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We present the case of a 19 year old female presenting to the Emergency Department with signs of pneumonia and sepsis, with her clinical status deteriorating rapidly to septic shock and respiratory failure. Her pneumonia was complicated by formation of an empyema and a bronchopleural fistula. Bronchopleural fistula (BPF) is a fistula between pleural space and a bronchus. It is an uncommon complication of lung surgery, endobronchial interventions or chest trauma. They are sometimes formed secondary to postoperative pneumonia. Management of BPF requires surgical or bronchoscopic intervention with supportive care. Since a BPF can cause physiological tension pneumothorax, it can lead to significant worsening of respiratory status of these patients. Ventilator settings need to be adjusted to reduce the Positive end expiratory pressure and tidal volume to support these patients. With this case we highlight the importance of recognizing and diagnosing a BPF and timely management of a BPF in the emergency setting to help patients get to the definitive treatment of the fistula.

Testicular cancer is seen commonly in young males and has a high cure rate if diagnosed and treated early. It clinically presents with painless testicular swelling. We discuss the case of a young previously healthy male with an aggressive testicular cancer which started with a testicular swelling but the primary site underwent necrosis secondary to its own vascular demand thus giving the false impression of resolution, but not before metastasizing to the rest of the body. With this case, we aim to highlight the importance of increasing awareness of testicular cancer and its presenting symptoms in young males and the need to overcome the stigma around the evaluation of testicular swellings.

A 48‐year‐old male patient with Type 2 diabetes mellitus(T2D), on insulin replacement therapy, glipizide, and dapagliflozin presented with generalized weakness with weight loss of 40 pounds in 6 months ever since he was started on dapagliflozin. He was hemodynamically stable on arrival with a finger stick glucose of 121 gm%. Physical examination was unremarkable except for dry mucus membranes. His laboratory results on arrival are shown in Table 1. His serum osmolar gap was within the normal range. He was treated insulin drip per DKA protocol and gap was closed, the patient was clinically and biochemically back to baseline, and he was discharged home. Delayed diagnosis of normoglycemic diabetic ketoacidosis (DKA) in adults with diabetes treated with multiple antidiabetic drugs (eg, sodium‐glucose cotransporter‐2 [SGLT‐2] inhibitors) can potentially increase morbidity and mortality. Patient education in terms of symptoms and signs, physician awareness of early recognition of ketoacidosis in the setting of paradoxically normal or near‐normal blood glucose levels in these patients is the primary focus of this case study. This is paradoxical DKA because theoretically patient is not meeting one of the criteria for DKA which include triad of hyperglycemia, Ketoacidosis with widened anion gap, Ketonemia. This is a short case report of presumed SGLT‐2 inhibitor euglycemic diabetic ketoacidosis. The main teaching point is recognition and early diagnosis of this issue when multiple diabetic medications are present with the absence of hyperglycemia. This is, by current definition, not DKA because theoretically, the patient does not meet one of the criteria for DKA as the patient was apparently not hyperglycemic, albeit with, ketoacidosis and widened anion gap. (ketonemia) A 48‐year‐old male patient with type 2 diabetes mellitus (T2D) on insulin therapy (Glipizide & Dapagliflozin) was admitted for generalized weakness, in euglycemic but occult DKA (Normal or Near normal glucose levels with high anion gap but recovered on intravenous Insulin therapy per DKA protocol). The main teaching point is recognition and early diagnosis of this condition and awareness of the DKA presenting in an unorthodox laboratory finding (in patients on multi‐antidiabetic drugs) to ensure timely management. The learning objective in this case study is early diagnosis and management of DKA in SGLT‐2‐treated patients with signs or symptoms of acedemia, ketonemia, or ketonuria. Educating treating physicians and patients who use SGLT‐2 inhibitors about early DKA recognition and management is of paramount importance to reduce both morbidity and mortality. Suspicious signs and symptoms of acidosis include nausea, vomiting, abdominal discomfort or pain, weakness, myalgias, history of polynocturia, signs of dehydration, and ketonuria even in the setting of normoglycemia.

