Endocrine Clinic Research Articles

FRI362 A Rare Case Of Coexisting Pancreatic Neuroendocrine Tumor And Nesidioblastosis

Abstract Disclosure: N. Mon: None. L.K. Tanwani: None. B. Martin: None. C. Scoggins: None. S.L. Mokshagundam: None. Introduction: Nesidioblastosis is a rare cause of endogenous hyperinsulinemic hypoglycemia in adult population. Pancreatic neuroendocrine tumors (NET) are also uncommon among pancreatic tumors. We report a case of a young man who presented with documented Whipple triad and was initially found to have pancreatic cyst. Further evaluation revealed concomitant pancreatic NET and adult nesidioblastosis. Case Report: A 36-year-old Caucasian male with history of anxiety, bipolar, and seizure disorder presented with witnessed seizures and was found to have blood glucose (BG) < 20 mg/dl. He reported recurrent hypoglycemia for 3 years with recent 4-5 ER visits for hypoglycemic seizures. Only medications he was taking were keppra and clonazepam. Physical exam was unremarkable. He was evaluated in Endocrine Clinic and a 72 Hour fast was performed. During the 72 hours fast his BG dropped to 48 mg/dl after 12 hrs. Insulin 16.1 uIU/mL, C peptide 3.02 ng/mL, Proinsulin 60.1 pmol/L, beta-hydroxybutyrate 0.08 mmol/l. BG increased to 116 mg/dl in 30 minutes after 1 mg glucagon injection. Other labs results were: 3PM cortisol 6.6 (7.0-25.0ug/dl), albumin 4.4 mg/dl, HbA1c 5.2%, Alcohol < 5ng/dl, negative urine toxicology screen. CT abdomen without contrast showed a 1.3 cm cyst in the tail of pancreas. Endoscopic ultrasonography revealed a round mixed solid and cystic mass (18x17 mm) with well-defined borders identified in the pancreas tail. The remainder of the pancreas was unremarkable. FNA of the cyst reported findings consistent with a well-differentiated neuroendocrine tumor. He underwent robotic enucleation of distal pancreatic lesion. Postoperative period was uneventful until 2 weeks after procedure when he again started having neuroglycopenic symptoms with lowest BG of 50 mg/dl in the fasting state. He was initiated on diazoxide 50 mg 3 times daily and then 100mg 3 times daily. He continued to have hypoglycemic episodes. Prednisone 10 mg was added at bedtime while waiting for surgery. He underwent distal 80 % pancreatectomy and splenectomy. Hypoglycemia resolved after the surgery. The final pathology was a well-differentiated NET WHO grade I with background neuroendocrine cell hyperplasia/nesidioblastosis. Conclusion: Endogenous hyperinsulinemic hypoglycemia is a rare disorder with nesidioblastosis being the important cause in children and insulinoma in adults, representing a spectrum of pathologic beta cell proliferation. There are very few reports of coexistence of both conditions in adults. Our patient also had an unusual type of insulinoma as it was cystic. The simultaneous occurrence of the two lesions offers significant challenges in diagnosis and management. The mainstay of treatment is surgical resection of insulinoma with localization of insulin hypersecretion; however, how much to remove in nesidioblastosis is still unclear. Presentation: Friday, June 16, 2023

THU381 A Case of Severe Type B Insulin Resistance Successfully Treated With Combined Immunosuppressive Therapy

Abstract Disclosure: A.K. Sumal: None. D.S. Martinez: None. Background: Type B insulin resistance is a rare autoimmune disorder caused by autoantibodies against the insulin receptor and is characterized by markedly high insulin requirements, severe catabolism, and a mortality rate over 50%. Clinical Case: A 50-year-old woman with Sjogren’s syndrome and a one-year history of diabetes treated with insulin presented with diabetic ketoacidosis (DKA) and was found to have type B insulin resistance. Initial laboratory workup demonstrated DKA with a blood glucose of 464 mg/dL (n: 65–99 mg/dL), CO2 8 mmol/L (n: 20–30 mmol/L), anion gap 16 (n: 8–12), pH 7.08 (n: 7.30–7.40) on venous blood gas, 2+ ketonuria, and a hemoglobin A1c of 11.7% (n: <5.7%). Additional workup revealed negative glutamic acid decarboxylase-65, insulin antigen-2, and insulin antibodies, positive C-peptide 2.7 ng/mL (n: 1.1–4.3 ng/mL), and elevated adiponectin 41 ug/mL (n: 5–28 ug/mL). Her physical exam was notable for 100 lb weight loss and extensive acanthosis nigricans, facial acne, and hirsutism. She was started on IV insulin infusion with resolution of her DKA but required more than 5000 units of insulin per day to obtain glycemic control. Due to the suspicion of type B insulin resistance, she was treated with metformin 1000 mg twice daily and pioglitazone 45 mg daily to reverse her hypercatabolic state and combined immunosuppressive therapy consisting of 2 cycles of rituximab 750 mg/m2 infusion, cyclophosphamide 100 mg daily, and dexamethasone 40 mg for 4 days administered 14 days apart based on a 2018 NIH protocol. Her serum was sent for confirmatory insulin receptor autoantibody testing, which is pending. Over the next 30 days, her insulin requirements improved immensely, and she was ultimately discharged without insulin in clinical remission. To prevent recurrence and hypoglycemia associated with low titers of insulin receptor autoantibodies, she was started on azathioprine 100 mg daily as maintenance therapy. Three months later, she was seen in endocrine clinic in sustained remission with a hemoglobin A1c of 6.0% and resolution of her acanthosis nigricans and hyperandrogenism. Review of her continuous glucose monitor showed no episodes of hypoglycemia. Conclusion: This rare case demonstrates the successful treatment of type B insulin resistance using metformin, pioglitazone, and combination immunosuppressive therapy with rituximab, cyclophosphamide, and pulse-dose steroids, followed by maintenance azathioprine. With a mortality rate over 50%, the use of combined immunosuppressive therapy has transformed this condition into a curable form of diabetes and should be recommended in all patients with type B insulin resistance. Presentation: Thursday, June 15, 2023

SAT174 Doege-Potter Syndrome In A Patient With Solitary Fibrous Tumor Of The Lung

