bluuebunny/crossref_metadata_2025_split huggingface dataset:
ODP481 Frequency and outcomes of reporting Bethesda class III thyroid cytopathology- An integrated health network's experience
Authors: Dantey Kossivi , Hasan Farhad , Tipu Ali , Verma Tanvi 
Published: November 2022

Abstract

Introduction
Indeterminate thyroid nodule cytologic diagnosis causes anxiety and confusion to the patient and typically results in additional intervention including thyroid surgery. This increases risk of harm and cost of healthcare. The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) recommends that cytologists attempt to limit reporting 'indeterminate' [Bethesda III (B-III)] category when interpreting thyroid fine needle aspiration (FNA) specimens, and that all effort be made to limit this diagnosis to less or equal to 7% of all thyroid FNA cases. B-III encompasses follicular lesion of undetermined significance (FLUS) and atypia of undetermined significance (AUS). Because we noted a high reporting of B-III cases at our institution, we aim to review the cytologic interpretation of thyroid FNAs, specifically, the rate of indeterminate cytologic diagnoses. Our second aim is to assess the outcomes of nodules labeled as B-III category.

Methods
We reviewed the electronic medical records of adults who underwent FNA of thyroid nodules at Allegheny Health Network between January 1, 2016 and December 31, 2019.

Results
700 patient records were reviewed, out of which 167 records were excluded (non-thyroid FNA or no relevant records). Meaningful records were available for 725 thyroid nodules biopsied during the study period (533 patient records). Mean age in our sample was 54.7±13.9 years and female-to-male ratio was 4: 1. Percent reporting of diagnostic categories based on Bethesda system were as follows: non-diagnostic/unsatisfactory (B-I) 8%; benign (B-II) 52%; FLUS/AUS (B-III) 28%; FN/SFN (B-IV) 6.2%; suspicious for malignancy (B-V)2.3%; and malignant (B-VI) 3.2%. Out of 28% reported as B-III, 73% were FLUS and 27% were AUS. Results of molecular diagnostic testing (ThyGeNEXT-ThyraMIR; Interpace Diagnostics®) were available for 95/203 of B-III category cases, of which 76% were labeled as very likely benign (probability of malignancy ≤5%) and 15% had low to moderate (10-40%) probability of malignancy. Only 9/95 (9%) had a ≥ 45% probability of malignancy. Four cases out of the 9 above cases were confirmed malignant and 1 was 'indeterminate' on surgical pathology. One in four of all B-III category nodules (n=52) underwent partial or total thyroidectomy, of which 32 were reported as benign, 18 malignant, one NIFTP, and one indeterminate by final surgical pathology.

Conclusion
We observed higher than recommended (28%) rate of B-III thyroid cytology at our institution. Most of these nodules underwent further interventions (molecular testing and/or thyroidectomy) where the majority were determined to be benign. All efforts should be made to decrease this rate with the ultimate goal of improving patient care, decrease unnecessary intervention, and reduce healthcare cost.
Presentation: No date and time listed
ODP486 Hypothyroidism And Its Relation To Clinical Outcome In Covid-19 Inpatients
Authors: Rech Carolina Leães , Viel Jessica , Camboim Isadora , dos Santos Lersch Andressa Gabriela , Lima Julia Fernanda Pereira 
Published: November 2022

Abstract
Thyroid dysfunction associated with Coronavirus infection (COVID-19) such as thyroiditis and sick euthyroid syndrome have been reported in recent studies, but the role of hypothyroidism in disease progression and severity remains uncertain. Our aim was to assess the frequency of hypothyroidism and its relationship with clinical outcome in patients hospitalized for COVID-19. The study was retrospective and observational with a cohort of 966 patients hospitalized for COVID-19 infection from February to August 2021, separated into two groups, with and without previous hypothyroidism, and compared in relation to the following variables: age, index of body mass (BMI), type of care, gender, initial hospitalization sector, comorbidities, requirement mechanical ventilation (MV), oxygen supplementation (O2), levothyroxine dose, thyrostimulating hormone (TSH) and free thyroxine (T4L) levels, total length of hospital stay and death. Of the 966 patients evaluated, 87 (9%) had hypothyroidism prior to hospital admission. Patients with hypothyroidism were on average 6.5 years older and had a significantly greater mean age than those without hypothyroidism. The outcome of death was evidenced in 38% of the total sample, with no statistically significant difference between the groups. In uni and multivariate analysis groups matched for sex, age and comorbidities, only older age (increase of 1.8% for each year) and the need for mechanical ventilation (increase of 9.5 times) were associated with a higher risk of death,with no impact of hypothyroidism in requirement mechanical ventilation, oxygen supplementation (O2), total length of hospital stay and death.
Presentation: No date and time listed
ODP487 Iatrogenic Thyroid Storm Treated with Plasmapheresis
Authors: Alam Mustafa , Abdelrahim Baha , Alam Mariam , Hosam Horani Mohamed 
Published: November 2022

