Nodular Thickening Research Articles

Cystitis glandularis: MR imaging characteristics in 27 patients.

To explore the diagnostic characteristics of cystitis glandularis (CG) using magnetic resonance imaging (MRI). A retrospective study was conducted on pathologically confirmed patients who underwent bladder MRI examination between January 2019 and November 2023. Image analysis was jointly conducted, with emphasis on lesion location, morphology, size, signal intensity, and pattern of enhancement, by two genitourinary radiologists with 22 and 15 years of experience, respectively. A total of 27 patients with 27 lesions were included (median age 47 years, 24 males). The lesions were mostly located in the bladder trigone area (18/27). The lesions could be categorized as focal thickening (17/27), nodular (8/27), and diffuse thickening of the entire bladder (2/27) in morphological terms. On T2-weighted imaging (T2WI), 15 of 17 focal thickening lesions appeared as a slightly hyperintense thickened inner layer, with a higher signal in the center of the thickened inner layer, resembling a sandwich sign, and 6 of 8 nodular lesions were slightly hyperintense. On T1-weighted imaging (T1WI), 19 patients showed slight hypointensity. The lesions on DWI showed mainly high (5/27) and slightly high signal (21/27), with an average mean apparent diffusion coefficient (mADC) value of 2.171 ± 0.052 × 10-3mm2/s. Among the 23 patients who underwent dynamic contrast-enhanced (DCE) scanning, 18 lesions showed mild enhancement in the arterial phase (average 1.7 times comparing to unenhanced phase), and the degree of enhancement gradually increased in the venous and delayed phases (average 2.2 and 2.3 times compared to the unenhanced phase, respectively), showing a progressive enhancement pattern. On MRI, the majority of CG manifest as focal thickening or nodules in the bladder trigone area, showing slight hyperintensity on T2WI, slight hypointensity on T1WI, and a progressive enhancement pattern, without significant restriction on DWI. Focal thickening lesions may exhibit a special sandwich sign.

Indirect-Oscillation Sign Suggesting Infective Endocarditis on the Routine Chest CT.

Routine chest CT is not essential for the diagnostic workup for infective endocarditis (IE), but this type of study may be the initial imaging modality in the evaluation of patients ultimately proven to have IE who present to the emergency department with nonspecific clinical symptoms. Although routine chest CT cannot directly assess valvular oscillating motion due to the lack of cine images, we hypothesized that a combination of elongated nodular valve thickening and abnormal orientation to the normal valve with a blind end on routine CT (indirect-oscillation sign) might suggest movable vegetation indirectly. To evaluate this possibility, we studied 27 patients with IE and 35 controls who underwent both routine chest CT and echocardiography. CT scanning was initiated following a delay of 60-80 s after the administration of the contrast medium. Two cardiothoracic radiologists retrospectively analyzed the CT images to assess the indirect-oscillation sign with consensus. The sensitivity, specificity, positive predictive value, and negative predictive value of the indirect-oscillation sign on routine chest CT were 29.6% (8/27), 100% (35/35), 100% (8/8), and 64.8% (35/54), respectively. Although uncommon, the presence of the indirect-oscillation sign involving the aortic or mitral valve on routine chest CT is a suggestive finding for IE.

8688 Pseudopheochromocytoma Due To Severe Obstructive Sleep Apnea

Abstract Disclosure: L.M. José: None. M. Ataide: None. F. Aratani: None. S. Beeby: None. G.F. Fagundes: None. F. Coelho: None. F. Ledesma: None. A. Latronico: None. B.B. Mendonca: None. M.C. Fragoso: None. M.Q. Almeida: None. Background: Obstructive sleep apnea (OSA) represents an independent risk factor for cardiovascular disease, and it is associated with a wide range of conditions, such as resistant hypertension and primary aldosteronism (PA). Patients with sleep apnea have a higher sympathetic activity during wakefulness due to chronic hypoxia. We present the case of pseudopheochromocytoma caused by severe OSA in an obese patient with RH and PA.Clinical Case: A 58-year-old female Brazilian patient was referred to an endocrinologist to investigate a 1.8 cm right adrenal nodule at computed tomography (CT) performed to investigate abdominal pain. Her medical history includes resistant hypertension diagnosed at 27 years of age, type 2 diabetes, dyslipidemia, Class II obesity, a previous acute myocardial infarction, and severe OSA (apnea-hypopnea index 61.6/hour). She has used irregularly the continuous positive airway pressure (CPAP) therapy at night. She is currently using carvedilol 50 mg bid, chlorthalidone 25 mg, olmesartan 40 mg, amlodipine 10 mg, spironolactone 50 mg, clonidine 0.2 mg tid, hydralazine 50 mg every 6 hours, acetylsalicylic acid 100 mg, atorvastatin 80 mg, and metformin XR 1000 mg. At physical examination, she had BMI 37 kg/m2, BP 150 x 90 mmHg, HR 64 bpm, and no signs of Cushing syndrome. Abdominal CT revealed a right adrenal nodule measuring 1.8 cm with 18 Hounsfield unit (HU) in the pre-contrast phase, reaching a density of 117 HU at the arterial phase and showing an absolute washout of 65% and a relative washout of 56%. A nodular thickening of 1.4 cm (-4 HU) at the left adrenal gland was also displayed at CT scan. Hormone evaluation showed basal cortisol 7 µg/dL, ACTH 15.7 pg/mL, DHEAS 1152 ng/mL (189-2050 ng/mL), 1 mg overnight dexamethasone suppression test 2.3 ug/dL, aldosterone 9.9 ng/dL, direct renin concentration 36.8 uIU/mL, plasma metanephrines 0.3 nmol/L (<0.5 nmol/L) and plasma normetanephrines 1.3 nmol/L (<0.9 nmol/L). It was not possible to change anti-hypertensive medications to investigate PA. A 0.3 mg clonidine suppression test did not suppress normetanephrine levels, confirming the biochemical diagnosis of pheochromocytoma. Then, alpha-blockade with doxazosin 4 mg was started and the patient underwent right adrenalectomy. Pathological examination revealed an adenoma with immunohistochemistry positive for CYP11B2. BP control was achieved with only two medications and aldosterone decreased to 3 ng/dL confirming PA. Plasma normetanephrine levels remained elevated post-surgery and only normalized after the CPAP regular use.Clinical lessons: Chronic activation of sympathetic autonomic drive in OSA can increase norepinephrine and normetanephrine levels. OSA is a very prevalent disease and it is frequently associated with RH. Therefore, OSA should be considered a possible cause of pseudopheochromocytoma in hypertensive patients. Presentation: 6/3/2024

