bluuebunny/crossref_metadata_2025_split huggingface dataset:
6657 A rare case of a composite pheochromocytoma and ganglioneuroma in a 47-year-old male
Authors: Ekladios Catherine , Jason Levine Matthew 
Published: October 2024

Abstract
Disclosure: C. Ekladios: None. M.J. Levine: None.
Introduction: Pheochromocytoma is a rare tumor that originates from adrenal chromaffin cells. It remains a diagnostic challenge due to its diverse clinical manifestations. We present a case of pheochromocytoma, shedding light on its atypical presentation and diagnostic complexity.Case reportA 47-year-old male was referred to our clinic with a recent diagnosis of pheochromocytoma. Patient started having symptoms approximately two months prior to referral to our office. He initially presented to the emergency department (ED) with generalized weakness for three days, accompanied by feelings of “rushing of blood to the head” and a “rush of blood in the arms” every time he laid down. Symptoms would last for a few seconds and resolve without intervention. Vitals signs and physical examination (PE) were within normal limits. He had basic laboratory studies including BMP and CBC without any abnormalities. He was discharged home with instructions to follow-up outpatient. He returned to the ED two days after with a chief complaint of left sided chest pain associated with palpitations, pain was non-persistent, lasting a few seconds. On presentation his blood pressure was 142/89 mmHg, Pulse: 66 bpm, Temperature: 98.4 °F, and oxygen Saturation 100%. On PE, he had clear bilateral air entry and regular heart rate with no murmurs noted, EKG demonstrated no ischemic changes. Chest Xray showed no evidence of cardiopulmonary disease. A CTA revealed no pulmonary embolism, pleural effusion, or pneumothorax. However, a large heterogeneous adrenal mass was partially visualized, measuring 8.3 cm anteroposteriorly concerning for adrenal cortical carcinoma. His labs were pertinent for Metanephrine level of 0.52 nmol/L (nl:0-0.49) and Normetanephrine of 4.22 nmol/L (nl:0-0.89). Aldosterone level is 16.2 ng/dL and Renin activity was 0.1ng/mL. An abdominal CT scan confirmed a left adrenal mass measuring approximately 9.2 x 8.8 cm transaxially and 9.9 cm craniocaudal. He was seen in our office after discharge, at that time he was still experiencing tingling in both lower extremities that sometimes would wake him up from sleep. His blood pressure at the office was 125/83 mm Hg. In preparation for the surgery, we started treatment with Prazosin, followed by addition of Metoprolol succinate. Further work-up included a dexamethasone suppression test that ruled out Cushing’s syndrome and a negative RET proto-oncogene, ruling out MEN 2. Patient underwent laparoscopic left adrenalectomy without complications. Pathology results interestingly showed a composite pheochromocytoma and ganglioneuroma constituting 5 % of the mass volume, Ki-67 proliferative index was less than 1% for the pheochromocytoma and overall findings were consistent with a benign tumor.ConclusionOur case report emphasizes the necessity of a high index of suspicion for diagnosing pheochromocytoma in the absence of the classic symptoms.
Presentation: 6/2/2024
6963 A Rare Case Presentation of Untreated Congenital Adrenal Hyperplasia with Bilateral Giant Myelolipoma
Authors: Omran Fatema , Bromley Sarah , Ilahi Marium , Zena Mohsen , Al-Refaie Waddah , Delto Joan , Preet Singh Awinder 
Published: October 2024

Abstract
Disclosure: F. Omran: None. S. Bromley: None. M. Ilahi: None. M. Zena: None. W. Al-Refaie: None. J. Delto: None. A. Singh,: None.