Abstract

Presentation: A 25-year-old man presented to the ED with intentional multi-drug overdose onset 9PM on the night prior to admission. PMHx is significant for seizures, hypothyroidism, resting tremors, and smoking. The patient expressed frustration over his persistent hand tremors with depressed mood and took 25 tablets of 500mg Keppra, 30-40 tablets of 150 mcg Levothyroxine, and 25 tablets of 10mg propranolol. The patient denied any chest pain, SOB, nausea, vomiting, lightheadedness, fever, focal weakness, numbness or tingling, prior SI, rash, dysuria, or bleeding. Hospital Course: Vitals were T: 37 Celsius, HR: 92 BPM, 135/87 BP, RR: 18, and SpO2: 93%. Initial EKG showed sinus rhythm with 80 heart rate. The physical exam was significant for profuse diaphoresis and generalized tremors. There were no ST or T wave abnormalities indicating ischemia. The patient had a lab workup that was significant for a TSH of 0. 006, FT4 of &gt;5, FT3 of 7. 09, and T4 of 22.77, after which he was placed on plasmapheresis. The FT4 trended downward to 2.56 after plasmapheresis. The patient experienced transient elevations in creatine kinase and bilirubin, but lab workup was otherwise unremarkable. The patient met admission criteria for inpatient psychiatry and discharged to a psych facility.

Discussion
Given the 7-day half-life of Levothyroxine, plasmapheresis was considered the best option to prevent fatal thyroid storm. This case also demonstrates the importance of how a multi-drug overdose can present more benign presentation with stable vitals. In this case, the effects of propranolol masked the initial symptoms of hyperthyroidism and decreased FT3 levels, indicating the importance to conduct a thorough history to manage polypharmacy drug overdoses. This case highlights plasmapheresis as an effective treatment modality for thyroid storm.
Presentation: No date and time listed
ODP496 Methimazole Induced Agranulocytosis Despite Minimal Intermittent Therapy
Authors: Uddin Ashraf , Gardner Michael 
Published: November 2022

Abstract

Introduction
Anti-thyroid drugs, such as methimazole (MMI), are standard therapies for the medical management of Graves Disease. Agranulocytosis is a rare but lethal adverse effect of anti-thyroid medications. Here we discuss a case that highlights the importance of monitoring not only in the early stages of therapy, but also low dosing of therapy, intermittent therapy and even missing doses/discontinuation of therapy.

Case History
A 65 year-old male with past medical history of end-stage renal disease on peritoneal dialysis who presented to the hospital with syncope, ventricular tachycardia, tremulousness, weight loss of 22 pounds over 2 weeks was subsequently diagnosed with pericardial effusion with tamponade as well as hyperthyroidism. Suppressed TSH of &lt; 0. 005 µIU/mL, Free T4 = 4.5 ng/dL, FT3 8.4 pg/ml, Negative TSI and TPO antibodies. He was started on methimazole 30 mg daily which he received 2 doses prior to discharge as well as beta-blocker therapy. He was re-admitted 1 week later for hypotension, nausea, vomiting and reportedly not taking any medications due to the vomiting right after last discharge supported by his hyperthyroidism being unchanged with a TSH of &lt;0. 005 µIU/mL, free T4 4.21, Free T3 5.8 pg/ml. He was restarted on methimazole 3 days into admission. He received 4 days total of 30 mg daily and was discharged on methimazole 20 mg bid. He was re-admitted 8 days later, during which time again he had nausea and vomiting resulting in not taking methimazole for 1 week prior to admission, maximally 1 day of therapy. At this 3rd admission he was found to have evidence of agranulocytosis with a WBC count of 0.97×10^9 and absolute granulocyte count of 0. 06×10^9. Methimazole was held, he was started on propranolol 60 q6 and cholestyramine 4g bid. Hematology Oncology consultation indicated there would be little benefit from granulocyte colony stimulating factor therapy in medication induced agranulocytosis. He was monitored inpatient for recovery of he neutrophil count. He began to improve after 3 days of monitoring and was discharged. Repeat blood counts 3 months later showed full normalization. Further work-up revealed the etiology of his hyperthyroidism as likely a sub-acute/viral thyroiditis with thyroid I-123 uptake scan at 0.8% at 4, 6, and 24 hours. His hyperthyroidism also resolved over a total of 3 months and his beta-blocker and cholestyramine were discontinued.

