History Of Diabetes Mellitus Type Research Articles

2035 Small Cell Carcinoma of Rectum: A Rare Cause of Hematochezia

INTRODUCTION: Small cell carcinoma (SmCC) is a subtype of neuroendocrine tumor that has commonly been associated with lung malignancy. However, it has been seen in <1% of colorectal malignancies. Majority of neuroendocrine tumors are asymptomatic and non-functioning, but about 75% have metastatic disease by the time of diagnosis. We present a case of SmCC of the rectum in a patient who presented with intermittent hematochezia. CASE DESCRIPTION/METHODS: A 65-year-old female with a medical history of Diabetes Mellitus Type II, Hypertension, and Hyperlipidemia, was referred for endoscopic evaluation of intermittent hematochezia ongoing for several months with the following associated symptoms: change in bowel habits, constipation, perianal discomfort increased upon defecation, urinary frequency, and dysuria. She was not on anticoagulation or NSAIDs. She had no personal or family history of GI malignancy or IBD, and she denied tobacco, alcohol, or illicit drug use. Screening colonoscopy ten years ago had been negative for any abnormalities. Laboratory data was unremarkable for anemia or liver disease, but did reveal a mildly elevated CEA 4.8 ng/mL. Subsequent colonoscopy revealed large ulcerated rectal mass at 15 cm with luminal narrowing concerning for rectal malignancy. Follow up imaging with CT of the abdomen and pelvis with contrast showed a large rectal mass with multiple enlarged peri-rectal lymph nodes, 1.5 cm right adrenal nodule, 3 mm non-calcified nodule of left lower lobe and multiple sub-centimeter hypodense lesions in left liver lobe. Biopsy with histological staining suggested neoplastic cells consistent with rectal small cell carcinoma. Patient was treated with neoadjuvant chemotherapy and radiation therapy followed by abdominoperineal resection. Ultimately, she could not tolerate adjuvant therapy and enrolled in hospice. DISCUSSION: To date, fewer than 1000 cases of GI SmCC have been reported with prevalence of 0.1% to 1% of all GI tumors. Seventy- five percent of patients present with metastasis at the time of diagnosis. Six-month survival rate is 58%, and five-year survival is 6%. Clinical presentation generally mimics the usual presentation of colorectal malignancies. Workup is also similar. However, there is no standard treatment approach for SmCC as none has been developed due to low incidence. Given the paucity of literature, cases should be reported to influence future prospective studies to establish standard diagnostic and treatment regimens and to improve the overall prognosis.

INVASIVE PULMONARY ASPERGILLOSIS SUPERINFECTION IN A CRITICALLY ILL PATIENT WITH INFLUENZA A AND LIMITED CORTICOSTEROID EXPOSURE

