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2010 ABSTRACT

1	     Adrenal

18	    Diabetes

67	    Hypoglycemia

68	    Lipid	Disorders

74	    Metabolic	Bone	Disease

96	    Obesity

102	   Other

123	   Pituitary	Disorders

137	   Reproductive	Endocrinology

144	   Thyroid	Disease

181	   Subject	&	Author	Index

209	   Author	Index
                                   ABSTRACTS
ADRENAL DISORDERS                                                      Therefore, additional noninvasive tests are still required to
                                                                       be helpful in the differential diagnosis of adrenal masses.
Abstract #100                                                          Previous studies reporting increases in MMP-9 levels with
                                                                       norepinephrine administration support the findings of the
USING SERUM MATRIX METALLOPROTEINASE-9                                 present study. In the present study, similar with PC patients,
LEVELS IN THE DIAGNOSIS OF FUNCTIONAL                                  we determined high levels of MMP-9 in the patients with CS,
ADRENAL TUMORS                                                         which significantly decreased in the postoperative period.
                                                                       	    Conclusion: In this study we demonstrated higher
Serhat Isik, MD, Dilek Berker, MD, Gonul Erden, MD,                    MMP-9 levels in functional adrenal tumors compared to non-
Yasemin Ates Tutuncu, MD, Hatice Nursun Ozcan, MD,                     functional adrenal tumors for the first time in the literature.
Sedat Caner, MD, Bekir Tekelek, MD, Yusuf Aydin, MD,                   Our data suggest that serum MMP-9 levels may be useful
Serdar Guler, MD                                                       in the differential diagnosis of benign subclinical functional
                                                                       adrenal tumors from nonfunctional benign adrenal tumors.
	    Objective: The aim of the present study is to demonstrate
the diagnostic value of serum matrix metalloproteinase-9               Abstract #101
(MMP-9) levels in functional benign adrenal tumors.
     Methods: Among 370 adrenal tumor cases, 52 patients               PHEOCHROMOCYTOMA SECRETING LARGE
with adrenal incidentaloma that met the inclusion criteria and         QUANTITIES OF BOTH EPINEPHRINE AND
25 healthy individuals were included in the study. Of the 52           NOREPINEPHRINE PRESENTING WITH EPISODES
patients, 2 patients with adrenocortical carcinoma have been           OF HYPOTENSION AND SEVERE ELECTROLYTE
excluded. Remaining patients were divided into 2 groups.               IMBALANCE
Group I included 20 patients with functional adrenal tumor
[14 with Cushing syndrome (CS) and 6 with pheochromo-                  Issac Sachmechi, MD, FACP, FACE, Harigopal Reddy, MD,
cytoma (PC)] and group II included 30 patients with non-               Wiroon Sangsiraprapha, MD, Ricardo Lopez, MD, FCCP,
functional adrenal tumor. Patients underwent routine endo-             David Reich, MD, FACE, Paul Kim, MD, FACE,
crinologic examinations and MMP-9 levels were compared                 Gurpreet Singh, MD
pre- and post-operatively.
     Results: Matrix metalloproteinase-9 levels were higher            	    Objective: To report an unusual case of Pheochromo-
in patients with non-functional adrenal tumors and functional          cytoma. Who presented with palpitations, headaches, sweat-
adrenal tumors compared to healthy controls (p<0.001). In              ing, anxiety and severe electrolyte imbalances.
addition, MMP-9 levels of patients with functional adrenal             	    Case	 Presentation: A 51 year old woman with type 2
tumors were significantly higher than those with non-func-             diabetes mellitus presented with chest pain and vomiting. She
tional adrenal tumors (p=0.002). After the surgical operation          had episodes of palpitations, sweating and weakness for the
MMP-9 levels decreased significantly both in patients with             last 3-4 years. These episodes were self-resolving and lasted
CS and in those with PC (p<0.001); however, patients with              10-15 minutes. On admission, her blood pressure was 130/80
CS and with PC had similar MMP-9 levels both pre- and                  mmHg, pulse 117/minute, respirations 24/min and spO2 100%
post-operatively. There was no significant linear correlation          on room air. While in the hospital, she had episodes of ortho-
between the tumor volume and MMP-9 levels (r=0,214 and                 static hypotension, sweating, palpitations and anxiety lasting
p=0,136). A significant positive correlation was determined            for 15-20 minutes. Her pulse remained high, ranging between
between preoperative MMP-9 and cortisol levels obtained at             110-140/min. Her electrolyte panel revealed persistently
the baseline and also after classic DST (r=0.402, p=0.003;             low magnesium, potassium and calcium despite aggressive
r=0.357, p=0.006 respectively). A significant positive corre-          replacement. She also had persistent hyperglycemia requir-
lation was determined between MMP-9 levels and 24-hour                 ing an insulin drip. Adrenal MRI revealed an 11x11 cm right
fractionated metanephrine and adrenaline levels (r=0.938,              suprarenal heterogeneous mass. Further workup revealed 24
p=0.006 and r=0.965, p=0.002, respectively).                           hr urine metanephrine 34,400 mcg (90-315mcg/24 hr), serum
     Discussion: Endocrine tests may sometimes be inad-                potassium 3.1mEq/liter (3.5-5.5 mEq/liter), magnesium
equate, especially in subclinical functional adrenal tumors.           0.62 mg/dL (1.7-2.7 mg/dL), ionized calcium 3.23 mg/dL


                                                                 –1–
                                       ABSTRACTS – Adrenal Disorders

(4.25-5.25 mg/dL), 24 hr urine and calcium magnesium                determined each study’s risk of bias. Standard deviation
1460 mg (100-150 mg/24 hr), 24 hr urine calcium 369mg               score (SDS) for final height and corrected height (defined
(<250 mg/24 hr), vitamin D, 25 OH 12ng/ml (20-100 ng/               as final height SDS – mid-parental height SDS) were esti-
ml). A diagnosis of pheochromocytoma was made, after 3              mated from each study and pooled using random-effects
weeks of Preoperative management with doxazosin 1mg                 meta-analysis. The I2 statistic was used to assess hetero-
once daily, propanolol and intravenous fluid. A right adre-         geneity across studies.
nalectomy was performed. Postoperatively, she remained                   Results	and	Discussion: We found 35 eligible stud-
hemodynamically stable. Her electrolytes, blood glucose             ies most of which were retrospective single-cohort stud-
and 24 hour urine metanephrines, calcium and magnesium              ies. The final height SDS achieved by CAH patients on
remained normal.                                                    treatment was -1.38 (-1.56, -1.20; I2 = 90.2 %). This was
	    Discussion: Hypotension in our patient can be                  not significantly associated with age at diagnosis, gen-
explained by down regulation of vascular alpha-1 adren-             der, type and dose of steroid and age of onset of puberty.
ergic receptors from exposure to large amounts of cat-              Mineralocorticoid users had a better height outcome
echolamines, resulting in decreased peripheral resis-               in comparison to the non-users (p=0.02). The corrected
tance. Decreased intravascular volume also plays a role.            height SDS was -1.03 (-1.20, -0.86; I2 = 63.1%). Most of
Persistent hypokalemia is explained by epinephrine                  the observed inconsistency across studies remains unex-
stimulating the beta 2 receptors causing an intracellular           plained. Data on the use and efficacy of growth-enhancing
shift of potassium. Hypomagnesaemia is explained by                 drugs and on parents’ or patients’ satisfaction with height
the increased urinary loss of magnesium, due to hypoka-             achieved were sparse.
lemia. Hypocalcaemia in our patient is likely explained                  Conclusion: Very low quality evidence suggests that
by increased urinary loss of calcium due to hypokalemia,            the final height of CAH patients treated with glucocorti-
hypomagnesaemia and low 25(OH) vitamin D, as well as                coids is lower than the population norm and is lower than
calcium sequestration in the tumor and within platelets.            expected given parental height.
	    Conclusion: Although most pheochromocytomas
present with episodes of hypertension, rarely pheochro-             Abstract #103
mocytomas can present mainly with hypotensive epi-
sodes. The clinician should be aware of the possibility             A CURIOUS CASE OF MEN 2 A WITH
that hyperglycemia, hypokalemia, hypomagnesaemia and                SPORADIC NON-SECRETORY PITUITARY
hypocalcaemia can be part of the presentation of a pheo-            MACROADENOMA
chromocytoma in the absence of hypertension.
                                                                    Lubna Mirza, MD, Hal Scofield, MD,
Abstract #102                                                       Nelson Agudelo, MD

HEIGHT IN PATIENTS WITH CONGENITAL                                       Objective: Timely diagnosis and treatment of MEN
ADRENAL HYPERPLASIA: A SYSTEMATIC                                   2A syndrome is important. Prophylactic thyroidectomy
REVIEW AND META-ANALYSIS                                            with autotransplantation of the parathyroids is the primary
                                                                    preventive measure for individuals with an identified
Kalpana Muthusamy, MD, Mohamed B. Elamin, MBBS,                     germline RET mutation and genetic testing recommenda-
Hassan M. Murad, MD, MPH,                                           tion for biological children to prevent significant morbid-
Victor M. Montori, MD, MSc                                          ity and mortality with medullary thyroid cancer.
                                                                         Case	presentation: A 62 year old hypertensive white
     Objective: To determine the distribution of achieved           man underwent elective unilateral adrenalectomy and
height in patients with classic CAH diagnosed at infancy            nephrectomy for an incidentally discovered 13 centimeter
or early childhood and treated with glucocorticoids. We             pheochromocytoma. This was seen on a magnetic reso-
also sought to determine patients’ satisfaction with their          nance imaging study which was performed due to back
achieved height and predictors of final height.                     pain. The day after surgery he had headaches and blurred
     Methods: We searched MEDLINE, EMABSE,                          vision. An MRI brain revealed a 1.8 centimeter pituitary
Cochrane library, ISI Web of Science and Scopus through             macroadenoma. The pituitary macroadenoma was non-
September 2008 and the reference section of included                secretory. Further work-up revealed an elevated high
studies. Eligible studies included patients diagnosed with          parathyroid hormone level with normal calcium; probably
CAH before age 5 and followed to final height. There                related to a low 25 OH-D3 level. There was a low total
were no restrictions in terms of study design or lan-               testosterone level, low luteinizing and follicle stimulating
guage. Reviewers working in duplicate, independently                hormone levels. Thyroid function tests were abnormal sug-
extracted data on study characteristics and outcomes, and           gestive of the euthyroid sick syndrome. A non-stimulated


