History Of Hyperlipidemia Research Articles

Osteomyelitis of the Proximal Ulna Positive for Aeromonas sobria Presenting as Olecranon Bursitis: A Case Report

Background Osteomyelitis is a bone infection, often arising secondary to trauma or infection. It most often occurs in the long bones such as the femur and tibia, and is characterized by swelling, pain, erythema, and constitutional symptoms. Olecranon bursitis often shares many of the characteristic findings of osteomyelitis including swelling, redness, edema, and localized pain. Case Presentation We report the case of a 71-year-old female with a history of osteoporosis, hyperlipidemia, and hypothyroidism who presented with symptoms and physical exam findings consistent with olecranon bursitis, but was determined to have posterior ulnar osteomyelitis from Aeromonas sobria. Unlike the common presentations of osteomyelitis, this patient presented without fever, pain, or associated erythema of the posterior ulna. X-rays were nondiagnostic but revealed subtle changes in the proximal ulna. An MRI was obtained which was concerning for a diagnosis of osteomyelitis versus neoplasm. Operative cultures and pathology confirmed osteomyelitis, and the patient was successfully treated with debridement of the affected tissue, followed by antibiotics PO for 42 days. The patient recovered with a full range of motion after two months, with no radiographic evidence of ulno-humeral arthritis. Conclusions While olecranon bursitis is one of the most common musculoskeletal diagnoses of the elbow, osteomyelitis of the proximal ulna is exceedingly rare. While MRI is not part of the standard work-up for olecranon bursitis, in this case, it was critical for obtaining the proper diagnosis. This case illustrates the importance of accurate radiographic interpretation as well as a high index of suspicion for underlying pathology when treating routine conditions such as olecranon bursitis.

Essential thrombocythemia complicated by multivessel intracranial dolichoectasia with subarachnoid hemorrhage and recurrent cerebral infarction

BackgroundPatients with essential thrombocythemia (ET) can develop systemic thrombotic and hemorrhagic vascular complications due to increased and dysfunctional platelets.Case presentationWe encountered a 49-year-old Japanese woman with a history of essential ET, cerebral infarction, hypertension, and hyperlipidemia. She had been taking anagrelide (2.5 mg/day) and aspirin (100 mg/day) and had vomited at home. At the time of admission to our hospital, she was in a deep stupor. We thought these symptoms were caused by intracranial hypertension. Head computed tomography showed severe subarachnoid hemorrhage (SAH) at the interhemispheric fissure, hematoma at the corpus callosum, and intraventricular hemorrhages. Digital subtraction angiography demonstrated multiple dilated, stenotic, tortuous intracranial arteries, and a dissecting aneurysm at the right anterior cerebral artery (ACA). The dissecting aneurysm measured 7.7 × 15.5 mm, and a bleb was observed. Our diagnosis was ruptured ACA dissecting aneurysm and diffuse intracranial arterial dolichoectasia (DIADE). We performed stent-assisted coil embolization of the aneurysm. She remained apathetic and manifested unilateral apraxia and alien limb syndrome due to a partial callosal disconnection. Two months thereafter her symptoms gradually improved, her consciousness level and limb function improved, and her modified Rankin scale (mRS) score was 2. However, when we tapered her antiplatelet therapy, she again developed an acute cerebral infarct.ConclusionsThis is the first presentation of a patient with ET complicated by DIADE, both of which can result in ischemic and hemorrhagic vascular complications including SAH. As antithrombotic therapy in patients with DIADE and ET may be associated with higher hemorrhage rates, its effects must be monitored carefully.

