bluuebunny/crossref_metadata_2025 huggingface dataset:
12556 Medullary Thyroid Cancer With Persistent Elevation Of Carcinoembryonic Antigen: Case Report
Authors: Campana Mario S , Vodopivec Danica , McCammon Susan , Heatherly Alexis
Published: October 2024

Disclosure: M.S. Campana: None.

Introduction: Medullary thyroid Cancer (MTC) is a rare neuroendocrine tumor that originates from thyroid parafollicular C-cells and represents 5 % of all thyroid cancers. MTC can be sporadic (75%) or hereditary (25%) associated with multiple endocrine neoplasia type 2 syndrome (MEN2). Serum calcitonin (Ctn) and carcinoembryonic antigen (CEA) are its tumor markers. We report a case of persistently elevated CEA levels despite an undetectable Ctn in a patient with MTC after initial thyroid lobectomy. Description of the case: A 42-year-old woman self-identified a neck lump after intentional weight loss. A neck US showed a right lobe thyroid nodule which resulted as suspicious for malignancy (Bethesda V) with subsequent right lobectomy. Pathology reported a 2.6 cm unexpected MTC with negative surgical margins, extrathyroidal extension, angioinvasion, and lymphatic invasion. No cervical lymph nodes (LNs) were removed. Immunohistochemistry was positive for CEA, chromogranin A, synaptophysin, and Ctn. T2 Nx. One month after lobectomy, the Ctn was 10.5 (0-3.0 pg/mL) and CEA 205.2 (0-3.0 ng/mL Non-smoker; 0-5.0 ng/mL smoker). The patient was then referred to our clinic for further management. Laboratories showed normal serum calcium, PTH, and fractionated plasma metanephrine/normetanephrine. A 2-month post-operative Ctn was undetectable, but CEA was elevated at 24.5. Subsequently, we broaden imaging studies to include neck US, CT neck /chest with contrast, and MRI abdomen pelvis with contrast. The only remarkable finding was a 6.7 cm pelvic mass with normal Ca-125. Genetic testing was negative for germline RET, ruling out MEN2. Patient underwent completion left lobectomy with prophylactic bilateral central neck dissection. Pathology showed benign thyroid parenchyma with multinodular hyperplasia and 0/12 LNs. Because of concerning pelvic mass, the patient was referred to OB/GYN. She underwent a laparoscopic bilateral salpingo-oophorectomy. Pathology showed a follicular ovarian cyst, negative for malignancy. A year post-completion total thyroidectomy Ctn remains undetectable, and a CEA is normal at 1.3. Discussion: Because Ctn was already undetectable 1 month after lobectomy with persistent elevated CEA a complete total thyroidectomy with prophylactic bilateral central neck dissection was indicated to achieve operative cure. Ctn is specific to MTC but variable. CEA is more reproducible with less variability; however, it is not specific to MTC and can also be elevated in smokers, benign breast and genitourinary disease, emphysema, cirrhosis, and cancer of colon, rectum, liver, genitourinary, and lung. If residual disease is present, Ctn tends to be proportionally more elevated than CEA. When the opposite occurs, poorly differentiated MTC with possibility of distant metastases vs. a second primary malignancy vs. a distant benign neoplasm known to elevate CEA need to be ruled out.

Presentation: 6/2/2024
6472 Methimazole Induced Agranulocytosis: Uncommon Complication of a Common Medication
Authors: Kaur Ravleen , Kaur Lavleen , Sridhar Archana , Chaudhary Taibah , Patel Nirali
Published: October 2024

Disclosure: R. Kaur: None. L. Kaur: None. A. Sridhar: None. T. Chaudhary: None. N. Patel: None.

Methimazole (MMI) induced agranulocytosis is a rare and life threatening adverse effect that usually occurs within 3 months of drug initiation and can rapidly lead to overwhelming infection. It is reported in 0.1 to 0.5 % of patients on treatment with methimazole. MMI is a standard drug used in graves disease and toxic multinodular goiter. We report a case of MMI induced agranulocytosis in an elderly female with recently diagnosed toxic multinodular goiter. A 66 year old female with past medical history of recently diagnosed toxic multinodular goiter for which she was started on methimazole 80mg/day two months ago presented to the emergency department with chief complaint of severe sore throat associated with rapidly increasing pharyngeal pain and fever over the past 24 hours. She was lethargic, febrile with temperature of 102 F, tachycardic with heart rate of 115/minute and hypotensive with blood pressure of 108/64 mm Hg. Physical examination revealed diffuse pharyngeal and tonsillar erythema with bilateral purulent exudate with tender anterior cervical lymphadenopathy. Thyroid was enlarged, firm, irregular and nontender. Pulmonary, cardiac and abdominal exam was unremarkable. Lab work showed severe leukopenia with WBC count of 1,600/mm3, neutropenia with absolute neutrophil count of 0.0 x 1000/ul (normal range 1.8-7.3 x 1000/ul) and erythrocyte sedimentation rate and C reactive protein were both elevated. Blood cultures and fungal cultures showed no growth. Urinalysis and urine culture were both unremarkable. She had an extensive haematological, rheumatological and infectious disease workup for neutropenia, which was largely unrevealing. Rapid streptococcal testing was negative but throat cultures grew beta haemolytic streptococci. Treatment included suspending methimazole, administering antimicrobial therapy with piperacillin - tazobactam, acyclovir and fluconazole. She was also started on a granulocyte colony stimulating factor. Patient presented satisfactory evolution with progressive increase in leukocyte count and remission of symptoms by day 5 of treatment, rendering further bone marrow testing unnecessary. Antibiotics were changed to oral amoxicillin-clavulanic acid after throat culture results were available and the patient was discharged in stable condition. One month after discharge she underwent total thyroidectomy for definitive cure and is currently followed up as an outpatient by endocrinology. The objective of this case report is to present an uncommon case of agranulocytosis secondary to use of methimazole and to increase awareness among the physicians about the need to consider this diagnosis in patients on this medication. It is also advised that these patients be educated about the drugs side effects, a practice that may avert suffering and unnecessary costs.

