Steroid Use Research Articles

The association between atopic dermatitis and linear growth in children- a systematic review.

To evaluate the association between atopic dermatitis (AD) and linear growth in children, and determine factors associated with compromised linear growth in children with AD. A PRISMA-compliant systematic review was conducted. Databases (PubMed, Embase, Scopus and Cochrane) were searched from inception to June 2024 for articles that reported a quantitative relationship between AD and linear growth in children (< 18years old). Quality of included articles was assessed using the Joanna Briggs Institute Critical Appraisal Tools while quality of evidence in these studies was evaluated using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Fourteen studies (comprising 50,146 patients with AD) were included. Seven studies reported a strong positive or positive association between AD and reduced height standard deviation score (SDS) in children; the others reported no association. Only 3 studies had moderate quality of evidence, all of which reported an association between AD and poorer height SDS; the remaining 11 studies scored low in quality of evidence. Three studies reported the impact of AD on height to be transient. Secondary analysis showed AD severity, earlier AD onset, sleep disruption and, food restriction, to be risk factors for linear growth impairment in patients with AD. Topical steroid use was not associated with shorter stature in patients with AD. Conclusion: Current evidence on the association between childhood AD and poor linear growth is weak and inconsistent. However, patients with more severe AD, earlier disease onset, poorer sleep quality and higher nutritional restrictions appear more susceptible to linear growth impairment. What is known? • There is inconsistent evidence of the association between atopic dermatitis (AD) and linear growth in children in current literature, with some studies suggesting that AD may negatively impact linear height while other studies do not report similar associations. What is new? • There is no strong association between AD in childhood and poorer linear growth. • There may be a transient slowing of linear growth in children with AD, mimicking constitutional growth delay. • Children with severe AD, earlier disease onset, poorer sleep quality and nutritional restrictions may be at risk of more significant linear growth impairment. • Topical steroid use does not appear to contribute to shorter height in children with AD.

7784 Perspectives Of Anabolic Steroid Users On Steroid Use, Side Effects, And Patient Education

Abstract Disclosure: D.D. Lam: None. M. Potemkin: None. J. Kreutz: None. H. Shah: None. P. Patel: None. P.K. Doyle-Baker: None. Background: Details on first-hand perceived and experienced effects of anabolic steroids (AS) on users are sparse. Furthermore, there is limited information on what type of AS knowledge users possess, irrespective of current published works in AS pharmacology. This study aimed to identify insights of AS users regarding their knowledge and patterns of AS use, commonly experienced side effects, sources used for steroid education, and their unique needs as a population. Study Design: AS users from Calgary, Alberta, Canada of various sexes and ages ≥ 18 were recruited through gyms in Alberta with convenience and snowball sampling techniques. Participant-centered-qualitative research using semi-structured interviews was conducted. Participants discussed their experiences as a user and shared their understanding of AS, details of usage including compounds used, and their commonly experienced or perceived side effects through one-on-one interviews of varying durations. Interviews were coded using NVivo 14 Software prior to thematic analysis. Resulting codes were organized into overarching themes based on researchers' consensus. Results: Seven AS users were confidentially interviewed over Zoom. Several important themes emerged. There existed a wide variety of AS that users have identified, with some of the most commonly mentioned being Anavar, Nolvadex, Testosterone, and Trenbolone. Steroid users frequently identified increased strength with faster recovery from training and better overall appearance as prominent advantages of AS use. Conversely, hair loss, gynecomastia, acne, aggression, erectile dysfunction, altered libido, hypogonadism, infertility, and injection related discomfort were commonly identified disadvantages of AS use. Lastly, individuals using AS report having consulted many different sources to learn about appropriate dosing, techniques, and side effects. These sources ranged from peers, coaches, online forums, social media, and scientific research articles, but rarely included healthcare professionals. Conclusions: This study identified the need for education and research in exploring the impact of AS use. A variety of AS exist on the market, yet information pertaining to the side effect profiles of these AS from a patient’s perspective is lacking and exploration of this topic is warranted. Further investigation as to the impact of user education on their understanding of the risks versus the benefits of AS use must also be conducted. Presentation: 6/1/2024

7635 Severe Osteoporosis in a Patient with Heterotopic Calcification: A Case Report

Abstract Disclosure: D. Salih Bacha: None. L.Z. Khan: None. Background: While osteoporosis and heterotopic ossification (HO) are distinct conditions affecting bone health, their coexistence poses intriguing clinical challenges. Osteoporosis, characterized by increased bone fragility, typically results from various factors such as aging, steroid use, or malabsorption. HO is a condition where bone forms abnormally in soft tissues. Risk factors that predispose to HO include male sex, spinal cord injury, trauma, surgery, and genetic factors. Treatment of HO is typically surgical resection and NSAIDs. Initial evidence supported the use of bisphosphonates for preventing ectopic bone formation post-trauma, but recent data failed to show significant benefit in HO prevention. This case presents a patient with unique challenges of both HO and bone fragility with multiple severe vertebral fractures. Case: A 44-year-old male patient had a major motor vehicle accident necessitating multiple recurrent abdominal surgeries. During one exploratory laparotomy, diffuse mesenteric calcifications were noted, indicative of HO. A baseline Dual X-ray Absorptiometry (DXA) scan revealed bone density of 1.003 g/cm2 and 0.788 g/cm2 at the spine and femoral neck, respectively, concerning for osteopenia. He was started on zoledronic acid in preparation for upcoming intestinal transplant. Few months after the transplant, he was started on daily tacrolimus and hydrocortisone for immunosuppression. Within months, he experienced sudden back pain while riding an elevator, and was found to have acute fractures in T8 and T9 vertebrae. A repeat DXA scan showed a further decline in bone density to 0.909 g/cm2 and 0.748 g/cm2 at the spine and femoral neck, respectively. Within a year, additional fractures occurred in the thoracic and lumbar spine (T10, T11, T12, L1, L2, L3, and L4), requiring multiple kyphoplasty interventions. Over time, worsening kyphosis, back pain, and height loss occurred, significantly affecting the patient's quality of life. He continued receiving yearly zoledronic acid infusions and underwent regular DXA scans, which revealed mild improvement in his bone density. Currently, there are no established guidelines specifying the optimal duration for bisphosphonate treatment in such cases. Therefore, our individualized treatment plan involves a tentative 10-year course of bisphosphonate treatment with yearly assessment of bone mineral density. Conclusion: Although the patient had some risk factors for osteoporosis, including daily steroid and tacrolimus use, the severity and frequency of his fractures suggested a potential synergy between osteoporosis and HO, where the formation of heterotopic calcifications may have been exacerbating his bone loss. The coexistence of osteoporosis and HO in this patient underscores the need for individualized care and establishment of treatment guidelines in patients with multiple bone disorders. Presentation: 6/3/2024

