Low Free T4 Research Articles

Are We Missing Hypothyroidism among Children with Sickle Cell Anaemia?

Children with sickle cell anaemia have been reported to have potential risk of hypothyroidism from chronic blood transfusions and probable thyroid tissue ischaemia. However, few studies on hypothyroidism status of children with sickle cell anaemia in Nigeria are available. The objective of this study was to determine the prevalence of hypothyroidism among children with sickle cell anaemia. A cross sectional study that assayed the thyroid hormones and thyroid stimulating hormone (TSH) of 71 children with sickle cell anaemia was conducted at Olabisi Onabanjo University Teaching Hospital Sagamu. Using age appropriate hormonal reference values, the subjects were classified into subclinical, primary and secondary hypothyroidism. The mean serum TSH, Free T3, and Free T4 were comparable irrespective of age category (p > 0.05). No subject was identified to have low TSH value while 7.0% had high TSH value. Low free T3 was identified in 1.4% and 8.5% had high free T3 values. Low free T3 and free T4 were seen in 11.3% each of the subjects. The overall prevalence of primary, secondary and subclinical hypothyroidism was 0%, 0% and 4.2%, respectively. Sub-clinical hypothyroidism does occur in Nigerian children with sickle cell anaemia. Routine screening for hypothyroidism is advocated in all children with sickle cell anaemia.

Abstract 16324: A Deep Learning Electrocardiogram Model Identifies Risk of Incident Heart Failure in Patients With Subclinical Hypothyroidism

Introduction: Subclinical hypothyroidism (SH) is associated with an increased risk of heart failure (HF). However, there are no established measures to predict HF development within the SH population. Hypothesis: Risk of incident heart failure in SH can be predicted from a 12-lead electrocardiogram using features extracted by a convolutional neural network-based model. Methods: To test the hypothesis, we developed a convolutional neural network (CNN)-based model to detect ECG features linked with low thyroid function by training to discriminate the presence of hypothyroidism from 10,745 ECGs (2,693 from patients with low free T4 (FT4) and 8,052 from age, sex-matched patients without evidence of low FT4). The model was applied to baseline ECGs from an external cohort of 2,293 patients with SH (defined TSH >4.5mIU/L and FT4 within 0.9-1.9ng/dl) to estimate the cardiac phenotype induced by hypothyroidism (ECG-hypothyroidism score). Cumulative incidences of HF admission were compared between groups stratified by the tertile of the model output (low, intermediate, and high score groups). Adjusted hazard ratios (aHR) were calculated using Cox proportional hazard model. Results: HF admission was more frequent in the high score group (9.60/100 person-year), compared with the intermediate or low score groups (5.08 and 2.29 per 100 person-year in the, respectively; Fig ). Subgroup analyses by sex and age group yielded similar results. The association between the ECG-hypothyroidism score and HF admission remained significant after adjustment for patient characteristics, conventional ECG abnormalities, and baseline thyroid function (high vs low score group: aHR 3.56, [95%CI, 2.26-5.61]; high vs intermediate score group: aHR 1.78, [95%CI, 1.25-2.54]). Conclusions: The CNN-based model, trained to detect prevalent hypothyroidism, accurately identified patients at high risk for HF admission within the SH population using baseline ECG.

The Relationship Between Blood Parameters, Sleep, Anxiety and Depression Symptoms: A Retrospective Polysomnography Study

Objective: It is known that anxiety and depression are associated with sleep disorders and many systemic diseases. This study aims to analyse the relationship between anxiety, depression symptoms and sleep parameters among the patients subjected to polysomnographic recording. Material and Methods: A total of 808 patients who were subjected to a polysomnographic recording were included in the retrospective cross-sectional and hospital-based study. Body mass index (BMI) was calculated. Anxiety and depression symptoms were evaluated using the Beck anxiety and Beck depression inventory. Patients were divided into groups according to anxiety and depression scores. The apnoea hypopnea index (AHI), oxygen desaturation index (ODI), and peripheral oxygen saturation (SaO2) were obtained from the polysomnographic recordings. Results: In the study, there were 528 (65.3%) male and 280 (34.7%) female patients with the mean age 47.64 ± 12.25 (18-82). Depression was detected in 307 (38.0%) patients according to Beck depression score. Mild anxiety symptoms were detected in 516 (63.9%), moderate anxiety symptoms in 215 (26.6%) patients and severe anxiety symptoms in 77 (9.5%) patients according to Beck anxiety score. There was a statistical difference for all polysomnographic parameters in depression and anxiety severity groups (p=0.001). In patients with depression had lower free-T3 and higher C-reactive protein (CRP) levels (p=0.001, p=0.014). The difference between thyroid stimulating hormone (TSH) and FT4 levels was determined according to the severity of the depression (p=0.037, p=0.047). CRP was higher in patients with severe anxiety (p=0.008); and free-T3 was lower in patients with moderate and severe anxiety (p=0.003, p=0.001). In the logistic regression analysis, free-T3, minimum SaO2 and BMI had an impact on anxiety (p=0.002, p=0.033, p=0.031) and depression (p=0.001, p=0.017, p=0.035). Conclusion: Anxiety and depression symptoms are affected by numerous factors, especially sleep characteristics. Minimum SaO2, CRP and free-T3 are main predisposing factors on anxiety and depression