Presentation: 6/3/2024
12264 Myxedema Coma And The Impact Of Treatment Noncompliance
Authors: Subramani Rashmi , Marasandra Ramesh Harshita , Yavuz Sahzene
Published: October 2024

Disclosure: R. Subramani: None. H. Marasandra Ramesh: None. S. Yavuz: None.

Introduction: Myxedema coma represents a critical medical condition marked by a heightened risk of both morbidity and mortality. It manifests as severe hypothyroidism, typically presenting with symptoms like lethargy, altered mental status, or potential obtundation. Various triggering factors, including infections, hypothermia, metabolic imbalances, surgery, and specific medications like amiodarone, lithium, and anesthetics, can precipitate this emergency. Here we outline a classic instance of myxedema coma stemming from non-adherence to levothyroxine treatment in the context of primary hypothyroidism. Case Summary: A 56-year-old woman with a medical history significant for primary hypothyroidism, hyperlipidemia, and mood disorder presented to the hospital exhibiting symptoms suggestive of a stroke. Upon arrival, she had a seizure episode and eventual unresponsiveness. Emergency intubation was performed due to a low Glasgow Coma Scale score and concern for airway protection. Further history revealed non-compliance with levothyroxine therapy. Laboratory findings included TSH of 150 uIu/ml, T4 of 1.1 ng/dl, T3 of 1.17 ng/dl, and cortisol of 21.9 ug/dl. Chest x-ray revealed complete atelectasis of the left lung with mediastinal shift initially before intubation. CT head and neck were unremarkable. A diagnosis of myxedema coma was made based on clinical presentation and a myxedema score of 75. Treatment included IV levothyroxine 50 mcg, increased to 100 mcg, nor-epinephrine drip for hypotension and 1000 mg of levetiracetam for seizures management. Pulmonary edema resolved following levothyroxine initiation. The patient was successfully extubated on day 3, weaned off oxygen, and discharged home after 8 days with counseling on medication adherence. Discussion: While encountering a case of myxedema coma is rare, it is crucial to maintain a low threshold for diagnosing this potentially fatal emergency. Early recognition, facilitated by a comprehensive history, physical examination, and prompt initiation of treatment, is essential for effective management. Despite early intervention, the mortality rate remains high, ranging from 50% to 60%. Wartofsky et al. advocate for the primary treatment approach with T4 alone, emphasizing its efficacy. Supportive measures such as warming, fluid resuscitation, mechanical ventilation, administration of antibiotics, vasopressors, and corticosteroids are also integral components of management. This case report underscores the considerable morbidity and mortality associated with myxedema coma. The most common trigger precipitating myxedema coma is non-compliance with levothyroxine therapy, particularly in elderly females with longstanding hypothyroidism. Therefore, counseling regarding strict adherence to levothyroxine is of paramount importance.

Presentation: 6/1/2024
12498 Outcomes In Thyroid Cancer Patients Having Undergone Us-guided (usg) Fine Needle Aspiration Sampling Of Cervical Lymph Nodes And Soft Tissue Nodules
Authors: castellanos Paula lorena , Maria Chindris Ana , Rao Sarika , Janus Jeffrey , Paz-Fumagalli Ricardo , Joseph Bernet Victor
Published: October 2024

Disclosure: P.L. castellanos: None. A.M. Chindris: None. S. Rao: None. J. Janus: None. R. Paz-Fumagalli: None. V.J. Bernet: None.

Introduction: Limited information exists regarding the relationship between outcomes and decision-making based on results from Ultrasound-guided fine needle aspiration (USG-FNA) of cervical nodes/nodules suspicious for thyroid cancer metastases. Management options for positive findings include surgery, percutaneous ethanol ablation, radioactive iodine therapy, external beam radiation systemic therapy, or observation. This retrospective review is aimed at describing the management and associated outcomes of a cohort of thyroid cancer patients who underwent USG FNA for cervically metastases. Methods: Following our Clinic IRB review and approval, we performed a chart review and identified 163 patients with thyroid cancer patients who had undergone USG FNA of apparent cervical metastases at the Florida campus between 2012 and 2018. Cytology results and corresponding tumor marker washout from each sampled focus were recorded. The records review included recording anatomical and biochemical outcomes related to management decisions based on USG FNA results. Appropriate statistical plots were used to help visualize the data pattern. ResultsThe median age was 59 years 69.9% were female and 91.3% were Caucasian. Initial presentation typically consisted of the appearance of a neck nodule and thyroidectomy was the first line of therapy in 155 of 163 cases. Imaging post-thyroidectomy demonstrated evidence of cervical lymphadenopathy in 75.5% of cases with localization in the lateral neck in 65.2% and central in 19.2% respectively. Regarding USG-FNA outcomes, 46.2% yielded malignancy while 26% were benign. The most prevalent cytology was papillary thyroid cancer detected in 87.1%.Thyroglobulin washout was performed on all patients with a history of papillary variant thyroid carcinoma, with positive results reported in 8.3%. Ethanol ablation was the most used treatment for lymph node recurrence followed by neck surgery in 56.2%. During the follow-up, 14% of the patients who were TGAB+ remained so.Outcome trends were as follows: The combined anatomical and biochemical negative was 82.3%, while the combined anatomical and biochemical positive was 2.5%. The combined anatomical negative and biochemical positive was 7.6%, alongside the combined anatomical positive and biochemical negative was 7.6%. Conclusion: Of 163 thyroid cancer cases with cervical lymphadenopathy, 46% had cytology-proven presence of malignancy. These patients underwent either observation, PEA, or surgery.At follow up the majority of the patients were without anatomical and biochemical evidence of disease while about 7-8% were positive by one of the parameters and much fewer were positive for disease by both parameters.