7945 Modelling the Factors Associated With Sexual and Mood Symptoms Within the First Year of Anabolic-Androgenic Steroid Cessation in Men

Abstract Disclosure: B. Grant: None. J. Kean: None. N.L. de Silva: None. O. Quinton: None. P. Bassett: None. J. McVeigh: None. A. Lingford-Hughes: None. S. Minhas: None. S. Bhasin: None. W.S. Dhillo: None. C.N. Jayasena: None. Context: Anabolic-androgenic steroids (AAS) are misused by millions of men worldwide to boost muscle size and physical performance. Recent studies have quantified the recovery of cardiovascular markers and testicular function following AAS cessation. Qualitative studies demonstrate that low mood, anxiety, suicidal ideation, and sexual dysfunction are also common following AAS cessation. However, no previous study has focused on quantifying symptoms within the first year of AAS cessation, nor investigated independently associated factors for these symptoms. Methods: Cross-sectional, observational study of 165 men in 3 groups; non-AAS (n=43); current-AAS (n=76); past-AAS ≤1 year (n=46). All participants completed questions on substance misuse, Beck Depression Inventory-II (BDI-II), International Index Erectile Function-15 (IIEF-15), General Anxiety Disorder (GAD-7), Quality-of-life (SF-36), and underwent fasting, morning blood sampling with urine toxicology. Results: As expected, current-AAS had lower gonadotropins and elevated serum total testosterone compared with past-AAS and non-AAS. Sexual function measured using IIEF-15 was impaired in men stopping AAS &amp;lt;1year (past-AAS) compared with current AAS users: (1) total: 69.0 [95% CI 64.0, 71.0], current-AAS; 61.0 [95% CI 56.0, 66.0], past-AAS; p=0.077; (2) erectile function: 30.0 [95% CI 29.0, 30.0], current-AAS; 28 [95% CI 21.0, 29.0], past-AAS; p=0.015; (3) sexual desire: 9.0 [95% CI 8.0, 10.0], current-AAS; 6.0 [95% CI 5.0, 8.0], past-AAS; p&amp;lt;0.0001; (4) overall satisfaction: 10.0 [95% CI 8.0, 10.0], current-AAS; 7.0 [95% CI 7.0, 8.0], past-AAS; p=0.002. Multivariable analysis suggested that psychiatric comorbidity (coefficient -6.5 [95% CI -13.0, -1.3] p=0.03) and AAS cessation (coefficient -10.8 [95% CI -5.6, -17.2]; p&amp;lt;0.001) were associated with lower total IIEF-15 scores.Depression scoring was worse in the past-AAS group compared with non-AAS: BDI-II 4.0 [95% CI 2.0, 7.0], non-AAS; 7.0 [95% CI 4.0, 16.0], past-AAS; p=0.0448. Multivariable analysis suggested that psychiatric comorbidity (OR 2.39 [95% CI 1.60, 3.57]; p&amp;lt;0.001) and lower serum total testosterone (OR 0.85 [95% CI 0.88, 0.94]; p=0.002) were associated with higher BDI-II scores.Energy and fatigue measured using SF-36 was lower in the past-AAS group compared with non-AAS: 70 [95% CI 65, 75], non-AAS; 60 [95% CI 50, 65], past-AAS; p=0.0498. No significant differences in anxiety scoring were detected. Discussion: We report the first, detailed quantification and modelling of symptoms in men currently misusing and stopped AAS within the previous year. These data reveal potentially treatable factors to improve symptoms of AAS cessation if proven within interventional studies. Presentation: 6/2/2024

7945 Modelling the Factors Associated With Sexual and Mood Symptoms Within the First Year of Anabolic-Androgenic Steroid Cessation in Men

Abstract Disclosure: B. Grant: None. J. Kean: None. N.L. de Silva: None. O. Quinton: None. P. Bassett: None. J. McVeigh: None. A. Lingford-Hughes: None. S. Minhas: None. S. Bhasin: None. W.S. Dhillo: None. C.N. Jayasena: None. Context: Anabolic-androgenic steroids (AAS) are misused by millions of men worldwide to boost muscle size and physical performance. Recent studies have quantified the recovery of cardiovascular markers and testicular function following AAS cessation. Qualitative studies demonstrate that low mood, anxiety, suicidal ideation, and sexual dysfunction are also common following AAS cessation. However, no previous study has focused on quantifying symptoms within the first year of AAS cessation, nor investigated independently associated factors for these symptoms. Methods: Cross-sectional, observational study of 165 men in 3 groups; non-AAS (n=43); current-AAS (n=76); past-AAS ≤1 year (n=46). All participants completed questions on substance misuse, Beck Depression Inventory-II (BDI-II), International Index Erectile Function-15 (IIEF-15), General Anxiety Disorder (GAD-7), Quality-of-life (SF-36), and underwent fasting, morning blood sampling with urine toxicology. Results: As expected, current-AAS had lower gonadotropins and elevated serum total testosterone compared with past-AAS and non-AAS. Sexual function measured using IIEF-15 was impaired in men stopping AAS &amp;lt;1year (past-AAS) compared with current AAS users: (1) total: 69.0 [95% CI 64.0, 71.0], current-AAS; 61.0 [95% CI 56.0, 66.0], past-AAS; p=0.077; (2) erectile function: 30.0 [95% CI 29.0, 30.0], current-AAS; 28 [95% CI 21.0, 29.0], past-AAS; p=0.015; (3) sexual desire: 9.0 [95% CI 8.0, 10.0], current-AAS; 6.0 [95% CI 5.0, 8.0], past-AAS; p&amp;lt;0.0001; (4) overall satisfaction: 10.0 [95% CI 8.0, 10.0], current-AAS; 7.0 [95% CI 7.0, 8.0], past-AAS; p=0.002. Multivariable analysis suggested that psychiatric comorbidity (coefficient -6.5 [95% CI -13.0, -1.3] p=0.03) and AAS cessation (coefficient -10.8 [95% CI -5.6, -17.2]; p&amp;lt;0.001) were associated with lower total IIEF-15 scores.Depression scoring was worse in the past-AAS group compared with non-AAS: BDI-II 4.0 [95% CI 2.0, 7.0], non-AAS; 7.0 [95% CI 4.0, 16.0], past-AAS; p=0.0448. Multivariable analysis suggested that psychiatric comorbidity (OR 2.39 [95% CI 1.60, 3.57]; p&amp;lt;0.001) and lower serum total testosterone (OR 0.85 [95% CI 0.88, 0.94]; p=0.002) were associated with higher BDI-II scores. Energy and fatigue measured using SF-36 was lower in the past-AAS group compared with non-AAS: 70 [95% CI 65, 75], non-AAS; 60 [95% CI 50, 65], past-AAS; p=0.0498. No significant differences in anxiety scoring were detected. Discussion: We report the first, detailed quantification and modelling of symptoms in men currently misusing and stopped AAS within the previous year. These data reveal potentially treatable factors to improve symptoms of AAS cessation if proven within interventional studies. Presentation: 6/2/2024