                                                              –2–
                                         ABSTRACTS – Adrenal Disorders

calcitonin level was elevated. Retrospective review of the            Adrenal vein sampling was performed and a greater corti-
surgical pathology suggested an aggressive pheochromo-                sol secretion from the right than the left adrenal gland was
cytoma; and a neck ultrasound neck showed thyroid nod-                detected. After right adrenalectomy, all her biochemical
ules. This patient had mixed features of MEN1 and MEN2                markers improved, including 24 hour urinary free corti-
syndrome. Genetic testing for MEN1 returned negative.                 sol and midnight salivary cortisol levels. The ACTH level
A DNA sequence analysis for the mutations in exons 10,                gradually increased to a maximum of 85 pg/ml (N= 10-60
11,13,14,15 and 16 of the RET proto-oncogene demon-                   pg/ml) at 18 months post-surgery and declined to 45 pg/
strated a known pathogenic mutation Cys618Ser in exon                 ml at 27 months. However, dexamethasone suppression
10. This mutation was consistent with a diagnosis of MEN              remains abnormal.
2A/ familial medullary thyroid carcinoma. The patient                 	    Conclusion: We describe a unique case of a woman
subsequently underwent total thyroidectomy. Pathology                 with hypercortisolism due to both a pituitary adenoma
showed the expected medullary carcinoma of the thyroid.               and an ACTH dependent adrenal adenoma. The evidence
A daughter, his only biological child was found to not                for the Cushing disease included the biochemical testing,
express this mutation.                                                pituitary pathology and post-operative normalization of
     Discussion: MEN 2 A syndrome is associated with                  glucocorticoids. The recurrence of hypercortisolism in a
development of medullary thyroid cancer (100%), pheo-                 patient with an adrenal nodule raised the important clinical
chromocytoma (50%) and hyperparathyroidism (30%). It                  differential of recurrent Cushing disease vs. primary adre-
is an unusual finding to see a pituitary adenoma in MEN               nal pathology. The adrenal adenoma was ACTH depen-
2 which is typically present in MEN 1 syndrome. This                  dent since both cortisol levels and tumor size declined
seems to be a sporadic finding in this patient.                       post-hypophysectomy and the cortisol levels declined
     Conclusion: Genetic testing can guide treatment                  more than 50% with dexamethasone suppression. Urinary
decisions in these types of cases where a clear diagnosis             free cortisol, ACTH, and cortisol levels are normal and
cannot be made by other clinical and biochemical mea-                 salivary cortisol levels show a normal circadian rhythm,
surements alone.                                                      but dexamethasone suppression remains abnormal.

Abstract #104                                                         Abstract #105

RECURRENCE OF HYPERCORTISOLISM DUE                                    IMPACT OF CONTINUOUS AND PULSATILE
TO AN ACTH-DEPENDENT ADRENAL NODULE                                   CORTISOL INFUSIONS ON RESTRAINING
AFTER THE RESECTION OF ACTH-PRODUCING                                 ACTH SECRETION
PITUITARY ADENOMA: CASE REPORT                                        Paul Aoun, DO, PhD, Jean Wigham, Joy Bailey,
                                                                      Daniel M. Keenan, PhD, John M. Miles, MD,
Jhosvani Miguel, MD, Alan Burshell, MD,                               Johannes D. Veldhuis, MD
Amer Kassar, MD, Saba Khayal, MD
                                                                      	    Hypothesis: Pharmacologically continuous and phys-
	    Objective: To present the management challenges                  iologically pulsatile cortisol infusions exert unequal nega-
associated with hypercortisolism with both an ACTH pro-               tive feedback on ACTH secretion.
ducing pituitary adenoma and an ACTH-dependent corti-                 	    Methods: Preliminary aggregate data on 11 (6M/5F)
sol secreting adrenal adenoma.                                        healthy participants, ages 45-72, pretreated with leu-
	    Methods: We present the clinical and laboratory find-            prolide prior to either placebo or sex-steroid addback.
ings before and after surgical interventions to the pituitary         Subjects were assigned randomly to 4 overnight visits
gland and the adrenal gland in a patient with Cushing                 in a within-subject, placebo-controlled crossover design.
syndrome.                                                             Experimental interventions included: 1) oral placebo and
	    Results: A 62 year old patient underwent transsphe-              a 14-h saline infusion (22:00-12:00), 2) saline infusion
noidal resection of the pituitary gland for Cushing disease           during reversible inhibition of adrenal cortisol synthesis
based on biochemical testing. Brain MRI did not show any              with ketoconazole (KTCZ), 3) KTCZ + 14-h continuous
pituitary gland abnormality but a right adrenal adenoma               cortisol infusion (7 mg/m2/14h), and 4) KTCZ + 10-min
and a thickening of the left adrenal gland were detected              cortisol pulses every 90 min (total 7 mg/m2/14h). Blood
by CT scan. Surgical pathology revealed the presence of               was sampled every 10 min for a total of 8 h (04:00-12:00)
an ACTH secreting pituitary adenoma. Clinical and bio-                for measurement of cortisol and ACTH. Oral hydrocor-
chemical improvement lasted for about one year followed               tisone was given at the end of each session. The primary
by return of the hypercortisolism. MRI of the pituitary               endpoints were mean, peak, and nadir ACTH concentra-
showed an empty sella. CT scan of adrenal gland showed                tions and approximate entropy (a sensitive measure of
a decreased in the size of the right adrenal adenoma.                 ensemble feedback control).


                                                                –3–
                                       ABSTRACTS – Adrenal Disorders

	    Results: The paradigm achieved statistically compa-            laboratory was 45 pg/mL for plasma MN, 100 pg/mL for
rable mean cortisol concentrations during both continuous           plasma NMN, 350 μg/24h for urinary MN and 600 μg/24h
and pulsatile infusions compared with double placebo (11            for urinary NMN. Putative thresholds were calculated by
mcg/dL ± 0.35). Cortisol peaks were lower (p<0.001) in              receiver operating characteristic (ROC) an analysis to bal-
the continuous (13 mcg/dL ± 0.88) and pulsatile (14 mcg/            ance between sensitivity (Sens) and specificity (Spec).
dL ± 0.84) groups compared with placebo (19 mcg/dL ±                The Local Ethical committee approved the study.
0.81). Cortisol nadirs were higher in the continuous (8.9           	    Results: Plasma MN and NMN were significantly
mcg/dL ± 0.63; p<0.01) but not pulsatile group relative             higher in PHEO than in INCID and HBP groups (136
to placebo. Both infusions normalized mean, peak, and               [20-3365], 16 [10-62] and 14 [10-80] pg/mL respectively,
nadir ACTH concentrations relative to the double pla-               P<0.05; 1381 [150-6030], 42 [15-150] and 47 [12-167]
cebo (21 ± 2.3; 42 ± 4.7; and 11 ± 1.4 ng/L, respectively).         pg/mL respectively, P<0.05). Urinary MN and NMN were
Cross-approximate entropy of cortisol feedback on ACTH              also significantly higher in PHEO than in INCID and
showed greater irregularity during both continuous (1.21            HBP groups (404 [112-3000], 94 [49-400] and 77 [14-
± 0.057) and pulsatile (1.11 ± 0.03) infusions compared             499] μg/24h respectively, P<0.05; 1500 [444-120000],
with placebo (0.88 ± 0.059; p<0.01). Cross-approximate              347 [120-1000] and 316 [100-1422] μg/24h respectively,
entropy did not differ between the two infusions groups.            P<0.05). ROC analysis indicated plasma-free NMN as
	    Conclusion: Both continuous and pulsatile cortisol             the best single test in the diagnosis of pheochromocytoma
infusions restrain ACTH secretion albeit with incomplete            (AUC=0.999 [CI 95%, 0.98-1.0]) followed by urinary
normalization of irregularity. We postulate that normalized         NMN (AUC=0.963 [CI 95%, 0,886-0,993]), plasma-free
regularity requires adequate peak cortisol concentrations.          MN (AUC=0.945 [CI 95% 0,902-0.972] and urinary MN
                                                                    (AUC=0.927 [CI 95%, 0,837-0,976]). The best cut-off
Abstract #106                                                       value for the diagnosis of pheochromocytoma, as indi-
                                                                    cated by ROC analysis, is 143 pg/mL for plasma-free
EVALUATION OF AN ENZYME                                             NMN (100% Sens, 98.9% Spec), 440 μg/24-h for urinary
IMMUNOASSAY FOR PLASMA AND URINARY                                  NMN (100% Sens, 85.7% Spec), 27 pg/mL for plasma
METANEPHRINES IN THE DIAGNOSIS OF                                   MN (88.2% Sens, 88.6% Spec) and 186 μg/24-h for uri-
PHEOCHROMOCYTOMA                                                    nary MN (91.7% Sens, 85.7% Spec).
                                                                    	    Conclusions: EIA provides a good alternative to
Dan Alexandru Niculescu, MD,                                        HPLC for measurement of plasma and urinary metaneph-
Monica Livia Gheorghiu, MD, Ionela Baciu,                           rines. Plasma-free normetanephrine has the best single-
Ana Maria Stefanescu, Corin Badiu, MD,                              test accuracy in the diagnosis of pheochromocytoma.
Catalina Poiana, MD, Serban Radian, MD,
Raluca Trifanescu, MD, Mihail Coculescu, MD                         Abstract #107

