bluuebunny/crossref_metadata_2025_split huggingface dataset:
SUN-420 Spontaneous Changes in TSH Levels After Thyroidectomy During Long-Term Follow-Up
Authors: Grani Giorgio , Ramundo Valeria , Armillotta Michele , Falcone Rosa , Filetti Sebastiano , Durante Cosimo 
Published: May 2020

Abstract
Background. Spontaneous serum TSH variations during levothyroxine replacement therapy and multiple dose changes in athyreotic patients seem to be frequent in clinical practice.
Aim. To describe the rate and extent of spontaneous serum TSH variations in patients after total thyroidectomy for differentiated thyroid cancer (DTC) in real-life practice, and the number of resulting levothyroxine (LT4) dose adjustments.
Methods. Data of DTC patients were prospectively collected at a single referral center between January 2005 and May 2019. TSH and fT4 serum levels, LT4 dose and formulation, and concomitant medications were recorded at 1, 3, and 12 months after primary treatment (surgery ± radioiodine therapy), and then yearly; the data were retrospectively evaluated for this study. Visit at one month was used to tailor LT4 dose and was not considered into the data analysis. Patients with structural evidence of disease or during pregnancy were excluded.
Results. Data of 2883 evaluations (472 patients) were collected; at baseline, the median age was 49.7 years, 73.5% were females. The LT4 formulation administered at baseline were tablets (84.9%), liquid solution (11.4%), or soft-gel capsule (3.7%). Overall, in 27.5% of clinical evaluation with unchanged levothyroxine dose (341/1243), there were meaningful spontaneous TSH variations (defined as delta TSH &gt; 1.5 mcUI/ml) at yearly follow-up visit. It is clinically significant: in 6.6% of visits, overt thyrotoxicosis was recorded. Furthermore, the treating clinicians decided to change the LT4 dose in 37.1% of cases. These figures were not significantly higher in the first years, and a rate above 25% persist even after ten years of follow-up. The median maintenance dose needed was 1.61 (interquartile range [IQR] 1.41-1.92) mcg/Kg/day for tablets, 1.54 (IQR 1.39-1.79) mcg/Kg/day for liquid solution, and 1.46 (IQR 1.23-1.71) mcg/Kg/day for soft-gel capsules. After correction for daily dose, there was no difference in the rate of TSH variations &gt; 1.5 mcUI/ml, or in the absolute value of median delta of TSH between the three formulations. In 20.1% of patients, the LT4 formulation was changed during the follow-up: it was more common in patients with a known gastroenteric disease (OR 1.76, p=0.03).
Conclusions. TSH spontaneous variations and dose adjustments are very common in patients after total thyroidectomy, even during long-term follow-up: wide variations happen in more than 1/4 of all visits, and dose changes are needed in more than 1/3 of all evaluations. We were more inclined to change LT4 formulation in patients with known interference in LT4 absorption: however, no difference in TSH variations was recorded between users of three different formulations, even if soft-gel capsules seem to have a lower maintenance dose.
SAT-490 A Case of Unilateral Exophthalmos Due to Thyroid Orbitopathy and Its Association with Chronic Kidney Disease
Authors: Muammar Ahmad R , khan Adeel A 
Published: May 2020

Abstract
Graves ophthalmopathy(GO)is the most common extra-thyroidal manifestation of Graves’ disease (GD). Most cases of GO are bilateral which may be asymmetric, whereas unilateral ophthalmopathy is less common and has been observed in 9-15% cases. Association between chronic kidney disease and unilateral Grave’s ophthalmopathy in a clinically euthyroid patient is rare. We report a case of a 24-year-old male with no previous history of any chronic medical illnesses who presented with protruded right eye for the past 6 months. He did not have any other visual symptoms or symptoms related to thyroid disease. Laboratory results revealed low TSH, normal free T3 and free T4. TSH receptor antibodies were positive. He also had elevated serum creatinine at 418 umol/L (normal levels 64 - 110 umol/L). US KUB showed bilateral small sized kidneys and increased parenchymal echogenicity suggestive of chronic kidney disease. MRI Head showed features suggestive of unilateral thyroid associated orbitopathy. Patient received 1-week course of oral prednisolone 10 mg per day after which his exophthalmos improved.Case report: A 24 year old male with no previous history of any chronic medical illnesses, presented to the clinic with protruded right eye for the past 6 months that was progressively getting worse. There was no eye pain, visual changes, ophthalmoplegia, dryness or discharge from eye. Patient did not report any other symptoms, Physical examination revealed a comfortable man with protruded right eye, lid retraction, normal eye movements and no signs of orbital cellulitis. Neck examination was significant for a mild diffuse goitre. Laboratory studies were significant for haemoglobin of 12.1 g/dl (normal 13-17 g/dl). He also had elevated serum creatinine at 418 umol/L (normal 64 - 110 umol/L). Serum electrolytes, liver function tests and lipid profile were within normal range. 