Normal Thyroid Function Tests Research Articles

Langerhans cell histiocytosis of the thyroid mimicking thyroiditis in a boy: a case report and literature review

BackgroundLangerhans cell histiocytosis affecting the thyroid commonly presents with nonspecific clinical and radiological manifestations. Thyroid Langerhans cell histiocytosis is typically characterized by non-enhancing hypodense lesions with an enlarged thyroid on computed tomography medical images. Thyroid involvement in LCH is uncommon and typically encountered in adults, as is salivary gland involvement. Therefore, we present a unique pediatric case featuring simultaneous salivary and thyroid involvement in LCH.Case presentationA 3-year-old boy with complaints of an anterior neck mass persisting for 1 to 2 months, accompanied by mild pain, dysphagia, and hoarseness. A physical examination revealed a 2.5 cm firm and tender mass in the left anterior neck. Laboratory examinations revealed normal thyroid function test levels. Ultrasonography revealed multiple heterogeneous hypoechoic nodules with unclear and irregular margins in both lobes of the thyroid. Contrast-enhanced neck computed tomography revealed an enlarged thyroid gland and bilateral submandibular glands with non-enhancing hypointense nodular lesions, and multiple confluent thin-walled small (< 1.5 cm) cysts scattered bilaterally in the lungs. Subsequently, a left thyroid excisional biopsy was performed, leading to a histopathological diagnosis of LCH. Immunohistochemical analysis of the specimen demonstrated diffuse positivity for S-100, CD1a, and Langerin and focal positivity for CD68. The patient received standard therapy with vinblastine and steroid, and showed disease regression during regular follow-up of neck ultrasonography.ConclusionsInvolvement of the thyroid and submandibular gland as initial diagnosis of Langerhans cell histiocytosis is extremely rare. It is important to investigate the involvement of affected systems. A comprehensive survey and biopsy are required to establish a definitive diagnosis.

SAT209 Metastatic Parathyroid Carcinoma And The Challenge Of Maintaining Calcium Balance

Abstract Disclosure: K.M. Tuna: None. S. Badour: None. E.P. Monsour: None. G. Acosta Garcia: None. D. Barb: None. Background: Parathyroid carcinoma is a rare malignancy representing less than 1% of all parathyroid disorders. Presentation is significant for highly elevated calcium (Ca) and parathyroid hormone (PTH) levels, and usually a palpable neck mass (&amp;gt;3cm). Diagnosis is often made after surgery based on histopathology findings. The primary treatment modality remains surgical, but there is no effective approach for metastatic disease. Case presentation: A 51-year-old woman initially presented with multinodular goiter and compressive symptoms in 2008. Workup showed an elevated Ca of 14.4 mg/dl (normal 8.4-10.2 mg/dl) and PTH of 502 pg/ml (normal 12-88 pg/ml) while albumin 4.3 g/dl (normal 3.5-5.2 g/dl) and normal thyroid function tests. Radioactive Iodine uptake scan showed a 4.4 cm cold nodule on the right inferior pole. Sestamibi scan showed increased left upper pole activity. The patient underwent total thyroidectomy with surgical exploration for parathyroid adenoma. Pathology showed right intrathyroidal parathyroid carcinoma with lymphovascular invasion. The patient was lost to follow-up until 2022 when she was admitted with severe hypercalcemic crisis (Ca 15.8 mg/dl, Albumin 3.9 g/dl, and PTH 805 pg/ml). The patient was treated with IV fluids, calcitonin, and multiple rounds of bisphosphonates, and was then maintained on high-dose cinacalcet due to refractory and recurrent hypercalcemia. Repeat Sestamibi and neck US were unremarkable, although CT chest showed a 1.3 cm nodule in the right lower lung lobe. This was not FDG- nor DOTATATE-avid on PET-CT. The patient underwent laparoscopic wedge resection of the right lung nodule, and the pathology was consistent with metastatic parathyroid carcinoma. Her Ca and PTH levels normalized immediately after surgery (PTH decreased from 883 to 27 pg/ml) suggesting possible remission. Prior to discharge, she was started on oral calcium and vitamin D due to dropping Ca levels and clinical signs of hungry bone syndrome. She was readmitted one month later for preexistent heart failure exacerbation and declining renal function. Her PTH was noted to be elevated again, although Ca remained normal, raising concern for recurrent or persistent disease. However, the patient’s renal impairment and lung effusion limited further imaging. Ca and PTH were monitored frequently during hospitalization and weekly after discharge. PTH levels peaked at 634 pg/ml and then dropped to 127 pg/ml without intervention. Ca remained in the normal range while on calcium citrate and calcitriol. Conclusion: Treatment of metastatic parathyroid carcinoma remains a challenge. Mortality is secondary to complications of hypercalcemia; therefore, controlling calcium levels should be the main therapeutic goal. Hungry bone syndrome should be considered after surgery. Metastatic disease may occur even after 20 years; thus, lifelong close monitoring is indicated. Presentation: Saturday, June 17, 2023

SAT081 Maturity Onset Diabetes Of The Young (MODY) Due To A New BLK Gene Mutation

