MRSA Thyroiditis and Thyrotoxicosis

Objective: 1) Learn that methicillin-resistant staphylococcus aureus (MRSA) thyroiditis causing thyrotoxicosis is a rare and potentially life-threatening condition. 2) Understand the diagnosis and management of suppurative thyroiditis and related thyrotoxicosis. 3) Understand the rising incidence of both community-acquired and hospital-acquired MRSA infections.

Method: We present a patient with MRSA thyroiditis and thyrotoxicosis who was evaluated by the otolaryngology–head and neck surgery service of an academic, tertiary care hospital in 2012. The literature was also reviewed through a directed PubMed search, and a relevant case was identified and discussed.

Results: A patient was transferred from an outside hospital in respiratory failure with a recent history of progressive neck pain and dysphagia. Computed tomography of the neck revealed an enlarged and inflamed thyroid gland, which was causing airway compression. Thyrotoxicosis was subsequently identified. MRSA was cultured in samples from an ultrasound guided thyroid biopsy and a surgical debridement. Antibiotics were started, and the thyrotoxicosis was followed clinically. With this management, the thyrotoxicosis resolved, and hypothyroidism immediately ensued. A literature review revealed only one previously reported case of MRSA thyroiditis and thyrotoxicosis, which resolved with medical management.

Conclusion: MRSA thyroiditis with associated thyrotoxicosis represents a rare complication of a bacterium that is becoming more common in community and hospital settings. To our knowledge, this is the second reported case of this particular clinical entity. Prompt identification of a causative organism and thyrotoxicosis can allow for potentially life-saving interventions.

Wavefront-guided photorefractive keratectomy in eyes with prior radial keratotomy: a multicenter study

PURPOSE

To investigate the outcomes of wavefront-guided photorefractive keratectomy (WG PRK) using prophylactic mitomycin C (MMC) in eyes that had previously undergone radial keratotomy (RK).

DESIGN

Retrospective, observational, consecutive case series.

PARTICIPANTS

Thirty-two eyes of 27 patients with previous RK that underwent WG PRK with MMC.

METHODS

The records were reviewed of consecutive RK patients whose eyes underwent WG PRK with MMC in 4 centers with postoperative follow-up of 6 months or longer (range, 6-21 months). Eyes were divided into myopic WG PRK and hyperopic WG PRK groups based on their preoperative spherical equivalent (SE). Preoperative best spectacle-corrected visual acuity (BSCVA) was compared with postoperative uncorrected visual acuity (UCVA) and BSCVA to ascertain efficacy and safety. Change in SE and attempted versus achieved SE were evaluated. Incidences of haze and other complications were recorded.

MAIN OUTCOME MEASURES

Uncorrected visual acuity, BSCVA, SE, corneal haze, and other complications.

RESULTS

In the myopic WG PRK group (n = 9), UCVA improved by 3 lines on average (P = 0.015) with UCVA of > or =20/20 in 56% and > or =20/40 in 100% of eyes; 55% were within 0.5 diopter (D), and 100% were within 1 D of attempted refraction. In the hyperopic WG PRK group (n = 23), UCVA improved for 3 lines on average (P<0.001), with UCVA of > or =20/20 in 48% and > or =20/40 in 100% of eyes; 57% were within 0.5 D and 74% were within 1 D of attempted refraction. One eye lost 2 lines of BSCVA as a result of the development of mild to moderate haze, but recovered in 4 months. No eyes lost more than 2 lines of BSCVA. Six eyes (19%; 6/32) experienced the development of haze in the postoperative course, with mild to moderate haze in 1 eye and trace haze in the other 5 eyes. No other complications were noted.

CONCLUSIONS

Wavefront-guided PRK with MMC in eyes with prior RK improved the UCVA significantly and was safe over the short follow-up of this series. Although haze occurred, no eye suffered persistent visual loss of 2 or more lines.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Value of pancreatic resection for cancer metastatic to the pancreas

BACKGROUND

Cancer metastatic to the pancreas from other primary sites is uncommon, and it has been treated with an aggressive surgical approach in fit patients when the primary tumor is controlled and the pancreas is the only site of metastatic disease. The value of pancreatic resection in this setting is unclear. The purpose of this study was to review cases of cancer metastatic to the pancreas.

METHODS

We reviewed our experience with cancer metastatic to the pancreas and the literature regarding resection of pancreatic metastases. Patient and tumor characteristics were summarized using descriptive statistics.

RESULTS

A total of 220 patients with pancreatic metastasis were analyzed. Three patients were selected from our own experience, and 217 were selected from a literature review. In the 127 patients whose symptoms were recorded at the time of presentation, the most common presenting symptoms were jaundice (n=32, 25.2%) and abdominal pain (n=25, 19.7%). In the 189 patients for whom the location of the metastasis in the pancreas was revealed, the most common location was the head of the pancreas (n=79, 41.8%). The primary tumor site was most commonly kidney (n=155, 70.5%). Surgical resection was attempted in 177 of 220 patients; 135 patients suffering from renal cell carcinoma (RCC) metastasis also underwent pancreatic resection. In the latter group, a median survival of 70 mo was seen, as well as 78% and 65% 2- and 5 y survival rates, respectively.

CONCLUSION

Survival after resection of RCC with isolated metastasis to the pancreas is favorable. However, a more detailed analysis considering outcomes without surgery for each primary tumor site is needed before the value of this aggressive surgical approach can be completely assessed in the general occurrence of pancreatic metastasis.