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Thyroglossal duct cyst is the most common thyroid developmental abnormality with a prevalence of 7%, but thyroglossal duct cyst cancer is rare. The incidence of thyroglossal duct cyst cancer is about 1%. The diagnosis is limited by low yield on fine-needle aspiration biopsy (FNAB), and most cases are diagnosed after surgery. There is a paucity of data on the utility of thyroglobulin washout for diagnosis of thyroglossal duct cyst cancer, and it has not been mentioned in previous case reports/series. Papillary thyroid cancer is the most common pathology. Preoperative planning is important as the decision about total thyroidectomy with the Sistrunk procedure (excision of the thyroglossal duct cyst, middle part of hyoid bone, and surrounding tissue around the thyroglossal tract) depends on the presence of clinical or radiological thyroid abnormality. Thyroglossal duct cyst cancer has an excellent prognosis. However, owing to a lack of standard of care for this type of thyroid cancer, there is institutional variability in management. We present a case of thyroglossal duct cyst cancer in a man presenting with painless midline neck swelling. Imaging was suspicious for thyroglossal duct cyst cancer. FNAB was benign. The patient underwent the Sistrunk procedure and pathology was positive for papillary thyroid cancer.

Hepatobiliary disorders are common in pregnancy and pose a management challenge. Minimally invasive interventional radiological (IR) techniques allow safe and effective management of these disorders. However, the available literature is scarce. Radiological interventions in this group of patients mandate a clear understanding of the risks of radiation to the fetus. The IR physician involved in the care of these patients should be aware of the measures to minimize the exposure to ionizing radiation. Additionally, the risk-benefit ratio should be clearly defined in a multidisciplinary discussion involving IR physicians, obstetricians, and gastroenterologists. This review is an effort to address issues related to the application of IR procedures for hepatobiliary disorders in pregnant patients.

Introduction - Sclerosing mucoepidermoid thyroid cancer is a rare entity with approximately 60 cases reported in the literature. Initially described by Chan. Et al in 1991,1 it was included as a separate entity by WHO in 2004.2 Previously considered to have indolent nature, recent evidence has reported aggressive nature ranging from local invasion to metastasis. Case - 66-year-old female with complaints of difficulty in swallowing, breathing, and sensation of a lump in her throat for last 6 months, was noted to have left thyroid mass on ultrasound. Thyroid ultrasound showed solid hypoechoic nodule, 8.2×5.3×5.9 cm replacing left thyroid lobe with solid hypoechoic nodule 2.2×1.1x 1.6 cm at the right end of the isthmus. The neck ultrasound was negative for lymph nodes. Past medical history was significant for long-standing hypothyroidism, and recently diagnosed invasive ductal carcinoma of the breast. CT chest showed an enlarged thyroid gland with substernal extension and mass effect on the trachea. FNA thyroid showed Bethesda category 5, suspicious for papillary thyroid cancer. The patient underwent a total thyroidectomy. Pathology for left nodule showed sclerosing mucoepidermoid carcinoma with eosinophils, 8.6×6.9×5.8 cm, p T4a N×Mx, with positive margins for tumor, no angiolymphatic invasion with co-existing right-sided papillary microcarcinoma (follicular variant) with chronic lymphocytic thyroiditis. Levothyroxine was dosed to aim goal TSH Discussion – Sclerosing mucoepidermoid cancer is thought to be derived from the ultimobranchial body.1 It is more common in females in age groups 3rd - 8th decade.3 Most common presentation is unilateral painless thyroid mass. Coexistent chronic lymphocytic thyroiditis and papillary thyroid cancer are usually found. On literature review of 56 cases, the gross extrathyroidal extension was seen in 26% of cases with distant metastasis was most commonly seen in lungs.3 No established treatment strategy exists due to a small number of reported cases, however, treatment ranges from only Thyroid surgery to Thyroid surgery with radiation +/- chemotherapy and radioactive iodine. References Shah AA, La Fortune K et al. Thyroid sclerosing mucoepidermoid carcinoma with eosinophilia: a clinicopathologic and molecular analysis of a distinct entity. Mod Pathol. 2017;30: 329–339. Pantola C, Kala S, Athar M, et al. Sclerosing mucoepidermoid carcinoma with eosinophilia of the thyroid: a cytological dilemma. J Cytol 2016; 33: 37. Chambers M, Nosé V et al. Salivary-Like Tumors of the Thyroid: A Comprehensive Review of Three Rare Carcinomas. Head Neck Pathol. 2021 Mar;15(1): 212-224. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Introduction Growth hormone (GH) and prolactin co-secreting pituitary adenoma is the most common type of pleuri-hormonal adenomas. We present a case of GH and prolactin co-secreting macroadenoma with somato-mammotroph (SMT) histopathology. Case A 48-year-old female presented with complaints of chronic headaches and coarsening of facial features for >5 years. Associated symptoms included chronic fatigue, joint pain, heat intolerance, diaphoresis, and 20 lbs weight gain. She noted acral enlargement and ill-fitting dentures. She also reported snoring and witnessed apneic spells. She denied peripheral vision loss, galactorrhea, or breast tenderness. Past medical history included prediabetes, bilateral carpal tunnel surgery, and uterine ablation. On examination, her weight was 269 lbs, height 5'8", and BP 148/92 mmHg. She had acromegalic features including frontal bossing with coarse facial features, prominent jaw, and large hands with sausage-like fingers and sweaty palms. Her oropharynx was crowded with Mallampati grade 4. Laboratory data showed elevated IGF-1 level of 981 ng/mL (77- 220) and prolactin level – 189 ng/mL (4.8–23.3). The fasting GH level was 5.1 ng/mL ( 3ng/ mL (goal for remission < 1 ng/ ml). Surgical pathology showed SMT type pituitary adenoma, with tumor cells staining both for GH and prolactin. The patient will have repeat pituitary MRI and biochemical testing 2 months following surgery to assess the presence and extent of residual disease. Discussion The WHO's 2017 classification divides GH and prolactin co-secreting tumors to 1) SMT cell adenomas where monomorphous cells co-secrete both GH and prolactin; 2) mixed GH cell and prolactin cell adenomas, bimorphous tumors where 2 different cell types secrete GH and prolactin; and 3) acidophil cell tumors. SMT adenomas are morphologically similar to densely granulated adenomas. These are usually slow growing and rarely invade surrounding structures. They have low intensity on T2-weighted MR imaging. In a study of 94 acromegaly cases, SMT adenomas were the smallest in size, with minimal cavernous sinus invasion, and had a higher chance of complete tumor resection. In contrast, our patient had a relatively large and invasive SMT adenoma. Presentation: No date and time listed