	    Objective:	High performance liquid chromatography              RETROCAVAL CATECHOLAMINE-SECRETING
(HPLC) is the gold standard method for measurement                  PARAGANGLIOMA
of plasma and urinary metanephrines but it is a cumber-
some, time-consuming technique with limited availabil-              Soumia Vijayan, MD, Shwetha Thukuntla, MD,
ity. Our objective was to assess the diagnostic accuracy of         Pratima Kumar, MD
an enzymatic immunoassay (EIA) for plasma and urinary
metanephrine (MN) and normetanephrine (NMN) in the                  	    Objective: To describe a case of paraganglioma (PGL)
diagnosis of pheochromocytoma.                                      presenting as refractory hypertension and retrocaval mass
	    Methods: This retrospective, single-center study               	    Case	Presentation: A 75 yo female with poorly con-
included 227 patients: 26 with histologically proven pheo-          trolled HTN who was on multiple medications was referred
chromocytoma (group PHEO), 103 patients with adrenal                to our hospital for evaluation of GI bleed. CT Abdomen
incidentalomas (group INCID) of whom 17 with exclusion              revealed a 5.7 cm mass between the inferior vena cava
of pheochromocytoma at histological examination and                 and the right adrenal gland as well as right 2.9 cm and
98 patients tested for high blood pressure and clinically           left 2.7 cm adrenal masses. Biopsy of the mass done at
considered not to harbour adrenal tumors (group HBP) of             another hospital revealed a neuroendocrine tumor. 24 hour
whom 29 with negative CT/MRI scans. All patients had                urine metanephrines were 2254 mcg/d (30-350), normeta-
at least one spontaneous plasma sample and/or one 24-h              nephrines 3151 mcg/d (50-650); epinephrine 51 mcg/d
urine sample. Plasma-free and urinary MN and NMN                    (0-25), norepinephrine 146 mcg/d (0-100), dopamine 242
were measured by an enzyme immunoassay. Results are                 mcg/d (60-440) and creatinine was 806 mg/d (500-1400)
given as median (range). Upper limit of normal of our               Plasma free metanephrines were 3.82 nmol/L (0-0.49),


                                                              –4–
                                       ABSTRACTS – Adrenal Disorders

normetanephrines 8.1 nmol/L (0.0-0.89) and chromo-                  CT. Left Adrenal lesion (LAL) measured 5.7 x 4.7 cm
granin A was 5115 ng/ml (0-50).There was no evidence of             described radiologically as angiomyolipoma, and Right
primary hyperaldosteronism or Cushing syndrome. Serum               Adrenal lesion (RAL) measured 4.6 x 3.5 cm suggestive of
calcitonin and calcium levels were normal. I-123MIBG                adenoma. Plasma rennin activity 1.2 ng/ml/h, Aldosterone
scintigraphy revealed positive uptake in the retroperito-           <2 ng/dl, Aldosterone/rennin of 1.7. Norepinephrine 71
neal mass, consistent with a PGL with no definite adrenal           mcg/24hr, Epinephrine 8 mcg/24hr, Dopamine 176mcg/
activity. MRI abdomen showed a 4.6 x 4.4 cm retrocaval              dl, Normetanephrine 211mcg/24hr, Metanephrine 58
mass with hyperintensity on T2 images most likely a PGL             mcg/24hr, Venillymandelic acid 2.2 mg/24hr, all meta-
and bilateral benign adrenal adenomas. Patient underwent            nephrines and catecholamines were within normal limits.
a successful resection of the PGL along with right adrenal-         Fasting cortisol 13.56 ug/dl, dexamethasone suppression
ectomy after adequate alpha and beta blockade. Surgical             test was positive with cortisol levels @ 8 am of 10.58
pathology was consistent with a 5.5 cm PGL and 3 cm                 ug/dl, ACTH < 5pg/ml, Urine free cortisol was 37.3
right adrenal adenoma. Chromogranin A was 1292 ng/ml                mcg/24hr and 17 ketosteroids 7.1 mg/24hr evidencing a
one week after surgery and her BP was normal at follow              SCS. Patient underwent bilateral adrenalectomy by open
up .Genetic testing for succinate dehydrogenase B, C and            laparotomy due to size of both masses. Pathology reported
D (SDHB, SDHC and SDHD) mutations were negative.                    LAL was consistent with angiomyolipoma and the RAL
	    Discussion: PGL are rare neuroendocrine neoplasms              was consistent with non functional adenoma associated
that arise from extra-adrenal chromaffin cells and can be           with adrenal cortex hyperplasia.
familial or sporadic. They may be associated with VHL               	     Discussion: Adrenal incidentaloma is a lesion greater
disease, MEN 2, neurofibromatosis and succinate dehy-               than 1cm in diameter found by radiologic imaging when
drogenase (SDHx) gene mutations. The PGL of sympa-                  investigating for unrelated symptoms and/or signs of an
thetic origin are usually catecholamine secreting, are              adrenal tumor. The prevalence peaks between the 50th
intraabdominal and are associated with SDHB mutation                and 60th year and is particularly high in patients with fea-
while the PGL of parasympathetic origin are mostly non-             tures of the metabolic syndrome. Discovery of an adrenal
functioning, are in the head and neck and are SDHC- and             mass raises two important questions: Is it malignant? Is
SDHD- related.                                                      it functioning? Bilateral adrenal masses can be seen with
	    Conclusion: Our case emphasizes that paraganglioma             metastatic disease, congenital adrenal hyperplasia, corti-
should be considered in the work up of an abdominal mass            cal adenomas, lymphoma, hemorrhage, ACTH-dependent
and must be evaluated for excess catecholamine secre-               Cushing syndrome, pheochromocytoma, amyloidosis,
tion so adequate alpha blockade can be achieved prior to            infiltrative disease of the adrenal glands, among others.
resection. Genetic testing for SDHx mutations should also           After evaluation of our patient a SCS was diagnosed,
be done in all patients with paragangliomas and if posi-            which is the most frequent hormonal abnormality detected
tive, genetic testing should be done in their first-degree          in patients with adrenal incidentalomas. The risk of malig-
relatives because of the high risk of malignancy associ-            nancy is low, but it increases with the size of the mass,
ated with these mutations particularly in those with SDHB           for this reason our patient underwent surgery. Nonetheless
mutations.                                                          after bilateral adrenalectomy was performed, our patient
                                                                    improved her blood sugar levels and hypertension.
Abstract #108                                                       	     Conclusion: Bilateral adrenal incidentalomas is a
                                                                    very rare condition and surgical intervention can improve
BILATERAL ADRENAL INCIDENTALOMAS                                    the metabolic derangement present in SCS.
AND SUBCLINICAL CUSHING SYNDROME IN A
DIABETIC PUERTO RICAN WOMAN
                                                                    Abstract #109
Mariela Nieves-Rodriguez, MD,
Myriam Allende, MD, FACP, FACE, MBA,                                CUSHING SYNDROME AND SECONDARY
Margarita Ramirez-Vick, MD, FACP, FACE,                             ADRENAL INSUFFICIENCY IN ASTHMATIC
Marielba Agosto, MD, Meliza Martinez, MD                            PATIENTS ON HAART (HIGHLY ACTIVE
                                                                    ANTIRETROVIRAL THERAPY)
	    Objective: To describe a case of bilateral adrenal
masses and subclinical Cushing syndrome (SCS) in a dia-             Praveena Gandikota, MD, Kara Rysman Fine, MD
betic and hypertensive puerto rican woman.
	    Case	Presentation: A 64 y/o woman with DM-2, HTN,              	    Objective: To increase awareness regarding a poten-
Dislipidemia and Osteoporosis who came to our clinics               tially life threatening interaction between inhaled steroids
due to bilateral adrenal masses found on abdomino-pelvic            and HAART.