Abstract Disclosure: D. Taha: None. R. Thirunagari: None. A. Adhikari: None. Background: The BLK gene is a tyrosine protein kinase involved in cell proliferation and differentiation. It has been identified as a modulator of beta cell function and plays a role in the regulation of insulin synthesis and secretion. We describe the case of a patient presenting with prediabetes associated with a heterozygous c.1366 C&amp;gt;T of the BLK gene. Case Report: We report a 10 year old Asian female who presented with a hemoglobin A1c (HbA1c) level of 6.1% (4.0-5.7), within prediabetes range. Her weight was 44 kg (Z score 1.34), height 148.2 cm (Z score 1.52) and BMI was 20 kg/m2 (85th percentile; Z score 1.06). She had no acanthosis nigricans by exam and she was at early Tanner stage 2 of puberty. Initial evaluation revealed normal C-Peptide level of 2.1 ng/mL (0.9-6.9), normal insulin level of 21.1 mcUnits/mL (3 - 25). She had normal complete blood count and comprehensive metabolic profile, and normal thyroid function tests. Glutamic acid decarboxylase (GAD65) antibodies and islet cell antibodies were negative. She had an oral glucose tolerance test which revealed a fasting glucose level of 101 mg/dL and a 2-hour glucose level of 158 mg/dL. Lipid profile was normal. She was advised regarding healthy lifestyle changes and her HbA1c level was stable. She was lost to follow-up until 16 years of age when she presented with irregular menstrual cycles and was diagnosed with polycystic ovary syndrome. Her HbA1c was elevated at 6.3% with a normal insulin level. Cortisol and thyroid function tests were normal. Pancreatic antibodies including GAD65, IA-2, insulin antibodies, islet cell antibodies, and zinc transporter 8 antibodies, were negative. C-peptide level was normal at 4.3 ng/mL (1.1-4.4). Family history was significant for patient’s father and paternal grandmother having diabetes and taking Metformin. Patient’s father was diagnosed with diabetes at 13 years of age. Maturity onset diabetes of the young (MODY) panel/ sequencing and deletion/duplication analysis was performed at GeneDx and revealed that she is heterozygous for a c.1366 C&amp;gt;T; p.Arg456Cys (R456C) variant in exon 13 of the BLK gene. This variant has not been previously published as a pathogenic or benign variant to our knowledge. No additional variants were identified in any of the MODY genes on this panel (ABCC 8, APPL1, CEL, GCK, GLUD1, HADH, HNF1A, HNF 1B, HNF4A, INS, KCNJ11, KLF11, NEUROD1, PAX4, PDX1). Conclusion: Variants of the BLK gene have been reported in association with autosomal dominant MODY, type 11. We report a pediatric patient presenting with MODY prediabetes associated with a heterozygous c.1366 C&amp;gt;T; p.R456C variant in the BLK gene. To our knowledge, this variant has not been previously reported in MODY patients. We propose that this is a pathogenic variant and review this rare MODY form. Presentation: Saturday, June 17, 2023

FRI561 The Thyroid Trifecta

Abstract Disclosure: P. Kachhadia: None. S. Khan: None. A. Abu Limon: None. S. Aldasouqi: None. Introduction: Autoimmune Hashimoto’s Thyroiditis (HT) and Graves’ Disease (GD) may co-exist or may occur alternatingly, known in many case reports as Graves’s Alternans. Hyperfunctioning (Toxic, hot) thyroid nodules (TN) may also co-exist with GD, a rare condition called Marine-Lenhart syndrome. However, the co-existence of HT, GD and TN is perceivably rarer. Case Presentation: The patient is a 45 year old female with a prior history of HT for 20 years, who presented to the clinic with symptoms of minimal eye pain, tremors, fatigue, diarrhea and anxiety. She was not on thyroid replacement, with normal thyroid function tests (TFTs). Physical exam showed bilateral proptosis, a moderate goiter, hand tremors, mild anxiety and tachycardia. Labs showed high TPO (3995.0 IU/mL, n &amp;lt;18 IU/mL), Thyrotropin receptor antibody (5.25 IU/L, n&amp;lt;1.75 IU/L), and Thyroid-stimulating immunoglobulins (1.8 TSI index, n&amp;lt;1.3 TSI index) with low-normal TSH of 0.42 uIU/mL (0.35-4.01 uIU/mL) , mid-range free triiodothyronine (FT3) at 3.6 pg/mL (2.8-4.4 pg/mL) and normal free thyroxine (FT4) at 0.80 NG/dL (0.61-1.37 NG/dL). Thyroid US showed a 2.4 cm left lobe inferior nodule classified as TI-RADS 3. Fine needle aspiration of this nodule was benign. Radioactive Iodine-123 Uptake Scan showed a hot nodule in the left inferior lobe and with visible uptake in the rest of the gland (uptake was mid-normal). She was started on methimazole 5mg once daily and propranolol 10mg BID with improvement in her symptoms. Subsequent TFTs showed stable T4 and T3 and normalization of TSH to 1.78 uIU/mL (0.35-4.01 uIU/mL). Discussion: Marine-Lenhart syndrome was described in 1911 by surgeons David Marine and Carl Lenhart. Graves’ Alternans has been described in the literature, with variable time separation. Though thyroid nodules occur in up to 35% of those with GD, only 1-4.1% are deemed functional nodules. Nuclear medicine imaging via Tc-99m pertechnetate or I-123 iodine at diagnosis of GD generally shows such nodules as cold nodules lacking uptake, while the rest of the gland has diffuse uptake. However, with normalization of TSH through treatment, these cold nodules may alternate uptake and present as hot nodules. Conclusion: In conclusion, this case presents the co-existence of HT, GD and HN, a term we are calling “Thyroid Trifecta”. It is imperative that HNs should be identified if RAI treatment is planned in such patients. Literature review portrays cases in which if thyrotoxicosis persists post RAI treatment for GD, careful examination and repeat RAIU may show a hot nodule consistent with Marine-Lenhart Syndrome. These patients may benefit instead from thyroidectomy. In the case of our patient, definitive treatment options have been discussed and she has been referred for thyroidectomy due to the presence of the TN. RAI ablation will be avoided in view of mild but active thyroid eye disease. Presentation: Friday, June 16, 2023