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: It is our aim to highlight less well-recognized risk factors for invasive pulmonary aspergillosis(IPA). Early recognition of risk factors can raise clinical suspicion for Aspergillus superinfection so that appropriate and prompt therapy can be initiated potentially reducing morbidity and mortality. CASE PRESENTATION: A 69 year old female with a history of diabetes mellitus type 2, pancreatic cancer in remission status post remote Whipple procedure and COPD presented with dyspnea, wheezing and non-productive cough. She quickly deteriorated and was admitted to the ICU with hypoxic respiratory failure. One week prior to admission, she had completed a five day corticosteroid steroid burst for COPD exacerbation. CT chest demonstrated bilateral ground glass alveolar opacities on a background of stable centrilobular emphysema. Influenza A molecular assay was positive and Oseltamivir therapy was initiated. Despite receiving broad spectrum antibiotics and oseltamivir she remained febrile, required more oxygen and declined. Repeat thoracic imaging demonstrated worsening of the infiltrates and bronchoalveolar lavage specimens isolated Aspergillus fumigatus prompting immediate voriconazole therapy. DISCUSSION: Classically, IPA has been regarded as an ailment of those with weakened host immune systems such as in hematological malignancy, solid organ transplant and neutropenia. Influenza A is known to lay the framework for bacterial superinfections, but predisposing patients to invasive fungal organisms has only garnered significant attention within the last decade. Abbott et al. documented a case of invasive aspergillosis plaguing a previously immunocompetent individual acutely infected with Influenza in 1952, but it was not until 2018 that Schauwvlieghe et al identified Influenza as an independent risk factor for IPA in patients admitted to the ICU with pneumonia. Further, those receiving prolonged, high-dose glucocorticoid therapy have also been shown to be at greater risk for development of IPA, but the threshold of glucocorticoid exposure remains unclear. In 2012, Wauters et al demonstrated that steroid administration within seven days of presentation was a significant risk factor for development of Aspergillus; however, no corticosteroid dose risk relationship could be identified. Both corticosteroid exposure and Influenza A infection predispose patients to Aspergillus superinfection, on their own, but additional investigation is necessary to determine the threshold of corticosteroid exposure as well as the concurrent additive risk of Aspergillus infection when these two factors are combined. CONCLUSIONS: Knowledge of risk factors and thus the ability to identify patients at increased risk for Aspergillus superinfection, earlier in the course of hospitalization, may lead to a better determination of who warrants empiric antifungal coverage with the end result being improved morbidity and mortality. Reference #1: Schauwvlieghe AFAD, Rijnders BJA, Philips N, Verwijs R, Vanderbeke L, Van Tienen C, Lagrou K, Verweij PE, Van de Veerdonk FL, Gommers D, Spronk P, Bergmans DCJJ, Hoedemaekers A, Andrinopoulou ER, van den Berg CHSB, Juffermans NP, Hodiamont CJ, Vonk AG, Depuydt P, Boelens J, Wauters J; Dutch-Belgian Mycosis study group. "Invasive aspergillosis in patients admitted to the intensive care unit with severe influenza: a retrospective cohort study". Lancet Respir Med. 2018 Oct;6(10):782-792. Reference #2: Lewis R, Kontoyiannis, D. "Invasive aspergillosis in glucocorticoid-treated patients". Medical Mycology, Volume 47, Issue Supplement 1, 1 January 2009, Pages S271–S281 Reference #3: Wauters J, Baar I, Meersseman P, Meersseman W, Dams K, De Paep R, Lagrou K, Wilmer A, Jorens P, Hermans G. "Invasive pulmonary aspergillosis is a frequent complication of critically ill H1N1 patients: a retrospective study". Intensive Care Med. 2012 Nov;38(11):1761-8. DISCLOSURES: No relevant relationships by Median Ali, source=Web Response No relevant relationships by James Gleason, source=Web Response No relevant relationships by Aleksandra Kozlova, source=Web Response No relevant relationships by Shawn Marein, source=Web Response No relevant relationships by Avneek Singh Sandhu, source=Web Response

2556 Duodenal Candidiasis Presenting as Mass-Like Lesion: A Rare Presentation

INTRODUCTION: Candida is a normal inhabitant in the GI tract. It is typical for candidiasis to appear in the esophagus and oropharynx in immunocompromised patients. However, candidiasis of the stomach or duodenum is rare. We report a case of a gastric outlet and biliary obstruction due to a duodenal mass-like lesion in the setting of duodenal candidiasis. CASE DESCRIPTION/METHODS: Patient is a 66 year old female with past medical history of diabetes mellitus type 2, hypertension and osteoarthritis who presented to the hospital with progressive non-bloody vomiting, poor oral intake and constipation for two months. She endorsed abdominal pain and yellowing of the eyes and skin. Her vitals on admission were normal. Physical exam was pertinent for diffuse abdominal tenderness and scleral icterus. Her laboratory findings were significant for AST of 137 U/L, ALT of 130 U/L, alkaline phosphatase of 205 U/L, total bilirubin of 8.9 mg/dL and direct bilirubin of 5.3 mg/dL. Abdominal CT scan showed duodenal thickening with possible mass-like lesion causing gastric outlet obstruction. MRI of the abdomen and MRCP only showed duodenal wall thickening. She had a subsequent EGD that showed mild gastric erythema and a mass like lesion in the duodenum hindering the visualization of the papilla. Biopsy results were significant for active chronic duodenitis with presence of Candida albicans. Gastric biopsy was positive for H. pylori infection. The patient was treated with a 21 day course of Fluconazole followed by bismuth based quadruple therapy. Follow-up EGD showed resolution of the duodenal lesion. At two months follow up after treatment, the patient had no symptoms and liver enzymes were normal. DISCUSSION: Candida is part of the normal flora of the GI tract and commonly causes infection in the mouth and esophagus. Stomach and duodenal infections are less common due to their relatively acidic environment creating a harsh environment for the fungal species to grow and cause disease. However, immunocompromised patients and patients on acid suppressive therapy are vulnerable to opportunistic candidal infection. The long standing history of diabetes may have predisposed patient to the infection. In conclusion, our case highlights a rare presentation of a duodenal candidal infection; mass-like lesion causing gastric outlet and biliary obstruction. This case should serve as a reminder to clinicians to keep candidiasis in the differentials for duodenal infections especially in diabetic patients.