Association of PET/CT and VATS findings with histology analysis in the study of pleural effusions

IntroductionHistological analysis of the pleura obtained by video-assisted thoracoscopic surgery (VATS) is the best diagnostic technique in the study of neoplastic pleural effusions. This study evaluates the relationship between Positron Emission Tomography (PET)/Computed Tomography (CT) and VATS findings, the result of the first pleural biopsy, and the final diagnosis of malignancy or non-malignancy. MethodsProspective study of consecutive patients with pleural effusions undergoing PET/CT and VATS from October 2013 to December 2023. The following variables were recorded: PET/CT score (nodular pleural thickening, pleural nodules with standardized uptake value (SUV) > 7.5, lung mass or extra pleural malignancy, mammary lymph node with SUV > 4.5 and cardiomegaly); VATS data (drained volume, visceral and parietal pleural thickening, nodules or masses, septa, plaques, fluid appearance, trapped lung, and suspected diagnosis of the procedure), as well as the histological study of the first pleural biopsy (benign or malignant) and the final diagnosis of benign or malignant pleural effusion. A logistic regression study of the variables was performed. Results95.8% of the patients with PET/CT and pleuroscopy not suggestive of malignancy had non-malignant histological findings, while 93.2% of the patients with PET/CT and pleuroscopy suggestive of malignancy had malignant histological findings. PET/CT, pleuroscopy, and the result of the first pleural biopsy showed a significant association with the final diagnosis of pleural effusion. ConclusionsThere is a strong association between PET/CT findings, VATS and pleural histology.

Clinical Observation on the Therapeutic Effect of Port-Wine Stains with Intravenous Injection of Hematoporphyrin Monomethyl Ether (HMME).

Hematoporphyrin monomethyl ether (HMME) is a promising photosensitizer for photodynamic therapy (PDT) and has found wide application in the treatment of port-wine stains (PWS). This study aims to observe and analyze the clinical efficacy and safety of HMME-PDT in the treatment of PWS patients. It also aims to evaluate the usefulness of color Doppler flow imaging (CDFI), an ultrasound technique for detecting blood flow in skin lesions, in assessing clinical efficacy. Thirty-three patients with PWS underwent HMME-PDT at our dermatology outpatient clinic between January 2019 and March 2020. Data on patient demographics, lesion location, lesion type (pink, purple, nodular thickening), treatment frequency, and pre- and post-treatment images were collected and retrospectively analyzed. CDFI was performed on three patients. All patients received intravenous HMME and underwent irradiation with 532 nm green LED light. Of these, 5 patients received 1 session of HMME-PDT, 14 received 2 sessions, 9 received 3 sessions and the remaining 5 patients received more than 3 sessions. Of the 33 patients, 9 were cured (27.27%), 10 showed improvement (30.30%), 11 experienced a reduction in symptoms (33.33%), and 3 showed no significant improvement (9.09%). Most patients reported local pain and oedema, and no systemic adverse effects were observed. Clinical efficacy correlated with lesion type and total number of treatment sessions. CDFI appears to be an excellent technique for assessing clinical efficacy. HMME-PDT is a safe and effective method for the treatment of PWS. CDFI examination appears to be a promising assessment tool. However, further validation with larger sample sizes is warranted.

The great mimicker: Pleural tuberculosis presents as nodular pleural thickening.

The great mimicker: Pleural tuberculosis presents as nodular pleural thickening.