THU234 An Adolescent Patient With Asymptomatic Hypocalcemia And Extensive Cerebral Calcification Due To Pseudohypoparathyroidism Type 1B: A Care Report

Abstract Disclosure: R. Alemzadeh: None. J.D. Ross: None. D. Guillen-Mendoza: None. Background: Pseudohypoparathyroidism (PHP) is a heterogeneous group of disorders due to renal resistance to parathyroid hormone (PTH) resulting in biochemical hypoparathyroidism but with skeletal sensitivity to PTH. Case Presentation: A 15-year-old African American male was incidentally found to have biochemical evidence of severe hypocalcemia during routine evaluation of his bilateral slipped capital-femoral epiphyses. The patient was at age-appropriate stage of puberty with normal height and without any features of hereditary osteodystrophy. However, he had history of mild developmental delay requiring school accommodations. On physical exam, there was some mild dyscoordination with finger and toe-tapping and a Myerson’s sign, negative tetany signs. The biochemical screening revealed markedly low serum calcium (4.9 mg/dL) with elevated phosphorus (7.8 mg/dL) and PTH (1314 pg/mL) levels. His hypocalcemia was accentuated by the presence of severe 25 hydroxy-vitamin D deficiency (7.5 ng/mL) with mild hypomagnesemia (1.4 mg/dL). He had normal renal and thyroid function tests with normal growth factors. There were minimal plasma cyclic AMP responses to a single dose of intravenous teriparatide (Ellsworth-Howard test) consistent with diagnosis of pseudohypoparathyroidism. The skeletal survey showed bowing and under-tubulation of the radius, ulna, tibia, and fibula as well as slipped capital femoral epiphysis bilaterally. His brain CT scan showed symmetrical severe dense calcifications in the basal ganglia, bilateral frontal, parietal and temporal subcortical white matter, pons and right dentate nucleus. Genetic testing did not reveal any GNAS mutations. The patient was initially treated with parenteral calcium followed by high-dose oral calcium supplements and calcitriol. His coexisting hypovitaminosis D and hypomagnesemia were corrected with oral high-dose cholecalciferol and magnesium sulfate, respectively. Conclusions: An incidental finding of severe asymptomatic hypocalcemia and elevated PTH without hereditary osteodystrophy phenotype raised the clinical suspicion of pseudohypoparathyroidism type 1B. This was associated with cerebral calcifications with increasing risk of worsening learning disabilities and minimal neurological findings. Presentation: Thursday, June 15, 2023

Clinical indicators that influence a clinician’s decision to start L-thyroxine treatment in prematurity with transient hypothyroxinemia

BackgroundTransient hypothyroxinemia of prematurity (THOP) is defined as a low level of circulating thyroxine (T4), despite low or normal thyroid-stimulating hormone (TSH) levels. Aims: We aimed to evaluate the incidence of THOP, the clinical and laboratory findings of preterm infants with this condition and the levothyroxine (L-T4) treatment.MethodsPreterm infants (n = 181) delivered at 24–34 weeks of gestation were evaluated by their thyroid function tests that were performed between the 10th and 20th days of postnatal life and interpreted according to the gestational age (GA) references. Clinical and laboratory characteristics of the patients with THOP and normal thyroid function tests were compared. Patients with THOP and treated with L-T4 were compared with the ones who were not regarding laboratory, and clinical characteristics.ResultsIncidence of hypothyroxinemia of prematurity was 45.8% (n = 83). Euthyroidism, primary hypothyroidism, and subclinical hypothyroidism were diagnosed in 47.5% (n = 86), 5% (n = 9) and 1.7% (n = 3) of the patients, respectively. Mean birth weight (BW) and GA were significantly lower in the hypothyroxinemia group than in the euthyroid group (p < 0.001). L-T4 was started in 43% (n = 36) of the patients with THOP. Treatment initiation rate was 44.4% (n = 16) in 24–27 wk, 41.6% (n = 15) in 28–30 wk, and 13.8% (n = 5) in 31–34 wk. As the GA increased, the incidence of THOP and the rate of treatment initiation decreased (p < 0.001). The lowest free thyroxine (FT4) cut-off value was 0.72 ng/dl in the treated group. In addition, incidences of vancomycin + amikacin, caffeine, dopamine treatments, RDS, IVH, BPD, central catheter, FFP transfusion, and ventilator support were higher in the treated group (P < 0.05).ConclusionThis study revealed that prevalence of THOP increased as the GA and BW decreased. As the GA decreased, THOP patients requiring L-T4 treatment increased. Additionally, association with comorbid diseases increased the requirement of treatment.

An Endocrinological Perspective on 22q11.2 Deletion Syndrome: A Single-center Experience

22q11.2 deletion syndrome (22q11.2 DS) is the most common chromosomal microdeletion disorder. Associated problems in 22q11.2 DS may include cardiac abnormalities, immune dysfunction, facial dysmorphism, with endocrine, genitourinary and gastrointestinal problems, and developmental delay. The aim of this study was to evaluate and present all endocrinological findings of patients with 22q11.2 DS from a single center. All participants had confirmed 22q11.2 DS by fluorescence in situ hybridization with hypoparathyroidism. Data were retrieved by retrospective review of patient records. A total of 17 patients were reviewed. On physical examination, all patients had similar dysmorphic features. The median age at diagnosis was 45 days (1 day-13 years). Most cases (64.7%, 11/17) were diagnosed with hypoparathyroidism incidentally after routine tests. At the time of diagnosis, mean calcium was 7.04±0.80 mg/dL, phosphorus was 6.2±1.1 mg/dL, and median parathyroid hormone (PTH) was 11.5 (3.7-47.6) ng/L. Transient hypoparathyroidism was detected in five cases (29.4%). There was no significant difference between patients with permanent or transient hypoparathyroidism regarding gender, age at diagnosis, calcium, phosphorus, and PTH levels. However, vitamin D levels were significantly lower in the transient group (p=0.036). During follow-up, short stature, obesity, and type 2 diabetes mellitus were absent. Thyroid autoantibodies were detected in two patients with normal thyroid function tests. Despite there being no pathological short stature, final stature was shorter than the general population (mean height standard deviation score: -0.94±0.83). Hypocalcemia may be detected during acute illness in some cases where hypocalcemia appears at later ages. There was no significant difference between permanent and transient hypoparathyroidism cases in terms of PTH level. Recognition of the more specific facial findings is important to trigger investigation of genetic variants, additional anomalies, and for follow-up.