6609 Central Serous Chorioretinopathy in the Eyes of the Beholder of Testosterone Depot Injection

Abstract Disclosure: H. Ni: None. D. Kankanamge: None. J. Jabbour: None. V.A. Preda: None. Background: Central serous chorioretinopathy (CSC) is a characterised by subretinal fluid accumulation causing detachment of the neurosensory retina and visual disturbance[1]. It has been postulated that increased focal choriocapillaris permeability results in leakage of interstial fluid into the subretinal space[1]. CSC is a rare side effect of testosterone therapy, the exact mechanism is unclear. Case : We present a 32-year-old male gym manager who has been self-administering anabolic steroids with testsoterone ethanoate IM injections every 14 days for body building. He reported left blurred vision for 8 weeks. He was normotensive and reported taking doxycycline and azithromycin for mycoplasma genitalia. There was no history of glucocorticoid exposure, smoking, alcohol use, gastoesophageal reflux disease, hypertension, shift work, sleep apnoea, nor other established risk factors for CSC. The visual acuity was OD 6/6 and OS 6/9 with intraocular pressures of 12mmHg on the right and 15mmg on the left. Fundoscopy revealed a left serous macular elevation involving the left fovea. A macular OCT confirmed the left acute central serous chorioretinopathy and right retinal pigment epithelial changes. The latter were suggestive of right CSC in the past. Discussion: Androgens have been associated with CSC in the literature. It has been hypothesised that exogenous testosterone may cause increased choriodal blood flow and permeability, promote atheroscleorsis, cause sodium retention and potentially interact with retinal pigment epithelium (RPE) via androgen receptors4. Intramuscular testosterone therapy causes fluctuation in plasma testosterone concentration (which is thought to be more relevant than absolute value of testosterone). Most cases (60%) of CSC resolve spontaneously, and appear to coincide with cessation of testosterone therapy5. Conclusion: Clinicans need to be alert to the use of testosterone and other anabolic steroids, prescribed or self administered, particularly in their patients with CSC or who have other risk factors for CSC, such as corticosteroids, smoking and hypertension.

8248 Glucocorticoid Induced Adrenal Crisis Masked By Metastatic Lung Carcinoma

Abstract Disclosure: N. Abrahimi: None. A. Abrahimi: None. Background: Chronic glucocorticoid use of three weeks or longer can cause hypothalamic-pituitary-adrenal axis inhibition by negative feedback, causing adrenal suppression. (1) Adrenal crisis is diagnosed by an acute clinical decompensation, persistent hypotension that resolves with high dose steroid administration. (2) Adrenal crisis is precipitated by several causes such as illness, dehydration, trauma, emotional distress and sometimes due to no identifiable cause. (2) Clinical Case: 64-year-old male past medical history of lung carcinoma metastatic to mediastinum who presented to the hospital with tachycardia. On presentation, patient was tachycardic, tachypneic, and hypotensive. Labs significant for WBC 22, Na+ 129, K+ 3.2, Cr 3.4. Patient received 2.5 L bolus of NS and was given one dose of azithromycin due to concern for sepsis. After fluid resuscitation, hypotension and tachycardia resolved. Presenting symptoms included ongoing nausea, decreased appetite and malaise for several weeks. Repeat labs post fluid resuscitation showed resolution of leukocytosis, improvement of AKI, and repletion of electrolytes. CT chest abdomen pelvis showed questionable pneumonia, however, consolidations were difficult to distinguish from known malignant masses. Clinical picture was not consistent with pneumonia and so additional antibiotics were held. Several hours later, blood pressure decreased, and patient began requiring vasopressors. Cefepime was started given concern for septic shock. Nearly 48 hours after initiation of broad-spectrum antibiotics hypotension persisted and patient remained on vasopressors. Given clinical decline, etiology of shock was reconsidered. Patient reported daily prednisone use over the last several months for COPD management. Given high clinical suspicion of adrenal crisis in setting of chronic steroid use and glucocorticoid withdrawal, patient was started on hydrocortisone 100 mg every 8 hours. Shortly after initiation of stress dosed steroids, the patient was successfully weaned off vasopressors with complete resolution of hypotension. Conclusion: Presentation and symptoms of adrenal insufficiency and crisis including nausea, anorexia, fatigue, malaise, hypotension and electrolyte abnormalities are nonspecific, can go unrecognized and be masked by other disease processes, such as metastatic cancer. (1) Adrenal crisis is life threatening and must be diagnosed and treated early to prevent mortality. (2) Therefore, adrenal crisis should always be on the differential in patients who present with shock.

