bluuebunny/crossref_metadata_2025_split huggingface dataset:
FRI507 Thyrotoxic Periodic Paralysis: A Rare Occurrence Of Exogenous Thyroid Replacement
Authors: Case James , Suravajjala Devi , Eranki Vijay 
Published: October 2023

Abstract
Disclosure: J. Case: None. D. Suravajjala: None. V. Eranki: None.
Thyrotoxic periodic paralysis (TPP) occurs suddenly through excess thyroxine in tandem with insulin spurring an intracellular shift of potassium via increased activity of Na+/K+ ATPase pump leading to depletion of extracellular potassium with subsequent destabilization of cellular membranes and ensuing paralysis presenting with proximal muscle weakness of the legs. Common triggers involve vigorous exercise, infection, carbohydrate-rich meals, thyroiditis and graves' disease. Patients may be treated with IV potassium, non-selective beta blockers and treating the underlying cause. Exogenous thyroid hormone replacement causing iatrogenic hyperthyroidism as a cause of TPP is very rare. We present one such case below. A 61-year-old male with a history of primary hypothyroidism on thyroid replacement, atrial fibrillation, diabetes mellitus and hypertension, was admitted in September 2019 for lower extremity weakness at which time he was found with hypokalemia; he symptomatically improved following potassium replacement. He had a similar hospitalization in October, 2022 at which time he was found to have weakness alongside hypokalemia and hypomagnesemia, both of which were replaced with symptomatic improvement. He presented as an outpatient for follow up with likely etiology being TPP. Upon further review he had been taking both LT4 (Synthroid) 75mcg daily and T4/T3(Armour) 60mg daily; of note his TSH had been suppressed since 2019, three years prior to presentation. He was unsure why he had been on combination therapy. At our initial visit his labs were: TSH &lt;0.005mIU/mL, free T4 1.38 ng/dL and T3 199 ng/dL. He was advised to stop all thyroid hormone replacement and experienced symptomatic improvement with normalization of potassium and magnesium. Repeat TFTs are pending for appropriate replacement dosing. Recognition of TPP and distinguishing from other etiologies of lower extremity weakness as well as other forms of periodic paralysis would aid in early resolution of an easily treatable, yet severe, condition given the implications of prolonged hypokalemia; earlier recognition of TPP in this patient as a sign of thyrotoxicosis may have prevented later hospitalizations and reduced risk of development of atrial fibrillation. This case also demonstrates the need for adequate monitoring and dosing of thyroid hormone supplement as well as potential complexities and risks of combination therapy in preventing an exogenously induced thyrotoxic state.
Presentation: Friday, June 16, 2023
FRI508 A Case Of Durvalumab Induced Hypothyroidism
Authors: Cecilio La Riva Estefania Del Valle , Acosta Crystal , Manzano Alex J 
Published: October 2023

Abstract
Disclosure: E.D. Cecilio La Riva: None. C. Acosta: None. A.J. Manzano: None.
Background: Immune checkpoint inhibitors (ICIs), like Durvalumab, have become a mainstay in cancer treatment as they have significantly improved survival rates, especially for lung cancer. These treatments, however, have been associated with immune-related adverse events (irAEs) including dermatological manifestations, gastrointestinal symptoms, and endocrinopathies. Clinical Case: A 62-year-old male was diagnosed with a poorly differentiated adenocarcinoma with signet ring cell features stage IIIA of the right upper lobe with concurrent prostate cancer who was initially started on chemotherapy with Cisplatin/Pemetrexed for two months (four cycles) and radiation. He was subsequently started on Durvalumab. Thyroid function tests were performed after starting Durvalumab and TSH was 3.46 mlU/L (reference range: 0.40-4.50), Free T4 was 1.2 ng/dL (reference range: 0.8-1.8) and Free T3 was mildly elevated at 4.3 pg/mL (reference range: 2.3-4.2). The patient remained asymptomatic until about 12 weeks later when he began feeling occasional episodes of anxiety and shortness of breath with fatigue that was brought on at random instances. Thyroid function tests at that time showed an undetectable TSH at &lt;0.01, an elevated free T3 at 4.9, and a normal free T4 at 1.6. Immunotherapy was continued and the patient was referred to endocrinology. Repeat thyroid function tests 8 weeks later showed an elevated TSH at 19.55, decreased free T4 at 0.7, and a normal free T3 at 3.1. The patient was started on levothyroxine at that time with improvement of his symptoms. Upon follow-up 4 weeks later, TSH was found at 30.56 and free T4 at 0.9 which improved with levothyroxine dose adjustment. Conclusion: The case of a patient with thyroiditis beginning as transient hyperthyroidism on Durvalumab is described. Hypothyroidism occurs in about 1.82% of patients on ICIs, with more common occurrences on Nivolumab (51.38%) and Pembrolizumab (24.44%). The incidence of hypothyroidism and thyroiditis on Durvalumab is about 3.11% and 2.04% respectively. Thyroid dysfunction with ICIs occurs with PD-1/PD-L1 blockade and an inflammatory, destructive thyroiditis can be seen. Routine monitoring of thyroid function should be performed before and throughout treatment with an ICIs. Preexisting autoimmune thyroid disease may be a risk factor for developing thyroid disease during treatment, but this has not been well studied. Meta-analysis has shown that preexisting autoimmune disease was a risk factor for irAE incidence. This case highlights the importance of proactive monitoring of thyroid function during treatment.
