bluuebunny/crossref_metadata_2025_split huggingface dataset:
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

Abstract
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] &lt; 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 &lt; 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 &lt;4.5); T4 12,9 (ULN &lt;12); T4L 3,3 (ULN &lt;1.7); T3 247 (ULN &lt;200) and αSU was 513 ug/l (ULN&lt; 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

Abstract
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.
SUN-500 Viral-Induced Autoimmune Hyperthyroidism in an Adult Patient Without Established Thyroid Disease
Authors: Das Dhriti , Linares Andrea , Bertolotti Cesar , Cortes Anais 
Published: May 2020

Abstract
Introduction: Subacute thyroiditis is a self-limited inflammation of the thyroid associated with recent upper respiratory tract viral infection. Graves’ disease has also been associated with viral illness.
Clinical Case:A 55-year-old female presented to the emergency department complaining of sore throat, cough, and shortness of breath. She also had fatigue, dyspnea on exertion, palpitations, and a family member who recently had bronchitis. She denied chest pain, weight changes, temperature intolerance, constipation, or diarrhea. She had never had similar symptoms before.
On initial evaluation, the patient was febrile at 101.2 °F, tachycardic at 156 beats per minute (bpm), and tachypneic at 33 breaths per minute. She was thin and her thyroid gland was tender upon palpation. She had eyelid lag, her skin was warm, and she was diaphoretic. Chest x-ray showed increased interstitial lung markings bilaterally. CBC showed anemia with hemoglobin of 9.7 g/dL (n&lt;12 g/dL). Lactic acid was elevated to 2.00 mmol/L (n&lt;1.9 mmol/L). D-dimer was 3020 ng/mL (n&lt;230 ng/mL) and BNP was 961 pg/mL (n&lt;100 pg/mL). An electrocardiogram showed sinus tachycardia at 140 bpm. Blood, sputum, and urine cultures were drawn, as were studies for viral respiratory pathogens. CT angiography of the chest and bilateral lower extremity venous ultrasound were ordered to rule out thromboembolism.
A point-of-care echocardiogram showed reduced ejection fraction of 20%. Thyroid function tests revealed TSH &lt; 0.03 mIU/mL (range 0.5-5.0 mIU/L), free T4 of 4.5 ng/dL (n&lt;2.15 ng/dL), and T3 251 ng/dL (n&lt;200 ng/dL). Patient was started on an esmolol drip for heart rate control. CT angiogram of the chest was negative for thromboembolism but revealed a bilaterally enlarged thyroid gland with multiple small nodules. RNA for Respiratory Syncytial Virus (RSV) type A was detected by PCR. A thyroid ultrasound was done and revealed heterogenous echotexture with increased blast flow.
Thyroid antibody studies revealed thyrotropin receptor antibody of 26.5 IU/L (n&lt;1.75 IU/L), thyroid-stimulating immunoglobulin 19.40 IU/L (n&lt;0.55 IU/L), thyroglobulin antibody 235.6 IU/mL (n&lt;0.9 IU/mL), and thyroid peroxidase antibody 11 IU/mL (range 0-34 IU/mL). Patient was started on methimazole 30 mg daily. A formal echocardiogram showed preserved ejection fraction of 50-55%. She was transitioned to oral propranolol. Patient’s shortness of breath and cough resolved, and she was discharged on methimazole 10 mg daily.
Conclusion:This case emphasizes the importance of measuring thyrotropin receptor antibodies in confirming Graves’ disease in a patient presenting with upper respiratory viral illness and supports the idea of viral-induced autoimmune thyroid disease.
MON-374 Management of 1,25-dihydroxyvitamin D (1,25-OHD) Mediated Hypercalcemia of Unknown Etiology
Authors: Menon Sruthi , Agarwal Swashti , Paul David L 
Published: May 2020