2490 A Rare Initial Presentation of HCC

INTRODUCTION: Metastasis accounts for approximately 1-4% of all oral malignancies. Other cancers that spread to the mandible include lung, breast, kidney and colon. Hepatocellular carcinoma (HCC) has the fifth highest prevalence worldwide but only 68 cases of mandibular metastasis have been documented between 1957 to 2011. The following is a rare case of HCC presenting as mandibular metastasis. CASE DESCRIPTION/METHODS: The patient is a 73-year old Hispanic male with history of diabetes mellitus type 2, hypothyroidism, mild dementia, and alcoholic liver cirrhosis who presented with a one-month history of progressively enlarging painless mass in the left mandible, anemia and a 9-month history of weight loss. Additionally, one month ago the patient suffered a traumatic fall. Physical exam was significant for the presence of a malodorous, bleeding oral mass and a left humeral fracture. Initial CT imaging revealed a well-defined, expansile lytic mass in the left mandible, with an additional mass in the right mandible and the right paraspinal area of C1. Additional imaging revealed multiple hepatic lesions, a left humeral mass associated with the fracture and multiple lytic spinal lesions. Alfa-fetoprotein was significantly elevated. Biopsy of the mandibular mass revealed HCC with positive staining of hep par 1 glypican-3 and focal villin. After discussion, the patient and family decided to pursue conservative management with hospice care. DISCUSSION: Mandibular metastasis has been reported during the late stages of HCC, however mandibular involvement as an initial presenting sign is extremely uncommon. Therefore primary liver malignancy should always be considered in patients who present with mandibular tumors with HCC risk factors.

Type 2 diabetes as a familial illness: Findings from a focus group study.

Type 2 diabetes mellitus (T2DM) is a prevalent illness with high societal and personal costs. Whereas there is some systemic research, there are still many pieces yet unknown about T2DM and families. The purpose of the current study is to understand the transgenerational health experiences related to T2DM for both patients and caregivers. Focus groups were the primary methodology. Interviews were recorded, transcribed, and coded for themes. Participants were recruited via community fliers and e-mail listservs. The primary inclusion criterion was having a (a) family history of T2DM or (b) personal history of T2DM. Participants also needed to be at least 18 years old and be able to read and speak English. In 4 focus groups, 32 people were interviewed. The sample was entirely rural yet reasonably diverse. Five dominant themes emerged from the data: physical health comorbidities, T2DM is a lifestyle illness affecting the whole family, mental health stresses and comorbidities, personal and family relationship with T2DM, and sharing knowledge. Participants indicated that their families had been influenced by T2DM and that the illness had both physical and mental health comorbidities-both of which caused considerable stressors. Participants also reported that they valued the sharing of knowledge related to T2DM with each other and people in their lives. Limitations to the study include lack of generalizability because of small sample size and the majority of recruitment being done via technology. Future research should include larger, more diverse samples and quantitative data collection. Implications are also discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Aneurysmal Subarachnoid Hemorrhage in a 68-Year-old Hyperglycemic Female Patient: Case Report and Literature Review

Background: While hyperglycemia is intimately associated with uncontrolled diabetes mellitus (DM), recent clinical studies have demonstrated that hyperglycemia is also present in the early acute phase of stroke and is associated with poor prognosis and increased long-term mortality. About half of patients with acute hemorrhagic stroke also present with hyperglycemia upon admission. But more than 50% of patients with acute hemorrhagic stroke develop hyperglycemia even without a previous history of DM. This sheds new light on the relationship between DM, hyperglycemia, and hemorrhagic stroke, with a pathophysiology that is perhaps more profound than is conventionally understood.
 The Case: We report a case of a 68-year-old female, with a history of DM Type 2 and stage 3 hypertension who presents to the emergency room (ER) at the Western Regional Hospital in Belmopan City, Belize, with hemorrhagic stroke and hyperglycemia. Diffuse subarachnoid hemorrhage was found in the frontal, temporal, and parietal regions. Mild intraventricular hemorrhage was also observed in the frontal horns and basal cisterns. And small areas of intraparenchymal hemorrhage were present in the frontal lobes. The patient was stabilized and treated conservatively with calcium channel blockers, and diuretics.
 Conclusion: Despite a unifying consensus that is still pending, maintaining glucose levels between 110-120 mg/dl by using continuous insulin infusions after traumatic brain injury or aneurysmal subarachnoid hemorrhage may carry some clinical benefit with slightly improved outcome.