Diagnostic value of computed tomography and magnetic resonance imaging in ovarian malignant mesothelioma

ObjectiveTo investigate the diagnostic value of computed tomography (CT) and magnetic resonance imaging (MRI) in ovarian malignant mesothelioma (OMM).MethodsThe clinical and imaging data of 10 pathologically-confirmed OMM patients were analyzed retrospectively.Result(1) The patients were 27 years to 70 years old, with an average age of 57.2 ± 15.4 years. Seven patients reported abdominal distension and pain, 1 reported lower abdominal discomfort and decreased appetite, and 2 patients had no symptoms. (2) Two cases of localized OMM with incomplete semi-annular “capsule” observed around the localized OMM tumors were reported while 8 cases had diffuse OMM in which the tumor parenchyma showed isointense or slightly hypointense on T1WI, inhomogeneous hyperintense on T2WI, and obviously hyperintense on DWI, with obvious inhomogeneous enhancement after enhancement. Diffuse OMM was not mainly composed of ovarian masses and was mainly characterized by mild ovarian enlargement, nodular and irregular thickening of the peritoneum, cloudy omentum, unclear fat gap, and reticular or irregular thickening, which can fuse into a “cake-shape”. (3) All 10 patients underwent surgery, while 9 patients underwent systemic chemotherapy or immunotherapy after surgery. All patients with localized OMM survived. Out of the 8 diffuse-type patients, 5 died, 1 was lost to follow-up, and 2 survived.ConclusionOMM has certain clinical and imaging characteristics. There is no liquefaction, calcification, or partition in the tumor. The ovarian enlargement in the diffuse lesion is not significant. The diffuse thickening of the peritoneum and omentum with early appearance of mural nodules and ascites in the upper abdomen, help the diagnosis of OMM.

Efficacy and influential factors of hematoporphyrin monomethyl ether mediated photodynamic therapy in the treatment for port-wine stains

BackgroundsHematoporphyrin monomethyl ether mediated photodynamic therapy (HMME-PDT) has emerged as an alternative approach for port-wine stain (PWS), which was primarily treated with pulsed dye laser (PDL). This study was aimed to evaluate the efficacy and safety of HMME-PDT for PWS and to explore influential factors on the efficacy. MethodsA total of 254 patients were enrolled. Patients received an intravenous injection of HMME at 5 mg/kg. Lesion areas were irradiated with 532-nm light for 20–25 min. Efficacy was assessed according to fading of lesions and graded as excellent (≥90 %), good (60 %–89 %), fair (20 %–59 %), or poor (<20 %). Adverse events were recorded. Clinical data were analyzed including gender, age, lesion sub-type, lesion location and number of treatments. ResultsOverall, 72.4 % of patients achieved an effective response, with 27.6% showing excellent efficacy, 24.8 % showing good efficacy and 20.1 % showing fair efficacy. Only 27.6 % showed poor efficacy. Patients under the age of 18 obtained a better efficacy than adults. Lesions in face showed a better therapeutic outcome than those in neck or trunk and extremities. A more effective response was seen in pink type compared with nodular thickening type. Multiple HMME-PDT treatments could improve the clinical response. Lesion location, lesion sub-type, number of treatments were independent influential factors on efficacy. Adverse events included edema, blister, crust, hypopigmentation, hyperpigmentation, pain, itch and burning sensation. No severe systemic side events were observed. ConclusionsHMME-PDT was effective for treating PWS and was safe and well-tolerated by patients. It is worth further investigation in efficacy and safety involving more patients from medical institutions in different regions in China. The optimal treatment parameters and treatment protocols are still being explored in the clinical treatment for PWS.

Macrodendritic ulcerative keratitis and conjunctival lymphoid hyperplasia in horses with equine herpesvirus-2 and equine herpesvirus-5 infections.

The aim of this study was to describe the clinical, confocal microscopic, histologic, and virologic features of horses with macrodendritic ulcerative keratitis and conjunctival lymphoid hyperplasia associated with equine herpesvirus-2 and equine herpesvirus-5 infection. Four foals with bilateral ocular disease. Complete ophthalmic examination was performed for each horse, and corneal samples were collected for cytology and microbiologic evaluation, including virus isolation and molecular diagnostics for the equine herpesviruses. Invivo confocal microscopy examination of the cornea was performed in two horses. Conjunctival biopsies for histopathology were collected from two horses with nodular conjunctival thickening. Each horse had bilateral, large, superficial dendritic corneal ulcerations that covered extensive regions of the corneal surface. Corneal invivo confocal microscopy examination in two horses detected inflammatory cells and populations of morphologically abnormal corneal epithelial cells adjacent to the ulcerations. The abnormal epithelial cells included round, relatively small, hyperreflective cells intermixed with elongated, enlarged, hyperreflective cells. Equine herpesvirus-2 was isolated from corneal samples of 2 horses and detected by PCR assay in the other two horses. Equine herpesvirus-5 was also detected by PCR assay in three of the horses. Conjunctival histopathology identified predominantly lymphocytic infiltrates. The macrodendrites and conjunctival masses resolved with topical antiviral therapy (cidofovir or idoxuridine) in all horses and did not recur. The equine gammaherpesviruses may be associated with the development of macrodendritic ulcerative keratitis and conjunctival lymphocytic masses in foals. Invivo confocal microscopy of horses with macrodendrites revealed similar findings to other host species with herpetic dendritic keratitis.