                                                              –5–
                                        ABSTRACTS – Adrenal Disorders

	    Case	Presentation: A 57 year old woman was admit-               Abstract #110
ted with hyperglycemia for 3 weeks without response to
maximal doses of Glucophage and Diabeta. The patient                 BILATERAL ADRENAL HEMORRHAGE
had a history of HIV, diabetes mellitus diet controlled              FOLLOWING UNCOMPLICATED CAESAREAN
since 2004 and asthma. Her HAART regimen was stable                  SECTION: A CASE REPORT AND REVIEW
since 2005 and included Ritonavir, Atazanavir, Abacavir
and Lamuvidine. She was hospitalized for pneumonia 5                 Brian Ellis Michael, MD, FACE
weeks prior to admission and was placed on antibiotics,
steroids and Advair 250/50 mcg (Fluticasone/ Salmeterol)             	    Objective: To report the occurrence of bilateral adre-
inhaler twice daily. Intravenous steroids were given for             nal hemorrhage in a healthy young female after uncompli-
5 days followed by oral taper. Last dose of oral steroids            cated Caesarean section.
was 3 weeks before this admission. She reported 15                   	    Case	 Presentation: A 20 year old gravida 1 para 1
pound weight gain over 3 weeks, predominantly in face                presented to the hospital with abrupt onset progressive left
and abdomen. She required 70 units of insulin daily to               upper quadrant and left flank pain. She was one week post
keep blood sugars between 150 and 200 mg/dl. Physical                partum from an uncomplicated C-section with estimated
examination was significant for buffalo hump and moon                600ml blood loss. There was no recent trauma. There was
facies. Further evaluation showed that with 250mcg                   no GI or urinary symptoms. Past history was negative.
ACTH (Adrenocorticotropic Hormone) stimulation, cor-                 Family history was negative for any known coagulopa-
tisol at 0min, 30min and 60min were <0, 3 and 4 mcg/dl               thy. She took no medications. Physical findings included
respectively.                                                        mild left upper quadrant and left flank percussion tender-
	    Discussion: Ritonavir is commonly used as part of               ness and were otherwise completely normal. Routine lab
HAART and is a potent inhibitor of cytochrome P450                   evaluation was within normal limits. CT imaging of the
3A4.Normally, plasma levels of inhaled fluticasone are               abdomen revealed stranding of the left adrenal gland con-
low due to extensive first pass metabolism through cyto-             sistent with adrenal hemorrhage and no other findings.
chrome P450 3A4. Administration of both fluticasone                  Random AM cortisol value was 12ug/dl and stimulated
and ritonavir leads to increased plasma levels of flutica-           cortisol after 250ug cosyntropin was 32ug/dl. The patient
sone because of inhibition of its metabolism. This leads             was treated conservatively and improved sufficiently for
to iatrogenic Cushing syndrome and secondary adrenal                 discharge within 48 hours. One week later she presented
insufficiency as seen in our patient. This phenomenon                with identical spontaneous symptoms in the right upper
has been described with as little as 2 weeks of fluticasone          quadrant and right flank. Routine laboratory values were
therapy in patients on ritonavir. Additionally, cases have           all normal. CT imaging was repeated and demonstrated
been reported with low dose of 500 mcg/day of fluticasone            right adrenal hemorrhage with no other findings. Repeat
and the lower boosting dose of ritonavir of 100 mg/day as            basal and stimulated cortisol values were similar to the
well. Patients with HIV can also develop HIV- associated             initial hospitalization. Upright aldosterone values were
lipodystrophy which can delay the diagnosis of Cushing               normal. Complete hematologic evaluation for coagulation
syndrome. During periods of stress, these patients need              abnormalities was within normal limits. After conserva-
additional corticosteroid support. It is also important to           tive treatment with analgesics she again improved suffi-
note that on abrupt discontinuation of fluticasone, patients         ciently for discharge. Subsequent course over two years
can develop signs and symptoms of adrenal insufficiency              has been uneventful, including additional uncomplicated
necessitating slow taper or temporary oral corticosteroid            out patient surgeries. Additional cosyntropin stimulation
therapy.                                                             testing at three months after the second episode of adrenal
	    Conclusion: It is imperative that physicians are aware          hemorrhage was normal.
of interaction between ritonavir and inhaled fluticasone             	    Discussion: Unilateral or bilateral adrenal hemor-
leading to iatrogenic Cushing syndrome and secondary                 rhage has been reported as a complication of sepsis,
adrenal insufficiency. High index of suspicion is needed as          hypotension, anticoagulant therapy, trauma, hypoten-
HIV-lipodystrophy can confound recognition of Cushing                sion, bleeding disorders and some surgical procedures.
syndrome.                                                            This patient report appears to be the first reported case of
                                                                     late onset bilateral adrenal hemorrhage shortly following
                                                                     uneventful normal Caesarean section with no identifiable
                                                                     precipitating cause.




                                                               –6–
                                       ABSTRACTS – Adrenal Disorders

Abstract #111                                                       concurrently. Even when an adrenal adenoma is identi-
                                                                    fied, AVS is an important diagnostic step because a contra-
COMBINED CONN ADENOMA AND                                           lateral adrenal adenoma may not be visible on computed
SUB-CLINICAL CUSHING SYNDROME                                       imaging.

Amitpal Kohli, MD, George Dailey, MD,                               Abstract #112
William Young, MD
                                                                    NORMOTENSIVE PHEOCHROMOCYTOMA
	    Objective: To report a patient with bilateral adreno-
cortical adenomas - one producing excess aldosterone and            Archana Reddy, MD, G. Matthew Hebdon, MD, PhD,
the other producing excess cortisol.                                Ved V. Gossain, MD, FACP, FACE
	    Case	 Presentation: A 54-year-old man presented
with hypertension and hypokalemia. The plasma aldo-                 	    Objective: To present a case of normotensive pheo-
sterone concentration (PAC) was 12 ng/dL (N<28 ng/dL)               chromocytoma and discuss outpatient preoperative
and the plasma renin activity (PRA) was 0.1 ng/mL/hr                management.
(N<0.65 ng/mL/hr). After a 2-h saline infusion, the PAC             	    Case	Presentation: A 74 year old woman had a CT
increased from 10 to 16 ng/dL (N<5 ng/dL). Abdominal                angiogram for evaluation of leg pain when an adrenal
CT revealed a 1.8 cm right adrenal mass and an appar-               mass was incidentally discovered. She denied history of
ent normal appearing left adrenal. The 24-h urinary free            hypertension, headaches, sweating, palpitations, weight
cortisol was 222.5 mcg (4-50 mcg), and 24-h urine meta-             loss, abdominal or chest pain. She had a history of rheu-
nephrine was 109 mcg (N<315 mcg). The serum ACTH                    matoid arthritis and hypercholesterolemia. Physical exam
concentration was <5 pg/mL (N 7-50 pg/mL). The serum                revealed blood pressure (BP) 100/60 without orthostatic
cortisol concentrations after 1-mg and 8-mg dexametha-              hypotension. The remainder of the examination was unre-
sone suppression tests were 16.9 mcg/dL and 17.8 mcg/               markable except for choreoathetosis of arms and face.
dL, respectively. The patient lacked signs or symptoms              CT angiogram revealed a 4.5cm left adrenal mass which
of clinical Cushing syndrome. A second opinion was                  was confirmed by MRI. PET-CT with FDG showed 4-5
requested. Adrenal venous sampling (AVS) showed a cor-              cm lesion with density of 17-18 Hounsfield units. Plasma
tisol step-up on the side of the right visible adenoma, and         free metanephrines were 18.9 nmol/L (normal <0.5) and
an aldosterone step-up on the left. A surgical consultant           free normetanephrines were 3.49 nmol/L (normal < 0.90).
declined to operate on the normal appearing left adrenal            A diagnosis of normotensive pheochromocytoma was
gland. After a year of marginally successful medical ther-          made and left adrenalectomy was recommended. A base-
apy for hyperaldosteronism, repeat adrenal CT showed an             line low BP precluded the initial use of α blockers. The
apparent 9 mm left-sided adenoma. Repeat AVS at Mayo                patient increased her salt intake, received intravenous nor-
Clinic Rochester showed aldosterone concentrations of               mal saline at home and her BP increased to 118/70. After
9700 ng/dL (left AV), 180 ng/dL (right AV), and 40 ng/              two days of outpatient hydration Phenoxybenzamine, 10
dL (IVC). Cortisol concentrations were 94 mcg/dL (left              mg/day was started and gradually increased to 20mg/
AV), 1016 mcg/dL (right AV), and 21 mcg/dL (IVC).                   day. She was hospitalized two days before surgery and
Subsequent bilateral adrenalectomy found a 9 mm left                Phenoxybenzamine was titrated to 30mg/day, at which
adrenal adenoma and a 2.5 cm right adrenal adenoma.                 point she developed orthostatic hypotension. A lapa-
Glucocorticoid and mineralocorticoid autonomy were                  roscopic adrenalectomy was planned but she required
cured.                                                              open abdominal adrenalectomy. Her BP remained stable
	    Discussion: Conn adenoma and adrenal-dependent                 intraoperatively but she developed hypotension and atrial
Cushing syndrome are uncommon disorders. The occur-                 fibrillation post operatively, which reverted to normal
rence of bilateral simultaneously functioning adrenal               sinus rhythm upon hydration. Plasma fractionated meta-
adenomas is extremely rare. Most reported cases have                nephrines normalized postoperatively and choreoathetosis
involved a single adrenal adenoma overproducing aldo-               improved. Histopathology confirmed pheochromocytoma.
sterone and cortisol. In most cases, patients lacked typi-          	    Discussion: Pheochromocytoma is a rare neuroendo-
cal signs and symptoms of Cushing syndrome - termed                 crine tumor that usually presents with stable or paroxys-
sub-clinical Cushing syndrome. We describe a rare patient           mal hypertension. Normotensive pheochromocytomas are
with a right adrenal cortisol-producing adenoma and a left          extremely rare. Despite elevated catecholamines, as in our
adrenal aldosterone-producing adenoma. Our patient also             patient, the BP remains normal, the mechanism for which
lacked signs and symptoms of Cushing syndrome.                      is not clear. Preoperative preparation with hydration, α
	    Conclusion: As previously reported, Conn adenoma               blockers and β blockers (if needed) is required even in
and adrenal-dependent Cushing syndrome can exist                    normotensive patients, but this may cause hypotension in