Presentation: Friday, June 16, 2023
FRI511 Bexarotene: A Deceptive Cause Of Iatrogenic Hypothyroidism
Authors: Ghaith Sarah , Ramachandran Aishwarya , Alcorn Chris , Amer Farah , Thompson Alicia , Ramachandran Akshaya 
Published: October 2023

Abstract
Disclosure: S. Ghaith: None. A. Ramachandran: None. C. Alcorn: None. F. Amer: None. A. Thompson: None. A. Ramachandran: None.
Background: Bexarotene, an antineoplastic agent used for the treatment of cutaneous T cell lymphoma, is associated with a rapid and profound suppression of thyrotropin, which may lead to central hypothyroidism. Case: A Seventy-four-year-old female with a recent diagnosis of Cutaneous T cell lymphoma presented with a 1-week history of progressive fatigue, lightheadedness, and night sweats. She was found to have hypotension and hypothermia. She was started on oral Bexarotene chemotherapy 225 mg daily five days prior to admission. The physical exam was unremarkable except for sinus bradycardia and hypothermia. Labs were significant for TSH 0.48 [0.4-4.2 uIU/mL] dropped from 3.3 uIU/mL one week prior, FT4 0.5 [0.8-1.7 ng/dL] and Total T3 111 ng/dL [87- 187 ng/dL] consistent with central hypothyroidism. Bexarotene was held during her hospitalization per hematology recommendations. The patient was started on Levothyroxine 50 mcg, which was later advanced to 75 mcg daily based on free T4 levels. At one month follow up, free T4 level normalized while on Levothyroxine and Bexarotene was restarted again by her hematologist. Discussion: Bexarotene, an antineoplastic agent approved for treating cutaneous T cell lymphoma, can rapidly suppress TSH levels by directly inhibiting its secretion and affect thyroid hormone metabolism, leading to central hypothyroidism. The degree of suppression of TSH increases with higher doses of Bexarotene while reduction in free T4 and TSH are reversible. Patients already receiving thyroid hormone therapy may require increased thyroid hormone doses to achieve therapeutic levels. If bexarotene is permanently discontinued, levothyroxine can either be stopped or can be resumed to doses used prior to bexarotene therapy. Recovery of thyroid function usually occurs within weeks of Bexarotene discontinuation. Conclusion: Oral Bexarotene can cause central hypothyroidism therefore, thyroid function tests should be measured at baseline and treatment. Thyroid hormone replacement should be considered if central hypothyroidism is suspected.
Presentation: Friday, June 16, 2023
SAT554 Follicular Variant of PTCA Initially Presenting with Widespread Metastases
Authors: Natividad Bisquera Nichole Andrea , Mirasol Roberto Cachola 
Published: October 2023

Abstract
Disclosure: N.N. Bisquera: None. R.C. Mirasol: None.