7725 Could COVID-19 Be the Trigger for Type 1 Diabetes?

Abstract Disclosure: E. Ahsan: None. F.F. Foo: None. A. Ravin: None. M. Akula: None. K. Hu: None. R. Ong: None. S. Holland: None. M. Hossain: None. J. Cheng: None. Introduction: COVID-19 disrupts glucose homeostasis, which may result in hyperglycemia and new-onset diabetes mellitus. It has been hypothesized to be caused by an increased inflammatory response, increased insulin resistance, and a degree of acute viral pancreatic damage. A meta-analysis showed that the incidence of new-onset diabetes was found to be as high as 14.4% (95% CI: [5.9%-25.8%]). Here, we report a case of COVID-19-induced diabetes to spread awareness among healthcare providers and encourage early detection to prevent long-term complications. Clinical Case: A 54-year-old African American female with a past medical history of hyperlipidemia, obesity, and hypothyroidism presented to our endocrinology office for evaluation and management of diabetes mellitus (DM). She presented with symptoms of 66-pound weight loss, polydipsia, polyphagia, and polyuria. Her labs on diagnosis were significant for blood glucose of 550 mg/dl (70-100 mg/dl), hemoglobin A1c &amp;gt;15.5% (&amp;lt;5.7%), and bicarbonate 23 mmol/L (20-31 mmol/L). She started on insulin and then switched to semaglutide after six months. Her fasting glucose on the follow-up visit was 103 mg/dl, the anti-glutamic acid decarboxylase 65 (GAD-65) antibody was 8,558.9 units/ml (&amp;lt;5 units/ml), C peptide was 1.9 ng/ml (0.5-2ng/ml), and Islet Antigen-2 (IA-2) autoantibody was &amp;lt;7.5 U/ml (0-7.49 U/ml). Despite positive antibodies, her C-peptide suggested enough beta-cell function, and she was switched from insulin to semaglutide. The patient was diagnosed with autoimmune diabetes, which may be from the COVID-19 infection, and was educated about regular follow-up and new medications like teplizumab that may help prevent the progression to needing insulin. Clinical Lesson: The exact mechanism of new-onset COVID-19-induced diabetes is still unknown. However, multiple risk factors are theorized to play a role in COVID-induced DM. These include defects in insulin production and glucose clearance, obesity, stress hyperglycemia, insulin resistance, and steroid therapy. Our patient had a history of obesity but no history of diabetes, steroid use, or any personal or family history of autoimmune processes. Compared to COVID-19 patients with normoglycemia or hyperglycemia, patients with preexisting diabetes and newly diagnosed diabetes experienced more severe complications, such as shock, ARDS, acute kidney injury, hypoalbuminemia, and severe COVID-19 complications. Additional research is required to investigate the various pathophysiologies and treatment options, including new medications that may prevent the disease's further progression. Diabetes caused by COVID-19 should be treated cautiously, and prompt diagnosis and care are essential to preventing further complications. Presentation: 6/3/2024

12460 Bilateral Parietal Thinning: A Rare Condition Of Unclear Etiology

Abstract Disclosure: T.L. Madsen-Barbosa: None. M. Cheikh: None. I. Marcano: None. Background: Bilateral parietal bone thinning (BPT) is an infrequent and often underdiagnosed condition characterized by the external thinning of the skull's parietal bone. The pathophysiology is unclear, but some studies suggest a link to osteoporosis. We present a case of osteoporosis diagnosed on evaluation of BPT. Case Description: A 77-year-old woman with a history of chronic kidney disease (CKD stage IV) and type 2 diabetes was referred to the Bone Health Clinic for evaluation of low bone density. She initially presented to Neurosurgery clinic for evaluation of head indentations. A dual energy x-ray absorptiometry (DEXA) scan showed values in osteopenia range (left total hip bone mineral density (BMD) 0.678 and T-score of -2.2, left femoral neck BMD 0.272 and T-score of -1.6, and left 33% radius BMD 0.577 and T-score of -2.0), leading to the referral. The patient reported painless indentations in the parietal bones that had been progressing for four years, with no history of head trauma, inflammatory disease, or prolonged steroid use. A head computed tomography (CT) scan showed symmetric thinning of the skull’s parietal bones, with an average thickness of 2.34 mm (compared to 5.1 mm four years earlier). Review of prior images also revealed a T11 compression fracture on spine X-ray from 2019. Laboratory tests showed elevated parathyroid hormone (PTH) 155 pg/mL (reference range 15-65 pg/mL), low vitamin D 25-OH 10.6 ng/mL (reference range 30-100 ng/mL), elevated alkaline phosphatase 142 units/L (reference range 46-116 units/L), and high creatinine level 2.7 mg/dL (reference range 0.5-0.8 mg/dL), other laboratory tests were normal. After discussion with the patient and Nephrology, Denosumab therapy along with Calcium and Vitamin D supplementation were started in November 2023. The patient continues the treatment with antiresorptive medication every 6 months and head CT scan to monitor the skull thinning changes. Discussion: BPT is rare, with only approximately 150 cases reported. Crucial aspects such as its etiology, pathophysiology, treatment, and prognosis remain unknown. It can result from various conditions like trauma, systemic mastocytosis, diabetes mellitus, hereditary diseases, or idiopathic causes and mainly affects women of advanced age. Osteoporosis is suggested as a possible cause based on histological findings on prior studies that propose BPT may result from osteoporosis-induced decreased bone formation rather than increased bone destruction. The reason for excessive bone resorption in the skull of osteoporotic patients remains unclear. Our case highlights progressive and symmetric BPT possibly related to systemic conditions like osteoporosis, with a focus on treatment options. Conclusion: This case sheds light on the clinical presentation, imaging findings, pathogenesis, and treatment options for the rare condition of bilateral parietal bone thinning. Presentation: 6/3/2024

12453 Osteoporosis Screening In A Primary Care Clinic: Barriers And Solutions

Abstract Disclosure: B.M. Laquidara: None. S. Mistry: None. L. Guo: None. Purpose/Objective: Osteoporosis is a prevalent bone disorder that affects over 10 million people in the United States. The US Preventive Services Task Force (USPSTF) recommends screening females aged 65 and older with a baseline DEXA scan and to screen postmenopausal females younger than age 65 who have an increased risk of osteoporosis. Despite these guidelines, the screening rate for osteoporosis remains very low. Our quality improvement project seeks to first identify at what rate eligible patients in our residency primary care clinic are being screened for osteoporosis and what barriers (patient, provider, or clinical factors) to screening may decrease this rate. Methods: We reviewed a random sample medical records of 300 female patients aged &amp;gt;/= 50 years who visited our clinic within the last two years. We collected patient demographics, insurance status, presence of ≥1 risk factor of osteoporosis (fracture, heavy alcohol use, tobacco use, steroid use, BMI&amp;lt;19), MyChart activity, provider training level, diagnosis code, and whether a baseline DEXA was ordered and/or completed. We compared patient characteristics by DEXA order status using descriptive statistics, and used multivariable regression models to determine odds of DEXA order and completion. Results: The patients who were at high risk for osteoporosis were more likely to have an order without completion (OR 6.11, p &amp;lt;0.001). Increased age was associated with increased odds of having an order (OR 1.09, p&amp;lt;0.001). Increasing BMI was associated with decreased odds of having an order. Black patients and current smokers were less likely to have a DEXA scan ordered and completed after controlling for age and other confounding factors (p= 0.002 and 0.001 respectively). Among the 96 patients who had a completed DEXA scan, 74 had osteoporosis. The only significant predictor for having osteoporosis was low BMI (OR 0.87%, p&amp;lt;0.001). Conclusion: The results of this study suggest that while patients with a clinically high risk for osteoporosis are more likely to have an order placed for a DEXA scan, these patients often do not have a completed scan. Patients who have an ICD-10 diagnosis of high-risk for osteoporosis or osteoporosis in their electronic medical record are more likely to have both an ordered and completed scan. Utilizing this data, we will develop a variety of interventions such as a clinical didactic case for osteoporosis, a flow-sheet summary of proper osteoporosis screening and treatment initiation to be distributed in the clinic setting, and a short presentation during noon didactics where we review the proper screening method for osteoporosis. Following our intervention, we will re-examine the screening rate in our residency clinic to evaluate the effect of our intervention. Presentation: 6/3/2024