FRI333 Neurosarcoidosis Induced Panhypopituitarism​

Abstract Disclosure: K. Alfares: None. H. Jeong Han: None. S. Athimulam: None. Introduction: We hereby present a rare case of neurosarcoidosis causing panhypopituitarism. According to Martin-Grace et al who conducted a literature search for the timeframe of 2002 to 2014, there were only 8 cases of neurosarcoidosis associated pan hypopituitarism. Case Report: A 35-year-old male with a known diagnosis of sarcoidosis on skin biopsies presented to the hospital for altered mental status, hypernatremia, hypotension and hypothermia. He reported symptoms of polyuria and polydipsia for several weeks prior to admission. MRI of the brain revealed a 3cm mass in the suprasellar region involving the hypothalamus and bilateral optic tracts with mass effect on the anterior third ventricle. No discrete pituitary or stalk lesion was identified. A ventriculostomy tube was placed for developing hydrocephalus. Biopsy of the suprasellar mass revealed non-caseating granuloma, confirming neurosarcoidosis. Laboratory work up revealed elevated serum sodium at 167 mmol/L, high serum osmolality at 381 mOsm/kg and low urine osmolality at 381 mOsm/kg, consistent with diabetes insipidus. Anterior pituitary hormone profile work up revealed low 8am serum cortisol (1.9 mcg/dL) and inappropriately normal ACTH (34 pg/ml), low serum free testosterone (<2.5 ng/dL) and low Luteinizing hormone (0.7 mIU/ml) and low follicular stimulating hormone (< 2.6 mIU/ml), low free T4 at 0.4 ng/dL and inappropriately normal TSH at 2.77 uIU/mL. Serum prolactin was mildly elevated at 86.8ng/mL. Angiotensin converting enzyme level was within normal range at 33 U/L. A diagnosis of panhypopituitarism was made. Treatment was initiated with high dose IV corticosteroids for management of secondary adrenal insufficiency and neurosarcoidosis. He was also started on IV desmopressin and IV levothyroxine for management of his panhypopituitarism. He was transitioned to oral therapy on discharge. Discussion: Panhypopituitarism secondary to neurosarcoidosis is a rare presentation. Panhypopituitarism from sarcoidosis can occur due to infiltration of the pituitary gland or infiltration of the hypothalamus affecting the hypothalamic-pituitary axis. Sarcoidosis should be considered a differential when evaluating patients with symptoms consistent with panhypopituitarism. Prompt diagnosis and initiation of corticosteroids and deficient hormones can be lifesaving. Presentation: Friday, June 16, 2023

SAT226 A Case Of Congenital Hypopituitarasim Has The Genetic And Phenotypic Features Of Orofacial Syndrome

Abstract Disclosure: A.A. Aljasser: None. A. Alhashem: None. Introduction: Reports on pediatric hypopituitarism are very scarce. The prevalence of hypopituitarism in children is not well documented; there are only pockets of case reports and case series in literature. Pediatric hypopituitarism has multifactorial etiologies and can occur in neonates, infants, children and adolescents. The incidence of congenital hypopituitarasim is 1in 4000-1in 10000. Majority of CH cases are sporadic. howfer small number of familial cases have been identified. A molecular basis has frequently been identified. Between 80-90% cases remain unsolved in terms of molecular genetics. It can be syndromic or isolated congenital hypopituitarism depend on stage of embryogenetic fault. Case: Her we describe a case of Syndromic type of congenital hypopituitarism. A term baby weigh;2.62 kg height; 49 cm and HC 32 cm found to be dysmorphic in form of bilateral cleft lip and palate and flat nose and hypertolirism. She was well until age 2-3 day where she became ill and hemodynamically ill needs ICU in the NICU. Her labs shows: from endocrine point of view: very low ACTH and very low Cortisol and low TSH and low Free T4 (table will be in the poster). After replacement therapy and stabilization, her MRI brain shows absent anterior Pituitary and ectopic neurohypophysis and absent pituitary stalk. Later investigations shows normal chromosomes and CGH array. After evaluation and investigation by our genetic colleges, there was an abnormality in the WES study. See results (table) Conclusion: her we present a positive correlation between the phenotypic and genetic results in our case shows an addition of similar cases reported before Presentation: Saturday, June 17, 2023