Discussion
This case demonstrates that agranulocytosis is not a dose dependent side effect and can occur with as little as 7 days of therapy that are not even sequentially given. It also may support what very few case reports have demonstrated that even discontinuation of therapy may incite agranulocytosis as a side effect. It helps prescribers inform frequency of surveillance and selection of therapy in hyperthyroidism management.
Presentation: No date and time listed
ODP498 Myocardial Ischemia precipitating thyroid storm diagnosed during recovery through Wellen's wave: An ECG for an eye
Authors: Patra Shinjan , Roy Ayan 
Published: November 2022

Abstract
Introduction: Thyroid storm is a major life-threatening condition in a patient of thyrotoxicosis which can accelerate the cardiovascular morbidity in forms of tachycardia, arrythmia and congestive heart failure. It can be precipitated by acute coronary syndrome. Most literatures have reported acute coronary syndromes during the presentation itself but here we shall describe an intriguing case where the diagnosis was possible after the resolution of the thyroid storm. Clinical case: A 55-year-old graves’ disease patient had presented with classical features of thyroid storm which was precipitated by discontinuation of the anti-thyroid drugs. His initial electrocardiogram (ECG) showed sinus tachycardia. He was promptly started on intravenous fluid, 80 mg of daily carbimazole along with lugol's iodine and intravenous dexamethasone. Within 48 hours of treatment, his vitals became normal with resolution of the thyroid storm. His thyroid hormone status also showed marked improvement (free T4 falls from 90.31 ng/dl to 2.31 ng/dl) (normal range: 0.7 ng/dl-1.7 ng/dl). Due to his persistent jaw pain, mild chest discomfort and hiccough, ECG recordings were done in regular intervals. Interestingly it showed dynamic changes consisted of biphasic T waves. This ECG changes were seen after the resolution of the thyroid storm features. The cardiac enzymes were within normal limits. We thought of wellen's syndrome and sought urgent cardiological consultation. Coronary angiography reveals left anterior descending artery (LAD) obstruction and patient promptly underwent percutaneous transluminal angioplasty. Patient's angina equivalent symptoms had resolved remarkably. He recovered satisfactorily and was discharged after 5 days. Clinical lesson: Ischemic heart disease is a well-known co-morbidity in a case of thyroid storm which can be identified at the initial presentation. But here the dynamic changes of ECG appeared after the resolution of the thyroid storm. It was classical of type A wellen's wave which is a harbinger of imminent massive anterior myocardial wall infarction due to near-complete blockage of LAD. Initial sinus tachycardia probably had hindered the appearance of typical wellen's wave in this case. But as soon as the thyroid storm resolved, typical dynamic changes appeared in the form of wellen's wave. Early suspicion due to following serial dynamic ECG changes has prevented a major catastrophe in this case. This case highlights the importance of tracking serial ECG changes in a patient of thyroid storm which can unmask any underlying ischemic cardiac disease even after apparent improvement of the clinical status. This clinical case also reports a unique association of thyroid storm and type A wellen's syndrome.
Presentation: No date and time listed
ODP631 Infectious Disease Causing Damage Of The Adrenal Glands, A Life Threating Event
Authors: Saleem Marwa , Correa Ricardo 
Published: November 2022

Abstract

Introduction
Primary Adrenal Insufficiency (PAI) is not a common cause of adrenal insufficiency. The most common cause is Addison disease that is an autoimmune condition. Other causes include hemorrhage, infiltration, infections, necrosis and metastasis. We present a rare case of primary adrenal insufficiency caused by disseminated histoplasmosis.