24 hr urine collection showed 3.08 gm/24 hr proteinuria. Serum TSH was 0.04 mIU/L (normal 0.45 - 4.5 mIU/L), free T4 was 13.8 pmol/L (normal 9 - 20 pmol/L) and free T3 was 4.56 pmol/L (normal 2.89 - 4.88 pmol/L). Thyrotropin Receptor Ab titre was 4.69 IU/L (normal 0.00 - 1.75 IU/L). ANA, ANCA, C3, C4, Anti thyroid peroxidase and Anti GBM antibodies were negative. Screening for hepatitis B, C and HIV was negative US KUB showed bilateral small sized kidneys and increased parenchymal echogenicity suggestive of CKD. MRI Head was remarkable for proptosis of the right eye with increased retro-orbital fat, thickening and T2 hyper-intensity with sparing of the tendinous insertion involving the right inferior, medial, superior and lateral rectus muscles with crowding at the orbital apex. Features were suggestive of unilateral thyroid associated orbitopathy. Patient received 1-week course of oral prednisolone 10 mg per day after which his exophthalmos improved. An association between CKD and GO in a clinically euthyroid patient is rare.
MON-242 A Hidden Thirst: Unmasking of Central Diabetes Insipidus
Authors: Dauterive Ellen , Subauste Jose 
Published: May 2020

Abstract
Introduction:
Central diabetes insipidus (CDI) is a common pathology following traumatic brain injury, intracranial operations, medication use, and some infections. This case highlights how CDI can be unmasked when access to free water is restricted.
Case Description:
A 50 yo AAM with history of Down syndrome, hydrocephalus with ventriculo-atrial shunt, and seizure disorder treated with phenytoin, was brought in from home after three back-to-back seizures. EMS was called and intubated the patient in the field. Medical history was significant for ventriculo-peritonal shunt placed shortly after birth with revisions in 2011 and 2016. Revision in 2016 was complicated by infection with klebsiella pneumoniae. He was admitted to NSICU. Shunt evaluation showed no abnormality or obstruction. Lab work on admission at 5 am was significant for low potassium and sodium was normal. Patient was stabilized and extubated later that day. Repeat labs, at 4 pm, showed a sodium of 155 mEq/L with a normal potassium. Urine output was reviewed and significant for greater than 400 cc’s per hour for at least 2 hours. Urine osmoles (264 mOsm/kg, n 50-1200) and serum osmoles (314 mOsm/kg, n 280-295) were consistent with diabetes insipidus (DI). His IV fluid intake during this time was 3 liters bolused on admission followed by continuous fluids at 125 cc’s per hour. On review of systems, patient admitted to polydipsia and polyuria throughout the day for last several years. He reported urinating 2-3 times at night. During an admission 3 years prior for ventriculo-peritoneal shunt revision, serum sodium had risen to 159 mEq/L following his surgery and returned to normal prior to discharge. MRI pituitary during admission was negative for pituitary abnormality. To treat as well as differentiate central versus nephrogenic DI, desmopressin 1mcg IV was given. The patient was allowed to drink to thirst. Urine osmolarity increased from 159 mOsm/kg to 494 mOsm/kg after 2 hours and serum sodium slowly trended down. His urine output and thirst decreased with continued administration of desmopressin. He was discharged on a maintenance dose of 0.1 mg desmopressin twice a day. On follow up in clinic, his sodium has been maintained between 140-145.
Discussion:
This patient with CDI was compensating with large fluid intake daily as an outpatient for at least three years. His risk factors included phenytoin use as well as previous VP shunt occlusion complicated by infection which has been reported to contribute to CDI in other case reports. This case highlighted how CDI can be unmasked when a patient loses access to free water such as with altered mental status or intubation for surgery.
