bluuebunny/crossref_metadata_2025_split huggingface dataset:
SAT489 Grave’s Disease Secondary To Alemtuzumabuse
Authors: Gong Michael Shifeng , Lee David , Arceo-Mendoza Rod Marianne 
Published: October 2023

Abstract
Disclosure: M.S. Gong: None. D. Lee: None. R. Arceo-Mendoza: None.
Introduction: We present a case of alemtuzumab-induced autoimmune thyroid disease in a patient with Multiple Sclerosis (MS). Clinical Case: A 42/F was evaluated by endocrine inpatient service for hyperthyroidism. She presented with tremors, dyspnea, and ataxic gait. She has known MS and was treated with Alemtuzumab (ALZ) in 2018 and in 2019, with her initial infusion being 4 years prior to this admission. Lab tests on admission showed TSH of &lt;0.01 uIU/mL with elevated Free T3 and Free T4 of 1987 pg/dL (NV:171-371 pg/dL) and 3.9 ng/dL (NV:0.7-1.5 ng/dL) respectively. Her Thyroid Stimulating Immunoglobulin and TSH receptor binding antibody were elevated. Baseline TSH prior to starting ALZ and a follow up TSH in 2020 were in the normal range. She denies personal or family history of thyroid disease. Hospital course was further compounded by ongoing leukopenia, with a WBC of 2.3 and ANC of 1.1. Initiation of thionamide therapy was discussed however patient declined to start methimazole when risk of agranulocytosis, albeit low, was explained. She had opted to proceed with RAI therapy for definitive management but then changed her mind. We were just initially able to treat her with prednisone, beta blocker and cholestyramine with close biochemical monitoring as an outpatient. Her Grave’s hyperthyroidism was refractory to medical management hence she was eventually admitted again for medical optimization and surgical evaluation. Her hospital course upon readmission was complicated by worsening hemoptysis and a diagnosis of pulmonary embolism. At this point, it was decided she is not a good surgical candidate for thyroid surgery given comorbidities. She eventually agreed to start methimazole after undergoing bone marrow biopsy for worsening leukopenia and cleared by hematology to start the antithyroid drug. At this time, she remains to be on methimazole as an outpatient. Clinical course however, is unfortunately complicated by patient’s ongoing poor compliance to clinic follow up. Clinical Lesson: ALZ is an anti-CD52 monoclonal Ab which induces depletion of B and T lymphocytes causing lymphopenia and immunosuppression. It is an effective treatment for MS but is linked to a number of autoimmune adverse event. Thyroid autoimmune dysfunction may occur in 20-30% of patients, and Grave’s disease accounts for 60-70% of cases. The ALZ product label recommends TFT monitoring every 3 months for at least 48 months after the last infusion. Our patient presented with Grave’s disease in 4 years following initial ALZ administration. To our knowledge, there is no published case with reported ALZ-induced Grave’s disease with this length of interval since infusion. Our case highlights not only the importance of pretreatment screening but continued vigilance and close thyroid function monitoring in patients treated with ALZ even several years after therapy.
Presentation Date: Saturday, June 17, 2023
SAT492 Hypothyroidism Induced Psychosis: A Rare Initial Presentation Of Severe Hypothyroidism
Authors: Shaukat Mishal , Mack Margaret , Galarza Emma , Saeed Rehan , Arzeno-Tejada Luis E 
Published: October 2023

Abstract
Disclosure: M. Shaukat: None. M. Mack: None. E. Galarza: None. R. Saeed: None. L.E. Arzeno-Tejada: None.
