bluuebunny/crossref_metadata_2025_split huggingface dataset:
ODP482 Graves Orbitopathy Secondary to Alemtuzumab Infusion for Multiple Sclerosis
Authors: Alam Mustafa , Abdelrahim Baha , Hosam Horani Mohamed 
Published: November 2022

Abstract

Presentation: This is a 51-year-old male with a history of Graves disease who presented to the ED with worsening proptosis and 10/10 eye pain. He reported being unable to shut his eyes, photophobia, decreased vision, and extreme eye sensitivity to touch. He was initially diagnosed with Graves disease 3 months ago, after which he was started on Methimazole 15mg 3x a day. Patient has a history of multiple sclerosis treated with an Alemtuzumab infusion 6 months ago. He additionally reports a history of depression, smoking, and alcoholism. Hospital Course: The patient presented with stable vitals signs with T: 36.5 C, HR: 97, BP: 117/68, O2 Sat 98% on RA. Physical exam was notable for Va: 20/100 OD, 20/200 OD with near card Sc. The R pupil was dilated Nr OU. EOM exam was notable for restricted ductions in all fields of gaze OU. IP was 20 mmHg OD and 22mmHg OS with Toponen 95%. Significant Proptosis OS more than OD with resistance to retropulsion. Bilateral conjunctival erythema with clouded corneas. Labs were significant for Hgb 12.2, MCV 80, Plt 342, ANC 12.1, Creatinine 0.69, albumin 2.8, Alk Phos 158, CK 41, FT4 0.53, TSH 0.318, and FT3 1.63. An US of the thyroid was significant for thyromegaly and a 5mm right thyroid nodule. A CT Orbit/Sella was significant for thyroid associated orbitopathy with greater exophthalmos on the left and maxillary sinusitis. The patient received 1000mg Rituximab infusion and IV Decadron every 4 hours with referral for possible thyroidectomy, orbital decompression as per ophthalmology, and continued multiple sclerosis management as per neurology.

Discussion
This complex case highlights worsening Graves orbitopathy as a rare side effect of Alemtuzumab. This orbitopathy persisted despite high dose methimazole. Urgent IV Decadron with orbital decompression should be considered in the acute setting with thyroidectomy for symptom resolution.
Presentation: No date and time listed
ODP485 Hyperthyroidism with Concurrent Thyroid Cancer: Causal Relation or Incidental Association?
Authors: Calin Cristiana , Ioana Dumitriu Roxana , Florentina Burcea Iulia , Poiana Catalina 
Published: November 2022

Abstract

Introduction
Thyrotoxicosis caused by Graves’disease (GD),toxic multinodular goiter (TMG) andtoxic adenoma (TA) can be associated with thyroid carcinoma; furthermore, tumors arisen in hyperthyroid tissue show an aggressive behavior (1).

Objective
To determine the incidence of thyroid carcinoma in thyrotoxic patients who underwent thyroidectomy and to analyzethe relationship between thyroid cancer, hyperthyroidism and outcomes of hyperthyroid versus euthyroid patients.

Materials and Methods
We retrospectively studied 304 consecutive hyperthyroid patients who underwent total thyroidectomy, presented in our institute between 2016 and 2021. The indications for surgery were GD (n=167, 3 of them were classified as Bethesda V on the basis of fine needle aspiration biopsy cytological examination prior to surgery), TMG (n=117) and TA (n=20).

Results
The incidence ofthyroid carcinoma in hyperthyroid patients was 18.1% (n=55) and was more common in patients with TMG (19.7%) and GD (18.6%), than in those with TA (5%). According to the post-surgical histological examination 41 patients were diagnosed with papillary thyroid carcinoma (92.7%), 2 patients were diagnosed with follicular thyroid carcinoma (3.6%), 1 patient with undifferentiated thyroid carcinoma (1.8%), and another patient with medullary thyroid carcinoma (1.8%). Papillary thyroid microcarcinoma accounted for 58.2% of all histological types. Lymph node involvement was found in 22% of the patients with GD, in 13% of those with TMG, and in none of those with TA. Distant metastases were found in 2 patients with GD and in other 2 patients with TMG. Compared with a similar group of 120 euthyroid patients who underwent surgery for thyroid cancer during the same time period, the patients with hyperthyroidism have a 3.4 times greater risk for developing lymphovascular metastases compared to euthyroid subjects (23.6% vs 8.3%, p=. 008).

