bluuebunny/crossref_metadata_2025 huggingface dataset:
8248 Glucocorticoid Induced Adrenal Crisis Masked By Metastatic Lung Carcinoma
Authors: Abrahimi Nora , Abrahimi Aryan
Published: October 2024

Disclosure: N. Abrahimi: None. A. Abrahimi: None.

Background: Chronic glucocorticoid use of three weeks or longer can cause hypothalamic-pituitary-adrenal axis inhibition by negative feedback, causing adrenal suppression. (1) Adrenal crisis is diagnosed by an acute clinical decompensation, persistent hypotension that resolves with high dose steroid administration. (2) Adrenal crisis is precipitated by several causes such as illness, dehydration, trauma, emotional distress and sometimes due to no identifiable cause. (2) Clinical Case: 64-year-old male past medical history of lung carcinoma metastatic to mediastinum who presented to the hospital with tachycardia. On presentation, patient was tachycardic, tachypneic, and hypotensive. Labs significant for WBC 22, Na+ 129, K+ 3.2, Cr 3.4. Patient received 2.5 L bolus of NS and was given one dose of azithromycin due to concern for sepsis. After fluid resuscitation, hypotension and tachycardia resolved. Presenting symptoms included ongoing nausea, decreased appetite and malaise for several weeks. Repeat labs post fluid resuscitation showed resolution of leukocytosis, improvement of AKI, and repletion of electrolytes. CT chest abdomen pelvis showed questionable pneumonia, however, consolidations were difficult to distinguish from known malignant masses. Clinical picture was not consistent with pneumonia and so additional antibiotics were held. Several hours later, blood pressure decreased, and patient began requiring vasopressors. Cefepime was started given concern for septic shock. Nearly 48 hours after initiation of broad-spectrum antibiotics hypotension persisted and patient remained on vasopressors. Given clinical decline, etiology of shock was reconsidered. Patient reported daily prednisone use over the last several months for COPD management. Given high clinical suspicion of adrenal crisis in setting of chronic steroid use and glucocorticoid withdrawal, patient was started on hydrocortisone 100 mg every 8 hours. Shortly after initiation of stress dosed steroids, the patient was successfully weaned off vasopressors with complete resolution of hypotension. Conclusion: Presentation and symptoms of adrenal insufficiency and crisis including nausea, anorexia, fatigue, malaise, hypotension and electrolyte abnormalities are nonspecific, can go unrecognized and be masked by other disease processes, such as metastatic cancer. (1) Adrenal crisis is life threatening and must be diagnosed and treated early to prevent mortality. (2) Therefore, adrenal crisis should always be on the differential in patients who present with shock. References: (1) Pazderska A, Pearce SH. Adrenal insufficiency - recognition and management. Clin Med (Lond). 2017;17(3):258-262. doi:10.7861/clinmedicine.17-3-258 (2) Elshimy G, Chippa V, Kaur J, et al. Adrenal Crisis. [Updated 2023 Sep 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.

Presentation: 6/2/2024
7659 Iodinated Contrast Induced Thyrotoxicosis Leading to Takotsubu Cardiomyopathy
Authors: Jain A , Naous E , Sedrakyan S , Sweeney A T
Published: October 2024

Disclosure: A. Jain: None. E. Naous: None. S. Sedrakyan: None. A.T. Sweeney: None.

Background: Thyrotoxicosis may cause many cardiovascular manifestations including tachycardia, hypertension, atrial fibrillation and heart failure. Iatrogenic exposure to iodinated contrast media (ICM) precipitating iodine induced thyrotoxicosis (or the Jod-Basedow phenomenon) is often overlooked. Here, we describe a case of iodine induced thyrotoxicosis leading to takotsubu cardiomyopathy, following multiple exposures to ICM. Case Presentation: An 88-year-old male with a history of hypertension, dyslipidemia, chronic obstructive pulmonary disease, and an ED visit one month ago for hemoptysis for which a CT Angiography (CTA) of the chest was obtained (which excluded Pulmonary Embolism(PE)), presented with fever and shortness of breath. On physical examination his temperature was 100.3F, heart rate was 104bpm, blood pressure 130/62mmHg, respiratory rate was 20/min and saturation was 88% (room air). He was frail but his examination was otherwise unremarkable. Electrocardiogram (EKG) revealed sinus tachycardia. Chest CTA excluded PE. Transthoracic echocardiogram (TTE) showed an ejection fraction (EF) of 73% and no wall motion abnormalities. He was admitted to the hospital for a viral upper respiratory infection and was treated conservatively with bronchodilators. Odynophagia prompted a CT with contrast of the neck soft tissue, which was unrevealing. He was planned to be discharged the next day, but overnight developed severe abdominal pain, and atrial fibrillation with a rapid ventricular response (Troponin t was 191 ng/L (normal {nl}: <9 ng/L)). EKG showed new T-wave inversions in the anterolateral leads, raising a suspicion of myocardial ischemia. A repeated TTE revealed a new drop in EF from 73 to 41%, with new apical akinesis, suspicious for takotsubo cardiomyopathy. CT of the abdomen with contrast was unrevealing. Lab results showed a suppressed TSH of <0.01uIU/mL (nl: 0.34-5.60 uIU/mL), elevated FT4 of 13ng/dL (nl: 0.93-1.70 ng/dL), and TSI 4.97 IU/ L (nl: 0-0.55 IU/ L). Endocrinology was consulted. His thyroid examination was normal, and he had no eye findings. Neck ultrasound revealed a homogeneous thyroid gland without any nodules. His clinical course was consistent with the diagnosis of acute thyrotoxicosis precipitating takotsubu cardiomyopathy. He likely developed iodine induced thyrotoxicosis from multiple exposures to ICM, in a background of previously undiagnosed Graves’ disease. Discussion: Screening for thyroid disease is critical in patients with new onset tachyarrhythmias and stress cardiomyopathy. Iodine induced thyrotoxicosis typically presents after patients with underlying thyroid disease are exposed to iodinated contrast. Prior to ordering studies requiring ICM, it is important to thoroughly evaluate patients for possible pre-existing thyroid disease.

