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We report a woman, 45th year old with Graves’ disease treated with anti-thyroid drug (thiamazole). She came to our clinic with severe and active Graves’ orbitopathy. We treated her with high dose intravenous methylprednisolone weekly (0.5 g weekly/ 6 weeks) and mycophenolate sodium 0.72 g daily/ 6 weeks. Because of her longterm consumption but not successful to achieve remission of anti-thyroid drugs and the size of her goiter, we decided to do total thyroidectomy. Only one week after thyroidectomy, her eye inflammation grade was reduced, but still bulging. We continue with the intravenous methylprednisolone weekly. Because of the partial response, we continue with another dose of methylprednisolone (0.25 g weekly for another 6 weeks). After 12 weeks of intravenous methylprednisolone (maximum dose for 1st course 4.5 g), there is a partial response make it to moderate to severe grade but still active inflammation. Our team decided to give her second-line treatment and we give her intravenous tocilizumab monthly for 4 weeks. After three tocilizumab infusion, the inflammation is reduced remarkably. Her overall appearance is getting better. But, because of her sight was not improved much as the inflammation reduced, we done orbital MRI and we decided to do another intravenous methylprednisolone 1 g for three days followed by orbital decompresion surgery. Shortly after the orbital decompresion, her sight was improved very well. She can now doing activities she can do previously. After recovery, we plan to give her the fourth (last) tocilizumab infusion. Overall, tocilizumab improves clinical outcome in patient with active corticosteroid-resistant moderate to severe Graves’ orbitopathy. Patient’s quality of life also improved.

Epidemiological data is a valuable source for decision-making in a clinical setting or from a public health perspective. It serves not only direct purposes by supporting evidence-based treatment but also indirectly contributes to guidelines and policies in healthcare services. Currently, there remains a pressing need for further epidemiological or population-based studies to be conducted in Indonesia. The availability of health data and information specifically from the Indonesian population is still limited and highly sought after. It is common for us to depend on epidemiological data from foreign countries, but this practice can introduce bias into our decision-making process due to the disparities between their conditions and our own. Indonesia possesses a distinct socio-demographic and health landscape, setting it apart from other countries. The diverse range of diseases, risk factors, healthcare access, health equity, and geographical characteristics all contribute to the uniqueness and variability of health problems within the nation. Specific regions across the Indonesian archipelago encounter health issues that are distinct to their locations. Infectious diseases, particularly tropical diseases, and nutrient deficiencies continue to present significant challenges in numerous provinces throughout Indonesia. Variations are observed across different areas and timeframes of study. These dynamic and variable factors make population studies particularly intriguing. It is the responsibility of clinicians, researchers, and epidemiologists to delve into the intricacies of the population and study its health problems comprehensively.

Thyroid eye disease (TED) is an autoimmune disorder that is associated with thyroid gland dysfunction which causes muscle and orbital fat enlargement. This case report is aimed to present a case of sight-threatening TED and how we should manage this condition. We present a case of patient with chief complaint of vision loss and prominent eyes for 5 months prior to the visit to our eye hospital. Patient had sought advice from an ophthalmologist and internist. TED was eventually diagnosed 2 months after consulted with an ophthalmologist in the rural area. According to EUGOGO guidelines, TED with sight-threatening condition should be treated with glucocorticoid IV 500-1000 mg for 3 days consecutively. Although the patient was already given steroid injection for the initial treatment, the dosage was inadequate. After the inflammation process was reduced, the patient was reluctant to have an orbital decompression that was suggested. Hence, TED progressed continuously besides sight-threatening complications arising. He indeed underwent fat decompression and tarsorrhaphy as eyelid surgery to prevent corneal exposure. In follow-up, both visual acuity and corneal improvement were finally achieved. In the management of TED, collaboration between ophthalmologist and internist, who may be specialized in endocrinology, is imperative. They should be able to manage TED promptly and correctly, hence sight-threatening and other complications can be prevented and satisfactory results are achieved. Fat decompression should be considered as a good help to improve visual acuity nevertheless orbital decompression cannot be done.

This is a case of 42nd year-old woman with history of sight loss in her both eyes. She experienced headache and visual field decrease gradually since 2014. After several laboratory and imaging examinations, from her dynamic pituitary magnetic resonance imaging (MRI), it is concluded that she had a giant adenoma of the pituitary gland which compressed to her optic chiasm. From her pituitary laboratory hormone panel, it is revealed that the tumor is a non-functioning pituitary adenoma. From the neuro-ophthalmology (campimetry) examinations, she had papillae atrophy in her both eyes and also bilateral temporal hemianopia.