Background: Papillary thyroid carcinoma accounts for most cases of thyroid cancer. Most cases of PTC have a good prognosis and low incidence of metastases. The follicular variant is the most common variant. First described in the 1960’s, the understanding of FV-PTC began to evolve with molecular profiling demonstrating a similarity with FTC, and clinical behavior profiling showing that a subtype may behave like PTC with a propensity for lymph node metastases. We are presented with an unusual case of an infiltrative FV-PTC presenting with widespread multiple metastases on diagnosis. Clinical Case: A 64-year-old female, presented with 1-year history of a slowly enlarging mass on the left mandible, which was also associated with an enlarging anterior neck mass. She had no constitutional symptoms and had previously been in good health. On examination, there was a 7x8x3 cm hard, fixed left mandibular mass. There was also a palpable right thyroid nodule measuring 2.5x2 cm. There was no difficulty in swallowing or breathing, but she had some difficulty in eating due to trismus. There were no associated symptoms of hypo/hyperthyroidism. Investigations revealed a euthyroid status. CT scan showed a solid lobulated heterogeneously enhancing mass measuring 4.2x5.1x5.2cm on the body and angle of the left mandible. Ultrasound showed multiple thyroid nodules, the largest - a mixed cystic and solid mass measuring 2.9 x 2.7 x 2.17 cm on the right thyroid lobe, for which FNA was performed. Histopathology showed benign follicular nodules. Incision biopsy of the mandibular mass showed presence of thyroid tissue. Further imaging showed metastases to the left frontal, parietal bone, T7 vertebra, and bilateral lungs. The case was discussed in a multi-disciplinary tumor board meeting. With a pre-operative diagnosis of a primary thyroid malignancy, the patient then underwent a total thyroidectomy with segmental mandibulectomy. Post-operative histopathology showed a metastatic multifocal infiltrative follicular variant of PTC. RAI was administered post-surgery, and she was started on suppressive thyroxine therapy. Steroids were given during RAI, with no untoward events post treatment. Post-ablative whole body scanning revealed increased tracer uptake in multiple areas: left frontal and parietal bone, bilateral thyroidal beds, left supraclavicular lymph node, the sternomanubrial junction, bilateral lung lobes, right humeral head and T7 vertebra. Further doses of RAI was planned and she is currently maintained on suppressive thyroxine therapy. Conclusion: Diagnosis of FV-PTC may be a greater challenge than conventional forms because of possible false-negative results on cytology. The infiltrative subtype has greater metastatic potential and higher recurrence rates. Multidisciplinary team management and careful preparation prior to treatment with RAI is indicated in these cases.
Presentation Date: Saturday, June 17, 2023
SAT312 CT-guided Cryoablation Of Hereditary Pheochromocytoma
Authors: Griffing Emily , Reading Brenton , De Luca Francesco 
Published: October 2023

Abstract
Disclosure: E. Griffing: None. B. Reading: None. F. De Luca: None.
Background: Guidelines surrounding the management of hereditary pediatric pheochromocytomas (PHEO) are lacking. This is the first report of a pediatric patient with bilateral hereditary PHEO treated with right adrenalectomy and computed tomography (CT) percutaneous-guided cryoablation (CRA) of the left-sided lesion.Clinical case: A previously healthy 15 years-old male presented to a tertiary care hospital with a months-long history of episodic chest pain, flushing, shortness of breath, diaphoresis, and tremulousness. Paternal family history was significant for PHEO and brain stem hemangioblastoma in grandmother and PHEO in the great-grandfather. Targeted familial mutation analysis of the von Hippel-Lindau tumor suppressor gene was positive for pathogenic mutation c.500G&gt;A (p.R167Q). Plasma free normetanephrine level was 4,625 pg/mL (nl: &lt;145 pg/mL), while free metanephrines were normal. Magnetic-resonance imaging of the abdomen visualized a 4.4 x 3.4 x 5.3 cm right adrenal mass and a 1.4 x 1.4 x 1.4 cm left adrenal mass, consistent with bilateral PHEO. He underwent right adrenalectomy after initiation of alpha-receptor blockade and later addition of beta-receptor blockade due to heart rates in the 150’s. After discussion with parents, it was decided to observe the smaller left-sided adrenal lesion. Plasma free normetanephrines initially decreased to 338 pg/mL, but then increased to 507 pg/mL five months post-operatively. Six months after surgery, due to the persistence of hypertension with systolic blood pressure in the 140’s as well as tachycardia with heart rates in the 150’s, he underwent CT-guided CRA of the left-sided PHEO. A 12-minute freeze, 5-minute thaw, and 10-minute freeze, followed by an active thaw were performed. There was an increase in blood pressure during the initial thaw with systolic blood pressure in the 230s, accompanied by bradycardia to the 30s, treated with nitroprusside, phentolamine, and increased sedation. He required continuation of nitroprusside infusion for five hours post-procedure. He was discharged the following day with normal blood pressure and heart rate. He was able to completely wean off anti-hypertensive medications within one month and symptoms of chest pain and tachycardia resolved. In the four years since his procedure, he has not had a recurrence of PHEO nor development of adrenal insufficiency. Plasma free normetanephrines and metanephrines have remained within normal limits. Conclusion: Percutaneous ablation of hereditary PHEO has not been reported before in the pediatric population and may represent a novel treatment strategy that reduces the risk of adrenal insufficiency.