Background: Adrenal myelolipoma is a rare benign neoplasm predominantly composed of mature adipose tissue and intermixed myeloid tissue, often associated with conditions like Congenital Adrenal Hyperplasia. The etiology of this neoplasm is not definitively known although there are numerous hypotheses, including research suggesting that excess ACTH could be responsible for the pathogenesis. Clinical Case: A 40-year-old female with a history of congenital adrenal hyperplasia noncompliant with treatment. She presented with cholelithiasis (s/p laparoscopic cholecystectomy), abdominal imaging revealed incidental finding of a large right retroperitoneal mass. She was noted to have generalized excessive hirsutism in male distribution, small breasts, enlarged clitoris, male body habitus, and amenorrhea after stopping steroids years prior. Laboratory workup showed the following hormonal abnormalities: elevated ACTH (1080 pg/ml), elevated testosterone (243 ng/dl) and free testosterone (31.3 pg/ml), elevated androstenedione (23.431 ng/ml), and low LH (&lt;0.02 miu/ml), low FSH (&lt;0.02 miu/ml). CT abdomen showed right lobulated retroperitoneal mass of 4x14.3x20cm with internal fat and soft tissue components, left lobulated retroperitoneal mass of 13.7x4.7x7.5cm with soft tissue and fat components. CT guided-biopsy showed pathology consistent with adrenal myelolipoma: fatty areas with interspersed hematopoietic tissue components, peripheral rim of normal adrenal cortical tissue. Given the large size of the mass and compressive effects on surrounding organs, patient underwent exploratory laparotomy with resection of right retroperitoneal mass, nephrectomy, and adrenalectomy. Discharged on hydrocortisone and fludrocortisone, instructed to follow up by endocrinologist, always wear medical alert bracelet, and provided with hydrocortisone emergency kit. Conclusion: This case serves as a classic presentation of a rare disease state. Adrenal myelolipomas, a rare benign adrenal neoplasm, have been found in several disorders associated with chronic ACTH hypersecretion including congenital adrenal hyperplasia. Most CAH patients with myelolipomas have untreated or poorly treated CAH. Adrenal myelolipomas that are asymptomatic and &lt;5cm in size are usually monitored if one is certain there is no occult malignancy. If these tumors are symptomatic or &gt;7cm, patients should undergo surgical excision. These patients should be followed by endocrinology. Importantly, further guidelines should be further developed for management.
Presentation: 6/3/2024
7762 A Unique Case Of Sepsis-Driven Bilateral Adrenal Hemorrhages In A Patient With HIT
Authors: Siddiqui A , Shalit B , Nadeem H , Khan Z , Pinkhasova D 
Published: October 2024

Abstract
Disclosure: A. Siddiqui: None. B. Shalit: None. H. Nadeem: None. Z. Khan: None. D. Pinkhasova: None.
Introduction: Bilateral adrenal hemorrhages, commonly seen in the setting of sepsis as Waterhouse Friderichsen syndrome, is a rare life-threatening condition. This process is driven by the release of bacterial endotoxins leading to the activation of coagulation, fibrinolysis, and proinflammatory pathways. It is by a similar process that now non-septic hypercoagulable states, including heparin-induced thrombocytopenia (HIT), factor V Leiden and protein C resistance are also being recognized as etiologic for bilateral adrenal hemorrhaging. The following case demonstrates a combination of the two etiologies leading to adrenal insufficiency from bilateral adrenal hemorrhages. Clinical Case: A 48-year-old male presented to the emergency department with right upper quadrant pain, dyspnea, and a low-grade fever. Laboratory results indicated leukocytosis with a predominance of neutrophils. Initial computed tomography imaging revealed a 4 x 3.5 cm right lower lobe multi-loculated lung abscess and multiple right lower lobe segmental/subsegmental pulmonary emboli. The patient was started on a heparin drip and empiric antibiotics. Infectious disease was consulted to help determine the etiology of the lung abscess. Extensive workup including sputum, blood, fungal cultures, and acid-fast bacillus smear testing were negative. The patient improved on routine broad-spectrum antibiotics and was planned to be transitioned to a direct oral anticoagulant until serial imaging revealed incidental bilateral 4 cm adrenal hemorrhages. Endocrinology was emergently consulted; a random cortisol level was drawn and found to be low at 2.7 (3-17 µg/dL) with an elevated Adrenocorticotropic hormone (ACTH) level of 114 (6 - 50 pg/mL) indicative of primary adrenal insufficiency. The patient subsequently became hypotensive and was started on stress-dose steroids. Upon further investigation, the patient was found to be thrombocytopenic, and hematology was involved. Based on his 4T score of 5, concern was raised for HIT and argatroban was initiated. Moreover, the patient was eventually stabilized for discharge with close follow-ups with endocrinology, infectious disease, and hematology as an outpatient. Conclusion: There have been 17 reported cases of bilateral adrenal hemorrhaging in the setting of HIT uniformly presenting with complete hemodynamic collapse. This case serves as even more unique given the added component of sepsis. Both sepsis and HIT respectively have been well established to pose individual risk for developing bilateral adrenal hemorrhages. Hence, we hope to highlight the importance of exploring all potential causes of adrenal insufficiency in the setting of bilateral adrenal hemorrhaging and emphasize the harms of anchoring to a single etiology.