Presentation: 6/2/2024
7142 Herbal Supplements Cause Cushing's Syndrome
Authors: Carpio-Orantes Luis Del , Aguilar-Silva Andrés , Munguía-Sereno Álvaro Efren , Salas-González Arturo , González-Medel Karem Samantha , González-Medel Kattya Marianny , Sánchez.Díaz Jesús Salvador , García-Méndez Sergio , Salazar-Lizárraga Raúl Enrique , Domínguez-Cámara Rubén , Rodriguez-Bonachea Brenda Leticia , Fonseca-Pouchoulen Victor Alejandro
Published: October 2024

Disclosure: L. Del Carpio-Orantes: None. A. Aguilar-Silva: None. Á. Munguía-Sereno: None. A. Salas-González: None. K. González-Medel: None. K. González-Medel: None. J. Sánchez.Díaz: None. S. García-Méndez: None. R. Salazar-Lizárraga: None. R. Domínguez-Cámara: None. B. Rodriguez-Bonachea: None. V. Fonseca-Pouchoulen: None.

Introduction: There are various supposedly herbal supplements that contain unreported doses of steroids and that cause Cushing's syndrome in their users, who most often suffer from various rheumatisms and chronic pain. There are international alerts on the consumption of these products by the FDAMaterial and methodsWe report a series of cases of patients affected by iatrogenic Cushing's syndrome due to consumption of apparently herbal products, in whom serum cortisol and ACTH and 24-hour urinary cortisol were measured.Results8 cases of iatrogenic Cushing's syndrome are reported, 75% women, average age 65 years, 75% suffered from osteoarthrosis and 25% rheumatoid arthritis, all consumed herbal supplements to relieve chronic pain, highlighting the intake of Artri king in 5 patients, Ortiga Ajo Rey in 2 patients and Artribion in 1 patient. Disruption of the hypothalamic-pituitary-adrenal axis was demonstrated in all of them, through the analysis of serum cortisol and ACTH and in some patients of 24-hour urinary cortisol. Unfortunately, 1 patient died from advanced Cushing's syndrome.ConclusionsThe consumption of these pseudoherbal products produces serious consequences for the health of the population, which is why regulatory authorities must put more emphasis on their control, being an international public health problem.

Presentation: 6/3/2024
6621 Iodine Nutritional Status in Different Trimesters of Pregnancy: A Prospective Observational Study in Taiwan
Authors: Pan Li-Hsin , Yeh Chang-Ching , Yang Chen-Chang , Hwu Chii-Min , Chen Harn-Shen , Wang Fan-Fen , Huang Chun Jui
Published: October 2024

Disclosure: L. Pan: None. C. Yeh: None. C. Yang: None. C. Hwu: None. H. Chen: None. F. Wang: None. C. Huang: None.

Pregnant women are susceptible to iodine deficiency. Iodine nutritional studies in pregnant women were mostly cross sectional evaluations of iodine status. This prospective observational study was designed to longitudinally follow the iodine status of pregnant women in different trimesters of pregnancy and to assess the clinical parameters and dietary influences on iodine status. A total of 209 pregnant women in their first trimester were enrolled in Taipei Veterans General Hospital, Taiwan from March 2019 to March 2023. Subjects provided a spot urine sample and completed a food frequency questionnaire at each trimester. Urinary iodine concentration (UIC) was measured by inductively coupled plasma mass spectrometry. The median UIC for the first, second and third trimester was 156.3 μg/L (Interquartile range [IQR]: 100.7-241.1), 146.2 μg/L (84.6-224.4), and 169.9 μg/L (94.4-283.5), respectively. Mild iodine deficiency was observed in the second trimester despite adequate iodine status in the first and third trimesters. Compared to the first trimester, intake of seaweed (p = 0.004, p < 0.001, respectively), fish (p < 0.001, p < 0.001, respectively), and prenatal multivitamins (p < 0.001, p < 0.001, respectively) increased in the second and third trimesters. A gradual increment in dairy product intake was also noted between each trimesters through pregnancy (p < 0.001, p = 0.004, respectively). Multivariate analysis indicated a positive association between multiparity and increased UIC in the second trimesters (multiparity vs. uniparity; adjusted odds ratio [OR]: 2.273, 95% confidence interval [CI]: 1.202-4.310). Additionally, increased prenatal multivitamin intake elevated the odds of adequate UIC in the third trimester (≥ 3 days/week vs. ≤ 1 day/week; adjusted OR: 2.890, 95% CI: 1.351-6.173). This study revealed the longitudinal changes in iodine status during pregnancy and suggested that women who regularly took prenatal multivitamins and were multiparous were more likely to have adequate iodine nutrition.

Presentation: 6/2/2024
12398 Isolated Thyroid Gland Langerhans Cell Histiocytosis In A Patient With Simple Goiter
Authors: Ziganshina Anna P , Callender Glenda G , Coppola Kristen , Druar Nicholas M , Jacob Jack
Published: October 2024

Disclosure: A.P. Ziganshina: None. G.G. Callender: None. K. Coppola: None. N.M. Druar: None. J. Jacob: None.

