bluuebunny/crossref_metadata_2025_split huggingface dataset:
FRI500 Atypical Case Of Undifferentiated Shock
Authors: Vadini Vidhu , Vasistha Prabhav 
Published: October 2023

Abstract
Disclosure: V. Vadini: None. P. Vasistha: None.
Introduction: Shock is encountered frequently in the ICU. Undifferentiated shock, however, poses a diagnostic challenge. The differentials and work up are broad and time sensitive. Endocrinopathies are a known etiology but thyroid cardiomyopathy causing cardiogenic shock is rare. Clinical case: A 78 y old man presented to the ER with hypotension that did not improve after administration of 2.5 L IV fluids. Vasopressors were initiated and he was admitted to the ICU. Patient reported 2-month history of generalized weakness, nausea, vomiting, falls and poor oral intake. Review of systems was notable for 20-pound weight loss in 6 months, dyspnea with exertion, loss of appetite and occasional diarrhea. On exam, patient was afebrile, hypotensive 80/40, PR 87, O2 saturation &gt; 90% on room air. He appeared pale with JVP measured at 11 cm of water. Pulse was irregular, heart sounds normal without murmurs. Bilateral lower extremities were mildly edematous. Strength in lower extremities was 4/5 proximal and distally. Labs were notable for normocytic anemia, troponin 1.05, elevated anion gap 18, lactate 1.8, creatinine 3.3 from a baseline of 1 and BNP 1425. ECG showed sinus rhythm with frequent premature atrial contractions. Chest Xray on admission was unremarkable. Additional labs were negative drug screen, normal cortisol, urinalysis. Blood cultures were sent. Overnight, the patient developed tachycardia and atrial fibrillation with rapid ventricular rate. Cardiology was consulted, bedside echo was suspicious for low left ventricular ejection fraction. The patient was anticoagulated with heparin. TSH was sent. He was requiring 2 vasopressors to maintain MAP&gt;65. CT chest abdomen pelvis was unremarkable except stable pulmonary nodule. Patient became hypoxic on Day 2 of admission, CXR now showed features of pulmonary edema. TSH returned less than 0.01, free T4 4.69 Endocrinology was consulted, methimazole was started for thyrotoxicosis. Formal TTE showed LVEF 20-25% with global reduction in left ventricular contractility, dilated left atrium and mild MR. He was given furosemide for pulmonary edema. TSI and TRAB were positive indicating Grave’s disease. He was successfully transferred out of the ICU. Patient gradually became euvolemic with significant improvement in energy, appetite and functional capacity. He was able to participate in physical therapy and was eventually discharged to rehab. Conclusion: This case addresses an uncommon but potentially life-threatening cause of undifferentiated shock. Physical exam, history and high degree of suspicion are key in early identification and treatment. Although thyroid cardiomyopathy is rare, Grave’s disease is common and ruling our thyrotoxicosis should be included in preliminary work up of undifferentiated shock.
Presentation: Friday, June 16, 2023
FRI504 Ectopic Hyperactive Mediastinal Thyroid Tissue: A Case Report
Authors: Dimech Christina , Jaiswal Gayatri , Bhargava Amit 
Published: October 2023

Abstract
Disclosure: C. Dimech: None. G. Jaiswal: None. A. Bhargava: None.
Ectopic thyroid tissue is usually located along the normal path of the caudal migration of thyroid tissue during embryonic life. Substernal goiters are thought to occur by either the enlargement of ectopic mediastinal thyroid tissue (primary mediastinal goiter) or abnormal extension of thyroid issue into the superior mediastinum (secondary mediastinal goiter). Typically these goiters remain asymptomatic, and rarely result in hyperthyroidism or local compression of the surrounding area. We report a case of an 89-year-old Caucasian female with history of a multinodular goiter status post right hemithyroidectomy, who initially presented for subclinical hyperthyroidism. Further evaluation revealed negative thyroid stimulating antibodies. A thyroid ultrasound demonstrated a surgically absent right lobe, with a small heterogenous left lobe. A nuclear medicine radioactive iodine uptake and scan showed hypermetabolic residual thyroid tissue with a large area of increased radiotracer uptake projecting over the right anterior chest, concerning for ectopic thyroid tissue. A subsequent chest CT without contrast revealed an approximately 5 centimeter partially calcified anterior mediastinal/retrosternal mass. Given the patient’s age and co-morbidities, a decision was made to treat the hyperthyroidism with methimazole and monitor the ectopic tissue for worsening symptoms of compression. In cases with severe compressive symptoms, or difficult to treat hyperthyroidism, a surgical option must be considered.
