bluuebunny/crossref_metadata_2025 huggingface dataset:
SUN-155 A Complex Case of Adrenal Insufficiency Associated with NLRP1 Gene Mutation in a Patient with Myopathy and Mitochondrial Cytopathy
Authors: Khan Mehvish , Khawaja Masuma , Haq Mohammad Adnan Ul , Quadir Humza , Jameson Brian C
Published: May 2020

Most cases of Addison’s disease are due to an autoimmune response, with the most commonly associated genes belonging to human leukocyte antigen (HLA) complex. Genome wide association studies have shown a significant association of variants of Nuclear Localization Leucine-Rich-Repeat Protein 1 (NLRP1) with Addison’s disease. NLRP1 protein is involved in the assembly of inflammasome which promotes the secretion of interleukin-1β, interleukin-18 and downstream inflammatory responses to regulate inflammation. With underlying myopathy and mitochondrial disease, coexisting adrenal insufficiency may be challenging to identify. A 36-year-old female presented for evaluation of fatigue, myalgia, and dyspnea for several years. She carried a diagnosis of asthma, myopathy, gastroparesis requiring a gastric stimulator, and recently diagnosed adrenal insufficiency secondary to long term fluticasone use. Beside low blood pressure of 91/64 millimetres of mercury, physical exam was unremarkable. Lab findings were significant for dehydroepiandrosterone-sulfate (DHEAS) of 7.0 micrograms per deciliter (mcg/dL), Adrenocorticotropic hormone (ACTH) of 7.2 picograms per milliliter and cortisol of 1.4 mcg/dL. Adrenal insufficiency was confirmed with cosyntropin stimulation test. Methacholine challenge test showed worsening asthma. She was managed with empiric stress dose steroids when indicated. Muscle fatigue progressed despite taking ubiquinol, B100 and carnitine. She was further evaluated with muscle biopsy that showed type two fiber atrophy. Muscle coenzyme Q10 was 0.08 mcg/dL, and citrate synthase was 50% of normal, insufficient for electron transport complex I. Whole exome sequencing showed mutations in NLRP1 in addition to Myosin Heavy Chain 2 (MYH2) and Sodium voltage-gated Channel alpha subunit 4 (SCN4a) both of which are associated with myopathy. She was then started on a short-acting glucocorticoid regimen. While her adrenal insufficiency was initially thought to be secondary to inhaled steroids, subsequent mutation analysis suggested that she was prone to autoimmunity. This case illustrates the association of adrenal insufficiency with NLRP1 mutation. Furthermore, the symptoms of adrenal insufficiency and myopathy can overlap making it difficult to delineate. While so far most studies have dealt with mitochondrial myopathies due to deletions or point mutations in the mitochondrial deoxyribonucleic acid (DNA), a new field of investigation is that of syndromes due to mutations in the nuclear DNA.
SUN-586 CXCR2 Repression by Glucocorticoids in Adipose Tissue
Authors: Amatya Shripa , Carroll Natalie G , Petrillo Maria Grazia , Cidlowski John A , Topete Diana Cruz
Published: May 2020

Obesity-induced type 2 diabetes (T2D) is a significant risk factor of cardiovascular disease (CVD), which affects 28.1 million adults in the United States. Adipose tissue chronic inflammation is one of the main factors that drive obesity-induced insulin resistance (IR) and T2D. Despite several studies that have shown a link between obesity, adipose tissue inflammation, and IR/T2D, the mechanisms underlying this association are not well understood. Synthetic glucocorticoids are widely used for their potent anti-inflammatory actions; however, their use is hampered due to off-target side effects. Glucocorticoids exert profound effects on adipose tissue, including the regulation of adipocyte metabolism and immune functions. However, whether their effects on adipose tissue are positive or negative it is still a controversial topic. Genome-wide microarray data obtained from adipocyte-specific glucocorticoid receptor (GR) knockout (AdipoGRKO) mice showed that lack of GR leads to a significant increase in the expression of pro-inflammatory genes in white adipose tissue (WAT). Moreover, WAT isolated from adipoGRKO mice demonstrated significant increase in immune cell infiltration, which correlates with our gene expression data. Among the most up-regulated genes, we found the C-X-C Motif Chemokine Receptor 2 (CXCR2), which is a critical mediator of chemotaxis to the sites of inflammation. Although studies have shown the presence of CXCR2 in adipocytes and suggested the contribution of CXCR2 signaling in adipocyte development, its role in obesity-driven adipose tissue inflammation is unknown. This led us to hypothesize that adipocyte specific administration of glucocorticoids can reduce obesity-induced adipocyte inflammation by inhibiting CXCR2 gene transcription and signaling. Our in vitro studies using 3T3-L1 cells derived adipocytes showed that treatment with the synthetic glucocorticoid, Dexamethasone (Dex) led to a significant repression of CXCR2 mRNA and protein levels. Correlating with these results, Dex treatment significantly inhibited macrophage migration to adipocytes in a mechanism dependent on GR activation and repression of CXCR2. Furthermore, these results were recapitulated in vivo. Together our findings suggest that local delivery of glucocorticoids to adipose tissue could ameliorate inflammation and reduce the risk of developing IR and T2D.
OR03-03 New Insights into the Functional Human Adrenal Cortex Zonation
Authors: Camponova Paméla , Duparc Céline , Roy Malanie , Lefebvre Hervé , Thomas Michael
Published: May 2020

