The recommended amount of iodide consumption for the majority of adults is approximately 150 mcg per day. During a computed tomography scan, patients can receive 14 to 35 million mcg of iodinated contrast. A 46-year-old African female with no known prior thyroid disease presented with dyspnea and tachycardia. She underwent computed tomography angiogram of the chest to rule out pulmonary embolism. She had evidence of hyperthyroidism four hours after receiving iodinated contrast. We presumed that her hyperthyroidism was a consequence of the Jod-Basedow phenomenon due to an underlying multinodular goiter that was later discovered.

INTRODUCTION: Sickle cell intrahepatic cholestasis (SCIC) with acute liver failure (ALF) is a severe variant of Sickle cell hepatopathy that has significant mortality despite aggressive supportive therapy. Even though packed red blood cells (pRBCs) exchange has vastly improved outcomes, there is little evidence on alternative therapies to treat those who show inadequate response to pRBC exchange transfusion (ET). CASE DESCRIPTION/METHODS: A 37-year-old African American male with Hemoglobin SS disease complicated by chronic pain and nephropathy ESRD on dialysis, who was referred to our liver transplant program for ALF. Patient presented with lethargy and fever. Upon arrival he was somnolent, jaundiced, cardiopulmonary and abdominal exam was unremarkable, no focal neurological deficits but presence of asterixis was noted. Hb 6 g/dL, WBC 13,000/µL, Platelet 147,000/µL, corrected reticulocyte count 5.9%, LDH 1816 IU/L, Total bilirubin 49 mg/dl, direct bilirubin 37 mg/dL, ALT 112 IU/L, AST 259 IU/L, ALP 296 IU/L, albumin 3.5 g/dL and INR 1.9. CT head was unremarkable. MRCP revealed hepatomegaly, cholecystectomy without evidence of biliary obstruction. Ultrasound duplex liver showed patent hepatic vessels. Other causes of ALF including drugs, alcohol, acetaminophen, and viral hepatitis etiology were excluded. N-acetylcysteine infusion protocol was initiated. Patient received 10 units pRBC ET. Despite successful reduction of HbS fraction from 79.5% to 16%, the patient remained encephalopathic with asterixis and developed severe headache. Furthermore, bilirubin and INR continued to rise (Figure 1). Transjugular liver biopsy revealed portosystemic gradient of 20 mmHg. Liver pathology showed sinusoidal distension by sickled erythrocytes, zone 3 predominant intracanalicular cholestasis with ballooned hepatocytes and hepatocyte siderosis (Figure 2). Total 9L of plasma ET was performed on 2 consecutive days with successful reversal of headache, encephalopathy, and coagulopathy. His bilirubin levels continue to decline. He did not require a liver transplant and was discharged home with prophylaxis pRBC ET to maintain HbS fraction < 30%. DISCUSSION: SCIC with ALF is rare with significant mortality. Plasma ET was used in our patient whom ALF was refractory despite adequate pRBC ET (HbS < 30%). Larger studies are needed to evaluate plasma ET benefit in sickle cell disease patients with end organ damage, regarding treatment outcome as well as transplant-free survival.

Angioedema is an allergic reaction that usually involves the face and pharynx. Intestinal angioedema is a rare subtype that is typically linked to the use of angiotensin-converting enzymes inhibitors (ACEIs). Intestinal angioedema is challenging to diagnose, as it can mimic gastroenteritis or other inflammatory bowel conditions. Herein, we present a 34-year-old female who presented with recurrent episodes of abdominal pain. She underwent extensive workup for her abdominal pain and rash, and all was unrevealing except for high Immunoglobulin E (Ig E). Multiple imaging came back negative for any pathology. The allergy and immunology team evaluated the patient, and they believed her symptoms are likely caused by isolated intestinal angioedema with a histamine-related rash. She was started on high doses of antihistamines; her symptoms partially improved. Subsequently, she was started on a trial of omalizumab, which resulted in complete resolution of her symptoms. In conclusion, intestinal angioedema is a rare disease that should be suspected in cases of recurrent abdominal pain with negative workup, especially if the patient is taking ACEIs. Few cases were reported in the literature for patients on ACEI. In our case, the diagnosis was a challenge, as the patient was never on ACEI.