Clinical and Biochemical Characteristics of Untreated Adult Patients With Resistance to Thyroid Hormone Alpha.

Thyroid hormone resistance due to pathogenic variants in thyroid hormone receptor alpha (THRA) is rare and descriptions of patients are sparse. The disorder is probably underdiagnosed as patients may have normal thyroid function tests. Treatment with thyroxine in childhood improves clinical symptoms. However, it is not clear if treatment has beneficial effects if started in adulthood. We investigated 4 previously untreated Caucasian adult first-degree-related patients with the THRA c.788C > T, p.(Ala263Val) variant identified by a gene panel for intellectual disability in the index patient. Clinical data and previous investigations were obtained from medical reports. During childhood and adolescence, short stature, short limbs, metacarpals, and phalanges, and delayed bone age maturation were observed. Delayed motor and language development and decreased intellectual and learning abilities were described. Abdominal adiposity, round face, and increased head circumference were common features. All individuals complained of tiredness, constipation, and low mood. While thyrotropin (TSH) and free thyroxine (FT4) were within the reference range, free triiodothyronine (FT3) was high. FT4/FT3 ratio and reverse T3 were low. Other main features were low hemoglobin and high LDL/HDL ratio. Investigation of 4 first-degree-related adult patients with untreated resistance to thyroid hormone alpha (RTHα) revealed more pronounced phenotype features and hypothyroid symptoms than previously described in patients treated with levothyroxine from childhood or adolescence. The delay in diagnosis is probably due to normal thyroid function tests. We suggest that THRA analysis should be performed in patients with specific clinical features, as treatment in early childhood may improve outcomes.

Circulating free T3 associates longitudinally with cardio-metabolic risk factors in euthyroid children with higher TSH.

Thyroid hormones play major roles in the regulation of body composition and metabolism, and therefore, the relationship between thyroid hormones and cardio-metabolic risk has been extensively studied in adults. In this study, we aimed to test whether free triiodothyronine (fT3) associates longitudinally with cardio-metabolic risk factors in euthyroid children. A prospective study cohort of 599 apparently healthy school-age children were assessed at baseline (mean age 8.1 ± 2.1 years), of whom 270 children were also assessed at follow-up (4 years later). Circulating thyroid-stimulating hormone (TSH), free thyroxine (fT4), and fT3 were measured, and cardio-metabolic risk was assessed by means of body mass index (BMI), waist circumference, visceral fat (by ultrasound), blood pressure, circulating lipids, and homeostasis model assessment of insulin resistance (HOMA-IR) index, both at baseline and at follow-up. All studied children had normal thyroid function tests. Independent associations between baseline fT3 and both baseline and follow-up BMI, systolic blood pressure, mean arterial blood pressure, triglycerides, and HOMA-IR were found using multivariate regression analysis (adjusting for sex and baseline age and BMI). Analyses of effect sizes showed that for each 1 unit-increase in baseline fT3 (pg/ml), follow-up BMI-standard deviation score (SDS) increased by 0.31 units (z-score) and systolic blood pressure by 6.6 units (mmHg). The observed longitudinal associations were more robust in children belonging to the upper TSH tertile who showed higher TSH levels and were characterized by weighing more and having the highest fT3 levels. In these children, for each 1 unit-increase in baseline fT3 (pg/ml), follow-up BMI-SDS increased by 0.67 units (z-score) and systolic blood pressure by 10.2 units (mmHg). Circulating fT3 associates longitudinally with cardio-metabolic risk factors in euthyroid children with higher TSH. The observed associations of thyroid hormones in these children could conceivably respond to a homeostatic attempt to reduce their cardio-metabolic risk.

Thyroid function and long-term outcomes of children born to mothers with Graves' disease: A 20-year review.

Thyroid dysfunction in infants born to mothers with Graves' disease (GD) is influenced by maternal factors including thyroid status, thyroid-stimulating hormone (TSH) receptor antibody (TRAb) concentration and antithyroid drug use. Thyroid dysfunction during early life could affect growth and development later in life. The aim of this study is to evaluate thyroid function tests (TFTs), and long-term growth and development of children born to mothers with GD. A retrospective chart review of children born to mothers with GD at the Faculty of Medicine Ramathibodi Hospital, Mahidol University, between January 2000 and December 2019 was performed. Clinical data including age of children at enrolment, sex, gestational age, birthweight, maternal thyroid status, maternal TRAb level, maternal GD treatment during pregnancy, neonatal TSH screening and TFT results, and growth and development outcomes of children were collected. There were 262 children (148 males) enrolled. Twelve (4%) infants had neonatal GD. Five (2%) infants had hypothyroidism requiring levothyroxine treatment: four had secondary hypothyroidism and one patient had congenital primary hypothyroidism. Seven (3%) infants had transient TSH elevation, which fell to normal by 2 weeks of age. The remaining 238 children had normal TFT results. Three out of 12 children with neonatal GD had either delayed growth or development. A number of infants born to mothers with GD had abnormal TFTs requiring specific management, and some of them had abnormal growth and development. Careful evaluation of TFTs and long-term follow-up are mandatory for those children.