The year of 2020 teaches us to prevent is always better than to cure. It is an old phrase that is being used for decades, but it is never been implemented cordially by our society nowadays. Covid-19 is a good lesson that reminds us to carefully prevent the spread of coronavirus which is now a pandemic worldwide. People now wash their hands more often and clean, wear a mask everywhere – everytime, do physical distancing, do healthy lifestyle such as physical activity, healthy diet, and consume multivitamins. They obey the cough and sneeze etiquette. Prevention awareness is never been such popular like todays. For internal medicine specialist, the role for prevention is very broad. Besides we still have a role in primary prevention, we can take our part in both secondary and (of course) tertiary prevention. Primary prevention can be defined as an action not allow a disease to occur, for examples vaccination (for internal medicine specialist more specific as adult vaccination), smoking cessation, physical activity (exercise) and healthy diet. Health promotion and prevention is the core of primary prevention. Secondary prevention aims to detect the disease as early as possible, in at risk population, such as mammography for breast cancer, swab test for Covid-19, colonoscopy for colon cancer in high risk patients. Last, tertiary prevention propose to hamper the progress of clinical disease and prevent more severe complications of the disease, for examples cardiac rehabilitation, or medications for prevent chronic kidney disease in patients with diabetes or hypertension. It is overlapping the curative or treatment strategies as it is states “to cure is to prevent”. In 2020, in which each underlying conditions require effective treatment and each disease should be prevented. We are now facing the era of preventive medicine. As an internal medicine specialist, we need to put in mind a philosophy of prevention in every of our action towards patient’s care and services.

a young18-year-old female patient with general bone pain and history of multiple fractures brought her to our medical attention. Laboratory work showed hypercalcemia and high parathyroid hormone levels in the blood. Radiograph imaging revealed severe scoliosis with multiple vertebrae fractures with decreased bone mineral density. Sestamibi showed parathyroid adenoma. This case emphasizes the importance of maintaining a primary hyperparathyroidism as a differential diagnosis when a young patient presents with a multiple pathologic fractures history.

Congenital hypothyroidism is the most treatable cause of mental retardation. It is also the most prevalent congenital endocrine disorder in childhood. A dramatic improvement can be made by early detection, diagnosis, and adequate treatment of levothyroxine in patients with congenital hypothyroidism. Severe cognitive impairment is associated with persistent disease in patients who have delayed or no treatment at all. In a modern era with complete healthcare facilities in a big city like Jakarta, the prevalence late-diagnosed congenital hypothyroidism is supposed to be very low. Since many districts have their own public healthcare facilities to screen and diagnose congenital hypothyroidism in children at very young age, a delayed diagnosis in adulthood is actually a rare case. In this medical illustration, we report a case of 21 year-old woman who came to our hospital with abdominal pain. She had mental retardation with no capability to communicate well with other person. She had a short stature (her height was less than 1 meter). She also had mongoloid face with big lips and a very big tongue. There was no goiter or lump on her neck. Her motoric performance was very weak and frail. During abdominal examination, we could see an umbilical bulging on her abdominal wall and on palpation, we could feel an umbilical hernia. By abdominal ultrasound, we could see the umbilical hernia. Unfortunately, no diagnosis of congenital hypothyroidism had been made when she was a newborn, there was also no past or known history of thyroid disease of her and her family. She had a diagnosis of mental retardation with no specific etiology since she was 5-years old. Based on the results of her laboratory examination, we had a confirmed diagnosis of primary hypothyroidism with T4 10.56 nmol/L (normal 60-120 nmol/L) and TSH > 100 mIU/mL. We provided her treatment using levothyroxine based on her body weight (25 mg daily). We arranged her to have abdominal CT Scan and digestive surgery as further management for her umbilical herniation. Some defects are correlated with congenital hypothyroidism when the disease is not treated properly and adequately. Neurocognitive, neuromotoric, growth, and development are some areas which can be disrupted by long-term hypothyroidism condition for patients who had the disease since their early years of life. Congenital hypothyroidism appears to be associated with an increased risk of congenital malformations. Several congenital malformations associated with congenital hypothyrodism are umbilical hernia, congenital heart disease, neurologic abnormalities, genitourinary malformations, cleft palate, and Down’s syndrome. Studies concluded that severity of the congenital hypothyroidism has more important role than timing of treatment initiation on long-term cognitive and motor outcomes. Detrimental effects on developmental outcomes in congenital hypothyroidism patients may persist over time; however, early treatment for patients at very early ages may bring the best cognitive outcomes and neuromotoric development. Regardless of the treatment options, we can say that it is a loss case and a very late diagnosis and treatment of congenital hypothyroidism. The unusual age of detection, delayed diagnosis and treatment are some reminders for primary care physicians in our society to pay greater attention to screening programs.6 Early detection and prompt treatment is an essential part of measures to reduce burden of mental retardation in our society. Delayed diagnosis of congenital hypothyroidism case, which is diagnosed at adulthood, indicates failure in screening program. Early diagnosis and treatment are necessary to prevent long-term catastrophic effects. This a wake-up call of attention and awareness for general public and primary care physicians in our country.