Conclusion
Our study showed that thyroid cancers in hyperthyroid patients have an aggressive behaviour, with a worse prognosis than euthyroid patients. A carefully evaluation of all patients with hyperthyroidism is needed to exclude the presence of concurrent malignancy. Routine thyroid ultrasonographic (US) scans and US-guided FNAB should be considered for complete evaluation of hyperthyroid patients. Reference: Medas F, Erdas E, Canu GL, Longheu A, Pisano G, Tuveri M, Calò PG. Does hyperthyroidism worsen prognosis of thyroid carcinoma? A retrospective analysis on 2820 consecutive thyroidectomies. J Otolaryngol Head Neck Surg.2018 Jan 22;47(1): 6.
Presentation: No date and time listed
ODP491 Levothyroxine Withdrawal Presenting as Myxedema Madness
Authors: Trusty Rhonda-Kaye , Bagar Darin , Kirupakaran Johnathan , Adoulphous Ifediba Nwachukwu , Rodriguez Giovanna , Bahtiyar Gul 
Published: November 2022

Abstract

Introduction
Myxedema coma, a medical emergency, refers to severe hypothyroidism which can be precipitated by several factors including acute infection, myocardial infarction, and hypothermia. Rarely, patients may present with myxedema psychosis which manifests as suicidal ideations, hallucinations and or delusions.

Case Presentation
A 60-year-old woman with a history of hypertension, hypothyroidism, anxiety disorder and heroin abuse on methadone 50 mg every day presented to the hospital with acute onset of altered mental status. Per the patient, she called 911 for "cardiac arrest and talking about dead bodies". Upon presentation, the patient was hypertensive, 184/124mmHg. Physical exam was notable for active hallucinations. She was alert and oriented to person and place, with an unsteady gait. Laboratory examination was remarkable for hyponatremia 131 mmol/L (137-147 mmol/L). She received workup for acute encephalopathy and ED physicians determined that if the workup was negative, she should be evaluated by Psychiatry. Infectious processes and drug intoxication/overdose were ruled out. Psychiatry determined that the patient's psychosis was due to an organic etiology. Follow-up laboratory showed TSH 155 ulU/mL (0.350-4.80 ulU/mL), free thyroxine 4 &lt; 0.1 ng/dL (0.90-1.8 ng/dL) and thyroid peroxidase antibody 460 IU/ml (&lt;34.9). While in the ICU, she became bradycardic, heart rate 25 bpm, and hypoxic, O2 saturation ∼ 75%. She was placed on nasal cannula with improved oxygenation. Later she experienced two seizures lasting approximately 1 minute. The patient received stress dose steroids intravenously every 8 hours and levothyroxine intravenously. Adrenal insufficiency workup was within normal limits. On hospital day 3, her mental status improved and she was transitioned to oral levothyroxine. The patient was transferred to the medical floor for further care. Upon questioning, she reported she stopped taking her levothyroxine for approximately 6 months. Her delusions decreased and later resolved on hospital day 10. She was discharged home with 100 mcg oral levothyroxine and outpatient follow-up with Endocrinology.