Presentation: 6/3/2024
7605 Patient Suffering from Pancytopenia Secondary to Methimazole in the Setting of Hyperthyroidism
Authors: Seidenberg J , Gupta V , Ansari M
Published: October 2024

Disclosure: J. Seidenberg: None. V. Gupta: None. M. Ansari: None.

Methimazole induced agranulocytosis is a rare but significant adverse effect of using thalidomide to treat Hyperthyroidism. Agranulocytosis is defined as a severe selective neutropenia associated with some drugs including opioids and specifically Methimazole. The risk has been found to be high in elderly population and those with blood dyscrasias and cross over from immunologic disorders. Patient is a 79 year old F with a PMH of hyperthyroidism started a month prior on Methimazole. While presenting to the endocrinology clinic for a follow up visit, Patient started having palpitations and lightheadedness, slurring of speech with left sided lower limb weakness and AMS and was found to be hypotensive with resolution of symptoms and neurological signs after fluid resuscitation. She was founfd to have undetectable TSH and Free T4 of 90.8-1.2ng/dL) . She was sent to the ED found to have septic shock with positive blood cultures of pseudomonas and drop in WBC from 6400 one month before to 700 (4000-11,000/mcL), an ANC of 0 (2,500-6,000 /mcL)and severe thrombocytopenia progressing from 235,000 on admission to 61,000 (150,000-450,000) on day 4. The patient was treated with antibiotics IV cefepime and IV Doxycycline. The patient was monitored off methimazole with daily CBCs, daily T3 and T4. Patient was transferred to the ICU for closer management due to septic shock. Patient improved with steady increase in ANC and WBC and was discharged home. Agranulocytosis in the setting of Methimazole use is a life-threatening rare side effect. The resultant decreased neutrophils count leading to an immunocompromised state increases risk of sepsis and shock as seen in this case. Patients who develop this side effect should immediately stop their methimazole, be monitored in the hospital for improvement in symptoms and WBC count. They should never be placed back on thalidomides due to increased future risk of agranulocytosis and while hospitalized be checked daily for T3/T4 and if elevated, should be administered cholestyramine to prevent rebound hyperthyroidism.

Presentation: 6/2/2024
8229 Prevalence of Thyroid Cancer in Patients with Hashimotos Thyroiditis Presenting Concomitant Thyroid Nodular Disease
Authors: Alvarez Castillo Marlen Alejandra , Sanchez Arriaga Luis Felipe , Segovia Palomo Antonio
Published: October 2024

Disclosure: M.A. Alvarez Castillo: None. L. Sanchez Arriaga: None. A. Segovia Palomo: None.

Introduction: Hashimoto's thyroiditis (HT) is the most frequent autoimmune thyroid disease and the main cause of goiter and hypothyroidism; it induces a process of aseptic autoimmune inflammation. Fibroinflammatory changes lead to the development of thyroid nodules (TN), additionally chronic inflammation is an important player in the development of cancer, although this association is controversial. The prevalence of thyroid cancer (TC) in patients with HT ranges from 0.61-58.4% (25.01%), being higher than in patients with TN without concomitant HT. Objective: To know the prevalence of malignancy in patients with HT who present thyroid nodular disease. Methodology: An observational, descriptive, retrospective, and longitudinal study was carried out. Patients with HT diagnosis were selected by measuring Ab TPO and/or Ab TG who presented an ultrasound diagnosis of TN and FNAB of the thyroid lesion had been performed. Descriptive statistics and linear regression were used. Results: 87 patients: 6 (6.9%) men and 81 (93.1%) women aged 47.9 (12.7) years. 4 (4.5%) required FNAB in 2 TN, for a total of 91 TN studied. 64% had a diagnosis of hypothyroidism and were taking LT4, TSH 4.40 (4.44) mUI/mL, FT4 1.00 (0.27) ng/dL. Mean Ab TPO was 794.7 ± 1354.6. Diagnosis time 19.5 (29.1) months. 39.6% the detection was made by the patient and 35.2% by the doctor. Major axis was 18.8 (12.1) mm. Ultrasound pattern of single TN 58.2% and multinodular 41.8%. Median TIRADS was 4, with a mode of 5. 81.3% reported Bethesda II and 18.7% malignant or suspected, were sent for surgery, malignancy was confirmed in 16/ 17 lesions. 14 (15.3%) were TPC and 2 lymphomas, the main subtypes were classic papillary and NHL, respectively. Mode of ATA risk was intermediate. Multivariate analysis only TIRADS represented risk factor (OR 2.08) Conclusions: The frequency of TC in our population was 15.3%, which reflects a higher prevalence of malignancy in thyroid nodules in patients with chronic thyroiditis, in accordance with what has been reported in other series.

Presentation: 6/3/2024
6973 Prospective Multicenter Registry-Based Study on Thyroid Storm: The 2016 Guidelines for the Management from the Japan Thyroid Association and Japan Endocrine Society Are Useful
Authors: Furukawa Yasushi , Tanaka Keiko , Isozaki Osamu , Suzuki Atsushi , Iburi Tadao , Tsuboi Kumiko , Iguchi Moritake , Kanamoto Naotetsu , Minamitani Kanshi , Wakino Shu , Satoh Tetsurou , Teramukai Satoshi , Kimura Eizen , Miyake Yoshihiro , Akamizu Takashi
Published: October 2024

Disclosure: Y. Furukawa: None. K. Tanaka: None. O. Isozaki: None. A. Suzuki: None. T. Iburi: None. K. Tsuboi: None. M. Iguchi: None. N. Kanamoto: None. K. Minamitani: None. S. Wakino: None. T. Satoh: None. S. Teramukai: None. E. Kimura: None. Y. Miyake: None. T. Akamizu: None.