Graves’ disease is an autoimmune disorder which affect thyroid gland. Graves’ disease is the most common cause of hyperthyroidism and thyrotoxicosis. Understanding of disease pathophysiology, diagnostic and treatment strategies, and prevention of disease relapse are important for all clinicians especially internal medicine specialist to give optimal and comprehensive management for Graves’ disease patients. This article highlights clinical points to treat Grave’s disease patients from reviews and latest guidelines from American Thyroid Association (ATA), European Thyroid Association (ETA), and Japan Thyroid Association/ Japan Endocrine Society.

Background: thyroid dysfunction is more likely to occur in diabetes mellitus patients than general population. Until now, no study has been done to find prevalence of hypothyroidism and hyperthyroidism in Indonesian diabetics. This study aimed to find the proportion and characteristics of thyroid dysfunction in Indonesian type 2 diabetes mellitus patients. Methods: a cross-sectional study was conducted in Endocrine and Diabetes Polyclinic, Department of Internal Medicine, Cipto Mangunkusumo Hospital from July to September 2015. This study include type 2 diabetes mellitus patients, age ≥ 18 year-old, willing to undergo thyroid laboratory testing. In this study, hypothyroidism defined as TSH more than 4.0 mIU/L, while hyperthyroidism is defined as TSH less than 0.4 mIU/L with eCLIA. Results: from 364 subjects who were recruited from Endocrine and Diabetes Polyclinic, Cipto Mangunkusumo Hospital, 303 subjects underwent this study until analysis. Two hundred and three (273) subjects (90.1%) were euthyroid, 7 subjects (2.31%) were hyperthyroid, and 23 subjects (7.59%) were hypothyroid. Majority of the patients had subclinical hypothyroidism (56.5% based on Zulewski and Billewicz Score and 65.2% based on fT4 laboratory result), while 42.9% and 71.4% subjects had clinical hyperthyroidism based on clinical appearance and fT4 laboratory result respectively. Conclusion: proportion of hypothyroidism was 7.59% and hyperthyroidism was 2.31%, while the proportion of total thyroid dysfunction was 9.9% among diabetics. It is suggested that screening for thyroid dyscfunction can be done in high risk condition as a part of comprehensive management in type 2 diabetes mellitus patients.

This is a case of 51 year-old woman with uncontrolled type 2 diabetes mellitus which was diagnosed 1.5 year earlier, obesity with body mass index 32.2 kg/m2, waist circumference of 113 cm, diffuse goiter with neck circumference 40 cm, and hypertension with blood pressure >140/90 mmHg. Since 6 months ago, she often seemed like having less concentration or daydreaming, chronic fatigue, depression, and low food intake. Her body weight had been increasing over time. Her hypothyroidism clinical scoring Billewicz and Zulewski criterias were 17 and 8 respectively, showing that she tended to experience hypothyroidism. From laboratory examination, fasting blood glucose was 216 mg/dL and 2-hour postprandial blood glucose was 320 mg/dL with level of HbA1c was 9.9%, triglyceride level was 486 mg/dL, HDL cholesterol 46 mg/dL, LDL cholesterol 157 mg/dL, and total cholesterol was 269 mg/dL. Thyroid ultrasound showed a diffuse goiter in both lobes of her thyroid gland.

Primary hyperparathyroidism is a medical condition caused by overactive of parathyroid gland. It is most commonly caused by solitary adenoma of the parathyroid gland. Other causes of this condition are hyperplasia, multiple adenomas, and parathyroid cancer. Primary hyperparathyroidism has some metabolic consequences in the calcium metabolism. Hypercalcemia in patient with primary hyperparathyroidism will resulted to the most important comorbidity that is chronic deposition of calcium in the kidney forming nephrolithiasis or other urolithiasis. It is not uncommon, patient with parathyroid adenoma come to health care professionals with the chief complain of recurrence nephrolithiasis.

Hypertriglyceridemia is a form of dyslipidemia, which usually occurs in combination with hypercholesterolemia, high-LDL or low-HDL cholesterol level. Most studies suggest that hypertriglyceridemia is associated with many metabolic disorders such as metabolic syndrome, diabetes, obesity, and also cardio-cerebrovascular diseases. Treatment of hypertriglyceridemia is often not comprehensively addressed by many physicians, who usually only include prescribing drugs without encouraging patients to perform physical activity, to take a true healthy diet for dyslipidemia and to stop smoking. This review article discusses evaluation, diagnosis and a comprehensive, yet simple management of hypertriglyceridemia, which can be easily pplied in daily clinical practice. Key words: hypertriglyceridemia, dyslipidemia, management, clinical guidelines.