Difficult situation in treatment of medullary thyroid carcinoma in patient with multiple endocrine neoplasia type 2 B(MEN2B)

Abstract Introduction Multiple endocrine neoplasia type 2B (also known as ‘MEN2B’,‘Multiple endocrine neoplasia type 3′ or ‘Wagenmann–Froboese syndrome’) is a genetic disease characterized by the presence of medullary carcinoma of the thyroid, pheochromocytoma, mucosal neuromas, marfanoid features and multiple skeletal abnormalities such as kyphoscoliosis and pes cavus. Clinical Case A 16 years male presented with neck swelling and dysmorphic feature in the form of marfanoid habitus, including multiple tongue and oral mucosal swelling with mucosal neuromas on the anterior third of the tongue, the lips and the inner eyelid. Lips are thickened and bumpy. Visible neck swelling, palpable solid neck mass, high arm span to height ratio at &amp;gt;1.05, elongated fingers, pes cavus and positive wrist sign which is defined as when the distal phalanges of the thumb and fifth finger overlap on encircling the opposite wrist, were present. Ultrasound of the neck revealed a left solid irregular mass (57mmx33mm), that is hypoechoic, has coarse calcification, hypervascularity, that is mostly central, Multiple cervical lymph node(abnormal nodes include shape (round), absent hilum, intranodal necrosis, reticulation, calcification, peripheral vascularity),Investigation at beginning, Normal thyroid function test and biochemical and electrolyte were observed, Chest x ray was normal, FNAC done for thyroid nodule that showed multiple clumps of large hyperchromatic oval cells picture suggesting high suspicion of thyroid malignancy, thyroid biopsy advised, The patient was referred the FDEMC center for further evaluation and investigation prior to the surgery. During investigation at FDEMC center, thyroid function test normal, biochemistry normal, including PTH and electrolytes, Calcitonin was very high 465 pg/mL (0.2–27.7 pg/mL),GH under GTT was normal, IGF 1 182µg/L (150–350),Plasma metanephrine 40 pg/ml(&amp;lt;90pg/ml),and Plasma normetanephrine 27pg/ml(&amp;lt;196pg/ml) were normal. The patient referred to surgery, total thyroidectomy with radical neck dissection with multiple lymph node resection was performed. The biopsy revealed medullary thyroid carcinoma with cervical lymph node secondaries (bilateral multiple foci in both lobes). The patient kept on levothyroxine tab 100mcg.The follow up of the patient after one month by ultrasound and calcitonin level revealed residual thyroid tissue and two large cervical LN in the the ultrasound and a calcitonin level of 322 pg/mL Another surgical neck dissection to the metastatic LN &amp;lt;multiple LN 7×5cm, multiple suprasternal mass dissection 3×2.5cm,remnant of thyroid tissue 0.8cm,Follow up the patient after one month by ultrasound and calcitonin level still showed that there is residual pathological cervical LN, while the calcitonin level still high 412 pg/mL. PET scan done for him showed there is uptake in the head, neck and chest. The calcitonin was repeatedly was high.

A prospective follow-up on thyroid function, thyroid autoimmunity and long COVID among 250 COVID-19 survivors.

We evaluated the evolution of thyroid function and autoimmunity among COVID-19 survivors over 6 months in relation to interferon beta-1b treatment and long COVID. We included COVID-19 survivors managed in a major COVID-19 centre between July 2020 and May 2021 who were reassessed three and/or six months after acute COVID-19. Thyroid function tests (TFTs) and anti-thyroid antibody titres were measured at acute COVID-19, 3-month and 6-month. 250 COVID-19 survivors were included (mean age 52.7 years, 50.4% men). Persistent thyroid function abnormalities were more likely in those with abnormal TFTs in acute COVID-19 (P < 0.001). Among 51 patients with abnormal TFTs in acute COVID-19, 82.4% resolved upon follow-up. Of 199 patients with normal TFTs in acute COVID-19, only 4.5% had incident abnormal TFTs, more likely in interferon-treated patients (P = 0.044) and none clinically overt. Among 129 patients with complete 6-month follow-up for anti-thyroid antibody titres, there was no significant change overall, except for modest increase in anti-thyroid antibody titres among the 84 interferon-treated patients (P < 0.05 at both 3 months and 6 months). Long COVID occurred in 19.5% and 10.4% at 3 and 6 months respectively, where TFTs and anti-thyroid antibody titres were not predictive of its occurrence. Over 6 months, most abnormal TFTs in acute COVID-19 resolved, with no significant incident thyroid dysfunction. SARS-CoV-2 infection did not lead to change in thyroid autoimmunity, while interferon treatment was associated with modest increase in anti-thyroid antibody titres. Thyroid function and anti-thyroid antibodies did not play a significant role in long COVID.