Background. Post-thyroidectomy hypocalcemia is the most common complication after total thyroidectomy. Studies to examine the role of low vitamin D in increasing post-thyroidectomy hypocalcemia incidence have produced varying results. This study aimed to assess whether vitamin D deficiency increases the risk of post-thyroidectomy hypocalcemia. Methods. This retrospective study involved 244 patients who underwent total thyroidectomy between 2014 and 2019. Patients were divided into two groups based on pre-operative vitamin D levels. Group A and Group B had pre-operative vitamin D (25-hydroxyvitamin D) levels of ≥20 ng/ml and <20 ng/ml (reference range for vitamin D is 30–100 ng/dl). The effect of vitamin D, gender, body mass index (BMI), and ethnicity on post-operative calcium and PTH levels was analyzed. Results. Post-operative calcium levels for Group A were not statistically different compared to Group B (8.52 ± 0.64 mg/dl vs. 8.45 ± 0.58 mg/dl (mean ± S.D.; p value = 0.352). The average post-operative PTH of the two groups did not differ significantly (Group A: 32.4 ± 27.5 pg/ml; Group B: 34.4 ± 41.7 pg/ml; p value = 0.761). Conclusion. Pre-operative vitamin D levels are not predictive of post-thyroidectomy hypocalcemia.

Disclosure: J. Sanchez Perez: None. M. Obeid: None. M. Fariduddin: None. D.J. Toft: None. Introduction: Thyroglobulin (TG) measurement is a major means of detecting recurrence of previously treated differentiated thyroid cancers. Human-Anti Mouse Antibodies (HAMA) can interfere with lab measurements of TG levels and affect clinical decisions and treatment for these cancers.Clinical Case: A 65-year-old female was diagnosed with papillary thyroid cancer (PTC). Surgical pathology following total thyroidectomy demonstrated a tumor of 3.5 cm in its greatest dimension, unifocal, without invasion of locoregional tissue classified as Stage I (pT2N0M0) per AJCC 8th edition. Radioiodine whole body scan (WBS) demonstrated iodine uptake in the neck and 126.5 mCi of I-131 was given. In surveillance 5 years later, TSH was found to be 0.17 mcIU/ml (ref range: 0.35 - 4.00) TG 64.7 ng/ml (ref range: 1.3 - 31.8 ng/mL), and anti-Tg antibodies were undetectable. Neck US consistently showed nonspecific findings of stable small nodes with normal morphology in both supraclavicular regions. Given elevated TG levels, 250 mCi of I-131 was given. Follow-up TG levels ranged from 27.8 to 36.4 ng/ml. A repeat WBS did not reveal any uptake, but as TG remained elevated, I-131 (238 mCi) was again given. Subsequent TG throughout the following 15 years ranged from 2.8 - 58.6 ng/ml. Repeat Neck US only showed benign-appearing lymph nodes. WBS did not have any focal activity to suggest recurrent disease and PET/CT did not show any abnormal FDG uptake. The persistently high TG levels without clinical evidence of tumor recurrence raised the suspicion of lab interference. The serum sample was treated with a blocking reagent that contained mouse immunoglobulin after which the TG level decreased to 2.7 ng/ml compared to untreated value of 20.5 ng/ml.Conclusion: HAMA are human antibodies against mouse antibodies which are believed to develop in humans from direct contact with rodents, including mice, and from the recent increase in the use of mouse monoclonal antibodies for diagnostic and therapeutic purposes. These antibodies implicate an unexpected source of interference in immunoassays, as seen in our patient, which can confound laboratory results and create a clinical dilemma. This patient with PTC had a complete radiological response after surgery, but an incomplete biochemical response which caused the patient to be given a total of 614 mCi of I-131. This case highlights the importance of recognizing the possible presence of HAMA when analyzing TG levels, particularly when the TG levels are used for treatment decisions. Presentation Date: Saturday, June 17, 2023