                                                              –7–
                                        ABSTRACTS – Adrenal Disorders

such patients. Therefore hospitalization for 7 to 10 days is         successful treatment of an adrenocortical carcinoma is
usually recommended. We have shown that such prepara-                surgical resection of the adrenal tumor.
tion can be safely done as an outpatient.                            	   Conclusion: Adrenocortical cancer is a rare tumor
     Conclusion: Pheochromocytoma with low/normal                    which may pose a diagnostic dilemma. Clinicians and
BP is an unusual presentation. In normotensive patients,             pathologists need to be aware of the diagnostic challenges
although preoperative preparation is required, it can be             and appropriate staining of a presumed renal mass should
safely done in the outpatient setting with close monitor-            be performed as dictated by patient’s presentation.
ing, thus saving a major expense.
                                                                     Abstract #114
Abstract #113
                                                                     ADRENOCORTICAL CARCINOMA SHOULD
ADRENOCORTICAL CANCER MISTAKEN                                       BE CONSIDERED WHEN ADRENAL
FOR A RENAL MASS                                                     NODULE SIZE IS GREATER THAN 3.5
                                                                     CENTIMETERS IN PATIENTS WITH PRIMARY
Rabia Cherqaoui, MD, Wolali Odonkor, MD,                             HYPERALDOSTERONISM
Gail Nunlee-Bland, MD
                                                                     Barbra Sue Miller, MD, Paul G. Gauger, MD,
	    Objective: To report a case of a functional adreno-             Gary D. Hammer, MD, Gerard M. Doherty, MD
cortical cancer, initially misdiagnosed radiologically as a
renal cell carcinoma and review the current literature on            	     Objective: In extremely rare cases adrenocortical car-
this subject.                                                        cinoma (ACC) can present as primary hyperaldosteron-
	    Case	 Presentation: 57-year-old postmenopausal                  ism (PHA). We sought to compare adrenal nodule size
African American female with history of hypertension                 and imaging characteristics to differentiate benign from
and diabetes was admitted for a hip abscess. Physical                malignant aldosterone producing adenomas (APA) and
findings were notable for a cushingoid appearance with               allow optimal preoperative planning and selection of an
a buffalo hump, truncal obesity, abdominal striae and                open surgical approach.
ecchymoses. There were no signs of hirsutism or viriliza-            	     Methods: A retrospective review of patients with
tion. Ultrasound and computerized tomography revealed a              PHA undergoing surgery at a tertiary referral institution
large mass appearing to originate from the upper pole of             from 2004-2009 was performed. Demographics, imag-
the right kidney. Cushing syndrome was suspected on the              ing, laboratory, operative, and pathology results were
basis of physical findings. Biochemically, there was evi-            reviewed. Results are reported using descriptive methods
dence of hyperandrogenism and hypercortisolism suggest-              and chi square analysis.
ing an adrenal tumor. Core-biopsy of the presumed renal              	     Result: Of 91 patients undergoing surgery for ACC, 5
mass was performed but cytological examination failed                had evidence of excess production of aldosterone (APACC)
to demonstrate any renal cells. Given that the patient had           without biochemical evidence of other adrenal hormone
Cushing syndrome, a staining for adrenal cell carcinoma              excess. 37 patients underwent surgery for PHA second-
was done confirming the mass to be an adrenocortical                 ary to benign disease. Median age for those with APACC
carcinoma. On immunohistochemical analysis, the tumor                was 48 years (range 39-53) and 54 years (32-72) for those
cells were positive for inhibin and vimentin supporting the          with APAs (p=0.07). Median nodule size of patients with
diagnosis of an adrenocortical neoplasm.                             APACC was 6.5cm (3.9-18.0). Two of five were suspected
	    Discussion: Primary adrenocortical carcinoma is a               to be APACC preoperatively and appropriately underwent
rare tumor with an estimated incidence of 1 per 1.7 mil-             open adrenalectomy. Three underwent laparoscopic resec-
lion. Approximately, half of these carcinomas are hyper-             tion at outside institutions. All APACCs had indeterminate
secretory tumors associated with increased production of             imaging characteristics noted (washout/signal loss crite-
glucocorticoids, sex steroids or more rarely mineralocor-            ria, etc.). Median nodule size in those patients with APAs
ticoids. Most of adrenocortical cancers are large (>6 cm)            was 1.5cm (0.4-3.1) (p<0.005). Twenty-three patients
at presentation. Radiologically, the diagnosis can be easily         with APAs had comments regarding imaging character-
confused with renal lesions. There have been few reported            istics other than size. Four (17%) showed heterogeneity,
cases of non functioning adrenocortical carcinoma mim-               inadequate washout or loss of signal despite being benign.
icking renal cell carcinoma based on preoperative imag-              Median APACC size appears less than for all ACCs but
ing and histologically proven postoperatively to actually            didn’t reach significance [10.2cm (3.2-27)] (p=0.24).
originate from the adrenal cortex. In adults, median sur-            	     Discussion: ACC continues to be a deadly disease.
vival without treatment is 3 months and with treatment               Awareness of PHA has increased among clinicians.
14 months. The single most important procedure for                   Because pure APACCs are extremely rare, the diagnosis


                                                               –8–
                                       ABSTRACTS – Adrenal Disorders

may not be entertained in the preoperative setting. Most            	    Discussion: CS is a very rare disorder with an inci-
APAs are removed laparoscopically. Recently presented               dence of 5 per million. The majority of the cases (80%)
data has shown that laparoscopic resection of ACC is                result from pituitary secretion while 10% of the cases
inappropriate. PHA is usually associated with very small            are due to ectopic secretion of ACTH. CS from ectopic
adrenal nodules averaging 1-2cm.This study shows that               corticotrophin-releasing hormone (CRH) by a pheochro-
APACCs are significantly larger than APAs. Size may                 mocytoma has been documented. Criteria to prove ecto-
be a more important assessment tool for differentiat-               pic secretion of ACTH/CRH include: Hypercortisolism,
ing APAs from APACCs than the use of other imaging                  elevated hormone level in the venous effluent from the
characteristics.                                                    pheo site, plasmatic normalization after pheo removal and
	    Conclusion: APACCs are extremely rare. Clinicians              hormonal activity in the pheo. Our patient fulfills some of
should carefully examine available imaging when evalu-              these criteria and the most important one that is the pres-
ating patients with PHA to identify potential malignan-             ence of CRH in the tumor tissue is under processing.
cies and allow selection of an open approach for surgical           	    Conclusion: Ectopic Cushing syndrome as a conse-
resection to optimize oncologic outcome.                            quence of ACTH or CRH production carries a high mor-
                                                                    tality rate of 57%. It is crucial as Endocrinologists to have
Abstract #115                                                       a high index of suspicion and to use a systematic approach
                                                                    to reliably diagnose pheochromocytoma as a source of
ECTOPIC CUSHING SYNDROME IN A PATIENT                               ectopic CS.
PRESENTING WITH PHEOCHROMOCYTOMA
                                                                    Abstract #116
Andrea Marcela Sosa Melo, MD,
Ana Cecilia Apaza Concha, MD, Maria del Pilar Solano                BILATERAL ADRENAL MASSES PRESENTING
                                                                    WITH PRIMARY HYPERALDOSTERONISM
	    Objective: To report a case of Cushing Syndrome                AND SUBCLINICAL CUSHING SYNDROME:
(CS) due to suspected CRH secretion in a patient with               DIAGNOSTIC CHALLENGES AND THE ROLE
pheochromocytoma producing paroxysmal hypertension                  OF ADRENAL VEIN SAMPLING
and brittle diabetes.
	    Case	 Presentation: 70 yo female with h/o HTN                  Aparna Madhav Ayyagari, MD, Elias S. Siraj MD, FACE
and diabetes, presented with 3 months of painless jaun-
dice, was transferred to a tertiary care center after ERCP                Objective: To report a case of bilateral adrenal masses
with CBD stenting for further evaluation of obstructive             presenting with primary hyperaldosteronism and subclini-
cholestasis. A CT scan of the abdomen revealed a 1.7 by             cal Cushing syndrome and discuss the challenges in the
2.4 cm pancreatic head mass as well as a 4.6 x 5.9 cm               workup.
incidental complex right adrenal mass. During admis-                      Case	 Presentation: A 45 year-old female presented
sion the patient developed brittle diabetes requiring esca-         with hypokalemia ranging 3.3-3.5 mmol/L. She has long-
lating doses of insulin and repeated episodes of severe             standing history of hypertension which has been treated
hypoglycemia. The patient had biochemical evidence of               with various medications. At the time of her initial pre-
hypercortisolism in conjunction with high ACTH levels               sentation, she was on atenolol, amlodipine and potas-
(279 pg/mL), non-suppressible on high-dose dexametha-               sium supplements. On examination, blood pressure was
sone suppression testing. The patient complained of pal-            130/80 and weight was 227 pounds. Laboratory tests over
pitations and diaphoresis. She had resistant hypertension.          a period of several months to rule out primary hyperaldo-
Biochemical testing confirmed elevated 24-hour urinary              steronism showed plasma aldosterone levels of 36-38 ng/
cathecolamines and metabolites. The patient was taken to            dL and plasma renin activity of 0.2 ng/mL/hr. Attempts
OR to perform adrenalectomy and Whipple procedure but               at performing oral salt load were unsuccessful on two
after adrenalectomy she developed sudden hypotension                occasions. CT scan showed bilateral adrenal lesions mea-
and Whipple procedure was aborted. ACTH level dropped               suring 1.6 x 1.4 cm on the right and 1.8 x 1.8 cm on the
to 12 pg/mL. Post-op Immunochemical studies revealed                left. Bilateral adrenal hyperplasia was favored over bilat-
a pheochromocytoma negative for ACTH. CRH immu-                     eral adenoma. MRI showed similar finding but bilateral
nochemical study is in process. Six days after surgery              adenomas were favored. With the clinical impression of
her respiratory status deteriorated. CT angiogram did not           primary hyperaldosteronism secondary to bilateral adre-
confirm PE, however lower extremities Doppler was posi-             nal masses (hyperplasia versus adenomas), we decided to
tive for DVT. She became lethargic, hypoxic. Intubation             start treatment with spironolactone 25 mg which lead to
was offered but patient declined. Unfortunately after an            resolution of her hypokalemia. Her blood pressure was
overwhelming hospital course, the patient succumbed.                controlled with spironolactone and amlodipine. On fur-
Autopsy was not done honoring family wishes.                        ther follow-up, she was noted to have lower extremity
                                                              –9–
                                          ABSTRACTS – Adrenal Disorders