SAT484 High Degree AV Block And Sinus Arrest: Cardiovascular Manifestations Of Myxedema Coma

Abstract Disclosure: J. Bosques-Lorenzo: None. P. Rivera: None. J. Colon-Castellano: None. Y. Otero-Dominguez: None. Bosques-Lorenzo Jaymilitte, Rivera-Cariño Patricia, Colon-Castellano Janet, Otero-Dominguez Yomaira. Background: Myxedema coma is a rare and life-threatening complication of severe hypothyroidism. The most common presenting symptoms are altered mentation, hypothermia, edema, and respiratory depression. The cardiovascular system is often involved, in the form of sick sinus syndrome, bradycardia, low voltage QRS complex, QT prolongation, and rarely cardiac arrest. Here we present a case of myxedema coma complicated with high degree AV block and sinus arrest. Clinical Case: A 84 year-old man with history of hypothyroidism on levothyroxine 125 mcg, presented to the ER due to disorientation, bilateral leg edema, and abdominal discomfort for 3 days. Vital signs revealed a temperature of 97.5 F, HR of 60bpm, BP 174/88 mmHg, and oxygen saturation of 100% at room air. Physical exam was pertinent for bilateral lower extremity edema, facial puffiness, macroglossia, slow mentation, and scattered rales on lung auscultation. Laboratories showed an elevated TSH (296.8 uIU/mL), with low total T3 and free T4 (45.03 ng/dL and 0.228 ng/dL respectively) with a myxedema score of 45. Altered renal parameters as per BUN and creatinine levels (83.4 mg/dL and 5.75 mg/dL) without electrolytes disturbances and elevated CPK (1250 U/L). Infectious process was ruled out. Chest X-ray showed vascular congestion. Echocardiogram showed a small pericardial effusion. Patient was admitted to ICU and started on IV Levothyroxine, along with hydrocortisone. Liothyronine was initially not available. On second admission day, the patient developed hypothermia (94.3 F) which was managed with passive warming. Telemetry monitoring recorded multiple episodes of bradycardia raging from 30 to 50 bpm, high-degree AV block, and one episode of sinus arrest of 15 seconds with self-resolution. Altered mentation persisted for which endotracheal intubation was performed to secure airway. A temporary transvenous pacing was placed emergently. Levothyroxine dose was further adjusted and liothyronine was initiated. After a few days of treatment, patient demonstrated clinical improvement that was supported with follow up thyroid function test. Patient was extubated and transitioned to oral levothyroxine. Nevertheless, he remained dependent of transvenous pacing for which permanent pacemaker placement was coordinated. Conclusion: Cardiovascular complications in myxedema coma are associated with poor prognosis with a mortality approaching 80%. Few cases of sinus or cardiac arrest associated to Myxedema coma have been reported in the literature. In this case, the patient developed high-degree AV block with concomitant sinus arrest despite prompt initiation of intravenous thyroid hormone. Prompt identification of cardiovascular involvement can prevent cardiovascular morbidity and mortality in myxedema coma. Presentation Date: Saturday, June 17, 2023

SAT617 Third Nerve Palsy As The Initial Presentation Of Pituitary Apoplexy, A Case Report