The zonation of the human adrenal cortex has long been established morphologically and histologically as three distinct layers of cells. The outer zona glomerulosa (ZG) comprises densely packed cells arranged in clusters that produce aldosterone; the zona fasciculata (ZF) is composed of cells with large cytoplasm, containing lipid droplets arranged in radial columns that synthetize cortisol; and the zona reticularis is composed of compact and pigmented cells producing androgens. The main purpose of this work was to study the expression of aldosterone synthase (CYP11B2 which catalyzes the last steps of aldosterone synthesis) and 11β-hydroxylase (CYP11B1 which catalyzes the last step of cortisol synthesis) in normal adrenal glands to address issues regarding the zonation and the fate of the cells constitutive of each zone through the expression of Ki-67 and cleaved Caspase-3. Thirty eight normal human adrenals (16 females, 22 males, ranging in age from 22 to 81 years old with a median age of 52 years old) were obtained from brain-dead organ donors (kindly provided by the Organ Transplant Clinics, University Hospital of Rouen). As early as 22 years old, we found that the histological ZG (h-ZG) does not correspond to the functional ZG (f-ZG) expressing CYP11B2. Moreover, the h-ZG CYP11B2- cells were CYP11B1+ showing that these cells ascribed to the h-ZG are in fact cortisol producing cells. The progressive replacement of CYP11B2+ cells by CYP11B1+ cells in the h-ZG might demonstrate the role of the extracellular matrix in the morphological maintenance of the adrenal cortex. Our analysis also showed that steroidogenic cells were either CYP11B1 or CYP11B2 positive. By immunofluorescence, we observed in many cases isolated or clusters of CYP11B2+ cells located deeply in the h-ZF and sometimes in the vicinity of the central vein. We were able to show that those cells were probably issued from CYP11B2+ cell clusters located in h-ZG which migrated centripetally. Ki-67 immunoreactivity was highly variable and observed throughout the entire cortex. We also found a positive correlation between the steroidogenic and endothelial cells proliferation. It is interesting to note that some Ki-67+ cells located in the h-ZG were CYP11B1+. Cortical cells positive for cleaved Caspase-3 were extremely rare but detected in all zones when present. These findings challenge the classic view of lineage conversion of differentiated ZG cells and show a new pathway where the CYP11B2+ cells migrate without changing their phenotype.
SUN-136 Clinico-Pathological Features, Treatment Modalities and Survival of Patients with Malignant Insulinoma: A Multicenter Study
Authors: Veltroni Alessio , Cosaro Elisa , Cingarlini Sara , Zatelli Maria Chiara , Maria Grossrubatscher Erika , Faggiano Antongiulio , Pia Anna Rosa , Bianchi Antonio , Piusceddu Sara , Spada Francesca , Piovesan Alessandro , Razzore Paola , Filice Angelina , Micciolo Rocco , Davi’ Maria Vittoria
Published: May 2020

Introduction: management of malignant insulinoma is challenging due to the need to control both hypoglycemic syndrome and tumor growth. Literature data is limited to small series.

Aim of the study: to analyze clinical-pathological characteristics, treatment modalities and prognosis of patients with malignant insulinoma.

Materials and methods: Multicenter retrospective study on 31 patients (M 61.3%) diagnosed between 1988 and 2017.

Results: The mean age at diagnosis was 48 ± 15 years. In 5 cases (16.1%) the hypoglycemic syndrome occurred after 46 ± 35 months from the diagnosis of NET, in 26 (83.9%) cases it led to the diagnosis of NET, of which 11 cases (42.3%) with mean diagnostic delay of 32.7 ± 39.8 months. The majority ​​of the NET were G2 (70.8 %) and in the pancreatic body-tail (78.6%). The mean NET diameter was 41 ± 31 mm. Metastases were widespread in 40.7%, only hepatic in 37%, only lymph nodal in 18.5%..Surgical treatment was performed in 21/31 (67.7%) with hypoglycemic control in 42.9%. Except for 2 patients with curative surgery, the others underwent further different lines of therapies including somatostatin analogues (SA), Peptide Receptor Radionuclide Therapy (PRRT), everolimus, chemotherapy, TAE/TACE/RFA, radiotherapy. PRRT was performed in 14/31 (45.1%) with complete (42.9 %) or partial (50%) syndrome control.

The median follow-up was 60 months. The 5-year survival rate was 62%. The median overall survival (OS) was 40 months. No significant difference in OS was observed according to the site of primary tumour and its dimension. A trend towards increased survival was found according to grading (5-year OS 100% for G1, 77% for G2, 33% for G3). Patients with Ki-67 ≤ 10% had a significant higher survival rate compared to patient with Ki-67 >10% (5-year OS rate 87% vs 43%, p: 0.03). As regards the type of treatment, patients who underwent surgery had a higher survival rate than those who did not (5-year OS 76% vs 31.7%, p= 0.006). Moreover, patients receiving PRRT as II line treatment had a better prognosis than those who underwent it in further lines, although the 5-year OS was not significantly different (80% vs 25% respectively, p=0.057).

Conclusions: Our study includes the largest series of patients with malignant insulinomas up to now reported. The hypoglycemic syndrome may occur after years in initially non-functioning NETs, or be misunderstood with delayed diagnosis of NETs. Surgical treatment and Ki67 <10% are prognostic factors associated with better survival. PPRT seems to be promising in the control of hypoglycemic syndrome.
SUN-574 A1AT: Novel Inhibitor of Active PCSK9
Authors: Melendez Quantil , Wooten Catherine , Ahmed Sumaira , Williams Ariel Renee’ , Kimbro Kevin Sean , Lopez Dayami
Published: May 2020