Conclusion
Our patient presented with a rare manifestation of severe hypothyroidism, myxedema madness. The relationship between psychosis and thyroid dysfunction has long been documented. In the same period, there has only been a few reported cases of myxedema madness in literature, generally reported in Psychiatric journals. This is surprising, given that these are endocrinological emergencies. Importantly, patients with an acute presentation of psychosis, should be tested for thyroid abnormalities, as this is reversible. In our patient's case, she had no previous documented psychiatric history. It is reasonable therefore to conclude that, herlikely myxedema madness resulted from prolonged thyroid replacement non-compliance.
Presentation: No date and time listed
ODP495 Medullary Thyroid Cancer Outcome in a Tertiary Care Centre in Atlantic Canada
Authors: Rajaraman Kye , Devereaux Emily , Rajaraman Murali , Imran Syed 
Published: November 2022

Abstract

Background
Medullary thyroid carcinoma (MTC) constitutes around 1-2% of all thyroid cancer with a paucity of published data. Distinctively, MTC has a strong genetic component with oncogene mutations. For AJCC stages I, II, III, and IV, 5-year overall survival (OS) rates are 100, 90, 86.5 and 55.5%. The aims of this study are to report outcomes of the MTC patient cohort managed at a single tertiary cancer centre and specifically that of the subset of patients who have a biochemically incomplete response to primary surgical management.

Objectives
Explore the incidence and outcome of MTC including demographics, stage, genetic mutation status, dynamic risk stratification (DRS), and OS rate. Compare the outcome of MTC patients found to have low detectable post-op calcitonin (POC) levels (10-200 pg/ml=Grp B)) with those who have undetectable (&lt; 10 pg/ml=Grp A) and significantly high-level POC levels (&gt;200 pg/ml=Grp C).

Methods
Patients with MTC were identified from the Interdisciplinary Thyroid Oncology Clinic (ITOC) prospective database. Data was extracted and completed with a chart review.

Results
35 cases with MTC were identified from 1570 cases. 21/35 were males. The diagnosis was made between 1988 and 2019 with a median age at diagnosis of 50 years (range=15 to 77) and a median follow-up of 8 years. Distribution (and 5-year OS, p=0.515) across Stages I, II, III, IV were 23% (100%), 14% (100%), 17% (100%) and 32% (90%) respectively with 14% unknown. 10 (29%) tested positive for RET gene mutations. Post-operative DRS response to initial treatment for 29 cases found 48%, 35%, and 17% were classified into excellent (E=undetectable calcitonin), biochemical incomplete (B=only detectable calcitonin), or structural incomplete (S=structural disease present) respectively. The 29 cases with available POC and DRS were divided into Groups A, B, and C based on POC levels as above. The final status at last follow up for Grp A was 13/14 (93%) with E and 1 (7%) with S, for Grp B 6/9 (67%) with B, 3/9 (33%) with S, and for Grp C 6/6 (100%) with S. The DRS for Grp A, B and C was 100% E, 89% B and 11% S, and 33% B and 67% S. The 5-year OS for Grp A, B, C was 100%, 89%, 100% (p=0.223) respectively.

Conclusion
This cohort of MTC cases failed to show significant differences in OS by stage and POC levels but did exhibit a higher rate of genetic mutations (29%) than those from other regions of Canada. Additionally, a biochemically incomplete response with a POC level above 200 pg/ml was highly suggestive of progressive structural disease as final outcome. This study will provide the template for a national survey of MTC in Canada facilitating analysis of a larger dataset.
Presentation: No date and time listed
ODP497 Multifocal Papillary Thyroid Carcinoma with Anaplastic Dedifferentiation
Authors: Jacinto Jorg Jurgen N , Isidro Maria Jocelyn C 
Published: November 2022