PATHOMORPHOLOGICAL CHANGES IN THE ORGANS OF CATS CAUSED BY ALIMENTARY LYMPHOMA. CLINICAL CASES

The article presents the results of clinical, ultrasonographic, pathomorphological and immunohistochemical studies of two random cases of alimentary lymphoma in 9- and 12-year-old domestic cats. Clinical signs of the disease were similar and characterized by anorexia, cachexia, vomiting and diarrhea that appeared in different periods of the disease. The mucous membranes of the oral cavity and eyes were icteric, the abdomen was visually enlarged, palpation revealed nodular thickenings in the abdominal cavity. During the ultrasound diagnostics, diffuse multiple non-encapsulated anechoic formations with uneven edges and growth of tumorous tissue into the intestinal wall were visualized. In another cat, there was an encapsulated formation of a hypoechoic fine-grained structure with well-defined vascularization.&#x0D; From the moment of the preliminary diagnosis until the very death, the cats were kept in the clinic under supervision. After the death, an autopsy was performed with the selection of material for histopathological examination. Organs’ fragments were fixed in 10% aqueous solution of neutral formalin and Carnois fluid. Histological preparations were made according to the generally accepted methods. Immunophenotyping of lymphoma type was performed using CD3 (T-cell) and CD79a (B-cell) markers. During the pathological autopsy, an increase in mesenteric lymph nodes, their compaction, and focal thickening of the small intestine wall were revealed. The histological examination showed that jejunum was the most infiltrated intestinal segment, in which massive, diffusely placed monomorphic lymphoblastic cells were localized in the mucous membrane lamina, submucosa and muscle layers. The submucosal layer vessels were sharply dilated, filled with erythrocytes; the muscles of the inner circular layer were swollen. The outer (longitudinal) muscle layer of the jejunum thickened significantly and was intensively infiltrated by lymphoblastic cells.&#x0D; Typical diffuse lymphoblastic proliferations were also detected in the cortical substance of lymph nodes and lymphoid nodules. Stasis and significant expansion of the marginal sinus vessels were visualized too. In addition, moderate mononuclear lymphoblastic infiltrates were detected in the pancreas parenchyma with their perivascular location. Immunohistochemically, a significant positive expression of CD3 cells was detected both in the jejunum mucous membrane and the marginal sinus area, around the germinal centers of the lymph nodes, which indicated a T-cell type of lymphoma.

A PET-CT score for discriminating malignant from benign pleural effusions

Background and objectivesThe results of previous PET-CT studies are contradictory for discriminating malignant from benign pleural effusions. We purpose to develop a PET-CT score for differentiating between benign and malignant effusions. Patients and methodsWe conducted a prospective study of consecutive patients with pleural effusions undergoing PET-CT from October 2013 to October 2019 (referral cohort). PET-CT scan features evaluated using the SUV were: linear thickening; nodular thickening; nodules; masses; circumferential thickening; mediastinal and fissural pleural involvement; intrathoracic lymph nodes; pleural loculation; inflammatory consolidation; pleural calcification; cardiomegaly; pericardial effusion; bilateral effusion; lung mass; liver metastasis and other extra-pleural malignancy. The results were validated in an independent prospective cohort from November 2019 to June 2021. ResultsOne hundred and ninety-nine patients were enrolled in the referral cohort (91 with malignant effusions and 108 benign). The most useful parameters for the development of a PET-CT score were: nodular pleural thickening, pleural nodules with SUV>7.5, lung mass or extra pleural malignancy (10 points each), mammary lymph node with SUV>4.5 (5 points) and cardiomegaly (−1 point). With a cut-off value of >9 points in the referral cohort, the score established the diagnosis of malignant pleural effusion with sensitivity 87.9%, specificity 90.7%, positive predictive value 88.9%, negative predictive value 89.9%, positive likelihood ratio 7.81 and negative likelihood ratio 0.106. These results were validated in an independent prospective cohort of 75 patients. ConclusionsPET-CT score was shown to provide relevant information for the identification of malignant pleural effusion.