Heart disease is the principal cause of death and disability for both men and women in the US, accounting for 40% of all annual deaths. African American populations are disproportionately burdened with metabolic diseases, due in part to cholesterol metabolism deficiencies. Elevated low density lipoprotein (LDL) cholesterol levels and inflammation promote atherogenic conditions which lead to heart disease. Proprotein convertase subtilisin/kexin-9 (PCSK9) is a biomarker which enhances athrogenic progression by controlling the number of LDL receptor molecules expressed at the plasma membrane. PCSK9 indirectly regulates LDL-cholesterol levels. Previous reports show some patients do not respond well to general anti-cholesterolemic treatments. We believe this is due to altered PCSK9 activity, which is currently not being evaluated. We have developed a novel assay to detect active PCSK9. A1AT is a SERPIN family member whose primary objective is inhibition of proteases. Specific levels of A1AT are required to maintain metabolic homeostasis. Based on this, we hypothesized that a specific ratio between A1AT serum levels and PCSK9 activity levels would eliminate statin intolerance/resistance, regulating LDL-cholesterol metabolism congruently. Using this novel active PCSK9 detection assay, we provide evidence that A1AT interacts with PCSK9 in the medium of C3A hepatic-like cells, preventing the formation of PCSK9/LDL receptor complexes in vitro. There was an approximate 20% inhibition in PCSK9-LDL receptor complex formation when liver cells were treated with recombinant A1AT (rA1AT). A dose dependent response analysis proved 200ng/ml of rA1AT had an 46% reduction in PCSK9 activity. We determined PCSK9 activty and A1AT levels correlate with key diabetic factors in humans, suggesting that A1AT could effect diabetes progression.
MON-063 Rare Cases of Local and Systemic Allergic Reactions Associated with Recombinant Human Growth Hormone Treatment Including Fixed Drug Eruption and Anaphylaxis
Authors: Kim Dae Hyun , Choi Ju-hee
Published: May 2020

Recombinant human growth hormone (rhGH) is widely used to increase growth velocity not only in growth hormone deficiency, but also in other growth related disorder to increase final adult height. RhGH is a safe and effective treatment, which has few side effects. Possible side effects include allergic reaction, joint pain, headache, progression of spine curvature in scoliosis, temporary increase in blood sugar levels. GH-associated allergic reactions include mostly local erythema and swelling at the injection site, and there have been a few reports about those reactions. However, we experienced fixed drug eruption associated with rhGH, which was thought to be an unusual local side effect. Also, we experienced another rare case showing GH-associated systemic allergic reactions including anaphylaxis, which have not been described. So, we would like to introduce these cases who developed repetitive allergic reactions to two different kinds of preservative-containing rhGH, fixed drug eruption and anaphylaxis. Case 1. At the time of initial visit, the patient was at the age of 9 years and 3 months with Tanner stage 3 development. Her height and weight was measured as 128cm (13%) and 27.6kg (24%). Bone age was advanced as 10.9 years by the TW3 method. She was diagnosed as precocious puberty, and combined treatment with GnRH analog and rhGH was started to delay rapid pubertal growth and improve her final adult height because of her short stature for advanced bone age. However, after 2 months of treatment, she showed oval shape of erythematous patch and urticaria on left cheek, which reappeared at the same site after switching to another kind of preservative-containing rhGH. The symptom was diagnosed as fixed drug eruption associated with rhGH therapy, and after discontinuing rhGH, the symptom resolved. Case 2. A 13 years and 8 months girl visited our clinic to check her growth status. She was 154.6cm (29%) tall and 40.1kg (9%), and showed Tanner stage IV development. Her MPH was calculated as 161.5cm, and pelvic AP x-ray showed Risser stage 3–4, which is compatible to 14.5–15 years of bone age in girls. Medical intervention for more height gain was thought to be ineffective, however, the patient and her parents strongly requested rhGH treatment. So, we decided to try rhGH treatment for only three months. However, after 1 weeks of treatment, she complaint of repetitive urticaria and itching sensation, which subsided after taking anti-histamine drugs. After switching to another kind of rhGH, she still complaint of generalized urticaria and itching sensation, aggravated with dyspnea and facing swelling especially around her eyes, the symptoms of anaphylaxis and angioedema. Because of those systemic allergic reactions from rhGH, we quit the treatment. In conclusion, physicians should be aware of these potential side effects and prepare appropriate management and evaluation of patients receiving rhGH treatment.
MON-710 ACVR1 Activation in Primary and iPS-Derived Human Skeletal Muscle Stem Cells Impairs Myogenic Transcriptional Signature and Function
Authors: Barruet Emilie , Garcia Steven , Tamaki Stanley , Morales Blanca M , Wu Jake , Moody Tania , Pomerantz Jason H , Hsiao Edward Chiaming
Published: May 2020

Developing optimal strategies for skeletal muscle regeneration and repair requires a detailed understanding of how these processes are regulated. The number of primary human satellite cells that can be obtained is usually extremely low, and may be impaired in disease of impaired skeletal muscle repair. One such condition is fibrodysplasia ossificans progressiva (FOP), a progressive disease characterized by massive heterotopic ossification in skeletal muscles and aberrant skeletal muscle repair after injury. FOP patients have activating mutations in the Activin A Type I receptor (ACVR1), a bone morphogenetic protein (BMP) receptor. Our overall hypothesis is that activated ACVR1 signaling caused by the ACVR1 R206H mutation incites inappropriate activation of human muscle stem cells (satellite cells, PAX7 expressing cells), causing loss of muscle cell fate and aberrant muscle repair. Since human satellite cells are difficult to obtain from live tissue donors, and injury can trigger heterotopic ossification, we created human induced pluripotent stem cell (iPSC)-derived muscle stem cells (iMuSCs) from FOP and control iPSC lines. We found that control and FOP iPSCs can differentiate into PAX7+ cells with high efficiency. Control and FOP iMuSCs can regenerate injured mouse muscle and form new human fibers, but both showed few PAX7 cells after transplant. Single cell RNA sequencing showed cell heterogeneity, and specific subsets of PAX7+ cells. FOP iMuSCs showed a chondrogenic/osteogenic signature (e.g COL1A1, DCN, OGN) with higher p38 pathway signaling activity. Skeletal muscle samples from autopsies of patients with FOP also showed increased expression of COL1A1. Additionally, we found that primary human FOP satellite cells can engraft and regenerate injured muscle, but with lower efficiency than control satellite cells. These studies used a novel iMuSC strategy to elucidate how increased ACVR1 activity affects human satellite cells function, and compare these iMuSCs to primary human satellite cells. These approaches will be useful to identify new therapeutic targets for conditions affecting skeletal muscle, and will improve our understanding of how muscle and bone interact in development and disease pathophysiology.
MON-174 Circadian Misalignment of the 24-H Profiles of Melatonin and Cortisol in Adrenal Insufficiency
Authors: Darji Monika , Pannain Silvana , Sam Susan , Cauter Eve Van , Hanlon Erin C
Published: May 2020

