bluuebunny/crossref_metadata_2025_split huggingface dataset:
7487 Iatrogenic Cushing’s Syndrome In A Patient On Prezcobix And Fluticasone
Authors: Davis A N , Nicholson M 
Published: October 2024

Abstract
Disclosure: A.N. Davis: None. M. Nicholson: None.
Introduction: The HIV medication Prezcobix contains darunavir, a protease inhibitor which is known to inhibit the hepatic enzyme CYP3A4. This may lead to accumulation of some medications in the blood, including fluticasone. We present a patient with iatrogenic Cushing’s syndrome while on Prezcobix and fluticasone. Case: Patient is a 55-year-old man who presented to clinic 3/13/23 for evaluation for cushingoid appearance at the request of his infectious disease (ID) physician. The patient has history of HIV, asthma, and seasonal allergies and had been taking Prezcobix, inhaled fluticasone, and intranasal fluticasone for over 3 years. Patient noted easy bruising and difficulty with weight loss. Vital signs were remarkable for elevated blood pressure at 165/86 despite taking amlodipine, HCTZ, and carvedilol. He was overweight with BMI 27.2. Physical exam revealed a somewhat rounded face, mild central obesity, no dorsocervical or supraclavicular fat pads, and no purple striae. Labs on 3/8/23 were remarkable for cortisol level &lt;0.40mcg/dL at 4:10PM. Labs on 3/13/23 were remarkable for cortisol &lt;0.40mcg/dL, ACTH level &lt;5.0pg/mL, and urine fluticasone 17-beta carboxylic acid elevated at 540pg/mL (&lt;10pg/mL) at 3:57PM. His ID physician planned to transition the patient off of Prezcobix and onto Tivicay, so patient was started on hydrocortisone 15mg PO daily at 8AM and 5mg daily at 2PM on the day he switched to Tivicay. He was gradually tapered off of hydrocortisone over a 2-3 month period without any symptoms concerning for adrenal insufficiency. His Cortisol level on 7/10/23 off hydrocortisone was 4.98mcg/dL at 7:56AM. Discussion: Prezcobix contains darunavir which is known to inhibit CYP3A4. With most patients, use of inhaled and intranasal fluticasone does not result in physiologically meaningful systemic levels of fluticasone. However, metabolism of fluticasone is dependent on CYP3A4, so systemic levels may increase with use of inhaled fluticasone with Prezcobix resulting in excess of corticosteroids and suppression of the native hypothalamic-pituitary-adrenal (HPA) axis. Fluticasone 17-beta carboxylic acid is a metabolite of fluticasone which is detectable in the urine. Sudden cessation of Prezcobix after prolonged use may result in secondary adrenal insufficiency from prolonged HPA axis suppression. Our case demonstrates how the use of Prezcobix with fluticasone may result in iatrogenic Cushing’s syndrome. Additionally, our case demonstrates that anticipation of secondary adrenal insufficiency after stopping Prezcobix allows for implementation of a safe transition plan.
Presentation: 6/1/2024
7099 Severe Hypothyroidism from Potassium Iodide Supplements: A Case of Failure to Escape from Wolf- Chaikoff Effect
Authors: Gbenga Hamilton Michael , Kulkarni Abhigna , Lekprasert Patamaporn 
Published: October 2024

Abstract
Disclosure: M.G. Hamilton: None. A. Kulkarni: None. P. Lekprasert: None.