Case Report: Concurrent primary CNS lymphoma and meningothelial meningioma - nuances of diagnosis and management

Background: The incidence of two distinct primary intracranial pathologies is an exceedingly rare phenomenon. Although meningiomas are well known to coexist with other primary intracranial malignancies there are only nine reported cases of a meningioma occurring simultaneously with primary CNS lymphoma in the literature. We report a case of a woman who sustained multiple injuries due to two distinct intracranial pathologies, however, lateralizing signs were unrecognized for two weeks prior to her final diagnosis. Case Description: A 64-year-old female with history of diabetes mellitus type 2 initially presented to the Emergency Department, two weeks prior, following a mechanical fall at home resulting in a left bimalleolar fracture. CT imaging revealed a right occipital mass with significant vasogenic edema causing 12mm of midline shift. MRI revealed two distinct homogeneously contrast-enhancing lesions: a right occipital mass with dural-based attachment, as well as a homogenously contrast-enhancing lesion adjacent to the right posterolateral ventricle. FLAIR signal changes were also appreciated and were noted to extend across the corpus callosum, raising concerns for a high-grade glial process. She underwent a right occipital craniotomy with gross total resection of the right occipital mass as well as subtotal resection and biopsy of the second lesion. Final pathology of the extra-axial lesion was found to be meningothelial meningioma and the deep lesion was found to be diffuse large B-cell lymphoma. Discussion: We describe a rare instance of simultaneous meningioma and primary CNS lymphoma that was found to be the underlying cause of a traumatic injury several weeks after the incident. We review the current diagnosis and management nuances in the setting of multiple intracranial oncologic processes.

Amylin as a potential link between type 2 diabetes and alzheimer disease.

Alzheimer disease (AD) is the leading cause of dementia, and although its etiology remains unclear, it seems that type 2 diabetes mellitus (T2DM) and other prediabetic states of insulin resistance could contribute to the appearance of sporadic AD. As such, we have assessed whether tau and β-amyloid (Aβ) deposits might be present in pancreatic tissue of subjects with AD, and whether amylin, an amyloidogenic protein deposited in the pancreas of T2DM patients, might accumulate in the brain of AD patients. We studied pancreatic and brain tissue from 48 individuals with no neuropathological alterations and from 87 subjects diagnosed with AD. We examined Aβ and tau accumulation in the pancreas as well as that of amylin in the brain. Moreover, we performed proximity ligation assays to ascertain whether tau and/or Aβ interact with amylin in either the pancreas or brain of these subjects. Cytoplasmic tau and Aβ protein deposits were detected in pancreatic β cells of subjects with AD as well as in subjects with a normal neuropathological examination but with a history of T2DM and in a small cohort of control subjects without T2DM. Furthermore, we found amylin deposits in the brain of these subjects, providing histological evidence that amylin can interact with Aβ and tau in both the pancreas and hippocampus. The presence of both tau and Aβ inclusions in pancreatic β cells, and of amylin deposits in the brain, provides new evidence of a potential overlap in the mechanisms underlying the pathogenesis of T2DM and AD. ANN NEUROL 2019;86:539-551.

Apolipoprotein E2 Genotype Is Associated with a 2-Fold Increase in the Incidence of Type 2 Diabetes Mellitus: Results from a Long-Term Observational Study.

Background The apolipoprotein E (APOE) polymorphisms are associated with cardiovascular (CV) disease, but its interaction with type 2 diabetes mellitus (T2DM) long-term incidence is unknown. We investigated the association between APOE genotype and long-term (i) CV events and (ii) T2DM incidence in a Southern European primary prevention cohort. Methods We assessed individual APOE genotypes in a total of 436 patients followed at a lipid clinic, with a 15-year median follow-up time. We collected data on major CV events (CV death, myocardial infarction, and stroke) and T2DM development. Results No differences were found regarding major CV event incidence among the different APOE genotypes. However, after excluding 39 patients with a prior history of T2DM, APOE2 carriers displayed a higher incidence of T2DM during follow-up (42.2%) than APOE3 (27.1%) and APOE4 (28.7%) carriers. The age-, sex-, triglycerides-, and statin usage-adjusted OR for T2DM incidence in APOE2 carriers was 1.8 (95%CI 1.1-2.9, p=0.03), compared with wild-type APOE3. To address the role of statins as a confounder, we analyzed T2DM incidence in statin-treated patients. Statin-treated APOE2 carriers also had a higher T2DM incidence (57.9%), in comparison with APOE3 homozygotes (31.6%) and APOE4 carriers (32.5%). After adjustment for confounding, APOE2 carriers on statins displayed a similar twofold increase in T2DM risk compared to APOE3 homozygotes (OR 2.1, 95%CI 1.1-4.0, p=0.03). Conclusion Our findings suggest a twofold increase in T2DM incidence in APOE2 carriers. This may prompt for a specific glucose dysmetabolism follow-up that might be tailored on the APOE genotype.