Background: Langerhans cell histiocytosis (LHC) is an overproduction of white blood cells - histocytes (Langerhans cells) - that accumulate in various organs, forming granulomas and affecting their function. It is a rare entity that can be systemic or confined to an isolated organ only. The thyroid gland is very infrequently a site for isolated LHC penetrance or part of multisystemic disease. Here we present a case of an incidental finding of an isolated LCH of the thyroid gland in a patient with simple goiter. Case presentation: This is a 42-year-old woman who is a chronic smoker with a history of primary hypothyroidism on thyroid replacement therapy, infertility, antiphospholipid antibody syndrome, MTFHR-mutated homocystinemia. She had a long-standing history of intermittent dysphagia and neck discomfort and was noted to have simple goiter measuring 8.9 x 2.8 x 2.8 cm in the right lobe and 7.3 x 2.6 x 2.2 cm in the left lobe. The patient was referred for a total thyroidectomy to relieve compressive symptoms. She had an uncomplicated operation; intraoperatively she was noted to have no suspicious central neck lymphadenopathy or other unexpected findings. The final pathology report demonstrated aggregates of Langerhans cells and eosinophils in a background of lymphocytic thyroiditis. Follow-up cytogenetics performed on the thyroid tissue found an activating (gain of function) mutation in MAP2K1 at codon 57, exon 2, with 7% allele frequency (MAP2K1 K57E). These findings support the diagnosis of LCH. There are no other sites of LCH on PET full body imaging. The patient continues on thyroid replacement therapy and will be closely monitored for PET evidence of systemic involvement of LCH. Conclusion: This clinical case raises awareness of the entity of LCH of the thyroid gland in patients presenting with simple goiter. It is important to differentiate LCH from a simple goiter because it can recur and requires prolonged follow up. Additionally, isolated thyroid LCH can precede or reveal disseminated disease; thus, whole-body surveillance is needed.

Presentation: 6/1/2024
7647 Myxedema Coma- A Rare and Fatal Manifestation of Severe Hypothyroidism
Authors: Ray B K , Kaur R , Kaur L , Thakur M
Published: October 2024

Disclosure: B.K. Ray: None. R. Kaur: None. L. Kaur: None. M. Thakur: None.

Introduction: Myxedema coma is a severe and life-threatening form of hypothyroidism. It is a rare occurrence with an incidence of 0.22 per million per year, associated with a high mortality rate ranging from 30 to 60% even with early diagnosis and treatment. This condition arises when the body's response to hypothyroidism is overwhelmed by factors like infection, surgery, and medication noncompliance. The definitive management is with thyroid hormones but supportive measures and identification and treatment of the precipitating factors is also vital. The case discussed concerns an elderly woman with myxedema coma due to noncompliance to Levothyroxine. This case stresses the importance of consistent medical follow-ups. Case Presentation: A 73 year old female presented to the hospital with altered mental status for about 32 hours. Vital signs at presentation showed hypotension (80/50 mmHg), bradycardia (54 beats per minute), tachypnea (32 breaths per minute) and hypothermia (33.2 °C). A computed tomography scan of the brain and Computed tomography angiography of the head/neck showed no stenosis or large vessel occlusion of the vasculature. Initial pertinent laboratory test results revealed a white blood cell count of 6.1 (3.7–11.0×103/uL), hemoglobin level of 14.3 (11.5–16.0 g/dL), sodium level of 131 (136–145 mmol/L), glucose level of 142 (65–125 mg/dL). Troponin, lactate and procalcitonin were normal. She was intubated and transferred to the Intensive care unit. Thyroid function tests revealed a markedly elevated TSH of 37.9 (0.4 to 4.0 mIU/L) and a decreased T4 of 0.3 (0.9-1.7 ng/dL). She was immediately started on hydrocortisone 100 mg Three times daily and initiated on intravenous levothyroxine monotherapy with a loading dose of 200 mcg followed by 100 mcg daily. Her T4 level was trended daily and she demonstrated gradual improvement. She was successfully extubated. On discussion she reported noncompliance with her medications. Hydrocortisone was tapered and she was started on her home dose of oral Levothyroxine (200 mcg) after four days of Intravenous levothyroxine. She was counselled on medication compliance and discharged to home. Conclusion: Myxedema, an extreme form of hypothyroidism, is life-threatening and requires immediate admission to intensive care. Symptoms are usually vague, and require a high degree of suspicion. Treatments include thyroid hormone supplementation, steroid replacement and supportive care. Early detection and quick intervention are crucial for survival. Patient education on medication compliance, regular testing, and reporting new medication to prevent interference with thyroid metabolism is crucial.

Presentation: 6/1/2024
7708 Navigating Thyroid Cancer With Differences in Thyroglobulin Assessment Techniques
Authors: Singh Shah Mahabir , Humayon Salman , Mungo Nicolas A
Published: October 2024

Disclosure: M.S. Shah: None. S. Humayon: None. N.A. Mungo: None.

