bluuebunny/crossref_metadata_2025_split huggingface dataset:
THU661 Marine-Lenhart Syndrome: An Unusual Presentation Of Hyperthyroid Disease
Authors: Ji Beisi , Adeniran Omolara , Soni Lina 
Published: October 2023

Abstract
Disclosure: B. Ji: None. O. Adeniran: None. L. Soni: None.
Background: Marine-Lenhart syndrome, also known as nodular Graves’ disease, is defined as the coexistence of functioning thyroid nodules and Graves’ disease. It is a rare syndrome, with a prevalence of approximately 0.8-2.7%. The two diseases may coexist or present at different times [1]. Treatment options include high doses of antithyroid medications or radioactive iodine and thyroidectomy in selected cases [2]. Clinical Case: A 72-year-old female with a medical history of right-sided breast cancer treated with lumpectomy and radiation therapy in 2012 on anastrozole was referred for multinodular goiter (MNG) evaluation in 2018. She was clinically and biochemically euthyroid. Her thyroid ultrasound demonstrated two isoechoic right lobe nodules measuring 2.1cm and 1.3cm, respectively. An isoechoic rounded isthmus nodule measures 2.1cm. Three isoechoic nodules in the left lobe measuring 2.6cm, 2.2cm, and 1.7cm. She underwent fine needle aspiration (FNA) of two nodules in 2019, and both demonstrated benign follicular nodules with Bethesda II classification. At a follow-up visit in 2021, she reported unintentional weight loss but denied any other symptoms of hyperthyroidism, including heat intolerance, palpitation, tremor, or diarrhea. Physical examination was significant for exophthalmos, lid retraction, and diffusely enlarged thyroid with non-tenderness to palpation. Thyroid function tests revealed subclinical hyperthyroidism with TSH of &lt;0.01uIU/mL (0.27-4.2uIU/ml) and FT4 of 1.5ng/dL(0.9-1.8ng/mL). Thyroid stimulating immunoglobulin (TSI) was 3.98IU/L (0.00-0.55IU/L), and TSH receptor antibody was 7.64 IU/L (0.00-1.75 IU/L). She was started on low-dose methimazole therapy. Thyroid uptake scan showed markedly elevated radioactive iodine uptake with 63.46% in 24 hours and focal nodular regions of increased uptake of the bilateral thyroid lobes compatible with toxic multinodular goiter. Repeated thyroid ultrasound in 2022 revealed stable-sized nodules with at least two new sub-centimeter nodules in both lobes. The patient was also seen by ophthalmology and plans to start teprotumumab treatment. At her most recent follow-up visit in January 2023, she has been continued on methimazole 2.5mg daily.
Conclusion: The criteria for diagnosing Marine-Lenhart syndrome have not been well established. The possibility of Marine-Lenhart syndrome should be considered in hyperthyroid patients with positive antibodies and nodular goiter. In this case, she was initially asymptomatic with an enlarged multinodular goiter; three years later, she developed subclinical hyperthyroidism due to Graves’ disease and toxic multinodular goiter. Her symptom and thyroid function are well-controlled with low-dose methimazole.
Presentation: Thursday, June 15, 2023
THU663 Therapeutic Plasma Exchange In Refractory Atrial Fibrillation Secondary To Thyroid Storm.
Authors: Mohammed ALShehri Sara , Salem Bafadel Marwah , Aljohani Naji J 
Published: October 2023