8141 A Rare Case of Follicular Adenoma with Osseous Metaplasia and Mature Bone Formation- Is Surveillance Important?

Abstract Disclosure: K. Madani: None. Y. Al-Khazraji: None. D.H. Sacoto: None. G.K. Rai: None. R. Belokovskaya: None. A.A. Franco-Akel, MD: None. Osseous metaplasia and mature bone formation (MBF) are common in malignant thyroid and parathyroid tumors. It is very unusual to have MBF in a benign tumor-like follicular adenoma, as in the case we describe. We found only twelve such cases reported in the literature, and none addressed the cancer risk or need for surveillance for the development of potential malignancy. Thus, further studies are required to investigate the need for surveillance in patients not undergoing excision and in those with remnant thyroid tissue post-removal of the adenoma for recurrence. A 43-year-old female with history of hyperlipidemia and hypothyroidism had an incidental finding of midline neck mass during the evaluation of a left upper extremity lipoma. Ultrasound of the neck showed two nodules in the Left (L) thyroid lobe: a complex nodule measured 2.2 x 1.2 x 2.1 cm and a calcified nodule measuring 1.5 x 0.8 x 0.6 cm. MRI of the neck revealed a 1.9 cm heterogeneously enhancing nodule in the mid to lower pole of the L thyroid lobe. The patient had symptoms suggestive of compression, such as dysphagia, odynophagia, and hoarseness; thus, left hemothyroidectomy was performed. Tissue biopsy was notable for follicular adenoma with osseous metaplasia and mature bone formation. The patient remained clinically and biochemically euthyroid, with only mildly elevated thyrotropin level, and treatment with levothyroxine 25 mcg once daily was initiated. On post-surgical follow-up, there was a lack of data to support close monitoring modality and strategy for the remnant thyroid lobe and neck nodal compartments. We concluded with the patient to follow up in a clinical visit for a physical exam of the neck and to obtain a follow-up sonogram at an interval of six months, in addition to monitoring TSH levels to guide hypothyroidism therapy. Osseous metaplasia has not been established as a premalignant condition, but in certain tissues like the esophagus, metaplasia is a risk factor for malignant conversion, for instance, in Barrett’s esophagus leading to esophageal adenocarcinoma. Moreover, MBF in thyroid tissue has been attributed to the activity of basic fibroblast growth factor (bFGF) and bone morphogenetic protein-2 (BMP-2), which are linked with mitogenesis and tumorigenesis. Thus, the question arises if post-excision surveillance is required in patients with a history of osseous metaplasia in remnant thyroid tissue post-lobectomy or partial thyroidectomy. At this point, more epidemiological data on similar cases may help us understand the true risk of this clinical scenario, in order to develop a reasonable approach for surveillance. Presentation: 6/3/2024

8800 A Case of Hypopituitarism Due to Sheehan Syndrome

Abstract Disclosure: N. Akabogu: None. S. Dejhansathit: None. F. Marium: None. B. Stanley: None. E.M. Bazuaye: None. L.S. Krusniak: None. L.G. Kurukulasuriya: None. U.Z. Khan: None. Background: Sheehan syndrome, which is also known as postpartum pituitary infarction, refers to the necrosis of the anterior pituitary gland due to postpartum hypovolemia, hemorrhage, shock, resulting in various degrees of hypopituitarism. The pituitary gland enlarges during pregnancy due to estrogen stimulation and becomes hyper-vascular, making it prone to infarction with postpartum hemorrhage. The initial symptoms include hyponatremia, weakness, weight loss, but the most prominent specific symptoms are inability to nurse and postpartum amenorrhea. Depending on the severity of hypopituitarism, symptoms may develop within the first few days to weeks after delivery or may take months to years to develop. Case presentation: 35year-old Caucasian female with a medical history of gestational diabetes, hyperlipidemia, and hypertension, who presented to the hospital with flu-like symptoms, leg pain, abdominal pain, and proximal muscle weakness. The evaluating hospitalist observed that patient appeared sluggish and spoke with a deep coarse voice, which concerned him for hypothyroidism. Thyroid function test revealed undetectable free T4 with inappropriately normal TSH of 1.38 – consistent with secondary hypothyroidism. Additional history from patient uncovered 9 months history of constant fatigue, weight gain, dry skin, hair loss, cold intolerance, and intermittent ankle swelling. There is no history of brain irradiation or head trauma. She has 4 biological children, and her last childbirth 3years ago was complicated by severe bleeding from her incision site, requiring transfusion of 6 units of blood. She has been amenorrheic since and is neither on birth control nor had hysterectomy. Physical exam showed mildly enlarged tongue, diffuse pallor, dry scaly skin on upper arms, scanty eyebrows, and slowed speech. Further work-up for pituitary insufficiency showed secondary adrenal insufficiency, secondary hypogonadism, low prolactin, and growth hormone deficiency. There was no evidence of AVP deficiency. Other lab and clinical findings were hypoglycemia, hyperlipidemia, elevated CK, elevated Cr, pericardial effusion, and diastolic hypertension. Pituitary MRI showed markedly attenuated and flattened pituitary gland with no focal mass. Patient was given stress dose hydrocortisone and thyroid hormone replacement, initially IV then oral. Following hydrocortisone and thyroid hormone replacement, her diastolic BP, hypoglycemia, CK, and Cr improved. Further management plans include initiating estrogen (plus progesterone) for bone health. Conclusion: Although Sheehan syndrome is rare in developed countries, it does occur. This case emphasizes the importance of detailed history taking, to discover the root of patients’ presentation. Even though TSH is the screening test for thyroid disease, when pituitary etiology is suspected, it is important to also check a free T4. Presentation: 6/1/2024