Abstract Disclosure: N. Mon: None. S.S. Krishnasamy: None. Doege-Potter Syndrome is a non-islet cell tumor hypoglycemia (NICTH) due to a solitary fibrous tumor (SFT) with overexpression of Insulin-like growth factor 2 (IGF2). We report a case of refractory hypoglycemia in a patient with SFT of the lung. Case presentation: A 67-year-old homeless male with hypertension, chronic smoker presented with altered mental status after his blood glucose was found 34mg/dl by EMS. His confusion improved after D50W. He could not recall the event but he reported that he missed his dinner prior to the event. He denied taking any antidiabetic medications. He was diagnosed with left lung solitary fibrous tumor without metastases a week ago after he presented to ER with dyspnea, cough and wheezing. CT chest reported a 21x15.6x18.7 cm lesion with mass effect on the left hemidiaphragm, mediastinum shift to the right and occluded left lower lobe bronchi. Core needle biopsy of the mass revealed SFT with necrosis. He was discharged with Medrol dosepak 4mg daily for presumptive treatment of COPD exacerbation and a plan for elective surgery. While in the ER his BG improved to 136mg/dl after D50W. Few hours later BG dropped to 42mg/dl and D10W infusion was started. Physical exam was unremarkable except bilateral pedal edema. Work up showed BG 42mg/dl, Insulin 3.3 (2.6-24.9 uIU/mL), C peptide 0.39 (1.1-4.4ng/mL), Proinsulin 4.7 (<18.8pmol/L), beta-hydroxybutyrate <0.05 (0.02-0.27mmol/l), 8AM cortisol 10.7 (7.0-25.0 ug/dl), albumin 3.2mg/dl, HbA1c 5.8%, IGF1 53ng/mL (34-245ng/mL), IGF2 203ng/mL (267-616ng/mL) with a IGF2:IGF1 ratio of 3.8. In our patient, the IGF2:IGF1 ratio was not >10 since his IGF 2 was suppressed by the recent steroid use. The rest of the clinical and biochemical features strongly suggested NICTH. His preoperative evaluation showed new onset HFrEF with volume overload. He underwent staged percutaneous coronary interventions with stents placement. He was given hydrocortisone 50mg q6H then to q8H during hospitalization and discharged home with hydrocortisone 40mg TID. He underwent radical resection of lung tumor after optimization of his cardiac condition. He was on stress dose of steroid during surgery. Since he was on high dose steroid for > 3months, hydrocortisone dose was tapered slowly after the surgery. Final biopsy reported solitary fibrous tumor extending to parenchymal staple line. Tumor cells are positive for CD34 and STAT6, and negative for desmin, SMA, and SOX10. He recovered uneventfully and was discharged home with prednisone 5mg daily and follow up in endocrine clinic. Conclusion: NICTH is a rare paraneoplastic syndrome characterized by low levels of insulin, C-peptide, proinsulin, and beta-hydroxybutyrate. A ratio of IGF-2/IGF-1 more than 10 confirms NICTH; however, normal ratio cannot exclude the diagnosis and factors such as low IGFBP 3 or steroid therapy for other conditions need to be considered. Surgery is the mainstay of treatment. Presentation: Saturday, June 17, 2023

SAT250 A Case Of Hypercalcemia In Pregnancy - A Diagnostic And Management Challenge

Abstract Disclosure: W. Cheng: None. Y. Kuan: None. Hypercalcemia in pregnancy is rare and poses significant diagnostic and management challenges especially in a low resource setting. Although primary hyperparathyroidism (PHPT) is the main cause, physiological changes in calcium homeostasis make it difficult to distinguish from familial hypocalciuric hypercalcemia (FHH) unless genetic testing is done. Furthermore uncertainty exists on the safety of pharmacotherapy for hypercalcemia in pregnancy which if untreated, can be detrimental to both mother and child. Described herein a 17 year-old primigravida who presented at 32 weeks of gestation for asthma exacerbation precipitated by COVID-19 infection. She was incidentally found to have PTH-dependent hypercalcemia with albumin-corrected calcium 3.42 mmol/L [2.10-2.55] associated with raised intact parathyroid hormone (iPTH) 15 pmol/L [1.6 - 6.0] and deficient serum 25OH Vitamin D at 19.95 nmol/L [50-125]. She was given IV saline of 3-3.5L/day but to no avail as her serum calcium was persistently above 3 mmol/L with an episode of premature uterine contraction. Calcitonin was given in short courses and withheld once albumin-corrected calcium dropped below 3 mmol/L but rebound within three days. As bisphosphonates is contraindicated in pregnancy, we introduced cinacalcet, up to 75mg/day after discussion with the patient and her family. Meanwhile, investigations were done to ascertain underlying cause. Fractional urine calcium excretion ranged from 0.0068 (spot urine sample) to 0.0568 (24-hour urine sample). Ultrasound neck did not reveal enlarged parathyroid glands or an adenoma. Sestamibi scan was contraindicated in pregnancy. Genetic testing for FHH was too costly but all her first-degree relatives tested to have normocalcemia. Blood pressure remained normal throughout pregnancy. She was discharged with cinacalcet at calcium level of 2.7 mmol/L. However she defaulted follow-up and medications and presented at 36 weeks of gestation for preterm labour. She gave birth to a healthy, 2.46kg baby girl. The baby had neonatal jaundice but normal calcium level. Postpartum, the patient was asymptomatic despite persistent hypercalcemia 3.12 - 3.15nmol/L. As she was non-compliant to cinacalcet it was stopped and serum calcium did not worsen. Sestamibi scan is planned after she stops breastfeeding and a reassessment of the urine calcium once vitamin D is adequately replenished. She refused exploratory parathyroidectomy. She continued to be followed up at the endocrine clinic while her baby at primary care. Contraception is advised untill definitive diagnosis and treatment of hypercalcemia. This case illustrates the challenges in managing hypercalcemia in pregnancy and difficulty in distinguishing PHPT vs FHH without genetic testing. Presentation: Saturday, June 17, 2023

OR26-06 Cardiovascular Morbidity And Mortality In Patients With Resistance to THYROID Hormone (RTH): A Linked Record Study

Abstract Disclosure: O. Okosieme: None. D. Usman: None. P. Taylor: None. C. Dayan: None. G. Lyons: None. C.M. Moran: None. V.K. Chatterjee: None. A. Rees: None. Introduction: Individuals with Resistance to Thyroid Hormone β (RTH-β) may develop cardiac disease, including cardiomyopathy or arrhythmia. Long-term survival outcomes in this group of patients have not been systematically evaluated. Objectives: We investigated all-cause mortality and cardiovascular event risk in a cohort of patients with RTH-β in endocrine clinics in Wales. Methods: In a retrospective cohort study using linked datasets within the Welsh Secure Anonymised Information Linkage (SAIL) Databank, Welsh patients with genetically-proven RTH-β were identified from laboratory records (n=55), matched to population controls by age and sex (n=2750), and linked to outcomes in SAIL. We used Kaplan-Meier and Cox regression models to analyse the association of RTH-β with all-cause mortality, acute myocardial infarction, atrial fibrillation, heart failure, strokes and major adverse cardiovascular events (MACE; a composite of cardiovascular death, acute myocardial infarction, heart failure, and strokes). We also investigated any association between baseline thyroid hormone concentrations and outcomes using restricted cubic splines. Results: Compared to controls, patients had an increased risk of all-cause mortality (Hazard ratio [HR] 2.84, 95% Confidence Interval [95%CI] 1.59-5.08), MACE (HR 3.49, 95%CI 2.04-5.99), atrial fibrillation (HR 10.56, 95%CI 4.72-23.63), and heart failure (HR 6.35, 95%CI 2.26-17.86). Positive associations between FT4 concentration at diagnosis and subsequent cardiovascular morbidity or death were observed, with a 7% increased risk of death per pmol/L increase in FT4. The relationship between FT4 and outcomes was non-linear, with increased risk associated with FT4 concentration exceeding 30 pmol/L. When compared to no intervention, treatment with antithyroid drugs, radioiodine/surgical ablation or levothyroxine, alone or in combination, did not effectively control thyroid hormone excess in the long-term. Conclusion: Patients with RTH-β have increased mortality and cardiovascular outcomes that correlates with high, circulating thyroid hormone levels. Ideal future therapies would target both thyroid hormone excess and tissue resistance and could potentially reduce cardiovascular risk in this disorder. Presentation: Saturday, June 17, 2023