Presentation: 6/3/2024
6572 Acute Adrenal Crisis Secondary To Undiagnosed Addison's Disease
Authors: Deirmenjian Jacqueline M , Nickowitz Harris , Kavafyan Talar 
Published: October 2024

Abstract
Disclosure: J.M. Deirmenjian: None. H. Nickowitz: None. T. Kavafyan: None.
Addison’s disease, also known as primary adrenal insufficiency, is when the adrenal gland has a defect in making cortisol. Signs and symptoms of Addison’s disease include nausea, vomiting, diarrhea, fatigue, dizziness, hyperpigmentation, and mood changes. Acute Adrenal Crisis can occur as a result of Addison’s disease when patients experience acute physiologic stress such as acute illness. Patient is a 35- year-old woman with a PMHx of iron deficiency anemia presenting with intractable nausea and vomiting for 10 days and a single witnessed syncopal episode two days prior to presentation. She was also had intermittent dizziness. Patient initially presented to urgent care where she was found to be hyponatremic and then was sent to the ED. She had no seizure like activity or rashes prior to admission. On initial physical exam, her skin was warm and dry with skin discoloration and hyperpigmentation. She was awake, alert, and oriented to person, place, time, and situation. Patient had no neurological deficits and no lateral or vertical nystagmus on initial assessment. On admission, patient was hyponatremic to 114 mEq/L, potassium was 5.0 mEq/L, and glucose level was 79 mg/dL. Despite receiving a 500 cc NS bolus, 1L NS bolus, 25 grams of albumin, and D5-0.45 NS at 50 cc/hr, the hyponatremia was difficult to correct. Her sodium initially corrected to 120 mEq/L but the sodium later decreased to 117 mEq/L. The morning after admission, patient became hypotensive and hypoglycemic. Random cortisol was measured and found to be 2.2 mcg/dL, raising concern for acute adrenal crisis as a result of undiagnosed Addison’s Disease. ACTH level was 17 pg/mL. Endocrinology was consulted and she was treated with IV 100 mg Hydrocortisone in addition to IV hydrocortisone 50 mg IV q6h. Patient was able to be transitioned to PO hydrocortisone 15 mg qAM and 5 mg qPM and was started on PO fludrocortisone 0.1 mg daily. On day of discharge, sodium improved to 127 mEq/L. CT Abdomen with contrast was completed to evaluate the adrenal glands and it showed a normal appearance of the adrenal glands. The etiology of the patient’s acute adrenal crisis was secondary to undiagnosed Addison’s Disease. It is interesting to note that patient was not hypoglycemic on admission but later became hypoglycemic during her hospital course. Adrenal crisis is a possible fatal complication of undiagnosed Addison’s disease. Therefore, a possible Addison’s Disease diagnosis is important to consider when patients are presenting with symptoms such as nausea, vomiting, dizziness, and electrolyte derangements including hyponatremia. If patient’s present with hyponatremia, ruling out possible adrenal insufficiency by checking a cortisol level may change the course of patient’s care. After discharge, she was able to establish care with Endocrinology and remain stable on treatment with PO hydrocortisone and PO fludrocortisone.
Presentation: 6/3/2024
12207 A Two-hit Model Of Pcb Exposure And Immune Challenge, And Effects On Behaviors In Rats
Authors: Khoury S E , Hynes A , Davis L K , Thompson L , Sanchez K , Fonken L , Gore A C 
Published: October 2024

Abstract
Disclosure: S.E. Khoury: None. A. Hynes: None. L.K. Davis: None. L. Thompson: None. K. Sanchez: None. L. Fonken: None. A.C. Gore: None.
This study evaluated how two common life experiences: exposures to environmental endocrine-disrupting chemicals (EDCs), and immune challenges, can act independently or in combination to affect social and anxiety-like behaviors in rats. The class of endocrine-disrupting chemical (EDC) used was polychlorinated biphenyls (PCBs), a family of industrial chemicals that, despite their ban in the 1970s, are detectable in the body tissues of virtually all humans and animals today due to their persistence. Exposures to PCBs were given prenatally and in early postnatal life through feeding of rat dams, during hormone sensitive periods of brain development in the offspring. The immune challenge was given postnatally during adolescence through injection of lipopolysaccharide, to induce neuroinflammation. These challenges are individually associated with increased behavioral disorders in humans and rodent models, but how they interact is unknown. In this 2x2 design, rats received either PCBs or oil in early life, and LPS or saline in adolescence. The animals were then tested in a series of behavioral assays to assess for social and anxiety-like behaviors, including Open Field (OF), Juvenile Social Exploration (JSE), Three Chamber Social Test (TCST), Light Dark Box (LD), and Elevated Plus Maze (EPM). An effect of PCB was observed in OF center time. Interactions of EDC and LPS were found in aspects of EP, and TCST. Further work examining protein and gene expression in the hippocampus and hypothalamus is in progress and will help to elucidate the underlying biological mechanism of the observed behavioral changes.