Abstract
Disclosure: S.M. ALShehri: None. M.S. Bafadel: None. N.J. Aljohani: None.
Thyrotoxic crisis (thyroid storm) is a severe form of hyperthyroidism. It has a wide range of symptoms, including cardiovascular manifestations that can be life-threatening and require prompt management. Cardiac manifestations of thyroid storm include hypertension, tachycardia, congestive heart failure, cardiac ischemia, and atrial fibrillation. Standard therapeutic approaches of thyroid storm are based on the use of thionamides, corticosteroids, and nonselective beta-blockers to inhibit thyroid hormone synthesis and release while also blocking thyroxin's peripheral effects. This approach is an effective measure in the management of these manifestations. However, when a patient fails to respond to conventional therapy or there is end organ damage and surgery is not feasible, therapeutic plasma exchange (TPE) is a life-saving measure. Here, we report a case of a 32-year-old female who is known to have hyperthyroidism, but she was not compliant with her medication. She presented with symptoms of hyperthyroidism and was found to have thyroid storm with refractory atrial fibrillation. Despite the effort to control her symptoms, she developed cardiac arrest, after 15 minutes of cardiopulmonary resuscitation she revived. Amiodarone, beta blockers, and cardioversion have all failed to improve the patient's status, and her condition has deteriorated. So, we decided to use TPE, and she received three sessions in total. After the first session of TPE, her rhythm converted to sinus rhythm, and her heart rate was controlled to less than 100 beats per minute. She showed dramatic improvement clinically and biochemically. In conclusion, cardiac complications are potentially lethal complications of thyroid storm. Prompt restoration of a normal thyroid state can reverse these complications. When conventional therapy fails to ameliorate symptoms or organ deterioration is rapid and severe, TPE can be a safe and effective measure.
Presentation: Thursday, June 15, 2023
THU665 Unilateral Graves’ Disease In A Bilobar Thyroid Gland: Unusual Cause Of Hyperthyroidism
Authors: Hamid Alaybaa Khaled , Alhuzaim Omar 
Published: October 2023

Abstract
Disclosure: K.H. Alaybaa: None. O. Alhuzaim: None.
Introduction: Graves' disease (GD) is an autoimmune condition that affects both thyroid gland lobes. GD patients with unilateral thyroid scan uptake are rare. These patients present with classic Graves' symptoms, occasionally with Graves' ophthalmopathy characteristics and increased thyroid hormones, and scintigraphic assessment reveals radiotracer uptake in only one lobe of the thyroid gland. Patient Findings: In this case, a 48-year-old female presented with symptoms and signs indicative of thyrotoxicosis. Lab results revealed that thyroid-stimulating hormone (TSH) was undetectable, while free thyroxine (T4) and free triiodothyronine (T3) were in the high-normal range. Positive results were observed for both thyroid-stimulating immunoglobulin and TSH receptor antibodies. Ultrasonography of the thyroid gland revealed an enlarged left lobe with heterogeneous echotexture and a hyperemic gland without any focal lesions, distinct nodules, or cysts. The NM TC-99M thyroid scintigraphy revealed enlarged and increased radioisotopes uptake in the left thyroid lobe and decreased uptake in the right thyroid lobe, with no hot or cold nodules. The calculated thyroid uptake is 4.5 percent (normal range: 0.5% to 3.5 percent). The most likely diagnosis was unilateral GD. The patient was administered carbimazole and within eight weeks had improved clinically and biochemically. Summary: This patient has thyrotoxicosis symptoms and positive autoantibodies. Tc99m uptake was increased in the left thyroid lobe and decreased in the right thyroid lobe. The left thyroid lobe was hypervascular and enlarged on ultrasonography, indicating the presence of unilateral GD. Unilateral GD is a rare disease with a poorly understood pathophysiology.
Presentation: Thursday, June 15, 2023
THU668 Euthyroid Graves’ Ophthalmopathy: Case Series
Authors: Saleh Alfadl Sultan , Ahmed Asiri Alanood , Ali Jammah Anwar , Alsagheir Osamah 
Published: October 2023