12618 A Rare Case Of Diabetic Ketoacidosis Leading To Severe Hypertriglyceridemia-induced Necrotizing Pancreatitis

Abstract Disclosure: E.R. Perez Roman: None. D.A. Lopez Rodriguez: None. K. Ramirez Gorbea: None. M. Sanchez Cordero: None. Y. Garcia Cruz: None. Acute pancreatitis is an acute inflammatory process of the pancreas that if left untreated can become complicated resulting in multiple organ damage and a fatal outcome in approximately 10%-40% of patients. There are well-known causes that can lead to pancreatitis such as alcohol, hereditary disorders, cholelithiasis, prior pancreatitis, and medications. Less frequently, it can be related to poorly controlled diabetes mellitus and diabetic ketoacidosis (DKA), given that in a state of low or deprived insulin, there is a breakdown of triglycerides into toxic fatty acids by pancreatic lipases; this lipotoxicity can result in the development of acute pancreatitis. We present a case of a 50-year-old woman with a past medical history of untreated hyperlipidemia and previous pancreatitis who was transferred to our institution with acute epigastric pain radiating to the back, nausea, and persistent vomiting. Upon arrival, blood glucose was 299 mg/dL, HbgA1c of 11.4%, lactic acid of 3.6 mmol/L, hypocalcemia of 6.0 mg/dl, hypoalbuminemia, and elevated pancreatic enzymes, amylase 869 U/L and lipase 2,493 U/L. The lipid panel was remarkable for total cholesterol of 1,085 mg/dL and triglycerides of 4,369mg/dL. Abdominopelvic CT scan confirmed acute pancreatitis with extensive peripancreatic and regional mesenteric edema. This patient was treated with aggressive IV fluid resuscitation and treated for DKA as per protocol. Despite prompt treatment, the patient rapidly deteriorated, developing pulmonary effusions and impending respiratory failure requiring mechanical ventilation. Her hyperglycemia was challenging to control and in the setting of severe hypertriglyceridemia, insulin requirements were higher, as intravenous insulin is useful in patients with concomitant findings, in the absence of plasmapheresis availability. Despite the marked reduction of triglyceride to 978 mg/dL and a decrease in pancreatic enzymes, multiorgan failure developed. Unfortunately, the patient died. Repeated abdominopelvic CT imaging revealed the progression of the disease to necrotizing pancreatitis involving the pancreatic head, uncinate process, and neck of the pancreas with evidence of a small hypodense lesion at the level of the tail of the pancreas. This case emphasizes the importance of prompt recognition of acute pancreatitis secondary to uncontrolled hyperglycemia with concomitant severe hypertriglyceridemia since it can lead to a worse clinical outcome as seen in our patient who developed rapid progression to necrotizing pancreatitis. It is paramount not to delay treatment with aggressive fluid resuscitation, continuous insulin infusion, and if available, plasmapheresis; as these treatment strategies in conjunction can be life-saving. Presentation: 6/3/2024

7822 Mild Autonomous Cortisol Secretion In High Suspicious Adrenal Incidentaloma

Abstract Disclosure: N. Zavrashvili: None. N. Margvelashvili: None. K. Chanturishvili: None. Mild Autonomous Cortisol Secretion in High Suspicious Adrenal IncidentalomaIntroduction: Incidentally discovered adrenal masses are common and mostly benign and non-functioning adenomas. However, evolving evidence suggests that a notable proportion of these adrenal adenomas may demonstrate mild autonomous cortisol secretion (MACS), which has been associated with an increased risk for hypertension, hyperglycemia, obesity, dyslipidemia, vertebral fractures, adverse cardiovascular events, and mortality. 55-year-old women with 5-year history of hypertension and hyperlipidemia. She was treated with a three-drug program: verapamil 250 mg daily, combined B-blocker, atenolol 100 mg and chlorthalidone 25 mg daily. Blood pressure control remained suboptimal. Her body mass index was 29,5 kg/m2. She had no signs or symptoms of overt Cushing syndrome.She was referred to CT coronary angiogram by her cardiologist, which revealed adrenal incidentaloma.Adrenal dedicated CT showed left-sided 3,4 cm high density node (41HU), with absolute washout <60. She was consulted by oncologist to exclude adrenal metastasis. The baseline laboratory test results excluded PA and Pheochromocytoma. The diagnosis of glucocorticoid secretory autonomy was based on positive low-dose dexamethasone suppression test (DST), low serum ACTH concentration, low-normal DHEA-S and lack of complete suppression of serum cortisol with an overnight 8-mg DST. Patient was referred to left-sided laparoscopic adrenalectomy with perioperative glucocorticoid coverage (100 mg hydrocortisone administered IV and again 8 hours later). Conclusion: Mild autonomous cortisol secretion is a term used to describe biochemical evidence of abnormal cortisol secretion in patients with adrenal incidentaloma, but without the classical external manifestations of overt CS, such as central muscle weakness, adipose tissue redistribution, and skin fragility. The management of patients with an incidentally discovered adrenal adenoma who do not have overt Cushing’s syndrome but who have MACS is more controversial as the available studies comparing outcomes of adrenalectomy vs conservative management have been generally small. It is associated with an increased risk of Type 2 diabetes mellitus, HBP, obesity, dyslipidemia, and global cardiovascular risk. Therefore, it is of great importance to correctly identify these patients. There are different tests for the screening of hypercortisolism. However, in the absence of a single test considered as the gold standard, it is necessary to combine the different tests to reach an adequate diagnostic capacity. The indication of surgery in ACS patients should be based mainly on the hormonal evaluation and the comorbidities potentially mediated by cortisol. Presentation: 6/1/2024

