Dust Evolution in V4334.Sgr: Insights from Spectral Analysis
The complex composition of dust in V4334.Sgr, a low-mass post-AGB star, through detailed spectral analysis using Spitzer data. Investigating potential candidates like melilites, PAHs, SiC, and carbonates to understand the dust formation and characteristics."
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IN THE NAME OF GOD Haniyeh Fayazi
Patient description Gender :male Age:37y/o Married 5 Childs Was born in Zahedan and living there
Chief complaint Weakness and swelling of lower limbs and gait disorder
Present illness 37 y/o man with weakness and swelling of lower limbs muscle pain and muscle cramp from 2 month ago that was progressive and gait disorder admitted in Zahedan hospital Dx: Rhabdomyolysis
1402/1/2 27 129 6000 4000 12/5 1402/1/22 117 84 1402/2/7 163 71 3569 2044 11/5 85/5 1/1 AST(U/L) ALT(U/L) CPK(U/L) LDH(U/L) Hb(g/dl) MCV(fl) Cr(mg/dl) TG(mg/dl) Cholesterol(mg/dl) HDL(mg/dl) LDL(mg/dl) U/A Na(meq/l) K(meq/l) ESR(mm/h) Ca(mg/dl) Fe(micg/dl) TIBC(micg/dl) 10/2 81 0/9 115 251 42 190 NL NL 137 4 140 3/9 18 9/4 57 321
In this center Symptom: Weakness and calves swelling (most in lower limbs)/ Fatigue muscle pain and muscle cramp Calves swelling Weakness with climbing stairs Slow body movement Slow gait Constipation Cold intolerance Hoarseness / slurred speech
PMH Negative Trauma : Neg FH Hypothyroidism in his sister on levothyroxine DH Atorvastatin 40mg/d (resent 1 month) SH Smoking neg Opium user (INH) Alcohol neg
ROS positive Fatigue/weakness cold intolerance Skin(dryness) Hair(loss/ dryness) Hoarseness / slurred speech Constipation Headache / lethargy / memory defect Slow body movement muscle pain and muscle cramp Calves swelling Weakness with climbing stairs Slow gait Erectile dysfunction reduced hearing
ROS Negative Cold extremity loss of appetite/weight gain edema Nausea and vomiting/abdominal pain Dyspnea Decrease libido
PHE Height=173cm Weight=64 kg BMI=21/4kg/m2 T=36/5 c HR=60 RR=14 BP supine=120/70mmHg up right=110/60mmHg Skin dryness/hair dryness Periorbital edema - / face puffiness - Goiter( soft, grade1 ,30 gr) Pedal edema - Force of muscle 5/5proximal 5/5 distal Gower sign +
PHE Plantar reflex downward Achill reflex 1+ Knee reflex 2+/delayed relaxation calves pseudohypertrophy(leg swelling) Myoedema Muscle tenderness - Neurologic exam Neg other exams were normal
1302/2/9 T3 (ng/ml) T4 (ug/dl) TSH (uIU/dl) Anti TPO (IU/ml) 0/3 1/7 116 52
Prablem list 37 y/o man with Weakness and calves swelling (most in lower limbs) muscle pain and muscle cramp Weakness with climbing stairs Slow body movement and gait Constipation Cold intolerance Hoarseness / slurred speech Goiter( soft, grade1 ,30 gr) Force of muscle 4/5proximal, 5/5 distal Gower sign + Achill reflex 1+ Knee reflex 2+/delay relaxation Elevated CPK,LDH,AST,LDL Elevated TSH and decreased T4
PLAN Started levothyroxine 100 ug/d Follow up after 6 weeks
Patient description Gender:female Age:58 y/o Married Was born in Tehran Living in Tehran
Chief complaint Gait disorder and slow movement
Present illness A 58 y/o woman with fatigue and depression from 6 month progressive muscle rigidity and cramp slow body movement gait disorder and imbalance with falling slurred speech from 4 month refer to neurologist Decrease Tendon reflex 1+ Muscle force 5/5 (proximal and distal) Tandem gait+ Dx:Parkinson started L-DOPA
Present illness OTHER SYPTOM: Stop in weight loss on diet Severe constipation Cold intolerance/Hair loss/skin dryness Edema/Face puffiness Cold extremities