This case report delves into the diagnostic journey of a patient with papillary thyroid carcinoma, emphasizing the importance of precise thyroglobulin measurement methods. The case highlights the differences between immunoassay and mass spectrometry in monitoring disease progression and treatment response.A 42-year-old female with a family history of thyroid-related issues, was found to have a thyroid nodule on physical exam. She underwent fine-needle aspiration (FNA) revealing papillary thyroid carcinoma, Bethesda category VI. Lymphatic invasion was present necessitating total thyroidectomy and lymph node dissection. Left level 3 and 4 lymph node excision showing 2 of 15 positive for metastatic papillary thyroid carcinoma without extranodal extension. Left superficial jugular lymph node excision showing 1 of 3 lymph node being positive for metastatic thyroid carcinoma without extranodal extension. RAI therapy and post-ablative scan showed focal moderate increased activity adjacent to the left hyoid bone. CT scan of the neck later showed stable appearance of the thyroidectomy bed with no new suspicious soft tissue mass. A small crescentic focus of enhancing soft tissue medial to the left common carotid artery is favored to represent residual thyroid tissue. Multiple small enhancing lymph node in the left neck at level llB and junction of levels ll and lll. Several of these are new or increased in size from prior examination and somewhat acidly enhanced. Although these are within normal limits by size criteria, recurrent diseases cannot be excluded. She underwent another surgical neck dissection with no cancer found. Given the negative findings, a shift from checking thyroglobulin (TG) from immunoassay to mass spectrometry was ideal.Patient was found to have persistent thyroglobulin elevation with Immunoassay, thyroglobulin level (60.5 ng/mL, n<35 ng/ml), without the presence of TG antibodies, whereas liquid chromatography-tandem mass spectrometry (LC-MS/MS) showing (<0.5 ng/mL), highlighting the methodological divergence. To date she has no imaging concerns and repeat testing from different labs similarly demonstrated undetectably Tg by LC-MS/MS and varying levels when tested by Immunoassay. Her levels by Immunoassay have trended down to her most recent level of (38 ng/ml).This case emphasizes the critical role of accurate thyroglobulin assessment in thyroid carcinoma follow-up. Immunoassay and mass spectrometry present divergent results, with LC-MS/MS proving more reliable in monitoring disease progression but more expensive and time consuming. Clinicians should consider the implications of methodological choices on patient management, particularly in cases of persistent elevation despite treatment. The potential discrepancies between these methods should be emphasized considering the impact on treatment decisions.

Presentation: 6/1/2024
6492 Novel compound heterozygous mutations in the SBP2 gene
Authors: Ahn Jungmin , Jeong Hwalrim
Published: October 2024

Disclosure: H. Jeong: None.

Mutations in the selenocysteine insertion sequence binding protein 2 gene (SECISBP2 also known as SBP2) result in a multisystemic disorder. A 4-year-old Korean girl presented with atypical thyroid function test result, characterized by normal TSH 2.13 μIU/mL, decreased T3 0.51 ng/mL, free T3(FT3) 1.71 (pg/mL), and elevated free thyroxine (FT4) 4.28 ng/dL. Additionally, she exhibited short stature below 2 standard deviations and delayed bone age. She has not yet begun speaking, and her waking ability commenced only recently. She conceived twins through natural pregnancy, but tragically, her twin sibling passed away in utero at 8 weeks of gestation.A targeted next-generation sequencing panel revealed compound heterozygous mutation in SBP2 gene (p.Arg120Ter/p.Arg672Ter) and in TPO gene (p.Glu413Gln).Her serum selenium level was relatively low,, easuring at 6.94 ng/dL. She underwent T3 supplementation and received a daily selenium supplement of 20mcg. Subsequently, her thyroid function tests normalized.

Presentation: 6/2/2024
6802 NRAS-Mutated Malignant Struma Ovarii with Papillary and Solid Histologic Variants
Authors: Wagle Sneha , Lomo Lesley , Dood Robert L , Chadwick Barbara , Abraham Devaprabu
Published: October 2024

Disclosure: S. Wagle: None. L. Lomo: None. R.L. Dood: None. B. Chadwick: None. D. Abraham: None.

Introduction: Struma ovarii is a mono-dermal teratoma of the ovary that is composed of more than >50% of mature thyroid tissue. It accounts for 5% of ovarian teratomas and 1% of ovarian tumors. Although rare, it is seen in women between 40-60 years of age. Most of these tumors are found incidentally. Malignant struma ovarii is even rarer and the mutational profile of these tumors is neither well studied nor understood. We present an uncommon case of malignant struma with NRAS p.Q61R mutation yet with papillary and solid histologic patterns. Case Description: A 53-year-old female with no significant medical or family history presented with acute worsening of chronic lower abdominal pain and irregular menstruation. Her symptoms developed gradually over 6 months. A pelvic and abdominal CT identified a 9.7 cm cystic left ovarian mass without evidence of ascites or peritoneal masses. She underwent laparoscopic left salpingo-oophorectomy. Histopathology examination of the ovarian tumor revealed classical type, well-differentiated papillary, and solid patterns of thyroid carcinoma. The cells revealed nuclear enlargement, irregular nuclei, finely dispersed chromatin, distinct nucleoli, and nuclear grooves. Due to the histologic pattern of classical papillary thyroid cancer, BRAF V600E pyrosequencing was conducted, which revealed wild-type BRAF. This was followed by NGS when NRAS p.Q61R pathogenic variant was identified. Her thyroid ultrasound did not reveal actionable nodules. A TSH (2.17mU/ml) and thyroglobulin (7.6 ng/ml, TG ab neg) levels are consistent with a normal functioning thyroid gland. This patient's tumor findings are unique in that papillary thyroid carcinoma (PTC) and solid growth patterns are typically associated with the BRAF V600E mutation but rarely seen in the context of an RAS mutation. Discussion: Typically, thyroid cancers with papillary and solid variant features are associated with the BRAF V600E mutation. RAS-type tumors have follicular histologic architecture. BRAF and RAS mutations are mutually exclusive in tumors. Our patient’s malignant struma is unique in that it contained a wild-type BRAF and was positive for NRAS p.Q61R mutation. However, the histology was that of papillary and solid patterns. NRAS mutation with papillary histology combination is rare and is seen in 12% of thyroid cancers. The mutational profile of malignant struma ovarii has not been fully understood or studied due to their rarity.