Introduction: Hypothyroidism presents as slowing of bodily functions that become more severe as the disease progresses. Common presentations of hypothyroidism are lethargy, constipation, hair and skin changes and mental slowing. We present a rare presentation of hypothyroidism induced psychosis, also called myxedema psychosis or more commonly, myxedema madness, triggered by lenalidomide. This, per our review, has only been reported a handful of times in prior literature. Case Description: 64-year-old male with a history of follicular Non-Hodgkins Lymphoma, currently on rituximab/lenalidomide who was brought to the Emergency Department (ED) for concerns of hallucinations, paranoia and manic episodes for three days. In the ED, his vitals were stable. Computed Tomography (CT) head was normal. Lab work revealed an elevated TSH at 51.70 uIU/ml (normal 0.30-5.0 uIU/ml), free T3 &lt;0.1 pg/ml (normal 2.0-4.4 pg/ml) and free T4&lt; 0.1 ng/dL(normal 0.7-1.7 ng/dL). Thyroid peroxidase antibody was 9 IU/ml (normal &lt;34.0 IU/ml). He was started on intravenous levothyroxine and as needed haloperidol to which he responded well in about forty-eight hours. During this time, he got a MRI of his brain that was normal. He was examined by neurology who did not recommend any further neurological workup. He continued IV therapy for 4 weeks after which he was switched to oral levothyroxine. His chemotherapy regimen has been changed to bendamustine/rituximab and he was discharged to a psychiatric facility for two weeks. He continues to be on oral levothyroxine and is currently doing well. Discussion: Hypothyroidism is described as decreased activity of the thyroid gland that results in retardation in growth and development of children and adults and common initial presentations of hypothyroidism include lethargy, hair loss, skin changes, cold sensitivity, weight gain and constipation. The most common psychiatric association of hypothyroidism is depression. Studies have also shown that there is an association between hypothyroidism and bipolar disorders. Other psychiatric manifestations include loss of memory, labile emotions and forgetfulness. However, in around 5 to 15 percent of the patients, the initial presentation of hypothyroidism is psychosis, also termed myxedema psychosis. The exact mechanism is uncertain, and the evidence is based on experimental animal models, but it is believed that the effects on the brain are due to increased dopamine levels and tyrosine hydroxylase activity in hypothyroid patients, mostly in the limbic system where most emotional and behavioral responses are processed. Prompt diagnosis with thyroid function tests along with removal of the offending agent is important in these cases since the cause of psychosis is reversible and early treatment has promising results.
Presentation Date: Saturday, June 17, 2023
FRI203 A Case Of Pseudoadrenal Tumor Mimicking Left Adrenal Pheochromocytoma
Authors: Tanabe Akiyo , Sugito Erika , Kajio Hiroshi 
Published: October 2023

Abstract
Disclosure: A. Tanabe: None. E. Sugito: None. H. Kajio: None.
Approximately 50% of adrenal incidentalomas are non-functional cortical adenomas, and 25% are adrenocortical hormone-secreting adenomas and pheochromocytomas. Adrenocortical carcinomas, and pheochromocytomas which have malignant potential, need to be differentiated and removed even if the tumors are hormonally inactive. In addition to these adrenal origin tumors, anatomic structures and tumors that develop in tissues neighboring the adrenal glands (pseudoadrenal tumors) may be confused with primary adrenal tumors. The larger the tumor, the more difficult it is to determine continuity with the adrenal glands. Herein we report a patient with gastrointestinal stromal tumor (GIST) that mimicked a left adrenal pheochromocytoma. A 47-year-old man was diagnosed with a left adrenal incidentaloma at 40 years of age. The tumor had irregular margins and grew from 18 mm to 30 mm in maximum diameter over 7 years. The mass appeared to be in the tip of the lateral limb of the left adrenal gland and was located between the left adrenal gland and the posterior wall of the stomach. The patient had no abnormal findings other than general obesity. The blood pressure was 106/72 mmHg with antihypertensive agents. The plasma corticotropin and cortisol concentrations were normal and suppressed normally after a 1-mg overnight dexamethasone suppression test. The plasma aldosterone concentration and renin activity were increased with angiotensin receptor blocker and diuretic therapy. The 24-h urine fractionated metanephrines levels were at the upper limit of the reference range. Because the tumor showed unenhanced computed tomography (CT) attenuation of 40-50 Hounsfield units, hormonally-inactive adrenocortical carcinoma or pheochromocytoma had to be differentiated. I-123-metaiodobenylguanidine (I-123-MIBG) scintigraphy showed tumor avidity consistent with a pheochromocytoma. A laparoscopic left adrenalectomy was performed; however, no tumor was present in the resected specimen. Abdominal CT postoperatively showed that the tumor remained intact and appeared to connect to the posterior wall of the stomach. A laparotomy was performed and the tumor was removed. The tumor was localized to the intraperitoneal space and isolated from the posterior wall of the stomach. The pathological diagnosis was a GIST. Although it has been reported that I-123-MIBG may accumulate in tumors other than neuroendocrine tumors, reports on GISTs are rare. Lessons learned from our case include the importance of clinicians need to be aware of the limitations of diagnostic imaging studies in diagnosing non-functioning adrenal incidentalomas, which require a pathologic analysis for the final diagnosis. Moreover, clinicians need to provide patients with sufficient informed consent when deciding on treatment strategies.
Presentation: Friday, June 16, 2023
SAT542 TDC or Not TDC: Isolated Ectopic Papillary Carcinoma in the Midline Neck with a Benign Native Thyroid
Authors: Fasen Madeline , Kosmiski Lisa 
Published: October 2023

Abstract
Disclosure: M. Fasen: None. L. Kosmiski: None.