Abstract Disclosure: U. Siddiqui: None. M. Ahmad: None. K. Abiko: None. P. Ucciferro: None. Pituitary apoplexy is characterized by hemorrhage or infarction of the pituitary gland occurring after growth of a pre-existing adenoma. These adenomas are often asymptomatic, however, hemorrhage can compress surrounding cranial nerves and cause symptoms. We report a case of a 48-year-old male who presented with headache and third nerve palsy, found to have pituitary apoplexy despite negative initial CT imaging. Hospital Course: A 48-year-old man with a past medical history of asthma, cirrhosis, type 2 diabetes mellitus, hypertension and end stage renal disease presented to the emergency room for bitemporal headache. The headache was associated with right-sided blurry vision and ptosis. He was hypertensive to 166/79 mmHg, bradycardic to 58 beats per minute, afebrile with a temperature of 36.8 C with a respiratory rate of 18 breaths per minute. He was noted to have ptosis and inferolateral deviation of his right eye. Initial labs demonstrated the following: sodium 139 mmol/L, potassium 5.2 mmol/L, creatinine 8.44 mg/dL (baseline 6.5 mg/dL), bicarbonate 20 mmol/L, and hemoglobin 8.2 g/dL (baseline of 8-9 g/dL). The patient’s CT head without contrast and CT angiogram head and neck which were negative for acute infarct or hemorrhage, however, the patient’s MRI demonstrated a 2.1 x 2.1 x 1.4 cm macroadenoma with suprasellar extension and mild elevation of the optic chiasm. Further testing demonstrated a normal thyroid stimulating hormone level of 0.74 uIU/ml (normal 0.3-5.0 uIU/ml), low normal free t4 of 0.7 ng/dL (0.7-1.7 ng/dL), ACTH of <9 pg/ml (normal 9-46 pg/ml), morning cortisol of 1.3 mcg/dL (normal of >18 mcd/dL), total testosterone <10 ng/dL (normal 270-1070 ng/dL), follicular stimulating hormone of 2.2 mIU/ml (normal 1.5-12.4 mIU/mL) and a prolactin of 49 ng/ml (normal 0-19 mg/ml). Due to the patient’s symptoms and imaging findings he underwent transsphenoidal resection of tumor. Prior to the procedure he was placed on stress dosed steroids with IV hydrocortisone. After the procedure, the patient was weaned off IV hydrocortisone and continued on oral 15 mg of hydrocortisone in the morning and 5 mg in the evening. A repeat free T4 after the procedure was 0.9 ng/dl and the patient was not discharged on levothyroxine supplementation. He follows up with endocrinology as an outpatient and has had resolution of his right sided ptosis and vision changes. Discussion: Pituitary apoplexy presents in a variety of different ways including headache, nausea, altered mental status, and hormonal dysfunction. Third nerve palsy is a potential presentation of this uncommon condition and should be considered even with negative initial CT imaging. Through our case we hope to highlight this manifestation of pituitary apoplexy as, if the etiology of third nerve palsy remains elusive, pituitary apoplexy should be considered as a differential and further imaging should be obtained. Presentation: Saturday, June 17, 2023

SAT347 Surprising Turn Of Events In A Patient With Weight Gain: Simultaneous Diagnosis Of Macroprolactinoma And Polycystic Ovary Syndrome

Abstract Disclosure: A.N. Keskinkilic: None. D. Sistla: None. Background: The differential diagnoses of excess weight gain are broad and endocrinopathies constitute a small proportion of these etiologies. A pattern of associated symptoms, classical exam findings and hormonal testing can signal some endocrine causes. However, diagnosis can still be challenging due to overlapping clinical and biochemical features and concurrent presentations of endocrine disorders. Here, we present a diagnostically challenging rare case of a young female with weight gain who had simultaneous diagnosis of macroprolactinoma and PCOS. Clinical Case: A 34-year-old healthy female presented with one year of weight gain despite lifestyle changes. She also reported headaches, acne, hirsutism, stretch marks, excessive sweating, and had 10 years of amenorrhea while on oral contraceptives (OCs). Labs revealed mildly low free T4 of 0.72 ng/dl (n: 0.70-1.48 ng/dl) and significantly elevated prolactin (PRL) of 259.8 ng/ml (n: 1.2-29.9 ng/ml); normal FSH, LH, GH, IGF, TSH, ACTH, 1 mg dexamethasone suppression test, and 24-hour urinary cortisol. HbA1c, lipid panel, plasma metanephrine and androgen levels were normal. MRI pituitary revealed a 2.1 x 1.9 x 1.5 cm macroadenoma with mild compression to the optic chiasm. A low dose levothyroxine and cabergoline 0.25 mg twice weekly was started with dose increment to 0.5 mg twice weekly. At 6-month follow-up, PRL decreased to 30 ng/ml. Repeat MRI showed a decrease in size of the pituitary adenoma (1.5 x 1.4 x 1.3 cm). However, she could not tolerate cabergoline due to persistent headaches and depression. Hence, she elected to undergo transsphenoidal pituitary resection. Tumor pathology showed sparsely granulated lactotroph adenoma. Post op PRL level normalized, and MRI showed radiological cure of the adenoma. Headaches improved but amenorrhea persisted despite discontinuation of OCs for 6 months. Progesterone challenge tests resulted in withdrawal bleed suggesting anovulation. Repeat work-up ruled out nonclassical CAH, Cushing’s, and androgen-secreting tumors. However, subsequent pelvic ultrasound confirmed polycystic ovarian morphology, suggesting PCOS. The patient preferred to avoid OCs and could not tolerate metformin. She elected progesterone IUD placement for endometrial protection in combination with lifestyle changes with notable improvement in her symptoms. Conclusion: PCOS is a diagnosis of exclusion. Thorough evaluation of symptoms like weight gain, amenorrhea, clinical hyperandrogenism is recommended to rule out serious pathology like prolactinoma. Dual diagnosis of PCOS and macroprolactinoma is rare and should be suspected if menstrual abnormalities persist even after treatment of hyperprolactinemia. Presentation: Saturday, June 17, 2023

Low Free T4 in a 13-Year-Old Girl with Short Stature and Blurry Vision.