Presentation: 6/3/2024
8812 Incidence And Clinical Experience Of Immune Checkpoint Inhibitors-Induced Endocrine Side Effects Among Filipino Cancer Patients: A Single-Center Retrospective Study
Authors: Luna N B , Mendoza E , Kho S A 
Published: October 2024

Abstract
Disclosure: N.B. Luna: None. E. Mendoza: None. S.A. Kho: None.
Incidence And Clinical Experience Of Immune Checkpoint Inhibitors-Induced Endocrine Side Effects Among Filipino Cancer Patients: A Single-Center, Retrospective Study Immune checkpoint inhibitors (ICIs) serve as immunomodulatory antibodies, which enhance the immune system and substantially improve the prognosis for patients with advanced malignancies [1]. Referral to endocrinology have been increasing because ICIs were associated with endocrine-related adverse effects including hypothyroidism, hyperthyroidism, diabetes, hypophysitis and adrenalitis. Hence, the study aimed to retrospectively determine the local prevalence and profile of Filipino patients who developed endocrinopathies during ICI therapy at the University of Santo Tomas Hospital (USTH), Manila, Philippines from 2013-2019. A single-center retrospective study of ICI-treated cancer patients with serial biochemical and/or radiologic monitoring of endocrine adverse effects was done upon approval by the Research Ethics Committee. A total of 27 subjects were included with a median age of 60 years and male predominance. Pembrolizumab consisted 93% of the ICIs given. The incidence of thyroid dysfunction was 36% (18% overt hypothyroidism, 9% subclinical hypothyroidism, and 9% subclinical hyperthyroidism). The median time at risk for development of overt hypothyroidism is 4 weeks with median TSH level of 9.05 uIU/mL from baseline level of 3.77 uIU/mL. All patients who had baseline hypothyroidism worsened with increase from baseline levothyroxine dose by 50 to 230% in order to achieve euthyroidism (p 0.037). Serial monitoring was done every 2 weeks until euthyroidism. ICIs were temporarily put on hold in 75%. Diabetes (p 0.05), renal carcinoma (p 0.001) and dose of 200mg (p 0.42) were associated to developing overt hypothyroidism. Checking of glycemic levels was not routine among non-diabetic patients. Fifteen percent of diabetic patients had worsening of control (median HbA1c 8.5% [8-9] and 23% were newly diagnosed pre-diabetes (median fasting glucose 114mg/dL [104-120]). With the available imaging results, there were no abnormal adrenal metabolic uptake on PET scan and no evidence of hypophysitis in pituitary MRI. In conclusion, overt hypothyroidism is a common occurrence during ICI therapy (18%). Worsening occurred among all patients with hypothyroidism at baseline. New-onset pre-diabetes and worsening of glycemic control were seen in 15 and 23%, respectively. Serial clinical and biochemical monitoring is important and referral to endocrinology should be made if deemed necessary. [1] L Agrawal, A Bacal, S Jain, V Singh, N Emanuele, Ma Emanuele & F Meah (2020) Immune checkpoint inhibitors and endocrine side effects, a narrative review, Postgraduate Medicine, 132:2, 206-214, DOI: 10.1080/00325481. 2019. 1709344
Presentation: 6/1/2024
5074 Licorice Root Supplement As A Cause Of Hypokalemic Hypertension
Authors: Gill Gurbir , Harman Sherman Mitchell , Robles Lydia Alejandra 
Published: October 2024

Abstract
Disclosure: G. Gill: None. S.M. Harman: None. L.A. Robles: None.