Case presentation
87 yo male from the Midwest with a history of HTN, HLD, CAD s/p CABG was admitted to our hospital for fatigue and 15 lbs weight loss. In the ED, he was found to have persistent hypoglycemia (BG in the 50s mg/dl after several vials of D50%). He was admitted to ICU for continuous D10% infusion. His laboratory showed Na 137mmol/L, K 3.7mmol/L. Further work up for hypoglycemia showed BG of 53 mg/dl with C-peptide of 0.92ng/ml and Insulin &lt;1uIU/ml. Due to the concern of non-insulin dependent hypoglycemia, AM cortisol was done which was low7ug/dl. Immediately, he was started on high dose hydrocortisone. Head CT was negative for pituitary lesions. CT showed lung nodules and bilateral peripherally calcified adrenal lesions 3.6 & 2.6 cm homogenous, well defined borders (HU 20-30). Adrenal hormones work up showed normal metanephrines, Aldosterone &lt;1ng/dl and PRA 1.35ng/ml/h (0.25-5.82). ACTH stim test revealed cortisol level of 9. 0 ug/dl, 9.4 ug/dl, and 9.2 ug/dl at baseline, 30min and 1hr respectively with a baseline ACTH of 539. Lung biopsy showed necrotizing granuloma and fungal spores compatible with histoplasmosis. He was started on amphotericin then transition to itraconazole for 1 year. Additionally, the dose of HC was decrease and Fludrocortisone 0.1mg daily was added. He refused adrenal biopsy at that point and wanted to continue current treatment with a plan to repeat imaging in 3 months and possible adrenal biopsy depending on CT results. On follow-up, patient regained weight and hypoglycemia resolved. Repeated adrenal CT showed shrinkage of the adrenal nodules bilateral. He was continued on PAI replacement.

Discussion
Histoplasmosis is a fungal infection caused by (H. capsulatum), found in soil contaminated with bird or bat droppings. Infection usually limited to respiratory disease in immunocompetent host but may cause disseminated infection in immunocompromised patient which can involve any organ system. Less commonly, disseminated type may occur in an immunocompetent host with the adrenal gland being the most common infected organ. Treatment involves systemic antifungal therapy; ketoconazole or itraconazole for mild-moderate forms and amphotericin B for 12-18 months for severe ones. Relapse rate is high; ∼ 7.5% and most patients require long-term glucocorticoid replacement. Because unrecognized disseminated histoplasmosis accompanying PAI usually results in a high mortality rate, considerable suspicion and appropriate investigations are necessary for correct diagnosis of this rare but treatable disease.
Presentation: No date and time listed
ODP503 Non-Small Cell Lung Cancer Metastatic to the Thyroid Gland
Authors: Pessoa Carolina Mendes , Madhavan Parvathy 
Published: November 2022

Abstract

Introduction
Metastatic disease affecting the thyroid gland is an uncommon phenomenon, with the most common primary sites being kidney, breast, lung and gastrointestinal tract. Thyroid metastases frequently occur simultaneously with spread to other sites and are rarely symptomatic. Clinical case: 73-year-old female with remote history of stage IA (T1c, N0, M0) invasive lobular carcinoma of the right breast treated with lumpectomy, radiation and tamoxifen, previous tobacco use, remote exposure to radiation during Chernobyl nuclear accident, developed progressive dyspnea on exertion. She was found to have a large left-sided pleural effusion. Thoracentesis was performed, and the cytology revealed adenocarcinoma with features favoring lung primary. Further imaging showed a left lower lobe mass with central necrosis and left hilar adenopathy, multiple pleural masses, and a small solitary brain lesion. PET-CT also demonstrated, amongst other findings, an FDG avid left lower pole thyroid nodule. Thyroid ultrasound was obtained to further characterize the lesion, which demonstrated a 0.8×1.3×1.3 cm solid hypoechoic nodule in the left mid lobe, which was thought to be corresponding to the PET avid nodule. Two additional nodules, a mixed cystic and solid measuring 1.7×2.1×2.9 cm on the right lobe, and another left-sided solid isoechoic measuring 0.8×0.7×0.9 cm, were noted. Thyroid FNA of the 1.3 cm PET avid nodule revealed rare cells in clusters, with large pale nuclei and prominent nucleoli, some with intracytoplasmic vacuoles, morphologically similar to those seen in the prior pleural fluid. Thin prep was stained with antibody to thyroglobulin, and the malignant cells showed lack of staining, supporting the diagnosis of metastatic lung cancer. Thyroid function tests were normal. Given lack of compressive symptoms, patient was maintained on her primary oncologic treatment with carboplatin and pemetrexed, and stereotactic radiation for the brain metastasis. Repeat PET-CT, performed approximately 8 months after the initial scan, showed mildly decreased focal FDG activity in the thyroid lesion.