Efficacy of hemoporfin-PDT on port-wine stains: A retrospective analysis of 2952 cases

ObjectiveTo conduct a retrospective analysis of Hemoporfin photodynamic therapy (HMME-PDT) in the treatment of port-wine stains (PWS). MethodA retrospective analysis was conducted based on the clinical data from March 2017 to December 2022, so as to summarize the demographic characteristics, clinical efficacy and adverse reactions. The effectiveness of HMME-PDT was examined with respect to treatment times, age, gender, subtype, and location of PWS lesions. ResultThe age of the 2952 cases ranged from 8 months to 56 years old (median, 2.8 years), with 1419 males (48.07 %), and 1533 females (51.93 %). There were 669 cases of pink type (22.66 %), 2184 cases of purplish red type (73.98 %), and 99 cases of nodular thickening type (3.35 %). The prevalence location was face (88.04 %), neck (14.94 %), limbs and trunk. 1602 cases (54.27 %) had never received treatment, 661 cases (22.39 %) had been treated by pulse dye laser (PDL), 229 cases (7.76 %) had previously been treated by PDT, 296 cases (10.03 %) had received both the modalities.The 2952 cases completed totally 7996 HMME-PDT times. Cure rate and effective rate increased continuously with the number of treatments. The pink type has the highest cure rate and effective rate, followed by the purplish red type and the last was the nodular thickening type. The therapeutic effects are considerably influenced by age, subtype, and treatment site (P < 0.05). However, there was no significant difference in the effectiveness of HMME-PDT between both genders.The local adverse reactions after the first treatment included edema (97.73 %), itching (82.62 %), purpura-like change (79.51 %), crusts (24.59 %), infection (4.07 %), scars (1.08 %), hyperpigmentation (0.61 %), and depigmentation (0.41 %). Nausea and vomiting occurred in 2 juveniles and 1 young adult (5, 6 and 22 years old respectively) immediately after treatment, and did not interfere with the administration of the treatment. Patients aged 21–30 were found to have a 3.4-fold higher likelihood of undergoing HMME-PDT under general anesthesia compared to those aged 15 or younger. There was no distinct systemic adverse reaction, such as allergic responses, cardiovascular effects, neurological symptoms, hematological abnormalities, respiratory symptoms, or musculoskeletal issues. ConclusionHMME-PDT is preferred in treating PWS, with relatively high effective rate and cure rate, mild local reactions and no distinct systemic adverse reaction.

SAT254 Elevated Vitamin D 1,25-Dioh Leading To The Diagnosis Of Diffuse Large B-cell Lymphoma With Excessive Vitamin D Intake Confounding The Clinical Picture

Abstract Disclosure: R. Barai: None. C. Hurtado: None. We present a patient with acute-onset hypercalcemia in the setting of excessive vitamin D intake, found to have elevated vitamin D 1,25-DiOH and PTHrP, eventually resulting in a diagnosis of diffuse large B-cell lymphoma. 76-year-old man with PMH of idiopathic pulmonary fibrosis s/p left lung transplant, CKD secondary to calcineurin inhibitor toxicity, hypothyroidism, HTN, type 2 DM, and OSA presented with progressively worsening fatigue for four weeks, found to be hypercalcemic to 15.3 mg/dL on presentation with low-normal intact PTH, 14 pg/mL. Three weeks prior to admission, patient had normal calcium, 9.9 mg/dL, with sudden increase to 12.8 mg/dL one week prior to admission, which was not treated. Patient reported taking 5,000 IU of vitamin D PO daily for 5 years, which confounded the clinical picture as the etiology was initially thought to be secondary to excessive vitamin D intake in the setting of frankly elevated vitamin D 25(OH)D of 160 ng/mL. Further work-up revealed elevated 1,25-DiOH of 339 pg/mL with elevated PTHrP of 5 pmol/L and low ACE level of &amp;lt;10 U/L, which was inconsistent with vitamin D intoxication and was concerning for malignancy as the etiology of the hypercalcemia. Patient was treated with 4 doses of calcitonin, fluids and 2 low-doses of pamidronate in the setting of AKI on CKD with only modest improvement in hypercalcemia during the hospitalization. Patient was discharged with calcium 11.4 mg/dL. On CT chest, patient was found to have an enlarged R epicardiac lymph node, prompting PET/CT that demonstrated extensive intensely FDG avid nodular thickening of the right pleura and peritoneum with FDG avid thoracic and abdominopelvic lymphadenopathy and two FDG avid liver masses. US-guided biopsy of a peritoneal nodule was consistent with diffuse large B-cell lymphoma (DLBCL). Colonoscopy demonstrated 5 cm cecal mass with DLBCL, and transverse colonic mass with adenocarcinoma. Liver biopsy flow cytometry was consistent with DLBCL. Patient’s calcium has since normalized with further treatments of denosumab, calcitonin, zoledronic acid and treatment of DLBCL with rituximab, high-dose prednisone, and cyclophosphamide with plan for surgical resection of colon adenocarcinoma. It is important to highlight that elevated 1,25-DiOH would not be typical of hypervitaminosis D as the activity of 1-alpha-hydroxylase (the enzyme that converts the inactive form of vitamin D, 25(OH)D, to the bioactive form, 1,25-DiOH) would be low with hypercalcemia. With the elevated 1,25-DiOH and PTHrP, we were concerned for granulomatous disease or malignancy as the etiology, and we recommended investigation for causes of hypercalcemia other than excessive vitamin D intake. The diagnosis of lymphoma was made due to the incongruity of the history of excessive vitamin D intake and the elevated 1,25-DiOH. Hypercalcemia, in our patient’s case, was due to lymphoma-induced vitamin D activation. Presentation: Saturday, June 17, 2023