Patients with adrenal insufficiency (AI), in whom cortisol release is absent, need to be on lifelong replacement therapy. Depending on the modality of glucocorticoid replacement, the resulting 24-h profile of circulating cortisol levels maybe dampened, enhanced, abnormally timed or inconsistent. The 24-h cortisol profile is a major internal synchronizing signal between central and peripheral circadian clocks. Misalignment between central and peripheral clocks has a host of adverse effects, particularly on metabolism and cardiovascular function. Melatonin, normally secreted by the pineal gland exclusively at night and considered a robust marker of central circadian timing, also plays a role as an internal synchronizing signal. Conditions like AI, where the 24-h profile of glucocorticoid levels deviates from normality, could produce misalignment between central and peripheral oscillators.

We examined whether AI patients are at higher risk of disturbances of the circadian system. Participants were 13 AI patients (11 females, 2 men; mean age 45.8 yrs old; mean BMI 25.5) and 13 controls (11 females, 2 males; mean age 48.5 yrs old, mean BMI 26.4) matched for age, sex, and BMI. 10 of the AI patients were on hydrocortisone treatment (total dose range: 20 to 40mg/day, number of doses: 1-5 doses/day) and 3 of the AI patients were on prednisone treatment. Cortisol and melatonin were measured over a 24-h period every 30-60 minutes in all patients and controls.

The 24-h profile of cortisol was quite variable across patients, dependent on replacement therapy. Those on prednisone had very little detectable cortisol with small peaks that occurred around dosing. Those on hydrocortisone, had multiple peaks across the 24-h cycle dependent on medication regime and dosing. As expected, control subjects had a quiescent period of cortisol release from early evening to mid-sleep (18:00 to 02:00) and a mid-sleep rise in serum cortisol that peaks in the morning and subsequently dissipates across the day. In contrast, AI patients have low levels of cortisol across the entire sleep period, with a sharp morning rise, delayed compared to controls. Unexpectedly, we observed a marked difference in the melatonin profile in AI subjects compared to controls. Indeed, a significant daytime phase of elevated melatonin levels was detected in 7 of the 13 AI patients. The nocturnal elevation in the patients was similar to that observed in controls albeit advanced.

In conclusion, the abnormalities of the circadian profile of glucocorticoid levels in AI are associated with an abnormal 24-hr profile of melatonin release, a marker of central circadian function, suggesting that the disruption of the glucocorticoid rhythm may affect central circadian function. It is possible that this circadian dysfunction contributes to the well-known adverse cardio-metabolic outcomes in AI.
SUN-156 Adrenal Cortical Carcinoma in a Male Patient Who Presented with Classic Signs and Symptoms of Cushing’s Syndrome
Authors: Humarang Jeffrey Magnaye
Published: May 2020

Background: Adrenal Cortical Cancer (ACC) is a rare malignancy with an annual incidence of 1-2 per million population. ACC is generally considered a highly malignant tumor and account for 0.05-2% of all cancer.Clinical case: A 32-year old male, newly diagnosed diabetic and hypertensive for 1 month, with a BMI of 37.91 kg/m2, presented with intermittent, vague, non-radiating flank pain. Within a month, patient started to develop weight gain associated with Cushingoid fascies, buffalo hump, elevated blood sugars, hypertension, and eventually developed purple striae in the abdomen associated with easy bruisability. Ultrasound was done which showed bilateral nephrolithiasis. Further work-up with CT-stonogram was done which showed bilateral nephrolithiasis and a 55x37x60mm heterogeneous mass above the left kidney in the area of the left adrenal gland. Further imaging with whole abdominal CT scan was done which revealed stable size of the mass in the region of the left adrenal gland with heterogeneous attenuation and enhancement.Initial hormonal work-ups done showed abnormal 1mg dexamethasone suppression test (874mmol/L N: 172-497mmol/L), but with normal aldosterone (73.22, N: <90pg/ml), renin (8.60pg/mL, N: 5-40pg/mL) and 24-hour urine metanephrines (31 mcg/24 hours N: 115-695mcg/24 hours). Serum K and blood glucose was managed accordingly and patient was cleared to undergo surgery. Patient underwent left unilateral laparoscopic adrenalectomy which revealed a 7cm soft, friable left adrenal mass with minimal hematoma on the antero-inferior portion of the adrenal gland, with active bleeding. Histopathology of the left adrenal mass revealed high-grade adrenal neoplasm, consistent with adrenocortical carcinoma.Postoperatively, patient did not have complications of hypo nor hyperglycemia, hypotension and serum potassium was stable. Hydrocortisone was given postoperatively in tapering doses. Repeat cortisol were done 24 and 48 hours post op which showed normal results (4.02ug/dL and 5.37 ug/dL respectively, N: 5-25 ug/dL). Patient was referred to Oncology service for Chemotherapy and was eventually discharged stable with home medications for his Diabetes mellitus.On follow-up, there was noted improvement on the signs and symptoms of Cushing’s syndrome, with no hypokalemia and better blood glucose control. Conclusion: Majority of adrenal mass are benign but a high index of suspicion for malignancy should always be part of the workup. The acuteness of symptoms and size of mass are important determinants of malignancy. Prior to adrenalectomy, perioperative endocrine therapy is a must. Adrenocortical carcinoma should be managed by a multidisciplinary specialist team including an endocrinologist, oncologist, surgeon, radiologist, and a histopathologist.
MON-372 Treatment-Resistant Vitamin D Deficiency: Is It a Vitamin D Binding Protein Issue?
Authors: Thambuluru Sirisha , Unal Imran , Frank Stuart , Warriner Amy , Ovalle Fernando , Banerjee Ronadip R
Published: May 2020