7481 Beyond the Operation Room: A Retrospective Study on Diabetes and Post-Operative Hyperglycemia Outcomes

Abstract Disclosure: P. Aron: None. T. Zaihra Rizvi: None. M. Hodge: None. J. Upadhyay: None. Introduction: Optimal, evidence based intraoperative and postoperative glycemic management may reduce poor surgical outcomes. Research design: This is a retrospective study from a single center to estimate quality gaps in perioperative glycemic management in patients with diabetes undergoing major surgery requiring general anesthesia between Oct 2022 and Dec 2022. Study Cohort: Patients &amp;gt; 18 years old, who underwent major surgery (&amp;gt;3 hrs) under general anesthesia, had diabetes mellitus based on Hba1c &amp;gt; 6.5% within last 1 year or as listed diagnosisThis is an ongoing study. We have currently looked at 79 patients of which 61 were in the hyperglycemic group (glucose &amp;gt; 180 mg/dL) and 18 in normoglycemic group (glucose &amp;lt; 180mg/dL) post-operatively. Methods: Baseline characteristics, perioperative outcomes, and operative details between the hyperglycemic and normoglycemic groups were compared using Kruskal-Wallis's rank sum test for continuous variables and χ2 or Fisher's exact tests using categorical variables. Results: Patients who were found to have hyperglycemia in the first 24 hours after surgery had a higher preop A1c of 7.4% vs 6.7% in the normoglycemia group (p-value = 0.047). They also had a higher BMI of 32 as compared to 30 respectively and a reduced GFR of 60 vs 73 in the normoglycemic group (P=0.069). 24 hours leading into surgery, the hyperglycemia group had a high average glucose of 196 mg/dL as compared to 135 mg/dL (p-value = 0.001). During the intraoperative period which lasted on average of 350 minutes (5.5 hours) there was an average glucose check of 3.2 times averaging 221 mg/dL for the hyperglycemia group compared to 2.2times averaging 174 mg/dL (P = 0.017). 62% of patients with intraoperative hyperglycemia DIDNOT receive IV insulin treatment in the hyperglycemic group. Steroid use was equal in both groups. 24 hours after surgery, patients in the hyperglycemia group had an average glucose reading of 252 mg/dL compared to 145 mg/dL in the normoglycemia group (P &amp;lt; 0.001).Endocrinology was not consulted in 87% of patients with hyperglycemia. Looking at our endpoints, readmission rate was 23% in the hyperglycemia group as opposed to 11% in normoglycemia. There were 4 patients who had a 90-day mortality from the hyperglycemia group compared to no patients in normoglycemia. 37% of patients had post-op complications in the hyperglycemia vs 22% in the euglycemia group (P 0.269). The hospital stay was the same for both groups averaging 8 days. Conclusions: Intraoperative hyperglycemia leads to poor outcomes. Formulating policy around insulin administration, frequency and monitoring of blood sugars during major surgeries and endocrine consultation in patients with Type 2 DM can achieve better glycemic management and postoperative outcomes. Presentation: 6/2/2024

The role of aryl hydrocarbon receptor agonists in the treatment of vitiligo.

Vitiligo is a chronic autoimmune disorder characterized by progressive skin depigmentation. Vitiligo significantly impacts patients' quality of life, contributing to psychological and social burdens. Despite readily available therapeutic options, many cases remain refractory to treatment, highlighting the critical need for safer and more effective therapies. Currently, ruxolitinib is the only FDA-approved medication for vitiligo; however, it carries a black box warning for serious adverse effects, including infections, malignancy, and major cardiovascular events, limiting its use. Recent studies have identified the aryl hydrocarbon receptor (AhR) as a promising therapeutic target, suggesting that AhR agonists could address the multifaceted pathogenesis of vitiligo. Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a comprehensive search to analyze the role of AhR agonists in the treatment of vitiligo on PubMed, Cochrane, Embase, MEDLINE, and Web of Science databases on April 15, 2024. Fourteen studies met the inclusion criteria, comprising two clinical trials, two case reports, and nine basic science studies. Our search revealed that culturing AhR agonists with melanocytes upregulates melanin-synthesizing enzymes, reduces reactive oxygen species, and modulates pro-inflammatory cytokines such as IL-17A and IL-22. Tapinarof, a topical AhR agonist used commonly for the treatment of psoriasis, demonstrated clinical efficacy in repigmentation with a favorable safety profile compared to long-term steroid use. Although limited by the number of clinical studies, this review underscores the potential of using AhR agonists, such as tapinarof, as a transformative approach to vitiligo management. Future clinical trials are necessary to evaluate the safety, efficacy, and long-term outcomes of AhR agonists.