Abstract
A 71-year old male with a two-year history of progressively enlarging right thyroid mass presented with hemoptysis. Chest CT scan showed multiple pulmonary nodules and enlarged right thyroid mass with intrathoracic extension. A fine needle biopsy of the right thyroid mass showed atypia of undetermined significance. Patient underwent total thyroidectomy and complete resection of the intrathoracic component. Histopathology reported multifocal Papillary thyroid carcinoma, right lobe, encapsulated follicular variant (9cm) with extensive and vascular invasion. There was also invasion of the left thyroid lobe, follicular variant, infiltrative (0.6 cm) and conventional (0.6 cm). Extrathyroidal extension to skeletal muscle and lymphovascular invasion was present. The tumor showed areas with more solid growth patterns and some ball-like clustering. Consequently, immunostaining was done which showed the following results: positive for cytokeratin, thyroglobulin and TTF-1 consistent with papillary morphology. The more solid areas with significant nuclear pleomorphism, necrosis and increased mitotic activity (atypical forms) support the focal progression to an anaplastic carcinoma. The final histologic reading showed multifocal papillary thyroid carcinoma with focal (20%) progression to undifferentiated (anaplastic) thyroid carcinoma. Two weeks postoperatively, he developed a 4cm×2cm manubrium mass. There were also several metastases on the brain, pancreas, liver and bones seen on FDG PET scan. One month postoperatively, TSH was 15 uIU/mL Thyroglobulin &gt;500 uIU/mL, anti-thyroglobulin &lt;0.20 ng/dl. Due to the widespread metastases even involving the brain, the multidisciplinary team decided to start treatment with Lenvatinib and check for BRAF V600E gene mutation for a more definitive treatment. He was started on Levothyroxine. He also underwent 27 cycles of radiation therapy to the manubrium mass and was given Denosumab 120mg subcutaneously to stabilize the bone and provide pain relief. BRAF gene mutation analysis result came back negative in two weeks. Close monitoring of his sensorium was done. However, he deteriorated clinically and he succumbed to sudden cardiac death two months after.
Presentation: No date and time listed
ODP501 New-Onset Graves’ Disease in a Patient with Recent Diagnosis of Covid-19 Infection
Authors: Ince Melda Sonmez , Daneshvar Farah , Esfandiari Nazanene 
Published: November 2022

Abstract

Background
Thyroid disorders have been described in patients with Covid-19 infection. Although thyrotoxicosis secondary to thyroiditis is mostly reported in several publications worldwide in patients infected with Covid-19, new-onset Graves’ disease is rarely reported.

Clinical Case
A 41-year-old female without significant past medical history presented to emergency room with nausea, vomiting, palpitations and syncope. She was diagnosed with COVID-19 infection five days prior to her presentation. On admission, patient was normotensive, tachycardic with heart rate of 135 beats/min, and oxygen saturation &gt;90% on room air. Thyroid exam was unremarkable. Initial labs showed suppressed TSH, elevated free T4 of 2.58 ng/dL (0.76–1.70 ng/dL) and elevated total T3 of 210 ng/dL (80–175 ng/dL). The computed tomography pulmonary angiogram (CTPE) was negative for pulmonary embolism. Transthoracic echocardiogram (TTE) showed moderate cardiac effusion without tamponade. Patient had no prior history of thyroid disease, but her mother had hypothyroidism. With Burch-Wartofsky score of 50, treatment for thyroid storm was initiated: Hydrocortisone, propranolol, and propylthiouracil (PTU), followed by cholestyramine, and super saturated potassium iodide (SSKI). Shortly after, patient developed hypotension requiring norepinephrine infusion and transfer to intensive care unit. Repeat TTE showed ejection fraction of 50%, moderate pericardial effusion without tamponade, and global hypokinesis suggestive of myocarditis. Propranolol was held. Although patient's blood pressure improved overnight, patient developed shock liver with AST elevated at 4,095 IU/L (8-30 IU/L), ALT at 2,837 IU/L (&lt;35 IU/L), and total bilirubin at 1.6 mg/dl (0.2-1.2 mg/dl) compared to normal values on admission. PTU was discontinued after two doses due to elevated liver enzymes. Thyroid scan showed diffuse mildly increased radiotracer uptake suggestive of autoimmune thyroid disease. Thyroid stimulating immunoglobulin (TSI) was elevated at 6.5 IU/L (&lt;0.55IU/L) with thyrotropin receptor antibody (TRAb) of 8.39 IU/L (0. 00 - 1.75 IU/L) suggestive of Graves’ disease. On discharge, patient was asymptomatic. At outpatient follow up, patient had improvement in liver enzymes and mild hyperthyroidism, methimazole was started with the plan for close monitoring of liver enzymes and thyroid function tests.