Abstract
Background: We describe the diagnostic dilemma and treatment challenges faced in a rare case of 1,25-OHD mediated hypercalcemia. Clinical Case: A 13 year old boy was admitted with severe hypercalcemia (calcium 15.5 mg/dl) in the setting of a non-specific rash, malaise, pancytopenia and acute kidney injury. He was incidentally also noted to have hypogammaglobulinemia a few months prior to presentation. Blood tests were suggestive of hypercalcemia mediated by 1,25-OHD (level &gt;200 pg/ml; ref: 30-83 pg/ml). 25-hydroxy vitamin D was normal (29 ng/ml) and PTH was appropriately suppressed (&lt;4 pg/ml). Workup for various etiologies including infectious, rheumatologic and oncologic diseases associated with ectopic production of 1,25-OHD was initiated. Hypercalcemia was initially managed with hyperhydration, furosemide and calcitonin. However after a brief period of improvement in hypercalcemia, levels started to rise again despite increasing calcitonin dose and frequency (secondary to tachyphylaxis). Kidney function also started to worsen. Extrarenal 1-alpha hydroxylase activity can be suppressed using steroid therapy, however it was contraindicated at the time given that malignancy and other infectious etiologies had not been excluded. At that point, a trial of zoledronic acid was done with subsequent resolution of hypercalcemia. However, this was only temporary given that the underlying disease process driving the production of 1,25-OHD had not been addressed. Various other treatment options were considered including a repeat dose of bisphosphonate, denosumab, ketoconazole and hydroxychloroquine, but since hypercalcemia was only mild, supportive measures were continued. An extensive workup revealed splenomegaly, lymphadenopathy, bilateral renomegaly and bilateral pulmonary ground glass opacities and nodules. Infectious workup and bone marrow biopsy were negative. Although non-specific, an elevated angiotensin converting enzyme (ACE) level (359 units/L; ref: 13-100 units/L) suggested an underlying granulomatous process. Renal biopsy showed non-caseating granulomas. The most likely unifying diagnosis was thought to be sarcoidosis, however presence of hypogammaglobinemia also raised suspicion for a granulomatous form of Common Variable Immunodeficiency (CVID) which, albeit rare, has previously been reported to be associated with hypercalcemia. Patient was started on empiric treatment with steroids and intravenous immunoglobulin following which calcium, 1,25-OHD and ACE levels normalized. Conclusion: Granulomatous form of CVID is a rare entity but should be considered in a patient presenting with 1,25-OHD mediated hypercalcemia and hypogammaglobulinemia. Treatment of this entity during an ongoing diagnostic workup can be challenging, particularly if the use of steroids is contraindicated due to potential interference with diagnostic investigations.
SUN-627 A Test for Variation in Insulin Concentrations at the Wilford Hall Ambulatory and Surgical Center
Authors: Jenkins Craig , Lovett Dennis P , Brinkman Joseph , Tate Joshua , Gibbons Thomas , Beckman Derrick , Jenkins Lydia , Wardian Jana 
Published: May 2020

Abstract
Background
Wilford Hall Ambulatory and Surgical Center is the Department of Defense’s largest outpatient ambulatory surgical center serving over 55,000 patients, and is the U.S. Air Force’s flagship medical facility for outpatient care.
As with the measurement of any medication concentration or lab value, there is some reasonable expectation that there may be some variability between the reported value and the objective measurement. However, expectations are that variability should be minimal in order to ensure reliable doses of medication. In the case of diabetes management, insulin concentration variability should be kept to a minimum for both its life-saving and stress-mitigating effects. Insulin in the correct doses is lifesaving for type 1 Diabetes, so understandably, the impact of degraded insulin is catastrophic. In both type I and type II diabetes, “diabetes distress” can lead to poor self management and is linked to higher A1C levels. A study published in 2017 testing insulin after receipt from their cold supply chain found shockingly low concentrations of insulin. Recent literature published in the Journal of Diabetes Science and Technology reported that insulin concentrations in randomly tested vials not only failed to meet a pre-established concentration standard per unit of insulin, but also had concerning variability. The prevalence of Diabetes in the Department of Defense population is approaching 20%, making the impact of degraded insulin concerning. There are expectations of variability in any medications prescribed, but the FDA states that the expected insulin concentration should be 95% or greater.
Methods
Overall, 40 vials representing two different types of insulin (20 vials of Novolog and 20 vials of Lantus) were collecting from the military pharmacy and transported to the clinical research laboratory for analysis. Following baseline analysis, half of the vials were stored in refrigerated conditions of 2-8 degrees Celsius; the other half were stored at room temperature according to manufacturer’s directions.
Results
At the laboratory, all vials underwent initial analysis to determine concentration at baseline. The Novolog insulin was found to have a concentration range of 105.1% to 107.7% and the Lantus insulin concentration was 99.0% to 103.9%. Thus, all vials met the minimum concentration of 95 U/ml at time of baseline testing. Vials will be tested weekly to determine if degradation occurs under refrigeration and at room temperature.
Discussion
Given the high cost of insulin and the high impact on the health of the person with diabetes, assurance of a minimum of 95 U/ml must be met. If this is not met, investigation of the cold supply chain should identify the source of the problem and address it. Our study demonstrates that Novolog and Lantus were meeting the minimum concentration upon receipt at the pharmacy.
SUN-912 The Rare Men of Mississippi Complications in the Diagnosis of Multiple Endocrine Neoplasia Type 1
Authors: Rashid Hytham , Clayton Tiarra , Bruckmeier Kurt , Drake Ben 
Published: May 2020