6984 New Onset Diabetes After Transplant: Need for Strict Glucose Monitoring

Abstract Disclosure: T. Chaudhary: None. O. Syed: None. M. Nawaz: None. R. Kaur: None. Introduction: Immunosuppressant use comes at a cost of challenging side effects, which are being discovered more as its use increases. One such example is our case of new-onset diabetes after transplant (NODAT).Patient presentation: A 36-year-old male with a past medical history of end-stage renal disease status post renal transplant (6/2023), hypertension, and hyperlipidemia who presented to the hospital in 10/2023 with fever, chills, and diarrhea. His vitals at that time were as follows: temperature 36.1C, blood pressure 148/84 mmHg, pulse 87 bpm, and a respiratory rate of 22. Lab work was significant for blood glucose 1144, anion gap 22, bicarbonate 13, potassium 7.3, Sodium 135, lipase 427, pH 7.3, urine ketones 80, HbA1C 11.5 %. CT scan of the abdomen revealed loss of peripancreatic fat and inflammatory changes surrounding the pancreas. His medication review included Tacrolimus 12 mg daily, Mycophenolate 500 mg BID, Valtrex 500mg daily, and fluconazole 200mg every other day. He was treated with 2 liters of normal saline bolus and started on maintenance fluid, and insulin drip as per DKA protocol. Calcium gluconate and an albuterol nebulizer were given for hyperkalemia. Tacrolimus and prednisone were held. Endocrinology and Nephrology were consulted. The patient was thought to have diabetes due to steroid use which were discontinued and the patient was discharged on subcutaneous insulin regimen and lower dose of tacrolimus. Despite discontinuation of steroids, patients continued to have raised glucose readings confirming the causative agent as tacrolimus. Conclusion: The current guidelines for post-kidney transplant patients recommend checking fasting blood glucose weekly for the first four weeks, then biweekly for two months, and then monthly thereafter. HbA1C should be checked every 3 months and if it is &amp;gt;6% then home glucose monitoring should be done as well. Although the frequency of these check-ups decreases, it is imperative for physicians to remember that patients can still develop NODAT months post-transplant. It is also essential to reinforce the importance of these glucose checks for the patient as missed diagnosis can lead to dangerous complications such as DKA. Presentation: 6/2/2024

5112 Late-Onset And Reversible Adrenal Insufficiency In Survivors Of Coronavirus Disease 2019: Results From A 24-Month Longitudinal Study

Abstract Disclosure: S.K. Sahoo: None. J.C. Menon: None. S.B. Yadav: None. Purpose We studied the temporal course of hypothalamic-pituitary-adrenal (HPA) dysfunction in patients with corona-virus disease (COVID19). Methods Three-hundred and two patients (median age 54 years [interquartile range 42-64], 76% males, 97 with severe/critical illness) were recruited. HPA axis was evaluated by adrenocorticotrophic hormone (ACTH)-stimulation test (APST) at admission in 243, and 12-months after discharge in 90 patients. Those with adrenal insufficiency (AI) at 12-months were further assessed by APST 6-monthly for recovery of hypoadrenalism. Results The median 0-min cortisol, peak cortisol, and ACTH during COVID19 were 295 (IQR 136-461) nmol/L, 846 (719-1088) nmol/L, and 3.9 (0.8-6.9) pmol/L respectively. AI was present in 21 (8.6%) patients. Plasma ACTH was elevated in five patients with AI, while it was low or inappropriately-normal in rest. Additionally, CIRCI was present in 22% (19/87) patients who had severe illness. At 12-months, AI was seen in 13% (12/90) patients and was hypothalamic-pituitary in origin in all. Nine (75%) of these had late-onset AI, who had normal HPA axis during COVID19. AI diagnosed at admission persisted at 12-months in three patients and resolved in six; the remaining 12 patients were lost to follow-up. The presence of AI at 12-months was independent of severity, and steroid use during COVID19. All the patients showed recovery of HPA axis in ensuing 6-12 months. A lower morning cortisol during COVID19 predicted presence of AI at one year. Conclusion AI was common during acute COVID19 and at 12-months of follow-up. AI can be late-onset, developing after recovery from COVID19. The AI was predominantly hypothalamic-pituitary in origin and resolved in the ensuing 6-12 months. Presentation: 6/1/2024

8653 A Rare Cause of a Pituitary Mass

Abstract Disclosure: L. El Musa Penna: None. W. Medina-Torres: None. L.R. Sepulveda-Garcia: None. I.C. Arroyo Gomez: None. J. Segarra-Villafane: None. Z. Maisonet -Feliciano: None. M. Ramirez: None. L.A. Gonzalez-Rodriguez: None. M. Alvarado: None. J. Feneque González, MD: None. M. Marcos Martínez, MD: None. M. Correa Rivas: None. Pituitary gland masses are the second most common tumor of the central nervous system (CNS) across all age group, as per Central Brain Tumor Registry in the United States. Most common lesions are adenomas, which can be categorized as functional and non-functional based on the presence of hormonal hypersecretion. In the differential diagnosis, there is also craniopharyngiomas, Rathke’s cleft cysts, pituitary hyperplasia, inflammatory lesions, malignancy and abscess. Pituitary abscess is a rare condition, and only 0.2-0.6% of pituitary lesions are diagnosed as abscesses.This is the case of a 42-year-old female with history of hypothyroidism, chronic sinusitis with nasal polyps, severe asthma, and chronic steroid use complicated by iatrogenic adrenal insufficiency and osteonecrosis of the hips bilaterally, who was evaluated for intractable headaches. On brain imaging was found with a pituitary macroadenoma. She denied any symptoms suggesting hypersecretion of hormones and was scheduled for transsphenoidal surgery. All hormonal work up was found within normal limits, except for prior iatrogenic adrenal insufficiency due to multiple systemic steroids courses to treat asthma exacerbation throughout her life.During surgery, upon mass resection, purulent secretions were found. Frozen section was done intraoperatively, showing respiratory epithelium, pus and actinomyces species. All infectious material was removed. Infectious Diseases services was consulted and patient was promptly started on IV antibiotics. Blood cultures were negative, and patient remained afebrile. Final pathology confirmed the presence of respiratory epithelium, actinomyces colonization and a fibrous capsule with acute and chronic inflammation. Special stains report was negative for fungi. She was discharge to continue home infusion of antibiotic regimen to complete 8 weeks of treatment.There is no specific imaging finding to identify pituitary abscesses so, most of them, are diagnosed intraoperatively. They can arise from hematogenous spread or from adjacent tissues or structures (ie. patient with meningitis or sinusitis). The condition is considered a life-threatening however, the majority of cases have a chronic course. Based on different reports, theses abscesses have a higher female predominance; the age range is between 12 to 76 years and the average period between onset of symptoms and diagnosis is 8 months on average. Most pituitary abscesses are sterile, however most common organisms isolated are: Gram-positive cocci (Staphylococcus and Streptococcus), and Gram-negative organisms such as Neisseria, Escherichia coli and Corynebacterium. The rarity of cases often leads to delayed diagnosis and treatment initiation, contributing to increased morbidity and mortality. Presentation: 6/2/2024