Introduction - Myotonic dystrophy (MD) is the most common cause of adult-onset muscular dystrophy. It has impaired HPA axis regulation with exaggerated ACTH response to CRH mediated stimuli and abnormal cortisol metabolism. We present a case of myotonic dystrophy in a male with elevated cortisol levels. Case report - 54-year-old male with a past medical history of type 1 myotonic dystrophy (MD1) presented for evaluation of hypogonadism with complaints of feeling fatigued, progressive weakness of muscles. During the workup, he was noted to have elevated cortisol levels 30.2 mcg/dL (6-18.4) with elevated ACTH 220 pg/mL (10-48). Other notable lab results included low total testosterone levels of 231, 185 with elevated LH of 17.3 m IU/ml (2-9) and FSH 37.7 m IU/ml (1-12). Prolactin levels were minimally elevated to 21.4 ng/mL (4-15.2). On further inquiry, the patient did not have headaches or vision changes. The patient did not report weight gain, easy bruising, change in facial appearance. Physical exam was significant for bilateral gynecomastia and small testes. No cushingoid facies, abdominal stria, proximal myopathy was noted. Given elevated ACTH and cortisol levels, further laboratory data showed a lack of suppression of cortisol levels with 1 mg dexamethasone - cortisol 2.9 micro g/dL ( Discussion – Even though Cushing's disease is one of the differential diagnoses for the above case, high cortisol levels have been reported in MD. Few mechanisms suggested causing this abnormality are increased ACTH responsiveness to CRH-mediated stimuli and abnormal cortisol metabolism. Patients with MD have high pro-inflammatory (IL-1 and TNF-a) markers, which mediate the increased ACTH responsiveness to CRH-mediated stimuli centrally by stimulating the HPA axis.1 In addition, IL-6 chronically stimulates steroidogenesis from the adrenal gland, whereas TNF-α inhibits ACTH-induced adrenal steroid synthesis and increases 11BHSD1 activity. Along with the impaired HP axis, abnormal metabolism of cortisol also contributes to elevated cortisol levels. Increased activity of 11 BHSD1 has been hypothesized to cause impaired clearance of cortisol.2 Impaired diurnal variation for cortisol is also seen in MD with elevated 24-hour cortisol levels. Elevated cortisol levels as in our case can be a diagnostic dilemma given impaired cortisol regulation as seen in MD. References Åsa Johansson et.al. Abnormal Cytokine and Adrenocortical Hormone Regulation in Myotonic Dystrophy, The Journal of Clinical Endocrinology & Metabolism, Volume 85, Issue 9, 1 September 2000, Pages 3169–76.Åsa Johansson et.al. Glucocorticoid Metabolism and Adrenocortical Reactivity to ACTH in Myotonic Dystrophy, The Journal of Clinical Endocrinology & Metabolism, Volume 86, Issue 9, 1 September 2001, Pages 4276–83 Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