Background: Thyroglossal duct carcinoma is a rare entity, occurring in about 1% of all thyroglossal duct cysts (TDC). Several cases have reported PTC within a thyroglossal duct cyst. Initially thought to be a TDC, we present an unusual case of a midline ectopic papillary thyroid carcinoma with absence of features characteristic of a TDC in the context of benign native thyroid tissue. Clinical Case: A 19 year old female presents to the clinic with a progressively growing midline neck mass over the past five years associated with mild dysphagia. Physical exam was notable for 2 x 2 cm mobile nontender midline mass. Neck ultrasound demonstrated a complex cystic lesion measuring 3.8 x 3.4 x 2.5 cm with partial calcification and mildly vascular. The thyroid itself had no nodules. She underwent a Sistrunk procedure with follow-up pathology revealing 1.6 cm classical PTC that extended into surrounding soft tissue and focal invasion into skeletal muscle without a definitive remnant thyroglossal duct lining despite cystic architecture. The differential included PTC completely replacing the thyroglossal duct cyst, PTC arising from ectopic thyroid tissue or metastatic PTC. Due to the unclear origin of the PTC, decision was made to perform total thyroidectomy. Pathology of the thyroid and four lymph nodes were negative for malignancy confirming a PTC origin from an extra-thyroidal remnant. The patient’s course was complicated by post-operative hypocalcemia resolved with calcitriol and calcium carbonate. She is pending discussion with endocrinology regarding adjuvant radioactive iodine. Conclusion: Thyroglossal duct carcinoma, most commonly papillary carcinoma, is a rare condition that should be considered in patients presenting with cystic midline neck masses. Sistrunk surgery should be performed in all cases for tumor removal. Thyroidectomy in individuals with normal thyroid can be considered due to the probability of concomitant intraglandular thyroid cancer and enables management with adjuvant radio-iodine if needed. In this particular case, PTC was found without evidence of a TDC and suggests PTC arose from ectopic thyroid tissue. Ectopic thyroid tissue can undergo malignant transformation along with the native thyroid gland. There are only a few other reports of isolated ectopic thyroid tissue malignancy with a benign thyroid gland.
Presentation Date: Saturday, June 17, 2023
SAT543 A Case of Non-iodine-Avid Papillary Thyroid Cancer With a Rare Distant Metastasis to the Pancreas
Authors: Huliganga Alcain Alistair Marie , C. Isidro Maria Jocelyn 
Published: October 2023

Abstract
Disclosure: A.H. Alcain: None. M.C. Isidro: None.
Papillary Thyroid Carcinoma is the most common type of differentiated thyroid cancer. Distant metastasis is rare occurring only in 5% of patients and typically involves the lungs and bones. Metastasis to the pancreas is extremely rare with few cases reported over the years. We present a case of a 65-year-old female, who presented with sudden onset of abdominal pain. A review of the patient’s medical history revealed a history of a non-iodine avid Papillary Thyroid Carcinoma in 2015. The patient underwent Radioactive Iodine (RAI) ablation therapy twice due to elevated Thyroglobulin (Tg) levels. Despite RAI, Tg levels were still elevated with no recurrence nor metastasis noted on scan. Chemotherapy was offered but the patient opted for Tomotherapy. The patient completed Tomotherapy in 2017 but afterward was lost to follow-up. A CT scan of the abdomen showed findings of a pancreatic tail and body mass (10 x 7 cm) with an invasion of the mid-descending colon with pulmonary nodules which are possibly metastatic. The patient underwent an endoscopic ultrasound-guided biopsy, and pathology showed findings of a pancreatic papillary neoplasm (CK and beta-catenin positive, synaptophysin negative). Chemotherapy was given (FOLFOX) and a PET scan was requested to monitor the response to treatment. However, PET-scan showed FDG-avid (SUV 32.1) mass in the pancreatic tail (7.2 x 7.8 x 13.3 cm), FDG-avid (SUV 17.61) nodules in the lungs, and an ill-defined heterogeneous mass in the left surgical site (2.2 x 2.6 x 5.3 cm). Given that patient had a thyroidectomy in 2015, recurrence was considered. The possibility of probable metastasis to the pancreas was entertained hence re-biopsy was done. Serum Tg levels were elevated (4,115 ng/ml NV: 1.59-50.0) and negative for Anti-Tg. Biopsy showed high-grade neoplasm with papillary features. IHC staining showed positive for CK7, Tg, and TTF-1, and negative for CK20 which was consistent with metastatic papillary thyroid carcinoma. The patient was given Lenvatinib and is at present tolerating the treatment well with evidence of decreasing Tg levels suggesting a response to treatment. This is a case of a rare site of distant metastasis of a non-iodine avid papillary thyroid carcinoma. Targeted therapy such as Tyrosine kinase inhibitors can improve the survival rate of patients with Radioiodine Refractory Thyroid cancers. Metastasis should be considered especially in patients with a history of prior malignancy.