Presentation: 6/3/2024
7290 Hippo Signaling Regulates Zona Glomerulosa Cell Fate In The Adrenal Cortex Of Mice
Authors: Nader N Abou , Jakuc N , Meinsohn M C , Charrier L , Paquet M , St-Jean G , Brind’Amour J , Boerboom D , Mao J , Pepin D , Zamberlam G , Breault D T , Boyer A
Published: October 2024

Disclosure: N. Abou Nader: None. N. Jakuc: None. M. Meinsohn: None. L. Charrier: None. M. Paquet: None. G. St-Jean: None. J. Brind’Amour: None. D. Boerboom: None. J. Mao: None. D. Pepin: None. G. Zamberlam: None. D.T. Breault: None. A. Boyer: None.

The Hippo signaling is a major signaling pathway that regulates processes such as cell proliferation and differentiation during both embryogenesis and postnatal homeostatic maintenance in several tissues. Our recent findings, using the Nr5a1-cre model, have highlighted the essential role of Lats1 and Lats2 (large tumor suppressor homolog kinases 1/2), the main kinases of the Hippo signaling cascade, in maintaining proper differentiation of mouse developing adrenocortical cells by suppressing their differentiation into myofibroblast-like cells. However, since the abnormal transdifferentiation of Lats1/2-negative adrenocortical cells occurs before the establishment of zonation when using the Nr5a1-cre model, the role of Hippo signaling in zona glomerulosa (zG) cells could not be assessed with this model. To overcome this limitation, we inactivated Lats1/2 in aldosterone-producing zG cells using the zG cell-specific AS-cre strain (Lats1flox/flox; Lats2flox/flox; AScre/+). We report here that specific loss of Lats1/2 in steroidogenic zG cells results in the accumulation of an important extracellular matrix (ECM) in the zG an outer zona fasciculata (zF) by 4 weeks of age; a phenotype that does not seem to progress with aging. In addition, tracing experiments demonstrate that the inactivation of Lats1/2 leads to the ectopic transdifferentiation of the zG cells into the ECM-producing cells rather than into zF cells. We then performed RNAseq experiments on whole adrenals which further suggested that the ECM producing cells derived from zG cells share characteristics with chondroblast/osteoblast mesenchymal progenitors among other cell lineages and, that the ectopic transdifferentiation of zG cells triggers a significant inflammation/immune response in the adrenal cortex. Our study also demonstrates that the increased activity of the Hippo pathway effectors YAP (Yes-associated protein) and TAZ (transcriptional coactivator with PDZ-binding motif) is responsible for the ectopic transdifferentiation of the zG cells as their concomitant inactivation with Lats1/2 (Yapflox/flox; Tazflox/flox; Lats1flox/flox; Lats2flox/flox; AScre/+) rescues the observed phenotype. Finally, we also demonstrate that the expression of a constitutively active form of YAP (YAP5SA) in zG cells (Rosa26YAP5SA/+; AScre/+) does not alter their identity as severely as the loss of Lats1/2 but leads to adrenal hyperplasia. Together, these novel findings underscore the crucial role of Hippo signaling in maintaining the identity of zG cells in the adrenal cortex.

Presentation: 6/2/2024
7235 Papillary Thyroid Carcinoma in a Hyperfunctioning Thyroid Nodule
Authors: Yang Jungyoon , Nadkarni Prashant V
Published: October 2024

Disclosure: J. Yang: None. P.V. Nadkarni: None.

Background: The prevalence of malignancy in a hyperfunctioning or hot thyroid nodule is considered to be low. According to the 2015 American Thyroid Association Guidelines, no cytologic evaluation is routinely recommended for hyperfunctioning nodules since they are rarely associated with malignancy (1). We present a case of a 71-year-old female with a hot nodule containing papillary thyroid cancer. Clinical Case: A 71-year-old female with Type 1 diabetes mellitus and coronary artery disease on dual antiplatelet therapy was found to have a 1.5 cm firm, non-tender right-sided thyroid nodule on a routine physical exam. Laboratory tests demonstrated low TSH <0.01 (normal 0.36 - 3.74 m[IU]/L) and FT4 level elevated at 1.62 (normal 0.76 -1.46 ng/dL). She noticed palpitations and started on low dose Methimazole. Thyroid ultrasound results showed a 2.1 x 2.0 x 2.0 cm right inferior lobe thyroid nodule. This thyroid nodule appeared mixed cystic and solid, hypoechoic, not taller than wide, with ill-defined margins and peripheral calcifications (ACR TI-RADS risk category: TR4). Nuclear medicine thyroid uptake scan demonstrated focally increased activity in the right lower pole corresponding with her right inferior thyroid nodule seen on ultrasound. Remainder of the gland appeared suppressed. She was recommended for ultrasound-guided fine needle aspiration biopsy of her right inferior thyroid nodule, given concerning characteristics on ultrasound findings despite results consistent with a hot nodule. Timing of her antiplatelet therapy was coordinated with her cardiologist, and her biopsy procedure scheduled after she stopped dual antiplatelet therapy. Her FNA results showed clusters of follicular cells with nuclear and architectural atypia, suspicious for papillary thyroid carcinoma. She underwent right thyroid lobectomy. Surgical pathology revealed 2 foci of papillary thyroid carcinoma, follicular variant (2.0 cm, 0.1 cm) and confined to the thyroid. All regional lymph nodes were negative for tumor. Methimazole was discontinued post-operatively, and she started Levothyroxine suppression therapy. Discussion: We present a rare association of papillary thyroid carcinoma presenting as a hot thyroid nodule. Though uncommon, detection of a hyperfunctioning thyroid nodule does not exclude the possibility of thyroid carcinoma and warrants careful evaluation. Clinicians should retain a high index of suspicion particularly when ultrasonography demonstrates findings suspicious for malignancy and consider additional evaluation with fine needle aspiration. Reference: (1) Haugen BR, Alexander EK, Bible KC et al. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2016 Jan;26(1):1-133.