Hb g/dl MCV fl Cr mg/dl Tg mg/dl LDL mg/dl Na meq/l K meq/l Ca mg/dl AST U/L ALT U/L CPK U/L T4 ug/dl T3 ng/ml T Uptake unit TSH uIU/ml Folic acid ng/dl Vit b12 pg/ml Cortisol ug/dl 12/8 96/9 1/2 60 105 135 4/1 9/4 149 135 3570 <0/91 0/44 1/38 141/5 4/09 (4/4-31) 477 14/5 1401/11/17 in Razi Patholab
PMH IHD DH Metoral 25mg/bd Atorvastatin 20 mg/d L-DOPA 100 mg/bd ASA 80/d FH Hypothyroidism in her sister on levothyroxine SH negative
ROS Fatigue/depression Stop in weight loss on diet Cold intolerance/Hair loss/skin dryness Periorbital Edema/tongue enlargement /Face puffiness Severe constipation progressive muscle rigidity, pain and cramp Weakness with brushing and climbing stairs slow body movement (bradykinesia) Walking difficulty and slow and imbalance with falling slurred speech Pedal Edema
PHE BP=100/60 mmHg T=37 c HR=56 RR= 16 Height=170 cm Weight=82 Kg BMI=28/3 kg/m2 Cold extremities/Hair loss/skin dryness Preorbital edema/face puffiness Tongue enlargement Thyroid exam was normal
PHE Muscle rigidity( symmetrical) Decrease Tendon reflex 1+ Plantar reflex downward Muscle force 5/5 (proximal and distal) Biceps muscle hypertrophy Muscle tenderness - Tandem gait+ Clasp-knife response Cogwheel like jerk - Tremor Myoedema - Other neurologic exams were normal
Prablem list 58 y/o woman with progressive muscle rigidity and cramp from 4 month slow body movement and gait disorder and imbalance with falling slurred speech Stop in weight loss on diet Severe constipation/Cold intolerance/Hair loss/skin dryness Edema/Face puffiness Tongue enlargement Thyroid exam was normal Muscle rigidity( symmetrical)/biceps muscle hypertrophy Decrease Tendon reflex 1+ Muscle force 5/5 (proximal and distal) Tandem gait+ Elevated CPK ,AST,ALT Elevated TSH and decrease T4,T3
plan Start levothyroxine 100 ug /d Taper off L-DOPA
Hb (g/dl) MCV ( fl) Cr (mg/dl) Cholestrol (mg/dl) HDL (mg/dl) LDL ( mg/dl) Tg (mg/dl) AST (U/L) ALT (U/L) CPK (U/L) T4 (ug/dl) T3 (ng/ml) TSH (uIU/ml) Anti TPO ( IU/ml) Ferritin (ng/ml) Folic acid (ng/ml) 13/1 95/3 1/2 180 66 84 99 34 48 129 10/86 (5-12) 0/75 ( 0/7-2/2) 5/25 15 72 29/2 After 6 weeks all symptoms improved and in Razi PathoLab
Myopathy Congenital Myopathy Mitochondrial Myopathy Muscle dystrophy Metabolic Myopathy: Inflammatory/Autoimmune Toxic(toxin/drug) Endocrine Infectious Critical illness
Endocrine Myopathy Hypothyroidism Hyperthyroidism Cushing disease/exogenous corticosteroid Adrenal insufficiency Acromegaly Hyperparathyroidism/hypoparathyroidism Osteomalacia DM Electrolyte imbalance
the real prevalence of neuromuscular complications in the course of hypothyroidism is likely to be underestimated The effects of hormone deficiency may involve the peripheral nervous system at one or more of the three possible levels: nerve, neuromuscular junction and muscle fiber Alessandro Sindoni et al. Springer Science+Business Media New York 2016 Rev Endocr Metab Disord DOI 10.1007/s11154-016-9357-0
IN Hashimoto s thyroiditis with HM differ from other HT (i) female/male ratio of 1:1, contrasts with the classical 5:1 (ii) predominance of the atrophic variant of HT (iii) age at onset of myopathy <40 years, in contrast with the higher average age of onset of the atrophic variant of HT without associated HM (iv) higher serum concentrations of (TgAb), compared to (TPOAb). Alessandro Sindoni et al. Springer Science+Business Media New York 2016 Rev Endocr Metab Disord DOI 10.1007/s11154-016-9357-0
the term hypothyroid myopathy (HM) should be applied to those patients in whom symptoms of muscular involvement dominate the clinical picture Alessandro Sindoni et al. Springer Science+Business Media New York 2016 Rev Endocr Metab Disord DOI 10.1007/s11154-016-9357-0