Context: The mortality rate in thyroid storm (TS) has been reported to be higher than 10%. Even when patients survive, some have irreversible damages. In order to improve the prognosis of patients with TS, appropriate management as well as prompt and accurate diagnosis are needed. We created the diagnostic criteria in 2012 and established guidelines for the management of TS in 2016. Objective: We aimed to evaluate the effectiveness of the 2016 guidelines for the management of TS proposed by the Japan Thyroid Association and Japan Endocrine Society. Design: Prospective registry-based study through a secure web platform. Setting: Prospective multicenter registry. Patients and Measurements: Patients with new-onset TS were registered in the Research Electronic Data Capture (REDCap) from May 1, 2018 to April 30, 2022, over four years. On day 30 after admission, clinical information and prognosis of each patient were added to the platform. On day 180, the prognosis was described. The questionnaire consisted of 176 items totally. Results: This study included 110 patients with TS (93 definite and 17 suspected). The median of Acute Physiology and Chronic Health Evaluation (APACHE) II score was 13, higher than the score in the previous nationwide survey, 10 (p=0.001). Nonetheless, the mortality rate at day 30 was 5.5%, approximately half compared with 10.7% in the previous nationwide survey (p=0.13). Lower BMI, lower left ventricular ejection fraction (LVEF) and shock were positively associated with poor prognosis at day 30. The lack of fever ≥ 38°C was surprisingly associated to the outcome. Approximately 80% of doctors followed the guidelines. The mortality rate in patients with an APACHE II score ≥ 12 for whom the guidelines were not followed was significantly higher than the rate in patients for whom the guidelines were followed (50% vs. 4.7%) (p=0.01). Conclusions: Prognosis seemed better than in the previous nationwide survey, even though disease severity was higher. The mortality rate was lower when the guidelines were followed. Thus, the guidelines are useful for managing TS.

Presentation: 6/2/2024
8728 Radiofrequency Thermal Ablation in Thyroid Microcarcinomas: Experience of the Brazilian Group with 143 Cases
Authors: Lima Amato Lorena Guimaraes , Machado Carani Pedro Henrique , Moura Volpi Leonardo De , Rahal Antonio , Martinho Volpi Erivelto
Published: October 2024

Disclosure: L.G. Amato: None. P.H. Carani: None. L.D. Volpi: None. A. Rahal: None. E.M. Volpi: None.

Introduction: Thyroid nodules are quite prevalent worldwide, with papillary thyroid carcinoma (PTC) being the most common histological subtype of thyroid malignant neoplasm, accounting for approximately 85% of thyroid cancers. When this carcinoma is less than 10 mm in its longest axis, it is defined as papillary thyroid microcarcinomas (mPTCs) which has had an increasing proportion of thyroid cancers and with a disease-specific survival of patients having this diagnosis more than 99% after 10 years of follow-up. Most guidelines concerning thyroid cancer care recommend a lobectomy as the first-line treatment strategy for low-risk unifocal mPTC but often results in aggressive overtreatment. Thyroid surgery comes with significant costs and morbidity rates caused by iatrogenic hypothyroidism and recurrent laryngeal nerve damage, resulting in poor quality of life, justifying the growing search for minimally invasive and effective methods in the treatment of mPTC and in this context Radiofrequency thermal ablation (RFA), a minimally invasive treatment that preserves thyroid function have been proposed for patients with low-risk mPTC. Clinical case: From April 2018 to January 2024, 143 patients with mPTC, were submitted to RFA and patient's follow-up were dated 1, 3, 6, 12 and 18 months after the procedure. During the follow-up we observed 3 (2%), complications, 1 case of permanent paralysis unilateral vocal cord, 1 Horner Syndromes and 1 case of transient paralysis, with total reversal. In all cases there was a reduction in the volume of the node after 6 months of the procedure. Conclusion: The reported incidence rate of postoperative hypothyroidism in patients underwent hemithyroidectomy is 10.9-48.8%, therefore, risks of complications with radioablation in our series were lower than those previously described during hemithyroidectomy. Radiofrequency thermal ablation (RFA) is a minimally invasive treatment that preserves thyroid function with a lower incidence of complications compared to thyroidectomy or lobectomy, and and should be considered the selection procedure for low-risk thyroid microcarcinomas.

Presentation: 6/3/2024
6537 Recurrent Graves Thyrotoxicosis After Prolonged Radioiodine-Induced Hypothyroidism
Authors: Kieran Deveaux Hillary , Gundeti Anjali , Mitrollari Kristjana , Pauline Calimag Angela , Yasmeen Tahira
Published: October 2024

Disclosure: H.K. Deveaux: None. A. Gundeti: None. K. Mitrollari: None. A.P. Calimag: None. T. Yasmeen: None.