Introduction: The Wolf-Chaikoff effect (WCE) is a physiological response of the thyroid gland to supraphysiologic iodide levels. Failure to escape the WCE can lead to thyroid dysfunction, and we present such a case in a patient with Hashimoto’s thyroiditis taking high-dose potassium iodide (KI). Case Description: A 44-year-old female with hypothyroidism secondary to Hashimoto’s thyroiditis presented with 10-pound weight gain, extremity swelling, fatigue, and abnormal menstruation. She was prescribed Levothyroxine several years ago but stopped taking it shortly after as she felt no improvement. On physical exam, she was bradycardic with heart rate of 58 bpm. There is no goiter but dry skin and edematous lower extremities. Labs revealed TSH of 127 pg/mL (0.35-4.94), free T4 0.1ng/dL (0.8-1.8), TPO Ab 645 (&lt;9) IU/mL in comparison to her labs 2 months ago of TSH 11 pg/mL and free T4 0.9 ng/dL. Suspicion for worsening hypothyroidism from Hashimoto’s was low given this dramatic change on labwork and clinically. On further questioning, she had been taking KI 130 mg/day (Iodine 100 mg, daily requirement 150 mcg/day) as advised by her homeopathic doctor. The supplements were stopped, and she was re-started on Levothyroxine. After 8 weeks, she reported improvement of symptoms and weight loss. TSH is normal at 3.54pg/ml and free T4 1.2 ng/dL. Discussion:The WCE serves as a protective mechanism to decrease thyroid hormone production in the setting of high iodide levels to prevent development of hyperthyroidism. WCE is explained by the formation of Iodopeptides inhibits thyroid peroxidase (TPO) mRNA and protein synthesis resulting in an inhibition of thyroglobulin iodination. WCE is temporary and expected to wane over a few days to weeks and is known as the Wolf-Chaikoff escape due to down regulation of the sodium iodine symporter (NIS) thereby decreasing the intrathyroidal inorganic iodine concentration and permitting normal TPO activity. Rarely, failure to escape WCE can lead to hypothyroidism due to continued suppression of thyroid hormone synthesis. Risk factors include underlying thyroid diseases i.e. Hashimoto’s or other causes of thyroiditis, use of Amiodarone, Lithium or Iodine-containing radiocontrast media and KI supplements. In our case, Hashimotos’ thyroiditis predisposed her to thyroid dysfunction and failure to escape from WCE after taking high-dose KI supplements causing severe hypothyroidism. Thus, this report highlights that in clinical practice, especially in patients with pre-existing thyroid dysfunction, a significant TSH increase, a high suspicion index is needed to investigate for other causes like concurrent use of iodine-containing food/drug leading to the failed escape from WCE apart from verifying compliance to thyroid replacement therapy.
Presentation: 6/3/2024
7914 Staged Treatment with Radioiodine Following Lobectomy in a Case of High Risk Papillary Thyroid Carcinoma
Authors: Pathak Leilani , Sharma Arun , Rao Krisha , Jakoby Michael G 
Published: October 2024

Abstract
Disclosure: L. Pathak: None. A. Sharma: None. K. Rao: None. M.G. Jakoby: None.
Introduction: Radioiodine ([1]3[1]I ) is usually reserved for patients with differentiated thyroid carcinoma (DTC) who are at high risk of persistence or recurrence after thyroidectomy. We present a case of papillary thyroid carcinoma (PTC) with extrathyroidal extension managed by lobectomy and staged [1]3[1]I ablation of the contralateral lobe and metastases due to comorbidities that made oncologic resection prohibitive. Case Description: A 58-year-old male had a 2.2 cm focus of PTC in the left thyroid lobe that extended into extrathyroidal soft tissue, adjacent trachea, and completely compromised the left recurrent laryngeal nerve. Due to left vocal cord paralysis and subglottic tracheal stenosis, left lobectomy was performed but oncologic resection (total thyroidectomy and tracheal resection) was deferred. The patient underwent recombinant human TSH (rhTSH) stimulated treatment with 30 mCi (1.1 GBq) of [1]3[1]I for right thyroid lobe ablation followed 60 d later by 180 mCi (6.7 GBq) of [1]3[1]I to treat metastases. Response to treatment was incomplete, with unstimulated thyroglobulin level falling from 293.9 to 18.9 ng/mL 1 y after [1]3[1]I and CT of the neck notable for a 2.7 cm left thyroid bed mass with invasion of adjacent trachea and a 1.0 cm right paratracheal mass, both of which exhibited hypermetabolism on PET imaging and yielded cytology consistent with poorly differentiated thyroid carcinoma (PDTC). A cluster of left supraclavicular lymph nodes showed both hypermetabolism on PET and radioiodine uptake on rhTSH scan. This patient is being prepared for surgical resection of the left thyroid bed and right paratracheal tumors and left lateral lymph node dissection. Discussion: Radioiodine lobar ablation is an alternative to completion thyroidectomy in patients with an unexpected diagnosis of DTC after lobectomy, with a recent meta-analysis finding a success rate of 69%. No difference in thyroid cancer recurrence rates was found in nearly 500 matched pairs of patients undergoing completion thyroidectomy or radioiodine lobar ablation. Unfortunately, staged lobar ablation followed by high dose [1]3[1]I was not successful in treating this high-risk PTC patient. Cases of coexisting PTC and PDTC are reported, and [1]3[1]I treatment was unsuccessful at treating PDTC that was not apparent on postsurgical histopathology. This case indicates that surgery is preferable to staged [1]3[1]I treatment of patients with aggressive PTC, especially if there are no comorbidities that make total thyroidectomy a high-risk procedure.