Abstract
Background: Multiple endocrine neoplasia type 1 (MEN1) is a rare, autosomal dominant disorder associated with tumors of the parathyroid glands, pituitary gland, and gastroenteropancreatic cells caused by mutations of the MEN1 tumor-suppressor gene. Thescarcity with which this syndrome is encountered makes diagnosis challenging in rural settings.
Clinical Case: A 34-year-old male presented to the Emergency Department complaining ofintermittent abdominal pain for the past year, that was associated with nausea, vomiting, and diarrhea. Past medical history was significant for hyperparathyroidism treated with parathyroidectomy, nephrolithiasis, and alcohol-induced chronic pancreatitis. Initial laboratory studies revealed elevated corrected calcium (11.5 mg/dL, n:7.6-10.6 mg/dL) with a subsequent elevated parathyroid hormone level (105, n:14-72 pg/mL). CT scan of the abdomen and pelvis revealed fatty liver changes, nonobstructive nephrolithiasis and pancreatic calcifications. Due to his recurrent symptoms, gastroenterology was consulted for esophagogastroduodenoscopy that revealed erosive esophagitis with multiple duodenal ulcers. The patient was started on a high dose Proton Pump Inhibitor IV and treated supportively. His symptoms improved within a few days. Additional studies were obtained including a gastrin level and H. pylori antigen testing that required sending out to an outside laboratory for analysis. He was discharged with close outpatient follow up scheduled, but then was readmitted two days later with recurrent symptoms. The patient was again treated with supportive care, and was able to provide additional family history revealing parathyroid and ulcer disease in both his father and paternal grandmother, which triggered suspicion for multiple endocrine neoplasia type 1. His gastrin level returned, and was found to be elevated (489 pg/mL, n &lt; 100) with a negative H. pylori antigen, supporting the diagnosis of MEN1. Further diagnostic testing was performed, revealing an elevated serum chromogranin A level (117 ng/mL, n &lt; 15) and abnormalities on MEN1 genetic testing. An Octreotide scan was then performed, showing a single intense area of uptake near the caudate lobe of liver. At this time, he was transferred to a tertiary medical center for further evaluation and management.
Conclusion: This case illustrates the significance of suspicion for multiple endocrine neoplasia and the value of a complete history. Additionally, while a serum chromogranin A level can be nonspecific, it can be obtained in an outpatient setting to help differentiate neuroendocrine pathology from other etiologies. Though the symptoms of MEN1 patients can mimic many other disease processes, recognition of symptoms is critical for medical communities to provide swift treatment.
SUN-022 Metformin-Fish Oil Adjunct Therapy Improves apoB-Remnant Lipoprotein and Triglyceride Levels in Women with Polycystic Ovary Syndrome
Authors: Proctor Ethan , Weaver Olivia , Ghosh Mahua , Maximova Katerina , Proctor Spencer , Vine Donna 
Published: May 2020