Radioactive iodine (I-131) ablation (RAI) is one of the effective therapies for Graves’ disease (GD). Successful treatment is indicated by sustained, irreversible hypothyroidism requiring lifelong replacement for which recurrence of disease rarely develops. Recurrent hyperthyroidism is a rare development without apparent predisposition. Here, we describe a case of recurrent thyrotoxicosis after 36 years of RAI.70-year-old female PMH atrial fibrillation (AFib) on apixaban s/p cardioversion, HTN, HFpEF, Pulmonary HTN, and Graves’ Disease s/p RAI ablation 36 years ago with RAI-induced hypothyroidism. The patient was initially on levothyroxine for post-ablative hypothyroidism and stopped taking levothyroxine around 2019. NM scintigraphy done in 2019 showed an abnormal I-123 thyroid uptake and scan with the five-hour radioiodine thyroid uptake showed mildly hyperthyroid. On the thyroid scan, there is a note of a prominent pyramidal lobe with some thyroid gland asymmetry. In 2022, the patient was admitted for new-onset AFib and was noted to have subclinical hyperthyroidism with TSH 0.157, fT4 1.4, TrAb>40, and TSI 34.8. The patient was started on methimazole, which she stopped one month later. During this admission, the patient presented secondary to a mechanical fall and was found to be in AFib with a rapid ventricular rate. Her labs were significant for TSH<0.008 fT4 4.2, TrAb >40. Methimazole was restarted with maximal doses of diltiazem and metoprolol for rate control. Thyroid ultrasound demonstrated an enlarged, heterogeneous thyroid gland with increased vascularity and multiple bilateral TR3 thyroid nodules.Hyperthyroidism affects approximately 1.2% of the population. GD involves autoantibodies activating the thyrotropin receptor, increasing synthesis and release of thyroid hormone and is for 50-60% of cases with a 5-to-10-fold preference for females. RAI ablation is preferred, being inexpensive, with a cure rate approaching 100%. The incidence of transient hypothyroidism post-RAI varies from 9-17%. Retrospective studies have observed hyperthyroidism within the first 12 months post-RAI; however, some cases have seen a resurgence as late as 22 years later. Recurrent hyperthyroidism is an uncommon occurrence with various postulated aetiologies, such as inadequate dosing/incomplete ablation with residual cells remaining viable and regenerating in the setting of increased TSIiv, Marine-Lenhart syndrome (MLS), or an unclear mechanism associated with autoimmunity in the presence of TSI. Hyperthyroidism rarely recurs in GD after successful post-ablative treatment with RAI. Our case, while an uncommon presentation and underlying aetiology yet to be determined, illustrates the importance of continued surveillance, even after successful treatment.‌

Presentation: 6/3/2024
6414 Refractory Hyperthyroidism Following COVID-19 Infection
Authors: Wahba A T , Shibli-Rahhal A A
Published: October 2024

Disclosure: A.T. Wahba: None. A.A. Shibli-Rahhal: None.

A 40-year-old man presented with 2 weeks of palpitations, weight loss, decreased appetite and malaise. The symptoms were preceded by neck pain for 1-2 weeks that improved spontaneously. He was in atrial fibrillation at 126 bpm, but otherwise clinically stable. He had a mildly tender enlarged thyroid with no palpable nodules, and the rest of his exam was negative. A chest CT with IV contrast ruled out pulmonary embolism. His TSH was < 0.01 µIU/mL (N:0.27-4.20), free T4 > 7.77 ng/dL (N: 0.80-1.80) and free T3 of 29.7 (N: 2.6-4.4 pg/ml), obtained prior to contrast administration. TSI antibody was negative and thyroid ultrasound showed diffuse enlargement with heterogeneous echotexture and reduced vascularity on doppler images. Thyroid uptake and scan could not be obtained due to iodinated contrast exposure. The patient’s medical history was notable for nonischemic cardiomyopathy (EF 50%), cardiac arrest with implantable cardiac defibrillator, and paroxysmal atrial fibrillation. He was previously treated with amiodarone for 2 years, and it was stopped 2 months before presentation. Other relevant medical problems included subclinical hypothyroidism diagnosed within the previous year and an uncomplicated acute COVID-19 infection 1 month prior to presentation.Given his cardiac history and high Burch-Wartofsky score, he received PTU 200 mg Q4h, hydrocortisone 100mg Q8h and propranolol for 3 days. As his FT3 level declined to 9.8 pg/ml, he was transitioned to methimazole 40 mg daily, propranolol and prednisone 40 mg daily and discharged with outpatient follow up. The atrial fibrillation worsened again 1 week later, and his FT3 increased to 20.2 with a FT4 > 7.77. He was put back on PTU 200 mg TID, prednisone and propranolol were continued and cholestyramine 2g BID was added. 1 week later, his FT4 and FT3 were unchanged. The tests were performed using a different assay and the results were consistent. Two sessions of plasma exchange (PLEX) did not yield a significant response, so thyroidectomy was eventually performed. Pathology showed morphologic findings consistent with type 2 amiodarone-induced thyrotoxicosis. While pathology showed amiodarone-induced changes, the patient’s hyperthyroidism occurred after a COVID-19 infection and was associated with neck pain, pointing to severe viral thyroiditis. De novo thyroid hormone production has been reported following COVID-19 infection, but the minimal improvement in thyroid hormone levels with thionamide therapy suggests that de novo secretion had little contribution to this patient’s hyperthyroidism.

Presentation: 6/3/2024
7370 Review of the Literature, and Report of a Series of Patients with Lactose Intolerance and Levothyroxine Malabsorption in Treatment with Liquid L-T4
Authors: Martina Ferrari Silvia , Patrizio Armando , Mazzi Valeria , Ragusa Francesca , Botrini Chiara , Elia Giusy , Balestri Eugenia , Barozzi Emilio , Rugani Licia , Bracchitta Fabiana , Stoppini Giulio , Frenzilli Giada , Baldini Enke , Virili Camilla , Benvenga Salvatore , Fallahi Poupak , Antonelli Alessandro
Published: October 2024

Disclosure: S. Ferrari: None. A. Patrizio: None. V. Mazzi: None. F. Ragusa: None. C. Botrini: None. G. Elia: None. E. Balestri: None. E. Barozzi: None. L. Rugani: None. F. Bracchitta: None. G. Stoppini: None. G. Frenzilli: None. E. Baldini: None. C. Virili: None. S. Benvenga: None. P. Fallahi: None. A. Antonelli: None.

