bluuebunny/crossref_metadata_2025_split huggingface dataset:
12238 A Case Of Drug-induced Vasculitis
Authors: Javier Christian , Horani Mohamad Hosam 
Published: October 2024

Abstract
Disclosure: C. Javier: None. M.H. Horani: None.
Title: A Case of Drug-Induced VasculitisChristian Javier, DOMohamad Horani, MD Introduction: Graves’ disease is commonly managed with thionamides. These have rare but serious complications of drug-induced lupus-like syndrome and vasculitis. In patients who present with rheumatologic and inflammatory findings, it is important to consider the possibility of these complications . Case Presentation: We present a 30-year-old female with Graves disease, asthma, and hypertension with concerns for cough, body aches, fatigue, bilateral flank pain, erythema, itching and burning of the hands, in the setting of recent spontaneous miscarriage. She was diagnosed with Graves’ nearly 2 years ago and was started on methimazole, but discontinued due to adverse effects of the medication. She was then started on PTU. The patient had a seizure, and head CT revealed a left-sided 4 cm brain mass in the left frontal lobe. The patient was admitted to the ICU, intubated, and started on IV Decadron. Further imaging showed multiple enlarged lymph nodes in the axilla, mediastinum, and hilum. Her brain mass was biopsied showing acute inflammation with early acute necrosis and multifocal fibrinous vascular necrosis, which has been reported in ANCA vasculitis. She had undetectable TSH (0.35-5.0) and free T4 of 1.54 (4.87-11.72). She was also found to have proteinuria and AKI. At this point, PTU-induced vasculitis and drug-induced lupus were suspected and PTU was discontinued. She was found to have low complement levels (C3 40, C4 6.1), elevated p-ANCA (&gt;1:1280), ANA (1:640), anti-histone IgG (2.3) dsDNA (1:160), SSB La antibodies (70), anti-Smith antibodies (319), anti-RNP antibodies (146). Renal biopsy is pending. After discontinuation of PTU and administration of IV steroids, her symptoms largely resolved and she was extubated and stable for discharge. Conclusion: In patients being treated for Graves’ disease with PTU, there are rare but life-threatening complications associated with this medication including lupus-like state or vasculitis with elevated ANCA antibodies. Common presenting symptoms of drug-induced vasculitis include fever, joint pains, myalgias, skin lesions, glomerulonephritis, cerebral angiitis, and pulmonary hemorrhage. The onset of vasculitis can occur at any time after starting medication, with one study showing an average onset of 36 months after initiation of therapy. Other case reports have demonstrated positive serologies for ANA and anti DS-DNA antibodies in those with PTU-induced lupus. Drug induced lupus can also occur in patients taking PTU, with kidney and CNS involvement being more uncommon. In those with p-ANCA associated vasculitis secondary to PTU, anti-GBM, antiphospholipid, and antinuclear antibodies can also be present.
Presentation: 6/1/2024
8673 Exploring A Case Study On Navigating Complexities In Endocrine Health And Reproductive Challenges
Authors: Yumna Rizvi Syeda , Villanueva Erika 
Published: October 2024

Abstract
Disclosure: S.Y. Rizvi: None. E. Villanueva: None.
Introduction: Polycystic ovary syndrome (PCOS) is a common endocrine disorder affecting many reproductive-age women, characterized by irregular menstrual cycles, hirsutism, and challenges with fertility. In this case study, we delve into the medical history of a 24-year-old female presenting with PCOS-related symptoms, hirsutism, and infertility, unraveling the multifaceted aspects of her healthcare journey. Case Description: This patient's diagnostic path began when she received an initial diagnosis of PCOS in her home country due to irregular menstrual periods and clinical signs of hirsutism. Her treatment included metformin, but it was interrupted when she relocated to the United States. Upon her arrival in the U.S., her medical course took an unexpected turn as further evaluations revealed elevated salivary cortisol (++), and a 24-hour urine free cortisol recorded 94.2 mcg (normal 4-50 mcg), indicating hypercortisolism. DHEAS: 730 mcg/dl (normal 18-390 mcg/dl), 17-hydroxyprogesterone: 508 (pre-midluteal: 431), free testosterone: 13 pg/ml (normal 0.1-6.4 pg/ml), with normal CBC, TSH, prolactin, and TPO. CT scan showed large 4.8 cm left adrenal mass. These findings indicated adrenal Cushing's syndrome, leading to referral to a tertiary care hospital's endocrine surgeon. Two months post-adrenalectomy, successful removal of the adrenal mass left the patient with relative adrenal insufficiency. Hydrocortisone replacement therapy was initiated, addressing Cushing's syndrome and revealing a potential factor contributing to infertility. Postoperatively, the patient entered the first trimester unexpectedly, complicating her case. Ensuring proper hydrocortisone levels became crucial for her well-being and the fetus, prompting a collaborative approach with obstetricians and maternal-fetal medicine specialists for optimal pregnancy care. Despite ongoing PCOS effects, including hirsutism, treatment options were limited by pregnancy constraints, deferring Aldactone due to its contraindication during pregnancy. Continuous monitoring included hormonal assessments, metabolic panels, and thyroid tests, aiming to balance adrenal insufficiency, PCOS symptoms, and a healthy pregnancy. Conclusion: This case emphasizes challenges in differentiating PCOS from adrenal Cushing's due to overlapping symptoms. Despite classic symptoms, the initial PCOS misdiagnosis highlights the need for vigilance and comprehensive diagnostics. Complex cases underscore the importance of individualized management and interdisciplinary collaboration. Positive outcomes in complex endocrine disorders and pregnancy are attainable through accurate diagnoses and tailored treatments. The case underscores the critical importance of meticulous evaluation for successful outcomes in challenging medical scenarios.