FRI128 Hiding In Plain Sight: Late Diagnosis Of Primary Hyperaldosteronism In Patient With Atypical Presentation

Abstract Disclosure: R.A. Zielinski: None. A. Syeda: None. B. Esayag-Tendler: None. Background: Primary hyperaldosteronism (PHA) can go undiagnosed in patients with primary hypertension without hypokalemia and increased plasma aldosterone concentration (PAC). Case: The patient is a 72-year-old male with a history of hypertension (HTN) diagnosed at age 55 who presented to the endocrinology clinic for further evaluation. He was asymptomatic. His antihypertensive regimen included atenolol 25 mg daily and amlodipine-benazepril 10-40 mg daily. Blood pressure (BP) was well-controlled with a goal BP under 130/80 mm Hg. Physical exam was without AV nicking in a limited retina exam, no abdominal tenderness, and no peripheral edema. Family history is notable for HTN in his father and HTN complicated by stroke in a sister and a brother, all diagnosed at an older age. Labs done 5 years prior showed potassium (K) of 4.3 mmol/L [3.6 - 5.1 mmol/L], PAC of 3.2 ng/dl [upright 4.0 - 31.0 ng/dl], and plasma renin activity (PRA) of 0.1 ng/ml/hr [upright 0.5-4.0 ng/ml/hr]. More recent labs showed K of 3.8 mmol/L, PAC of 21.5 ng/dl and PRA of 0.3 ng/ml/hr. Repeat labs 6 months later showed K of 3.4 mmol/L, PAC of 15 ng/dL and PRA of 0.2 ng/mL/hr. A 3-day dexamethasone suppression test was performed to exclude familial hyperaldosteronism or glucocorticoid remediable aldosteronism. Following the test, K was 3.6 mmol/L, PAC was 11.3 ng/dl, and cortisol was undetectable. CT abdomen showed bilateral nodular thickening of the adrenal glands without a distinct adenoma. Adrenal venous sampling was done before and after ACTH stimulation. Prior to ACTH stimulation, the mean ratio of the dominant adrenal aldosterone concentration corrected with cortisol from left to right was 1.32. Following ACTH stimulation, the ratio was 2.79. A ratio greater than 4 is consistent with a good outcome after adrenalectomy. Hence, it was decided to pursue medical management. The cause of our patient’s primary hyperaldosteronism is likely due to bilateral idiopathic hyperplasia. He was started on eplerenone 25 mg twice daily and salt restriction with a goal of increasing the PRA above 1 ng/ml/hr. Discussion and Conclusion: It was initially thought that PHA represents 1% of all patients with primary HTN. However, more recent studies indicate that the prevalence is significantly higher. Additionally, the PAC in patients with PHA can fluctuate and patients can present with normokalemia, making the diagnosis more difficult to establish. It is an important diagnosis to establish and treat appropriately because there is a higher risk of cardiovascular morbidity and mortality in patients with PHA compared to patients with primary HTN. Presentation: Friday, June 16, 2023

FRI329 COVID-19: An Uncommon Cause Of Hypophysitis

Abstract Disclosure: W. Medina-Torres: None. M.A. Ortiz-Rivera: None. L.N. Madera Marin: None. A. Rosado-Burgos: None. L.R. Sepulveda-Garcia: None. L. El Musa Penna: None. M. Ramirez: None. L.A. Gonzalez-Rodriguez: None. M. Alvarado: None. M. Feliciano-Emmanvel: None. COVID-19 is an infectious disease caused by the SARS-CoV-2 virus. One of the virus four structural proteins, the spike(S) protein, contains a region that binds to the extracellular domain of angiotensin-converting enzyme 2 (ACE2). The virus uses the S protein to enter the cell by binding to the ACE2 receptor. Literature has reported that ACE2 receptors are extensively expressed in numerous human tissues and organs, such as in the heart, lung, kidney, testis and brain. Despite it is demonstrated that lungs inflammation is one of the main symptoms during SARS-CoV-2 infection, the moderate expression of ACE2 among other organs may explain the involvement and subsequent impairments of various organs during and after the SARS-CoV-2 infection. Although ACE2 is expressed in several endocrine glands, including the pancreas, thyroid gland, ovaries and testes; pituitary gland expression is limited. Only few cases have been reported in the literature of direct damage to the pituitary gland post covid-19 infection. This is the case of a 31-year-old healthy athlete female without prior systemic illness who was taken to ER after developing hypotension and symptomatic hypoglycemia while flying from Barbados to Miami. Upon questioning, patient referred she was in her usual state of healthy athletic performance until 7 months ago when had mild symptomatic COVID-19. She was 4-months post-partum of a healthy baby and lactating normally, but after the 2-weeks isolation period since COVID-19 infection, she had no return of menstruation and unable to lactate. In addition, patient developed a depressive state, loss of appetite and progressive weight loss. Was found with low Blood pressure and initial laboratories showed pancytopenia and sustained hypoglycemia requiring uninterrupted D10 IV infusion. Laboratory work-up revealed both central adrenal insufficiency (ACTH &amp;lt;1.5 pg/mL and serum cortisol 0.20 mcg/dL), secondary hypothyroidism (TSH: 2.8 mIU/L and free T4: 0.36 ng/dL). Contrast enhanced magnetic resonance imaging (MRI) of the brain was performed with evidence of prominent partial empty sella and slight nodular thickening of the pituitary stalk. Based on these findings a presumptive diagnosis of hypophysitis was made. Rapid clinical improvement was observed on corticosteroid replacement with resolution of hypoglycemia, hypotension, and anorexia, but diabetes insipidus was unmask. Additional laboratories revealed there was definitive panhypopituitarism, with evidence of hypogonadotropic hypogonadism, hypoprolactinemia and growth hormone deficiency. This case illustrates panhypopituitarism secondary to hypophysitis as an uncommon COVID-19 virus sequel. Thus, in patients with persistent non-specific symptoms post COVID-19 infection, it is important to have a high index of suspicious for endocrinopathies such as hypophysitis in order to provide prompt therapy and improve quality of life. Presentation: Friday, June 16, 2023