6977 Unraveling Secondary Adrenal Insufficiency and an Invasive Pituitary Macroadenoma in a COVID-19 Positive Patient

Abstract Disclosure: F. El Sayed: None. A.A. Banka: None. Invasive pituitary macroadenomas extend into the extrasellar region and invade surrounding dural, periosteal, or mucosal tissues, often exceeding 1 centimeter and potentially compressing adjacent structures. Nonfunctioning pituitary adenomas (NFPAs), as they enlarge, can cause visual field impairment and ophthalmoplegia, with the decision for surgical intervention influenced by the degree of optic chiasm compression. NFPAs are sometimes associated with impaired endocrine function, particularly secondary adrenal insufficiency (sAI), which, warrants specific clinical attention. Management involves a combination of surgical interventions, such as transsphenoidal surgery, and medical approaches, including tailored hormone therapy or radiation therapy based on the tumor's characteristics. Clinical case: A 51-year-old female with a history of Sjogren's disease presented with a one-week duration of nausea, vomiting, diarrhea, and fatigue. Upon admission, she tested positive for COVID-19. Her vital signs indicated hypotension with a blood pressure in the 80s/40s range, a heart rate in the 90s, and she was afebrile on room air. Laboratory findings revealed significant hyponatremia (Na+ 118), K+ 4.3, HCO3- 19, and glucose 80. Workup for hyponatremia included a cortisol stimulation test, revealing secondary adrenal insufficiency with baseline cortisol of 3.5 ug/dl, 10.7ug/dl after 30 minutes, and 12.7ug/dl after 60 minutes. The patient denied exogenous steroid use, hypothyroid symptoms, polyuria, or polydipsia, and reported no headaches or visual symptoms. Endocrine evaluation showed hypogonadism despite post-menopausal status, with low estrone, estradiol, LH, and FSH levels. She was initiated on Cortef (hydrocortisone) with symptomatic improvement. Further investigation through an MRI revealed a large lobulated sellar mass measuring 3.2 x 2.8 x 3.5 cm compressing the optic chiasm and partially encasing the right internal carotid artery, leading to peripheral visual defects confirmed on perimetry. Following endoscopic endonasal pituitary macroadenoma resection, there was no evidence of interval growth on a one-year follow-up MRI scan. Discussion: The presented case highlights the importance of considering invasive pituitary macroadenomas in the differential diagnosis of patients with hyponatremia, particularly when accompanied by suggestive symptoms and an atypical cortisol response. The coexistence of COVID-19 adds a layer of complexity to the clinical scenario, necessitating a comprehensive approach to both infectious and endocrine management. Timely recognition, appropriate endocrine assessment, and targeted interventions, such as hydrocortisone replacement and surgical resection, are crucial for optimizing outcomes in patients with this intricate interplay of pituitary pathology and infectious states Presentation: 6/1/2024

6768 A Rare Presentation of Primary Adrenal Insufficiency with Hypertension &amp; Hypokalemia

Abstract Disclosure: A.M. San Hernandez: None. R. Alshantti: None. G. Espinoza Mercado: None. J.L. San Hernandez: None. Introduction: Adrenal Insufficiency is caused by the failure of the adrenal cortex to produce glucocorticoids +/- mineralocorticoids. This can be due to a defect in the adrenal cortex, or in the hypothalamic pituitary axis. The clinical manifestations are usually non-specific, ranging from mild vague symptoms to life threatening crisis. Therefore, diagnosis requires a high level of suspicion by providers. Unusual presentations of primary adrenal insufficiency (PAI) with hypertension and hypokalemia have been rarely described in the literature. We present a rare case of PAI with hypertension and hypokalemia. Case Presentation: A 68 years old female with a medical history of rheumatoid arthritis, hypothyroidism on Levothyroxine, chronic transaminitis, and bicytopenia presented to the hospital with a 6 weeks history of generalized weakness, loss of appetite, weight loss, and dizziness. Patient denied any diuretic or steroid use within the last 2 years. On arrival, she was afebrile, hypertensive (168/84mmHg), with normal oxygenation and pulse. Physical examination was unremarkable with normal volume status. Initial laboratory results showed low sodium 116 mEq/L, low serum osmolality 247 MEQ/kg, normal potassium 3.6 mEq/L, Creatinine 0.3 mg/dL &amp; BUN 9 mg/dL. She was initially started on IVF normal saline. Further workup revealed normal TSH &amp; FT4 levels. Urine study showed urine osmolality (477 MOSM/KG), &amp; urine sodium (127 mEq/L). Given these findings, SIADH was suspected and fluid restriction was started. Sodium level continued to be low with minimal improvement to 120 mEq/L, potassium levels also dropped (3.3-3.2 mEq/L), requiring daily replacement. BP remained elevated ranging from 150s to 160s systolic and 80s to 90s diastolic. Hypertension was controlled with her home medication Amlodipine. Although atypical presentation with hypertension &amp; hypokalemia, the diagnosis of adrenal insufficiency was considered. Laboratory evaluation showed low morning cortisol 5.2 ug/dL, with album level 3.5 g/dL. Cosyntropin stimulation test showed 1.3 ug/dL (at baseline), 9.9 (30 min post administration), and 14.4 (1 hour post administration); results confirming PAI. ACTH, Renin, Aldosterone, &amp; DHEAS levels were normal. CT adrenal was normal. Patient was started on hydrocortisone; some of her symptoms &amp; Na level improved. Further investigation of the etiology of PAI and possible hyperaldosteronism is pending outpatient follow up. Conclusion: Adrenal insufficiency is a life threatening condition with serious consequences if diagnosis is missed. It manifests by a wide spectrum of symptoms and signs, some can be masked by the presence of other comorbid conditions leading to atypical presentations. Our case highlights the importance of maintaining a high level of suspicion of adrenal insufficiency in patients with atypical presentation, including those with hypertension &amp; hypokalemia. Presentation: 6/3/2024