edema and weight gain of about 60 lbs over two years              above included back pain and significant weight loss of
Workup for Cushing syndrome showed an AM cortisol of              60 pounds over 2-1/2 years. Work up of the adrenal mass
13 µg/dl following 1 mg overnight dexamethasone sup-              showed no excess cortisol production, normal androgens,
pression test. Twenty four hours urine free cortisol levels       normal renin and aldosterone. Plasma metanephrine level
were 67, 88 & 139 µg/day on three occasions (4-50 µg/             was 191, plasma normetanephrine level was 11,863. An
dL). Salivary cortisol levels from 11 PM were 0.11 and            open left adrenalectomy was performed with pre operative
0.19 µg/dL on two occasions (<0.09 µg/dL). ACTH levels            treatment with phenoxybenzamine. The histopathology
were < 5 pg/mL(5-27 pg/mL) on two occasions. Adrenal              showed adrenal cortex compressed by the pheochromo-
vein sampling was performed. Although the results were            cytoma, a pseudocapsule without invasion, and immunos-
inconclusive, they suggested higher aldosterone secretion         taining revealed chromogranin, syaptophysin, CD56 and
from the right adrenal gland. However there was no clear          vimentin, and stained negative for S-100, and Ki-67 was
lateralization in regard to cortisol. Because of the subclini-    less than 1%.There were focal areas of increased mitoses.
cal nature of her symptoms, we decided to stay conserva-          No local or distant metastases were noted. After surgery,
tive and observe.                                                 patient has been doing well with no recurrence of embolic
	    Discussion: Primary hyperaldosteronism and                   phenomena. She is still on chronic anticoagulation.
Cushing syndrome may coexist as a result of bilateral             	    Discussion: Arteriovenous thromboembolism is
adrenal masses. While primary hyperaldosteronism can              not a known complication of pheochromocytomas.
be controlled with medications, Cushing syndrome may              Furthermore, there are few cases described in humans
necessitate surgery and therefore identifying the relative        with this condition. There are case descriptions of very
significance of each lesion is of importance. Even though         high levels of catecholamine production causing persistent
at times adrenal vein sampling may be helpful, at other           arterial vasospasm which led to marked and irreversible
times results may be inconclusive.                                ischemia. There was clear evidence of recurrent embolic
                                                                  phenomena that persisted despite anticoagulation and this
Abstract #117                                                     was hypercoagulable condition was ameliorated by adre-
                                                                  nalectomy. In canine models, epinephrine caused more
PHEOCHROMOCYTOMA CAUSING                                          coronary thromobosis than norepinephrine. Epinephrine
ARTERIOVENOUS THROMBOEMBOLISM WITH                                is a stimulatory factor for platelet aggregation in vitro and
RESOLUTION AFTER ADRENALECTOMY                                    a prothrombogenic agent for arterial thrombosis in vivo.
                                                                  There is however conflicting data with norepinephrine in
Jagdeesh Ullal, MD, M. Elizabeth Mason, MD                        coronary artery circulation in that it inhibited thrombosis.
                                                                  	    Conclusion: This is a case of a benign pheochromo-
	    Objective: To describe a case of catehcholamine              cytoma that had recurrent arterial and venous thromboem-
secreting adrenal mass causing multiple arterial and venous       bolism. Few cases have been reported so far with such a
thrombembolism with resolution after adrenalectomy.               phenomenon. It is difficult to make a causal relationship
	    Case	 Presentation: A 40 yo lady with a history of           but it has been known that excess catecholamines have
mild hypertension, controlled type 2 diabetes, Grave’s            pro-inflammatory and thrombogenic effects. It is uncer-
disease and post ablative hypothyroidism had hemoptysis,          tain as to why this phenomenon is not seen more often.
and presented with acute, painful, ischemic right lower           We surmise that it is because of the differential effects of
extremity, and immediate right femoral thromboembo-               norepinephrine and epinephrine on vascular endothelium.
lectomy was performed. She had both acute and chronic
appearing thrombus of femoral bifurcation and extending           Abstract #118
into the popliteal and tibial vessels. The procedure restored
circulation to her right lower extremity and she was con-         A CASE OF SECONDARY HYPERTENSION IN
tinued on intravenous anticoagulation. Two weeks into             A PATIENT WITH CONGENITAL ADRENAL
hospitalization, she had another episode of arterial throm-       HYPERPLASIA
boembolism which was successful treated with embolec-
tomy. During work up for hemoptysis, 3 months prior to            Alina Khan-ghany, MD, Reyan Ghany, MD,
the acute presentation, a CT scan of the chest revealed a         Denise Armellini, MD
mobile intracardiac mass in the left ventricle of 2 x 2 x 4
cm, which was a thrombus. Further evaluation revealed             	    Objective: To describe a rare cause of secondary
large volume pulmonary embolus involving both left and            hypertension in a patient with a history of congenital adre-
right lungs, left renal infarct and a left suprarenal mass        nal hyperplasia (CAH).
is 7.9 x 7.9 x 9.2 cm containing fine calcifications. The         	    Case	Presentation: A 23 year-old Hispanic male with
patient’s symptoms leading up to the episodes described           a past medical history significant for non-salt wasting


                                                             – 10 –
                                       ABSTRACTS – Adrenal Disorders

CAH secondary to 21-hydroxylase deficiency presented          Abstract #119
to the ER with a hypertensive emergency. He reported a
3 week history of severe headaches, nausea and vomit-         CUSHING SYNDROME IN PREGNANCY
ing and was found to have a blood pressure of 230/130
mmHg. On the physical exam, he was phenotypically a           Miguel E. Pinto, MD, FACE, Miguel Guillan, MD,
male, although his genotype was XX at birth. He had no        Milagros Ortiz, MD, Jaime E. Villena, MD
breast development with scant axillary, facial, chest and
abdominal hair. His genitalia were consistent with a small    	    Objective: To report a case of a pregnant woman who
penile size and testicular implants as he underwent sexual    developed hyperglycemia and preeclampsia secondary to
reconstructive surgery including clitoridectomy, hysterec-    Cushing’ syndrome.
tomy and testicular implants. During his hospital course,     	    Case	 Presentation: A 39-year-old woman with pre-
blood work revealed elevations in serum creatinine of         vious history of hypertension and diabetes, both of them
1.6 mg/dl, 11-deoxycortisol levels of 634 ng/dl, 17-OH        without regular treatment, presented at 24 weeks’ gesta-
progesterone 5238 ng/dl, ACTH 56 pg/ml, testosterone          tion in her fourth pregnancy with severe headache and
200 ng/dl and androstenedione 931 ng/dl confirming the        uncontrolled blood pressure. She experienced preeclamp-
diagnosis of 11-hydroxylase deficiency. Other secondary       sia in her previous pregnancy. Physical examination
causes of hypertension including coarctation of the aorta     showed a blood pressure of 180/110 mmHg, heart rate
and renal artery stenosis were excluded by imaging stud-      of 104 beats/min, respiratory rate of 24 breaths/min, and
ies. Plasma renin activity, aldosterone and plasma meta-      BMI of 38. Other findings were acne, hirsutism, and striae
nephrine levels were normal. MRI of the abdomen with          in the abdominal wall. A hypertensive crisis diagnosis was
contrast revealed macronodular disease of the adrenals        established, and patient was admitted in ICU for manage-
consistent with CAH. The patient was discharged with          ment of blood pressure. Further work up showed, hyper-
normal blood pressure readings after starting a calcium       glycemia, severe proteinuria, morning hypercortisolemia
channel blocker and a beta-blocker.                           and elevated 24-hour urinary free cortisol. Fetal ultra-
	    Discussion: CAH is an autosomal recessive condition      sonography revealed a single viable fetus with normal
that may result from several enzymatic deficiencies, most     morphology and parameters. Patient was discharged from
commonly 21-hydroxylase deficiency. 11-hydroxylase            ICU with oral methyldopa 3000mg/day. Her pregnancy
deficiency produces similar androgenic but different min-     is going without complications, and she is continuing her
eralocorticoid effects. Hypertension that ensues results      controls in the outpatient setting of our unit.
from increased levels of mineralocorticoid precursors and     	    Conclusion: The occurrence of pregnancy in the face
is often a clue that a patient has 11-hydroxylase rather      of untreated Cushing’ syndrome is rare because of the
than 21-hydroxylase deficiency. Treatment strategies          high incidence of ovulatory disturbances experienced by
may include glucocorticoid therapy in sufficient doses to     patients with this disorder. Fifty percentage of pregnancies
reduce ACTH secretion and therefore excess androgen as        and untreated Cushing’ syndrome are caused by adrenal
well as 11-deoxycorticosterone leading to improvement         adenoma. In contrast, Cushing’ syndrome in nonpregnant
in blood pressure control. However, patients may require      women is related to pituitary disorders. Cushing’ syn-
concurrent standard antihypertensive therapy.                 drome in pregnancy follows a hazardous course with an
	    Conclusion: 11-hydroxylase deficiency is a rare          increased rate of abortion, premature labor, hypertension,
cause of hypertension that should be entertained in a         gestational diabetes, cardiac failure and even pulmonary
patient with a history of CAH. It is therefore important      edema. Fetal complications are also severe, with preterm
to define the specific enzymatic defect upon diagnosis of     deliveries, intrauterine growth retardation, and perinatal
CAH as this will help recognize specific complications        deaths.
such as hypertension and prevent sequelae such as chronic
kidney disease, left ventricular hypertrophy, retinopathy,
and macrovascular events.