6366 Elevated Baseline Triglycerides As an Independent Risk Factor For Coronary Artery Disease

Abstract Disclosure: E. Askar: None. H. Moran: None. D. Bleich: None. Introduction: Diabetes is considered a coronary artery disease (CAD) risk equivalent. Studies have shown that the baseline level of triglycerides plays a role in cardiovascular risk independent of LDL levels lowered with statins. Numerous studies demonstrate that, in the general population, coronary artery calcium (CAC) scoring predicts and reclassifies cardiovascular disease (CVD) events, even in the absence of other risk factors. Here, we present a case of a 65 -year-old Caucasian male with elevated baseline triglycerides and a high CAC score, increasing his CVD risk despite the normalization of his triglycerides with statin therapy.Case presentation: A 65-year-old Caucasian male with a history of hypertension, hyperlipidemia, and diabetes presented to our endocrinology clinic for the management of hyperlipidemia and diabetes. His medications included empagliflozin 10 mg daily, repaglinide 1 mg three times a day, atorvastatin 20 mg daily, and amlodipine 10 mg daily. He had no complaints, and the physical examination was unremarkable. His recent HbA1c was 7.4%. Six months prior to presentation, he was found to have elevated triglycerides of 253 mg/dL (normal range: 10-149 mg/dL), low HDL of 34 mg/dL (normal range: >39 mg/dL), LDL of 84 mg/dL (normal range: 0-99 mg/dL), and total cholesterol of 167 mg/dL (normal range: 100-200 mg/dL). At that time, he was started on atorvastatin, and his recent triglycerides and HDL levels normalized. He was referred for CAC scoring, and the result was 2733 , which is above the 90th percentile for men between the ages of 65 and 69. As a result, he was further referred to a coronary angiogram. Conclusion: McGarry at the University of Texas Southwestern Medical Center was the first to describe the elevated triglyceride along with low HDL phenotype associated with insulin resistance. They explained this phenotype as a result of hepatic insulin resistance. Elevated insulin levels reduce the activity of lipoprotein lipase (LPL). As a result of that, the VLDL triglycerides rise, forming small dense LDL with a strong atherogenic potential.In the 2010 published ACCORD study, the effects of simvastatin alone versus simvastatin and fenofibrate were compared in 5500 Patients with type 2 diabetes. The experimental group did not exhibit any significant adverse cardiovascular events after eight years. However, the mean triglyceride was only 162 mg/dL. Consequently, no assumptions about the impact of the treatment on cardiovascular events in a more pertinent subset of people with greater baseline triglycerides could be made.While there has been controversy on the role of triglycerides in CVD, the idea of lowering triglycerides in diabetes patients with high triglycerides and low HDL to lower the risk of CVD is well supported. Presentation: 6/2/2024

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 >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