Presentation: 6/3/2024
6784 A Case of Euthyroid Hyperthyroxinemia due to Thyroid Binding Globulin Excess Syndrome
Authors: Iyer A S , Barghouthi N , Haider A 
Published: October 2024

Abstract
Disclosure: A.S. Iyer: None.
Background: Congenital thyroid binding globulin (TBG) excess is a rare phenomenon associated with elevated serum total T3 and total T4 concentrations but normal serum concentrations of free thyroid hormones, with clinically euthyroid patients. While TBG excess can be caused by pregnancy, estrogen-secreting tumors, and estrogen therapy, congenital TBG excess follows an X-linked pattern, with hemizygous males most affected, and heterozygous females showing a spectrum of disease due to random inactivation of one X chromosome. Clinical Case: A 39-year-old Caucasian female presented as a referral from the Gastroenterology clinic due to concern for thyroid resistance syndrome. Symptoms included chronic constipation (improving with Miralax®), gradual weight gain of 8 pounds in one year, fatigue, and palpitations. She reported that her total thyroid hormone levels have always been elevated, with other thyroid labs remaining within normal limits, along with family history of similar labs noted in her two sons, father, and paternal grandmother. Upon initial encounter, TSH was 1.637 (0.430-3.550 uIU/mL), total T4 15.4 (4.8-11.7 ug/dL), total T3 231 (80-200 ng/dL), free T4 0.97 (0.70-1.25 ng/dL), free T3 3.2 (1.7-3.7 pg/mL), and albumin 4.2 (3.5-5.0 g/dL). The patient was not on oral contraceptive pills and she denied any pregnancies in the last three years. Thyroid ultrasound showed a normal-appearing homogeneous thyroid gland with a small cyst with colloid and no cervical lymphadenopathy. Initial differential diagnosis included TBG excess syndrome versus familial dysalbuminemic hyperthyroxinemia. Permission was obtained from the patient to access one of her son’s medical records from age 8-weeks old when he was also evaluated for abnormal thyroid labs. TSH was 2.144 (0.350-6.500 uIU/mL), total T4 28.2 (5.0-12.0 ug/dL), free T4 1.55 (0.8-1.8 ng/dL), and free T3 4.0 pg/mL (no reference available). Thyroid binding globulin was found to be elevated at 81 (12-26 mcg/mL) in her son and found to be elevated to 78.0 (13.5-30.9 mcg/mL) in this patient, confirming a diagnosis of TBG excess syndrome. Conclusions: TBG excess syndrome should be considered in the differential of patients with high total T3 and total T4 levels with normal levels of free T3, free T4, and TSH, especially in individuals who have a known family history and who have minimal or nonspecific symptoms. Definitive diagnosis will make further testing and treatment unnecessary. However, if these patients develop hypo- or hyperthyroidism, then use of TSH and free levels of T4 and T3 is necessary to direct management and avoid confusion. Reference: Pappa, T., and S. Refetoff. “Thyroid hormone transport proteins: Thyroxine-binding globulin, transthyretin, and albumin.” Reference Module in Neuroscience and Biobehavioral Psychology, 2017, https://doi.org/10.1016/b978-0-12-809324-5.03494-5.