THU670 Serum TSI Concentration In Patients With Graves’ Disease Undergoing Maintenance-dose Of Antithyroid Drug (ATD) And Its Relationship With Disease Relapse After ATD Withdrawal

Abstract Disclosure: P.V. Nguyen: None. K.T. Nguyen: None. Background: Graves' disease (GD) is an autoimmune disorder in which thyroid-stimulating immunoglobulin (TSI) plays a key role in its pathogenesis. TSI assays have been recently optimized in their accuracy, and the procedure has also been simplified, which can potentially replace TRAb measured by conventional TSH-binding inhibitory immunoglobulins (TBII) assays in routine clinical practice. Objectives: Our objective was to study the serum TSI concentration in patients with Graves’ disease undergoing maintenance-dose ATD. We also aimed to assess the predictive value of TSI immunoassay, as well as the clinical signs and thyroid function tests in predicting Graves’ disease relapse following ATD discontinuation. Finally, follow-up would be continued to check for relapse or long term euthyroid status. Methods: Retrospective follow-up study of 352 patients with hyperthyroidism due to GD, treated at the endocrine outpatient clinic of Medic Medical Center, Ho Chi Minh City from January 2000 to April 2021. TSI was measured several times during the course of treatment when planning to stop the medication (at the discretion of the attending physician). ATD withdrawal would be considered when the patients achieved clinical euthyroidism with normal FT4 tests for at least 3 months with minimal dose of ATD. The decision to withdraw ATD was also based on TSI concentration, as well as the goiter’s characteristics and parenchymal vascularity observed via thyroid Doppler ultrasound. Results: The median TSI concentration of patients with GD undergoing maintenance-dose ATD was 1.45 IU/L (normal range <0.10 IU/L), and their thyroid function measured at the same time tended to be euthyroid in our study. TSI cut-off level at ATD withdrawal to predict the recurrence of GD was 1.31 IU/L which corresponded with the sensitivity, specificity, positive and negative predictive values of 63.64%, 78,79%, 50% and 86.67%, respectively. Multiple logistic regression analysis showed that the following factors were associated with an increased risk of relapse after the end of medical treatment: Graves' ophthalmopathy (GO), OR 3.69 (95% CI: 1.06-12.87; p=0.04), treatment duration less than 18 months, OR 7.77 (95% CI: 1.92-31.42; p<0.01), TSI level before ATD withdrawal ≥1.31 IU/L, OR 9.92 (95% CI: 2.77-35.42; p<0.01). Conclusion: At the time of ATD withdrawal, while normal FT4 levels were observed, high TSI levels were indicative of an ongoing immune process. These findings suggest that TSI measurements, in addition to clinical and ultrasound evaluations, may aid in the prediction of GD relapse after ATD discontinuation. In addition, GO, treatment duration of less than 18 months and TSI level before ATD withdrawal ≥1.31 IU/L were associated with an increased risk of relapse of GD after ATD discontinuation. Our study contributes to the expanding literature supporting the clinical utility of TSI assay in the management of GD. Presentation: Thursday, June 15, 2023

THU669 Time To Achieve Euthyroidism In Graves Disease Using Methimazole In An Urban Population

Abstract Disclosure: S.S. Habbsa: None. E. Yunasan: None. A. Krishnan: None. K.M. Munir: None. Context: Previous studies of treatment response in Graves disease have shown that that the mean time to reach euthyroidism with methimazole (MMI) was several weeks to months. In 1987 Okamura et al. concluded that the average period was 6-7 weeks with MMI 30mg daily. Nakamura et al. showed similar data in 2007 (5.8 +/- 4 weeks). These studies were performed in Japanese hospitals over 15 years ago. Limited data exists regarding treatment response times with different doses in a diverse urban population, which may vary with regards to typical dietary patterns, thyroid hormone metabolism and thionamide pharmacokinetics. Objective: The objective of this retrospective chart review was to determine the mean time to achieve euthyroidism with MMI in patients with newly diagnosed Graves disease in Baltimore City. Methods: Patients with Graves hyperthyroidism newly diagnosed in the last 5 years were identified from outpatient endocrine and primary care clinics within the University of Maryland Medical Center healthcare system. Time to achieve euthyroidism (from the start of thionamide therapy to date of euthyroid labs, defined as normal free T4 level) was assessed. Results: 128 patients with recently diagnosed Graves hyperthyroidism were identified (126 patients treated with MMI only and 2 with PTU only). 78% of subjects were female and the mean age at diagnosis was 47 years. The average daily dose of MMI ranged from 2.5mg to 60mg. On average, Free T4 decreased by 0.47 ng/dL per week. The mean time to achieve euthyroidism was 10.1 weeks (8.6, 11.6) overall, similar in males and females. On sub analysis, time to achieve euthyroidism was lower in younger males (age < 40 years) [6.6 weeks (3.9, 9.3)] and older females (age > 40 years) [8.3 (6.9, 9.7)]. Conclusion: The above data may inform expectations for treatment response for newly diagnosed Graves disease, specifically in an urban population on a Westernized diet. Patient forums have shown increasing interest in therapeutic alternatives to thionamides, including specialized diets. This data may help to determine whether other proposed therapies for initial treatment of Graves hyperthyroidism are more or less efficacious. Presentation: Thursday, June 15, 2023

SAT377 Revisiting The Utility Of Simplified Ferriman-Gallway Score (Sfg) To Predict Hirsutism In Brazilian Women