Abstract
Disclosure: S.S. Alfadl: None. A.A. Asiri: None. A.A. Jammah: None. O. Alsagheir: None.
Introduction: Graves’ ophthalmopathy is an autoimmune disorder that affects the eyes, characterized by swelling, proptosis, lid lag, inflammation and eyelid retraction. A significant proportion of cases are associated with thyrotoxicosis and positive serum TSH receptor antibody tests. Case Description: We present a case series of euthyroid Graves’ ophthalmopathy in patients with a negative TSH receptor antibody. The first case is of a 37-year-old lady who was recently diagnosed with idiopathic intracranial hypertension due to history of recurrent headaches and was found on CT brain to have an incidental empty sella syndrome and findings highly suggestive of thyroid associated orbitopathy. A dedicated MRI orbit showed bilateral mild proptosis with bilateral medial and inferior recti thickening, sparing the tendinous insertion. The involved extraocular muscles show mild peripheral high T2 signals and minimal enhancement on post gadolinium images. The enlarged extraocular muscle demonstrates diffusion restriction with low Apparent Diffusion Coefficient (ADC) value. Clinically, the patient did not exhibit any symptoms of hyperthyroidism or hypothyroidism. She did not notice any changes in her eyes’ appearance, nor any changes in vision or double vision. On examination, she had mild proptosis, no restriction of extraocular movement or provoked double vision. Consequently, she was referred to Ophthalmology for further management. Investigations included a pituitary panel which did not reveal any abnormalities and a thyroid panel which revealed that she was biochemically euthyroid with a negative TSH receptor antibody test. The second case is of a 24-year-old male who is medically free and initially visited the ophthalmology clinic complaining of double vision, without any additional ophthalmic complaints. He was subsequently referred to our care to rule out thyroid eye disease. Clinically, the patient had no indications of thyroid dysfunction. Upon examination, he exhibited severe right eye proptosis with dystopia and early left eye proptosis. CT orbit showed swelling of the right-sided superior rectus, medial rectus, lateral rectus and left-sided superior rectus muscles. The left-sided superior rectus muscle was abutting the optic nerve. Nevertheless, all tendons were spared. Biochemically, he was euthyroid with unremarkable laboratory results. Conclusion: These findings provide insight into the clinical presentation of euthyroid Graves’ ophthalmopathy in patients without thyrotoxicosis or detectable circulating levels of TSH receptor antibodies. Thus, suggesting that thyroid ophthalmopathy might present earlier than Graves’ disease and even earlier than the presence of TSH receptor antibodies. We conclude that a high index of suspicion and proper follow up is recommended in similar patients for the development of Graves’s disease.
Presentation: Thursday, June 15, 2023
THU671 Genes Encoding Adaptive Immune Receptor Repertoire Might Be Associated With The Risk Of Graves’ Disease And Antithyroid Drug-induced Agranulocytosis
Authors: Jui Huang Chun , Yang Shun-Jie , Lai Sheng-Kai , Chen Harn-Shen , Chen Pei-Lung 
Published: October 2023

Abstract
Disclosure: C. Huang: None. S. Yang: None. S. Lai: None. H. Chen: None. P. Chen: None.
Graves' disease (GD) is an autoimmune disorder characterized by the immune system attacking the thyroid gland cells, leading to hyperthyroidism. One serious adverse effect that can occur in GD patients receiving antithyroid drugs, such as thionamides, is antithyroid drug-induced agranulocytosis (TiA), which affects 0.1% to 0.4% of patients. While previous research has shown that specific human leukocyte antigen (HLA) genes/alleles are associated with GD or TiA, the role of the genes encoding adaptive immune receptor repertoire (gAIRR), including the B cell receptor and T cell receptor genes, in GD or TiA has not been explored. This study aims to investigate whether gAIRR has a genetic association with GD or TiA. We enrolled 128 GD patients, 19 TiA patients, and 104 controls, and conducted gAIRR genotyping using gAIRR Suite, a probe capture-based targeted sequencing and analysis platform. Our results identified several gAIRR alleles that were more prevalent in GD cases than in controls, including IGLV1-41*02N (a novel allele with the sequence closest to IGLV1-41*02, 20.3% in GD patients vs. 7.7% in controls, p=0.008), IGHV1-69*04N (12.5% vs. 3.8%, p=0.02), TRGV4*01 (46.9% vs. 31.7%, p=0.022), and several other alleles (such as TRBV6-6*03, IGKV1/OR22-5*01N, TRVB12-2*01N, TRAV8-4*01N, IGHV3-71*02, IGHV2-70*04N, etc.) We also found several gAIRR alleles that were less prevalent in GD cases than in controls, including IGLV5-45*03N, IGLV2-14*04, IGLV(V)-66*01, IGLV3-13*01N, TRBV20/OR9-2*02N, TRBD2*01, TRAV6*02, among others. Regarding the TiA cohort (compared to GD patients without TiA), some gAIRR alleles showed frequencies difference, but did not reach statistical significance. Overall, our findings provide supporting evidence that gAIRR genes/alleles might be associated with the development of GD or TiA. Future studies with larger sample sizes are necessary. Furthermore, a joint analysis of HLA and gAIRR genotypes might provide valuable insight into the pathogenesis of GD and TiA.
Presentation: Thursday, June 15, 2023
THU673 Unusual Metastasis Of Differentiated Thyroid Carcinoma
Authors: Aiad Mina , Aluko Oluwatomisin A , Bhatt Bankim 
Published: October 2023