Low Free T4 in a 13-Year-Old Girl with Short Stature and Blurry Vision.

Commentary on Low Free T4 in a 13-Year-Old Girl with Short Stature and Blurry Vision.

Commentary on Low Free T4 in a 13-Year-Old Girl with Short Stature and Blurry Vision.

Endocrinology for the hepatologist.

Endocrinology for the hepatologist.

Surgical Treatment of Hyperthyroidism Can Be Performed Safely Before a Euthyroid State is Achieved.

Background: The 2016 American Thyroid Association guidelines recommend that hyperthyroid patients should be euthyroid before thyroidectomy. This recommendation is based on low-quality evidence. In this retrospective cohort study, we compare peri- and post-operative outcomes of patients with hyperthyroidism who were controlled versus uncontrolled at the time of thyroidectomy. Methods: A retrospective cohort study was performed on 275 hyperthyroidism patients at a single institution from December 2015 to November 2022. Patients were defined as hyperthyroid if they had a diagnosis of hyperthyroidism with at least one suppressed thyrotropin (TSH). Patients were considered uncontrolled if triiodothyronine or thyroxine (T4) was elevated immediately before surgery. Patient demographics, perioperative data, and postoperative outcomes were compared with Chi-square and Wilcoxon Rank Sum tests, as appropriate. Results: Of the 275 patients, 84.3% were women and 51.3% were uncontrolled at time of surgery. Controlled patients had higher median [interquartile range] TSH (0.4 [0.0, 2.4] mIU/L vs. 0.0 [0.0, 0.0] mIU/L, p < 0.001) and lower free T4 (fT4) (0.9 [0.7, 1.1] ng/dL vs. 3.1 [1.9, 4.4] ng/dL, p < 0.001), respectively. Uncontrolled patients were more likely to be diagnosed with Grave's disease (85.1% vs. 67.9%, p < 0.001) and to undergo surgery due to medication intolerance (12.1% vs. 6%) or history of thyroid storm (6.4% vs. 1.5%) (p = 0.008). Uncontrolled patients were also more likely to take a larger number of preoperative medications (2.3 vs. 1.4, p < 0.001). No patient in either group experienced thyroid storm precipitated by surgery. Controlled patients had shorter operative times (7.3% vs. 19.8% <1 hour, p < 0.014) and decreased median estimated blood loss (15.0 [5.0, 30.0] mL vs. 20.0 [10.0, 50.0] mL, p = 0.002). Both groups experienced similar, low rates of postoperative complications, apart from an increase in temporary hypocalcemia in the uncontrolled group (13.4% vs. 4.7%, p = 0.013). Conclusion: Our study is the largest to date examining the postoperative outcomes of patients with uncontrolled hyperthyroidism who undergo thyroidectomy. Our results affirm that thyroidectomy in actively thyrotoxic patients is safe and will not precipitate thyroid storm.

Association between serum-free thyroxine level and all-cause mortality in critically ill patients: a retrospective study from MIMIC-IV.

Low thyroxine (T4) levels have been observed in critically ill patients; however, controversial results regarding T4 supplemental therapy are reported. The association between serum free T4 (FT4) levels and mortality in critically ill patients has not been fully established and needs to be clarified. Data from the Medical Information Mart for Intensive Care (MIMIC)-IV were collected and analyzed. The association between FT4 level and 30-day mortality after ICU admission was analyzed using Kaplan-Meier curves, spline smoothing fitting, martingale residuals of the null Cox model, and restricted cubic spline (RCS). Logistic regression, Cox regression, and receiver operating characteristic curve (ROC) were used to uncover the relationship and predictive value of serum FT4 and 30-day mortality in critically ill patients. In the final analysis, 888 patients were enrolled, and the serum FT4 levels were divided into four groups. A significant difference in 30-day mortality was observed between the four groups. Kaplan-Meier curves also presented significantly higher 30-day mortality in groups 1 and 2 (p < 0.0001). Further multivariance logistic regression showed that group 1 with FT4 levels lower than 0.7 μg/dl can predict 30-day mortality (odds ratio (OR) = 3.30, 95% confidence interval (CI) = 1.04-11.31). Spline smoothing fitting analysis showed a "V"-shaped line between 30-day mortality and FT4 level within 0-3 μg/dl. Further RCS analysis showed that the risk of death decreased rapidly as FT4 levels increased when serum FT4 levels were lower than 1.2 μg/dl and started to become flat afterward. The area under the ROC of the lower FT4 level to predict 30-day mortality was 0.833 (95% CI = 0.788-0.878). Both multivariant Cox regression and logistic regression showed that FT4 levels lower than 1.2 μg/dl can independently predict 30-day mortality when adjusted for other potential confounders (HR = 0.34, 95% CI = 0.14-0.82; OR = 0.21, 95% CI = 0.06-0.79, respectively), but its predictive power disappeared when adjusted for T3 or total T4. Serum FT4 levels were significantly negatively associated with 30-day mortality when they were lower than 1.2 μg/dl and could predict the risk of 30-day mortality. A higher FT4 level is potentially related to increased 30-day mortality.