References
1.Central diabetes insipidus: A complication of ventriculoperitoneal shunt malfunction during pregnancy. Goolsby, Lynn et al. American Journal of Obstetrics & Gynecology, Volume 174, Issue 5, 1655-7
SAT-400 Pregnancy Outcome in Women with Hypoparathyroidism:Aswedishpopulation-Based Cohort Study
Authors: Bjornsdottir Sigridur , Clarke Bart Lyman , Makitie Outi , Spelman Tim , Kampe Olle 
Published: May 2020

Abstract
Context: The majority of patients with hypoparathyroidism (HypoPT) are women. It is not known whether the presence of hypoparathyroidism influences the pregnancy outcomes. Sweden has excellent conditions for research in this area, with high-quality population-based registers covering essentially all inpatient care and birth records. In this study, data were linked from the Swedish National Patient Register and Swedish Medical Birth Register to examine the potential influence of maternal hypoPT on the number of childbirths and various pregnancy outcomes.
Design and Setting: Population-based cohort study in Sweden.
Patients: Through the Swedish National Patient Register and the Total Population Register, we identified 1267 women with HypoPT and 12 670 age-matched controls who gave birth between 1997 and 2016.
Results: There was no significant difference in mean age at delivery for women with HypoPT (32 (SD, 5.2)) years and controls (32.5 (5.0)). There were significantly more women with HypoPT who smoked at baseline (p= 0.007) and within 3 months of pregnancy (p=0.022) compared to controls. Significantly more women with HypoPT had part time work or were not working during pregnancy compared to controls (p = 0.002). The mean number of infants per woman was 0.30 (SD, 0.62) in the HypoPT group and 0.33 (SD, 0.60) in the control group (p=0.644). Compared with the control group, the risk of elective cesarean section was higher in the HypoPT group (p=0.002). However, there was no difference in the proportion of women undergoing an acute cesarean section between cases and controls (p=0.754). The mean pregnancy duration in women with HypoPT was 38.87 (2.11) weeks compared to 39.23 (2.04) weeks for the controls (p= 0.001). Infants born to mothers with HypoPT were significantly shorter (p=0.016), but no difference was seen in weight or head circumference compared to infants born to controls. No difference was observed in prevalence of small- or large-for gestational age compared to controls. There were no differences between groups with respect to infant sex or Apgar scores at 1, 5 and 10 min, congenital malformations or stillbirth. There was furthermore no difference in pain medication use by mothers during delivery between the groups (p=0,733).
Conclusion: The majority of women with HypoPT had normal pregnancy outcomes, and the overall risks must be considered to be low. Still, our findings are of importance for antenatal counseling in women with HypoPT as their risk for elective cesarean section was significantly higher compared with controls. Their children were shorter and the higher rate of smoking among HypoPT women may be an additional risk factor.
SAT-172 FDG PET/CT in Benign vs. Malignant Adrenocortical Tumors
Authors: He Xin , Caoili Elaine M , Avram Anca Mihaela , Miller Barbra S , Else Tobias 
Published: May 2020

Abstract
18F-fluorodeoxyglucose positron emission tomography computed tomography (FDG PET/CT) is frequently used for evaluation of indeterminate adrenal nodules.
The objective of this study was to evaluate the diagnostic performance of FDG PET/CT in distinguishing benign adrenocortical adenomas (ACA) from adrenocortical carcinoma (ACC).
We identified 139 patients in our institution who completed both FDG PET/CT and adrenal biopsy or adrenalectomy from 2001 to 2019 using the institutional Electronic Medical Record Search Engine (EMERSE). Patients with adrenal pathology revealing non-adrenocortical tumors were excluded. The imaging characteristics of ACAs were compared with ACCs.
Sixteen patients with ACAs and 50 patients with ACC were identified; of the latter, 30 were excluded, because FDG PET/CT imaging was completed after adrenalectomy. The average age of the ACC vs. ACA group was 48±14 and 52±17 years, respectively, with a gender composition of 35% and 25% men, respectively. All 20 patients with ACC had FDG avid lesions, defined by imaging report and increased ratio of adrenal tumor maximum standardized uptake value (SUVmax) to hepatic parenchymal average SUV (SUVmean) of greater than 2.5. Among those with ACAs, 11 had positive, 1 had mildly positive, 3 had indeterminate, and 1 had negative FDG PET/CT findings according to the report. Ratio of adrenal SUVmax to hepatic SUVmean was greater in ACC compared to ACA (13.5 versus 1.6, respectively, p = 0.13), but did not reach statistical significance, likely due to the small sample size and unavailability of SUV ratios for all lesions.