Presentation: 6/2/2024
6601 A Case of Recurrent Painless Thyroiditis and Discussion of Management
Authors: Slack Margaret Carolyn , Grock Shira 
Published: October 2024

Abstract
Disclosure: M.C. Slack: None. S. Grock: None.
Introduction: Painless (silent) thyroiditis is characterized as a subacute and generally self-limited disease process in which patients develop transient thyrotoxicosis, which is often followed by a hypothyroid phase before entering the recovery euthyroid phase. Given high frequency of positive thyroid antibodies, it may be autoimmune-mediated; recurrence is rare. Here we present a case of recurrent painless thyroiditis and discuss management options. Clinical Case: A Korean woman was followed by endocrinology from age 38 to 60 and experienced at least seven episodes of painless thyroiditis over this time. The episodes occurred without an identifiable trigger and were not preceded by viral illness. During episodes she developed palpitations, hair loss, and dyspnea on exertion and biochemical evidence of thyrotoxicosis with TSH suppressed to &lt;0.2 mIU/mL (normal 0.3-4.7) and elevated free T4 levels as high as 5.4 ng/dL (normal 0.8-1.7). TSI, TPO, and TSH receptor antibodies were checked during multiple episodes and resulted negative, though thyroglobulin antibody was significantly elevated. A radioactive iodine uptake scan was obtained during an active episode of thyroiditis and revealed diffusely low uptake. The patient’s episodes lasted approximately two to three months before normalization of her TSH and FT4. She had at least one instance of transient hypothyroidism after thyrotoxicosis with a TSH of 13.2 and FT4 of 0.6 which subsequently normalized 6 weeks later. The patient did not have known cardiovascular disease and DXA scans revealed mild osteopenia with the lowest T-score -1.3. RAI was considered for the patient based on the total number and increasing frequency of her episodes. She ultimately declined treatment with RAI and continues to follow with endocrinology. Clinical Lessons: While the deleterious effects of prolonged hyperthyroidism (e.g. osteoporosis, arrhythmia, cardiovascular disease) are well known, it is unclear what risk recurrent painless thyroiditis episodes pose. As there are no guidelines regarding treatment, clinical gestalt incorporating frequency and duration of episodes, as well as symptoms, is often used to determine if definitive management is indicated. There are case reports in the literature of treatment of recurrent thyroiditis with RAI ablation performed during a euthyroid state, which eliminated recurrence of episodes but did lead to permanent hypothyroidism necessitating hormone replacement. Surgical thyroidectomy may also be considered in select patients. This case highlights the challenges in treating rare cases of recurrent painless thyroiditis given the lack of research or established guidelines. It is reasonable to consider the frequency, severity, and total number of episodes, as well as patient risk factors, symptoms, and preferences when making recommendations regarding management.
Presentation: 6/1/2024
7915 A Case of Severe Hypothyroidism in a Patient with Nephrotic Syndrome presenting with Rhabdomyolysis requiring Levothyroxine and Liothyronine combination therapy
Authors: Mohammed S S , Ngo E T , Tadisina S , Drees B M 
Published: October 2024

Abstract
Disclosure: S.S. Mohammed: None. E.T. Ngo: None. S. Tadisina: None. B.M. Drees: None.