Introduction

Vitamin D is present in free and bound forms; the bound form is complexed mainly to vitamin D binding protein (DBP). Vitamin D levels are affected by age, pregnancy, liver disease, obesity, and DBP mutations. We report a patient with treatment-resistant vitamin D deficiency suggestive of a DBP with abnormal vitamin D binding.

Clinical Case

A 58-year-old Pakistani male with a history of hypertension, sleep apnea and hypogonadism presented to endocrine clinic with symptoms including fatigue, generalized muscle cramps, and joint pain. Evaluation of common causes of fatigue, such as anemia, thyroid dysfunction and adrenal insufficiency were ruled out with CBC, thyroid hormone levels and ACTH stimulation test results all within normal ranges. A 25-OH vitamin D level was profoundly low (4.2 ng/ml; normal 30-100), and a 1,25-OH vitamin D level was undetectable (<8 pg/ml; normal 18-72), leading to a presumptive diagnosis of severe vitamin D deficiency. However, his calcium, phosphorus, alkaline phosphatase and kidney function were in the normal range. Furthermore, the absence of osteoporosis, fracture history, or kidney stones suggested adequate vitamin D action at target tissues; PTH levels were high-normal to minimally elevated, ranging 70-94 pg/ml (12-88pg/mL). Aggressive supplementation with vitamin D3 at 50,000 IU 3 times a week and 5,000 IU daily failed to normalize 25-OH vitamin D (ranged 4.6-10ng/ml; normal 30-100) and 1,25-OH vitamin D levels remained undetectable. Addition of calcitriol resulted in mild hypercalcemia and was discontinued. Malabsorption did not appear to be a contributing factor, as a negative tTG antibody (with normal IgA) excluded celiac disease. Vitamin D metabolites levels measured with mass spectrometry showed undetectable 25-OH vitamin D levels (D2 <4 ng/ml, D3 <2 ng/ml; total <6ng/ml; normal 20-50) and 1,25-OH vitamin D levels (<8 pg/ml). Urine N-telopeptide, 24-hour urine calcium (177mg; 100-240) and bone-specific alkaline phosphatase were all normal. Repeat testing over more than five years showed similar results. DBP levels of 269 ug/ml [104-477] excluded DBP deficiency.

Clinical Lesson

Vitamin D deficiency is increasingly part of routine testing in internal medicine and endocrinology clinics, as is repletion with high-dose vitamin D. However, in rare cases such as this, relying on 25-OH vitamin D levels can be misleading, and supplementation unnecessary or potentially harmful. Thus, treatment decisions should consider the full clinical context and further evaluation performed when warranted. This patient’s labs are suggestive of an abnormality in the DBP, supporting future examination using molecular testing.
OR22-07 Novel Variants in Protein Kinase a Signaling-Related Genes Identified in Obese Children with and Without NAFLD
Authors: Bloyd Michelle , Coon Steven , Iben James , Sinaii Ninet , Faucz Fabio Rueda , Santoro Nicola , Caprio Sonia , Stratakis Constantine A , London Edra
Published: May 2020

Context: Nonalcoholic fatty liver disease (NAFLD) is estimated to affect nearly 10% of Americans age 2-19 and about 38% of those affected are obesei. NAFLD is characterized by triglyceride accumulation in hepatocytes and can progress to nonalcoholic steatohepatitis, end stage liver disease and hepatocellular carcinoma. The underlying causes of NAFLD in youth are unclear although obesity, insulin resistance, type 2 diabetes mellitus and metabolic syndrome are risk factors. Genome-wide association studies and candidate gene studies have found several single nucleotide polymorphisms that affect susceptibility to and progression of NAFLD, but clinical translation for some of these genetics is lackingii.

Study design: Because mouse models of dysregulated PKA signaling demonstrate the centrality of this pathway in hepatic lipid metabolism and glucose homeostasis, we hypothesized that defects in hepatic PKA signaling genes could affect susceptibility to or severity of NAFLD in children. We asked whether identified variants might be associated with differences in clinical markers in a cohort of obese pediatric patients (non-NAFLD, n=295; NAFLD, n=165) followed at Yale Medical School, where clinical data and genomic DNA were collected. Exon sequencing of 54 PKA-related candidate genes included those coding for PKA subunits, PDEs and other proteins integral to the hepatic PKA system. Variants were ranked by allele frequency and potential pathogenicity. Ongoing analyses aim to identify associations between single variants and potential additive effects with clinical parameters (anthropometric, liver function, glucose metabolism, plasma lipids).