Abstract
Disclosure: M. Aiad: None. O.A. Aluko: None. B. Bhatt: None.
Background: Papillary thyroid cancer (PTC) is the most common form of differentiated thyroid malignancy. Distant metastasis of PTC are rare and usually occur in the bones, lungs, and lymph nodes of the neck. Retinal and skin metastases are extremely rare. We present a case of PTC with metastasis to the distal extremity with sites including retina, skin and breasts. Clinical Case: A 40-year-old Caucasian female with a past medical history of papillary thyroid cancer at age 16 status post total thyroidectomy followed by two radioactive iodine treatments, who is incidentally found to have recurrent metastatic disease to lungs, retina, subcutaneous soft tissue and bones. After having an accident, trauma CT revealed pulmonary nodules and around the time patient started to notice subcutaneous lumps on the chest and gradually worsening blurry vision indicating further imaging as well as ophthalmological evaluation. The biopsy of the right lower lung nodules showed metastatic differentiated follicular variant papillary thyroid cancer, positive for RET mutation. TSH was appropriately suppressed at 0.128uIU/mL on levothyroxine 100 mcg daily, with elevated thyroglobulin level 47ng/mL and antibody 1.7IU/mL. The molecular testing was positive for RET gene mutation; thus she started targeted therapy with selpercatinib 120 mg twice daily. Shortly after starting therapy, she presented to the ER with complaints of headaches and refractory nausea. Imaging done showed evidence of intracranial metastases, bilateral intraocular lesions in the posterior globe as well as intraventricular hemorrhage. She received IV steroids, selpercatinib was held due to the possibility of exacerbating intraventricular hemorrhage. Following multidisciplinary discussion between neuro-oncology and radiation oncology, she started stereotactic radiotherapy (SRT) to choroidal plexus lesions with a plan to restart systemic therapy once SRT is completed. Conclusion: The epidemiological aspects of thyroid metastases in rare sites are likely unknown and could significantly impact patient management. Most cases of uncommon metastasis have been reported after several years of diagnosis such as in our patient who developed multiple metastasis to rare sites including skin, retina, breast and choroid plexus.
Presentation: Thursday, June 15, 2023
FRI461 Two-years Course Of Subacute Thyroiditis After COVID-19 Vaccination: A Case Report
Authors: Yoshida Sumiko 
Published: October 2023

Abstract
Disclosure: S. Yoshida: None.
COVID-19 has been reported to cause subacute thyroiditis. Furthermore, the literature includes cases of COVID-19 vaccine-related subacute thyroiditis, but few reports describe the long-term course of vaccine-induced subacute thyroiditis. Herein, we report the case of a 47-year-old woman with no medical history who developed subacute thyroiditis after mRNA COVID-19 vaccination and was followed up for 2 years. Her fever persisted after the second dose of the COVID-19 vaccine, and she became aware of left anterior neck pain 8 days later. There were no infectious disease symptoms or signs in the patient’s history or at a recent physical examination. All thyroid autoantibodies were negative. On ultrasound, the thyroid gland was diffusely enlarged, and internal echogenicity was diffusely hypoechoic, coarse, and color Doppler blood flow signals were decreased without confinement to the pain area. She was diagnosed with subacute thyroiditis with tender thyroid swelling, thyrotoxicosis, and an inflammatory reaction. It was suspected that there was a causal link between the onset of subacute thyroiditis and COVID-19 mRNA vaccination because it developed immediately after vaccination and there were no other obvious causes. She was started on prednisolone, and her symptoms improved rapidly, leading to hypothyroidism 1 month later. The swelling of the thyroid gland improved rapidly, and it became atrophic several months after the onset of subacute thyroiditis. She never received any additional vaccinations. Two years after the onset, there was no recurrence of subacute thyroiditis, thyroid atrophy persisted, and the patient required levothyroxine supplementation (100 µg/day). Subacute thyroiditis generally has a good prognosis and rarely leads to permanent hypothyroidism. Subacute thyroiditis due to vaccination may follow a different course than that due to typical viral infection, and we need to examine its long-term prognosis.
Presentation: Friday, June 16, 2023
FRI462 Incidence Of Graves Hyperthyroidism Before And After The Implementation Of COVID-19 mRNA Vaccination
Authors: Oliveira Pinto Jessica , Yvonne Roth Mara , Hoofnagle Andrew N , Failor Richard A , Susan Tylee Tracy , Endo Mayumi 
Published: October 2023