12363 A Unique Case Of hüRthle Cell Carcinoma of the Thyroid Gland and Meningioma

Abstract Disclosure: I. Elsayed: None. R. Khan: None. H. Dhaliwal: None. Introduction: MEN1 gene is a tumor suppressor gene on chromosome 11q13 that encodes the nuclear protein menin, which regulates cell growth and cycle. When menin protein is deficient, MEN1 develops. MEN1 mutation usually involves tumors within the parathyroid glands, pancreas, or pituitary. Case Description: A 66-year-old male with past medical history of hypertension, hyperlipidemia, and coronary artery disease presented with sudden onset dizziness, nausea and vomiting for 1 hour. He had similar symptoms on and off for several months, however on the day of presentation, these symptoms were much more acute and severe. Stroke work-up was done including CT and CTA head which revealed a 1.7cm enhancing lesion to R temporal lobe with surrounding edema with an incidental 3 x 3 cm heterogeneous mass in the large portion of the right thyroid gland. Steroids initiated. MRI brain imaging revealed findings consistent with meningioma with local mass effect and pronounced parenchymal edema. Patient underwent successful resection of the mass and pathology confirmed diagnosis of Meningioma, WHO Grade 1. Ear Nose Throat specialist was consulted for incidental thyroid mass. Ultrasound guided Fine needle aspiration biopsy was, Pathology report returned suspicious for follicular neoplasm, Hürthle cell-type. Patient initially underwent right substernal semi-thyroidectomy. Pathology confirmed diagnosis of Oncocytic (Hürthle cell) carcinoma, minimally invasive, 4.3 cm with a single focus of capsular invasion, negative for lymphovascular invasion Discussion: This case presents a 66-year-old male with a rare coexistence of two distinct tumors: a meningioma and a Hürthle cell carcinoma of the thyroid gland. While meningiomas and Hürthle cell carcinoma are not commonly associated with MEN1 syndrome, there have been reports of atypical cases with unusual tumor associations. MEN1 is usually characterized by abnormalities in at least two affected endocrine glands, but variations can involve other endocrine and non-endocrine tumors as well. 25% of thyroid disease can be seen in MEN 1 syndrome; typically papillary thyroid cancer. Only one case in literature found Hürthle cell carcinoma and meningioma in the setting of MEN-1 phenotype. A second case unique case was Hürthle cell carcinoma with metastases to the meninges. The discovery of both a meningioma and a Hürthle cell carcinoma in this patient emphasizes the importance of clinicians being vigilant for the possibility of multiple neoplasms. This case highlights that there may be a relation between role of MEN1 with atypical neoplasms not commonly seen. Presentation: 6/2/2024

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 >15.5% (<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 (<5 units/ml), C peptide was 1.9 ng/ml (0.5-2ng/ml), and Islet Antigen-2 (IA-2) autoantibody was <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

6606 Connshing Syndrome: An Uncommon Presentation Of Bilateral Adrenal Mass

Abstract Disclosure: C.S. Botero Suarez: None. N. Meda: None. K. Lamar: None. S.K. Suryanarayanan: None. Introduction: Mild autonomous hypersecretion of cortisol in the underlying setting of hyperaldosteronism has been described before and coined the term Connshing Syndrome. Even though it was described in 1979, recently W. Arlt et al in 2017 revived interest in the topic of Connshing Syndrome represents a distinct entity among PA (primary hyperaldosteronisms). We present a case of bilateral adrenal mass associated with mild autonomous hypersecretion of cortisol as well as the development of primary aldosteronism. Case Description: A 62-year-old male with a medical history of hyperlipidemia, hypertension, spontaneous hypokalemia, and T2DM was referred to the clinic due to concerns for hyperaldosteronism. Exam was unremarkable for signs of hypercortisolism. Blood pressure in the clinic was 143/88 mmHg, pulse 81 bpm, weight 105.4 Kg (231.8 lbs.), and a BMI of 28 kg/m2. A non-contrast abdominal CT performed, showed a 2.9 x.1.4 cm right adrenal lipid-rich adenoma with -3.7 HU, as well as a left adrenal lipid-rich adenoma of 1.8 x 1.3 x cm and -7.7 HU. A hormonal workup showed normal plasma metanephrines, an aldosterone of 39 ng/dL, plasma renin activity 0.16 ng/mL/h, and aldosterone/PRA ratio of 243. The patient underwent 1 mg dexamethasone suppression test which resulted in an ACTH <5 pg/mL, dexamethasone level of 288 ng/dL, and cortisol of 1.9 mcg/dL. AVS with Cosyntropin was performed (see Table 1). Right sided adrenalectomy is being considered but the identification of possible lateralization of cortisol is being considered. Discussion: Surgical management is usually preferred treatment modality for both unilateral PA and MACS, but identification of lateralization of both cortisol and aldosterone can be difficult. Although identifying lateralization of aldosterone with Cosyntropin-stimulated AVS is well understood, lateralization of cortisol production is not well understood. Johnson et. all have suggested the use of adrenal venous sampling with dexamethasone suppression as well as measurement of epinephrine levels to identify the source of hypercortisolism. They demonstrated identification of cortisol lateralization with adrenal vein sampling with specificity of 95 – 100% for unilateral disease utilizing a AV/IVC cortisol ratio > 9 and a cortisol lateralization ratio (CLR) of > 2.3. Although our case had a Cosyntropin-stimulated AVS showing clear lateralization of aldosterone production to the right adrenal, the lateralization of cortisol production is yet unknown and AVS with dexamethasone suppression is being considered. Although the treatment considerations are traditionally utilizing the guidelines for both PA and Cushing Syndrome guidelines respectively, very little is known when there are divergence of autonomous secretion amongst the bilateral adrenal masses and more studies are needed to clarify the long-term treatment considerations. 1 Presentation: 6/3/2024