Presentation: Friday, June 16, 2023
FRI558 Hidden Cause Of Decreased Fertility Rate During Grave’s Disease
Authors: Kutchukhidze Tinatin , Khurodze Tea 
Published: October 2023

Abstract
Disclosure: T. Kutchukhidze: None. T. Khurodze: None.
Introduction: Thyroid autoimmune disorders interfere with the physiology of reproduction, cause premature ovarian aging, and mimic the early stage of menopause. Recently, no specific research was made to measure Grave’s disease and infertility rates in young patients. Case Report: Due to an inability to conceive for two years, a 24-year-old Caucasian female was referred to the clinic with typical symptoms and complaints of Grave's disease. She has a family history of Grave’s disease and Diabetes mellitus. Ultrasound confirmed the presence of a highly vascularized non-homogeneous hyperplastic thyroid gland. A thyroid scan with Tc99m revealed generalized increased uptake. Laboratory investigations showed a decrease in TSH-&lt;0.005mIU/ml (n.0.4mIU/ml - 4.0mIU/ml), elevated FT4-31.8 pmol/l (n.8.0pmol/l-22.0pmol/l), FT3- 9.69pmol/l (n3.4 pmol/l-6.76pmol/l) and positive Anti-TG -190.05 AU/ml (n&gt;150), Anti-TPO -75.7 IU/ml (n&gt;75) Anti-TSHR-27.3 IU/l (n&gt;1,5). Prolactin and gonadal hormones were within normal limits AMH - 1.8 ng/ml(n1.52ng/ml-9.95ng/ml), FSH- 6mIU/ml(n3.9mIU/ml-12.4mIU/ml). The patient was started on Methimazole and Beta-blocker. While decreasing the Methimazole dosage for further discontinuation, disease recurrence developed, and a total thyroidectomy was performed. Postoperatively, the patient was maintained on Levothyroxine. After 6 months of follow-up due to irregular Levothyroxine intake, the patient reached a hypothyroid status, during which, the patient had 2 consecutive spontaneous pregnancies, from which, one ended with spontaneous miscarriage in the early weeks of pregnancy and another, ectopic pregnancy treated with right salpingectomy. HSG confirmed weak left fallopian tube patency. After several months of keeping TSH below 2.5 mIU/ml, IVF treatment was scheduled. The results of the infertility workup showed a decrease in ovarian reserve AMH - 0.163ng/ml (n1.52ng/ml-9.95ng/ml), FSH-16.23 mIU/ml(n3.9mIU/ml-12.4mIU/ml), due to it, modified natural cycle IVF was performed. She received 2 oocytes and 2 embryos. One high-grade blastocyst was transferred in a fresh cycle that ended with pregnancy and delivery. The child was born without a genetic disorder but with natal teeth. Conclusion: This is a rare case of infertility with diminished ovarian reserve due to Grave’s disease. A pregnancy was reached by proper correction of thyroid hormonal parameters and modified natural cycle IVF. It indicates a possible need for close monitoring of the functional ovarian reserve in patients planning pregnancy even in the young age group.
Presentation: Friday, June 16, 2023
SAT546 Papillary Thyroid Cancer Surveillance: Thyroglobulin Levels Affected by HAMA
Authors: Perez Julienne Sanchez , Obeid Michele , Fariduddin Maria , Toft Daniel Joseph 
Published: October 2023

Abstract
Disclosure: J. Sanchez Perez: None. M. Obeid: None. M. Fariduddin: None. D.J. Toft: None.