A 67-year-old female Veteran presented to an emergency room with a one-day history of high blood pressure, chest tightness, and exertional dyspnea. Her blood pressure was 162/90 mm Hg, pulse regular at 71 BPM, and pain level 5/10. She had a history of hypertension, stable on hydrochlorothiazide alone, hyperlipidemia, anxiety, and depression. Physical exam was benign. EKG revealed normal sinus rhythm at 60 BPM, normal axis, a prolonged QT interval of 510 ms, and no ST changes. Lab evaluation showed a low potassium of 2.4 mEq/L, sodium 145 mEq/L. Other lab measurements (CBC, liver function tests and cardiac enzymes) were within laboratory reference ranges. Medications included topiramate for migraine and over-the-counter supplements for constipation, “thyroid health,” and a topical “testosterone booster” prescribed by a non-allopathic practitioner. Her hypokalemia was attributed to hydrochlorothiazide and topiramate and both were discontinued. She was started on nifedipine for blood pressure control and 40 mEq/day of potassium for hypokalemia. Within 2 weeks of discharge, she presented again with elevated blood pressure and a plasma potassium of 4.0 mMol/L. Further history revealed that her constipation supplement consisted of licorice root (glycyrrhiza glabra) extract 900 mg per capsule, of which she took 3 to 4 capsules daily. The patient was advised to discontinue all supplements. Thyroid function tests were within normal limits. Due to a suspicion of hyperaldosteronism, the ED physician requested an abdominal CT scan which showed a 1 cm, -17.5 Hounsfield unit, right adrenal nodule. Also consistent with hyperaldosteronism, plasma renin activity (PRA) was suppressed at 0.07 ng/mL/hr. However, a serum aldosterone level was less than 1 ng/dL. Her 24-hour urinary metanephrines were normal and a 24-hour urine free cortisol was 31.6 mcg/dL. Morning plasma cortisol was 5.1 mcg/dL. A tentative diagnosis of licorice-induced hyperaldosteronism was made and the patient was treated with a taper of spironolactone. After discontinuing spironolactone, blood pressure was 116/70mmHg and serum potassium was 4.5 mMol/L with a PRA of 0.66 ng/mL/hr and serum aldosterone of &lt;5.0 ng/dL. The syndrome of factitious hyperaldosteronism due to licorice consumption has been well described. The mechanism, inhibition of renal (type 2) 11-beta-hydroxysteroid dehydrogenase by glycyrrhizic acid, allowing cortisol to exercise its considerable mineralocorticoid action, is well understood. Most prior reports have been in patients habitually consuming licorice candy, usually imported, since conventional licorice sold in the U.S. is artificially flavored. Our report illustrates the importance of obtaining a history of use of over-the-counter supplements and assessing their ingredients and the fact that presence of an adrenal nodule and a low PRA does not always indicate endogenous hyperaldosteronism.
Presentation: 6/2/2024
7115 Long-Term Exposure To Air Pollution And Precocious Puberty In Korea
Authors: Choi Jung Eun , Oh Jongmin , Lee Ro Sie , Mun Eunju , Kim Kyung Hee , Ha Eunhee , Kim Hae Soon 
Published: October 2024

Abstract
Disclosure: J. Choi: None. J. Oh: None. R. Lee: None. E. Mun: None. K. Kim: None. E. Ha: None. H. Kim: None.
Backgrounds and Aims The increasing prevalence of precocious puberty is emerging as a significant medical and social problem worldwide. However, limited research has investigated the relationship between long-term air pollution exposure and precocious puberty. We aimed to investigate the association between long-term air pollution exposure and first onset of precocious puberty in South Korea, nationwide. Methods: We investiagted a retrospective cohort using Korea National Health Insurance Database. Children born from 2007 to 2009 were followed-up from the age of six (2013 to 2015). We included boys aged ≤10 years and girls aged ≤ 9 years who visited hospitals for early pubertal development and were diagnosed with precocious puberty according to the ICD-10 (E228, E301,and E309) and gonadotropin-releasing hormone agonist (GnRHa) treatment. We conducted the association between long-term air pollution exposure and first onset of precocious puberty using a Cox proportional hazard model. We estimated the hazard ratios (HR) and 95% confidence intervals (CI) per 1 μg/m3 increase for fine particulate matter (PM2.5) and particulate matter (PM10) and per 1 ppb increase for sulfur dioxide (SO2), nitrogen dioxide (NO2), and ozone (O3). Results: A total of 1,205,784 childrens aged six years old were included during 2013­-2015. A positive association was found that the association between 48-month moving average PM2.5 (HR: 1.019, 95% CI: 1.012, 1.027), PM10 (HR: 1.009, 95% CI: 1.006, 1.013), SO2 (HR: 1.037, 95% CI: 1.018, 1.055), O3 (HR: 1.006, 95% CI: 1.001, 1.010) exposure and precocious puberty in girls. In contrast, no association was found in boys. Conclusions Our findings supported that long-term exposure to air pollution is associated with an increased risk of precocious puberty. The study provides valuable insights into the harmful effects of air pollution during childhood and adolescence, emphasizing that air pollution is a modifiable risk factor that can be managed and improved.
Presentation: 6/1/2024