The Relationship between Hepatic Steatosis, inflammation and insulin Resistance in type 2 Diabetes with Metabolic Imbalance

Abstract Aim. Non-alcoholic fatty liver disease (NAFLD) and type 2 diabetes mellitus (T2DM) are in a bidirectional relationship. This prospective study focused on associations between parameters common to the pathogenesis of insulin resistance, inflammation and hepatic steatosis in T2DM patients with metabolic imbalance. Methods. We used clinical data, insulin resistance and inflammation indices, and hepatic steatosis markers from 120 patients. Results. The patients (44% men, mean age 58) had a mean body mass index (BMI) of 32 kg/m2 and mean T2DM history of 6 years. With exceptions, significant correlations were found between metabolic, inflammatory and hepatic parameters. Conclusions. In T2DM patients with poor glycemic control, hepatic steatosis correlates significantly with insulin resistance and inflammation. Increased prevalence and poor prognosis of these diseases together justify the need for NAFLD screening of diabetic patients.

An Evaluation of Digital Health Tools for Diabetes Self-Management in Hispanic Adults: Exploratory Study

BackgroundAlthough multiple self-monitoring technologies for type 2 diabetes mellitus (T2DM) show promise for improving T2DM self-care behaviors and clinical outcomes, they have been understudied in Hispanic adult populations who suffer disproportionately from T2DM.ObjectiveThe objective of this study was to evaluate the acceptability, feasibility, and potential integration of wearable sensors for diabetes self-monitoring among Hispanic adults with self-reported T2DM.MethodsWe conducted a pilot study of T2DM self-monitoring technologies among Hispanic adults with self-reported T2DM. Participants (n=21) received a real-time continuous glucose monitor (RT-CGM), a wrist-worn physical activity (PA) tracker, and a tablet-based digital food diary to self-monitor blood glucose, PA, and food intake, respectively, for 1 week. The RT-CGM captured viewable blood glucose concentration (mg/dL) and PA trackers collected accelerometer-based data, viewable on the device or an associated tablet app. After 1 week of use, we conducted a semistructured interview with each participant to understand experiences and thoughts on integration of the data from the devices into a technology-facilitated T2DM self-management intervention. We also conducted a brief written questionnaire to understand participants’ self-reported T2DM history and past experience using digital health tools for T2DM self-management. Feasibility was measured by device utilization and objective RT-CGM, PA tracker, and diet logging data. Acceptability and potential integration were evaluated through thematic analysis of verbatim interview transcripts.ResultsParticipants (n=21, 76% female, 50.4 [SD 11] years) had a mean self-reported hemoglobin A1c of 7.4 [SD 1.8] mg/dL and had been diagnosed with T2DM for 7.4 [SD 5.2] years (range: 1-16 years). Most (89%) were treated with oral medications, whereas the others self-managed through diet and exercise. Nearly all participants (n=20) used both the RT-CGM and PA tracker, and 52% (11/21) logged at least one meal, with 33% (7/21) logging meals for 4 or more days. Of the 8 possible days, PA data were recorded for 7.1 [SD 1.8] days (range: 2-8), and participants averaged 7822 [SD 3984] steps per day. Interview transcripts revealed that participants felt most positive about the RT-CGM as it unveiled previously unknown relationships between lifestyle and health and contributed to changes in T2DM-related thoughts and behaviors. Participants felt generally positive about incorporating the wearable sensors and mobile apps into a future intervention if support were provided by a health coach or health care provider, device training were provided, apps were tailored to their language and culture, and content were both actionable and delivered on a single platform.ConclusionsSensor-based tools for facilitating T2DM self-monitoring appear to be a feasible and acceptable technology among low-income Hispanic adults. We identified barriers to acceptability and highlighted preferences for wearable sensor integration in a community-based intervention. These findings have implications for the design of T2DM interventions targeting Hispanic adults.

Prevalence of Chronic Kidney Disease in Adults with Type 2 Diabetes Mellitus from Oxcutzcab, Yucatán