6637 A Rare Case of a Possible Non-functional (Clinically Silent Biochemically Negative) Adrenal Pheochromocytoma

Abstract Disclosure: V.K. Babu: None. M.T. Corwin: None. S.T. Olatunbosun: None. Introduction: Adrenal pheochromocytomas (pheo) are rare neuroendocrine tumors arising from the chromaffin cells of the adrenal medulla. Their incidence is around 0.8 per 100,000 patient years. They are usually sporadic, with about 40% having a pre-existing familial genetic disease. About 3% of adrenal incidentalomas prove to be pheo. They have a heterogenous presentation and are diagnosed by measuring urinary and plasma fractionated metanephrines (met) and catecholamines (catecho). The diagnosis becomes challenging in patients presenting with small tumors and normal levels of biochemical metabolites, as in our patient. Clinical Case: A 32-year-old male with no significant past medical history was referred to us with a left adrenal incidentaloma of 1.2 cm x 1 cm with 23 Hounsfield units during a non-contrast CT scan performed for abdominal pain. He denied spells of headaches, excessive perspiration, palpitations, history of hypertension, hypokalemia, history of kidney stones, fractures, muscle weakness, easy bruisability, new abdominal striae, change in weight, steroid use, or family history of endocrine tumors. MRI with adrenal protocol 3 months later showed a 1.2 cm x 1.4 cm left adrenal nodule that was markedly hyperintense on T2-weighted and hypointense on T1-weighted images without microscopic fat, suspicious for a pheo. It also demonstrated peripheral enhancement with progressive central filling on the delayed images without washout. Plasma met and catecho were normal: normetanephrines (normet) (45.2 pg/mL), met (36.4 pg/mL), epinephrine (epi) (34 pg/mL), norepinephrine (norepi) (295 pg/mL) and dopamine (&amp;lt;30 pg/mL). Subsequent 24-hour urine testing revealed normal met (155 mcg/day, 154 mcg/day), and normal normet (248 mcg/day, 236 mcg/day) on two separate occasions, and normal epi (9 mcg/L), norepi (36 mcg/day), and dopamine (228 mcg/day). The patient was subsequently referred to Endocrine Surgery for evaluation. Conclusion: Our patient likely has a non-functional pheo. Another possibility is an adrenal hemangioma, which would show discontinuous peripheral nodular enhancement in addition to progressive central filling. Patients with pheo less than 2 cm may present with normal biochemical testing. The size of a pheo is usually proportional to the levels of its biochemical metabolites. This case is unique because patients with a similar sized pheo are expected to have 3 times higher levels of plasma met and catecho, even if still within normal limits. It is important to take tumor size into consideration when interpreting labs to determine its functional status. This may help in determining the need for a pre-operative alpha blockade prior to adrenal surgery. A definitive diagnosis of a pheo’s non-functional status can only be confirmed after histopathological examination of the tumor tissue. Presentation: 6/3/2024

9397 Shatter Proofing Bones: Revamping Osteoporosis Screening

Abstract Disclosure: R. Subramani: None. T. Gupta: None. M. Anwar: None. J. Pamula: None. Background: Osteoporosis is a common disease characterized by low bone mass, structural deterioration of bone tissue, and increased risk of fractures. The World Health Organization (WHO) has defined osteoporosis based on bone density measurements. According to their definition, osteoporosis is diagnosed when the bone density at the hip or spine is at least 2.5 standard deviations (SDs) below the mean bone density of a reference population of young, healthy women (T score ≤ -2.5). According to NHANES data from 2017-2018, the overall prevalence of osteoporosis among adults over 50 was found to be 12.6%. It was observed that the prevalence of osteoporosis was higher among women (19.6%) compared to men (4.4%). According to US Preventative Services Task Force (USPSTF), the guidelines for screening are as follows: BMD Testing (DEXA) for all women aged 65 and older, postmenopausal women younger than 65 with clinical risk factors for fracture including advancing age, previous fracture, glucocorticoid therapy, parental history of hip fracture, low body weight, current cigarette smoking, excessive alcohol consumption, rheumatoid arthritis, secondary osteoporosis. BMD Testing for Men is not recommended. The most used bone measurement test to screen for osteoporosis is central DXA which measures BMD at the hip and lumbar spine. Goal: To improve the osteoporosis screening using DXA scan in the outpatient internal medicine resident patient panel by 5% Study Design:Subjects were identified by an EPIC report and will include retrospective chart review of records from July 2022 and prospective screening until April 2024 for the outpatient IM clinic list of patients including both resident panel. Methods: Pre-intervention data analysis of current rates; Educating residents about appropriate screening; Utilization of osteoporosis screening as care-gap in EPIC ;Calling patients who are due for screening from IM residents patient panels; Post-interventional data analysis Results: The total number of patients on the residents panel was 196. Before interventions, screening rate for osteoporosis were 71.2% among residents' patients. After intervention, screening rates increased to 75.5%. There was a 4.3 % improvement in screening rate. Conclusion: Resident education, addressing Osteoporosis care gaps in EPIC and patient outreach are effective interventions to improve screening rates. Discussion: Osteoporosis screening remains an area of needed improvement in IM clinic. EPIC system should not only take age for prompting osteoporosis screening but also other factors such as family history, pre-mature fractures, steroid use, etc. Adding osteoporosis screening into the metric system are few steps to be considered for future directions. Presentation: 6/3/2024

7203 A case of undifferentiated shock found to be due to voriconazole-related primary adrenal insufficiency

Abstract Disclosure: K.X. Zhang: None. C. Bergwitz: None. Primary adrenal insufficiency can be a rare effect observed with azole antifungal therapy, classically ketoconazole, via inhibition of cortisol and aldosterone synthesis. Whether primary AI can be observed with newer triazole drugs used for neutropenic prophylaxis and treating invasive fungal infections is far less understood. We describe a case of a 65-year-old man with medical history notable for COPD and gout, who was on voriconazole for Aspergillus pneumonia, and admitted to the medical ICU with confusion and undifferentiated shock. His potassium was 6.5 mmol/L, sodium 133 mmol/L, bicarbonate 18 mmol/L, and blood pressure 72/63 requiring pressor support. Voriconazole was withdrawn. He also had a fever to 101.7F that was attributed to a gout flare, and he received a course of high dose prednisone. His shock and electrolyte abnormalities quickly resolved, and he was discharged on isavuconazole. At the 1 week mark, he was found to have a morning cortisol 2.3 ug/dL, potassium 5.4 mmol/L, and sodium 134 mmol/L, along with fatigue, nausea, and hypotension, which prompted resumption of steroid and mineralocorticoid replacement. One month after completing his course of isavuconazole, morning cortisol normalized to 11.0 ug/dL and ACTH 22.3 pg/mL. We present a convincing clinical story supporting the etiology of this patient’s initial shock as primary adrenal insufficiency related to a voriconazole effect. This case illustrates how iatrogenic AI can be a missed diagnosis in the emergency room setting. Primary AI has classically been reported following ketoconazole therapy, but there are only 4 reports of primary AI involving the newer triazole posaconazole, and none for voriconazole or isavuconazole. Due to the rarity of this effect, AI due to voriconazole was not on the initial shock differential and timely endocrine labs to seal the diagnosis (morning cortisol, ACTH, and renin/aldosterone levels) were not obtained. If our patient had not received steroids serendipitously for gout, he may have been at risk for adrenal crisis. Whereas central AI is more common and induced by chronic use of systemic steroids, it is important to also think about AI caused by antifungal therapy with newer azoles. Presentation: 6/3/2024