![]() ![]() Doppler sonography to assess vascularity and diagnose small nodules is successful in classifying 80% of cases. Patients with Type 2 sometimes have elevated IL-6 levels. Detectable uptake on thyroid scan or nodules on exam suggest Type 1. Clinically, determining the mechanism of hyperthyroidism can be challenging but can direct therapy. In Type 2, patients develop a destructive thyroiditis often followed by hypothyroidism. In Type 1, synthesis of T4 is increased due to iodine load in a patient with underlying autonomy secondary to a nodule or goiter. Hyperthyroidism secondary to Amiodarone toxicity also occurs by a variety of mechanisms. Treatment of hypothyroidism is with replacement therapy and is rarely an indication to discontinue therapy. Lastly, synthesis of thyroid hormone is inhibited by high levels of iodine in Amiodarone (Wolff-Chaikoff effect). Additionally, Amiodarone decreases the peripheral conversion of T4 to T3 and acts to directly block the T3 receptor. Hypothyroidism occurs by several mechanisms, the most common being a destructive thyroiditis which is often preceded by a hyperthyroid phase. Up to 20% of patients on long-term therapy will develop hypothyroidism as a result of toxic effects of Amiodarone, and 3% will develop hyperthyroidism. Given all of these findings, the patient was diagnosed with acyclovir-induced respiratory depression. Twenty-four hours after stopping the acyclovir the patient became alert and was extubated within 48 hours. ![]() Acyclovir was discontinued on the sixth hospital day and a serum acyclovir level 12 hours after stopping the acyclovir was 5.5 mcg/mL (reported therapeutic peak range of 0.40–2.0 mcg/mL). ![]() The skin biopsy demonstrated findings consistent with calciphylaxis and pressure necrosis and the absence of viral inclusions. Cultures of the peritoneal fluid, bronchoalveolar lavage, blood, and spinal fluid, were all negative. Chest radiography demonstrated pulmonary edema. The arterial blood gas revealed a pH 7.21, PaCO 2 67 mmHg, PaO 2 163, HCO 3 27 mmol/L, O 2 saturation 97.8% on 100% oxygen via a non-rebreathable mask. The next day the patient developed delirium and hypoxemia. Empiric therapy with intravenous acyclovir 5 mg/kg/day was empirically started on hospital day 2. Computerized Tomography of the right lower extremity with contrast and multiplanar 3D reconstructions revealed no abscess. The Alveolar-arterial gradient was 71053.25 mmHg. Laboratory data included a white blood cell count of 8.1K with 74% neutrophils blood urea nitrogen of 74 mg/dL creatinine of 15.7 mg/dL and creatinine kinase 1,303 U/L. Her physical exam revealed an edematous right thigh and a tender 3 × 5 cm irregular ecchymotic area present on her lateral thigh near a small shallow ulcer. ![]() Her past medical history was significant for a history of shingles, orolabial herpes simplex disease, pancreatitis secondary to nucleosides, Candida esophagitis, and asthma. She had been in stable health without recent opportunistic infections. Doppler ultrasounds were negative for deep venous thrombosis on two different tests. A 46 year-old woman with AIDS (recent CD 4 + lymphocyte count 145 per mL & plasma HIV RNA level <400 copies per mL) and ESRD on continuous ambulatory peritoneal dialysis (CAPD) presented with pain in her right thigh for three months. ![]()
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