Introduction: Thyroglobulin (TG) measurement is a major means of detecting recurrence of previously treated differentiated thyroid cancers. Human-Anti Mouse Antibodies (HAMA) can interfere with lab measurements of TG levels and affect clinical decisions and treatment for these cancers.Clinical Case: A 65-year-old female was diagnosed with papillary thyroid cancer (PTC). Surgical pathology following total thyroidectomy demonstrated a tumor of 3.5 cm in its greatest dimension, unifocal, without invasion of locoregional tissue classified as Stage I (pT2N0M0) per AJCC 8th edition. Radioiodine whole body scan (WBS) demonstrated iodine uptake in the neck and 126.5 mCi of I-131 was given. In surveillance 5 years later, TSH was found to be 0.17 mcIU/ml (ref range: 0.35 - 4.00) TG 64.7 ng/ml (ref range: 1.3 - 31.8 ng/mL), and anti-Tg antibodies were undetectable. Neck US consistently showed nonspecific findings of stable small nodes with normal morphology in both supraclavicular regions. Given elevated TG levels, 250 mCi of I-131 was given. Follow-up TG levels ranged from 27.8 to 36.4 ng/ml. A repeat WBS did not reveal any uptake, but as TG remained elevated, I-131 (238 mCi) was again given. Subsequent TG throughout the following 15 years ranged from 2.8 - 58.6 ng/ml. Repeat Neck US only showed benign-appearing lymph nodes. WBS did not have any focal activity to suggest recurrent disease and PET/CT did not show any abnormal FDG uptake. The persistently high TG levels without clinical evidence of tumor recurrence raised the suspicion of lab interference. The serum sample was treated with a blocking reagent that contained mouse immunoglobulin after which the TG level decreased to 2.7 ng/ml compared to untreated value of 20.5 ng/ml.Conclusion: HAMA are human antibodies against mouse antibodies which are believed to develop in humans from direct contact with rodents, including mice, and from the recent increase in the use of mouse monoclonal antibodies for diagnostic and therapeutic purposes. These antibodies implicate an unexpected source of interference in immunoassays, as seen in our patient, which can confound laboratory results and create a clinical dilemma. This patient with PTC had a complete radiological response after surgery, but an incomplete biochemical response which caused the patient to be given a total of 614 mCi of I-131. This case highlights the importance of recognizing the possible presence of HAMA when analyzing TG levels, particularly when the TG levels are used for treatment decisions.
Presentation Date: Saturday, June 17, 2023
SAT547 Hereditary Paraganglioma: The Rare Co-Existence Of Two Genetic Syndromes Associated With PPGL-pheochromocytoma
Authors: Samuel Kelara 
Published: October 2023

Abstract
Disclosure: K. Samuel: None.
Hereditary Paraganglioma: the rare co-existence of two genetic syndromes associated with PPGL-Pheochromocytoma Kelara Samuel MD, Bryan McIver MD, Colleen Veloski MD, Julie Hallanger-Johnson MD, Valentina D. Tarasova, John Tourtelot MD, George Q. Yang MD, Sarimar Agosto-Salgado MD Background: Paragangliomas are neuroendocrine tumors arising from neural crest chromaffin cells of the autonomic ganglia and can be parasympathetic or sympathetic in nature. Approximately 30 percent of all paragangliomas are hereditary either associated with familial paraganglioma syndromes and other autosomal dominant syndromes, such as multiple neuroendocrine neoplasia 2A and 2B, neurofibromatosis type 1, and von Hippel Lindau disease.Case: A 73-year-old Hispanic female with a past medical history of hypothyroidism, hypertension, hyperlipidemia, and Lupus presented with a large neck mass of 11 years of evolution. An evaluation revealed a large near 12cm hypervascular, hyperenhancing left neck mass that encased the distal common carotid artery, carotid bifurcation, and internal and external carotid arteries and their branches. The multidisciplinary team recommended, given the tumor's extent, a non-surgical localized treatment consisting of radiation. Clinically, the patient had compressive symptoms, including tenderness over the tumor region, hoarseness, dysphagia, and changes in phonation. The patient also had a positive family history of paraganglioma in her grandson and nephew, but specific genetic alteration data from relatives was unavailable. Plasma normetanephrines were 0.68 (normal range 0-0.89), and plasma metanephrines were 0.23 (normal range 0-0.49). Genetic testing was positive for germline alterations in both SDHB p.Q214 and NF1 c.2970_2972delAAT. At this time, there is no evidence of metastatic disease and no clinical manifestations of NF1, suggesting a mild neurofibromatosis phenotype. Restaging imaging revealed an ongoing partial response to radiation and clinically patient has noted a significant improvement in the prior compressive symptoms. Conclusion: We present a case where we see an uncommon presentation of a non-secretory, hereditary paraganglioma with two concomitant rare genetic syndromes. This case highlights the importance of genetic testing for patient-appropriate tumor surveillance and family counseling implications.
Presentation Date: Saturday, June 17, 2023
SAT570 Thyroid Lymphoma In A Patient With Hashimoto’s Thyroiditis
Authors: Aggarwal Tanya , Reyes Stephanny , Glitza Oliva Isabella C , Korytnaya Evgenia 
Published: October 2023

Abstract
Disclosure: T. Aggarwal: None. S. Reyes: None. I.C. Glitza Oliva: None. E. Korytnaya: None.