Our study identified a large number of ACAs that were deemed FDG avid but without adrenal SUVmax to hepatic SUVmean ratio of greater than 2.5. Although the sensitivity, and therefore the negative predictive value, of FDG PET/CT scan is excellent for the diagnosis of ACC, our data does not allow for the calculation of specificity. This is due to the selection bias inherent in our patient population referred for evaluation of unusual adrenal masses, and the fact that ACAs with negative FDG PET/CT often do not undergo surgery or biopsy, and therefore pathology results are not available. Despite this limitation, our findings show that calculation of the ratio of adrenal SUVmax to hepatic SUVmean, rather than lesion SUVmax alone, helps for characterization of adrenal lesions as malignant vs. benign, and that a negative FDG PET/CT is valuable in excluding ACC.
MON-489 Comorbidity of Primary Hyperparathyroidism and Papillary Thyroid Cancer. A Single Center Outcomes
Authors: Papadopoulou Nektaria , Papanikolaou Eleni , Chrousos George P , Karvounis Evangelos 
Published: May 2020

Abstract
Introduction Concurrence of primary hyperparathyroidism in patients with thyroid disease has been previously reported by several studies. However, comorbidity between primary hyperparathyroidism (PHPT) and papillary thyroid cancer (PTC) has been sparsely described by previous, mostly case-series studies, and is considered rare. Since pathophysiological mechanisms behind the two diseases are supposed to be different, any link between these diseases has not been explained as yet. Hypothesis: Aim of the study was to investigate the possible concurrence for the two diseases in people who underwent thyroidectomy for suspected thyroid nodules. Methodology Retrospective observational study that included 2913 patients (24% men with mean age 49.82 yrs, 76% women mean aged 47.73 yrs), who underwent total thyroidectomy during the last 13 years (2005-2018) at the Department of Endocrine Surgery, Euroclinic Hospital, in Greece. The patient-groups were categorised according to histopathology criteria of the thyroid and/ or parathyroid glands (in case of comorbidity of primary hyperparathyroidism (PHPT) diagnosed prior to surgery). Results: Statistical analysis revealed benign histopathology findings in 1945 patients (64%), while papillary cancer was found in 978 (32%). Among patients with non-malignancy, 16 (11 women/5 men) had PHPT, but in those with papillary cancer, PHPT was diagnosed in 38 (33 women/5 men) individuals. The relative risk for the concurrence of PHPT and PTC was 2.033 (95%CI 1.69 to 2.43, P&lt;0.0001). Age groups between 30 and 60 yrs were associated with the highest relative frequency of comorbidity (82%). A significant positive correlation was observed between less aggressive PTC histopathology findings and PHPT concurrence (P&lt;0.0001). Interestingly, no patient with PTC and PHPT had either capsular invasion or regional/distant metastases. Moreover, most patients with comorbidity (92%) had a tumour diameter smaller (mean 6.3 mm) than those with PTC alone (mean 18 mm). Conclusions: Our study found that the comorbidity between primary hyperparathyroidism and PTC may be considered as possible. Endocrinologist’s diagnostic approach may add serum calcium and parathormone levels in patients who undergo evaluation for suspected thyroid nodules. Patients with PHPT and PTC had mostly microcarcinomas, and histopathology findings showed a less aggressive PTC pattern. Further large cohorts as well as genetic studies, are needed to duplicate our results and further highlight possible common pathogenetic pathways behind PHPT and PTC concurrence.
SUN-493 A “Curve Ball” in the Management of an Infertile Hyperthyroid Patient
Authors: Lessard Kimberly K , Miller Jeffrey L , Arzeno Luis 
Published: May 2020

Abstract
Introduction: We present the case of a young female patient referred for hyperthyroidism with persistently detectable TSH despite elevated free thyroxine (FT4) levels which, interestingly, failed to normalize following anti-thyroidal treatment. Further testing elucidated the underlying causation for detectable TSH in presence of hyperthyroxinemia to be due to interfering substances in the thyroid function assays.