Presentation: 6/2/2024
7860 Predictors of Remission in Patients with Graves' Disease Treated with Antithyroid Drugs at the University of Santo Tomas Hospital - A Retrospective Cohort Study
Authors: Sorsona F E , Cunanan E C
Published: October 2024

Disclosure: F.E. Sorsona: None. E.C. Cunanan: None.

This is a local study with the objective to determine the predictors of remission in Graves’ disease patients who completed 12 to 18 months of antithyroid drug therapy in University of Santo Tomas Hospital (Manila, Philippines) from 2017 to 2022. The study employed a retrospective cohort design. Patients included were all Graves’ disease patients seen at University of Santo Tomas Hospital who were treated with antithyroid drug methimazole. Data were collected via a retrospective review of medical charts. From the 203 Graves’ disease patients, a total of 59 patients met the inclusion criteria and were included in the study. Following completion of antithyroid drug therapy, patients were divided into remission and non-remission groups. Predictive factors analyzed were age, gender, smoking history, presence of orbitopathy and goiter, duration of ATD therapy, and thyroid function tests (TSH, free T3 and free T4) at time of initiation and completion of ATD. Forty-nine patients (83%) were females, and ten patients (17%) were males. The median age at the time of ATD initiation was 35 years old. The median duration of ATD therapy was 24.2 months. Following completion of ATD, 34 patients had remission with incidence of 57.63% (95% CI: 44.07-70.39%). Age, gender, smoking history, presence of goiter and orbitopathy, duration of ATD therapy, thyroid function tests at initiation, and FT3, FT4 and FT3/FT4 ratio at time of completion showed no significant differences between the two groups. After univariate and multivariate analyses, only one factor was significantly associated with 1-year remission which was the TSH at the time of ATD completion, with a median of 1.54 mIU/L, range: 0.001-7.94 mIU/L. Median TSH was significantly higher among patients who had remission than those with non-remission. Compared to patients with normal TSH at the time of ATD completion, the odds of remission was 14 times lower among patients with low TSH, and 7 times lower among patients with high TSH. A normal TSH at the time of ATD completion was associated with 1-year remission from Graves’ disease.

Presentation: 6/2/2024
12327 Presenting Features of Papillary Thyroid Cancer with Hobnail Histology and Factors Associated with Advanced Disease at Presentation
Authors: Majumdar S K , Sinard J
Published: October 2024

Disclosure: S.K. Majumdar: None. J. Sinard: None.

The Hobnail subtype of papillary thyroid cancer (PTC) is reported to be a rare form of PTC that manifests with higher rates of extrathyroidal extension, metastases, disease recurrence, and mortality, when compared to classic PTC. We set out to characterize the clinical manifestations and initial pathologic findings of patients with PTC and hobnail histology at our institution. A retrospective search of pathology records from 1/2014 through 1/2024 was conducted to identify rare thyroid cancer variants including those with hobnail histology. An electronic medical record review was then performed to collect clinical information. The study was approved by our institutional IRB. A total of 15 patients with PTC of the hobnail subtype (≥ 30% features) or with hobnail features (< 30%) were identified: 8 hobnail subtype, 5 having hobnail features, 1 had hobnail and oncocytic features, 1 had hobnail and tall cell features. Sixty percent were female, mean age 50.6 years (SD 16.4), 67% white, 27% Hispanic, 6% black. Mean BMI was 29.4 kg/m^2 (SD 5.4), 33% had a history of prior or current smoking. Cancers were found incidentally in 33% of cases (3 after physical exam noting goiter or nodule), 53% presented with a newly noticed neck lesion, one of these presented with hoarseness and cough from tracheal invasion which was found later at surgery. Mean tumor size 2.65 cm (SD 1.7), 13 patients had 1 or more lymph nodes removed with at least one node being positive in 77% of cases. Rates of lymphatic invasion were 73% (33% extensive), vascular invasion 13%, and 13% had gross extrathyroidal extension. After initial surgery 60% had stage 1 disease, 27% stage 2, and 13% stage 3. One patient was changed to stage 4 upon the later discovery of lung metastases and this patient had 30% tall cell features on pathology. Three patients had T3 or T4 tumors, all of whom were from minority and vulnerable populations (2 non-English speaking Hispanic, 1 Black with mental illness), had significantly higher BMI than others (36.2 ± 4 vs 27.2 ± 4.5, p = 0.01), and tended to be older (67 ± 9.5 vs 46.5 ± 16, p = 0.057 ns). Long term follow up was limited since hobnail histology was only found in reports beginning in 2017 and became more frequent in 2022 and 2023. Although limited by case number, our findings show that patients who presented with the most advanced disease were from vulnerable populations, were older, and had higher BMI’s than those with lower stage disease. Also, coexistence of other variants, like tall cell changes, may impact presentation. Therefore, while PTC with hobnail histology is typically associated with more advanced disease presentations, psychosocial and other factors appeared to explain higher stage disease at presentation in our series.

Presentation: 6/3/2024
7706 Racial Disparities in Thyroid-Related Procedure Reoperation Rates: Insights from NSQIP Database
Authors: Akin Erol Huseyin , Liu Amy , Wardwell Kirra , Woodruff Stacey
Published: October 2024

Disclosure: H.A. Erol: None. A. Liu: None. K. Wardwell: None. S. Woodruff: None.

