Joel M. Goldman

Aplastic Anemia Associated with Antithyroid Drugs

Prognosis in aplastic anemia is usually linked to the degree of hypoplasia in the bone marrow and pancytopenia in the blood. The authors were, therefore, intrigued when a patient with methimazole-associated aplastic anemia who satisfied criteria for severe disease recovered rapidly and completely once her drug was withdrawn. Review of the English language literature revealed ten fully documented cases of aplastic anemia associated with use of the antithyroid drugs methimazole, carbimazole, and propylthiouracil. Analysis of the ten and of an eleventh case presented here indicated that the disorder is typically characterized by severe pancytopenia and profound marrow hypoplasia, yet surprisingly good prognosis, ie, minimum survival of more than 70% with partial or complete recovery from symptoms and cytopenias in survivors within 2-5 weeks. The only deaths, both in the 1950s, were from brain hemorrhage in patients who were not transfused with platelets. The discrepancy between the clinical and laboratory severity of antithyroid drug-associated aplasia, on the one hand, and its relatively good prognosis and short term course, on the other, should be kept in mind when considering these patients for bone marrow transplantation or for therapy with antithymocyte globulin.

Hypothyroid Cardiomyopathy: Echocardiographic Documentation of Reversibility

ABSTRACT: The concept of hypothyroid heart disease remains controversial. Although hemodynamic abnormalities have been describecd, the presence of underlying abnormal cardiac structures has not been confirmed. The authors studied 20 hypothyroid patients using M-mode echocardiography before and after 1-thyroxine therapy. Fifteen additional hypothyroid patients were studied using two-dinensional echocardiography to confirm the data of the first study. The findings were the same in both studies: during hypothyroidism, the interventricular septum is thickened, the ratio of septal thickness to left ventricular posterior wall thickening is increased, the right ventricular wall is thickened, regional wall motion of interventricular septum and right ventricular wall is decreased, and global function of the left ventricle is decreased. These findings are reversed with 1-thyroxine therapy; they occur within 6 months of the development of hypothyroidism, but appear unrelated to elevated TSH levels. Whether the thickened interventricular septum and right ventricular wall represent true muscular hypertrophy requires further elucidation. Nevertheless, these data demonstrate the existence of a hypothyroid cardiomyopathy.

Case Report: Advanced Upper Airway Obstruction Caused by Cervical Goiter

Goiters are an unusual cause of advanced upper airway obstruction. Previously described patients have been clearly symptomatic, and most have had substernal goiters. We present a patient with minimal symptoms with severe upper airway obstruction from a cervical goiter despite long-term therapy with thyroid hormone. Her spirometry exceeded criteria for urgent surgery. Patients with large goiters should have spirometry with flow-volume loop performed despite minimal or absent symptoms of respiratory distress.

Diabetic ketoacidosis with alkalemia.

A case of diabetic ketoacidosis presenting with alkalemia (pH, 7.61) instead of acidemia (pH less than 7.35) is discussed. Severe vomiting results in electrolyte depletion and hypovolemia, which in turn results in bicarbonate reabsorption and an alkalemia state despite the presence of ketoacids. Severe respiratory alkalosis can also result in alkalemia. Recognition of the alkalemia and its cause will lead to the institution of appropriate therapy.

Remission of Diabetes After Irradiation of Head and Neck

REFERENCES 1. Surwit RS, Scovern AW, Feinglos MN: The role of behavior in diabetes care. Diabetes Care 5:337-42, 1982 2. Surwit RS, Feinglos MN, Livingston EG, Kuhn CM, McCubbin J A: Behavioral manipulation of the diabetic phenotype in oblob mice. Diabetes 33:616-18, 1984 3. Surwit RS, McCubbin JA, Livingston EG, Feinglos MN: Classically conditioned hyperglycemia in the obese mouse. Psychosom Med 47:565-68, 1985 4. Surwit RS, McCubbin JA, Gerstenfeld DA, McGee DJ, Feinglos MN: Alprazolam reduces stress-induced hyperglycemia in oblob mice. Psychosom Med 48:378-82, 1986 5. Surwit RS, Feinglos MN: The effects of relaxation on glucose tolerance in non-insulin-dependent diabetes. Diabetes Care 6:176-79, 1983 6. Guigliano D: Morphine, opioid peptides and pancreatic islet function. Diabetes Care 7:92-98, 1984

Effect of moderate weight changes on glucose levels.

and weight loss fail, oral hypoglycemics can be used, but primary and secondary failures are common. Insulin can be used next, but large doses are frequently required because of insulin resistance associated with obesity. As a result, weight gain, increased insulin resistance, and increased requirements for insulin frequently occur. The only way to break this cycle is through caloric restriction and weight loss. For five years, we have been following a Type II diabetic patient who demonstrates in a dramatic fashion the

Primary renal candidiasis associated with a penile prosthesis in a diabetic man

Infectious complications of penile prostheses are unusual even in diabetic patients, and generally involve Staphylococcus or gram-negative enteric organisms. This paper presents a diabetic patient who developed fatal, primary renal candidiasis associated with an infected penile prosthesis. He is the fourth patient we have seen with refractory nausea and vomiting associated with a cryptic urinary infection. Invasive Candida should always be considered in a diabetic patient with evidence of a urinary tract infection.