HİPEREMEZİS GRAVİDARUM HASTALARINDA TİROİD FONKSİYON TESTLERİ NORMAL OLANLAR VE TİROİD FONKSİYON TESTLERİ NORMAL OLMAYANLAR ARASINDAKİ DUYGU DURUM KARŞILAŞTIRILMASI

In this study, it was aimed to evaluate the mood differences between those with normal thyroid function test (TFT) and those with normal TFT in patients with hyperemesis gravidarum. Therefore, thyroid function tests of pregnant women who were diagnosed with hyperemesis gravidarum during the three-month study period were evaluated. Patients were divided into two groups according to normal and abnormal thyroid function tests. Each group consisted of 50 patients. The demographic characteristics of both groups were recorded and Beck depression and anxiety scales were applied to the groups. Although the Beck depression inventory score was 58% in pregnant women with normal TFT and 56% in non-normal patients, this difference was not statistically significant (p&amp;gt;0.05). According to Beck Anxiety Inventory scores, there was a statistically significant difference between patients with abnormal TFT and patients with normal TFT (p&amp;lt;0.05). Also, patients with abnormal TFT tended to be more anxious than those with normal TFT (p&amp;lt;0.1). A moderately strong negative correlation was found between Beck depression and Beck anxiety inventory scores in the patient group with abnormal TFT (Spearman's rho =-0.403; p=0.004). In addition, there was a weak negative correlation between Beck depression inventory score and social security status (Spearman's rho = -0.287; p=0.043), while a weak positive correlation was found between Beck depression inventory score and history of miscarriage (Spearman's rho = 0.287; p=0.043). In this study, although there was no significant difference in depression between patients with hyperemesis gravidarum with and without normal TFT, it was determined that anxiety levels were higher in patients with abnormal TFT compared to those with normal TFT.

Indirect evaluation of amyloid deposition by ultrasonography and its relationship with MEFV gene mutation in FMF patients.

The most significant complication in familial mediterranean fever (FMF) patients is dysfunction and organ failure developing depending on amyloid deposition in organs. The golden standard for showing amyloid deposition is the biopsy; however, tissue stiffness was examined by shear wave elastography as a non-invasive method in a restricted number of studies conducted, and it is considered that amyloid deposition can be shown indirectly. In our study, we aimed to indirectly evaluate amyloid deposition in organs with Shear wave and Doppler ultrasonography and to reveal its relationship with MEFV gene mutation analysis. 42 FMF patients with normal thyroid and renal function tests and 35 participants with no FMF symptoms were included in our study. FMF patients were grouped depending on their MEFV mutation analyses. Thyroid, salivary glands, and renal parenchymal tissue stiffness were evaluated by shear wave elastography. Thyroidal artery and both renal artery resistances were evaluated by Doppler ultrasonography. Both parotis gland, thyroid and renal parenchymal stiffness and arterial vascular resistances in the patient group were found higher than the control group. A significant difference was not found in any parameters in classification based on gender. Tissue stiffness and vascular resistance values in the patient group with M694V homozygote mutation were found statistically significantly higher than the other mutation groups (p < 0.001). Our study shows that identifying genetic mutation type in FMF patients will help determine possibly amyloidosis risk. Imaging of tissue stiffness by shear wave elastography and evaluation of vascular resistance by Doppler can be useful for routine screening of those patients.

Neonatal Outcomes of Pregnancies Complicated by Maternal Hyperthyroidism.

This study aimed to determine the proportion, clinical characteristics, hormonal status, median time for normalization of serum thyroxine (FT4) and thyroid-stimulating hormone (TSH) and factors affecting time to thyroid function test (TFT) normalization of neonates born to mothers with maternal hyperthyroidism admitted in our institution. This was a retrospective cohort study that included 170 newborns admitted to the Neonatal Intensive Care Unit (NICU) of Hospital Universiti Sains Malaysia (HUSM) with a history of maternal hyperthyroidism from January 2013 until December 2018. We analyzed their baseline demographic and clinical characteristics, maternal thyroid status and antibody levels. Finally, we analyzed newborn thyroid function and thyroid antibodies. The proportion of neonates born to mothers with maternal hyperthyroidism was 0.8% (170 of 20,198 neonates within the study period). Seven (4.1%) developed overt hyperthyroidism, while four (2.4%) had thyroid storm. The median time for thyroid function test normalization was 30 days (95% CI: 27.1 to 32.8). The median time for TFT normalization was longer among neonates of mothers with positive thyroid antibodies [46.6 days (95% CI, 20.6 to 39.4)] and of mothers who received anti-thyroid treatment [31.7 days (95% CI, 23.5 to 39.9)]. Neonates born to mothers with hyperthyroidism is uncommon. These babies were observed to have a longer time for normalization of thyroid function tests if their mothers had thyroid antibodies or received anti-thyroid treatment.

LBODP096 High Failure Rate Of Radioactive Iodine-131 (Rai) Therapy For The Treatment Of Grave's Disease And Toxic Multinodular Goiter In An Urban Municipal Hospital Clinic

Abstract Background Radioactive iodine-131 (RAI) therapy is used to treat hyperthyroidism secondary to toxic multinodular goiter (TMNG) and Graves’ Disease (GD). The treatment failure (TF) rate for RAI as reported in previous studies is 8-16% (1). Most patients respond to RAI with normalization of thyroid function tests and improvement of clinical symptoms within 4–8weeks. Previous studies also report higher TF rates amongst Black patients (2), but due to the low number of Blacks included in the study, identification of factors related to higher TF rates was difficult. Study Purpose: Determine treatment failure rates in patients who underwent RAI treatment for hyperthyroidism and characteristics related to Treatment Failure. Methods This is a retrospective study that included patients treated with RAI for either TMNG or GD from 2014-2021 at an urban hospital. Patients with thyroid cancer, less than 18 years, or toxic adenoma were excluded. TF was defined as persistent hyperthyroidism 6 months after RAI. Remission was defined as euthyroid or hypothyroid state off of anti-thyroid hormones 6 months after RAI. Factors evaluated included age at RAI, gender, race, cause of hyperthyroidism, percentage uptake in pretreatment scan, peak Ft4 / Ft3 pre-treatment, RAI dose, and treatment with methimazole post RAI. Comparison of TF to those who achieved remission was performed using two-sample t-test or the Wilcoxon rank-sum test for continuous variables and fisher tests for categorical variables. Results 66 patients were included in the analysis. Mean age was 49 years, majority female (76%), African (21%), African American (45%), GD (68%), TMNG (32%). 19 had TF (28.7%). There was no significant difference in characteristics between TF andremission groups prior to RAI. The RAI dose was not significantly different between the groups (21. 0;21.1mCi). However, patients given methimazole shortly after RAI were at significantly higher risk of TF compared to patients who did not receive methimazole after RAI (64% vs 89%, p=0. 04). Conclusion Previous studies report TF after RAI as high as 16%. Patients at our Hospital with TMNG or GD who underwent RAI had a higher TF rate of 28.7%. The high TF rate was not due to low RAI treatment dose. Randomized Controlled Trials have found 61%-86%(1) success with RAI dose ranging from 5.4 -15.7 mCi (1). In comparison, mean RAI dose at our hospital was high at 21. 0. Patients prescribed methimazole within 4 weeks of RAI were more likely to have TF at 6 months. Based on the results of this study, we will initiate a change in protocol at our institution to hold methimazole for at least 4 weeks after RAI to see if this lowers the TF rates.