Introduction - Collision tumors, i.e., co-occurring distinct histopathological lesions are rare. We present a case of a 48-year-old female present with co-existing Rathke cleft cyst (RCC) and pituitary adenoma with Cushing disease. Case - 48-year-old female presented for evaluation of an incidental sellar mass with enlarged pituitary noted on MRI brain. The patient complained of symptoms of mental fogginess, confusion, intermittent dizziness for the last 1 year. The patient had complained of easy bruising with no reported weight gain, change in facial appearance, proximal muscle weakness. MRI brain showed mildly enlarged pituitary measuring 13 mm with RCC.Past medical history was significant for recent-onset Type 2 Diabetes and Hypertension. The examination was unremarkable with no signs of Cushing's syndrome. Lab work showed elevated ACTH of 51 pg/ml (10-48) with AM cortisol level of 14.7 mcg/dl (6- 18.4). IGF-1 levels elevated at 307 ng/ml (77- 220). LH, FSH, FT4, prolactin levels were normal. Given elevated ACTH levels, further testing showed elevated midnight salivary cortisol at 0.22 and 0.239 mcg/dl (0.010-0.090), elevated 24-hour urine cortisol 141 ug/ 24 hrs. (6- 44), absence of suppression with 1 mg dexamethasone with cortisol 12.4 mcg/dl (< 1.8), ACTH 123 pg/ml (10-48) with dexamethasone levels 432 ng/dl (140- 295). Lab work was consistent with ACTH-dependent hypercortisolism. MRI pituitary showed 7.5×7.8 mm RCC.8 mg dexamethasone suppression test and CT chest, abdomen, and pelvis were performed to differentiate between ectopic Cushing's and Cushing's disease. Cortisol levels suppressed greater than 50% after 8 mg dexamethasone from baseline cortisol – 17.7 mcg/dl and ACTH 67 pg/ml to cortisol 3.4 mcg/dl and ACTH – 34 pg/ml with dexamethasone levels of 3120 ng/dl (1600–2850). CT chest abdomen, pelvis showed no evidence of bronchial carcinoid or other potential lesions. With neuroimaging findings and biochemical confirmation of Cushing's disease, the patient underwent transsphenoidal resection. Discussion – The association between RCC and pituitary adenoma was found in 0.5–1.9% cases per literature review1, co-occurrence with ACTH producing pituitary adenoma being rarer. The diagnosis of collision tumors can be challenging as the most common presentation on imaging is a cystic mass. Appropriate biochemical testing is indicated based on clinical presentation, initial laboratory testing, and level of suspicion. Elevated ACTH levels along with diabetes and hypertension led to a diagnosis of Cushing's disease in our patient with the initial presentation of an incidental RCC. The knowledge about collision tumors is important, especially in unusual presentations as in our case. References Sagan KP et al. Cushing's Syndrome in a patient with Rathke's cleft cyst and ACTH cell hyperplasia detected by 11C-Methionine PET Imaging-A Case Presentation. Front Endocrinol (Lausanne). 2020; 11: 460. Published 2020 Jul 22. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