Abstract Disclosure: T.F. Oliveira: None. T. Oliveira: None. K.L. da Penha: None. D.C. Santana: None. A.L. Rocha: None. F.M. Reis: None. M.O. Premaor: None. A. Candido: None. F.V. Comim: None. Hirsutism is a common condition in women, being a hallmark of polycystic ovary syndrome (PCOS). Currently, the unique way to determine hirsutism is through the modified Ferriman Gallway score (mFG) based on the analysis of nine body areas. Establishing the mFG score also requires a trained observer, a well-lit room, and time to perform a satisfactory examination. Due to these requirements, alternatives have been proposed. Our study investigated the performance of the simplified Ferriman-Gallwey (sFG) hair growth scoring system, as proposed by Cook et al. (2011). sFG includes only three areas of mFG (cheek, upper and lower abdomen) identifying hirsutism when the score is equal or superior to 3. Since the presence of hirsutism depends on the ethnical background, we explored the performance of sFG to predict the diagnosis of hirsutism in Brazilian women. This study was approved by the local ethics committee. Women at reproductive age were recruited from the Endocrine and Gynecologic outpatient clinics. Clinical and anthropometric data were obtained; two independent observers performed the modified FG score. Hirsutism was defined as mFG > 6 for South Americans [the criteria suggested by the Endocrine Society (ES)] or mFG > 4 [European Society of Human Reproduction and Embryology (ESHRE)]. Overall, 199 women were evaluated. The (mean + SEM) for age was 33.7 + 0.7 years, BMI 29.8 + 0.5 kg/m2, Abdominal circumference 92.4 + 1.2 cm, total mFG score 2.8 + 0.2. The frequency of ethnic background was 20.8% for whites, 28.7% for blacks, 47.8% for multiracial, and 2.7% for others (e.g., indigenous). The prevalence of the established diagnosis of PCOS was 24.6%. When inquired, 50% of the group (n=98) complained of excessive hair growth. Our results confirmed by multiple linear regression (Adjusted R2=0.986; p<0.001) that the best five predictors for mFG score were the upper abdomen, cheek, lower abdomen, thorax, and upper lip. When using the criteria of ES (mFG > 6) (n=147), the sensibility and CI of sFG was 76.9%, (95% CI =56.4-91.0%), and the specificity 95.0%, (95%CI =89.5-98.2%) with an accuracy of 91.8% (95% CI= 86.2 – 95.7%). The positive predictive value (PPV) was 76.9%, and the negative predictive value (NPV) was 95.0%. Using the criteria for diagnosing hirsutism by ESHRE (mFG > 4) (n=188), the sensibility and CI of sFG was lower 55.6%, (95% CI 40.0-70.4%), and the specificity higher, 97.2% (95%CI 93.0-99.2%) with an accuracy of 87.2% (95% CI 81.6 – 91.6%). The PPV was 86.2% and the NPV of 87.4%. Our results in South American women replicated those reported in the largest study performed in a predominant white ethnicity (approximately 70%) in the US. From our point of view, as a screening or as a substitutive tool, the sFG below three can exclude hirsutism with a reasonable negative prediction; nevertheless, more studies need to be performed in the clinical setting. Presentation Date: Saturday, June 17, 2023

FRI305 Impulse Control Disorders In Patients With Prolactinomas And Non-Functioning Pituitary Adenomas Treated With Dopamine Agonists

Abstract Disclosure: T. Kolitz: None. E. Shemesh: None. A. Nathan: None. R. Eldor: None. E. Izkhakov: None. Y. Greenman: None. Objective Impulse control disorder (ICD) is a well-recognized side effect of dopamine agonist (DA) treatment in patients with Parkinson’s disease and restless leg syndrome. The available data on the incidence of ICD in patients treated with DA for pituitary tumors are sparse. This study aimed to assess the occurrence of ICD among patients with prolactinomas or NFPA treated with DA compared to patients with prolactinomas or NFPA not treated with DA and to patients with non-pituitary endocrine disorders. Methods Patients attending the general endocrine and pituitary clinics at the Institute of Endocrinology in our medical center were invited to fill in an anonymous validated questionnaire on hypersexuality, pathologic gambling, compulsive shopping, and punding. Associated relevant clinical information was also obtained. Results In total, 174 patients consented to participate. Those with pituitary disorders other than prolactinomas and NFPA were excluded. The final study cohort consisted of 67 patients with NFPA (31 DA-treated) and 40 with prolactinomas (35 DA-treated). The control group consisted of 67 non-DA-treated subjects with other endocrine disorders. The entire cohort was comprised of 77 men and 97 women (mean age 56±17 years). ICDs were reported by 19/66 (29%) DA-treated patients with prolactinomas or NFPA, 3/41 (7%) non-DA-treated patients with prolactinomas or NFPA and 8/108 (7.5%) non-DA-treated patients with prolactinomas, NFPA or other endocrine disorders (p<0.001). There were no significant differences in ICD rates between DA-treated patients with prolactinomas compared to those with DA-treated NFPA, or between non-DA-treated patients with either prolactinomas or NFPA and controls. The ICD rate among DA-treated women was significantly higher than that of non-DA-treated women (34.5% and 7.5%, respectively. p<0.001). No comparable differences were observed in DA-treated versus non-DA-treated men or between all participating men and women. Conclusion ICD rates are significantly higher among patients treated with DA for prolactinomas or NFPA compared to non-DA-treated patients with prolactinomas, NFPA or other non-pituitary endocrine disorders. Patients being treated with DA for any pituitary lesion should be informed of the greater risk of associated ICD. Presentation: Friday, June 16, 2023

FRI559 An Uncommon Association Of Two Common Etiologies Of Hyperthyroidism

Abstract Disclosure: C. Chew: None. Introduction: Subacute thyroiditis and Graves’ disease are two common etiologies of hyperthyroidism. Association of these two diseases in patient presented with recurrent hyperthyroidism has rarely been reported. Case Report: A 35 years old women, with no known medical illness, was referred to Endocrine Clinic for painful anterior neck swelling associated with palpitation for 2 weeks. The symptoms were preceded by 3 days history of sore throat and mild fever She denied other symptoms of hyperthyroidism. Her last menses was 3 weeks prior. On physical examination, she was tachycardic with heart rate of 115 beats per minute. Her blood pressure was 135/90 mmHg and she was afebrile. There was a tender and diffusely enlarged goiter. However, there were no signs of thyroid eye disease and other signs of hyperthyroidism. Examinations of her throat, lung, abdomen, cardiovascular system and neurological system were unremarkable. There was also absence of lymphadenopathy. She denied family history of thyroid disease. Results of laboratory investigations were suggestive of hyperthyroidism secondary to subacute thyroiditis: Free T4 52 pmol/L (8-16), TSH <0.01 mIU/L (0.45-4.50), TRAb 0.8 IU/L (0-1.0) and ESR 108 mm/hr (1-10). The technetium scan showed mildly enlarged gland with decreased uptake of Tc-99m tracer suggestive of thyroiditis. She was treated with Ibuprofen and Propranolol, and her symptoms improved. At 6 weeks follow up, her thyroid function normalized with Free T4 of 13 pmol/L (8-16), TSH of 1.28 mIU/L (0.45-4.50). However, she complained of weight loss and palpitation at 6 months follow up. Examination revealed a small painless diffuse goiter and she was tachycardic with heart rate of 115 beats per minute. Thyroid function test confirmed recurrence of hyperthyroidism: free T4 45.8 pmol/L (8-16) and TSH <0.01 mIU/L (0.45-4.50). Elevated TSH receptor antibody (TRAb) level at 16.8 IU/L confirmed the diagnosis of Graves’ disease. Carbimazole was then started. Discussion: Subacute thyroiditis and Graves’ disease are two common etiologies of hyperthyroidism. The incidence of association of these two diseases had been reported to be rare at 0.15% in patients with Graves’ disease and 0.76% in patients with subacute thyroiditis (1). The postulated mechanism of the association is that the release of thyroid antigens and corresponding activation of the immune system due to viral invasion of the thyroid gland in subacute thyroiditis may cause the subsequent Graves’ disease (1,2). Conclusion: Graves’ disease should be suspected in patient with persistent or recurrent hyperthyroidism after an episode of subacute thyroiditis although it is rare. Reference: 1. Nakano Y et al. Graves’ disease following subacute thyroiditis. Tohoku J. Exp. Med. 2011; 225:301-309. 2. Bartalena L et al. Graves’ disease occurring after subacute thyroiditis. Report of a case and review of the literature. Thyroid. 1996; 4:345-348. Presentation: Friday, June 16, 2023