ODP480 Failure to achieve remission post Radioactive iodine therapy

Abstract Background Radioactive iodine-131 (RAI) therapy is used to treat hyperthyroidism secondary to toxic multinodular goiter (TMNG) and Graves’ Disease (GD). The treatment failure (TF) rate for RAI as reported in previous studies is 8-16% (1). Most patients respond to RAI with normalization of thyroid function tests and improvement of clinical symptoms within 4–8 weeks. Previous studies also report higher TF rates amongst Black patients (2), but due to the low number of Blacks included in the study, identification of factors related to higher TF rates was difficult. Study Purpose Determine treatment failure rates in patients who underwent RAI treatment for hyperthyroidism and characteristics related to Treatment Failure. Methods This is a retrospective study that included patients treated with RAI for either TMNG or GD from 2014-2021 at an urban hospital. Patients with thyroid cancer, less than 18 years, or toxic adenoma were excluded. TF was defined as persistent hyperthyroidism 6 months after RAI. Remission was defined as euthyroid or hypothyroid state off of anti-thyroid hormones 6 months after RAI. Factors evaluated included age at RAI, gender, race, cause of hyperthyroidism, percentage uptake in pretreatment scan, peak Ft4 / Ft3 pre-treatment, RAI dose, and treatment with methimazole post RAI. Comparison of TF to those who achieved remission was performed using two-sample t-test or the Wilcoxon rank-sum test for continuous variables and fisher tests for categorical variables. Results 66 patients were included in the analysis. Mean age was 49 years, majority female (76%), African (21%), African American (45%), GD (68%), TMNG (32%). 19 had TF (28.7%). There was no significant difference in characteristics between TF and remission groups prior to RAI. The RAI dose was not significantly different between the groups (21. 0;21.1mCi). However, patients given methimazole shortly after RAI were at significantly higher risk of TF compared to patients who did not receive methimazole after RAI (64% vs 89%, p=0. 04). Conclusion Previous studies report TF after RAI as high as 16%. Patients at our Hospital with TMNG or GD who underwent RAI had a higher TF rate of 28.7%. The high TF rate was not due to low RAI treatment dose. Randomized Controlled Trials have found 61%-86% (1) success with RAI dose ranging from 5.4 -15.7 mCi (1). In comparison, mean RAI dose at our hospital was high at 21. 0. Patients prescribed methimazole within 4 weeks of RAI were more likely to have TF at 6 months. Based on the results of this study, we will initiate a change in protocol at our institution to hold methimazole for at least 4 weeks after RAI to see if this lowers the TF rates.

LBODP103 Ectopic Thyroid Tissue In A Pediatric Patient After Total Thyroidectomy

Abstract Introduction Ectopic thyroid tissue is defined as any functional thyroid tissue outside the normal anatomical location. It is rare and occurs with a frequency of 1 in 100,000-300,000. Most commonly, it is located along the normal track of thyroid development along the floor of the primitive gut to the pre-tracheal region of the neck; however, rarely it has been found in other areas. Malignancy is very rare in ectopic thyroid tissue (&amp;lt;1%) and when it occurs, papillary carcinoma is the most common type. Maki et al have reported multiple cases of lateral neck ectopic thyroid tissue in the presence of an orthotopic thyroid gland in the adult population. Only 2 pediatric cases have been reported in the literature so far. Clinical Case A 11-year-old male presented with concerns of morbid obesity and a neck swelling. He endorsed a previous history of thyroid nodules measuring over 2 cm that were being monitored by his previous endocrinologist. On exam, he was noted to have a goiter. Labs were obtained which indicated normal thyroid function tests (TSH 3. 040 uIU/mL, nl 0.45-4.5 uIU/mL and free T4 0.96 ng/dL, nl 0.93-1.6 ng/dL) and negative anti thyroid antibodies (TPO antibody &amp;lt;9 IU/mL, nl 0-26 IU/mL and thyroglobulin ab &amp;lt;1 IU/mL, nl 0. 0-0.9 IU/mL). His previous medical records revealed that a FNA was completed 2 years prior which was reported as benign. A repeat thyroid ultrasound revealed a multinodular goiter with 5 nodules measuring 3.3 x1.5×1.3cm and 5×6×5mm in the right lobe and 7×6×4cm, 2.4×2.1×1.8cm, and 5×6×5cm in the left lobe. After reviewing different management approaches, the family preferred thyroidectomy. He was referred to general surgery and subsequently underwent total thyroidectomy. Post-operatively, he was started on levothyroxine and calcium carbonate supplementation. The calcium supplementation was subsequently weaned and discontinued. Final pathology was reported as benign. Unfortunately, he was lost to follow up and presented to his primary care provider 6 months post-operatively with continued weight gain and a right sided neck mass. Labs obtained showed an elevated TSH (9.820 uIU/mL, nl 0.45-4.5 uIU/mL) and normal free T4 (1. 07 ng/dL, nl 0.93-1.6 ng/dL). Ultrasound of the neck revealed a 2.5 cm heterogeneous nodule in the right neck adjacent to the thyroid bed, concerning for recurrent/residual disease. FNA was completed and was consistent with normal appearing thyroid tissue. Ultrasound monitoring will continue to assess for change in size and need, if any for surgical removal in the future. Discussion Ectopic thyroid tissue with an orthotopic thyroid is a very rare finding in the pediatric population. Ectopic thyroid tissue outside of the thyroglossal duct is rare as well. We present an 11-year-old male who underwent thyroidectomy for multiple large thyroid nodules and subsequently developed a new neck mass diagnosed as ectopic thyroid tissue. Presentation: No date and time listed