Discussion
In this scenario, a patient with primary lung malignancy was found to have an FDG avid thyroid nodule which on FNA proved to be a metastatic lesion. Per some studies, such lesions can be seen in 1.4%–3% of patients who undergo surgery for suspected malignancy in the thyroid gland. Management of metastatic thyroid cancers depends on multiple factors including the primary malignancy location and staging, patient comorbidities, compressive symptoms, etc. Surgical management may be of benefit in isolated lesions in the thyroid.

Conclusion
When evaluating thyroid nodules in patients with known history of malignancy, it is important to consider the differential of metastatic lesions and to perform a thorough evaluation including fine-needle aspiration for clinical elucidation and management.
Presentation: No date and time listed
ODP505 Polymorphisms of ITM2A rs1751094 on×Chromosome Is Associated with intractable Graves’ disease in Korean Children
Authors: Ahn Moonbae , Cho Kyoung Soon , Ho Jung Min , Suh Byung-Kyu , Kim Sung Eun , Cho Won Kyoung , Kim Mirae , Baek In-Cheol , Kim Tai-Gyu , Shin Chungwoo , Jeong Jang Min , Ju Choi Young , Lee Na Yeong , Kim Seul K , Kim Shin Hee 
Published: November 2022

Abstract

Background
Autoimmune thyroid diseases (AITDs) are female predominant and much attention has been focused on integral membrane protein 2A (ITM2A) on the X chromosome as Grave's disease (GD) susceptible locus.

Methods
We genotyped ITM2A rs1751094 single nucleotide polymorphism (SNP) in 166 patients (142 females and 24 males) diagnosed with AITD (67 HD and 99 GD cases). The mean age (±SD) of GD patients at enrollment was 14.4 ± 3.5 years and HD patients was 13.8 ± 3.5 years. In GD patients, 49 patients (49/99, 49.5%) had thyroid-associated ophthalmopathy (TAO). Among the 85 GD patients, 60 patients (60/85, 70.6%) were intractable GD. The data were analyzed by sex-stratified or combined with 198 healthy Korean individuals (97 females and 101 males).

Results
Target SNP fits the HWE. In patients with AITD (n = 166), the genotype and allele frequencies of rs1751094 AC (OR=2.5, corrected P (Pc) = 0. 000), C (OR=2. 0, Pc = 0. 000) were higher and those of AA/A (OR=0.3, Pc = 0. 000), A (OR=0.5, Pc = 0. 000) were lower than those in controls (n = 198) (Table 3). In female AITD patients (n = 143), those of rs1751094 CC (OR=2.4, Pc = 0. 031), C (OR=1.8, Pc = 0. 003) were higher and those of rs1751094 AA (OR=0.5, Pc = 0. 027), A (OR=0.6, Pc = 0. 003) were lower than those of female controls (n = 97). In patients with GD (n = 99), rs1751094 CC/C (OR=3.5, Pc = 0. 000) and C (OR=3.4, Pc = 0. 000) were higher those in controls (n = 198). In intractable GD Patients (n = 60), rs1751094 AC (OR=2.2, Pc = 0. 026) and C (OR=2.5, Pc = 0. 000) were higher than those in controls. In GD with TAO (n=49), rs1751094 CC/C (OR=2.9, Pc = 0. 003), C (OR=3.3, Pc = 0. 000) were higher than those in controls. In patients with HT (n = 67), the genotype frequencies of rs1751094 AC (OR=3. 0, Pc = 0. 000) was higher and those of AA/A (OR=0.4, Pc = 0. 002) were lower than those in controls (n = 198).

Conclusions
Polymorphisms in ITM2A rs1751094 on the X chromosome might be associated with AITD in Korean children.
Presentation: No date and time listed