SAT185 Parathyroid Adenoma Localized By Cytogenetic Testing

Abstract Disclosure: S. Khadija: None. A. Rao: None. Introduction: Primary hyperparathyroidism can be caused by a parathyroid adenoma, hyperplasia or rarely by parathyroid carcinoma. Most patients have few or no symptoms. Diagnosis of primary hyperparathyroidism can be challenging in the setting of secondary/tertiary hyperparathyroidism. Correct diagnosis can be reached by clinical evaluation, biochemical and radiological tests. We describe a case that was diagnosed by cytogenetic testing of the biopsy specimen. Case Report: We report a case of a 64-year-old man. He was referred to the endocrine clinic for an incidental thyroid nodule on CT scan. He had hypothyroidism after I-131 treatment for Graves’ disease 15 years back. He had a long history of hypertension with renal failure. He had a renal transplant in 2017 and had hypercalcemia intermittently with elevated PTH since 2012. Ultrasound of thyroid reported a 1.6 x 1.7 x 2.0 cm nodule in the left thyroid lobe. He denied any compressive symptoms and was euthyroid on levothyroxine. An ultrasound guided FNA of the left thyroid nodule was reported as Bethesda III FLUS and sent to Veracyte for Affirma, which indicated a parathyroid adenoma. A sestamibi scan indicated a left lower parathyroid adenoma. He had surgery and intraoperative parathyroid hormone (PTH) dropped from 122pg/ml to 35.8pg/ml(29.1-79.7 pg/ml). Pathology confirmed parathyroid adenoma 3.8 grams in weight. Postoperatively calcium normalized with drop in PTH to 36.1pg/ml. After 2 weeks his calcium remained normal. Discussion: Parathyroid adenoma is a relatively rare condition and causes a majority of cases of primary hyperparathyroidism. A few cases are due to hyperplasia, more common in secondary hyperparathyroidism due to renal disease. Parathyroid adenoma is difficult to diagnose in patients with underlying hyperplasia due to chronic renal disease. Sonography and 99mTc preoperative sestamibi (MIBI) scan are the primary imaging modalities utilized for the visualization of diseased glands. MIBI scan is approximately 90% sensitive for localizing a parathyroid adenoma. Ultrasonography is the first-line imaging modality and parathyroid adenomas are nearly always homogeneously hypoechoic to the overlying thyroid gland and are commonly detected using gray-scale imaging alone when they are larger than 1 cm in diameter. Nodular goiter or enlarged lymph nodes are causes of false-positive results. Biopsy is very rarely used to diagnose a parathyroid adenoma with cytogenetic testing. Conclusion: Parathyroidectomy is the main stay in management of primary hyperparathyroidism due to parathyroid adenoma. Cervical sonography and sestamibi imaging are used for prediction of adenoma location. Both are limited by increased thyroid volume. Biopsy with cytogenetic testing can help in diagnosis in difficult patients. Presentation: Saturday, June 17, 2023

THU363 Misdiagnosing Latent Autoimmune Diabetes Mellitus In Adults: A Case Report

Abstract Disclosure: U. Rafat: None. W. Akhter: None. R. Alshantti: None. J.L. Gilden: None. Background: Latent Autoimmune Diabetes Mellitus (DM) in Adults (LADA) is often misdiagnosed as Type 2 DM. This can lead to increased risk of complications. Therefore, knowledge and awareness of LADA is essential. LADA is diagnosed based on three features, age greater than 35 years, presence of antibodies to pancreatic islet cell antigens (Glutamic Acid Decarboxylase GAD, Insulinoma antigen-2 IA-2A, Zinc Transporter 8 ZnT8A) and lack of insulin requirement for at least 6 months after diagnosis. It is important to diagnose LADA early, so that patients can be started on insulin earlier, thereby achieving better glycemic control and preserving residual beta cell function. Case Presentation: We present the case of a 44-year-old female of mixed African American and Greek ethnicity with a history of DM complicated by nephropathy, hypertension, obesity, acne and uterine fibroids. She was diagnosed with Type 2 DM at age 36 from routine screening with a HbA1c of 6.9% and started on Metformin by primary care provider. Family history was significant for transient postpartum hypothyroidism in her mother, and DM in both maternal and paternal grandparents. She was unable to tolerate Metformin due to gastrointestinal side effects and was switched to Insulin Detemir therapy one year later. She first presented to the endocrine clinic for evaluation and management of abnormal thyroid function tests with symptoms of weight loss, excessive hair fall, anxiety, and palpitations. Vital signs: Blood pressure 146/65 mmHg, Heart rate 89 bpm, Respiration 14 breaths/min, BMI 31 kg/m2. Physical examination was significant for marked edema of eyelids, but no thyromegaly or tremors, and marked acanthosis nigricans. Laboratory tests were consistent with Grave’s disease with TSH less than 0.005 uIU/mL (n= 0.358-3.74), free T3 22.93 pg/mL (n=2.18-3.98), free T4 4.63 ng/dL (n=0.76-1.46) and positive TSI of 291%. (n<140). The patient was started with methimazole therapy. GAD 65 was found to be positive >250 IU/mL (n<5) and islet cell antibodies were negative. A revised diagnosis of LADA was made. The co-existence of Grave’s disease enabled reclassifying the type of her DM. Conclusion: Type 1 diabetes mellitus or autoimmune diabetes mellitus should always be ruled out if the clinical picture does not match with type 2 Diabetes Mellitus or in a relatively young patient. Our case aims to increase awareness of Autoimmune Polyendocrine syndrome, which occurs as a result of loss of immune tolerance, leading to impairment of multiple endocrine glands.