Introduction Antiresorptive therapy (ArT) has been known to decrease the risk of skeletal-related events (SRE), such as bone pain and pathological fractures, in cancer patients with bone metastasis (BM). While beneficial, ArT may cause adverse effects in this population including hypocalcemia, which can be severe and life-threatening. We examined the incidence, severity, and risk factors for hypocalcemia associated with the use of ArT to treat BM in cancer patients. Methods We conducted a retrospective review of the electronic medical records of adult patients with advanced cancer complicated by BM who were treated at our institution between January 2016 and November 2020. Our primary aim was to compare the incidence and severity of hypocalcemia with the use of IV Zoledronic acid (ZA), a bisphosphonate, vs SQ Denosumab (DM), a RANKL inhibitor, to treat BM in cancer patients.Our secondary aim was to compare risk factors associated with severe hypocalcemia (defined as albumin-corrected serum calcium < 7 mg/dL). Inclusion criteria were patients aged 19-99 years with a history of cancer with known BM, who received either ZA or DM. Results We reviewed 860 EMRs of patients treated within the specified period. 392 patients met inclusion criteria, among them, 297 (76%) and 95 (24%) received DM and ZA, respectively. There were no between-group differences in age, ethnicity, or weight. The median patient age was 71 years (range: 27–96). There were, however, between-group differences in gender (p=0.01) and cancer diagnoses (p=0.03). Females comprised 53.9% of the DM group vs. 40% of the ZA group. The top three cancer diagnoses were (DM vs ZA groups): breast (40.1% vs 26.3%), prostate (25.9% vs 40%), and lung cancer (17.8% vs 15.8%). Overall incidence of hypocalcemia was 48.8% (n=144) and 45.3% (n= 43) with the use of DM and ZA, respectively (p=NS). Severe hypocalcemia was more frequently observed with the use of DM vs ZA (6.6% vs 1.1%, p Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Bronchial artery embolization (BAE) is an established minimally invasive treatment for massive or recurrent haemoptysis. Anterior spinal artery (ASA) infarct is an uncommon but serious complication of the procedure. The interventional radiologist doing these procedures must be well versed with the bronchial artery anatomy, its variations, and its relation with ASA to avoid this dreaded complication. The authors report a case in which the patient developed monoparesis and mild transient autonomic dysfunction post BAE but magnetic resonance imaging of spine showed diffuse symmetric cord involvement in ASA territory from D1–D4 level.

Context: Electrophysiological and hemodynamic data can be integrated to accurately identify the generators of abnormal electrical activity in drug-resistant focal epilepsy. Arterial Spin Labeling (ASL), a magnetic resonance imaging (MRI) technique for quantitative noninvasive measurement of cerebral blood flow (CBF), can provide a direct measure of variations in cerebral perfusion associated with the epileptogenic zone. Aims: 1. To evaluate usefulness of ASL for detecting interictal temporal hypoperfusion to localize the epileptogenic zone in patients of drug resistant mesial temporal lobe epilepsy (MTLE). 2. Correlation of localization of epileptogenic zone on ASL MR perfusion with structural MRI and EEG. Methods and Materials: 30 patients with MTLE and10 age and gender matched normal controls were studied. All patients underwent ictal video EEG monitoring non-invasively, MR imaging with epilepsy protocol and pseudocontinuous ASL (PCASL) perfusion study. Relative CBF (rCBF) values in bilateral mesial temporal lobes were measured utilizing quantitative analysis of perfusion images. A perfusion asymmetry index (AI) was calculated for each region. Results: In patients, ipsilateral mesial temporal rCBF was significantly decreased compared with contralateral mesial temporal rCBF (p = 0.021). Mesial temporal blood flow was more asymmetric in patients than in normal control participants (p = 0.000). Clear perfusion asymmetry on PCASL-MRI was identified despite normal structural-MRI in 5 cases, agreeing with EEG laterality. Conclusions: Pseudo-continuous ASL offers a promising approach to detect interictal hypoperfusion in TLE and as a clinical alternative to SPECT and PET due to non-invasiveness and easy accessibility. Incorporation of ASL into routine pre-surgical evaluation protocols can help to localize epileptogenic zone in surgical candidates.