Abstract #1413762: Acute Mesenteric Ischemia: A Rare Presentation of Severe Hypothyroidism

Hypothyroidism has been associated with several gastrointestinal symptoms (GI) including constipation, ileus, atrophic gastritis, atony and dilation in various parts of the GI tract including myxedema megacolon. A more rarely reported association is ischemic colitis. We present a case of suspected mesenteric ischemia secondary to severe hypothyroidism. 65-year-old female with a history of oropharyngeal cancer treated with radiation therapy and Superior Mesenteric Artery syndrome with stent, presented with abdominal pain, nausea and vomiting for ten days. Imaging showed severe constipation with fluid-filled thick-walled small bowel loops. She was hemodynamically stable but with an elevated lactate (4 mmol/L) that improved with intravenous fluids. Overnight, she became disoriented, dyspneic and her abdominal pain worsened. She was upgraded to the ICU with suspected bowel ischemic. Her lactate was elevated but repeat CT was unchanged. Later, thyroid function tests were obtained showing an elevated TSH of 35.5 uIU/ml, low free T3 0.8 pg/ml and undetectable free T4. She was given a dose of intravenous levothyroxine that resulted in marked improvement in her abdominal pain and mental status by the next day. She was switched to oral levothyroxine. Over the course of her hospitalization, she developed staphylococcal bacteremia and later became obtunded requiring intubation. Over the subsequent days, she developed edema, hypothermia, bradycardia, and hypotension. Imaging showed bilateral pleural effusions, a new pericardial effusion, and ascites. She was diagnosed to be in myxedema coma and restarted on IV levothyroxine with high-dose steroids. After several days with minimal improvement in her condition, her family opted for palliative extubation. Hypothyroidism can result in decreased intestinal motility due to loss of gap junctions resulting in constipation and intestinal edema and can develop years after completion of radiation therapy as seen with our patient. We suspect that our patient’s symptoms were because of mechanical compression of the vascular supply of the small intestine due to severe dilation of the bowel wall as reported previously in cases of hypothyroidism-associated ischemic colitis. Given that the major focus was on the diagnosis of acute obstructive mesenteric ischemia, there was a delay in the diagnosis of severe hypothyroidism that later progressed to myxedema coma triggered by bacteremia. This case highlights the importance of checking thyroid function in patients with evidence of bowel dilation and ileus, since a delayed diagnosis of hypothyroidism can be fatal if left untreated.

Abstract #1408202: A Case of Rathke's Cleft Cyst with Multiple Associated Endocrinopathies

Rathke Cysts are cystic sellar or suprasellar lesions deriving from the remnants of Rathke’s pouch. During fetal development, Rathke’s pouch migrates from the oral ectoderm to what eventually develops as the sellar region. The pharyngohypophyseal stalk connecting Rathke’s pouch to the stomodeum is obliterated by growth of the sphenoid bone. Inadequate obliteration of the pharyngohypohyseal stalk results in formation of the rathke cyst. While most cases of Rathke cyst are asymptomatic, they may present with headache, vision loss, pituitary hormone deficiency, and diabetes insipidus. We present the case of a 44-year-old female with a history of cerebral palsy, secondary amenorrhea beginning at age 30, and blindness who presented to the hospital with generalized weakness and altered mental status. The degree and nature of visual impairment could not be assessed in the inpatient setting due to the patient’s altered mental status. She was found to have a urinary tract infection and was started on antibiotic therapy. Hospital course was complicated by hypotension refractory to fluid resuscitation. Further workup demonstrated low AM cortisol responsive to cosyntropin stimulation, and hypotension resolved with IV scheduled hydrocortisone. Pituitary lab follow-up demonstrated low estradiol with inappropriately normal gonadotropin levels, low Free T4 with inappropriately normal TSH, low IGF-1, and normal prolactin. MRI revealed a 2.4x1.7x2.2cm suprasellar mass consistent with Rathke cyst, with obliteration of the optic chiasm, pituitary parenchyma, and infundibulum. The patient’s adrenal insufficiency, panhypopituitarism, blindness, and amenorrhea were likely caused by mass effect on the optic chiasm and pituitary gland. Secondary adrenal insufficiency was managed with physiologic hydrocortisone dosage and secondary hypothyroidism was managed with oral levothyroxine. Outpatient neurosurgical intervention was recommended for cyst resection. This case represents a rare, symptomatic presentation of a Rathke cyst with vision loss and multiple endocrinopathies. Visual symptoms, which may include visual field defects, decreased visual acuity or oculomotor palsies, arise from mass effect on the optic chiasm or cavernous sinus. For these patients, surgical resection may recover visual function or prevent irreversible vision loss. Rathke cyst may also present with hypopituitarism. Restoration of pituitary function following resection is less common than resolution of visual symptoms. In patients presenting with visual disturbances, adrenal insufficiency, and hypopituitarism, a diagnosis of symptomatic Rathke cyst or other sellar mass should be considered.