THU362 A Diagnostic Dilemma: Type 1 Diabetes Vs. Pancreatic Diabetes

Abstract Disclosure: U. Rafat: None. R. Alshantti: None. M. Kim: None. J.L. Gilden: None. Background: Several presentations of diabetes mellitus (DM) do not fit the classic descriptions. Type 1 DM, characterized by immune-mediated destruction of insulin-secreting cells of the pancreas, typically appears before age 40. The first antibodies described associated with development of Type 1 DM were islet cell autoantibodies, and later antibodies to insulin, glutamic acid decarboxylase, protein tyrosine phosphatase, and Zinc transporter 8. Pancreatic DM or type 3c, is characterized by functional deficiency of the pancreas to secrete insulin and maintain glucose homeostasis. It may be caused by acute or chronic pancreatitis, trauma, neoplasia, hemochromatosis, fibrocalculous pancreatopathy, genetics, or idiopathic, and is commonly misdiagnosed as type 2 DM. Case Presentation: We present a 73-year-old Caucasian male with Type 1 DM and retinopathy, neuropathy, hypertension, hyperlipidemia, benign prostatic hyperplasia, obstructive sleep apnea. He was diagnosed with Type 1 DM at age 33 with BMI=29 and hospitalization for diabetic ketoacidosis, and symptoms of polyuria, weight loss, and visual disturbances. He was started with insulin injections. Antibodies were not measured, as they were not widely available at that time. Family history: MI in father and brother and type 2 DM in grandfather. He later started using insulin pump at age 58 for wide fluctuations in blood glucose levels. At age 64, he presented to our endocrine clinic for continued management of assumed autoimmune Type 1 DM. Physical examination: BMI 36, abdominal lipodystrophy, abnormal monofilament with decreased sensations in the left foot. Laboratory: HbA1c=6.7%. c-peptide was low (0.09 ng/mL; normal range: 0.81 - 3.85) with a concomitant BG of 243 mg/dL suggestive of low insulin reserves. After several years, with the development of increased trust, the patient felt confident to reveal a hidden history of extensive alcohol abuse in his 20s, resulting in recurrent episodes of symptoms suggestive of pancreatitis, which required extensive rehabilitation for his drinking problem. He admitted that he had not divulged this history previously. This additional history proved critical to acquiring a correct diagnosis. With this in mind, we deduced that it is highly probable this patient's recurrent bouts of subacute pancreatitis due to alcohol consumption resulted in development of pancreatic DM. Conclusion: Our patient initially presented with the diagnosis of autoimmune type 1 DM. However, after many visits, he first admitted to a past history of long-standing alcohol abuse, which now suggests that he actually has pancreatic DM. Correctly classifying DM can prove crucial to formulating an individualized treatment plan. It is important to note that the classification of DM is not always clear-cut and involves a periodic review of the medical history and clinical characteristics, besides review of laboratory data. Presentation: Thursday, June 15, 2023

THU108 Pituitary Carcinoma Diagnosed After Ten Years Of Smoldering Ectopic Nasopharyngeal Cushing’s

Abstract Disclosure: L. Carafone: None. E. Vates: None. M. Johnson: None. I. Shafiq: None. Introduction: Pituitary carcinomas are rare and typically carry a poor prognosis. Diagnosis of pituitary carcinoma is made when there is metastasis to one or more sites distant from the pituitary, including craniospinal or systemic metastases. Clinical Case: A 54-year-old man presented to the endocrine clinic in 2011 with recurrent urinary tract infections, thoracic compression fractures, uncontrolled hypertension with hypokalemia, and weight gain. Examination revealed facial plethora, supraclavicular fat pad, central obesity, multiple ecchymoses, proximal muscle weakness and muscle atrophy of the upper and lower extremities. Workup demonstrated abnormal 1 mg overnight dexamethasone suppression test (cortisol after 1 mg dexamethasone 25.7 mcg/dL, n≤1.8 mcg/dL), elevated salivary cortisol (4340 and 2950 ng/dL, n≤99 ng/dL), elevated 24 hr urinary-free cortisol (271.7 mcg/24hr, n≤60 mcg/24 hr), and elevated ACTH (240 pg/mL, n≤46 pg/mL). MRI brain showed a large, lobulated mass in the sphenoid sinus adjacent to the inferior left lateral aspect of the pituitary fossa. He underwent surgical resection of the mass and pathology was consistent with pituitary adenoma, corticotroph cell type. Following surgery, laboratory studies showed normal salivary cortisol (<50 ng/dL, n≤99 ng/dL) and 24 hr urinary-free cortisol (22.4 mcg/24hr, n≤60 mcg/24 hr). After two years of sustained remission, he experienced local recurrence for which he underwent repeat surgery with subsequent remission. One year later, this was again followed by recurrence for which he was treated with intensity-modulated radiation therapy and medical therapies including cabergoline, ketoconazole and eventually metyrapone. Six years after the second surgery, MRI showed increasing heterogeneous enhancement at the postoperative site, and he underwent a third surgery with tumor resection and the same pathology results as the initial resection. He was subsequently treated with fractionated proton therapy. He continued to require metyrapone to manage hypercortisolism despite reassuring serial MRI scans. A right neck mass was palpated in 2022 and CT demonstrated a right level 2b lymph node measuring 2.3 x 1.8 x 2.3 cm. FNA revealed neoplastic cells and he underwent right neck dissection with excision of the lymph node. Pathology was consistent with pituitary tumor, corticotroph cell type. Given metastasis of the pituitary tumor to a cervical lymph node, a diagnosis of pituitary carcinoma was made. Conclusion: The time course in pituitary carcinoma is highly variable from the initial diagnosis of the pituitary tumor to the diagnosis of metastatic disease. In this case, the diagnosis of pituitary carcinoma was made nearly one decade after the initial identification of a pituitary tumor. Metastatic disease should be considered in aggressive pituitary tumors when biochemical and radiologic findings are discordant. Presentation: Thursday, June 15, 2023

FRI321 Aggressive Prolactinoma Empirically Treated With Cabergoline Leading To Rapid CSF Leak

Abstract Disclosure: A. Yau: None. T. Reisman: None. Over two-thirds of pituitary tumors are prolactinomas. These are discovered as a result of symptoms of hypogonadism, menstrual irregularities, infertility or galactorrhea, as well as symptoms of mass effects including visual field deficit or acute severe headaches.1 A more rare subgroup, aggressive prolactinomas, in which the tumors are radiographically invasive and show resistance to dopamine agonist treatment as well as surgery, account for 10% of all hypophyseal neoplasia. 2 During medical treatment of prolactinomas, there is a known rare complication of CSF rhinorrhea; recorded time of onset of leak following treatment ranges from 14 days to 5 years.3 We present a case in which a patient with an aggressive prolactinoma rapidly developed a CSF leak within 48 hours of starting cabergoline treatment. Case: A 36-year-old male with type 2 diabetes, erectile dysfunction and infertility presents to Endocrine clinic after initial evaluation by Urology revealed elevated prolactin. He reported headaches, gynecomastia associated with liquid discharge from nipples, and minor issues with peripheral vision. He was started empirically on cabergoline for probable prolactinoma and within 48 hours developed worsening frontal headache, cough and clear fluid leakage from his right nostril. Labs revealed prolactin over 2600 ng/ml. MRI pituitary showed evidence of pituitary adenoma as well as likely CSF leak. Cabergoline was stopped and the patient was sent to the emergency room. The patient was underwent urgent neurosurgical transsphenoidal endoscopic surgery and CSF leak repair with resolution of rhinorrhea and cough. Post-operative MRI was consistent with minimal residual tumor. He was monitored in the NICU with no obvious post-operative pituitary hormone imbalance, diabetes insipidus, adrenal insufficiency or syndrome of inappropriate ADH. Months after discharge, the patient’s prolactin remained elevated to the 600’s ng/ml and repeat MRI showed a mass occupying the entire sella and suprasellar cistern, compressing the optic chiasm. Conclusion: In this case of a patient with the subtype of aggressive prolactinoma, there seems to be a more rapid presentation of complications. When treating these rare subtypes, physicians need to stay vigilant of developing complications or even consider nonstandard therapies as first-line management. 1. Molitch ME, Drummond J, Korbonits M. Prolactinoma Management. In: Feingold KR, Anawalt B, Boyce A, et al., eds. Endotext. South Dartmouth (MA): MDText.com, Inc.; January 6, 2022.2. Lasolle H, Ilie MD, Raverot G. Aggressive prolactinomas: how to manage?. Pituitary. 2020;23(1):70-77. doi:10.1007/s11102-019-01000-73. Arimappamagan A, Sadashiva N, Kandregula S, Shukla D, Somanna S. CSF Rhinorrhea Following Medical Treatment for Prolactinoma: Management and Challenges. J Neurol Surg B Skull Base. 2019;80(6):620-625. doi:10.1055/s-0039-1677686 Presentation: Friday, June 16, 2023