Presentation Date: Saturday, June 17, 2023
SAT544 Abnormal Labs Reveal Metastatic Papillary Thyroid Cancer
Authors: Shahid Muhammad , Bellamy Shannay , Ottley Anroy , Griffith Mindy 
Published: October 2023

Abstract
Disclosure: M. Shahid: None. S. Bellamy: None. A. Ottley: None. M. Griffith: None.
Objective:Abnormal thyroid function studies are commonly referred to Endocrinology for further evaluation. In most cases, once studies are repeated and normal no further work up is considered. It is uncommon to order a thyroid ultrasound if the patient is asymptomatic with repeat normal labs and physical exam. Clinical Case:43 yo female with no significant medical history who presented to Endocrine clinic for evaluation of abnormal thyroid function labs. She denied taking any medications. Review of systems was positive only for a five pound weight gain over three months. Her physical exam was unremarkable. Labs were significant for TSH level of 0.25 uIU/mL (normal range 0.45 - 5.33 uIU/mL), free T4 of 0.57 ng/dL (normal range 0.61 - 1.12 ng/dL). At the initial visit, thyroid function tests, thyroid antibodies, and thyroid ultrasound were ordered. Results included a normal serum TSH , Free T4 and Thyroid Stimulating Immunoglobulin. Thyroid Peroxidase Antibody resulted as detectable at 124 IU/mL (normal value &lt;9 IU/mL). Thyroid ultrasound showed nodules bilaterally; some subcentimeter in size with two meeting criteria for FNA; one in the right mid pole measuring up to 1.8 cm with suspicious features of hypoechogenicity and a feeding blood vessel, and another isoechoic left mid pole nodule measuring up to 1.8 cm. Per pathology, the right mid pole nodule was considered Betheseda Category V, suspicious for Hurtle cell neoplasm or Hashimoto’s thyroiditis, with the possibility of medullary or papillary thyroid carcinoma. The left mid pole nodule was considered Bethesda Category II. Following surgical consultation, the patient underwent total thyroidectomy with right cervical neck dissection. Pathology revealed pT3N1Mx Metastatic Papillary Thyroid Cancer (conventional type) involving the skeletal muscle and one out of six right cervical neck lymph nodes. The resection margins were negative for carcinoma. Post operatively the patient received radioactive iodine treatment and Levothyroxine was initiated. DISCUSSION:In Endocrine practice, the use of thyroid ultrasonography is common. However, the clinician is usually prompted to order an ultrasound due to consistent abnormal thyroid studies revealing thyrotoxicosis and/or abnormal physical exam findings such as nodular goiter. Or in the case of known diagnoses such as thyroid cancer, it is useful for pre and post surgical management. Nonetheless, in some cases, when ordered outside of common practice, unexpected pathology may be discovered. CONCLUSION:This case demonstrated an unexpected finding of metastatic papillary thyroid cancer , despite initial presentation of abnormal thyroid function tests with normal repeat result and physical exam. Thyroid ultrasound was useful in revealing the diagnosis, preventing a delay in treatment.
Presentation Date: Saturday, June 17, 2023
SAT401 The Aftermath Of Pueraria mirifica: A Case Of Hypertriglyceridemia And Necrotizing Pancreatitis In A Non-binary Individual With Surreptitious Use Of Oral Estrogenic Compounds
Authors: Tobolsky Seth , Hayes Frances J , Lo Janet 
Published: October 2023

Abstract
Disclosure: S. Tobolsky: None. F.J. Hayes: None. J. Lo: None.
Background Prescription of gender-affirming hormone therapy (GAHT) has become an increasingly prevalent aspect of endocrine care meriting greater attention from our specialty. We report a case where surreptitious use of an unregulated compound with estrogenic activity in a patient with gender dysphoria resulted in severe hypertriglyceridemia and necrotizing pancreatitis. The compound, Pueraria mirifica, is readily available for purchase online.
CaseThe patient is a 26yo non-binary individual assigned male at birth who presented to the ED with 1.5 days of abdominal pain and vomiting. CT abdomen showed acute necrotizing pancreatitis. On arrival, serum triglycerides 2,559 mg/dl (nl 40-150 mg/dL) and lipase 481U/L (nl 13-60 U/l). The patient reported no alcohol use. Family history of unspecified hyperlipidemia in father. Patient was admitted, made NPO, and started on insulin/dextrose infusions, continued until serum triglycerides dropped to &lt;1,000 mg/dL. Fenofibrate started and extensive nutritional counseling on low-carbohydrate and low-fat diet given.