Background: Sarcoidosis involves the nervous system in 3-10% of cases. Neurosarcoidosis (NS) can mimic other diseases, leading to delay in diagnosis and management. We present 2 cases of hypothalmo-pituitary (HP) NS with widely differing initial presentations. Case Presentations: Case 1: A 58 year old African American (AA) male presented with decreased libido and hot flashes of 8-10 months duration. He also reported headaches, pain in the face and behind the eyes and dyspnea on exertion. On evaluation, he had central hypogonadism. MRI brain showed thickening and enhancement of pituitary infundibulum (PI). CT chest showed lung lesions and bilateral hilar adenopathies. EBUS with biopsies of lung and hilar lymph node showed non caseating granulomas (NCG). He was started on Prednisone and testosterone leading to symptomatic relief. However, he stopped prednisone after 3 months due to weight gain. He was then started on azathioprine. 9 months later, he presented with recurrence of neurologic symptoms and weight loss of 30 lbs. Labs showed new findings of low prolactin, low IGF-1, central hypothyroidism and central adrenal insufficiency (AI). MRI pituitary showed diffuse thickening of 3rd and 5th cranial nerves and of PI. He was re-started on Prednisone and levothyroxine (LT4) was started with improvement of symptoms. Plan was to start him on Infliximab instead of Azathioprine. Case 2: A 26 year old AA female presented with near syncope and visual impairment in the left eye that started a few weeks prior. Testing showed superior visual field loss and evidence of optic neuropathy, disc edema with mild dyschromatopsia in the left eye. She had had polyuria and polydipsia for the preceding 2-3 months and amenorrhea for 2 years. Lab testing revealed hyperprolactinemia and central DI, hypothyroidism, AI and hypogonadism. Pituitary MRI revealed a suprasellar mass measuring 20 x 19 x 11 mm, displacing the optic chiasm. CT scan showed bilateral hilar lymphadenopathy and lesions in liver and spleen. EBUS and biopsy of mediastinal lymph nodes showed NCG. Patient was treated with IV steroids leading to improved vision. She was started on DDAVP and LT4 and initiated on methotrexate and prednisone on discharge. Discussion: Pituitary hormone abnormalities due to HP NS include anterior hypopituitarism, hyperprolactinemia and DI. The most common (MC) presentation is of DI. Among anterior pituitary hormone deficits, central hypogonadism is the MC. Systemic high dose glucocorticoids (GC) are the mainstay of initial treatment. Optic atrophy is the MC neuro-ophthalmologic manifestation of NS. Only 10 - 20 % of patients have been found to have biochemical improvement of HP axis in response to high-dose GC treatment. Since pituitary involvement commonly leads to permanent endocrine deficits, it is essential to recognize it early and to treat it aggressively to prevent further permanent hormonal and neurologic deficits.

This article is a Letter to the Editor and does not include an Abstract.

Pituitary apoplexy is a rare endocrine emergency. The extent to which hyperglycaemia is a contributory risk factor in the precipitation of pituitary apoplexy is not known. A 38-year-old man with poorly controlled diabetes presented to the emergency department with sudden onset of nausea and headache with drooping of his right eyelid for about 4 days. On physical examination, he had orthostatic hypotension, ptosis of the right eye, lateral and downward positioning of the eye and absent pupillary reflex. Visual field testing of the left eye revealed superolateral quadrantanopia. MRI of the brain showed pituitary macroadenoma with necrosis. Investigations showed hyperglycaemia, decreased T3, T4 with normal Thyroid stimulating hormone (TSH), low serum Leutinizing hormone (LH), Follicle stimulating hormone (FSH), testosterone and low normal serum prolactin levels. About 21% of non-functioning pituitary adenomas present with apoplexy as was seen in our patient. It is likely that his uncontrolled diabetes precipitated this episode of apoplexy as hyperosmolarity and dehydration, caused by hyperglycaemia can lead to changed pituitary microvascular environment increasing the risk of pituitary infarction.

Introduction: In modern civilization different kinds of animals live with us as pets. These pets have different diseases and are on medications. Close contact with animals can cause medication adverse reactions or may worsen pre-existing conditions in humans. Here we present an interesting case of hypothyroidism worsened by transdermal absorption of methimazole administered for feline hyperthyroidism. Case History: 66-year-old Caucasian female with past medical history of postoperative hypothyroidism s/p total thyroidectomy secondary to multinodular goiter due to Hashimoto’s thyroiditis with a 0.2 cm papillofollicular microcarcinoma and 0.7 cm follicular adenoma presented for follow up. She complained of weight gain, lethargy and dry skin for the past 4 months. She was on a stable dose of levothyroxine 112 mcg daily for the past year. She took her pill correctly and did not miss any doses. Her other medical problems were impaired fasting glucose, osteopenia and B12 deficiency. Her repeat thyroid function tests showed TSH 11.2 mc IU/ l (0.4 -4) (TSH - 0.538 mc IU/ L 6 months back), T4 - 6.8 mcg/ dl (4.5 - 12) (T4 8.9 6 months back). She had a measurable serum thyroglobulin of 0.4 ng/ml with antithyroglobulin antibody 11 IU/ml ( References: 1. Hill KE, Mills PC, Jones BR et.al. Percutaneous absorption of methimazole: an in vitro study of the absorption pharmacokinetics for two different vehicles. J Vet Pharmacol Ther. 2015;38(6):581-589. PMID: 25683868 2. Kasraee B et al. Safety of topical methimazole for the treatment of melasma. Transdermal absorption, the effect on thyroid function and cutaneous adverse effects. Skin Pharmacol Physiol. 2008;21(6):300-305. PMID: 18667842