Placental transmogrification of the lung: CT findings with pathologic correlation in six patients.

Placental transmogrification of the lung is a very rare benign lung disease with a characteristic finding being alveoli resembling chorionic villi of the placenta. The purpose of this study was to assess the computed tomography (CT) findings of placental transmogrification of the lung in six patients and their relation to the histopathologic findings. Six patients with histopathologically proven placental transmogrification of the lung from 2004 to 2021 were included. Their CT findings were analyzed and their imaging features were compared with pathology specimens. In four of six cases, CT showed variable sized cystic lesions confined to a unilateral lung. One case presented nodule and cystic lesion together. The other case showed solitary pulmonary nodule without cystic lesion. Moreover, nodular interlobular septal thickening and clustered interstitial nodules were observed in all six cases. In four of the six cases, these nodules merged into dense nodular consolidation. Three cases showed dilated pulmonary vasculatures of the involved lung. On CT, placental transmogrification of the lung typically presents as cystic lesion confined to a unilateral lung. Pulmonary nodule with or without associated cystic lesion can also be seen. Nodular interlobular septal thickening and clustered interstitial nodules were observed in all cases. This might be attributable to the proliferation of chorionic villi-like structures in interstitium which are found in histopathologic specimens.

A PET-CT score for discriminating malignant from benign pleural effusions

Background and objectivesThe results of previous PET-CT studies are contradictory for discriminating malignant from benign pleural effusions. We purpose to develop a PET-CT score for differentiating between benign and malignant effusions. Patients and methodsWe conducted a prospective study of consecutive patients with pleural effusions undergoing PET-CT from October 2013 to October 2019 (referral cohort). PET-CT scan features evaluated using the SUV were: linear thickening; nodular thickening; nodules; masses; circumferential thickening; mediastinal and fissural pleural involvement; intrathoracic lymph nodes; pleural loculation; inflammatory consolidation; pleural calcification; cardiomegaly; pericardial effusion; bilateral effusion; lung mass; liver metastasis and other extra-pleural malignancy. The results were validated in an independent prospective cohort from November 2019 to June 2021. ResultsOne hundred and ninety-nine patients were enrolled in the referral cohort (91 with malignant effusions and 108 benign). The most useful parameters for the development of a PET-CT score were: nodular pleural thickening, pleural nodules with SUV>7.5, lung mass or extra pleural malignancy (10 points each), mammary lymph node with SUV>4.5 (5 points) and cardiomegaly (−1 point). With a cut-off value of >9 points in the referral cohort, the score established the diagnosis of malignant pleural effusion with sensitivity 87.9%, specificity 90.7%, positive predictive value 88.9%, negative predictive value 89.9%, positive likelihood ratio 7.81 and negative likelihood ratio 0.106. These results were validated in an independent prospective cohort of 75 patients. ConclusionsPET-CT score was shown to provide relevant information for the identification of malignant pleural effusion.

Morphology, taxonomy, biogeography and ecology of Micrasteriasfoliacea Bailey ex Ralfs (Desmidiales, Zygnematophyceae).

Micrasteriasfoliacea (Desmidiales, Zygnematophyceae) is an interesting desmid species as its filamentous life form is quite different from all other species within the genus. Due to the large size of the filaments and cells, accurate species identification is easy. After its original description from Rhode Island (USA) it was recorded from five continents, but no record could be found of its presence in Europe. In this paper a review of the worldwide distribution of M.foliacea (Desmidiales, Zygnematophyceae) is presented, together with notes on the species' ecology. In addition to its currently known geographical distribution, the paper also records the species' presence at two new locations in southern Africa, namely Botswana (Okavango River) and Mozambique (Palma, Cabo Delgado). The paper presents a discussion of taxonomical levels of intraspecific taxa, based on morphological characteristics. It is proposed that the taxonomical status of M.foliaceaBailey ex Ralfsf.nodosa should be raised to the variety, as its nodular cell wall thickenings are unique morphological features.