Presentation: 6/2/2024
12345 Staying Ahead of Cowden’s Syndrome in Differentiated Thyroid Cancer
Authors: Gordon Michael S , Gordon Murray B 
Published: October 2024

Abstract
Disclosure: M.S. Gordon: None. M.B. Gordon: None.
Cowden’s syndrome or multiple hamartoma syndrome, is an uncommon autosomal dominant genodermatosis and is a member of the spectrum of disorders involving mutations in the phosphatase and tensin homolog gene (PTEN). It is associated with differentiated thyroid cancer (DTC), ¾ papillary, including follicular variant (FVPTC), 1/4 follicular (FTC), and other malignancies, including breast (most common), colorectal, renal cell, endometrial and skin cancers. We report a case of Cowden’s syndrome in which the patient presented with FVPTC but had no other apparent indication of a genetic abnormality until she was found to have a melanoma and was noted to have macrocephaly. The patient presented at age 26 with a thyroid nodule of 2.7 cm in maximal dimension. FNA was benign. By age 31 the lesion had grown to 3.3 cm and a repeat FNA showed a follicular neoplasm. She underwent left lobectomy and isthmusectomy revealing a 3.0 cm FVPTC with focal Hurthle cell features. There was capsular irregularity, and subsequently she underwent completion thyroidectomy showing a right sided 8mm FVPTC. She then received 30 mCi I 131. There were no apparent pathologic mucocutaneous lesions, intellectual deficits, and no family history of Cowden’s syndrome. At age 39 she was found to have a Stage IA malignant melanoma of the periumbilical skin which was resected. With two malignancies diagnosed at a relatively young age, she was evaluated for genetic syndromes and it was simultaneously noted that she had macrocephaly with head circumference of 66 cm. (&gt;99 percentile). An analysis of 69 genes by Ambry genetics revealed a pathogenic variant in the PTEN gene (c.388 C&gt;T (p.R130*). PTEN R130* results in a premature truncation of the PTEN protein at amino acid 130 of 403 within the phosphatase tensin-type domain resulting in loss of function. Macrocephaly (2% population frequency) is seen in 80% of patients with PTEN mutations. Twenty percent of patients with thyroid carcinoma and macrocephaly have a PTEN mutation and lifetime risk of melanoma in DTC is 25%. BRAF and RAS mutations may cooperate with PTEN loss and explain the increased co-occurrence of malignancies with BRAF and RAS mutations such as melanoma, FTC, and PTC in Cowden’s syndrome. In conclusion, we suggest that head circumference should be measured in all patients with DTC to screen for PTEN abnormalities. Patients with DTC also should have a thorough skin examination.
Presentation: 6/2/2024
6390 Takotsubo Cardiomyopathy (Case Report)
Authors: Ahmad Ballout Hajar , Malas Ibrahim , Sakor Zahraa , Ismail Mohamad , Najjar Claudette 
Published: October 2024

Abstract
Disclosure: H.A. Ballout: None. I. Malas: None. Z. Sakor: None. M. Ismail: None. C. Najjar: None.