In absence of clear etiology for hypertriglyceridemia, patient was questioned carefully on supplement use and revealed they took 2 tablets of Pueraria mirifica daily with intent of transitioning without medical guidance given prior negative encounters with healthcare. Patient discharged on fenofibrate 200 mg, atorvastatin 20 mg and omega-3 acid ethyl esters 2 g BID, with plan for endocrinology follow-up for initiation of medically supervised GAHT.
At follow-up on this regimen, LDL was 79 mg/dL and triglycerides 160 mg/dL. Goals of transition were discussed with the patient as was importance of avoiding oral estrogens, prescribed or over-the-counter. Given patient’s desire for partial transition, low dose transdermal estradiol 0.05 mg patch and spironolactone 50mg BID started. On above regimen, estradiol was 179 pg/mL and total testosterone suppressed at 72 ng/dL. The patient’s triglycerides remained &lt;150 mg/dL with no further complications.
ConclusionThis case highlights a potentially fatal complication of hormone use in a transgender individual with likely underlying familial hypertriglyceridemia. It also illustrates how distrust of the medical system led to surreptitious hormone use and emphasizes the need to create a safe, welcoming environment for individuals with gender dysphoria. Finally, it emphasizes the need to interrogate possible surreptitious hormone use in patients with unusual presentations and for endocrinologists to be aware of the need to avoid oral estrogen use in patients with hypertriglyceridemia.
Presentation: Saturday, June 17, 2023
THU539 Pembrolizumab-induced Hypophysitis Occurring Concurrently With Takotsubo Cardiomyopathy
Authors: Nadeem Ifrah , Chaudhry Hammad S , Aslam Sadia , Asif Muhammad , Khan Wahab J 
Published: October 2023

Abstract
Disclosure: I. Nadeem: None. H.S. Chaudhry: None. S. Aslam: None. M. Asif: None. W.J. Khan: None.
Abstract: Immune checkpoint inhibitors (ICI) are novel medications used to treat a wide range of solid organ tumors and work by stimulating the cellular immune response. With their increasing use, more and more multiorgan side effects including endocrine system are reported in the literature. Prompt recognition of these findings is vital for the safe clinical use of these agents. We report a case of a pembrolizumab-induced triad of hypophysitis, takotsubo cardiomyopathy, and pneumonitis. Case Report: A 72-year-old female with metastatic NSCLC on single therapy with pembrolizumab had received her second session three weeks before the presentation. She presented with progressive dyspnea and generalized weakness but no reported chest pain, fever, or chills. At presentation, she had a BP of 82/62 mmHg, and a pulse rate of 160/min; EKG showed new-onset atrial fibrillation with a rapid ventricular response (RVR) but no acute ischemic changes. Physical examination revealed a pale lady in distress due to shortness of breath. Laboratory analysis revealed hypophysitis with ACTH &lt;5 pg/ml (7.2-63 pg/ml), aldosterone &lt;4 ng/dl (&lt;21ng/dl), TSH 0.26 uIU/ml (0.34-4.94 Uiu/ml), FSH 8.4 mIU/ml (low for age), LH 1.6 mIU/ml (low for age). She was managed with methyl prednisone 60 mg twice daily for seven days, followed by a taper to a final maintenance dose of 5 mg prednisone due to adrenal insufficiency. Unfortunately, two months post-discharge, she passed away at her home due to sudden cardiac death. Discussion: ICI is increasingly used for different malignancies and is frequently linked to various immune-mediated entities simultaneously or at separate times including the pituitary gland. The adverse effects involving the endocrine system are hypo- or hyperthyroidism, hypophysitis, adrenal insufficiency, and type 1 diabetes mellitus. Immune-mediated Takotsubo cardiomyopathy pneumonitis and hypophysitis are treated with systemic steroids with a slow taper and close monitoring of side effects from corticosteroids. Other options include pulse steroids, mycophenolate mofetil, and plasmapheresis on a case-by-case basis. The median onset of hypophysitis and pneumonitis was noted to be 76 and 90 days from the initiation of ICIs, respectively. The mortality rate is relatively high with these complications. Our case report underscores the importance of provider awareness for closely monitoring all patients treated with ICI for various multisystem complications. We anticipate that identifying and reporting these rare complications will help get data for developing monitoring protocols in the future and help other providers recognize these complications in their patients currently on ICI treatment and take appropriate management steps for patient safety.
Presentation: Thursday, June 15, 2023