Intolerance to lactose-containing foods is frequent, with a prevalence of 7-20% in Caucasians, and of 80-95% among Native Americans. Therefore, lactose intolerance (LI) issue needs to be taken in account in the management of hypothyroid patients needing large doses of levothyroxine (L-T4) (> 1.7-2 μg/kg/day) to achieve euthyroidism. Indeed, the absorption of oral T4 may be affected in patients with LI, by following a diet containing lactose, whereas it is resulted to be improved with a lactose-free diet. Lactose is often present as a supplementary ingredient in many commercially available drugs, as L-T4 preparations. In susceptible individuals, drugs containing lactose can cause LI symptoms, and lactose in L-T4 preparations could impair thyroxine absorption. Moreover, it has been shown that patients with LI requiring an increased dosage of L-T4 benefit from a treatment with a lactose-free L-T4 formulation. The lactose-free liquid L-T4 formulation is able to circumvent LI malabsorption leading to the normalization of thyroid-stimulating hormone (TSH) in patients with subclinical hypothyroidism, and long term stable TSH levels. Further studies will be needed to evaluate the liquid L-T4 formulation in larger numbers of patients with hypothyroidism and LI.

Presentation: 6/3/2024
12475 Revisiting Myxedema Coma
Authors: Hamad Islam Muhammad , Jimenez Corado Daniel Ricardo , Siddiqui Shiza , Aquino Camey Maria Fernanda , Yeasmin Shamima
Published: October 2024

Disclosure: M.H. Islam: None. D.R. Jimenez Corado: None. S. Siddiqui: None. M.F. Aquino Camey: None. S. Yeasmin: None.

Background: Myxedema coma is a rare and life-threatening complication of hypothyroidism.Although it is rare in the era of better diagnostics and treatment modalities, its life-threatening nature mandates its timely recognition and better understanding. Case:81-year-old female with a history of hypothyroidism (unclear medication compliance) and alcohol use disorder was admitted due to alcohol withdrawal and treated with benzodiazepines. A few days prior to the presentation, she was found to have worsening confusion, unsteady gait, and multiple falls. On presentation, she was hemodynamically stable, tremulous, anxious, and oriented to person only. Blood work was remarkable for mild transaminitis. CT scan of the head revealed sequelae of microvascular disease. The day after admission, she was noted to be lethargic, and benzodiazepines were held. Later, she became hypothermic, hypotensive, bradycardic, and hyponatremic. Further investigation was pursued, revealing a TSH of 55 (normal 0.27 to 4.2 mlU/L), free T4 of <0.10 ng/dL (normal 0.8-1.7 ng/dL), free T3 of <1.0 pg/mL (normal 2.2-4 pg/mL), and cortisol of 10.7 ug/dL. Due to concerns of myxedema coma, she was started on stress dose steroids and IV levothyroxine. She was transferred to the ICU as her mental status continued to deteriorate; she underwent endotracheal intubation and received additional doses of IV levothyroxine and liothyronine. After a few days, her clinical condition and her cortisol, free T4, and free T3 levels improved; she was extubated and later discharged with an adjusted levothyroxine dose. Conclusion: It is of absolute importance to keep myxedema coma as a differential diagnosis when evaluating encephalopathic elderly patients, especially those with a history of thyroid disorders.There is a paucity of evidence to suggest a clear benefit of combining levothyroxine-liothyronine over levothyroxine alone. Treating initially with intravenous levothyroxine over oral is beneficial, as GI absorption and bioavailability are likely variable and unpredictable. In this case, oral liothyronine was used with IV levothyroxine to speed up clinical and biochemical recovery.Adrenal insufficiency often coexists with hypothyroidism, with considerable overlap in clinical features like hypotension, hypoglycemia, and hyponatremia. Administration of levothyroxine before steroids can lead to a rapid increase in metabolic rate and subsequent depletion of the existing reserves. Considering this, it can be said with fair confidence that patients need prior or concomitant stress doses of corticosteroids on an emergent basis. Later, biochemical testing can be done to evaluate the functioning of the hypothalamic-pituitary-adrenal axis and then adjust steroid doses accordingly.

Presentation: 6/1/2024
5103 Synthroid Absorption Conundrum: A Case Deciphered
Authors: Nadeem Hana , Alzohaili Opada
Published: October 2024

Disclosure: H. Nadeem: None. O. Alzohaili: None.

Hypothyroidism is a disorder requiring lifelong Synthroid therapy. Untreated patients have high morbidity rate and suffer from weight gain, cold intolerance, fatigue and constipation. Inadequate therapeutic outcomes may result in the case of malabsorption, like GI tract conditions, medication interactions and dietary ingredients. Here, we describe the case of a 50-year-old woman who despite compliance to therapy, had refractory hypothyroidism. Complexity of unexplained Synthroid malabsorption is highlighted, emphasizing the importance of managing and optimizing thyroid hormone replacement therapy. A 50-year-old woman with a history of papillary carcinoma s/p thyroidectomy and radioactive iodine therapy came in with fatigue, weight gain and constipation. Despite taking Synthroid 150 mcg, thyroid function tests (TFTs) remained high with TSH 150 uIU/mL and fT4 0.25 ng/dL. Her dose was gradually increased until it reached 1800 mcg yet repeat TFTs showed refractory hypothyroidism with TSH 179 uIU/mL, fT4 0.8 ng/dL. Compliance was addressed to which she demonstrated strict adherence, while avoiding concurrent intake of food, supplements or medications interfering with the absorption. Autoimmune conditions were ruled out and no dietary patterns affecting absorption were identified. A thyroid absorption test was then performed, during which 2100 mcg of Synthroid were given orally in the AM, and thyroid hormones were measured for 8 hours. She was found to have a TSH in 200s uIU/mL and fT4 <0.10 ng/dL, deeming her to have refractory hypothyroidism. She was seen by GI and had an EGD/ colonoscopy, revealing no abnormalities. In a follow up visit, she was still complaining of the same symptoms, periorbital edema, and mild confusion. Her TSH was still elevated at 225 uIU/mL. She was then started on IV 500 mcg of weekly Synthroid infusions and after several weeks, she reported symptoms improvement. Subsequent TFTs showed a progress in TSH, now 26.6 uIU/mL, with fT4 1 ng/dL, indicating successful management of Synthroid malabsorption. During this process, she had a nutritional assessment and was consistently having hyperlipidemia with LDL 243 mg/dL. She was compliant with Praluent and max dose of atorvastatin 80 mg, but LDL only decreased to 134 mg/dL after adjusting her thyroid hormone levels. With nonadherence being the top cause of medication non responsiveness, ruling out causes of malabsorption is vital. In this case, compliance, nutritional assessment, medication interactions, GI abnormalities, autoimmune conditions were all addressed and no interfering factors were identified. IV treatment with unexplained thyroid hormone malabsorption was the effective treatment, ultimately improving outcomes. With the hope to transition her to oral medication, the possibility of it happening is still not clear. More research is necessary to discover the underlying causes in such an exceptional case.

