No abstract

positive with elevated ESR and low complement levels. The patient later developed acute hypoxic respiratory failure needing intubation, with drop in hematocrit requiring transfusion. CT angiogram of the thorax revealed bilateral airspace disease consistent with edema or hemorrhage. Broncho-alveolar lavage was done which confirmed pulmonary hemorrhage due to cryoglobulinemia flare secondary to Hepatitis C. He was started on high dose methylprednisolone followed by prednisone 60 mg daily. CD 20 subset of B-cells were found to be elevated and hence he received two infusions of rituximab. Patient improved clinically over the next few days and was discharged on a steroid taper. Cryoglobulins can be found in hematological malignancies, chronic infections like hepatitis C and lymphoproliferative disorders. Pulmonary involvement can include vasculitis, interstitial lung disease and alveolar hemorrhage which is rare but usually life threatening. Only 18 patients have been reported in the literature so far to the best of our knowledge. Therapies include steroids, immunosuppressants, rituximab for maintenance and plasmapheresis for acute emergencies.Case Report: We describe the case of a 40 year old female who was brought with altered mental status, slurred speech and possible seizure. She had a history of pulmonary sarcoidosis with presumed CNS involvement, SLE limited to skin and traumatic brain injury. She had been noncompliant with immunosuppressive and antiepileptic therapy. She was oriented to herself only. On physical examination, she had dry mucus membranes. Neurological examination was unremarkable. Differential diagnosis at that point was altered mental status secondary to infectious etiology, post-ictal stage or flare up of neurosarcoidosis. Laboratory workup was essentially unremarkable. Urine analysis was suggestive of urinary tract infection (UTI). EEG did not reveal any seizure activity. MRI of the brain showed new punctate right parietal infarctions. Treatment with empiric antibiotics for UTI showed very little improvement in her confusion. Over the next 5 days, her sodium level started to rise and reached a maximum of 170mmol/L, with some rise in urine output (UO). D5W administered as therapy showed no improvement in sodium levels. CT of the head was unremarkable. DDAVP stimulation test confirmed central diabetes insipidus (CDI). A thorough hypothalamic-pituitary axis evaluation revealed low normal levels of TSH, FSH, LH consistent with pituitary dysfunction, later confirmed by MRI. She was started on DDAVP and levothyroxine resulting in normalization of sodium levels. Discussion-The influence of thyroid on renal function has been discussed extensively but less often put into clinical practice. The thyroid hormones affect the water/ sodium metabolism by their direct effect on renal tubular function. Hypothyroidism, results in decreased glomerular filtration rate and increased serum creatinine. Here we present a unique case of neurosarcoidosis induced CDI with low UO. The role of hypothyroidism in masking po...

No abstract

No abstract