7480 Isolated IgG4-Related Infundibulo-Hypophysitis

Abstract Disclosure: M. Allen: None. R.T. Beck: None. N.T. Zwagerman: None. R.J. Ryzka: None. D. Coss: None. A. Fisco: None. A.G. Ioachimescu: None. Background: 130 cases of IgG4-related hypophysitis (IgG4-RH) have been reported, usually in context of multi-organ IgG4-disease (e.g., siladenitis, pancreatitis, retroperitoneal fibrosis). Among patients with IgG4-disease, up to 5% develop hypophysitis. Presentation entails mass effects, AVP-D and anterior hypopituitarism.Case report: A 72-year-old man with history of hyperlipidemia presented with gradual decrease in strength, energy, appetite, libido, and depressed moods. Laboratory tests (8 AM) indicated undetectable AM cortisol, ACTH 6.8 pg/mL (7.2-63.3), TSH 0.20 mIU/mL (0.35-4.94), free thyroxine 0.64 ng/dL (0.7—1.48), prolactin 50.9 ng/mL (3.46-19.4), IGF-1 57 ng/mL (53-222), testosterone 7 ng/dL (240-950), LH 0.16 mIU/mL (0.57-12.07), and FSH 1.5 mIU/mL (1.0-12). MRI revealed a homogenously enhancing nodular suprasellar mass adjacent to the hypothalamus (0.8x0.7x0.8 cm) and contiguous with a 0.5 cm area of infundibular thickening. Neuro-ophthalmological evaluation was normal. In absence of mass effects, patient was monitored conservatively and treated with hydrocortisone, levothyroxine and testosterone replacement. Six months later, the mass enlarged to 1.2x0.8x1.1 cm. Patient underwent a transsphenoidal biopsy which revealed a dense fibrous mass with lymphoplasmacytic infiltration. Most cells stained for CD138 and IgG4. Postoperatively, serum IgG and complement levels, inflammatory markers, hemogram, serum protein electrophoresis, amylase and lipase were normal. CT chest and abdomen and thyroid ultrasound were unremarkable. After 4 weeks of prednisone 40 mg daily, the nodular lesion significantly decreased on MRI (0.6x0.5x0.4 cm). Prednisone was gradually tapered to 5 mg daily over 3 months. After 2 months of physiologic prednisone therapy, imaging remained stable. During follow-up of 1.5 years, no systemic IgG-4 disease was apparent and patient remained on glucocorticoid, thyroid and testosterone replacement.Discussion: Suprasellar masses can be inflammatory, infiltrative, infectious or neoplastic. The possibility of IgG4-RH should be considered even in absence of IgG4 systemic disease, as it happened in our case. Primary involvement of the infundibulo-hypophysis was suggested by a retrospective review study that found isolated IgG4-RH in 41% specimens initially diagnosed as primary autoimmune hypophysitis. Our case maintained a good radiological response after prednisone taper to physiologic doses. Response to prednisone is generally good in IgG4-RH, but relapse can occur upon taper, and long-term studies are lacking. Conclusion: We present a histologically-confirmed case of isolated IgG4-RH presenting with clinical manifestations of anterior hypopituitarism. Diagnosis and management of IgG4-RH requires multidisciplinary collaboration (endocrinology, rheumatology, neurosurgery, neuropathology and neuroradiology). Presentation: 6/3/2024

Development and internal validation of prehospital prediction models for identifying intracerebral haemorrhage in suspected stroke patients

IntroductionDistinguishing patients with intracerebral haemorrhage (ICH) from other suspected stroke cases in the prehospital setting is crucial for determining the appropriate level of care and minimising the onset-to-treatment time, thereby...

A Rare Case of Hemolysis Secondary to Severe Vitamin B12 Deficiency

An 80 year old female with a past medical history of hypertension, hyperlipidemia, hypothyroidism, and chronic back pain presented to the hospital with fatigue and was found to have a severe macrocytic anemia. Blood work showed pancytopenia and positive markers of hemolysis. Additional work up was consistent with severe vitamin B12 deficiency and pernicious anemia. Her blood counts improved with blood transfusions and vitamin B12 repletion. We discuss the proposed pathophysiology of this rare case of pernicious anemia presenting with hemolysis.