Background:Primary thyroid lymphoma (PTL) accounts for &lt; 5% of thyroid malignancies. Patients with Hashimoto’s thyroiditis (HT) are at greater risk for developing PTL, with a relative risk of 67 compared to those without thyroiditis. The most common and more aggressive subtype of PTL is diffuse large B cell lymphoma (DLBCL) which is found in more than 50% of the cases, followed by MALT lymphoma and follicular lymphoma (FL), which represents only about 10% of cases. PTL can be classified as a nodular, diffuse, or mixed type based upon ultrasound (US) findings. Diffuse type PTL presents the biggest diagnostic challenge due to resemblance to thyroiditis on US imaging. Certain US features such as enhanced posterior echoes, markedly hypoechoic appearance of thyroid tissue and linear echogenic strands are suggestive of diffuse type PTL but can also be seen in HT. Positive predictive value for US was only 33.7% for diffuse type of PTL. Diagnosis of PTL is ultimately established by biopsy with immunophenotypic assessment. Management of PTL includes chemotherapy, radiation therapy or combined modality treatment. Given sensitivity of PTL to radiation and chemotherapy, surgery is rarely performed and is reserved only for alleviation of severe compressive symptoms in aggressive disease or protection of airway. Case Presentation: A 58-year-old female with 10-year history of HT, hypothyroidism and goiter underwent total thyroidectomy due to worsening compressive symptoms in her neck. She denied weight loss, fevers, or night sweats. Preoperative US showed enlarged heterogenous hypoechoic thyroid gland with echogenic strands and normal vascularity, consistent with the appearance in HT. Surgical pathology unexpectedly showed extensive follicular hyperplasia, focal grade 3b FL (80%), and large foci of DLBCL arising within FL (20%). Background changes of oncocyte metaplasia and lymphocytic infiltrates consistent with Hashimoto Thyroiditis were described. Both cytogenic FISH studies as well as immunohistochemistry failed to reveal MYC and BCL2 and/or BCL6 rearrangements. Positron emission tomography (PET) scan showed mild to moderately fluorodeoxyglucose- avid lymph nodes in the right superior mediastinal, right superior paratracheal and left neck region. The patient has completed 6 cycles of R-CHOP chemotherapy with complete response as evidenced by normal follow up PET imaging. Conclusion:PTL is a rare malignancy and less than 1% patients with Hashimoto’s thyroiditis develop thyroid lymphoma. Diffuse- type PTL should be included in the differential diagnosis while managing patients with HT who present with worsening compressive symptoms involving aerodigestive tract and rapid enlargement of goiter and have markedly hypoechoic thyroid gland with heterogenous internal echoes and posterior acoustic enhancement on US images.
Presentation: Saturday, June 17, 2023
SAT571 When Two Is Too Few: Bethesda IV Pathology On Repeat Thyroid Fine Needle Aspiration
Authors: Godar Cassandra M , Spiro Andrew J , Shakir Mohamed K M , Hoang Thanh D 
Published: October 2023

Abstract
Disclosure: C.M. Godar: None. A.J. Spiro: None. M.K. Shakir: None. T.D. Hoang: None.
Background: The 2015 American Thyroid Association Guidelines for Adult Patients with Thyroid Nodules provide a strong recommendation against routine ultrasound surveillance of thyroid nodules for which two benign fine needle aspiration (FNA) cytology results have been previously obtained. Strict adherence to these guidelines may hinder detection of malignancy, especially in large nodules where there is potential to miss heterogeneous pathology based on sampling technique.
Clinical Case: A 36-year-old female was evaluated for surveillance of a large non-toxic multinodular goiter. Thyroid ultrasound demonstrated a dominant right thyroid nodule greater than 7 centimeters in size. The patient had undergone FNA of this nodule in 2014 and 2019 with Bethesda II (benign) cytopathology results.
A chest x-ray showed tracheal deviation without evidence of narrowing. She noted a sensation of neck pressure without dysphagia or shortness of breath. She denied fatigue, heat or cold intolerance, hand tremor, or pretibial myxedema. She denied a family history of thyroid cancer or any history of neck irradiation. Due to new compressive symptoms a repeat FNA was performed. Three passes were performed with adequate samples, and the final FNA cytopathology demonstrated a Hurthle cell oncocytic-type follicular neoplasm with Bethesda IV classification. The sample was submitted for ThyGeNEXTTM and ThyraMIRv2TM molecular testing, which returned with NRAS q61R mutation of moderate-to-high risk of malignancy (65-75%). The patient was subsequently referred for total thyroidectomy with pending surgery date.