The muscular symptom may also be the first and only event in HM they may be the sole symptoms, the classical signs and symptoms of hypothyroidism being absent characterized by a stable decrease in strength with a predominant proximal distribution and slow evolution. Alessandro Sindoni et al. Springer Science+Business Media New York 2016 Rev Endocr Metab Disord DOI 10.1007/s11154-016-9357-0
symptoms suggestive of muscular involvement, affect quality of life exercise intolerance, myalgias, cramps, stiffness, myoedema weakness, painful muscles, limited joint mobility, sluggish movements and reflexes, and myoedema elicitation of myoedema significantly increases the probability of HM deep tendon reflexes, the delayed relaxation phase Alessandro Sindoni et al. Springer Science+Business Media New York 2016 Rev Endocr Metab Disord DOI 10.1007/s11154-016-9357-0
In some patients with HM, do not have the typical myopathic pattern and progressive proximal weakness. Rather, complaints consist in exertional pain, stiffness, myalgias, fatigue and muscle cramps, that may lead the patient to a neurologist s consultation Alessandro Sindoni et al. Springer Science+Business Media New York 2016 Rev Endocr Metab Disord DOI 10.1007/s11154-016-9357-0
Finally, in about 40 % of patients, especially if old, also signs of sensorimotor polyneuropathy localized predominantly in the lower limbs can be observed Alessandro Sindoni et al. Springer Science+Business Media New York 2016 Rev Endocr Metab Disord DOI 10.1007/s11154-016-9357-0
In the polymyositis-like presentation of hypothyroidism: involvement of axial muscles(extensors of the head and abdomen) and pelvic muscles which is only rarely found in patients with HM. the differential diagnosis between myopathy associated with HM and inflammatory myopathies, may not be clinically easy Alessandro Sindoni et al. Springer Science+Business Media New York 2016 Rev Endocr Metab Disord DOI 10.1007/s11154-016-9357-0
Rhabdomyolysis Rhabdomyolysis is rare characterized by the triad muscle weakness, myalgias and dark urine (due to myoglobin), CK levels are usually high A serious complication is kidney failure Alessandro Sindoni et al. Springer Science+Business Media New York 2016 Rev Endocr Metab Disord DOI 10.1007/s11154-016-9357-0
Acute compartment syndrome (ACS) ACS is caused by decrease the size of the compartment or increase the content of the compartment. if prolonged, may be irreversible. anatomical sites already prepared for compression phenomena (for example, tibial and peroneal muscles). only 5 cases of hypothyroidism-associated ACS in the literature Alessandro Sindoni et al. Springer Science+Business Media New York 2016 Rev Endocr Metab Disord DOI 10.1007/s11154-016-9357-0
Koche Debresemelaigne syndrome (KDSS) KDSS is a rare association of muscular pseudohypertrophy and long- standing moderate-to-severe hypothyroidism mainly in the pediatric age group . The condition is rare in countries with screening programmes for hypothyroidism at birth. Alessandro Sindoni et al. Springer Science+Business Media New York 2016 Rev Endocr Metab Disord DOI 10.1007/s11154-016-9357-0
The vast majority of cases were reported from Asia, particularly from India. Males are more affected an autosomal mode of inheritance has been postulated . The underlying thyroid defect congenital hypothyroidism or autoimmune Alessandro Sindoni et al. Springer Science+Business Media New York 2016 Rev Endocr Metab Disord DOI 10.1007/s11154-016-9357-0