Case: A 35-year-old female is evaluated for hyperthyroidism discovered in preparation for embryo transfer. History includes transient hyperthyroidism two years ago while undergoing in vitro fertilization. Prior workup included negative antibodies and nuclear uptake scan revealing a right-sided autonomously functioning thyroid nodule with 24-hour uptake of 40.7%. She was briefly treated with PTU in first trimester and lost to follow-up. While once again undergoing fertility treatment with clomiphene, the patient developed tremor and heat intolerance. She was found to have TSH 0.3 (0.45-4.12 mU/L) and analog FT4 of 6.4 (0.8-1.8 ng/dL). She denied use of OTC supplements. PTU 50 mg twice daily was initiated with minimal improvement with TSH 0.7 mU/L, FT4 3.7 ng/dL. On evaluation, slight tremor and mild thyroid enlargement were noted. Our differential expanded to include TSH-secreting pituitary adenoma, thyroid hormone resistance (no family history), and assay interference. Both MRI pituitary and an alpha-subunit level (0.36) were normal. Symptoms improved gradually with repeat TSH 1.79 mU/L, FT4 2.4 ng/DL by standard analog methods. We suspected ‘assay interference’ for which FT4 via direct equilibrium dialysis was obtained and was indeed normal at 0.76 ng/dL. Further lab testing verified interference in both in the standard TSH and FT4 assays presumed secondary to heterophile antibodies.
Discussion: Interpretation of thyroid studies discordant with the clinical picture or incongruent with each other requires understanding of thyroid physiology and the intricacies of commonly utilized assays. The differential of elevated thyroxine levels with detectable/normal TSH rests between thyroid hormone resistance syndromes, TSH secreting pituitary tumors and interfering substances in the assay. Most commercially available TSH assays are based on a ‘sandwich’ assay which is notoriously interfered with by heterophile antibodies and excess biotin. Determination of FT4 is also challenging as the assay must detect very low concentrations of free hormone relative to excess of protein-bound analyte. When in question, it is important consider utilization of laboratory expertise and retesting by alternative assays.
OR15-03 High Prevalence of Gene Variants in Boys of Prepubertal Age with Clinical Suspicion of Central Hypogonadism and Low AMH
Authors: Brunello Franco , Sansó E Gabriela , Scaglia Paula , Azcoiti María Esnaola , Berenstein Ariel , Izquierdo Agustín , Bedecarrás Patricia , Martí Marcelo , Ropelato M Gabriela , Rey Rodolfo Alberto , Grinspon Romina , Freire Analía 
Published: May 2020

Abstract
Introduction: In boys of prepubertal age, the diagnosis of central hypogonadism may be difficult to ascertain since gonadotropins and testosterone are normally low. Sertoli cell markers, like AMH and inhibin B, may be useful. In recent years, with the development of next generation sequencing (NGS) technology, the number of genes associated with central hypogonadism has had an exponential increase. However, even with these advanced techniques, the gene variants with potential pathogenicity can be found at present in only 30-50% of the patients. Hypothesis of the study: Low serum AMH is an appropriate screening biomarker to select patients for NGS, in order to make a genetic diagnosis in boys of prepubertal age with suspected central hypogonadism. Patients and methods: All patients aged 1-10 yr referred between 2001 and 2018 with clinical suspicion of central hypogonadism (micropenis and cryptorchidism and/or microorchidism), with low serum AMH (&lt;10th centile) were included. Serum AMH was determined by ELISA (Beckman-Coulter), and LH, FSH and testosterone (T) by ECLIA (Roche). NGS was performed with the TruSight™ One Sequencing Panel in a NextSeq® 500 sequencer (Illumina). Results are expressed as medians (range). Results: 13 patients were included. Age at first visit was 4.4 (0.1-9.2) yr. Cryptorchidism was present in all of them, micropenis in 10 and microorchidism in 11. Orchiopexy was required in 11 boys and the other 2 responded to hCG treatment. 4 patients had olfactory disturbances, 1 had sensory deafness and 1 had piebaldism. 2 patients had a family history of olfactory disturbances and/or central hypogonadism. 7 patients could be followed up to pubertal age, and the diagnosis of central hypogonadism was clinically confirmed. At age 6.1 yr (1.2-10), AMH was 159 pmol/L (65-363), LH was &lt;0.1 IU/L in all, FSH was 0.61 IU/L (&lt;0.1-1.9). 17 variants in 9 genes associated with central hypogonadism were found in 10 of 13 patients. 5 boys had 1 gene variant, while 4 had 2 gene variants and 1 had 3 gene variants indicating probable oligogenicity, in the following genes: FGFR1 (n:4), CHD7 (n:3), PROKR2 (n:2), SOX10 (n:2), AXL (n:2), HS6ST1 (n:1), AMHR2 (n:1), NSMF (n:1), DCC (n:1). Conclusion: A high prevalence of gene variants was found in boys of prepubertal age with a suspicion of central hypogonadism based on micropenis and cryptorchidism and/or microorchidism with low serum AMH.