Background: Nephrotic syndrome is known to worsen hypothyroidism via urinary loss of thyroid binding globulin, transthyretin, albumin and other proteins, often requiring escalating levothyroxine doses. Severe uncontrolled hypothyroidism can result in rhabdomyolysis, although this presentation is quite rare. Clinical case: We present a case of a 50-year-old male with long-standing Hashimoto’s hypothyroidism, biopsy-proven minimal change disease with nephrotic syndrome, dyslipidemia, and hypertension, who was admitted for generalized myalgia, weakness, and progressive swelling of bilateral hands and feet for one month. He had been off levothyroxine 3 months prior to presentation. He previously required large doses of oral levothyroxine, as high as 350mcg daily, but never achieved a euthyroid state despite reported adherence to therapy with the high levothyroxine doses.Laboratory workup showed severe hypothyroidism (free thyroxine &lt;0.25ng/dL [0.6-1.6ng/dL] with markedly elevated thyroid stimulating hormone 282.03 mIU/mL [0.3-5.6mIU/mL]), along with acute kidney injury and rhabdomyolysis (Creatine kinase 4882 U/L[38-234U/L]). He was hemodynamically stable with intact mentation and was not deemed to be in myxedema coma. Physical examination was consistent with hypothyroidism with periorbital swelling, dry skin, deep hoarse voice, bilateral hand and feet edema, and delayed deep tendon reflexes. Thyroid function tests and clinical symptoms failed to improve after 8 days, despite high doses of levothyroxine IV (200mcg). Creatine kinase remained high at 4994 U/L [38-234U/L] despite adequate fluid hydration. Liothyronine 5mcg orally was started in addition to levothyroxine 200mcg IV. Repeat thyroid function tests after 2 days of combined IV levothyroxine and oral liothyronine therapy showed significant downtrend in TSH to 154.12 uIU/ml [0.3-5.6mIU/mL] and increase in free thyroxine to 0.44ng/dl [0.6-1.6ng/dL]. Creatine kinase also down trended to 3181U/L[38-234U/L] on D4 of IV levothyroxine 200mcg IV with liothyronine 5mcg daily. He was discharged stable and clinically improved on oral levothyroxine and liothyronine. Laboratory evaluation 10 days later showed further improvement in TFTs (TSH 66.0[0.3-5.6mIU/mL]), free thyroxine 0.6 [0.6-1.6ng/dL] Conclusion: This case presents a unique and unusual clinical course in symptomatic primary hypothyroidism with rhabdomyolysis and AKI. Rhabdomyolysis due to hypothyroidism, without an obvious precipitating factor, has been previously reported, but is very rare. There is limited evidence regarding combination treatment with levothyroxine and liothyronine in primary hypothyroidism; however, as demonstrated in this patient, combination therapy resulted in clinical and biochemical improvement of thyroid function.
Presentation: 6/2/2024
12575 Exploring Patient And Parent Perceptions Of Administering Hydrocortisone Injection During Adrenal Crisis: A Cross-Sectional Study
Authors: Llahana S V , Anhony J 
Published: October 2024

Abstract
Disclosure: S.V. Llahana: None. J. Anhony: Employee; Self; Solution Medical LLC.
Background: Adrenal insufficiency (AI) necessitates lifelong glucocorticoid replacement therapy for most patients, with parenteral hydrocortisone crucial for managing adrenal crisis, a potentially life-threatening complication. Despite this, approximately 1 in 6-12 patients are hospitalised at least once a year, while 1 in 200 patients die from a potentially preventable adrenal crisis. While timely self-administration of hydrocortisone mitigates these risks, the complexity of current injection devices, requiring up to 20 steps to administer, often impedes effective self-treatment. Evidence shows that although 70% of patients possess emergency hydrocortisone injection kits, only 19% have received training for self-administration. Aim: This study aimed to investigate the experiences and perceptions of patients with AI and their caregivers regarding the usage of Solu-Cortef Act-O-Vial (parenteral hydrocortisone) for adrenal crisis management. Methods: A cross-sectional online survey was conducted, involving participants recruited through USA-based patient advocacy groups, CARES Foundation and Adrenal Insufficiency United. Participants provided insights into factors influencing their ability to manage adrenal crisis using Solu-Cortef Act-O-Vial. Content analysis generated themes, which were quantitatively analyzed using SPSS descriptive statistics and correlations. Results: The survey encompassed 689 patients and caregivers. Content analysis revealed eighteen themes across three domains: patient-based factors, external influences, and emotional aspects. Predominant themes, identified by over 80% of participants, included the complexity of the hydrocortisone device, the necessity for assistance during adrenal crisis episodes, and emotional distress due to fear associated with injection. Conclusion: This study underscores the necessity for a simpler injection device to enhance patient self-confidence and self-administration ability. Heightened awareness among healthcare professionals and the public regarding adrenal crisis is imperative for timely management and prevention of avoidable hospital admissions.
Presentation: 6/3/2024
8087 A Case Series on Thyroid Eye Disease Precipitated by the COVID Vaccine in Patients with Long-Standing Primary Hypothyroidism
Authors: Hassan R , Islam J 
Published: October 2024

Abstract
Disclosure: R. Hassan: None. J. Islam: None.