Results: Gene variants were identified in ABCA1, ADCY4, ADCY5, AKAP7, CREB3L1, CREB3L4, CREM, CYP27A1, DHCR7, ERN1, GYS2, IL6, IL10RB, MC2R, PDE1B, PDE2A, PDE3B, PDE4A, PDE7B, PDE10A, PDE11A, PPARGC1B, PRKAR2A, and PRKAR1B. Reported variants met criteria of high to moderate impact based on 9 in silico scores that predict pathogenicity. Allele frequency ranged from 2.5 to over 50 times higher in our cohort than the general population. One or more variant was identified in 34.9% of non-NAFLD and 19.4% of NAFLD patients (p=.0004).

Conclusion: We report PKA-related gene variants among a cohort of pediatric obese patients that might serve as useful predictors of risk of NAFLD or obesity. Further analyses will help determine whether any of these variants may play a functional role in NAFLD.

Endnotes

i Schwimmer JB, Deutsch R, Kahen T, Lavine JE, Stanley C, Behling C. Pediatrics. 2006;118(4):1388.

ii Vespasiani-Gentilucci U, Gallo P, Dell’Unto C et al. World J Gastroenterol. 2018;24(43):4835-4845.
SUN-546 18-Day Lifestyle Program Improves Metabolic Equivalent Measures, BMI, and Exercise Capacity Among Overweight and Obese Adults
Authors: Mpyisi Atieno , Ramirez Francisco , Nedley Neil , Michel Rebecca , Seidel Vinicius
Published: May 2020

Introduction Various kinds of diets, workout programs, exist to lower one’s Body Mass Index (BMI), increase strength, and endurance. Metabolic Equivalent Measures (METS) is often used to measure exercise intensity1. A simple 18-day lifestyle program may be effective in raising METS, lowering BMI, and building endurance among overweight and obese adults. Methods Participants took part in an 18-day residential lifestyle program that encouraged daily outdoor exercise. Those with a BMI greater than 24.9kg/m2 were selected for this study. BMI, METS, and miles walked per day were measured at baseline and 14 days into the program. METS was measured using the Bruce Protocol while participants reported miles walked per day. Participants were given a walking goal of 5 miles per day. Participants ate 2 vegeterian meals a day that were low in sugar and fat but high in fiber. The program also encouraged moderate sunlight exposure, adequate water intake, sleep hygiene, and temperance. The program incorporated spiritual activities such as corporate prayer, spiritual contemplation, and hymn singing. A patient-doctor relationship was established and participants were consistently monitored. Results A total of n=627 participants were used in this study. METS increased from a baseline mean of 7.61 kcal/kg/hour to a final mean of 9.19 kcal/kg/hour. This is an increase of 1.58 kcal/kg/hour, ±1.26, with t(626)=-25.35 and p<0.001. BMI decreased from a baseline mean of 32.49 kg/m2 to a final mean of 31.39 kg/m2. This is a decrease of 1.094 kg/m2, ± 2.22, with t(626)=39.22 and p<0.001. Miles walked per day (MPD) increased from a baseline mean of 0.86 MPD to a final mean of 4.04 MPD. This is an increase of 3.18 MPD, ±2.01, with t(626)=-33.36 and p<0.001. Conclusion The program significantly improved METS, BMI, and physical endurance among the participants. This suggests that simple lifestyle changes are effective even among overweight and obese adults and should be encouraged by health professionals. Longitudinal studies are needed to examine these lifestyle effects outside of this program.
OR21-03 Determining Novel Therapeutic Targets Using an in Vitro Model of TRb Tumor Suppression in Anaplastic Thyroid Cancer
Authors: Gillis Noelle E , Bolf Eric L , Davidson Cole , Cozzens Lauren , Tomczak Jennifer , Lian Jane B , Frietze Seth , Carr Frances E
Published: May 2020

Anaplastic thyroid cancer (ATC) is one of the most lethal endocrine cancers, with an average survival time of six months after diagnosis. These aggressive tumors are characterized by rapid local extension, distant metastasis, and resistance to radioactive iodine therapy and mainstream chemotherapy. There are very limited treatment options for this aggressive form of thyroid cancer, highlighting a need for a deeper understanding of its mechanisms for development of more effective therapies. Loss of expression of the thyroid hormone receptor beta (TRβ) via epigenetic silencing is common amongst solid tumors, including ATC. Despite its recognized role as a tumor suppressor, the mechanisms underlying TRβ tumor suppressor activity remain uncharacterized. We previously created a stable ATC cell line with constitutive re-expression of TRβ (SW-TRβ). These stable cells exhibit a slower baseline growth rate than both the corresponding parental cell line (SW1736) and the stable empty vector control cell line (SW-EV). Since the effects of thyroid hormone treatment on the growth of cancer cells remain unclear, we investigated changes in growth rates of these cells in response to hormone treatment (triiodothyronine (T3) 10-8M). While T3 had no effect on SW-EV cells, the addition of hormone significantly slowed the growth of the SW-TRβ cells after two days. With longer exposure to T3 (five days), the SW-TRβ cells exhibited an apoptotic phenotype. We confirmed that the observed cell death was due to induction of apoptosis by assessing caspase 3 cleavage by immunoblot. The parental SW1736 cell line harbors a deleterious p53 truncating mutation, which is maintained in our stable cell lines. Therefore, we hypothesize that this T3-induced apoptosis is occurring through an alternate, p53-independent, signaling pathway. This prompted us to examine RNA-seq data obtained from these cell lines under similar conditions to identify potential regulators of this response. Interestingly, pathway analysis revealed decreased CDK4/6-mediated cell cycle progression and activation of JAK1/STAT1 signaling upon T3 treatment. These are novel mechanisms by which activation of T3-TRβ signaling can slow tumor growth and promote apoptosis in p53-deficient cancer cells. Furthermore, these pathways represent novel therapeutic targets specifically for ATC with potential high impact clinical applications.
SAT-516 A Severe Case of Pembrolizumab-Induced Thyroiditis
Authors: Lane Kyrstin , Kim Sarah , Wei Jeffrey , Darwin Christine Hema
Published: May 2020

Pembrolizumab, a programmed death 1 (PD-1) inhibitor used for advanced malignancies, can be associated with thyroid dysfunction.1-2 Specifically, thyroiditis occurs in nearly 2.3% of individuals.2 The hyperthyroid phase is typically non-severe, requiring only beta blockers. Our case illustrates that conservative therapies may be ineffective in pembrolizumab-induced severe thyroiditis.