Introduction:The complications of type 2 diabetes mellitus (T2DM), such as chronic kidney disease (CKD), are the second leading cause of death in Oxcutzcab municipality of Yacatan, Mexico. The objective of the study was to estimate the burden of chronic kidney disease in a sample of patients with T2DM from Oxcutzcab municipality of Yacatan, Mexico, region characterized by high amound of poverty and vulnerabidity.Methods:This is a descriptive study involving 108 adult patients between 26 and 79 years old with T2DM who attended the PROSPERA, social protection program under the direction of Ministry of Social Development of Mexico (88% female and 12% male). Weight, height, BMI, and years of post T2DM diagnosis were measured. Estimated glomerular filtration rate (eGFR) was calculated using the Cockcroft-Gault formula.Results:We found that 39.81% of participants had stage one kidney damage, 34.26% stage two, 24.07% stage three, one case of stage four, and one of stage five. BMI measurements indicated that 40.74% of participants were obese (≥30kg/m2), 35.19% were overweight, and 1.85% were underweight. In terms of years since diagnosis, 37.04% of the participants were diagnosed five years ago and less, 29.63% of participants were diagnosed 6-10 years ago, 22.22% between 11-15 years ago, 8.33% between 16-20 years ago, and 2.78% of participants over 20 years ago.Conclusions:Most participants were in stages one to three of kidney damage, where the main objective of the medical team was medical treatment of T2DM and comorbidities, as well as nutritional support to prevent further complications. There was only one case in stage four and five each, where dialysis and kidney transplantation became necessary. Both cases presented had a history of T2DM for over 20 years. It is important to identify early kidney damage to improve quality of life, reduce the treatment costs, and lower mortality.

SUN-210 Testosterone Replacement Therapy Implicated in Osteonecrosis

Background Testosterone is indicated for men demonstrating testosterone deficiency clinically and biochemically1. One of the possible adverse effects of testosterone is an increased risk of venous thromboembolism (VTE) especially in those with an underlying thrombophilia2. Excessive Factor VIII activity is a common, but often underrecognized cause of hypercoagulability3. Similarly, a less acknowledged manifestation of hypercoagulability may be osteonecrosis4. We present a patient who developed osteonecrosis of the hip while on testosterone replacement therapy (TRT) and later found to have excessive Factor VIII activity. Clinical Case A 47-year-old male with past medical history of diabetes mellitus type 2, hyperlipidemia, obstructive sleep apnea compliant with continuous positive airway pressure device, non-smoker, presented for evaluation of secondary hypogonadism and TRT. Total testosterone was 229.7 ng/dL and free testosterone was 3.86 ng/dL at 9 AM. LH was 3.8 mIU/mL, and FSH was 5.6 mIU/mL. He had multiple complaints including reduced libido and sexual activity. Prolactin, TSH and salivary cortisol were within normal limits. Iron saturation was low. He was started on TRT. Total testosterone increased to 746.6 ng/dL. Approximately one year after TRT was started, he experienced persistent left hip pain. MR of the left hip revealed focal avascular necrosis involving the femoral head. He denied prior corticosteroid use, heavy alcohol use and prior hip injury. The patient has no known personal or family history of coagulopathy. A hypercoagulable work-up was completed and patient was found to have Factor VIII activity of 179% and 175% on repeat. He discontinued testosterone therapy. Fortunately, with the discontinuation of TRT and initiation of anticoagulation therapy, his osteonecrosis remained stable. Conclusion This case raises the question of whether patients should be screened for coagulopathies prior to TRT. One study found that of 16 cases of osteonecrosis after TRT, 4 (25%) had high (>150%) Factor VIII levels versus 7 of 103 (7%) healthy control subjects (P=.04)5. Clinicians should be mindful when prescribing TRT given the potential increased risk for VTE including osteonecrosis. References 1) Bhasin et al. Guidelines for Testosterone Therapy in Men. J Clin EndocrinolMetab. 2018;103(5):1715-1744. 2) Martinez, C. et al. Testosterone treatment and risk of venous thromboembolism:population based case-control study. BMJ. 2016; 355:i5968. 3) Bobrow, R. Excess Factor VIII: A Common Cause of Hypercoagulability. J AmBoard Fam Pract. 2005;18(2):147-9. 4) Lykissas, M. et al. The role of hypercoagulability in the development ofosteonecrosis of the femoral head. Orthopedic Reviews. 2012;4:e17. 5) Glueck CJ et al. Testosterone Therapy Can Interact With Thrombophilia, Leadingto Osteonecrosis. Orthopedics. 2015;38(12):e1073-8.