Background: Thyroid eye disease (TED) is an autoimmune disease characterized by progressive inflammation and damage to the tissues around the eyes, especially extraocular muscle, connective, and fatty tissue. It is most commonly seen in patients with Graves' disease. Less commonly, TED may occur in patients with hypothyroidism. Case Discussion We are presenting a case series on TED precipitated by the COVID vaccine in three patients with known cases of long-standing hypothyroidism. References ranges:TPO Ab: (Ref range: &lt;9.0 IU/mL)TSI: (Ref range: &lt;=1.3 TSI index)TRAb : (Ref range: 0.00-1.75 IU/L)TSH: (Ref range: 0.450-4.500 uIU/mL)Free T4: (Ref range: 0.82-1.77 ng/dL)T3: (Ref range: 87.00 - 178.00 ng/dL) CASE 1: 59 year-old female patient with 18-year history of primary hypothyroidism on levothyroxine who presented with a 5 month history of progressive ocular symptoms of double vision and “puffy eyes” along with other thyrotoxic symptoms. These occurred after receiving her second COVID-19 vaccine. Labs showed elevated TSI and TRAb (3.0, 6.32). TPO antibody was within normal limits at 0.5. Patient had undetectable TSH and free T4 within normal range (162, 1.08). CASE 2: 70 year-old female patient with 25-year history of primary hypothyroidism on levothyroxine who presented with a 4 month history of eye discomfort, eyelid blistering and ocular swelling after she receiving her first dose of COVID-19 vaccine. She was found to have increased ocular pressure per her ophthalmologist. On lab work, she was found to have elevated TSI and TRAb (7.1, 2.60). TPO antibody was within normal limits at 0.8. TSH was undetectable and free T4 were within normal range (159.76, 1.49). CASE 3: 82 year-old female with 30-year history of primary hypothyroidism on levothyroxine who started developing diplopia and proptosis over a 6 month course after she received her first COVID-19 vaccine.Labs showed elevated TSI and TRAb (5.1, 17). Her TPO antibody was within normal limits at 0.4. Her TSH was undetectable, and free T4 was within normal limits (71.76, 1.32). All three patients were started on low-dose methimazole, prednisone, and completed an eight week infusion course of Teprotumumab (Tepezza) with subsequent improvement of proptosis and diplopia. Conclusion Providers should be aware that patients with long standing hypothyroidism, who suddenly require less to no thyroid hormone replacement along with new onset ocular symptoms could be developing TED. This had previously been thought to be solely associated with Graves’ Disease but now has been seen with an uptick in incidence in patients with chronic hypothyroidism during the COVID pandemic. This is likely related to immune response that been associated with vaccines.
Presentation: 6/3/2024
6689 A Multicentric Study for Validation of the Diagnostic Accuracy of ACR-TIRADS in a Mexican population
Authors: Romero Ibarguengoitia M , Villarreal-Ondarza I A , Mercado Basurto J , González Cantu A 
Published: October 2024

Abstract
Disclosure: M. Romero Ibarguengoitia: None. I.A. Villarreal-Ondarza: None. J. Mercado Basurto: None. A. González Cantu: None.
The diagnostic performance of ultrasonographic ACR-TIRADS classification to evaluate thyroid nodules is poorly studied in a Mexican population. The aim was to assess the diagnostic accuracy of ACR-TIRADS classification for identifying malignant thyroid nodules in adults aged &gt;18 years. This retrospective research study was conducted in 4 medical centers in Northern Mexico from 2022 to 23 to obtain ACR-TIRADS classification of nodules from thyroid ultrasound. Information about Bethesda classification after fine needle aspiration and cytology from thyroidectomy was analyzed for diagnostic performance tests. A total of 160 patients were included. Thyroid nodules were classified as TIRADS 3 in 12%, TIRADS 4 in 44%, and TIRADS 5 in 41%. Twenty-six (16%) were classified as Bethesda 1, 39 (24%) were classified as Bethesda 5, and 30 (19%) were classified as Bethesda 6. The sensitivity (S) of TIRADS 4 was 41%, specificity (E) was 50%, positive predictive value (PPV) was 59%, negative predictive value (NPV) was 32%, and accuracy was 44%. The S of TIRADS 5 was 51%, E 77%, PPV 80%, NPV 47%, and accuracy of 61%. When comparing with other populations, the performance was the same as the Turkish (their accuracy was 59.93%) population but lower than a population from China (their accuracy was 86%) and Germany (PPV 100% for TIRADS 5). The proportion of malignancy in our sample compared with a reference sample from Germany was lower, 36 vs. 85% for TIRADS 3, 59 vs. 85% for TIRADS 4, and 80% vs. 100%, p&lt; 0.001. Concerning Bethesda's classification, the proportion of malignancy was the same according to the reference sample from the American Thyroid Association. In conclusion, there was a moderate accuracy of the ACR-TIRADS classification system in our population, the same in comparison with the Turkish population; slightly lower than what is reported in a population from Germany and China.
Presentation: 6/1/2024