Background: Racial disparities in health outcomes are well-documented, with specific conditions affecting racial groups differently. However, the influence of race on endocrine surgery outcomes remains an evolving field of study. This research seeks to evaluate the effect of race on unplanned reoperations using the National Surgical Quality Improvement Program(NSQIP)-database and to investigate additional risk factors for reoperations in this cohort. Methods: We analyzed the NSQIP-database for thyroid-related procedures from 2012-2021 using CPT codes. Patient demographics, including age, sex, height/weight, ASA classification, and comorbid conditions, were assessed for unplanned reoperations. Univariate, multivariable logistic regression, and adjusted residual analyses were conducted assessing individual variables, adjusted odds ratios(ORs), and for post-hoc analyses. Results: Over the 10-year period, 169,251 patients were identified, with an overall reoperation incidence of 1.32%. Univariate analysis revealed that race correlated with increased reoperation rates, with the highest incidence observed among American Indian/Alaska Native (2.13%) patients, followed by Native Hawaiian/Pacific Islander (1.93%), Black/African American(1.84%), White (1.22%), and Asian(1.08%) patients. In multivariate logistic regression analysis, Black/African American (OR 1.452, 95% CI 1.293-1.630, p < 0.001) and American Indian/Alaska Native (OR 1.775, 95% CI 1.039-3.031, p = 0.036) patients had a higher risk of reoperation compared to White patients. Other factors associated with increased reoperation risk included male gender, higher ASA class, smoking, partially dependent functional status, ventilator dependency, hypertension, dialysis, disseminated cancer, bleeding disorders, and systemic inflammatory response syndrome or sepsis. Most reoperations were hematoma related(63.02%), with statistical significance noted among different ethnicities and types of reoperations. White patients had lower rates of hematoma-related procedures, fewer tracheostomies, and more additional thyroid procedures. Black/African American patients had more tracheostomies and fewer lymphatic-related or additional thyroid procedures. Conclusions: Using the NSQIP-database, Black/African American and American Indian/Alaska Native patients were at a greater risk of reoperation following thyroid surgeries, even after accounting for multiple variables. Black/African American patients also had disparate types of reoperations. These findings highlight the impact of race on thyroidectomy-related outcomes. Further research is imperative to comprehensively understand the role of race in surgical outcomes and to address healthcare disparities and inequities.

Presentation: 6/2/2024
8105 Radiation-Induced Hyperthyroidism in the Context of Palliative Radiation Therapy
Authors: Randhawa A , Palaguachi G , Karam J G
Published: October 2024

Disclosure: A. Randhawa: None. G. Palaguachi: None. J.G. Karam: None.

Introduction: Palliative radiotherapy, designed to alleviate focal symptoms in advanced, incurable cancer, aims to enhance quality of life with minimal treatment burden. The thyroid gland's susceptibility to neck radiation is known, primarily leading to hypothyroidism. However, hyperthyroidism is a much less frequently reported adverse effect that is poorly understood. This case report highlights an unusual instance of radiation-induced hyperthyroidism. Case Presentation:The patient is a 53 years-old woman with history of Ewing’s sarcoma of the sacrum diagnosed in August 2022, treated initially with chemotherapy (cyclophosphamide, vincristine, etoposide and ifosfamide), but diagnosed with leptomeningeal metastasis and T12/L1 mass in October 2023 when she presented with lower extremities weakness and urinary incontinence. She underwent T12-L1 laminectomy, resection of tumor and fusion, and was started on palliative intent radiation therapy for the brain and C-spine. A month later, she was admitted for altered mental status and was found to be persistently tachycardic at 140 bpm. Thyroid function testing was sent and revealed hyperthyroidism with TSH of 0.07 mIU/L (0.39-4.08), Free T4 of 1.74 ng/dl (0.58-1.64), T4 of 10.7ug/ml (4.4-9.5), T3 of 0.54 ng/ml (0.72-1.35), with undetectable Thyroid Peroxidase Antibodies and Thyroid Stimulating Immunoglobulin level. Thyroid Ultrasound showed a small and homogenous thyroid gland with no discrete nodules. Radioactive Iodine uptake and scan was not obtained because of exposure to iodized contrast during hospital stay. The patient had no available baseline thyroid function tests. She had no recent fever or viral illness. Unfortunately, her clinical condition deteriorated rapidly, and she passed away on the seventh day of admission. Conclusion: While hypothyroidism is a well-established consequence of high-dose irradiation, the mechanisms behind the rarer radiation-induced hyperthyroidism remain unclear. Speculation includes the release of autoantigens from damaged thyroid glands, triggering an immune response and potentially leading to Graves' hyperthyroidism. However, our case more likely represents a hyperthyroid phase in the triphasic sequence of destructive subacute thyroiditis, given the absence of elevated thyroid antibodies, thyroid nodules, and other causes of thyroiditis. Increasing awareness of radiation-induced hyperthyroidism, unraveling its mechanisms, and refining diagnostic strategies such as obtaining baseline and monitoring thyroid function testing are crucial, particularly in the context of palliative therapy, where striking the delicate balance between efficacy and minimizing toxicity is paramount.