SUN-LB037 Encephalitis as a Cause of Acquired Hypogonadotropic Hypogonadism

Introduction:The diagnosis of hypogonadism, either primary or secondary, is centered on the presence of signs and symptoms of hypogonadism along with low testosterone levels. AM fasting total testosterone level is the test of choice, along with other investigations to determine the cause. LH and FSH are performed to distinguish between primary or secondary hypogonadism. Both should be supranormal to indicate primary hypogonadism; otherwise, it is indicative of secondary hypogonadism. For those with secondary hypogonadism, other pituitary hormones should be performed, followed by brain imaging, MRI being the modality of choice. Case: 57 year old male with past medical history of diabetes mellitus type 2, hypertension, hyperlipidemia, was referred to endocrinology clinic after findings of a stable nonfunctional adrenal incidentaloma. Patient had history of viral encephalitis 1 year prior to presentation. During the visit, patient reported symptoms of hypogonadism that started after his hospital discharge. Prior to hospitalization patient had normal libido and erectile function. He has six biological children, worked as a pharmacist, and no history of head trauma, alcoholism or drug abuse. Initial test, showed total testosterone level of 149.9ng/dL (348-1197ng/dL) with a free testosterone level of 3.1pg/ml (7.2-24.0pg/ml). Subsequently, LH and FSH levels were performed, revealing 3.46 U/L (1.5-9.3 U/L) and 3.2U/L (1.0-14 U/L), respectively. Other hormone levels were measured, including: ACTH 11 pg/ml (0-40pg/ml), AM fasting cortisol 7.6 ug/dL (6-21ug/dL), prolactin 5.0 ug/L (0-20 ug/L), TSH 1.079 uIU/ml (0.35-4.80 uIU/ml), free T4 by direct dialysis 0.92 ng/dL (0.9-1.9 ng/dL). ACTH stimulation was done, fasting cortisol level was 9.7 ug/dL, ACTH level was 13 pg/mL, repeat cortisol level after one hour of cosyntropin administration was 34.1 ug/dL which ruled out adrenal insufficiency. Later, MRI brain showed sella turcica of normal caliber with no evidence pituitary adenoma, structural or vascular disease. Patient was then diagnosed with hypogonadotropic hypogonadism and started on androgen patch. With treatment, patient symptomatically improved, and testosterone levels were maintained at a normal range. Learning point: Although very rare, CNS infections are not only a cause of hypopituitarism, but can also lead to acquired hypogonadotropic hypogonadism. For this particular case, hormonal levels prior to encephalitis were not performed to confirm past normal gonadal function; however, since the symptoms and time of onset clinically correlate with our diagnosis, and based on our reviews of current available data, this may be the first recorded case of acquired isolated hypogonadotropic hypogonadism secondary to encephalitis. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. s presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

TCTAP C-142 Distal Protection Device Inentrapped Rota Ablation BURR - A Basket of Delight

### Patient Initials or Identifier Number BSA ### Relevant Clinical History and Physical Exam A 61 years old male with a history of Diabetes Mellitus Type 2 presented to the hospital with complaints of chest pain NYHA II for 15 days. The patient had positive cardiac enzymes, ECG showed no ST-T

TAKOTSUBO CARDIOMYOPATHY IN DKA

Takotsubo cardiomyopathy (TC) is a syndrome characterized by transient myocardial dysfunction, usually predisposed by an overwhelming psychological or physical stressor. 34-year-old man with history of type-1 diabetes mellitus (on insulin pump) and a prior history of TC in the setting of diabetic

Serum Immunoglobulin Concentrations and Risk of Type 2 Diabetes Mellitus in Adults: A Prospective Cohort Study

Background: Type 2 diabetes mellitus (T2DM) has emerged as a global epidemic due to lifestyle changes and urbanization. Numerous experimental studies have demonstrated that inflammation plays an important role in the etiology of T2DM. However, very few prospective studies are available on the link between immunoglobulins concentrations and risk of T2DM in adults. Hence, the aim of the present study was to investigate the associations between immunoglobulin levels and the risk of incident T2DM in a large cohort. Methods: The prospective study was performed among 6,245 adults in Tianjin, China. Participants without T2DM history were followed up for 1 to 8 years with a mean follow-up duration of 3*64 years. T2DM were diagnosed in accordance with the guidelines of the American Diabetes Association. Serum immunoglobulins levels were measured by the immunonephelometric assay. T2DM and immunoglobulins levels were assessed yearly during the follow-up. Multiple COX regression models were used to assess the association between serum immunoglobulin concentrations and the incidence of T2DM. Findings: The incidence of T2DM was 16*58 per 1,000 person-years. After multivariate adjustments, compared with the lowest quartiles, the hazard ratios (95% confidence intervals) of T2DM for the highest quartiles of IgG, IgE, IgM and IgA were 0*64(0*47-0*89), 1*01(0*75-1*35), 0*64(0*46-0*90) and 1*80(1*34-2*42) (P for trend were <0*01, 0*75, 0*01 and <0*0001), respectively. Interpretation: Our findings firstly suggest that IgG, IgM and IgA concentrations were independent predictors for developing T2DM. However, we found no association between IgE concentrations and the incidence of T2DM. Funding Statement: This study was supported by grants from the National Natural Science Foundation of China (No. 91746205, 81872611, and 81673166), China Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: The study protocol was approved by the Institutional Review Board of Tianjin Medical University. All participants had provided written informed consent prior to participation in the study.