Takotsubo is a reversible stress-induced cardiomyopathyusually associated with emotional or physical stress.Thyroid stormhas been identified as a rare cause of takotsubo. We report a rarecase of 64-year-old female presented with high BP. Blood testsshowed elevated troponin level and high FT4 FT4 Cardiacultrasound revealed normal size of the LV &anteroseptal wallakynisia,low ejection fraction,&diastolic LVD.Cardiac cathshowed normal coronary arteries, ventriculography showed apicalballooning and bulging in the left ventricle, suggesting Takotsubocardiomyopathy as a final diagnosis. patient was treated for thethyroid storm&takotsubo cardiomyopathy.month later she showedsignificant improvement in the cardiac function &thyroid hormone levels. As this case represented a rare stress-induced cardiomyopathy, the early diagnosis &suitable therapy areessential to prevent ongoing myocardial damage and providebetter chance for recovery.
Presentation: 6/2/2024
7445 The Effect of Combination Thyroid Hormone Therapies on Symptoms in Patients with a Suboptimal Response to Levothyroxine: A Post-Hoc Analysis
Authors: Patel A A , Shakir M K , Tuamokumo F , Bianco A C , Hoang T D 
Published: October 2024

Abstract
Disclosure: A.A. Patel: None. M.K. Shakir: None. F. Tuamokumo: None. A.C. Bianco: None. T.D. Hoang: None.
The standard treatment of hypothyroidism is levothyroxine (LT4). Combination therapies such as desiccated thyroid extract (DTE) or LT4 + liothyronine (LT3) are used much less. There is now evidence that combination therapies are effective and safe if serum thyroid stimulating hormone (TSH) is kept within a normal range. We studied whether there is a role for combination therapies specifically in hypothyroid patients who remain symptomatic despite biochemical evidence of adequate treatment with LT4, an issue that remains a challenging clinical conundrum for clinicians and patients alike. We conducted a post-hoc analysis of a prospective, randomized, double-blind, cross-over study of 75 patients with hypothyroidism performed at our institution. Patients were originally allocated to 1 of 3 treatment arms (LT4: Group A, DTE: Group B, or LT4+LT3: Group C) for 22 weeks and then crossed-over to the other two treatment arms sequentially for 22 weeks at a time until they had completed all treatment regimens. The Thyroid Symptom Questionnaire (TSQ) was completed by all patients during the initial study (a set of 12 questions with a total point range of 0-36; a higher score indicates more symptoms). We stratified patients by their TSQ score while on LT4 into three quantiles: Category 1 (TSQ 0-12; n=23), Category 2 (TSQ 13-24; n=42), Category 3 (TSQ 25-36; n=10). Differences were detected with a one-way ANOVA test and the Tukey multiple comparison post-test. No significant difference was found among treatment groups in Category 1 (p=0.063). In Category 2, the DTE group had significantly lower TSQ scores than the LT4 group (mean LTE score 18.9, SD 3.7; mean DTE score 14.3, SD 6.9; p=0.026). In Category 3, the LT4+LT3 group had significantly lower scores than LT4 and DTE groups (mean LTE score 27.7, SD 2.4; mean DTE score 23.1, SD 8.7; mean LT4+LT3 score 15.8, SD 4.7; p&lt;0.001 LT4+LT3 vs LT4; p=0.026 LT4+LT3 vs DTE). This study demonstrates that patients with hypothyroidism who remain symptomatic while on LT4 may benefit from use of combination therapies such as DTE or LT4+LT3. Patients who generally have minimal residual symptoms with LT4 are unlikely to have significant symptomatic improvement on combination therapies. In addition, patients with moderate severity symptoms (TSQ 13-24) on LT4 had significant symptomatic improvement with DTE and patients with the most severe symptoms (TSQ 25-36) on LT4 had significant symptomatic improvement with LT4+LT3. No single TSQ question was more sensitive or prevalent in groups 2 and 3 (the most symptomatic groups). The results suggest a potential clinical role for combination therapies such as DTE and LT4+LT3 in patients who do not have improvement in hypothyroid symptoms on LT4 (TSQ score &gt;13).