Conclusion
New-onset Graves’ disease can occur in the setting of Covid-19 infection. It is crucial to report this type of cases to gain more insights in the exact relationship between thyroid disease and Covid-19 infection. Physicians should be aware of the possibility of Graves’ disease in addition to thyroiditis in the setting of thyrotoxicosis and Covid-19 infection. Making the right diagnosis is essential as treatment and course of disease are very different.
Presentation: No date and time listed
ODP502 Nodular Pretibial Myxedema without Graves’ Orbitopathy: A Case Report
Authors: Veeramachaneni Ravali , Veeramachaneni Ravali , White-Cotsmire Alexander , Norwick Paige , Demidova Olga , Roseberg Arlene , del Rincon Juan P 
Published: November 2022

Abstract

Background
Nodular myxedema is an uncommon skin manifestation of autoimmune thyroid disease. Almost always associated with significant orbitopathy from the deposition of glycosaminoglycans by stimulated fibroblasts.

Clinical Case
A 57-year-old male presented to dermatology clinic with multiple, non-tender, non-erythematous, nodular lesions of the distal left leg, which had been increasing in size and number over the past one year. The initial clinical impression was lipoma, versus leiomyoma, versus pilomatricoma. The pathology report from punch biopsy of one of the lesions revealed diffuse dermal mucin deposition, consistent with pretibial myxedema. The patient was then referred to endocrinology. His symptoms included increasing fatigue and weight gain of 20.4 kilograms over the last 7 years. He had long-standing history of untreated hypothyroidism and tobacco use disorder. There was no known history of hyperthyroidism, neither thyromegaly, acropachy, nor any signs of orbitopathy were found on examination. Laboratory tests revealed a mildly elevated TSH (5.491 uIU/ml, reference 0.450-5.491 uIU/ml), normal free thyroxine (0.98 ng/dl, reference 0.45-1.80 ng/dl) and elevated anti-microsomal antibody (66. 0 IU/mL, reference &lt;9. 00 IU/ml). Following the pathology report, thyroid stimulating immunoglobulin was requested and found to be elevated (322%, reference &lt;140%). Thyroid ultrasound showed estimated volume of 5. 04 and 2.96 ml for the right and left thyroid lobes, respectively, and only one sub-centimeter nodule. Treatment with levothyroxine was started.

Conclusion
Thyroid dermopathy, including pretibial myxedema, is attributed to high serum concentrations of thyroid stimulating immunoglobulin leading fibroblasts to deposit mucopolysaccharides in the papillary and reticular dermis. The resulting nonpitting edema can occur anywhere in the skin, despite its notorious penchant for the anterior tibial region. Thyroid dermopathy is seen in 4.3% of patients with Graves’ disease in general, and 15% of patients with Graves’ orbitopathy 1 . Thyroid dermopathy is very rare in the absence of concurrent orbitopathy. Here we present a very unusual case of biopsy-confirmed nodular pretibial myxedema in the absence of current or remote history of known hyperthyroidism, and without any apparent orbitopathy.
Presentation: No date and time listed
ODP522 Thyroid Sarcoidosis: A Rare Manifestation of Systemic Sarcoidosis
Authors: Alameri Majid , Alnuaimi Abdulla , Wernig Florian 
Published: November 2022

Abstract

Introduction
Sarcoidosis is a multisystem granulomatous disease of unknown aetiology characterized by noncaseating granulomas. Thyroid infiltration remains extremely rare. If present, it can cause diffuse goitre and rarely a solitarythyroid nodule. Almost all patients are euthyroid. Here, we report a case of systemic sarcoidosis with thyroid involvement.