Pseudo hypertrophy is most striking in the trunk,limbs,hands, feet, tongue and facial muscles The elevation of CK levels is usually of mild degree Electromyogram is usually normal or may show myopathic low amplitude and short motor unit s potential Alessandro Sindoni et al. Springer Science+Business Media New York 2016 Rev Endocr Metab Disord DOI 10.1007/s11154-016-9357-0
Hoffmans syndrome (HS) HS is a rare syndrome seen in adults, mostly males, with longstanding untreated hypothyroidism . An increase in the volume of muscle mass, mainly at limbs, associated with a difficulty in muscle relaxation (pseudomyotonia) and with painful muscle spasms , but with preservation of muscular strength , are the typical elements of Hoffmann syndrome(HS). Patients present with muscle stiffness, weakness, hyporeflexia, delayed deep tendon reflexes and (or without) muscle cramps Alessandro Sindoni et al. Springer Science+Business Media New York 2016 Rev Endocr Metab Disord DOI 10.1007/s11154-016-9357-0
Muscle enlargement (pseudohypertrophy) is very rare, and its etiology remains controversial . Calf muscles (gastrocnemius) are almost always involved, whereas the thigh , arm and forearm muscles are involved to a lesser extent Mild to moderate elevation of serum CK level is seen in 70 90% patients with HS , does not correlate with the severity of weakness Alessandro Sindoni et al. Springer Science+Business Media New York 2016 Rev Endocr Metab Disord DOI 10.1007/s11154-016-9357-0
Biochemical diagnosis Muscle enzymes The increase in serum muscle enzymes (particularly, CK)is observed in 57 90 % of hypothyroid patients . elevated serum CK has low specificity, In HM , increase in serum CK values fluctuates from 10 to 100 times Serum levels of CK are usually very high in the polymyositis like presentation of hypothyroidism Alessandro Sindoni et al. Springer Science+Business Media New York 2016 Rev Endocr Metab Disord DOI 10.1007/s11154-016-9357-0
Serum CK values correlated positively with serum TSH and negatively with serum FT3 and FT4, but not with the clinical severity of the muscular symptoms absence of cardiomyopathy, it is possible to found increased values of CKMB Serum levels of CK fall within the normal range after a few weeks from replacement L-T4 therapy Alessandro Sindoni et al. Springer Science+Business Media New York 2016 Rev Endocr Metab Disord DOI 10.1007/s11154-016-9357-0
According to the American Thyroid Association guidelines: increased one or both of the muscle enzymes CK and lactic dehydrogenase (LDH), that persist elevated for at least 2 weeks, is enough to justify the request of serum TSH assay Alessandro Sindoni et al. Springer Science+Business Media New York 2016 Rev Endocr Metab Disord DOI 10.1007/s11154-016-9357-0
Electromyography Electromyography studies have demonstrated a decreased average duration of the motor unit potentials, as in primary myopathies, and an increased number of polyphasic potentials. abnormalities occur only in half of the patients with HM For this reason, electromyography cannot be considered among the diagnostic tools with relevant discriminating value Alessandro Sindoni et al. Springer Science+Business Media New York 2016 Rev Endocr Metab Disord DOI 10.1007/s11154-016-9357-0
Therapy Treatment of HM is replacement therapy with L-T4. The signs and symptoms of hypothyroidism revert ,in weeks to months, Sometimes the recovery is incomplete, since symptoms may persist for a long time reduced intramuscular deiodation of T4 to T3 could lead to incomplete resolution of myopathy The variability in the response to treatment may be related to the severity and age Alessandro Sindoni et al. Springer Science+Business Media New York 2016 Rev Endocr Metab Disord DOI 10.1007/s11154-016-9357-0