Discussion: The current ATA guidelines offer a cost-effective surveillance strategy for the vast majority of patients with thyroid nodules. False negative FNA results are rare and are reported to occur in about 1% of cases1. As in this vignette, it is reasonable to perform an additional FNA after two consecutive Bethesda II results in nodules with clinically significant growth, new compressive symptoms, or if there is concern for incomplete sampling in nodules of large size. During an FNA, care should be taken to gently move the needle at various angles to capture follicular cells from different areas within a nodule. Large nodules should be sampled via multiple, separate skin entry points when feasible. Judicious use of repeat FNA along with these sampling techniques may help to prevent under-diagnosis in nodules containing multifocal areas of heterogeneous pathology.
Reference: 1) Durante C, Costante G, Lucisano G, Bruno R, Meringolo D, Paciaroni A, Puxeddu E, Torlontano M, Tumino S, Attard M, Lamartina L, Nicolucci A, Filetti S. 2015. The natural history of benign thyroid nodules. JAMA 313:926-935
Presentation: Saturday, June 17, 2023
SAT339 Osteopenia In The Setting of Mild Autonomous Cortisol Secretion
Authors: Mao Jimmy J , McCowen Karen Clare , Choe Charles 
Published: October 2023

Abstract
Disclosure: J.J. Mao: None. K.C. McCowen: None. C. Choe: None.
Jimmy J. Mao, MD (1); Karen C. McCowen (1); Charles H. Choe (1)(1) Division of Endocrinology, Diabetes, and Metabolism, University of California San Diego, La Jolla, CA.
Background: Over 80% of adrenal incidentalomas are benign adrenal cortical adenomas, of which 30-50% are found to have mild autonomous cortisol secretion (MACS). Bone fragility is a known complication of MACS. Clinical Case: A 57-year-old postmenopausal female with no prior history of fracture, venous thromboembolism, and atherosclerotic cardiovascular disease, was referred for incidental bilateral adrenal nodules. Body mass index was normal at 21 kg/m2, and no clinical stigmata of Cushing syndrome were noted on physical exam. Unenhanced computed tomography scan revealed a 4.6 cm right adrenal nodule and a 3.3 cm left adrenal nodule; both nodules measured less than -18 Hounsfield Units.
Biochemical work-up for pheochromocytoma, primary aldosteronism, and non-classical congenital adrenal hyperplasia was negative. Evaluation for hypercortisolism revealed a morning cortisol of 20.3 mcg/dL (ref. 4-22 mcg/dL) with concurrent adrenocorticotropic hormone of &lt;5 pg/mL (ref. 6-50 pg/mL), 24-hour urine free cortisol of 16.9 mcg (ref. 4-50 mcg), and midnight salivary cortisol of 0.07 mcg/dL (ref. &lt;0.09 mcg/dL). A 1 mg dexamethasone suppression test measured on two separate occasions was elevated at 6.3 mcg/dL and 7.9 mcg/dL (ref. &lt;1.8 mcg/dL). A subsequent 8 mg dexamethasone suppression test was also elevated at 6.1 mcg/dL (ref. &lt;1.8 mcg/dL). The diagnosis of MACS was made. A bone mineral density (BMD) scan revealed T-scores at the right femoral neck, left femoral neck, and lumbar spine at -1.6, -1.3, and -0.8, respectively. Ten-year probability of major osteoporotic fracture and hip fracture were 8.3% and 1.0%, respectively. To reduce the risk for future fractures, the decision was made to proceed with adrenal vein sampling (AVS) in preparation for potential adrenalectomy.
Conclusion: MACS is the most frequent hormonal abnormality in adrenal incidentalomas, with an estimated prevalence of 0.8-2 cases per 1000 persons. A previous prospective study found that surgical cure of unilateral MACS may lead to a substantial risk reduction (up to 15-fold) of future incident asymptomatic vertebral fractures. Additionally, the highest risk for clinical fracture in those with adrenal adenomas (either nonfunctional or with cortisol hypersecretion) appears to occur at 7-10 years after initial diagnosis. BMD does not perfectly correlate with fracture risk, so unilateral adrenalectomy (if lateralization is observed on AVS) and/or pharmacotherapy should be strongly considered in patients with an expected longevity of &gt;10 years even with mild osteopenia and low fracture risk assessment tool scores.
Presentation: Saturday, June 17, 2023