Sarcoidosis is an inflammatory disease with multisystem involvement characterized by the presence of noncaseating granulomas. It can affect virtually every organ of the body, with lung involvement being most common occurring in >90% of patients. Other organs affected are skin, eye and liver. Skin involvement is common, affecting 25-35%. Here we present a rare case of a 15 year-old male with isolated oculocutaneous sarcoidosis without systemic involvement.

We report a case of 19 year-old female patient diagnosed as systemic lupus erythematosus (SLE) presented with fever and diffuse cutaneous lesions. During the hospital stay she had acute pneumonia, pleural effusion and respiratory failure, which required intensive care unit (ICU) care and mechanical ventilator support. A fulminant course of the disease, decreased values of complement levels and positive antinuclear antibodies (ANA) in pleural fluid and repeated negative sputum for acid-fast bacillus, blood cultures enabled diagnosis of fulminant lupus pneumonitis. Fulminant lupus pneumonitis is a rare but potentially life threatening complication of SLE. Management requires involvement of multiple specialties and rigorous efforts in reviving the patient.

Dengue fever is a mosquito borne arboviral disease endemic in tropical countries. The spectrum of presentation of dengue fever ranges from classical flu like illness to dengue hemorrhagic fever and dengue shock syndrome. It is usually regarded as a non-neurotropic virus and neurological manifestations of dengue are rare and hypokalemic quadriparesis is even rarer. Here we present a case report of a patient who presented with hypokalemic quadriparesis due to dengue.

Cloud computing has been emerged as a new service model in computing world and giving lot of interest to the researchers to find its benefits. Task scheduling is a major conflict in cloud environment and genetic algorithms are one of the optimization techniques to solve that problem. Virtual machine’s processing elements are important criteria to solve a scheduling problem. In proposed algorithm called upgraded Genetic algorithm, initial population is sorted according to the number of processing elements of each virtual machines. Proposed algorithm is compared with MGA in terms of cost and with MACO in terms of make span. Experiment results shows upgrade genetic algorithm gives better efficiency in term of cost and make span.

Objectives: Cases of dengue are on the rise and India experienced its worst epidemic during 2015. There was almost a 2 times rise in the number of cases. This study was done to understand the varied presentation and manifestation of dengue at a tertiary care centre of Haryana, India. Methods: This was an observational cross sectional study undertaken at PGIMS Rohtak, Haryana, India. One hundred and one patients aged ≥ 14 years, who had positive test results for dengue, as NS1/IgM, were included in the study. Clinical presentations, haematological, and biochemical markers were studied and analyzed. Results: Out of 101 patients, 63.3% were males. Overall, 95% had fever followed by headache (62.3%), rash (53.4%), retrorbital pain (43.5%), and abdomenal pain (43.5%). Furthermore, 31.8% of patients had bleeding manifestation, of which the commonest was petechiae (12.8%) followed by malena (7.9%) and bleeding gum (6.9%). All patients had raised liver enzymes. Platelet count of < 50,000/mm3 was present in 79.2%. Leucopenia was found in 43.5% of patients. Ultrasonography suggestive of free fluid was found in 44.5%. Hypokalemia was seen in 21.7% of patients. Complications, such as acute respiratory distress syndrome (ARDS) and DIC, were seen in 2.9% and 5.9% cases. Overall mortality rate was 2.97%. Conclusions: Dengue could have varied presentations ranging from a simple febrile illness to fatal multiorgan failure. It is crucial to understand the features, which predict the progress of dengue fever (DF) to dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS). Considering that the treatment of dengue is relatively simple, early institution of appropriate therapy with close monitoring of vital signs and laboratory parameters could help prevent morbidity and mortality related to dengue.

We report a rare case of primary hyperparathyroidism in a young female who presented with recurrent diabetic ketoacidosis. The patient had suffered an episode of acute pancreatitis in the past. On evaluation patient was found to have primary hyperparathyroidism and after removal of left inferior parathyroid adenoma her insulin requirement decreased by twelve units.

Organophosphate poisoning is very common in India. Its presentations are very vivid. Here we present a case of organophosphate poisoning in a young male with only bradycardia as sole manifestation of poisoning.