Presentation: 6/3/2024
6893 The Interaction Effect Between BMI, Diabetes, and Age at Diabetes Onset on the Risk of Thyroid Cancer: A Population-Based Cohort Study
Authors: Hou T , Li Y , Tian J , Bloomgarden Z , Shi Y 
Published: October 2024

Abstract
Disclosure: T. Hou: None. Y. Li: None. J. Tian: None. Z. Bloomgarden: None. Y. Shi: None.
ObjectiveThe relationship between type 2 diabetes mellitus (T2DM) and thyroid cancer was confounded by some characteristics of diabetes. We aimed to determine the association of the presence of diabetes and, among persons with diabetes, the age at T2DM onset, BMI, and the interactive effect with the subsequent thyroid cancer risk. MethodsWe conducted a population-based longitudinal cohort study including 428,568 persons with new-onset T2DM matched with the general population (100,649,346 person-years). Risk of thyroid cancer by subgroups were calculated based on standardized incidence ratio (SIR), hazard ratio (HR), and Cox proportional hazards models. ResultsIn T2DM patients, 1142 thyroid cancer cases were identified during eight years of follow-up, with an incidence rate of 59.01/100,000 person-years and a higher SIR: 1.21 (95% CI: 1.14-1.28) compared to the general population. New-onset T2DM had an overall 21% higher risk of thyroid cancer. Both the earlier age at T2DM onset and higher BMI were associated with a significant increasing risk of thyroid cancer independently (T2DM onset age &lt;50: SIR 1.46 (1.27-1.69); BMI ≥30.0 Kg/m2 SIR: 1.93 (1.57-2.38)). The highest risk of cancer appeared in the patients with both BMI ≥30.0 Kg/m2 and T2DM onset age &lt;50 years (SIR=3.91, HR=3.04). Among patients with T2DM onset age &lt;60 years, SIR shows an increasing trend of cancer risk with higher BMI levels, while no significant increasing trends with higher BMI in T2DM onset age ≥60 years. For patients with BMI ≥25.0 Kg/m2, SIR of cancer risk decreases with an later T2DM onset age, whereas no significant decreasing trends of cancer risk in BMI &lt;24.9 Kg/m2 group. Obese (BMI ≥30.0 Kg/m2) patients had a significant higher HR of thyroid cancer only when T2DM onset age &lt;60 years. ConclusionsBoth earlier age of T2DM onset (&lt;50 years) and higher BMI (≥30 Kg/m2) contributed to higher risk of thyroid cancer. These results suggest that earlier screening of thyroid cancer might be appropriate in patients diagnosed with T2DM, especially in individuals with young-onset T2DM and obesity.
Presentation: 6/3/2024
6897 The Role of Neutrophil Heterogeneity on T-cell Immunity in Advanced Thyroid Cancer Patients
Authors: Kang Y , Lee S , Yoon J , Kang D , Lee J 
Published: October 2024

Abstract
Disclosure: Y. Kang: None. S. Lee: None. J. Yoon: None. D. Kang: None. J. Lee: None.