Case presentation
A21-year-old female of Nepalese origin with past medical history of Asthma presented with painful eyes and was diagnosed with bilateral anterior uveitis. Symptoms improved with topical Dexamethasone and Cyclopentolate. A screening chest radiograph showed significant hilar adenopathy. Chest CT scan confirmed extensive mediastinal adenopathy particularly in the right paratracheal, subcarinal and hilar node suggestive of sarcoidosis. Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA) revealed non-necrotising granulomas. There was no evidence of tuberculosis on any materials obtained. TB-PCR and AFB were both negative. Further investigations showed raised serum ACE (163 units/L) with normal adjusted calcium levels and normal 24-hour urine calcium levels. During follow up, she developed palpable cervical and submandibular lymphadenopathy. Systemic examination revealed a smooth goitre and erythema nodosum. She did not have any neck pain and remained clinically euothyroid. Thyroid ultrasound showed several small microlobulated hypoechoic regions in both thyroid lobes, the largest measuring 7 mm in the right and left upper poles. Fine needle aspiration cytology revealed granulomata consistent with thyroid sarcoidosis. The thyroid MDT recommend conservative management with periodic clinical and biochemical assessment. She remains well at 6 months of follow up.

Conclusion
Sarcoid granulomata within the thyroid gland remains rare. This case report illustrates that in patients with known sarcoidosis, careful thyroid assessment should be carried out.
Presentation: No date and time listed
ODP523 Thyroid Storm in a Patient With Alemtuzumab Induced Graves’ Disease
Authors: AlShehri Sara , Alajmi Sarah , Ekhzaimy Aishah 
Published: November 2022

Abstract

Background
Thyroid storm (TS) is a rare and life-threatening medical emergency, most commonly caused by Graves’ disease (GD). GD can beinduced by immune reconstitution therapy (IRT) such as Alemtuzumab (ALZ), a humanized monoclonal antibody against CD52, which is shown to be effective in the treatment of relapsing-remitting multiple sclerosis (RRMS). Evidence shows that ALZ induced GD may be less aggressive than conventional GD. Below we present a rare case of thyroid storm developing in a patient with ALZ induced GD.

Clinical Case
A 39 year-old female non-smoker, known to have RRMS, wasstarted on ALZ. Presented to our emergency room13months later with palpitation, diarrhea and oligomenorrhea. Found to have TSH of 0. 007 mIU/L (0.250-5), T4 50 pmol/L (11.5- 22.7), thyroid scan demonstrated diffusely enlarged thyroid gland with increased tracer uptake compatible withGD. Our impression was ALZ- induced GD (not in thyroid storm),she wasstarted on carbimazole and propranolol and discharged home. Neurology team gave hera second cycle of ALZas she was euthyroid on carbimazole. One month later, the patient presented to our emergency room with nausea and vomiting. On examination, she was febrile 38.2°C, tachycardic reaching 140 beats/min (regular). Her blood pressure was 138/87 mmhg. The patient was agitated, anxious, alert and oriented. She was diaphoretic with mild peripheral oedema and had pulmonary crackles. The thyroid was diffusely enlarged with no signs of graves’ ophthalmopathy, or pretibial myxedema. On the Burch-Wartofsky Point Scale for thyroid storm, she scored 60. The patient was admitted to the intensive care unit (ICU), with endocrinology and neurology consultation. Laboratory investigation revealed TSH of 0. 009 mIU/L, T3 26.5 pmol/L (3.39-5.82) T4 65 pmol/L, positive thyroid peroxidase antibody 183 units (&gt;100 positive). Despite treatment with maximum dose of carbimazole, B-blocker, hydrocortisone, and potassium iodide her T4 was not improving, and her liver function was deteriorating. Finally, she underwent total thyroidectomy. Three days post total thyroidectomy, the patient clinically improved. Steroids were stopped and the B-blocker dose was gradually tapered. She was then maintained on Levothyroxine.

Conclusion
It is thought that ALZ- induced GD behaves less aggressive than the conventional GD as spontaneous and/or drug-induced remission may be more likely. However, physicians should be aware that severe thyrotoxicosis and thyroid storm can happen which required prompt recognition and aggressive therapy.
Presentation: No date and time listed