Clinical features and prognosis of patients hospitalized with heart failure and low T3 syndrome

Objective: To investigate the association between triiodothyronine (T3) and inflammatory factors, and its potential effect on long-term outcomes in hospitalized patients with heart failure (HF). Methods: A total of 2 475 patients with HF admitted in Heart Failure Care Unit were consecutively enrolled in this retrospective cohort study from December 2006 to June 2018. Patients were divided into low T3 syndrome group (n=610, 24.6%) and normal thyroid function group (n=1 865, 75.4%). The median follow-up time was 2.9 (1.0, 5.0) years. A total of 1 048 all-cause deaths were recorded at the final follow-up. The effects of free T3 (FT3) and high-sensitivity C-reactive protein (hsCRP) on the risk of all-cause death were evaluated by Cox regression analysis and Kaplan-Meier analysis. Results: The age of the total population was 19-95 (57±16) years, 1 823 cases (73.7%) were male. Compared to those with normal thyroid function, albumin [(36.5±5.4) vs. (40.7±4.7) g/L], hemoglobin [(129.4±25.1) vs. (140.6±20.6) g/L], total cholesterol [3.6 (3.0, 4.4) vs. 4.2 (3.5, 4.9) mmol/L] (all P<0.001) were lower, Whereas age [(60.5±16.0) vs. (55.2±15.4) years], creatinine [105.0 (83.6, 137.0) vs. 87.8 (75.6, 106.3) mmol/L], log N-terminal B-type natriuretic peptide [(8.2±1.3) vs. (7.2±1.4) ng/L] were higher in LT3S patients (all P<0.001). In Kaplan-Meier survival analysis, patients with lower FT3 and higher hsCRP had significantly lower cumulative survival (P<0.001), lower FT3 combined with higher hsCRP subgroup had the highest risk of all-cause death (Ptrend<0.001). In multivariate Cox regression analysis, LT3S was an independent predictor of all-cause mortality (HR=1.40, 95%CI 1.16-1.69, P<0.001). Conclusion: LT3S is an independent predictor of poor prognosis in patients with heart failure. FT3 combined with hsCRP improve the predictive value of all-cause death in hospitalized patients with heart failure.

Abnormal thyroid function: an unusual presentation of pituitary stalk interruption syndrome.

An 11-year-old girl with past medical history of septic shock and multi-organ failure at age 5 presented to her primary care doctor with concern for pallor of the lips. Laboratory studies demonstrated low free thyroxine (T4) and normal thyroid-stimulating hormone (TSH). A referral to endocrinology was made where the patient was evaluated, and laboratory evaluation was repeated. The patient was asymptomatic and clinically euthyroid with a height consistent with her mid-parental height and was in mid- to late-puberty. The repeated laboratory evaluation demonstrated a pattern suggestive of primary hypothyroidism with low free T4 and an elevated TSH. However, the magnitude of elevation of TSH was less than expected, given the degree of lowering of free T4; therefore, central hypothyroidism was considered. Workup was initiated, and laboratory studies and MRI imaging confirmed an underlying diagnosis of panhypopituitarism in the setting of pituitary stalk interruption syndrome. Pituitary stalk interruption syndrome is a rare but important cause of panhypopituitarism. Central hypothyroidism should be suspected in patients with low free thyroxine with an inappropriate degree of elevation of thyroid-stimulating hormone. Workup of central hypothyroidism should include multi-pituitary hormone assessment, and, if evident, MRI imaging should be done. Adrenal insufficiency should be suspected in a hypotensive, critically ill patient who is failing to improve on standard-of-care therapy.