Presentation: 6/2/2024
8078 TERT Positive Thyroid Nodule in the Setting of Metastatic Melanoma
Authors: Langnas Emily , Chao Shing , Gomes Kellyann M , Bhan Arti
Published: October 2024

Disclosure: E. Langnas: None. S. Chao: None. K.M. Gomes: None. A. Bhan: None.

Metastatic disease to the thyroid gland is uncommon with a reported incidence of up to 4% in post-surgical specimens. Lung cancer is the most common primary tumor site in autopsy series. Clinically, renal cell carcinoma is the most common primary tumor site. Metastatic melanoma to the thyroid gland is clinically rare, however, in autopsy series, it has been reported with incidence of up to 39%. A 61-year-old man presented to the endocrinology clinic for an incidentally detected thyroid nodule. He had recently presented with a chronic cough, prompting a chest x-ray that revealed pulmonary nodules. Subsequent computed tomography (CT) showed numerous bilateral lung nodules measuring up to 2.5 cm and an incidental thyroid nodule. Ultrasound of the thyroid identified a 2.7 cm mixed cystic-solid right thyroid nodule. No risk factors for thyroid cancer were identified. His TSH was 3.51uIU (0.45 - 5.33 uIU/mL). The thyroid nodule was biopsied, and pathology revealed atypical spindle cells with irregular nuclear membranes and scattered histiocytes. A further review with cytopathology suggested non-thyroidal origin of the cells. Molecular testing with AFIRMA reported a telomerase reverse transcriptase (TERT) promoter mutation at C228T. The sequencing was negative for TERT C250T, BRAF, RET, PETC1, PTC3 and MTC. Due to concerns about metastatic disease, a positron-emission tomography (PET)-CT was conducted, revealing hypermetabolic lesions in numerous bilateral lung nodules, right thyroid nodule, porta hepatis lymph node, and a soft tissue nodule within the greater curvature of the gastric body. Subsequent biopsies of the right lung and gastric body confirmed the diagnosis of metastatic melanoma. On further questioning, it was found that the patient had a history of a skin lesion on his back that was excised several years ago with pathology reporting tumoral melanosis. Malignant melanoma has a poor prognosis due to high recurrence and metastatic rates. In melanoma, TERT promoter mutations are the most common mutations in noncoding regulatory regions. TERT C228T mutations and C250T mutations are seen in malignant melanoma and studies have shown that TERT promoter mutations are associated with aggressive clinical behavior. These TERT promoter mutations can also be seen in various other cancers including primary thyroid cancers with a similar association with more aggressive thyroid tumor characteristics. Our case describes a patient with a thyroid nodule and molecular testing noting a TERT promoter mutation. Both primary thyroid cancer and metastatic disease to the thyroid should be considered in these cases. This case also highlights the importance of obtaining a thorough history of prior malignancy in patients with thyroid nodules to assess the risk of metastatic disease.

Presentation: 6/1/2024
8490 The mRNA for the Nonsyndromic Deafness Gene Atp2b2 Is Reduced Following Developmental Hypothyroidism
Authors: Gregersen Emily A , Patrick Peeters Robin , Forrest Douglas , Sharlin David S
Published: October 2024

Disclosure: E.A. Gregersen: None. R.P. Peeters: None. D. Forrest: None. D.S. Sharlin: None.

Thyroid hormone (TH) is essential for auditory system development. In rodent models, low levels of TH during the early postnatal period delay cochlear tissue remodeling and alter ion channel function required for normal auditory function. TH receptors are ligand-dependent transcription factors that regulate gene expression. Considering this, auditory deficits observed in hypothyroidism are thought to be largely the result of altered expression of specific TH target genes. However, few TH-regulated genes in the developing cochlea have been reported. TH is reported to impact calcium signaling in several tissues, but whether regulators of calcium signaling are altered following developmental hypothyroidism in the cochlea is largely unexplored. In this report, we investigated the spatial and temporal expression of the ATPase, Ca++ transporting, plasma membrane 2 (Atp2b2) gene in a mouse model of developmental hypothyroidism. Timed-pregnant dams were treated with thyroid gland inhibitors to induce developmental TH insufficiency from embryonic day 12.5 (E12.5) through post-natal day 15 (P15). Untreated timed-pregnant dams served as euthyroid controls. Control and experimental cochleae were collected over a developmental period ranging from embryonic day 18.5 (E18.5) through P15. Cochleae were then processed to detect Atp2b2 mRNA by in situ hybridization or quantitative real-time PCR. In situ hybridization showed that Atp2b2 localizes to inner and outer hair cells as expected, but Atp2b2 was also observed at lower levels in the greater epithelial ridge and spiral ganglion. Quantification of Atp2b2 mRNA revealed an effect of postnatal day and treatment on Atp2b2. In euthyroid animals, Atp2b2 expression gradually increased until P10, then decreased slightly by P15. In hypothyroid animals, Atp2b2 mRNA was consistently decreased (2-2.5 fold). Hypothyroidism similarly impacted expression regardless of sex. The reduction in Atp2b2 mRNA expression in the hypothyroid animals suggests that Atp2b2 is developmentally regulated in part by thyroid hormone signaling. This study characterizes the relationship between TH and Atp2b2 expression during early cochlear development while providing insight into abnormal cochlear development due to hypothyroidism.