                                                         – 11 –
                                         ABSTRACTS – Adrenal Disorders

Abstract #120                                                    Virilizing ovarian tumors have been described in patients
                                                                 with congenital adrenal hyperplasia including ACTH-
CONGENITAL ADRENAL HYPERPLASIA AND                               dependent ovarian masses, hilus cell tumor, steroid cell
LEYDIG CELL TUMOR OF OVARIES -                                   tumor, and stromal luteoma. In our patient the ovarian
RARE COMBINATION CAUSING                                         tumor became evident some time after removal of the adre-
VIRILIZATION SYNDROME                                            nal glands. We suggest that the bilateral adrenalectomy
                                                                 could have played a causative role in the development of
Jose Maireni Cabral, MD, FACE, Rolando Perez, MD,                Leydig cell hyperplasia. ACTH and LH had been previ-
Vishal Mundra, MD                                                ously suppressed by the use of high-dose exogenous glu-
                                                                 cocorticoids and endogenous overproduction of 17-OH-P
	    Introduction: During the work up of virilization, a         and testosterone. Normalization of its levels after reduc-
combination of adrenal and ovarian causes, although rare,        tion in the dose of glucocorticoids and surgery could have
may be present. Failure of resolution of hormonal abnor-         been a stimulant for the Leydig cells to eventually become
malities after adrenal surgery should raise a suspicion for      a new androgen-producing tumor.
ovarian tumors.
	    Case	 Presentation: Here we describe a 37-year-old          Abstract #121
female who presented with chief complaint of hirsutism.
At birth she was diagnosed with congenital adrenal hyper-        HIRSUTISM AND HYPOKALEMIA IN A PATIENT
plasia due to 21-hydroxylase deficiency. Despite optimal         WITH A NEUROENDOCRINE TUMOR
medical therapy with glucocorticoids and mineralocor-            OF THE BREAST
ticoids, the patient developed progressive virilization
including excessive hair, and infrequent menstrual cycles        Kiarash Zarbalian, MD, Richard Horenstein, MD
On examination, she had increased musculature and hir-
sutism, no alopecia or acne. Laboratory work up showed           	    Objective: To describe a case of documented ecto-
elevated androgens, total testosterone 466 ng/ml (2-45           pic ACTH secretion in a patient with a breast mass with
ng/ml), free testosterone 75.5 pg/ml (0.1-6.4 pg/ml), and        unusual pathologic features.
high 17-hydroxyprogesterone (17-OH-P) of 3153 ng/dL.             	    Case	 Presentation: A 60-year-old female presented
LH and FSH were suppressed. CT scan of the abdomen               to her primary care with a 2 month history of worsen-
showed significant enlargement of the adrenal glands, 7          ing hirsutism of the upper lip and chin, weight gain of 15
x 4 cm on the left, and 4.5 x 2.5 on the right. Because          lbs, and difficulty getting out of a chair. On lab evalua-
of the unresponsiveness to supraphysiologic doses of             tion, the potassium was 1.6 mmol/L with a blood glucose
glucocorticoids, the patient underwent bilateral adrenal-        338 mg/dl. An abdominal CT without contrast was per-
ectomy. After surgery, her total testosterone was 29 ng/         formed in light of the new hypokalemia showing bilat-
ml, free testosterone was 2.8 pg/ml, and 17-OH-P (1.7ng/         eral symmetrical thickening of her adrenal glands and
dL) was almost undetectable. LH and FSH levels became            multiple low density liver lesions. She was admitted. An
normal. However, nine months after, hirsutism was still          AM cortisol of 57.1 mcg/L was found after 1 mg dexa-
present. Laboratory studies showed that her testosterone         methasone suppression, with an ACTH level of 871 pg/
levels raised again, with total testosterone being 290 ng/       ml. Following an 8 mg dexamethasone suppression, the
ml, and free testosterone 60.9 pg/ml, with elevation of          AM cortisol was 47.1 mcg/L. A 24 hour urine free cortisol
17-hydroxyprogesterone (2532 ng/dL) was found. As the            was 1126 ug/L. A pituitary MRI was not completed due to
patient had bilateral adrenalectomy, search for an addi-         extreme claustrophobia despite sedation, although a head
tional source of androgen production was initiated. CT           CT with contrast showed no masses. DHEA-S was 68
scan of the pelvis showed a possible 2 cm right ovarian          ug/dL with a total testosterone of 128 ng/dL. A chromo-
mass and the patient underwent hysterectomy and bilat-           granin A level was 17 nmol/L. Biopsy of the liver lesions
eral salpingo-oophorectomy. There were bilateral masses          showed metastatic adenocarcinoma that was ER and PR
medial to the ovaries of approximately 2 cm in size.             negative, although a breast source could not be ruled out.
Pathologic examination showed Leydig cell hyperplasia            Chest CT was otherwise negative except for a 6 mm lung
in both ovaries. After removal of the ovaries, her total tes-    nodule. A closer exam revealed a left sided breast lesion.
tosterone decreased to 51 ng/ml, and the free testosterone       A core needle biopsy revealed features consistent with
to 2.4 pg/ml.                                                    neuroendocrine tumor and stained positive for synapto-
     Discussion: To our knowledge, this is the only case         physin but negative for ACTH and chromogranin. PET/
of congenital adrenal hyperplasia and bilateral Leydig cell      CT images showed bilateral uptake in the adrenal glands
tumor of ovaries in a female patient to be described in the      and liver, and no uptake in the lung lesion, the breasts,
English literature.                                              or axillae. Ketoconazole and spironolactone were started


                                                            – 12 –
                                          ABSTRACTS – Adrenal Disorders

for Cushing syndrome. She received one round of chemo-            function tests, routine urinalysis, chest X-ray and ECG,
embolization of the liver lesions and chemotherapy. The           which revealed a concomitant finding of a granuloma over
patient died one month after treatment was initiated and          the right lower lobe, left ventricular hypertrophy with
before an octreotide scan could be performed for defini-          strain pattern most likely a complication of long-standing
tive localization.                                                hypertension and incidental finding of subclinical hyper-
	    Discussion: Neuroendocrine tumors comprise                   thyroidism (TSH IRMA 0.046 n.v. 0.27-3.75; FT4 RIA
12-20% of the tumors that elaborate ACTH and are usually          16.584 n.v. 8.8-33.0). Hormonal studies revealed elevated
found in sites other than the breast such as the pancreas         basal plasma cortisol levels (8am 1808.821 nmol/L, 9am
(see Ilias et al, JCEM 2005; 90: 4955-62). A 2005 review          1736.447 nmol/L) with a loss of diurnal variation. A dexa-
of tissue from 150 cases of primary breast cancer showed          methasone suppression test was also done which revealed
that ACTH peptides were detected in 16.7% of cases, with          an elevated plasma cortisol level (1646.407nmol/L). An
the highest expression in postmenopausal cases. Only five         abdominal CT scan done revealing both adrenal glands to
cases of ACTH elaborating breast adenocarcinoma have              be enlarged but remained in proportion with no contour
been documented in the literature. It is unusual that this        abnormality which was subsequently signed out as bilat-
breast neuroendocrine tumor did not stain for ACTH or             eral adrenal hyperplasia.
chromogranin. A 2006 case series showed that 5 out of             	    Discussion: Cushing syndrome is a relatively rare
22 documented ACTH producing ectopic neuroendocrine               endocrine disorder resulting from excessive exposure to
tumors did not stain for chromogranin A and eight did not         the hormone cortisol. This condition is most commonly
stain for ACTH despite a substantial postoperative drop in        cause by taking medications containing this hormone for
ACTH and cortisol after surgical removal, (Salgado et al,         long periods of time. A more rare form of the disorder
Eur J of Endocrinol; 155: 725-33).                                occurs when the body itself produces an excessive amount
	    Conclusion: Diagnosis of ectopic ACTH syndrome               of cortisol. Bilateral adrenal hyperplasia is a distinct but
can be problematic and immunohistochemistry negativity            uncommon cause of Cushing syndrome.
does not rule out a hormone elaborating tumor.                    	    Conclusion: Bilateral adrenal hyperplasia resulting
                                                                  to increase serum cortisol levels may present in a wide
Abstract #122                                                     and varied clinical spectrum making establishing a preop-
                                                                  erative diagnosis difficult.
BILATERAL ADRENAL HYPERPLASIA
PRESENTING WITH HYPERCORTISOLISM                                  Abstract #123

Jimmy B. Aragon, MD, FACE, Nerissa Sia Ang, MD                    A RARE CASE OF AUTOIMMUNE PRIMARY
                                                                  ADRENAL INSUFFICIENCY
	    Objective: To present a rare case of Cushing syn-
drome who presented to us with generalized body weak-             Debmalya Sanyal, MBBS
ness, hypokalemia, edema, hypertension and metabolic
alkalosis                                                         	    Objective: To report a case of Autoimmune Primary
	    Case	 Presentation: An 89-year-old female, single,           Adrenal Insufficiency (PAI) in a 44 year-old lady preced-
menopausal, presented to us with generalized body weak-           ing Primary Antiphospholipid Syndrome (PAPS).
ness, especially of the proximal muscles, with decreased          	    Case	 Presentation: A 44 year-old Indian woman,
in functional capacity and activities of daily living. Patient    P1, presented with haemoptysis, cough and shortness of
was also noted to have an increase in sleeping time with          breath for 1 day. She had a 4-month history of progressive
significant loss of appetite. She denied any history of           darkening of skin along with weakness, anorexia, nausea,
headache, vomiting, visual field cuts, polyuria, polydip-         and weight loss of 3 kg. No prior history of DVT, PE,
sia, polyphagia, back pain nor weight loss. On examina-           connective tissue disorder. On examination she had fever,
tion, she was hypertensive, overweight, no note of purple         tachycardia, anemia and skin and mucosal pigmentation.
striations on the skin of the abdomen, thighs and breasts         A CTA of the lungs showed right descending pulmonary
nor excess body hairs, excessive bruisability nor char-           artery embolism. Duplex scan revealed partially recana-
acteristic moon facie and truncal obesity. There was a            lised right superficial femoral vein. Platelets were 86,000,
noted hyperpigmentation of the face and grade 2 bipedal           Prothrombin time: 13.8(Normal [N]: 11.2-14.2), APTT:
edema for one month prior to consultation. Upon initial           142secs (N: 31-42), lupus anticoagulant and anticardio-
investigation, she was noted to have severe hypokalemia           lipin antibody were markedly positive. ANA, dsDNA,
with a serum potassium level of less than 2.0mmol/L and           ANCA, RA factor were negative. CT of adrenal along
metabolic alkalosis. Other tests were carried out; includ-        with CTA was normal. A 250mcg ACTH stimulation test
ing complete blood count, serum chemistries, thyroid              showed a baseline cortisol of 2.3mcg/dL with an ACTH