Thyroid status in pregnant women with pregnancy induced hypertension – A case control study

Introduction: Pregnancy induced hypertension (PIH) is an important cause of maternal and fetal morbidity and mortality affecting 5-10% of pregnancies. PIH is more frequently associated with elevated TSH (Thyroid-stimulating hormone). Thyroid dysfunction plays an important role in the development of gestational hypertension. However, this relationship remains unclear. The study was performed to evaluate the thyroid status in pregnant women with PIH and normal pregnant women. Methodology: This was a hospital based observational case control study done in Dr M K Shah Medical College, Ahmedabad. Total 100 pregnant women were included, out of them 50 PIH women were included in the case study group and 50 normotensive healthy pregnant women were included in the control group. After taking written consent, thyroid profile (TSH, free T3 and free T4) were measured in all 100 subjects. Results: Women with PIH had higher TSH levels and lower free T3 and free T4 as compared to normotensive pregnant women. There was a significant association between hypothyroidism and PIH cases. There was a significant positive correlation between TSH and systolic BP (r=0.42) and diastolic BP (r=0.52). Conclusion: PIH women are at greater risk of decreased thyroid function. Therefore, PIH women should be monitored for thyroid levels regularly.

Frequency of hypothyroidism among patients of pulmonary hypertension.

Objective: To determine the frequency of hypothyroidism in patients with pulmonary hypertension. Study Design: Observational Cross-sectional study. Setting: Department of Medicine, Sandeman Provincial Hospital, Bolan University of Medical &amp; Health Sciences Quetta Pakistan. Period: March 2020 to March 2021. Material &amp; Methods: Pulmonary Hypertension was defined as mPASP of &gt;25 mm Hg at rest on transthoracic echocardiogram and hypothyroidism was labeled when TSH was high with low Free T4 and/or Free T3. Patients with congestive cardiac failure, pulmonary malignancy or pulmonary metastasis assessed by history and examination were excluded from the study. Using non-probability consecutive sampling, 186 patients of both genders, aged 20-65 years with pulmonary hypertension were included. Demographic information along with clinical variables noted, echocardiography was done and thyroid profile was sent for each patient. Results: Mean age was 41.2+11.2 years with 56 (30.1%) males and 130 (69.9%) females. The mean height, weight and BMI were 1.6+0.2 meters, 56.5+14.4 kilograms and 21.8+3.6 kg/m2 respectively. The mean mPASP was 40.2+7.1 mmHg. The mean serum TSH, free T3 and free T4 levels were 6.6+4.8 IU/L, 2.5+1.0 pmol/L and 1.1+0.4 pmol/L respectively. In our study, hypothyroidism was seen in 46 (24.7%) and was not significantly associated with age, gender, BMI or mPASP. Conclusion: Hypothyroidism was noted in about a quarter of the patients with pulmonary hypertension in this study.

High-normal free thyroxine level is related with decreased bone mineral density in nonobese male patients with type 2 diabetes over 50 years old.

The prevalence of 'low bone mineral density (BMD)' in Type 2 diabetes (T2DM), especially stratified by body mass index, is seldom reported. The relation of the euthyroid range and low BMD in T2DM remains to be further elucidated. We aim to investigate the thyroid hormones' impact on BMD among euthyroid patients with T2DM. A total of 1452 hospitalized T2DM patients with normal thyroid function (43.6% males aged over 50 and 56.4% postmenopausal females) were enrolled in this cross-sectional study. BMD was measured at lumbar spine by GE lunar dual-energy X-ray absorptiometry system, and 'low BMD' was defined as T-score <-1.0 SD. The prevalence of 'low BMD' was compared between obese and nonobese (body mass index < 25 kg/m2) groups for both sexes, and the relation of low BMD and free T4 quartiles was explored by multiple logistic regression. The general prevalence of 'low BMD' was 12.3% for male patients aged over 50 (15.5% in the nonobese group and 8.0% in the obese group) and 49.8% for postmenopausal females (56.7% in the nonobese group and 48.9% in the obese group). After adjustment in multiple linear regression, free T4 level remained significantly related to decreased BMD in nonobese male subgroup. Multiple logistic regression revealed that BMD of the highest free T4 quartile (1.12-1.48 ng/dL) decreased significantly than other three quartiles after adjusting for confounding factors including age, body mass index, serum calcium and creatinine level, fasting glucose, alkaline phosphatase, glycosylated hemoglobin, total cholesterol, and smoking history (OR = 2.724, 95% CI = 1.085-6.840, p = 0.033). No significant relation was found in obese male or postmenopausal female groups. High-normal free T4 is a potential independent risk factor for 'low BMD' in nonobese male T2DM patients aged over 50. Close attention should be paid to thyroid function profile, even within normal range, in nonobese men with underlying higher fracture risks on diabetes status.