all cases and the degree of prolongation was inversely proportional to the level of serum calcium. The duration of the T wave segment in general was unchanged. Changes in the contour of the T waves were observed in all patients. In nine patients these were slight and consisted only of slight elevation, peaking and displacement of the apex to the end of the Q-T interval; in nine patients the T waves showed sharp, late inversions; in one, the T waves were flattened; and in three, tall, peaked T waves were observed. These changes were most pronounced in the right precordial leads. They were observed in all forms of both acute and chronic tetany due to hypoparathyroidism. Upon gradual restoration of the normal serum calcium level by appropriate antitetanic therapy, all electrocardiographic abnormalities were eliminated. Acute infusions of intravenous calcium during the hypocalcemie period, however, achieved only shortening of the Q-oTc and hence the Q-Tc intervals, but had only minor effects on abnormalities of the T wave. This suggests that hypoparathyroid hypocalcemia may produce two distinct effects on the myocardium. One, related to ionic calcium and the permeability of the cell membrane, is responsible for the increased duration of the repolarization phase of the ventricular complex. The other, perhaps related to organic calcium and the contractile substance of the myocardium, inconstantly affects the configuration of the T wave, often causing variations in its polarity.

Calcium and the Electrocardiogram: II. The electrocardiographic manifestations of hyperparathyroidism and of marked hypercalcemia from various other etiologies☆

Abstract The electrocardiograms of twelve patients with hyperparathyroidism and twenty-three patients with marked hypercalcemia from various other etiologies have been studied. In nine patients with hyperparathyroidism repeat electrocardiograms were available for comparison following restoration of the normal serum calcium level. In all patients shortening of the Q-oTc duration was inversely proportional to the serum calcium level. The Q-Tc interval was inversely proportional to the serum calcium level only up to levels of 16 mg. per 100 ml. At levels greater than this, prolongation of the T waves was observed and the Q-T duration, therefore, became disproportionately long. The Q-oTc duration was, however, an accurate electrocardiographic guide to levels of serum calcium up to 20 mg. per 100 ml. A tendency toward prolongation of the P-R interval was often observed. Severe elevation of the serum calcium apparently has no effect upon either the polarity of the T waves, the cardiac rhythm, the P wave, the QRS or the Q-U intervals.

Hypophysial tuberculoma with hypopituitarism

Abstract In this patient with a caseating pituitary tuberculoma the diagnosis of hypopituitarism was established antemortem by modern tests of pituitary function. Pituitary tuberculoma is rare and may resemble pituitary adenoma. Tuberculoma should be considered in patients with hypopituitarism or enlargement of the sella turcica, or both, who have or have had tuberculosis of any site. Antituberculous therapy should be instituted in such patients, especially when surgery is contemplated.

Vibrio fetus endocarditis: Report of 2 cases☆

Abstract The case histories of 2 patients with Vibrio fetus endocarditis have been recorded. The organism apparently has a predilection for the aortic valve, particularly when there is a pre-existing abnormality of this valve. Peripheral vascular manifestations, such as a mycotic aneurysm or thrombophlebitis, have been observed. The infection responds readily to the usual therapeutic doses of chloramphenicol or tetracycline and does not respond to penicillin alone. Vibrio fetus , therefore, should always be considered as a possible cause of bacterial endocarditis.

Familial hypogammaglobulinemia, splenomegaly and leukopenia. With a review of the etiological factors of the hypogammaglobulinemias.

Abstract The death from disseminated histoplasmosis of a patient with hypogammaglobulinemia, increased susceptibility to infection, splenomegaly and leukopenia led to an investigation of his family. Three of his six living children, a thirteen year old boy and six year old fraternal twin girls, were found to have a similar syndrome without evidence of infection with histoplasmosis. The patients father had splenomegaly but no other features of this syndrome. The other members of the family had none of these abnormalities. In the involved members the level of gamma globulins and the degree of immunologic responsiveness, while depressed, were greater than usually observed in other forms of hypogammaglobulinemia. The evidence suggests that this apparently new clinical entity is an hereditary disturbance transmitted possibly by an autosomal dominant gene. The etiological features of the known forms of hypogammaglobulinemia are reviewed and commented upon.