FRI208 Treating Pheochromocytoma For Glycemic And Blood Pressure Control

Abstract Disclosure: A.M. Santiago Carrion: None. A.N. Gonzalez Bossolo: None. Pheochromocytomas are catecholamine-secreting tumors of the adrenal medulla chromaffin cells. They account for 0.2-0.6% of hypertension (HTN) in patients of general outpatient clinics. In addition, is known that this excess of catecholamine production is associated with impaired insulin release from pancreatic beta-cells leading to hyperglycemia. However, pheochromocytoma as a cause of diabetes and HTN is frequently overlooked. A 60-year-old woman with medical history of arterial HTN and type 2 diabetes mellitus since 10 years ago was referred to the Endocrine clinic by Nephrology for glycemic control. Her medical regimen consisted of linagliptin 5mg daily, metformin 1000mg twice daily, insulin glargine 40 units daily, losartan 50mg twice daily, amlodipine 10mg daily and hydrochlorothiazide 25mg daily. Physical examination was unremarkable, including adequate vital signs with blood pressure 110/64 mmHg and heart rate 93/min. Laboratories were notable for glycated hemoglobin 8.7%, fasting blood glucose 118 mg/dL, and urine albumin-creatinine ratio (UACR) 4622 mg/g with adequate glomerular filtration rate. Upon further investigation of nephrotic-range proteinuria, patient was incidentally found with a right adrenal mass on ultrasound, which was confirmed to have absent signal dropout on MRI and measured 5 cm. On retrospective, patient revealed feeling episodic palpitations, diaphoresis, and occasional headaches which she attributed to menopausal symptoms. Plasma free metanephrines were negative, but free normetanephrines were elevated at 2160 pg/mL (range <148 pg/mL). Patient underwent successful right adrenalectomy and pathology confirmed a right 5 cm pheochromocytoma with negative margins. Unfortunately, she wished to defer genetic testing. Four weeks after surgery, plasma normetanephrines fell to normal levels 141.8 pg/mL. Furthermore, patient was able to wean off basal insulin completely and HTN remained controlled with losartan monotherapy. Glycated hemoglobin improved to 6.7%. Additionally, UACR improved to 1352.94 mg/g and empagliflozin was added to avoid diabetic kidney progression. In this case we presented a patient with common comorbidities encountered in the clinic, but with an unusual etiology. Moreover, this patient presented with nephrotic-range proteinuria that has significantly improved after removal of the tumor, which has only been seen in case reports. Some authors propose a possible immunological pathogenesis or glomerular hyperfiltration. Detection of resistant HTN should had prompted earlier detection of pheochromocytoma in this patient. As physicians, we should be aware of endocrine causes of diabetes and HTN, such as Cushing syndrome, Acromegaly, Primary Aldosteronism, and Pheochromocytoma and Paraganglioma, as treating these may lead to better quality of life, and less disease-related complications and polypharmacy. Presentation: Friday, June 16, 2023

SAT540 A Case of Simultaneous Medullary Thyroid Cancer (MTC) And Papillary Thyroid Cancer (PTC) In a Patient With Germline RET Mutation

Abstract Disclosure: N. Vaghasia: None. G. Jaiswal: None. Introduction: There are only handful of cases reported of concurrent MTC and PTC in a patient with germline RET proto-oncogene mutation. Case: A 41 year old female with no PMH presented to Endocrine clinic for evaluation of recently diagnosed RET mutation. Patient’s nephew passed away at 5 weeks of age from abnormal organogenesis of heart and brain. Genetic testing showed germline RET mutation. Subsequently her brother and his two children was tested positive for RET mutation. Patient underwent genetic testing which was positive for RET mutation. Patient was found to be heterozygous for p.V804M (c.2410G>A) mutation reported as moderate risk mutation in the RET gene. The result was consistent with an increased risk for RET-related cancers. No family history of MTC, pheochromocytoma or primary hyperparathyroidism was identified. Patient was asymptomatic on presentation and no previous symptoms concerning for any RET mutation related disease. Her physical examination was normal. Patient underwent testing for pheochromocytoma and hyperparathyroidism which was unremarkable. Patient’s calcitonin level was also normal. Patient had US thyroid done to evaluate for nodule and was found to have 1.62 x 0.97 x 1.50 cm mixed solid cystic, hypoechoic, irregular margins and punctate echogenic foci right sided nodule. No abnormal cervical lymph nodes. Patient underwent FNA of the suspicious nodule which was reported as benign based on Bethesda classification. Patient’s calcitonin level was undetectable <0.2 pg/ml (0.0-5.0). Patient underwent total thyroidectomy and on surgical pathology had three papillary microcarcinomas, classic type, 0.4 cm (right lobe), 0.3 cm (left lobe) and 0.1 cm (right lobe). Patient had medullary microcarcinoma 0.2 cm on left lobe. Background thyroid with C-cell hyperplasia. No lymphovascular invasion, no extrathyroidal extension and margins cleared. Discussion: Association of simultaneous MTC-PTC have been reported in few case reports in patient with germline RET mutation. There has been no risk factors or specific patient phenotype identified in previous cases to suggest any association between the two. One important feature in our case is the presence of highly suspicious thyroid nodule which on FNA was benign. This raise an important question on whether the co-existence of MTC and PTC in germline RET mutation decreases sensitivity of FNA. Also it is yet unknown if specific mutation like in our case p.V804M (c.2410G>A) is associated with higher incidence of multi-tumor pathology or not. Finally, our patient had normal calcitonin level despite having MTC which is unusual. Conclusion: Coexistence of MTC and PTC in germline RET mutation is an uncommon association and more information is required to understand common features, risk factors, phenotype and cancer aggressiveness in these patients. At this point it cannot be concluded that the association is a mere coincidence. Presentation Date: Saturday, June 17, 2023

FRI573 Liver Enzyme Elevation In A Patient With Grave’s Disease; Could This Be Due To Anti-thyroid Drug Therapy?