Presentation: Saturday, June 17, 2023
THU420 Analysis Of Factors Affecting Bone Mineral Density In Children And Adolescents With Systemic Lupus Erythematosus
Authors: Ahn Moon Bae , Park Su Jin , Suh Byung-Kyu 
Published: October 2023

Abstract
Disclosure: M. Ahn: None. S. Park: None. B. Suh: None.
Background: Children and adolescents with chronic disease are at risk of developing bone fragility. In particular, low bone mineral density(BMD) is increasingly recognized in pediatric patients with glucocorticoid treated rheumatic disease. The purpose of this study was to evaluate the clinical characteristics of children and adolescents with systemic lupus erythematosus(SLE), and to analyze the factors associated with a lower BMD in these patients.
Methods: Children and adolescents diagnosed with SLE who had received GC treatment were included. Clinical and laboratory data including anthropometry, GC exposure, other anti-rheumatic drug treatment, biochemical markers related to bone metabolism, serologic markers of disease activity in SLE, lateral thoracolumbar(D-L) spine radiography, and BMD were collected. Lumbar spine bone mineral density (LSBMD) was measured by Dual-energy x-ray absorptiometry(DXA). The correlation between BMD and anthropometry, steroid and anti-rheumatic treatment, biochemical variables was investigated. Results: A total of 30 patients with median age of 17.5 years (range 12 -25years) were included. Of the 29 patients who had DXA done, 7 patients had LSBMD z score lower than −2.0, and diagnosed as osteoporosis. SLE patients with osteoporosis were compared with those with a z score higher than −2.0. These patients had longer GC exposure, higher cumulative GC dose, longer hydroxychloroquine exposure. The main factor correlated with a low BMD was duration of GC exposure. BMD was positively correlated with height at diagnosis. Bone metabolic markers and serologic markers of disease activity in SLE had no significant correlation with BMD. Conclusion: Children and adolescent SLE patients with OP had longer GC exposure, higher cumulative GC dose compared with those with LSBMD z score higher than −2.0. The main factor correlated with a low BMD was duration of GC exposure. Therefore, efforts should be made to reduce the duration of GC exposure and reduce medication to the lower possible maintenance dose. Since longer treatment duration affects BMD, close monitoring during the treatment period is recommended to prevent further loss of bone mass in pediatric SLE patients.
Presentation: Thursday, June 15, 2023
FRI650 Effectiveness Of Non-pharmacological Strategies In The Management Of Type 2 Diabetes In Primary Care: A Systematic Review And Network Meta-analysis
Authors: Giacomini Occhiuto Renata , Banzato Luisa , Lucia Mendes Adriana , Bolfi Fernanda , Santos Nunes-Nogueira Vania dos 
Published: October 2023

Abstract
Disclosure: R.G. Occhiuto: None. L. Banzato: None. A.L. Mendes: None. F. Bolfi: None. V.D. Nunes-Nogueira: None.