Presentation: 6/3/2024
7847 Radiomic Ultrasound Checkup of Thyroid Nodules Before Radiodiodine Therapy
Authors: Andreevich Trukhin Alexey , Vadimovich Manaev Almaz , Mikhailovna Zakharova Svetlana , Sergeevna Sheremeta Marina , Anatolyevna Troshina Ekaterina
Published: October 2024

Disclosure: A.A. Trukhin: Grant Recipient; Self; Russian Science Foundation (project N 22-15-00135). A.V. Manaev: Grant Recipient; Self; Russian Science Foundation (project N 22-15-00135). S.M. Zakharova: Grant Recipient; Self; Russian Science Foundation (project N 22-15-00135). M.S. Sheremeta: None. E.A. Troshina: Grant Recipient; Self; Russian Science Foundation (project N 22-15-00135).

Background: Over 83 years radioiodine therapy (RIT) of autonomous thyroid nodules still have uncovered pages, according to its complexity and thyroid nodules variety. There are two main criteria to allow RIT – no malignancy and presence of iodine uptake, the last one could be checked by Tc-99m-pertachnetate or I-123, I-131 iodine scintigraphy. Case with thyroid nodules first undergo ultrasound (US) TI-RADS classification, then fine needle aspiration stratification according to the Bethesda system. Publications applied such algorithm shows 75-85% accuracy in malignancy determination, that in 15-25% can lead to improper RIT application. Aim: Method development for thyroid nodules ultrasound checkup before I-131 administration and I-131 24h uptake prognosis. Methods: Study includes 150 nodules (65 benign, 60 malignant, 25 autonomous benign thyroid nodules). Both US longitudinal and transversal thyroid nodule projections were obtained via GE Voluson E8 (36% benign cases / 27% malignant cases) and GE Logiq E (64% benign cases / 73% malignant cases) in cinematic loop regime. Autonomous thyroid nodules underwent I-131 pharmacokinetics examination with 24h uptake determination and RIT. Statistical textural features were obtained through spatial adjacency matrix. Results: Analysis of 16 statistical textural features shows weak correlation between 11 statistical textural features E (Energy), S (Entropy), LU (Local homogeneity), MP (Maximum probability), TR (Matrix trace), CORR (Correlation), IMC (information measure of correlation), DV (Difference variance), DE (Difference entropy), SE (Sum entropy), SA (Average value of the sum). ROC-analysis using 11 statistical textural features shows the best model for benign/malignance determination with AUC = 0.83, Se = 74%, Sp = 73%, PPV = 75%, NPV = 72%, Acc = 74%. I-131 pharmacokinetics examination shows strong correlation SA to I-131 24h uptake. Conclusions: The performed study demonstrates the possibility of using textural statistical features of ultrasound images as instrument for thyroid nodules ultrasound checkup before I-131 administration, for extra FNA prescription and prognosis the I-131 24h important in exact therapeutic I-131 activity calculation.

Presentation: 6/2/2024
5128 Role of Plasmapharesis- A Tale of Two Thyroid Storms
Authors: Zhang Z , Joseph S , Kodali A M , Eagerton D
Published: October 2024

Disclosure: Z. Zhang: None. S. Joseph: None. A.M. Kodali: None. D. Eagerton: None.

Background: Thyroid storm is an acute life threatening endocrinological emergency. The standard treatment for a thyroid storm is antithyroid medication, iodine, beta blockers and corticosteroids. However, when patients are refractory to standard treatment, plasmapheresis may be an effective and safe intervention. Case 1: A 49-year-old male with typical symptoms of hyperthyroidism, presented with a Ventricular tachycardia arrest. After the return of spontaneous circulation, he was febrile, and developed new onset atrial fibrillation (AF) and Amiodarone drip was started. Physical exam showed a thin gentleman with an enlarged thyroid. ECHO showed LVEF 50% with moderate to severe dilatation of left atrium and mild mitral and tricuspid valve regurgitation. CT abdomen/pelvis and CTA chest did not show any pathology. Labs showed TSH of 0.02 (reference range: 0.465-4.68); Free T 4 >6.99 (reference range: 0.78- 2.19). He was started on Propylthiouracil (PTU), Hydrocortisone, Potassium Iodide, and Cholestyramine. His blood pressure was too low to tolerate a beta blocker. He developed increased liver enzymes thought to be due to shocked liver. PTU was switched to Methimazole due to less risk of hepatotoxicity. A Thyroid Stimulating immunoglobulin was 13.40 (reference range 0.00-0.55), confirming Graves’ disease. He developed multiorgan failure and plasmapheresis was initiated. His Free T4 level prior to his first apheresis was still >6.99 but improved to 6.20 after two days. After the second session, free T4 level drastically improved to 2.65. He sustained a level of 2.09 until his hospital discharge. Case 2: A 59-year-old male with untreated hyperthyroidism and AF, who presented with shortness of breath. He was tachycardic, febrile and developed AF with rapid ventricular response. A TSH and free T4 level showed <0.02 (reference range: 0.465-4.68); and >6.99 (reference range: 0.78- 2.19), respectively. Physical exam shows a cachectic man with an enlarged thyroid. ECHO showed reduced ejection fraction of 35% with biventricular failure. He was initially started on PTU, Potassium Iodide, hydrocortisone and esmolol drip and eventually Cholestyramine. Patient developed multisystem organ failure and PTU was switched to methimazole due to continued deterioration of his liver enzymes. Plasmapheresis started with a total of 3 sessions. His free T4 improved from 4.32 to 3.59 by the second session. Round three was performed when his Free T4 increased back to 4.56. Unfortunately, he had a sudden decline in mentation and CT head showed an acute/subacute left anterior parietal stroke and after family discussion, was palliatively extubated and expired. Discussion: This case series shows two cases of thyroid storm treated with plasmapheresis and had two stark contrasts. Further studies should be done to elucidate the usefulness of plasmapheresis for thyroid storm when refractory to standard of treatment.

Presentation: 6/2/2024