Abstract
Background: Polycystic ovary syndrome (PCOS) is highly associated with the metabolic syndrome (MetS): obesity, insulin resistance and atherogenic dyslipidemia. Women with PCOS-MetS are at higher risk of developing ischemic cardiovascular disease (CVD) and Type-2 Diabetes. First-line intervention in PCOS-MetS includes targeting diet and lifestyle, and metformin is commonly prescribed to treat insulin resistance, however these interventions have shown limited effectiveness to improve dyslipidemia. At present there are limited safe and efficious options to target atherogenic dyslipidemia in young women with PCOS. Fish oil (FO) and Icosapentyl ethyl supplementation have been shown to reduce fasting TG, apoB and to improve ischemic CVD outcomes. The efficacy of FO or as an adjunct therapy to metformin to improve ApoB-remnant lipemia in PCOS-MetS is unknown. The aim of this pilot study was to determine the effect of metformin, FO and FO-metformin combination treatment on fasting and non-fasting plasma TG and apoB-remnant lipoprotein metabolism in patients with PCOS-MetS.
Methods: Participants diagnosed with PCOS aged 18-30yrs received dietary counselling and were randomly assigned to receive FO (n=8), metformin (n=7) or FO-metformin (n=12) treatment for 12 wks. Plasma lipids (TG and cholesterol), ApoB48 and ApoB100 lipoprotein metabolism were assessed in the fasting and non-fasting state using a standardized high-fat meal test.
Results: At baseline, the fasting plasma TG, ApoB48 and ApoB100 was 238.0 ± 21.0 mg/dL, 9.00 ± 1.12 ug/ml and 290 ± 18.00 mg/dL. FO and FO-metformin decreased fasting plasma TG by 10% and 30% compared to the metformin treatment group (7%). Fasting ApoB48 was reduced 45%, 16% and 19% in FO-metformin, FO and metformin treatment groups, respectively. Non-fasting plasma TG and apoB48 lipoprotein area under the curve were reduced by 30% in the FO-metformin treatment group.
Conclusion: These pilot findings demonstrate FO-metformin adjunct therapy may have greater efficacy to improve atherogenic apoB-dyslipidemia compared to metformin or FO alone in high-risk patients with PCOS-MetS. A larger clinical trial is warranted to determine the long term effects of FO-metformin intervention on apoB-dyslipidemia and atherosclerotic cardiovascular disease indices.
SUN-142 Clinical Characteristics of Patients Diagnosed with Functional Neuroendocrine Tumors Treated at a Tertiary National Referral Center in Mexico
Authors: Enríquez-Román Arlette , Reza-Albarran Alfredo A , Iniguez-Ariza Nicole M 
Published: May 2020

Abstract
Neuroendocrine tumors (NET) represent up to 0.5% of all new cancers and can be functional or non-functional. Epidemiologic data on NET in Mexico is very limited. To delineate the clinical characteristics of patients with functional NET at a tertiary national referral center in Mexico we performed a retrospective cohort study (January 1987-June 2019). The target study population was adults with functional NET with biochemical and histopathological confirmation. Results: 126 patients with functional NET were included in this study. The median follow-up was 47.4 months (IQR 10.8 to 93.7). Most were female (64.3%). The mean age at diagnosis was 46.3 ± 14.48 years. The most frequent insulinomas (59.5%), followed by (12.7%) carcinoid tumors, gastrinomas (11.1%), ACTHomas (10.3%), VIPomas (2.4%) glucagonomas (2.4%) and PPomas (1.6%). Nineteen subjects (15.1%) had genetic syndromes, mainly MEN1 (89.5%); and 8.7% had other neoplasms, most frequently non-functional gastrointestinal (GI) carcinoids (36.3%) and thyroid cancer (18.8%). The median duration of symptoms prior to diagnosis was 24 months (IQR 7.75 to 48). The most common locations were, the GI tract (86.5%), whereas 7.1% were outside the GI tract and 6.4% were of unknown primary origin. Functional NETs outside GI tract were localized primarily in lungs
(66.6%). Functional pancreatic NETs occurred more commonly in the tail (39.6%). 24.6% had locoregional or distant metastasis during follow-up. The most frequent metastatic sites were liver (86.5%), regional lymph nodes (59.8%) and bone (13.5%). The most common treatment was surgery (87.3%, with 13.6% ≥2), followed by 18.3% somatostatin receptor analogues and 11.1% cytotoxic chemotherapy. Most subjects (73%) had complete remission with first line therapy, but 14.1% had recurrence at a median of 50.7 months (IQR 15.4 to 97.6). Subjects with an incomplete remission progressed after a median of 14.85 months (IQR 10 to 38.9). Conclusions: The clinical characteristics of functional NET treated at a tertiary center in Mexico are similar to those in other population and geographic locations described in the literature.