Association of socioeconomic and lifestyle factors with prevalence of diabetes in rural southwest China: a structural equation modelling approach

ObjectivesThis study aimed to investigate the prevalence of diabetes using structural equation modelling (SEM) to examine the pathways and associations of socioeconomic and lifestyle factors on diabetes in rural southwest...

The current status of early nursing for emergency pancreatitis and analysis of factors influencing prognosis: A retrospective study.

This study is to investigate the incidence of pain and the influencing factors of prognostic complications in early admission care of pancreatitis in the emergency department patients. This provides a basis for clinical nursing management and prognosis improvement. Hundred patients with acute pancreatitis admitted to the tertiary hospital between January 2021 and December 2023 were selected according to the inclusion and exclusion criteria. It collected basic baseline data and medical data of patients during admission, clarifies whether patients have complications, and analyzed the length of hospital stay. Comparing hospital stays >7 days with <7 days. A questionnaire on patient psychological status was collected, and single factor analysis was conducted on different prognostic factors. Binary logistic regression was used for single factor analysis, and P < .05 was considered statistically significant. The presence or absence of complications during treatment is the main criterion for determining the prognostic impact of pancreatitis in the emergency department patients. Among 100 patients, 26 (26%) had complications during hospitalization, 74 (74%) had no complications during hospitalization, and 64 (64%) had a stay of >7 days. There were statistically significant differences (P < .05) in smoking status and history of hypertension between the complication group and the non-complication group. In the comparison between the group with <7 days of hospitalization and the group with >7 days of hospitalization, age, education level, smoking status, and history of hyperlipidemia showed statistical significance (P < .05). The fasting days, BISAP score, first bowel movement time, C-reactive protein, blood urea nitrogen, albumin, duration of severe pain within 24 hours of admission, and duration of severe pain within 24 to 48 hours of admission were all statistically significant (P < .05). Pancreatitis in the emergency department patients are prone to exacerbation and prolonged pain during early hospitalization. In nursing, timely attention should be paid to the patient's pain issues, timely pain relief measures should be taken, and the occurrence of complications should be reduced, reducing the patient's hospitalization time. Meanwhile, it is necessary to constantly pay attention to changes in the patient's gastrointestinal function and experimental indicators.

Association of classic cardiovascular risk factors with myocardial infarction and ischemic stroke: A cross sectional analysis of the Shiraz Heart Study

BackgroundMyocardial infarction (MI) and ischemic stroke are the leading deadly clinical outcomes globally. This study aimed to investigate the association of classic cardiovascular risk factors with MI and ischemic stroke in a general population. MethodsThis cross-sectional study used the baseline data of the Shiraz Heart Study, a prospective cohort that investigate risk factors of coronary heart disease in a general population of Iran. Middle-aged citizens of 40–70 years old were included. Univariable and multivariable logistic regression analysis was performed to explore the association between sociodemographic, clinical, and metabolic factors and prevalent MI and stroke. ResultsOut of 7225 adults, 1.9 % (n = 135) had prior MI or stroke. Multiple logistic regression revealed that age≥60 years (aOR: 2.22, 95 % CI 1.45–3.20; P < 0.001), male sex (aOR: 3.82, 95 % CI 2.56–5.71; P < 0.001), history of hypertension (aOR: 1.71, 95 % CI 1.18–2.50; P < 0.005), history of hyperlipidemia (aOR: 2.42, 95 % CI 1.68–3.48; P < 0.001), having four 1st degree family members with sudden cardiac death (aOR: 26.28, 95 % CI 0.59–432.09; P < 0.022), and having a 1st degree family member with history of cardiovascular disease (aOR: 1.69, 95 % CI 1.13–2.54; P < 0.001) were associated with prior MI and stroke. Unlike high-density lipoprotein (P = 0.723) and triglyceride (P = 0.643), there were significant differences in the levels of fasting blood sugar (P < 0.001), total cholesterol (P < 0.001), and low-density lipoprotein (P < 0.001) between those with and without history of MI/stroke. ConclusionsBeing aged ≥60 years, history of hypertension and hyperlipidemia along with familial history of CVD and sudden cardiac death were in association with MI and stroke.

Lumbar laminectomy and washout of emphysematous osteomyelitis infection of the spine: illustrative case.