ODP314 Gynecomastia as the Initial Presentation of Acromegaly.

Abstract Acromegaly is caused by persistent hypersecretion of growth hormone. In the US, its prevalence is less 20,000 per year. It is noted that co-secretion of growth hormone and prolactin from a single pituitary adenoma is common. Prolactin is co-secreted in about 25% of patients with acromegaly. We present a case of middle-age man who initially presented to our clinic for evaluation of bilateral gynecomastia with hypogonadism and found to have growth hormone secreting pituitary macroadenoma with co-secretion of prolactin. A 50 year-old Caucasian male veteran with past medical history of hypertension, hyperlipidemia, pre-diabetes, carpal tunnel syndrome, obstructive sleep apnea was referred to our clinic for evaluation and management of 5 months history of bilateral gynecomastia. He also reported chronic fatigue and erectile dysfunction. He denied headache, vision changes, change in shoes or ring size. He had gynecomastia with a larger left breast with some tenderness to palpation with no nipple discharge. He has short stature with large hands and feet. Some skin tags were also noted on physical examination. He was found to have elevated prolactin of 49.3 ng/ml (2.64-13.13ng/ml) with normal thyroid function test. His morning total testosterone was also low at 186 ng/dl (250-1100 ng/dl) with LH of 2.81 mIU/ml (1.24-8.26 mIU/ml), FSH of 5.98 mIU/ml (1.27-19.26 mIU/ml). Since his prolactin was elevated, MRI brain was done that showed 2.3 cm pituitary macroadenoma close to cavernous sinuses with no optic chiasm compression. Other pituitary function tests showed an elevated IGF-1 of 585 ng/ml (52-328 ng/ml). His morning cortisol and ACTH were normal. Oral glucose tolerance test revealed that growth hormone was not suppressed (GH &amp;gt; 2.4ng/ml post OGGT) confirming growth hormone excess/Acromegaly. He was given a trial of octreotide but did not tolerate the medication. He underwent transsphenoidal hypophysectomy and developed transient post-operative diabetes insipidus requiring Desmopressin. His prolactin, IGF-1 and testosterone level had returned to normal after surgery and gynecomastia completely resolved. Repeat MRI in 6 months after surgery showed postoperative changes and OGTT showed that GH suppressed appropriately (GH &amp;lt; 0.1 ng/ml post OGTT) and IGF-1 was149 ng/ml. Prolactin and testosterone had remained in the normal range. Acromegaly presents organomegaly with coarse physical features, enlarged hands and feet but some early symptoms are hyperhidrosis and extremity swelling with arthritis. We describe a case of acromegaly that initially presented with gynecomastia and secondary hypogonadism with hyperprolactinemia that lead to the diagnosis of acromegaly. The gynecomastia resolved completely with treatment. We hope that our case report is for the clinicians to be aware that acromegaly can present with metabolic syndrome, hypogonadism with gynecomastia and hyperprolactinemia and include screening tests to help diagnose and treat these patients at the early stages of the disease. Presentation: No date and time listed

Liquid levothyroxine improves thyroid control in patients with different hypothyroidism aetiology and variable adherence - case series and review.

It is estimated that hypothyroidism treatment may be either suboptimal or excessive in about 32-45% patients treated with L-thyroxine (LT4). There are multiple possible causes of poor control of hypothyroidism, including narrow LT4 therapeutic index, food and drug interactions, comorbidities, and patient non-adherence. Some of these obstacles could possibly be overcome with the novel liquid LT4 formulation. Liquid LT4 reaches maximum blood concentration about 30 minutes faster than the tablet form. Faster pharmacokinetics might lead to more efficient LT4 absorption, as suggested by a recent real-world study in patients with primary and central hypothyroidism. Liquid LT4 treatment led to increased free thyroxine (FT4) and sex hormone binding globulin (SHBG) with decreased low-density lipoprotein (LDL) cholesterol concentration and substantially improved quality of life for the patients. Herein we present a series of 31 patients with hypothyroidism of different aetiologies treated with the novel liquid LT4 formulation in standard clinical care in light of the latest scientific publications on liquid LT4 formula. We observed normalization of thyroid function tests shortly after introduction of liquid LT4, irrespective of concurrent diseases or concomitant medications that could diminish LT4 absorption. In more detail, the treatment with liquid LT4 managed to normalize thyroid-stimulating hormone (TSH) concentrations in patients without any known causes of LT4 absorption disturbances, as well as in those with malabsorption: with gastric bypass, partial small and large intestine resection, scleroderma, gluten intolerance, celiac disease, atrophic gastritis, and polytherapy. In conclusion, considering many factors disturbing LT4 absorption, hypothyroidism therapy with liquid LT4 seems to be a particularly effective option.