Abstract
Disclosure: J.O. Pinto: None. M.Y. Roth: None. A.N. Hoofnagle: None. R.A. Failor: None. T.S. Tylee: None. M. Endo: None.
Background: There have been several case reports of post COVID-19 vaccination early-onset Graves’ disease (PVGD) and their distinct clinical features documented. The purpose of this study was to investigate whether the incidence of Graves’ disease (GD) increased after the administration of the COVID-19 vaccine or after COVID-19 infection. Methods: This is a single academic center retrospective study. This study compared the incidence of new-onset GD during two separate time periods. Periods were defined as December 2017-October 2019 and December 2020-October 2022 to assess for differences in new-onset GD before and after COVID-19 vaccine administration. PVGD was defined as laboratory-confirmed hyperthyroidism and GD within 4 weeks of vaccination/infection or reporting of symptoms of thyrotoxicosis within 4 weeks of vaccination/infection and laboratory evidence within 3 months. Results: There was a total of 803 patients in the pre-vaccination period that carried the diagnosis of GD, 131 (16.4%) of which were new diagnoses. There was a total of 901 patients in the post-vaccination period that carried the diagnosis of GD, 138 (15.3%) of which were new. There was no statistically significant difference in the incidence of new onset GD between the pre- and post-vaccination groups (p=0.52). Twenty-four (17.4%) out of the 138 newly diagnosed patients in the post-COVID group met criteria for PVGD. There was a higher median free T4 (3.9 vs 2.5; p=0.05), higher TRAb titer (7.5 vs 6.9; p=0.94), and higher TSI titer (3.61 vs 3.60, p=0.82) in the PVGD group when compared to the control although none were statistically significant. There was no statistically significant difference in age, gender, race, or vaccine type. Twenty patients (87%) from the PVGD group were started on methimazole and all cases achieved a euthyroid state with a relatively low median methimazole dose of 12.5 mg. Hyperthyroidism resolved spontaneously in three patients (13%) without any anti-thyroid medication. Conclusion: This study did not demonstrate statistically significant evidence that COVID-19 vaccines increase the incidence of GD. In addition, all patients with PVGD had a good clinical response and achieved a euthyroid state at follow-up. This evidence may be beneficial in reassuring patients on vaccine administration.
Presentation: Friday, June 16, 2023
FRI465 Thyroid Incidentalomas In Hospitalized Patients With COVID-19: A Single-Center Retrospective Analysis
Authors: Jantarapootirat Methus , Sriphrapradang Chutintorn , Traiwanatham Sirinapa , Boonsomsuk Woranan , Sungkanuparph Somnuek , Hirunpat Pornrujee 
Published: October 2023

Abstract
Disclosure: M. Jantarapootirat: None. C. Sriphrapradang: None. S. Traiwanatham: None. W. Boonsomsuk: None. S. Sungkanuparph: None. P. Hirunpat: None.
Context: During the COVID-19 pandemic, both people with underlying diseases and previously healthy people had been infected with SARS-CoV-2. In our institute, most hospitalized patients underwent chest computed tomography (CT) to evaluate pulmonary involvement and complication of COVID-19. There is currently limited data regarding thyroid incidentalomas in healthy people. Objective: We aim to investigate the prevalence and predictors of thyroid incidentalomas among hospitalized patients with COVID-19. Methods: A single-center retrospective study included hospitalized patients aged ≥ 15 years with COVID-19 who underwent chest CT during April 2020 and October 2021. Thyroid incidentalomas were reviewed and identified by an experienced radiologist. Logistic regression analysis was used to determine predictors for thyroid incidentalomas. Results: Of 1,326 patients (mean age 49.4 years and 55.3% female) that were included, the prevalence of thyroid incidentalomas was 20.2%. Patients with thyroid incidentalomas were older (59.6 years vs 46.8 years, p &lt;0.001) and had a higher proportion of females (63.4% vs 53.2%, p=0.003) than those without incidentalomas. On multivariate analysis, only female gender (OR 1.56; 95%CI, 1.17-2.07) and older age (OR 1.04; 95%CI, 1.03-1.05) were significantly associated with thyroid incidentalomas. Conclusion: In COVID-19 patients, the prevalence of thyroid incidentalomas identified on chest CT was higher (20.2%) compared with previous studies in the general population (&lt;1% to 16.8%). The female gender and older age were independent factors associated with thyroid incidentalomas. The higher prevalence of thyroid incidentalomas among COVID-19 patients needs further studies to explore the association between thyroid nodules and SARS-CoV-2 infection.
Presentation: Friday, June 16, 2023