Resident education as a valued activity and as a specific chair function varies inversely with both program size and the percentage of fellows among all trainees.

Myxedema coma (MC) is a rare manifestation of severe hypothyroidism. This is a true endocrine emergency that may remain unrecognized. We present a case of a 49-year-old man who presented to the emergency department with generalized weakness and confusion. He was found to have low temperature, bradycardia, hypoxia, hypotension, glucose of 59 mg/dL, normal electrolytes, thyroid-stimulating hormone of 154 IU/mL, and free T4 of 0.1 ng/dL. His anti-peroxidase antibody level was 99 IU/mL. Echocardiography revealed a normal ejection fraction and no evidence of pericardial effusion. On the basis of his presentation and laboratory findings, he was diagnosed with MC, intubated, and admitted to the intensive care unit. Thyroid hormone replacement and glucocorticoid treatment were initiated immediately. After the clinical improvement, the patient was extubated. MC is associated with a high mortality rate and requires prompt recognition and treatment. This rare case reminds us that MC might still be the first manifestation of primary hypothyroidism, although considered an "old enemy".

Kolber, S., Anderson, R. McD., Campbell, P. E., and Roy, R. N. D. (1979). Aust. Paediatr. J., 15, 47–48. Birth Injury with unusual features simulating Werdnig Hoffmann disease. The clinical and pathological details of a newborn with cerebral birth injury are presented. This case is presented because of the unusual finding of prolonged tongue fasciculation 3 hours after a short period of hypoxic hypoglossal nuclear damage. The pathological distinction between birth injury and Werdnig Hoffmann disease in general and in this particular case is discussed. The case illustrates the value of autopsy examination in resolving diagnostic difficulties particularly when there are genetic implications.

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Objective:To present an unusual patient with Hashimoto thyroiditis, encephalopathy with features of steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT), and acute kidney injury secondary to minimal change renal disease.Methods: We present clinical, laboratory, imaging, electroencephalography, and renal histopathologic findings, and review the relevant literature for evaluation and treatment of SREAT.Results: A 53-year-old woman with a history of hypothyroidism on levothyroxine was admitted for progressive altered mental status and bizarre behavior for 3 weeks. On exam she was lethargic with myoclonic jerks, hypertonia, and hyperreflexia. Laboratory analyses showed thyroidstimulating hormone of 0.057 μU/mL (normal, 0.27 to 4.0 μU/mL), free thyroxine of 1.5 ng/dL (normal, 0.7 to 1.5 ng/ dL), triiodothyronine of 0.7 ng/mL (normal, 0.6 to 1.6 ng/ dL), and elevated anti-thyroid peroxidase (>600 U/L) and antithyroglobulin (57.2 U/L) antibodies. The patient failed to improve with empiric antibiotics and anticonvulsants.She developed oliguric acute kidney injury with proteinuria requiring hemodialysis. Renal biopsy was consistent with minimal change disease and acute tubular necrosis. Further workup failed to identify infectious, structural, toxic, or neoplastic causes of the encephalopathy. SREAT was suspected and the patient was started on high-dose steroid therapy. Both the patient's mental status and renal function significantly improved with steroids and she was discharged home.Conclusion: We present, to our knowledge, the first case of Hashimoto thyroiditis associated with both encephalopathy with features of SREAT and minimal change renal disease. SREAT should be suspected in a patient with Hashimoto thyroiditis and unexplained encephalopathy that fails to respond to treatment. (AACE Clinical Case Rep. 2017;3:e299-e302) Abbreviations: anti-TPO = anti-thyroid peroxidase; CNS = central nervous system; CSF = cerebrospinal fluid; fT4 = free thyroxine; MRI = magnetic resonance imaging; SREAT = steroid-responsive encephalopathy associated with autoimmune thyroiditis; T3 = triiodothyronine; TSH = thyroid-stimulating hormone e300 SREAT Minimal Change Disease, AACE Clinical Case Rep. 2017;3(No. 4)