Disclosure: M. Fariduddin: None. A. Lupieri: None. H.L. Calero: None. A. Rubenfeld: None. Y. Eisenberg: None. Case: 22 y/o pregnant female (5 weeks gestation) presented to the endocrinology clinic after a hospital admission for nausea, vomiting, constipation, fatigue and joint pain with labs showing calcium (corrected) of 14 mg/dL and PTH of 1200 pg/ml. Labs in the clinic showed calcium at 16 mg/dL and PTH 1500 pg/ml. She was re-admitted for IV fluids, calcitonin and zoledronic acid. Severe hypercalcemia, young age, and extremely high PTH levels were highly suggestive of parathyroid cancer. CT of neck showed a 2 cm right inferior parathyroid mass abutting the esophagus with concern for esophageal invasion with no evident plane between the mass and the esophagus. No cervical adenopathy was noted. Patient in conjunction with her obstetrician made an informed decision to terminate the pregnancy as this was an undesired pregnancy. She underwent an urgent right inferior gland parathyroidectomy. The mass was not fixed to underlying structures and was resected in-toto. Pathology showed chief cells with clear cytoplasm, and homogeneously round nuclei. There were no atypical mitoses, lymphovascular invasion, perineural invasion, or other invasive features concluding the final pathology as parathyroid adenoma. Discussion: Primary hyperparathyroidism predominantly affects postmenopausal women. Most common cause is parathyroid adenoma (80-85%). Parathyroid carcinoma is a rare cause of primary hyperparathyroidism (1-2%).80% people with parathyroid adenoma and primary hyperparathyroidism are diagnosed incidentally with mildly elevated calcium. PTH elevation is around 1.5-2 times the upper limit of normal. Symptoms are mild sequelae of hypercalcemia. PTH levels 5-10 times upper limit of normal, severe hypercalcemia (Ca > 14 mg/dl) or a hypercalcemia crisis are highly suspicious for parathyroid cancer. Surgical resection is the mainstay of treatment. Clinical criteria play a key role in early identification of parathyroid carcinoma in order to get these patients to surgery before tumor spread and improve long term survival. Our patient with significantly elevated calcium and parathyroid hormone had an atypical presentation of a parathyroid adenoma thus uncovering the limitations of clinical criteria in identifying a parathyroid carcinoma. Most of the patients with a parathyroid adenoma will eventually require surgery, however the technique, extent and urgency of surgery is affected based on clinical situations like these. The timing of the surgery could be detrimental when coupled with a scenario like our patient’s pregnancy wherein you could delay the surgery until the second trimester had the patient wanted to continue the pregnancy. This case highlights the importance of awareness of atypical presentations of parathyroid adenomas and to have a cautious approach in patients with clinical concern for parathyroid carcinoma especially if there is a potential benefit to delay surgery. Presentation: Saturday, June 17, 2023

Disclosure: M. Fariduddin: None. J. Sanchez Perez: None. U.N. Syed: None. Y. Eisenberg: None. R.M. Sargis: None. Introduction: Ectopic ACTH-dependent Cushing’s syndrome (CS) is a rare entity accounting for 10-20% of hypercortisolism cases. We present a patient with this syndrome. Case Presentation: A 72-year-old man diagnosed with metastatic prostate cancer to the lumbar spine and pelvis was admitted for persistent hypokalemia. Potassium levels were 2.1 mmol/L (ref. range: 3.5-5.2) despite aggressive potassium supplementation. He reported 30-lb weight gain in the previous 2 months, rounding of his face, increased abdominal girth, and proximal muscle weakness. Facial plethora with puffiness was noted on physical exam. Labs were relevant for impaired glucose tolerance with fasting blood glucose of 110 mg/dL and elevated A1c of 6.3% (<5.7%), compared to 5.0% 1 year earlier. 8 AM cortisol was 59 ug/dL (6.7-22.6) and after dexamethasone, cortisol remained elevated at 65.8 ug/dL (<1.8). ACTH level was 312 pg/mL (7.2 - 63.3) and 24-hr urine cortisol was 3586 ug/dL (<= 60.0). Abdominopelvic CT showed new bilateral adrenal thickening without discrete nodularity or mass. Pituitary MRI showed a 1mm microadenoma, inconsistent with the degree of hypercortisolism observed. Patient’s age, known prostate adenocarcinoma with differentiation into neuroendocrine tumor and rapid onset of development of hypercortisolism were all suggestive of ectopic Cushing’s syndrome. Ketoconazole 200 mg BID, Spironolactone 200 mg BID and Amiloride 5 mg daily were started which resolved the hypokalemia. ACTH staining of the prostate tissue biopsy was negative. Patient later died of respiratory failure from Influenza pneumonia. Conclusion: Ectopic ACTH hypercortisolism is a rare but aggressive form of hypercortisolism. Symptoms like proximal muscle weakness, hyperglycemia, hypokalemia, infections, and blood clots develop rapidly, however, these patients rarely have the clinical stigmata of CS. Neuroendocrine tumors of the lung and small cell lung cancer are the most common tumors associated with ectopic ACTH production, but cases of paraneoplastic prostate cancer have been reported. Published case reports demonstrate positive ACTH staining of these tumor cells, but this was not the case in our patient even though his presentation was consistent with ectopic hypercortisolism. The ACTH staining was done on a sample of prostate tissue taken 2 months prior to presentation, at the time of diagnosis of prostate cancer. Neuroendocrine differentiation could have happened within 2 months after the biopsy. This case impresses upon us that ACTH staining can be negative in ectopic ACTH hypercortisolism and patients can still have CS as tumor cells continue to differentiate throughout the course of the malignancy- and this can be especially rapid in neuroendocrine differentiation of tumors. CS increases mortality by 3 times, therefore making it crucial to recognize it early to institute prompt treatment. Presentation: Thursday, June 15, 2023