Emphysematous osteomyelitis (EO) is a rare, rapidly progressing infection characterized by gas within bones, leading to severe morbidity if untreated. In the spine, EO can cause significant bone destruction and instability, requiring urgent surgical and medical intervention. Early diagnosis and a multidisciplinary approach are crucial for effective management and improved patient outcomes. The authors present a unique case of EO involving the lumbar spine in a 40-year-old male patient with a medical history of diabetes mellitus, hyperlipidemia, and hypertension. Magnetic resonance imaging and computed tomography revealed the formation of gas within the L4 vertebral body and spinal canal, which led to the diagnosis of EO. Blood cultures grew Streptococcus dysgalactiae. The patient underwent laminectomy, discectomy, and vertebral body abscess washout to prevent further spread of the infection and successfully recovered. The authors report the first case of spinal EO caused by S. dysgalactiae, treated using laminectomy with debridement of the affected disc spaces. https://thejns.org/doi/10.3171/CASE24434.

Cohort Study in Outcome and One-Year Mortality of Acute Stroke Patient in Academic Hospital Universitas Gadjah Mada

Background: Stroke is still becoming one of the most common non-communicable diseases in Indonesia. Sample Registration System survey in 2016 showed that in Indonesia stroke has become the most common cause of death at all age, about 19.9%. 4 Research conducted by Novbakht found that age, sex, BMI, type of stroke, family history of stroke, hyperlipidaemia, diabetes, and severity of stroke was related and increased the mortality rate. 6 Academic Hospital Universitas Gadjah Mada had not conducted this type of research, so that researcher wanted to know the one-year mortality rate after stroke, factors that related to mortality, and to improve the quality of stroke treatment at Academic Hospital Universitas Gadjah Mada.Objective: To know one-year mortality rate in acute stroke patients in Academic Hospital Universitas Gadjah Mada by looking for the acute stroke characteristic, outcome of stroke patients, and risk factors that cause mortality in stroke patients.Method: This is an analytic research using retrospective cohort study through data collection of acute stroke patients (patients with &lt;5 days stroke onset) during July 2019 until June 2022 then we followed up the condition in the first year after stroke by using medical records, direct examination, or via telephone or video call. Mortality rates were assessed one year after stroke and the predictors of death were evaluated using the cox proportional hazard model.Result: One-year mortality after stroke in our study were related to age (&gt;67 years old) (OR=2,29; 95% CI 1,18-4,46; p=0,015) and the severity of stroke was related to higher NIHSS score (NIHSS score during admission 16-42, (OR=38,49; 95% CI 8,92-166,0; p&lt;0,001)) and ICU admission ((OR=8,01; 95% CI 4,03-15,90; p&lt;0,001)). Conclusion: An association was found between stroke severity and one-year outcomes of acute stroke patients with old age (&gt;67 years), high NIHSS scores, and ICU admissions

Impact of cigarette smoking on the outcomes of ST-elevation myocardial infarction after primary percutaneous coronary intervention in metropolitan Tehran

Objective: Although the adverse effects of smoking are well-established, evidence shows a longer survival rate following an acute myocardial infarction (MI) among smokers or the so-called “smoker's paradox”. This study aimed to determine the impact of smoking on the one-year clinical outcomes of ST-elevation myocardial infarction (STEMI) after primary percutaneous coronary intervention (PPCI) in a large registry of the Iranian population. Methods: A total of 3087 patients diagnosed with acute STEMI who underwent PPCI between 2013 and 2018 were enrolled in the study. Patients' smoking status was determined based on self-reported history and categorized into two groups: current smokers and non-smokers. Clinical and angiographic data were collected from the Tehran Heart Center (THC) registry. The primary outcome was one-year of major adverse cardiac and cerebrovascular events (MACCE). The effect of smoking on MACCE was evaluated using a Cox model. Results: From the study population, 1967 (63.7%) were non-smokers, and 1120 (36.3%) were current smokers. Non-smokers had higher rates of prior CABG (5.3%) as well as a higher history of co-morbidities, including a history of diabetes mellitus (46.0%), hypertension (52.7%) and hyperlipidemia (55.4%) than smokers (2.3%, 30.4%, 35.7%, and 49.8% respectively). Smokers had a higher reference vessel diameter than non-smokers (P=0.005). The unadjusted hazard ratios (HRs) for MACCE within one year were significantly lower in smokers than non-smokers (0.73, 95% CI: [0.58,0.92]; P=0.009); however, after adjustment for confounders, the HRs for MACCE in smokers were similar to non-smokers (HR: 1.00, 95% CI: [0.73,1.38]). Conclusion: The study found that smoking had no significant impact on the one-year clinical outcomes of STEMI patients after PPCI in the Iranian population. This study is the first of its kind to assess the effect of smoking on STEMI patients in Iran and highlights the need for further research in this area.