Incidence of type 2 diabetes mellitus and prediabetes in Kerala, India: results from a 10-year prospective cohort

BackgroundKerala, the southern state of India, has experienced sudden rise in the prevalence estimates of diabetes. A cohort study on the incidence of type 2 diabetes mellitus (T2DM) in Kerala state thus aptly bridges the lacuna of incidence estimate of T2DM from a population at risk.MethodsA 10-year prospective cohort study was carried out in two urban wards of central Kerala. The individuals who participated in the baseline survey in 2007 were again invited for a follow-up study in 2017. The data was analyzed using IBM SPSS Statistics for windows (version 21.0). Logistic regression analysis was used to estimate odds ratios and 95% confidence intervals. Findings are based on the 10-year follow-up data from 869 participants from the cohort.ResultsThe overall follow-up and response rate of the study was 68.9 and 86.9% respectively. During the follow-up period, 190 people (21.9%) developed T2DM. The incidence rate of T2DM and impaired fasting glucose (IFG) were 24.5 per 1000 person years and 45.01 per 1000 person years respectively. Nearly 60% of participants with baseline IFG were converted to T2DM group in the follow-up period. Age > 45 years, family history of T2DM, BMI ≥ 25 kg/m2 and presence of central obesity emerged as important risk factors for incident T2DM.ConclusionHigh incidence of prediabetes over diabetes observed in this study shows an epidemic trend of T2DM in Kerala, India. It requires an immediate public health action.

Case Report: Concurrent primary CNS lymphoma and meningothelial meningioma - nuances of diagnosis and management

Background: The incidence of two distinct primary intracranial pathologies is an exceedingly rare phenomenon. Although meningiomas are well known to coexist with other primary intracranial malignancies there are only nine reported cases of a meningioma occurring simultaneously with primary CNS lymphoma in the literature. We report a case of a woman who sustained multiple injuries due to two distinct intracranial pathologies, however, lateralizing signs were unrecognized for two weeks prior to her final diagnosis. Case Description: A 64-year-old female with history of diabetes mellitus type 2 initially presented to the Emergency Department, two weeks prior, following a mechanical fall at home resulting in a left bimalleolar fracture. CT imaging revealed a right occipital mass with significant vasogenic edema causing 12mm of midline shift. MRI revealed two distinct homogeneously contrast-enhancing lesions: a right occipital mass with dural-based attachment, as well as a homogenously contrast-enhancing lesion adjacent to the right posterolateral ventricle. FLAIR signal changes were also appreciated and were noted to extend across the corpus callosum, raising concerns for a high-grade glial process. She underwent a right occipital craniotomy with gross total resection of the right occipital mass as well as subtotal resection and biopsy of the second lesion. Final pathology of the extra-axial lesion was found to be meningothelial meningioma and the deep lesion was found to be diffuse large B-cell lymphoma. Discussion: We describe a rare instance of simultaneous meningioma and primary CNS lymphoma that was found to be the underlying cause of a traumatic injury several weeks after the incident. We review the current diagnosis and management nuances in the setting of multiple intracranial oncologic processes.

Prevalence of type 2 diabetes mellitus among adult population of District Srinagar

Over the previous 30 years, the status of diabetes has changed from being considered as a mellow issue of the elderly to one of the significant reasons for morbidity and mortality influencing the young and moderately aged individuals. The aim of the study was to estimate the prevalence of type 2 diabetes mellitus (T2DM) and impaired fasting glycemia (IFG) in the adult population, age ≥ 20 years of District Srinagar and determine its sociodemographic and lifestyle correlates. The study was conducted among the adult population of District Srinagar with a sample size of 580. A three-stage cluster random sampling design was used, and study participants were selected using a Kish grid method. Sociodemographic data, anthropometric data, and other data were collected as per the pretested semi-structured proforma. The participants were then subjected to fasting venous blood glucose estimation. The American Diabetes Association (ADA) criteria 2015 were used for classifying the subjects as normal, pre-diabetic, and diabetics. The prevalence of T2DM was 9.8% and that of IFG was 22.2%,the majority of them (9.1%) had known T2DM. The prevalence of IFG and T2DM was statistically associated with increasing age (p < 0.001), marital status (p < 0.001), educational status (p < 0.001), high chocolates and carbonated drinks consumption (p < 0.001), level of physical inactivity (p < 0.05), body mass index (p < 0.001), family history of T2DM (p < 0.001), and smoking behavior and hypertension (p < 0.001). Our analysis suggests an increase in the prevalence of T2DM in District Srinagar.