A 54-year-old woman with metastatic non-small cell lung cancer with normal baseline TSH received pembrolizumab. She was hospitalized nearly 30 days later with nausea, vomiting and tachycardia. Labs showed TSH <0.02 mcIU/mL (normal 0.3-4.7), free T4 >7 ng/dL (normal 0.8-1.7) and free T3 2105 pg/dL (normal 222-383). TSH receptor antibody was undetectable; hyperthyroidism was attributed to pembrolizumab. Metoprolol was initiated. She was re-hospitalized three days later with persistent symptoms and inability to tolerate orals. Labs again showed severe hyperthyroidism and TPO antibody 201 IU/mL (normal ≤ 20). Burch-Wartofsky score was 25. Given her symptom severity, propylthiouracil, hydrocortisone, and propranolol were initiated to reduce peripheral T4 to T3 conversion. A cortisol of 5 mcg/dL (collected 9:47AM) further supported the use of hydrocortisone. Following a normal Cosyntropin stimulation test, hydrocortisone was discontinued. Her symptoms improved but hypothyroidism developed 68 days after pembrolizumab initiation. Propylthiouracil was discontinued; levothyroxine was started. Her TFTs ultimately normalized.

Beta blockers are the mainstay of treatment of the hyperthyroid phase of PD-1 inhibitor-related thyroiditis, though case reports have described use of glucocorticoids, anti-thyroid drugs and iodine.2 -4 In our patient, severe thyrotoxicosis was not responsive to beta blockers. Consideration of additional therapies is reasonable in these cases.

References:

1. Puzanov I, Diab A, Abdallah K, Bingham CO 3rd, Brogdon C, Dadu R, Hamad L, Kim S, Lacouture ME, LeBoeuf NR, Lenihan D, Onofrei C, Shannon V, Sharma R, Silk AW, Skondra D, Suarez-Almazor ME, Wang Y, Wiley K, Kaufman HL, Ernstoff MS; Society for Immunotherapy of Cancer Toxicity Management Working Group. Managing toxicities associated with immune checkpoint inhibitors: consensus recommendations from the Society for Immunotherapy of Cancer (SITC) Toxicity Management Working Group. J Immunother Cancer. 2017 Nov 21;5(1):95.

2. de Filette J, Andreescu CE, Cools F, Bravenboer B, Velkeniers B. A Systematic Review and Meta-Analysis of Endocrine-Related Adverse Events Associated with Immune Checkpoint Inhibitors. Horm Metab Res. 2019 Mar;51(3):145-156.

3. Tan MH, Iyengar R, Mizokami-Stout K, Yentz S, MacEachern MP, Shen LY, Redman B, Gianchandani R. Spectrum of immune checkpoint inhibitors-induced endocrinopathies in cancer patients: a scoping review of case reports. Clin Diabetes Endocrinol. 2019 Jan 22;5:1.
SUN-718 Reciprocal Regulation of miR-375 and ICER in Pancreatic Beta Cells
Authors: Frias Stephanye , Nielsen Ryan , Perez Isis , Garcia Jesse , Keller David M
Published: May 2020

MicroRNA-375 (miR-375) is overexpressed in people with type 2 diabetes (T2D) and has been linked to decreased insulin secretion and beta cell proliferation. Investigation into the transcription factor inducible cAMP early repressor (ICER) as an intermediate regulator of miR-375 was proposed because both are regulated by the cAMP pathway. This overexpression of miR-375 in T2D led us to hypothesize that beta cells with elevated and reduced levels of miR-375 will result in decreased and increased glucose-stimulated insulin secretion (GSIS), respectively. Results showed that when miR-375 was overexpressed, GSIS decreased by 61% when compared to a control in 25 mM glucose. Results showed that when miR-375 was inhibited, GSIS increased 6% when compared to a control in 25 mM glucose. In human islets, we found that inhibiting miR-375 led to an average 19% increase in GSIS, though due to the variability of human tissue these data were not significant (N=5). To investigate ICER’s binding affinity to the miR-375 promoter, a luciferase reporter assay was conducted. HEK-293 (human embryonic kidney) cells that were transfected with a luciferase reporter plasmid containing a cAMP recognition element (CRE) and a plasmid driving the overexpression of ICER had a 75% decrease when compared to our control (P<0.05). When transiently-expressed ICER was knocked down via siRNA, promoter activity increased by 13.1-fold (P< 0.05). Using a chromatin immunoprecipitation assay we found that an ICER antibody pulled down the rat miR-375 promoter an average of 13-fold compared with a control antibody (N=2). Additionally, because of a sequence alignment showing possible binding of miR-375 to the human ICER transcript we hypothesize that the two are in a negative feedback loop and can regulate each other’s expression. To investigate the double negative feedback loop a plasmid was constructed containing the GFP reporter gene and either the human or rodent ICER 3’UTR predicted miR-375 binding site. The GFP reporter assay was conducted to determine if miR-375 binds to ICER’s microRNA recognition element (MRE) in a species-specific way. In our GFP reporter experiment, data shows there is a 50% reporter gene decrease between our negative control and the human ICER MRE (N=4, P=0.017). Understanding microRNA gene regulation in the pancreas may have important implications for patients with T2D. MiR-375 may have the ability to interact with human ICER in a double negative feedback loop in the cAMP second messenger pathway, which will further clarify cellular mechanisms to potentially improve T2D drugs.
SAT-253 Long-Term Management and Successful Pregnancy of a Patient with a TSH Secreting Macroadenoma Treated with Octreotide
Authors: de Almeida Tobias Skrebsky , Salla Rafaela Fenalti , Casagrande Alessandra , Costenaro Fabíola , Czepielewski Mauro Antonio
Published: May 2020