Calcium and the electrocardiogram: III. The relationship of the intervals of the electrocardiogram to the level of serum calcium☆

Abstract The time relations of the electrocardiographic events of the ventricular repolarization process have been correlated with the level of serum calcium in a study of 114 electrocardiograms obtained from thirty-four patients with disease of the parathyroid gland and twenty-three other patients with marked hypercalcemia. The duration of the Q-oTc segment is inversely proportional to levels of serum calcium as high as 20 mg. per 100 ml. The duration of the Q-Tc interval is inversely proportional to the serum calcium level as high as levels of approximately 16 mg. per 100 ml. At higher levels its duration again grows longer. The duration of the T wave is independent of the serum calcium level but is often prolonged at very high levels and may also be prolonged at low levels in individual patients. The duration of the Q-oTc interval is the best guide to the assessment of the serum calcium level from the electrocardiogram. The effects of the serum calcium level upon the human electrocardiogram have been briefly reviewed.

Idiopathic juvenile myxedema and myasthenia gravis: A case with circulating thyroid and skeletal muscle antibodies

Abstract Idiopathic juvenile myxedema developed in a Negro boy when he was fourteen years old. One year later he experienced a transient episode of generalized myasthenia gravis. The diagnosis of myxedema was not made until he was eighteen years old. Two years later, while euthyroid on thyroid replacement therapy, ocular myasthenia gravis intervened and was resistant to drug therapy. Six months later thyroid therapy was inadvertently discontinued, and myxedema recurred. Thyroid replacement therapy made him euthyroid but the myasthenia continued to respond poorly to therapy. Immunologic studies demonstrated circulating antibodies to the thyroid gland and skeletal muscle, as well as antibodies to gastric parietal cells, although there was no evidence of achlorhydria or pernicious anemia. The patients clinical course fluctuated between cholinergic and myasthenie crises. He died at the age of twenty-one. The autopsy findings were meager. The medical literature relating to the concurrence of myasthenia gravis, myxedema and pernicious anemia is reviewed. There is evidence which suggests that these diseases may have in common a defect of the immune process.

Diuretic action of benemid: Its effect upon the urinary excretion of sodium, chloride, potassium and water in edematous subjects

Abstract 1.1. In thirteen subjects with uncomplicated congestive heart failure benemid in dosage of 4 gm. daily produced a significant diuretic response. The mean increment of water excreted on the day of maximal response was 1,330 cc., of sodium 91 mEq. and of chloride 76 mEq./24 hours. A fourteenth subject with associated gout and renal disease showed a lesser but significant response. Diuresis occurred in most instances on either the first or second day of drug administration. 2.2. Water diuresis without enhancement of sodium or chloride excretion occurred in seven other subjects. Failure of diuresis to occur in the remaining five subjects was associated with the presence of hepatic disease, renal disease, hyponatremia and hyponatruria. 3.3. It is postulated that benemid-induced diuresis is the result of decreased tubular reabsorption of water, sodium and chloride.

SERUM PROTEINS IN CYANOTIC AND ACYANOTIC CONGENITAL HEART DISEASE.

Abstract The serum proteins of patients with cyanotic and acyanotic congenital heart disease of different etiologies have been partitioned by paper electrophoresis and compared to those of nutritionally normal patients without heart disease. A lesser concentration of the serum albumins and a greater concentration of the alpha-1 and beta globulins was found in the patients with congenital heart disease than in the control subjects. There was a further statistically significant greater concentration of the beta globulins in the patients with cyanotic congenital heart disease than in those of the acyanotic group. The sequential changes with age of the concentrations of the total proteins and the electrophoretic fractions were not altered by the presence of chronic hypoxemia and right-to-left shunting of blood from the lung.