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Pancytopenia, Cholestatic Jaundice, and Pulmonary Hypertension: Rare Extrathyroidal Manifestations of Graves' Disease

Khor J, Jamie Hong Im T

Cureus, 2024 Oct;16(10):e71175.
PMID: 39525157 DOI: 10.7759/cureus.71175

Pancytopenia, cholestatic jaundice, and pulmonary hypertension are rare but serious complications of thyrotoxicosis. It is uncommonly seen in patients with hyperthyroidism and may result in treatment-related dilemmas as bone marrow suppression and drug-induced liver injury are known complications of anti-thyroid treatment. We describe a case of Graves' disease presenting with all three manifestations of pancytopenia, cholestatic jaundice, and pulmonary hypertension during a relapse of thyrotoxicosis. Her anti-thyroid medications were initially withheld for fear of worsening the above manifestations, but no improvement was noted clinically or biochemically. Other lab investigations, such as hepatitis serology, autoimmune liver markers, and ultrasound, were unrevealing. Anti-thyroid medications were subsequently reinitiated after discussion with the endocrine team, with improvements in clinical condition, as well as full blood counts and liver function tests. Pulmonary hypertension also improved on her latest echocardiography. This case report intends to shed light on the atypical extrathyroidal manifestations of Grave's disease and the importance of recognition and therapy.
CHARACTERISATION AND EVALUATION OF AL2O3:C-BASED OPTICALLY STIMULATED LUMINESCENT DOSEMETER SYSTEM FOR DIAGNOSTIC X-RAYS: PERSONAL AND IN VIVO DOSIMETRY

Wong JHD, Bakhsh M, Cheah YY, Jong WL, Khor JS, Ng KH

Radiat Prot Dosimetry, 2019 Dec 31;187(4):451-460.
PMID: 31650160 DOI: 10.1093/rpd/ncz186

This study characterises and evaluates an Al2O3:C-based optically stimulated luminescent dosemeter (OSLD) system, commercially known as the nanoDot™ dosemeter and the InLight® microStar reader, for personal and in vivo dose measurements in diagnostic radiology. The system characteristics, such as dose linearity, reader accuracy, reproducibility, batch homogeneity, energy dependence and signal stability, were explored. The suitability of the nanoDot™ dosemeters was evaluated by measuring the depth dose curve, in vivo dose measurement and image perturbation. The nanoDot™ dosemeters were observed to produce a linear dose with ±2.8% coefficient variation. Significant batch inhomogeneity (8.3%) was observed. A slight energy dependence (±6.1%) was observed between 60 and 140 kVp. The InLight® microStar reader demonstrated good accuracy and a reproducibility of ±2%. The depth dose curve measured using nanoDot™ dosemeters showed slightly lower responses than Monte Carlo simulation results. The total uncertainty for a single dose measurement using this system was 11%, but it could be reduced to 9.2% when energy dependence correction was applied.
Fulltext Influenza in Malaysian adult patients hospitalized with community-acquired pneumonia, acute exacerbation of chronic obstructive pulmonary disease or asthma: a multicenter, active surveillance study

Pang YK, Ismail AI, Chan YF, Cheong A, Chong YM, Doshi P, et al.

BMC Infect Dis, 2021 Jul 05;21(1):644.
PMID: 34225647 DOI: 10.1186/s12879-021-06360-9

BACKGROUND: Available data on influenza burden across Southeast Asia are largely limited to pediatric populations, with inconsistent findings.
METHODS: We conducted a multicenter, hospital-based active surveillance study of adults in Malaysia with community-acquired pneumonia (CAP), acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and acute exacerbation of asthma (AEBA), who had influenza-like illness ≤10 days before hospitalization. We estimated the rate of laboratory-confirmed influenza and associated complications over 13 months (July 2018-August 2019) and described the distribution of causative influenza strains. We evaluated predictors of laboratory-confirmed influenza and severe clinical outcomes using multivariate analysis.
RESULTS: Of 1106 included patients, 114 (10.3%) were influenza-positive; most were influenza A (85.1%), with A/H1N1pdm09 being the predominant circulating strain during the study following a shift from A/H3N2 from January-February 2019 onwards. In multivariate analyses, an absence of comorbidities (none versus any comorbidity [OR (95%CI), 0.565 (0.329-0.970)], p = 0.038) and of dyspnea (0.544 (0.341-0.868)], p = 0.011) were associated with increased risk of influenza positivity. Overall, 184/1106 (16.6%) patients were admitted to intensive care or high-dependency units (ICU/HDU) (13.2% were influenza positive) and 26/1106 (2.4%) died (2.6% were influenza positive). Males were more likely to have a severe outcome (ICU/HDU admission or death).
CONCLUSIONS: Influenza was a significant contributor to hospitalizations associated with CAP, AECOPD and AEBA. However, it was not associated with ICU/HDU admission in this population. Study registration, NMRR ID: NMRR-17-889-35,174.
Fulltext Cross-sectional study of influenza trends and costs in Malaysia between 2016 and 2018

Wan Puteh SE, Aazmi MS, Aziz MN, Kamarudin N', Sam JI, Thayan R, et al.

PLoS One, 2024;19(3):e0301068.
PMID: 38517867 DOI: 10.1371/journal.pone.0301068

BACKGROUND AND OBJECTIVES: While influenza circulates year-round in Malaysia, research data on its incidence is scarce. Yet, this information is vital to the improvement of public health through evidence-based policies. In this cross-sectional study, we aimed to determine the trends and financial costs of influenza.
METHODS: Data for the years 2016 through 2018 were gathered retrospectively from several sources. These were existing Ministry of Health (MOH) influenza sentinel sites data, two teaching hospitals, and two private medical institutions in the Klang Valley, Malaysia. Expert consensus determined the final estimates of burden for laboratory-confirmed influenza-like illness (ILI) and severe acute respiratory infection (SARI). Economic burden was estimated separately using secondary data supplemented by MOH casemix costing.
RESULTS: Altogether, data for 11,652 cases of ILI and 5,764 cases of SARI were extracted. The influenza B subtype was found to be predominant in 2016, while influenza A was more prevalent in 2017 and 2018. The distribution timeline revealed that the highest frequency of cases occurred in March and April of all three years. The costs of influenza amounted to MYR 310.9 million over the full three-year period.
CONCLUSIONS: The study provides valuable insights into the dynamic landscape of influenza in Malaysia. The findings reveal a consistent year-round presence of influenza with irregular seasonal peaks, including a notable influenza A epidemic in 2017 and consistent surges in influenza B incidence during March across three years. These findings underscore the significance of continuous monitoring influenza subtypes for informed healthcare strategies as well as advocate for the integration of influenza vaccination into Malaysia's national immunization program, enhancing overall pandemic preparedness.