Presentation: 6/3/2024
7650 Thionamide Induced Pancreatitis and Agranulocytosis, a Rare Case of Concurrence
Authors: Lin Jack , Shariff Julia
Published: October 2024

Disclosure: J. Lin: None. J. Shariff: None.

Introduction: Thionamides are considered first line in the treatment of Graves’ Disease due to their efficacy and safety. We present a case of Graves’ in which methimazole resulted in not only agranulocytosis but also pancreatitis. Case Report: A 29yo female was diagnosed with Graves’ 5 months postpartum by her PCP. Her labs at diagnosis revealed a TSH <0.01 uIU/mL, free T4 of 6.4 ng/dL, and positive TRAb. She was started on methimazole 10mg and propranolol 20mg three times a day by her PCP. One month after starting treatment, she presented to the ED due to throat pain/fevers and was diagnosed with tonsilitis. She was given a 10mg dose of dexamethasone and sent home with antibiotics. No labs were drawn that visit. She went to her PCP 3 days later due to persistent symptoms and nausea/vomiting. A CBC revealed she had a WBC of 0.7 K/uL and an absolute neutrophil count (ANC) of 0.1 K/uL. Her last dose of methimazole had been the day prior to seeing her PCP. It was recommended she be seen in the ED due to concern for agranulocytosis where she was started on antibiotics and a CT abdomen pelvis with contrast revealed she had acute pancreatitis. She was admitted and started on filgrastim 5mcg/kg daily for thionamide-induced agranulocytosis. Her pancreatitis improved with conservative measures. Her propranolol was resumed at 30mg three times a day with symptom improvement. On her fifth hospitalization day, her ANC had recovered to 2.22 K/uL, WBC was 6 K/uL. Her free T4 was 1.65 ng/dL, free T3 4.1 pg/mL, TSI >40 IU/L. This change was suspected to be from propranolol, steroids, iodine load from her CT, and prior methimazole use. It was strongly recommended she pursue surgery that hospitalization given inability to treat her Graves’ medically. The patient refused, stating she wished to consider her options further outpatient. She would be seen one week later in a satellite ED. Her free T4 was 5.9 uIU/mL, T3 >30 pg/mL, TSH <0.010 uIU/mL. She left against medical advice. She subsequently declined further endocrine follow-up. Clinical Lessons: Thionamide-induced agranulocytosis is a rare but known complication of use, with some studies showing a prevalence as low as 0.2-0.5% [1]. Pancreatitis is a lesser-known complication of thionamides. There are several case reports of its occurrence, with the European Medicines Agency even listing it in the potential adverse reaction. Absolute risk of occurrence remains low, some studies showing <0.4% [1]. This case shows a rare concurrence of two uncommon complications from thionamide use and brings awareness to both pancreatitis and agranulocytosis as potential adverse events. References: [1]: Lee SY, Pearce EN. Hyperthyroidism: A Review. JAMA. 2023 Oct 17;330(15): 1472-1483. doi: 10.1001/jama.2023.19052. PMID: 37847271.

Presentation: 6/2/2024
8409 Thyroid Nodules A to V: A Discussion on Thyroid Nodules and a Case Report of a Rare Thyroid Arteriovenous Malformation
Authors: Townsend Mary , Brennan Michael , Kazmierczak Chris , Czako Peter
Published: October 2024

Disclosure: M. Townsend: None. M. Brennan: None. C. Kazmierczak: None. P. Czako: None.

Introduction: Thyroid nodules are an increasingly common finding on imaging, and the differential is broad. Arteriovenous malformations (AVMs) are a very rare cause of thyroid lesions, with only 6 reported cases to date. Given their scarcity, there is a lack of information regarding these lesions and how they are diagnosed and managed. Our case aims to address these gaps in information. Case: A 58-yo female with a history of hypertension was found by her PCP to have an enlarged left thyroid lobe with a new left sided bruit and palpable thrill. She had undergone prior thyroid ultrasonography for the enlarged left thyroid lobe which noted dilated and tortuous vascular structures at the posterior aspect of the left thyroid consistent with varices. These were being monitored clinically. Thyroid function tests were all normal. Due to concern for atherosclerotic disease, carotid ultrasound was obtained and showed patent carotid arteries with a large left sided thyroid mass. CTA of the neck revealed the mass to be a large (6.0 x 3.0 x 2.4 cm) AVM centered at the left thyroid gland. She underwent diagnostic angiography that confirmed the size of the mass and showed predominant arterial supply from the left superior thyroidal artery as well as bilateral inferior thyroidal arteries. Since the patient was asymptomatic with no reported neck pain, dysphagia or dyspnea, non-operative management with angioembolization was pursued given the risk of significant blood loss with surgical intervention. Following angioembolization, the results and adequacy of treatment are to be followed with repeat imaging given the high risk of reoccurrence. Discussion: AVMs of the thyroid are a very rare but clinically significant cause of thyroid lesions. Left untreated, they can grow in size and lead to compression of the esophagus or trachea, serious bleeding and high output heart failure. Their presentation is often non-specific and on routine thyroid imaging they can be difficult to differentiate from malignant tumors or varices, as in the case of our patient. Management prioritizes embolization, either alone or in conjunction with surgery, depending on the clinical scenario. Regardless of the treatment modality, reoccurrence rates remain high. Conclusion: Our case aims to add to the available information about thyroid AVMs and discuss the clinical presentation, challenges in diagnosis, imaging findings and treatment modalities available to manage these lesions.

Presentation: 6/2/2024