Neutrophil heterogeneity is involved in autoimmune diseases, sepsis, and several cancers. However, the link between neutrophil heterogeneity and T-cell immunity in thyroid cancer is incompletely understood. We investigated the circulating neutrophil heterogeneity in 3 undifferentiated thyroid cancer (UTC), 14 differentiated thyroid cancer (DTC) (4 Stage IV, 10 Stage I-II), and healthy controls (n=10) by transcriptomic data and cytometry. Participants with UTC had a significantly higher proportion of immature high-density neutrophils (HDN) and lower proportion of mature HDN in peripheral blood compared to DTC. The proportion of circulating PD-L1+ immature neutrophils were significantly increased in advanced cancer patients. Unsupervised analysis of transcriptomics data from circulating HDN revealed downregulation of innate immune response and T cell receptor signaling pathway in cancer patients. Moreover, UTC patients revealed the upregulation of glycolytic process and glutamate receptor signaling pathway. Comparative analysis across tumor types and stages revealed the downregulation of various T cell related pathways, such as T cell receptor signaling pathway and T cell proliferation in advanced cancer patients. Moreover, the proportions of CD8+ and CD4+ T effector memory CD45RA+ (TEMRA) cells from peripheral blood were significantly decreased in UTC patients compared to DTC patients. Finally, we demonstrated that proportions of tumor infiltrated neutrophils were increased and related with poor prognosis in advanced thyroid cancer using data from our RNA-seq and TCGA (The Cancer Genome Atlas) data. In conclusion, observed prevalence of circulating immature high-density neutrophils and their immunosuppressive features in undifferentiated thyroid cancers underscore the importance of understanding neutrophil dynamics in the context of tumor progression in thyroid cancer.
Presentation: 6/3/2024
6422 Identifying Predictive Symptoms Of Adrenal Insufficiency
Authors: Han Ashley J , Achenbach Sara J , Atkinson Beth J , Bancos Irina 
Published: October 2024

Abstract
Disclosure: A.J. Han: None. S.J. Achenbach: None. B.J. Atkinson: None. I. Bancos: None.
Background: Diagnosis of adrenal insufficiency (AI) is often delayed due to its vague and non-specific symptomatology. As classic symptoms of AI such as fatigue and nausea are prevalent in the general population, identifying clinical features that are more specific to AI may help clinicians determine which patients require additional testing. Methods: A single-center retrospective study was performed of patients who underwent outpatient Cosyntropin stimulation testing (CST) between 2005-2018. Patients with oral glucocorticoid or estrogen use within 2 months of CST, and patients without available Current Visit Information (CVI) form at the time of CST were excluded. Presence of symptoms was obtained from CVI, and laboratory findings were electronically extracted. Adrenal insufficiency was defined as post-CST peak cortisol &lt;18 mcg/dL. Morbidity was assessed using the Elixhauser index. Variables for multivariable analysis were defined a priori and included fatigue, dizziness, muscle pain, joint pain, weight loss &gt;10 pounds, abdominal pain, nausea/vomiting, and hyponatremia. Results: Among 5347 patients who underwent CST, 376 (7.0%) of patients were found to have AI. There were no sex differences between patients with and without AI, however patients with AI were slightly older (median age 48.9 vs 47.1 years, p=0.026), and had a higher median BMI (26.5 vs 25.6 kg/m2, p=0.002). Prevalence of comorbidities was similar between the two groups, with a median Elixhauser index of 1 (IQR 1-3), however, patients with AI were more likely to report difficulties with activities of daily living (69% vs 57%, p&lt;0.001). Hyponatremia was diagnosed in 4% of patients with AI and 3% of those without AI, p=0.208. Although patients in our cohort reported a high prevalence of fatigue (79%), dizziness (50%), joint pain (50%), muscle pain (48%), nausea (40%), abdominal pain (39%), and weight loss in the past 6 months (29%), there were no statistically significant differences in reported symptoms between patients with and without AI with the exception of joint pain (59% vs 49%, p&lt;0.001) and muscle pain (54% vs 47%, p=0.009). Based on multivariable analysis, only joint pain (OR 1.51, 95% CI 1.14-1.99) and weight loss &gt;10 pounds in the past 6 months (OR 1.31, 95% CI 1.02-1.68) were associated with higher odds of AI diagnosis. Interestingly, patients who reported fatigue had lower odds of AI diagnosis on CST (OR 0.66, 95% CI 0.49-0.88). Conclusions: Commonly associated symptoms of AI such as fatigue, dizziness, nausea, and abdominal pain were poor predictors of AI diagnosis based on CST. Consequently, the presence of these symptoms alone may not warrant additional testing. Notably, clinical features such as myalgia, arthralgia, and weight loss &gt;10 pounds in the past 6 months were found to be more predictive of AI.
Presentation: 6/1/2024