Introduction: TSH-secreting pituitary adenomas (TSHomas) are the rarest form of pituitary tumors. Transsphenoidal surgery is usually the treatment of choice, although somatostatin analogs (SSAs) are a reasonable and effective option. Pregnancy in the setting of TSHomas is an even rarer situation, scarcely reported in the literature. We report the long-term management of a TSHoma treated with octreotide who developed a successful pregnancy.

Case Report: A 16 year-old girl was diagnosed in 2003 with a TSHoma after presenting with goiter, weight loss, tremors and headache. Laboratory tests showed central hyperthyroidism: TSH 2,78 uUI/ml (0,27-4,02); T4 22,4 ng/dl (4,8-12,7); T3 430 ng/dl (72-170) and pituitary MRI showed a 2 cm adenoma. TRH test showed a blunted response, and TSH did not suppress after T3 test, with hormonal values returning to normal range after octreotide administration. Since 2003 the patient have been treated with Octreotide LAR 20 mg. At 34 years-old she expressed her willingness to become pregnant. At this time, hyperthyroidism was controlled (TSH 1.79; T4 12; T3 181) and the pituitary adenoma was smaller (1.2 cm) while on octreotide LAR 20 mg every 8 weeks. Before conceiving, she did a visual field test that was normal and measured α-subunit (αSU), which was slightly increased (0.73 ug/l, upper limit of normal [ULN] < 0.6 ug/l). After 3 months, she successfully conceived. During first trimester, thyroid function remained controlled. The patient was asymptomatic and the fetus was developing as expected. From 18 weeks on, T3 started to increase (T3 227 ng/dl– ULN 200 ng/dl) with normal T4 and FT4 and without symptoms or fetal repercussion. Alpha-subunit increased to 9.5 ug/l. Throughout pregnancy, octreotide was administered in the same pre-pregnancy dosage. At 37 weeks, αSU was 272.314 ug/l after 1:100 dilution (ULN < 604 ug/;) and HCG was 38.316. The patient developed gestational diabetes mellitus that was managed with diet counseling. Spontaneous delivery occurred at 39 weeks, birth weight was 3160g, APGAR 9/10. Newborn thyroid function was normal. Three months after delivery, the patient complained of hand tremors and hair loss. New laboratory tests revealed TSH 6,7 uUI/ml (ULN <4.5); T4 12,9 (ULN <12); T4L 3,3 (ULN <1.7); T3 247 (ULN <200) and αSU was 513 ug/l (ULN< 0.6). Octreotide LAR 20 mg interval was decreased to every 6 weeks. Currently, ten months after delivery, the patients is asymptomatic and thyroid function is normal.

Conclusion: TSHoma appears to be safely managed throughout pregnancy without the need of stopping octreotide, which seems not to adversely affect outcomes for the mother and the fetus. This case also illustrates the long-term management (16 years) of TSHoma with octreotide with excellent hormonal and structural response.
SAT-284 Musashi Exerts Translational Control Within Anterior Pituitary Cells of the POU1F1 Lineage
Authors: Allensworth Melody Lyn , Odle Angela Katherine , Moreira Ana Rita Silva , Lim Juchan , Banik Jewel , Haney Anessa , Lagasse Alex , Hardy Linda , Byrum Stephanie , Avaritt Nathan , MacNicol Melanie C , Childs Gwen V , MacNicol Angus M
Published: May 2020

The activation of transcription factor Pou1f1 at embryonic day 13 gives rise to the pituitary populations of somatotropes, lactotropes, and thyrotropes and these populations maintain expression of Pou1f1 throughout life. The Musashi family of RNA regulatory proteins is known to regulate stem cell fate by repressing translation of target mRNAs needed for differentiation. Previously our lab has shown that female Lepr-null somatotropes have reduced POU1F1 protein levels but do not have changes in Pou1f1 mRNA expression. Stimulation with leptin increased the POU1F1 protein levels 3-fold, but did not change Pou1f1 mRNA suggesting a post-transcriptional mechanism for leptin’s regulation of Pou1f1. An in silico analysis indicated the presence a number of potential regulatory elements (MBEs) within the Pou1f1 mRNA 3’ UTR, including 8 consensus Musashi binding elements. Interestingly, we found musashi mRNA and protein levels were increased in Lepr-null somatotropes. This suggested that leptin regulates the expression of musashi in somatotrope populations and may be a candidate translational regulator of the Pou1f1 mRNA. We verified that MSI binds directly to the Pou1f1 mRNA 3’ UTR MBEs by EMSA in vitro and exerts translational repression (using reporter mRNA assays in transfected cell populations). Single cell RNA sequencing of pituitary cells from control male and female mice indicates that MSI and Pou1f1 mRNAs are co-expressed in somatotropes, lactotropes as well as thyrotropes. Immunocytochemical analyses confirmed that Musashi protein is present in mixed and purified somatotrope populations. Furthermore, immunoprecipitation with Musashi1 antibody showed a 5-fold enrichment of Pou1f1 mRNA in control female mouse pituitaries. These findings point to a critical in vivo role for Musashi-mediated mRNA translational regulation within the Pou1f1 lineage and specifically in the control of somatotrope maturation and response to metabolic cues.