Introduction: Primary hypoparathyroidism is a relatively rare cause of hypocalcemia with cases of primary hypoparathyroidism in the US estimated at 24–37 per 100,000 with 75% being due to neck surgery and 25% due to non-surgical causes. The clinical presentation depends on the acuity of development of hypocalcemia and the absolute level of serum calcium. Here is a case of severe hypocalcemia secondary to hypoparathyroidism of unknown etiology followed by the development of severe aplastic anemia.Case report: A 60-year-old Caucasian male presented to our ED with fatigue, tingling, numbness in extremities and was found to have severe hypocalcemia at 6.8 mg/dl and decreased PTH at 11 pg/mL. Calcium levels 8 months prior to presentation were normal. No history of neck surgery, radiation exposure or family history of autoimmune disorders. Initial workup included creatinine, magnesium and TSH were normal. Autoimmune panel (including PTH Abs and CaSR Abs), HIV test, hepatitis panel, serum protein electrophoresis were also negative. Infiltrative causes of hypoparathyroidism including hemochromatosis, malignancy and granulomatous diseases like sarcoidosis were ruled out with tissue sampling and lab workup. Sestamibi scan obtained showed no parathyroid activity in all four glands. Patient was initially treated with IV calcium to improve serum calcium to more than 7.5mg/L and then switched to oral calcium carbonate 500mg TID and calcitriol 0.5mcg BID until the calcium level was brought up to the lower limit of normal. Patient was seen in follow up and was doing well without any adverse effects. Consequently, the patient developed severe aplastic anemia which was treated with steroids and interestingly, has caused a gradual but consistent increase in PTH levels.Discussion: Idiopathic hypoparathyroidism (IHP) is a rare condition with an incidence of 0.02%. IHP can occur sporadically or as part of a familial condition with autosomal dominant, recessive and X-linked recessive patterns. Certain autosomal forms of hypoparathyroidism have mutations in the PTH gene and Calcium-Sensing Receptor (CaSR) gene. The challenging nature of this case is due to the subacute nature of the patient’s presentation along with the lack of a definitive etiology. The patient’s negative family history and older age makes genetic causes less likely, and Abs against PTH and CaSr were also negative. The patient’s diagnosis of severe aplastic anemia has made the case more fascinating, especially since its management with steroids has causes an improvement in the patient’s PTH status. Regardless of etiology, primary hypoparathyroidism is treated with lifelong supplementation of calcium and calcitriol to a goal serum calcium level at the lower limit of normal. Reference: Abate EG,Clarke BL. Review of Hypoparathyroidism. Front Endocrinol (Lausanne). 2017; 7:172. Published 2017 Jan 16

INTRODUCTION: Chronic HCV is one of the leading causes of cirrhosis and hepatocellular carcinoma in the United States. Current national data shows 75% of HCV infected adults are born between 1945–1965 (baby boomers). The USPSTF recommends one-time screening of this population for HCV. The aim of our study is to assess the impact on the rate of detection of HCV by implementing a screening tool in the health maintenance tab for this subset of high-risk individuals and improving treatment rates METHODS: In March 2017, our health center established a Health Maintenance tab for Screening HCV for all baby boomers.Yearly data regarding the number of patients screened, patients who had positive screening, data on confirmatory testing and the number that finally received treatment was collected between March 2012-February 2018. The percentage of patients screened and later confirmed positive was calculated. RESULTS: We compared the screening of baby boomers 5 years prior to the health maintenance tab and 1 year after it was introduced. In 2012, a total of 30915 patients were seen in the health facility with 1.83% screened, followed by 2.57% of 30679 patients in 2013, 2.4% from 29614 patients in 2014, 1.8% from 29081 patients in 2015, 1.7% from 28887 patients in 2016 and 7.8% from 29896 in 2017. There was 4.5 times increase in the screening of patients after the intervention. The number of patients who were screened positive with HCV Antibody from March 2012 to Feb 2018 were 15, 15, 55, 73, 64 and 182 in the consecutive years. The number of patients that had confirmatory testing with HCV RNA titers from 2012 to 2018 was 80%, 60%, 83%, 80%, 71.8% and 77.4%. Of those who had HCV RNA titers ordered between 2012 to 2018, the number of patients who were confirmed positive were 9 in 2012, 4 in 2013, 30 in 2014, 35 in 2015, 18 in 2016. The year after the intervention identified 73 patients who had confirmed Hepatitis RNA titers. Of the patients identified as having the infection, 4 were treated in 2012, 2 in 2013, 25 in 2014, 22 in 2015, 18 in 2016 and 52 after the intervention. CONCLUSION: Screening baby boomers using the health maintenance tab in the Electronic health record identified more patients who may in fact have Subclinical HCV. Identifying these individuals earlier would help initiate necessary treatment promptly and help prevent chronic complications. However, treatment of identified patients remains a challenge as other socioeconomic problems prevents individuals getting complete eradication of the infection