LOW SUGAR? NOT SO SWEET: A CASE OF OSMOTIC DEMYELINATION SYNDROME SECONDARY TO RAPID CORRECTION OF HYPERGLYCEMIA Hanna Almoaswes, Farhan Mohiuddin., Ross Dies, Blane Edwards, Hannah Zulli, Stephen Ford, Allison Pinner; Louisiana State University School of Medicine, New Orleans, LA.
Introduction: Osmotic demyelination (ODS) syndrome is characterized by non-inflammatory demyelination in response to an osmotic challenge. The mechanism involves osmotic stress leading to apoptosis of oligodendrocytes and subsequent demyelination in myelin-rich regions such as the pons and basal ganglia. This can lead to symptoms of altered mental status, dysarthria, dysphagia, and quadriparesis. Cases of ODS have been associated to rapid correction of hyperglycemia. Case: A 37-year-old female with type 2 diabetes and recent hospital admission for hyperglycemic hyperosmolar state (HHS) presented for abdominal pain and weakness. The patient noted that she began having generalized weakness worse in her left lower extremity and exacerbated by exertion. These symptoms acutely worsened, and she began with emesis, dysphagia, and dysarthria. Workup included a negative CT and CT angiogram of the brain. Labs were significant for hyperglycemia in the 400s mg/dL, bicarbonate of 22 mmol/L, anion gap of 12, beta hydroxybutyrate 2.57 mmol/L, serum osmolality of 300 mOsm/kg, and ketonuria. She was
treated for hyperglycemia and gastroparesis, and an MRI was ordered to complete her stroke work- up which showed an abnormal restricted diffusion in central pontine fibers suggestive of osmotic demyelination. On review of the patient’s prior labs, her serum sodium had ranged from 134-139 mmol/L over the last several months. Her glucose varied with readings between 458 and 167 mg/dL in a twenty- four-hour period. This created suspicion for rapid correction of glucose as etiology of her ODS. During her hospitalization, insulin was initially titrated to a glucose of 200-300 mg/dL, and endocrinology specialists recommended a decrease in A1C by 1.5% over 3 months. After roughly three weeks, her glucose goal was decreased to 140-180 mg/dL. Clinically, the patient’s dysarthria, dysphagia, oral intake, and strength gradually improved with therapies. Discussion: Widely accepted international guidelines exist for correction of severe hyponatremia to avoid osmotic demyelination. However, ODS associated with rapid changes in blood glucose
is not well documented, and there are no specific guidelines to direct management.
INVESTIGATION OF CYTOLOGICAL CHANGES IN BENIGN THYROID NODULES POST-RADIOFREQUENCY ABLATION Milee Patel, Emad Kandil, Mohammad Hussein, Kavin Sugumar, Eman Toraih; Tulane University School of Medicine, New Orleans, LA.
Background: Radiofrequency ablation (RFA) has recently gained traction as a minimally invasive treatment for benign thyroid nodules. Yet, concerns persist regarding the potential cytological progression following RFA. This study aimed to examine the incidence of cytological progression from benign (Bethesda 2) to indeterminate (Bethesda 3-4) and assess the long-term safety and efficacy of RFA in the management of benign thyroid nodules. Methods/Results: In this prospective study, patients with benign thyroid nodules who underwent RFA between July 2019 and December 2023 at a single institution were included. Fine-needle aspiration
(FNA) cytology was performed pre- and post- ablation to evaluate the incidence of progression to indeterminate cytology. Efficacy was measured by changes in nodular volume and thyroid function, while safety was assessed based on the rate of complications. A total of 312 benign thyroid nodules were treated with RFA. Post-ablation FNA revealed cytological progression from Bethesda 2 to Bethesda 3 in 12 cases (3.84%), with all nodules subsequently confirmed as benign through the Afirma Gene Sequencing Classifier. Three patients required surgical resection due to insufficient volume reduction, and final histopathology verified the benign nature of the nodules. RFA led to a significant 69
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