Introduction: Arginine vasopressin deficiency (AVP-D) is characterized by impaired antidiuretic hormone secretion, leading to polyuria and a significant dehydration risk. The British Islamic Medical Association classifies AVP-D as a “very high risk” condition, advising against Ramadan fasting. However, many patients fast due to religious convictions, creating a gap between clinical guidelines and patient practice. This study evaluates the clinical outcomes and safety of fasting in this population. Methodology: A single-centre retrospective cohort study was conducted at Hospital Putrajaya. We included adults with permanent AVP-D on desmopressin therapy for more than 1 year who fasted during Ramadan 2025. Data were extracted from electronic medical records and patient consultations. Primary outcomes included hospitalization rates, dehydration symptoms, and desmopressin dose adjustments. Results: Of the 43 patients (mean age 42.4 ± 15.28 years; 53.5% female), 27 successfully fasted for a mean of 27.6 ± 6.56 days. Pre-Ramadan counseling was documented in only 55.8% of cases. While 25.9% of participants experienced dehydration symptoms (thirst, dizziness), and 22.2% broke their fast for safety reasons, there were no hospitalizations. None of the patients required additional desmopressin dose adjustments. Most patients (66.7%) maintained twicedaily desmopressin dosing (Sahur and Iftar). Anterior pituitary deficiencies were present in 70.3% of the cohort. Conclusion Despite being classified as very high risk, many AVP-D patients safely complete Ramadan fasting without severe adverse events. However, the high rate of dehydration symptoms and the significant gap in pre-Ramadan counseling (44.2% un-counseled) highlight the need for structured clinical reviews 4–6 weeks prior to Ramadan to optimize hydration and dosing
Humans ; Diabetes Insipidus, Neurogenic ; Retrospective Studies ; Arginine ; Fasting

Introduction: Primary thyroid lymphoma (PTL) is a rare malignancy representing 1–5% of all thyroid cancers, most frequently arising on a background of chronic autoimmune thyroiditis. Case: We report a 73-year-old Malay male who initially presented with large goiter, symptomatic bradycardia, and subsequently developed severe primary hypothyroidism (thyroid-stimulating hormone 231 mIU/L, anti-thyroid peroxidase 643 IU/mL), consistent with Hashimoto’s thyroiditis. During his clinical course, he also sustained a non-ST elevation Myocardial Infarction which was attributed to demand-supply mismatch of hypothyroidism. Computed tomography scan of the neck revealed a large multinodular goiter with retrosternal extension, tracheal compression, and extensive nodal lymphadenopathy. Initial Fine needle biopsy was non-diagnostic, but a repeat biopsy was performed due to rapidly enlarging goiter within weeks with suspicious nodules seen on bedside thyroid ultrasound. Ultrasound-guided core biopsy confirmed Diffuse Large B-cell Lymphoma (DLBCL), non-germinal centre B-cell (non-GCB) subtype. Despite initiation of levothyroxine and corticosteroid therapy, the patient deteriorated with remarkable rapidity over the ensuing weeks, culminating in a 15 × 10 cm compressive neck mass, Type 1 respiratory failure, hypercalcemia, complete dysphagia, and concurrent pneumonia. He was then transferred to hematology tertiary centre for commencement of his chemotherapy. Conclusion This case of PTL presenting in the background of Hashimoto’s thyroiditis emphasizes the role of early tissue diagnosis in patients with rapidly enlarging goiter. Identification of PTL is critical because management shifts from surgical intervention to systemic chemotherapy.
Thyroiditis

Introduction: Graves’ disease is typically managed with antithyroid drugs (ATDs) and beta-blockers like propranolol. While allergic reactions to ATDs are common, beta-blockers are rarely identified as allergens. Case: A 42-year-old female with Graves’ disease was started on carbimazole 5 mg daily and propranolol 40 mg daily. She developed mild itchiness, which was tolerable. One month later, liver enzyme derangement led to the discontinuation of carbimazole. Propylthiouracil (PTU) 300 mg daily was initiated while continuing propranolol, but caused generalized urticaria, necessitating its cessation. Prednisolone was started, but her thyroid function worsened. Alternative therapies were proposed but declined by the patient. Upon resolution of urticaria, PTU was reintroduced at 50 mg daily without adverse effects, and propranolol was discontinued. Her cutaneous symptoms did not recur, implicating propranolol as the allergen. Conclusion In hyperthyroidism, increased hepatic clearance reduces plasma propranolol levels, minimizing the risk of adverse effects. However, as thyroid function normalizes, propranolol clearance slows, leading to drug accumulation and increased susceptibility to side effects. Clinicians should consider all medications as potential allergens and understand how thyroid states affect drug metabolism to optimize treatment.
Graves Disease ; Allergens