Introduction: Despite the increasing number of drugs and various guidelines on the management of type 2 diabetes mellitus (T2DM), several patients continue with the disease uncontrolled. There are several non-pharmacological treatments available for managing T2DM, but various of them have never been compared directly to determine the best strategies. Objective: This study has evaluated the comparative effects of non-pharmacological strategies in the management of T2DM in primary care or community settings. Methods and Analysis: We have performed a systematic review and network meta-analysis (NMA) and have include randomized controlled trials if non-pharmacological strategies in the management of type 2 diabetes were applied in adult patients with T2DM in primary care. The primary outcome was glycemic control (glycated hemoglobin [HbA1c] [%]). We have developed search strategies for Embase, Medline, Latin American and Caribbean Health Sciences Literature, Cochrane Central Register of Controlled Trials, Trip database, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Australasian Medical Index, and Chinese Biomedical Literature Database. Four reviewers have assessed the studies for their eligibility and their risk of bias in pairs and independently. A NMA have been performed using Stata Statistical Software 17 (Stata Statistical Software: Release 17. College Station, TX, StataCorp LLC, USA). Results: After removing duplicates, the search strategies yielded 4314 studies. After a thorough evaluation of the references, 129 studies encompassing a total of 35975 individuals have been included in this review. Twenty and three strategies were founded. The most frequent strategy was diabetes self-management and support (DSMES) (60%), followed by diabetes self-management education (22%), self-monitoring of blood glucose (7%) and health coach (5). The most frequent comparator has been usual care (92%). Regarding relative rankings of treatments, the NMA has showed that nutritional therapy plate method has a 37.6% probability of being the best treatment in terms of HbA1c reduction, followed by DSMES associated with social support (24%) and low-fat diet (19.6%). Conclusion: This review has founded 23 non-pharmacological strategies in the management of type 2 diabetes in primary care, being the most frequent DSMES. Grant FAPESP:2021/07229-0
Presentation: Friday, June 16, 2023
FRI665 Hirata's Syndrome: Autoimmune Hypoglycemia Diagnostic Pathway, A Mexican Case Report
Authors: De La Cruz German Gonzalez , Porras Farret Diego 
Published: October 2023

Abstract
Disclosure: G. Gonzalez De La Cruz: None. D. Porras Farret: None.
Introduction: Autoimmune hypoglycemia or Hirata syndrome is a very rare cause of hypoglycemia in western populations, as an example, in Mexico until 2015, there was only a single case reported with these characteristics. Diagnosis is based on episodes of spontaneous, fasting or postprandial hypoglycemia, with endogenous hyperinsulinism, without pancreatic lesions on imaging and positive tests. Objective: To describe the approach to a patient with hypoglycemia, specifically to those with characteristics of autoimmune hypoglycemia syndrome, as well as the general approach to hypoglycemia of endogenous origin and the differential approach in those with a history of type 2 diabetes or drug use with secondary effects. Case description: An 86-year-old woman with a history of high blood pressure, prediabetes, and osteoporosis, presented episodes of dizziness, palpitations, diaphoresis, and syncope, documenting plasma glucose of 40 mg/dl. She was attended by paramedics responding adequately to oral glucose. She was evaluated by Cardiology, Holter was performed with predominant sinus rhythm, frequent atrial extrasystoles (2%) and infrequent ventricular extrasystoles. Next, she was referred to Endocrinology for evaluation and treatment, she was taken empagliflozin as prediabetes medication, and it was suspender. Laboratory studies are requested to address hypoglycemia, with serum insulin levels greater than 600 mU/l, c-peptide 3.9 ng/ml, TSH 6.1, T4T 7.5, T3T 67.8, T4L 1.1, ALT 26 U/L, AST 18 U/L, DHL 247 U/L, GGT 26 U/L, Cortisol 13.8 mcg/dl. An MRI of the upper abdomen was performed where there is no evidence of pancreatic injury. A profile of serum hypoglycemic agents (sulfonylureas in blood) was requested, which were not detected. Subsequently, anti-insulin studies were requested, which were reported in amounts greater than 100 U/ml. The diagnosis of autoimmune hypoglycemia syndrome was made, starting management with prednisone 70 mg every 24 hours, in addition to dietary changes. Conclusion: The approach to hypoglycemia in patients without clear evidence of exogenous administration of hypoglycemic agents must be ordered, taking into account differential diagnoses such as autoimmune causes. In the case of autoimmune hypoglycemia, remission is expected at 6 months, with constant monitoring and adjustment of drugs for underlying pathologies.
Presentation: Friday, June 16, 2023