Browsing by Author "Saeed, Zeb Ijaz"

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    Not a Grave Finding: Thymic Hyperplasia in the Setting of Graves’ Disease
    (Elsevier, 2020) Voss, Michael; Saeed, Zeb Ijaz; Donegan, Diane; Medicine, School of Medicine
    A 30-year-old Caucasian male with no previous medical history presented to the emergency department with sudden onset chest pain brought on by exertion at work. He had never experienced similar episodes before, and chest pain was described as severe, mid-sternal, non-radiating, and was associated with palpitations, dyspnea, and near-syncope. Patient also reported unintentional weight loss of 40 pounds over the 3 months leading up to presentation. Review of systems was positive for diaphoresis, increased anxiety, heat intolerance, and a mild hand tremor for several weeks. He denied cough, changes in vision or voice, nausea, vomiting, diarrhea, constipation, or abdominal pain. He reported no history of tobacco or illicit drug use and no family history of thyroid disease or autoimmune conditions.
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    Prolonged Hypocalcemia After a Single Dose of Denosumab in Chronic Kidney Disease
    (Endocrine Society, 2021-05-03) Puar, Akshan; Saeed, Zeb Ijaz; Medicine, School of Medicine
    Introduction: Denosumab, a monoclonal antibody that inhibits RANK L (receptor activator nuclear factor-kappa beta ligand), is one of the few medications that can be used to treat osteoporosis in patients with chronic kidney disease (CKD). However, its use is associated with a much higher incidence of hypocalcemia in this patient population. What remains unclear is the duration of hypocalcemia after denosumab use. We describe a case of prolonged hypocalcemia of 9 months in a patient with CKD after a single dose of denosumab. Case: A 64-year-old Caucasian man with a history of bilateral lung transplant for interstitial pulmonary fibrosis and CKD Stage IV was referred to the Endocrinology clinic for evaluation of steroid-induced osteoporosis. Bone density scan was consistent with osteoporosis with the lowest T-score of -2.8 at the left femoral neck, which showed a 25.3% decline from a previous one two years prior. His labs upon initial visit: 25 hydroxy Vitamin D: 36.5 ng/mL (30–100), 1, 25 hydroxy vitamin D 32 pg/ml (19.9–79.3), corrected Serum Calcium 8.9 mg/dL (8.5–10.5), Serum Cr 4.38 mg/dL (0.6–1.4), PTH 157 pg/mL (10–65), Serum Alkaline Phosphatase 61 Units/L (25–125), Urine NTX 39 nM BCE/mM creatinine (21–83). After discussing risks and benefits, he was given a dose of subcutaneous denosumab 60 mg. He had been started on Calcium/Vitamin D (600 mg/400 IU BID) prior to receiving his dose. Keeping in mind the increased risk of hypocalcemia given his history of CKD, his corrected serum calcium was checked one week later, and it was 6.5 mg/dL. The patient was asymptomatic. However, given the severity of his hypocalcemia, he was started on calcitriol 0.25 mcg oral BID and calcium carbonate 1200 mg daily. He did show mild improvement in three days to a corrected calcium of 7.0 mg/dL. His calcitriol was briefly increased to 0.5 mcg BID and calcium carbonate was increased to 1800 mg daily. The regimen was weaned to calcitriol 0.25 mcg daily and previous calcium/Vitamin D dosing later that month. Thereafter, his labs were monitored regularly and there were several unsuccessful attempts made to decrease the calcitriol/calcium carbonate. Given persistent hypocalcemia, other bloodwork including a bone specific alkaline phosphatase and celiac screen were checked which were unremarkable. Finally, nine months after his denosumab dose, calcitriol was discontinued safely. Serum calcium levels have remained stable thereafter. Given prolonged hypocalcemia, it was decided not to administer another dose of denosumab. Conclusion: Patients with CKD who receive denosumab are not only at risk for developing severe, but also prolonged hypocalcemia. Therefore, it is imperative to monitor serum calcium levels, not only immediately after receiving a dose, but serially.