Adenomyomas of the Gallbladder: An Analysis of Frequency, Clinicopathologic Associations, and Relationship to Carcinoma of a Malformative Lesion.

The nature and associations of gallbladder (GB) "adenomyoma" (AM) remain controversial. Some studies have attributed up to 26% of GB carcinoma to AMs. To examine the true frequency, clinicopathologic characteristics, and neoplastic changes in GB AM. Cholecystectomy cohorts analyzed were 1953 consecutive cases, prospectively with specific attention to AM; 2347 consecutive archival cases; 203 totally embedded GBs; 207 GBs with carcinoma; and archival search of institutions for all cases diagnosed as AM. Frequency of AM was 9.3% (19 of 203) in totally submitted cases but 3.3% (77 of 2347) in routinely sampled archival tissue. A total of 283 AMs were identified, with a female to male ratio = 1.9 (177:94) and mean size = 1.3 cm (range, 0.3-5.9). Most (96%, 203 of 210) were fundic, with formed nodular trabeculated submucosal thickening, and were difficult to appreciate from the mucosal surface. Four of 257 were multifocal (1.6%), and 3 of 257 (1.2%) were extensive ("adenomyomatosis"). Dilated glands (up to 14 mm), often radially converging to a point in the mucosa, were typical. Muscle was often minimal, confined to the upper segment. Nine of 225 (4%) revealed features of a duplication. No specific associations with inflammation, cholesterolosis, intestinal metaplasia, or thickening of the uninvolved GB wall were identified. Neoplastic change arising in AM was seen in 9.9% (28 of 283). Sixteen of 283 (5.6%) had mural intracholecystic neoplasm; 7 of 283 (2.5%) had flat-type high-grade dysplasia/carcinoma in situ. Thirteen of 283 cases had both AM and invasive carcinoma (4.6%), but in only 5 of 283 (1.8%), carcinoma arose from AM (invasion was confined to AM, and dysplasia was predominantly in AM). AMs have all the features of a malformative developmental lesion, and may not show a significant muscle component (ie, the name "adeno-myoma" is partly a misnomer). While most are innocuous, some pathologies may arise in AMs, including intracholecystic neoplasms, flat-type high-grade dysplasia or carcinoma in situ, and invasive carcinoma (1.8%, 5 of 283). It is recommended that gross examination of GBs include serial slicing of the fundus for AM detection and total submission if one is found.

Invasive Fungal Infection of the Duramater as the Presenting Manifestation of Disseminated Sarcoidosis (P10-10.005)

<h3>Objective:</h3> To describe a case of invasive fungal infection of the duramater which was the presenting manifestation of Disseminated sarcoidosis <h3>Background:</h3> Invasive Central nervous system fungal infections are usually encountered in the setting of immunosuppressive conditions, craniospinal trauma or instrumentation. It is rare for a treatment naïve patient with sarcoidosis to develop fungal infection of the duramater. <h3>Design/Methods:</h3> We describe the case of a young male who was found to have nodular thickening of the duramater due to Invasive CNS fungal infection. <h3>Results:</h3> We had a 27 year old man who had no prior comorbidities who presented with a single seizure. On evaluation, he was found to have nodular thickening of the Duramater. Differentials of infective, inflammatory, histiocytic and malignant conditions were considered. He underwent detailed evaluation and PET-CT revealed generalized lymphadenopathy. Biopsy from the dural thickening revealed septate hyphae and fungal culture showed Acremonium species. There were granulomas found on histopathologic examination of the dural as well as subcarinal lymphnode biopsy. He was treated with Voriconazole for 24 weeks followed by treatment of sarcoidosis. <h3>Conclusions:</h3> Sarcoidosis may be associated with immunodeficiency due to its effects on the lymphocytes, bone marrow and other organs such as the thymus. There have been several reports of patients with sarcoidosis being predisposed to infections such as Progressive multifocal leukoencephalopathy, fungal infections, tuberculosis and other bacterial infections. These infections may occur de-novo in the absence of immunosuppressant drugs or corticosteroids which have been traditionally used in the management of sarcoidosis with organ threatening or life threatening symptoms. Infections that occur as the first manifestation of an underlying autoimmune condition are challenging to diagnose. Appropriate diagnosis is essential to ensure optimum treatment of both conditions. <b>Disclosure:</b> Dr. Elavarasi has stock in Pfizer. Dr. Elavarasi has stock in PGHL. The institution of Dr. Elavarasi has received research support from All India Institute of Medical Sciences, New Delhi. The institution of Dr. Elavarasi has received research support from Indian Council for Medical Research. Dr. SINGH has nothing to disclose. Dr. CHHATTERPAL has nothing to disclose. Dr. Wig has nothing to disclose. Dr. Mittal has nothing to disclose. Mehar Chand Sharma has nothing to disclose. Dr. DAS has nothing to disclose. Ajay Garg has nothing to disclose. Dr. Jagdevan has nothing to disclose. Dr. Shamim has nothing to disclose. Dr. Tripathi has nothing to disclose. Dr. Vibha has nothing to disclose. Rajesh Kumar Singh has nothing to disclose.