Abstract Disclosure: C.S. Park: None. J.L. Gilden: None. Introduction: Abnormal liver enzymes (LFTs) are often observed in patients with both hypothyroidism, as well as in 2.5% of patients with Grave’ s (GRAVES) Hyperthyroidism (HTH) treated with anti-thyroid medications (ATD). Furthermore, abnormal Liver function tests are reported within 6 months of untreated thyrotoxicosis in 39% of patients. The other common causes of abnormal LFTs in HTH are congestive hepatopathy with thyrotoxic heart failure, previous underlying liver disease, hypermetabolism of hepatocytes due to HTH with subsequent anoxia and free radical damage, hepatocyte degeneration due to glycogen and protein decomposition acceleration, and autoimmune-related liver injury. Case: A 52-year-old Mexican American female, with allergies, and recent COVID vaccine, was referred to the endocrine clinic for an unknown duration of GRAVES with unintentional weight loss and occasional tremors of three months duration, and some leg weakness, but denied other symptoms of hyperthyroidism, gastrointestinal disorders, or other autoimmune disorders. There was no known family history of HTH, or other autoimmune disorders. She presented after initiation of methimazole (MMI) 5 mg twice daily, prescribed by her primary care provider. VS BP 137/70 HR 94 BMI 25.32. Exam-slight tremor on outstretched arms, no ophthalmopathy, 35-40 gm thyromegaly, no onycholysis or pretibial myxedema. Labs: TSH <0.010 (0.27-4.20 mIU/mL); Free T4 1.84 (0.5-1.6 ng/dL); T3 Free 5.31 (2.52-4.34 pg/mL); TG AB 100 (0-4 IU/mL); Thyroid Peroxidase 1,425.00 (0.00-9.00 iu/Ml); TSI 27.10 (<=0.54 iu/l). LFT’s were elevated (AST 105, repeat 53, (13-39 U/L);ALT 272,repeat 150 (7-52U/L); Alkaline Phosphatase (AP) 305,repeat 290 (34-104 U/L); T.Bilirubin 0.4 (0.0-1.0 mg/dL)]. AP Bone 159 (0-55 U/L) AP liver 195 (0-94 U/L). ANA was positive with SCL-70 autoantibodies 5.0 (<1.0 AI). Thyroid US: slightly heterogenous thyroid gland of chronic thyroiditis. RUQ abdominal US-normal. MMI was stopped for 2 weeks, then restarted. 1 week later-TSH <0.10 uIu/mL, Free T4 1.79 ng/dL, Free T3 5.91 pg/mL and LFT’s improved over the next several weeks (AST 39 U/L; ALT 85 U/L; Alkaline Phosphatase 220 U/L. SCL-70 remained positive, and she remained asymptomatic. Conclusion: Although the etiology for LFT elevation is suggestive of MMI treatment, since it occurred with the initiation and titration of this therapy, this patient also had markedly elevated SCL-70, seen in 20% of patients with systemic sclerosis, which can also be associated with lupus erythematosus, and primary biliary cirrhosis. Furthermore, the elevation continued, even after MMI had been stopped and then when restarted, was lower. This case demonstrates that it is crucial to evaluate for other etiologies of elevated LFTS in any patient with HTH, and not just assume that it is due to GRAVES or ATD, and also to consider the possibility of other autoimmune conditions. Presentation: Friday, June 16, 2023

SAT384 Is This A Case of Androgen-Secreting Endometrial Cancer in A Postmenopausal Woman?

Abstract Disclosure: V. Taqi: None. P. rimal: None. J.L. Gilden: None. Background: Hirsutism (HIR) is a common disorder of women of reproductive age, often due to polycystic ovary syndrome (PCOS). During post menopause (PM), there is usually diminishment of androgenizing hormone levels and symptoms associated with PCOS. However, rapidly progressive HIR and symptoms of virilization in PM women should always raise the question of androgen-secreting tumors, whether of ovarian or adrenal origin. Other rare causes include ovarian hyperthecosis and Leydig cell hyperplasia. We present a rare case of hyperandrogenism with endometrial carcinoma, associated with increasing hirsutism and normal ovarian imaging and pathology. Clinical case: A 56-year-old woman G3P3 PM for 2 yrs, with Type 2 Diabetes, obesity, HTN, hypercholesterolemia, IBS, Factor S Leiden, menarche at age 12-13 yrs, and PCOS s/p laser HIR removal, and previous regular menses, was referred to endocrine clinic for increasing HIR with diffuse hair loss for 6 months and suprapubic/abdominal discomfort. She also had prior corneal melanoma treated with radiation and cardiac ablation for arrhythmia. Her paternal grandmother had uterine cancer. Physical Exam: VS BP=121/78; HR=66; BMI=31 Kg/m²: (Ferriman-Gallwey score 16/36) with HIR on face, abdomen, chest and back, but no other virilization or cushingoid signs. Initial labs: elevated total and free testosterone (59 ng/dl, n<45), (9.3 pg/ml, n<6.4) respectively, unconjugated DHEA (55 ng/dL, n 77-85) low DHEA-S (29 mcg/dl, n 35- 430 mcg/dl) 17-OHP (50 ng/dL, repeat 44 (n≤ 45) with normal prolactin (5.4 ng/mL, n 0.7-31.6) ACTH (7 pg/mL, n 0-47), salivary cortisol <0.03 mcg/dL, FSH (50.3 mIU/mL ;n=5.9-72.8), LH (29.7 mIU/ml, n 1.1-52.4), estradiol (21.71 pg/mL (n <11-32.2). CT abdomen-hepatic steatosis, normal adrenals. US- heterogenous mass uterine fundus 1.1 x 1.0 x 1.0 cm with subendometrial calcifications, subcm follicles in ovaries. MRI-hypoechoic 0.7X0.8X0.7 cm uterine lesion, normal ovaries; Endometrial biopsy-disordered proliferative endometrium. Hysteroscopy with biopsy confirmed grade I endometrial adenocarcinoma. A total laparoscopic abdominal hysterectomy with bilateral oophorectomy (TAH/BSO) was performed. Pathology-endometrial carcinoma, endometroid type F1GO stage 1A with positive estrogen and progesterone receptors, normal ovaries. By 3 months postop, the HIR significantly decreased with normalized total and free testosterone levels (14 ng/dl), (1.8 pg/ml). Conclusion: This is a rare case of hyperandrogenism associated with endometrial cancer in a postmenopausal woman causing hirsutism with the resolution of symptoms and normalization of androgen levels following TAH/BSO. Clinicians should be aware to thoroughly evaluate postmenopausal women who develop sudden increasing signs of androgenization, particularly if it is of recent onset, and consider other rare diagnoses. Presentation Date: Saturday, June 17, 2023

SAT544 Abnormal Labs Reveal Metastatic Papillary Thyroid Cancer

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