                                                             – 13 –
                                       ABSTRACTS – Adrenal Disorders

of 306pg/mL, and one-hour cortisol level after ACTH was        with heterogeneous appearance prompting an endocrinol-
2.5mcg/dL. Ant adrenal Abs titers (21-hydroxylase Abs)         ogy consult. A previous CT scan done at another facility
was 315 IU/ml, i.e. markedly positive. She was started         four months earlier showed normal adrenals. On exam
on hydrocortisone 100mg three times daily and heparin.         the patient looked sick. His blood pressure and heart rate
She was subsequently discharged on replacement dose of         were ranging between 93/52-125/77 mm Hg and 60-126/
hydrocortisone and warfarin.                                   min respectively. His over all clinical situation started to
	    Discussion: PAI is a well-recognized, albeit rare,        deteriorate with significant hypotension and lethargy. In
manifestation of the antiphospholipid syndrome, in 36%         the setting of the newly discovered HIT, bilateral adre-
AI was the first clinical feature of APS. The pathogenesis     nal hemorrhage leading to adrenal insufficiency was sus-
of PAI in APS involves hemorrhagic adrenal infarction.         pected. A random cortisol was low at 2 mcg/dL supporting
CT in PAI with APS will show in over 80% of the cases          the clinical impression. He was started on stress doses of
an enlargement of the adrenal glands consistent with hem-      hydrocortisone resulting in prompt improvement in his
orrhage with H/P showing haemorrhagic infarction &             clinical condition. A dedicated CT scan of adrenals was
thrombosis. In this case PAI preceded other clinical evi-      performed later which showed findings consistent with
dence of APS by several months. PAI in our case was due        bilateral adrenal hemorrhage. The steroid regimen was
to autoimmune etiology with positive adrenal antibody          tapered and patient was discharged home on maintenance
without any evidence of adrenal hemorrhage or infarc-          dose of hydrocortisone.
tion in CTA. These features are at variance with previous      	    Discussion: HIT is seen in about 1-5% of patients
cases described in the literature. In patients with autoim-    exposed to heparin. Adrenal vein thrombosis leading to
mune thyroid disease circulating aPL have been detected,       adrenal hemorrhage may be associated with HIT. If bilat-
however, no clinical manifestations of APS have been           eral, it can lead to acute adrenal insufficiency and can be
described.                                                     potentially life threatening. Most patients who survive
	    Conclusion: Endocrinologists need to have a high          the acute situation will have chronic adrenal insufficiency
clinical suspicion for PAI in APS or APLA positive             requiring long-term steroid replacement. The need for
patients especially with abdominal pain, nausea, weak-         mineralocorticoid replacement is variable. A high index of
ness, asthenia given the high mortality rate when this con-    suspicion in the right setting is the key, as the manifesta-
dition goes undiagnosed and untreated. Though adrenal          tion is often nonspecific and can be similar to other more
imaging shows hemorrhage in most cases, it may be rarely       common problems seen in acutely sick patients. Once sus-
normal as PAI may be of autoimmune origin with positive        pected, a dedicated CT scan of adrenals is the imaging of
adrenal antibody.                                              choice.
                                                               	    Conclusion: Physicians must be aware of the pos-
Abstract #124                                                  sibility of adrenal crisis resulting from bilateral adrenal
                                                               hemorrhage in patients with HIT and other coagulopa-
ADRENAL CRISIS SECONDARY TO BILATERAL                          thies. A high index of suspicion is the key to timely diag-
ADRENAL HEMORRHAGE IN A PATIENT WITH                           nosis and prompt treatment.
HEPARIN INDUCED THROMBOCYTOPENIA
(HIT)                                                          Abstract #125

Swapnil Khare, MD, Madhavi Yarlagadda, MD,                     PARAGANGLIOMA OR MALIGNANT
Elias S. Siraj, MD, FACE                                       PHEOCHROMOCYTOMA?

	    Objective: We present a rare case of bilateral adrenal    Louis C. Chen, MD, MBA, Karen Barnard, MD
hemorrhage associated with heparin induced thrombocy-
topenia (HIT), causing adrenal insufficiency.                  	    Objective: Discuss the importance of differentiating
	    Case	 Presentation: A 43 year-old man was admit-          paraganglioma (PGL) from pheochromocytoma (Pheo)
ted for complications after a recent Nissen’s fundoplica-      	    Case	 Presentation: A 62 yo male with HTN was
tion and underwent repeat surgery. Postoperative course        found to have an incidental retroperitoneal mass on MRI
was complicated by hypoxia, recurrent fevers and poor          in 2001 (12.8cm X 6.5cm). CT showed an 8mm lingu-
recovery. He had a CT scan of chest, abdomen and pel-          lar nodule, 1.1cm lesion in R kidney (26 HU), and nor-
vis as part of his postoperative evaluation. This revealed     mal adrenal glands. Biopsy was chromogranin and S-100
bilateral pulmonary emboli as well as thrombi in the large     positive, with indeterminate cytokeratin test. The patient
veins of the neck. These findings along with thrombocyto-      denied HA, palpitations, or sweats. Family history was
penia after heparin exposure raised the suspicion for HIT.     negative for thyroid CA, malignant HTN, adrenal lesions,
Incidentally the CT also revealed bilateral adrenal masses     renal cell CA, cerebellar disease, or polypoid skin lesions.


                                                          – 14 –
                                        ABSTRACTS – Adrenal Disorders

Surgery revealed tributaries between the tumor and infe-        of 110 beats per minute, blood pressure (BP) of 140/90
rior vena cava, with fibrous attachments to the R renal         (mmHg) sitting and 110/70 (mmHg) standing. She was
vein and vertebral bodies. Pathology of the 271gm mass          also found to be thyrotoxic with thyrotropin (TSH) less
showed clean margins, severe nuclear atypia, and adrenal        than 0.01 miu/ L (0.35-5.5 miu/ L), free T3 was 631 pg/
cortex at the periphery. Because cytokeratin and inhibin        dL (228-423 pg/dL) and free T4 was 1.9 ng/dl (0.7-1.8
stains confirmed adrenal cortex, a diagnosis of Pheo was        ng/dl) with a normal serum albumin of 49 g/l (normal
made. In 2009, lytic lesions were found in the left humerus.    range 34-50 g/l). The diagnosis of Grave’s disease was
CT showed unchanged lingular and renal lesions, normal          confirmed with a positive thyroid uptake scan and thyroid
adrenal glands, and a large left hydrocele. Biopsy and          antibodies. Random cortisol was performed at 12:30 hours
resected humerus were chromogranin-positive and cyto-           when she was an in-patient in the hospital, because of the
keratin-negative, consistent with a diagnosis of PGL. PET       symptoms of postural hypotension and dizziness, to rule
and MIBG scans showed uptake in a lytic lesion at the           out the possibility of concomitant autoimmune adrenal
T12 vertebral body, and the patient was referred for radio-     insufficiency and was found to be low at 1.9 μg/dl (4.3-
therapy. Testing for SDHB, SDHD and vHL was negative.           22.2 μg/dl). Short synacthen test (250 mcg cosyntropin-
	    Discussion: An initial diagnosis of Pheo was made          stimulation) was performed and showed a baseline corti-
because the retroperitoneal lesion connected to the adrenal     sol of 2.0 μg/dl, however this had risen at 30 minutes with
cortex. Our patient’s adrenal glands were noted on mul-         serum cortisol of 18.8 μg/dl and a 60 minutes cortisol of
tiple scans to be normal. Malignant Pheo occurs in 10% of       22.5 μg/dl; unfortunately the ACTH sample was haemo-
cases and arises from intraadrenal lesions, where as 50% of     lysed. She was adequately treated with Carbimazole and
PGL cases develop metastases. PGL is the correct diagno-        short synacthen test was repeated a few months later when
sis here based on staining characteristics and tumor behav-     she was clinically and biochemically euthyroid; baseline
ior. PGL requires close attention on follow-up. Familial        cortisol was 11.4 μg/dl, with a 30 minutes cortisol of 22.5
PGL is autosomal dominant and is found in the head and          μg/dl and a 60 minutes cortisol of 24 μg/dl. Full biochemi-
neck but could occur elsewhere. Syndromic PGL is rare,          cal assessment including LH, FSH, prolactin, renin and
but syndromic Pheo is noted in 10-20% of patients with          aldosterone, renal and liver function tests were all normal
vHL, 50% with MEN2, and 0.1-5.7% with NF-1. Gene                and her adrenal antibodies were negative.
mutations in sporadic catecholamine-secreting tumors are             Discussion: Our case report confirms the emerging
common: Neumann (NEJM 2002; 346:1459) identified                evidence of hypocortisolemia in Graves’ hyperthyroidism
mutations in 66/271 cases, including 30/271 with vHL,           without adrenal insufficiency, recently reported by Karl
12/271 with SDHB and 11/271 with SDHD mutations. In             et al. However, this was reported in 2 patients with long-
this series, the majority (14/22) of patients with PGL had      standing Graves’ disease. It also illustrates that hyperthy-
genetic mutations.                                              roidism can be associated with low basal serum cortisol
	    Conclusions: It is important to distinguish PGL            and is not always associated with concomitant adrenal
from Pheo. The two entities have distinct clinical signifi-     insufficiency in patients with Graves’ thyrotoxicosis. This
cance. PGL requires attention to genetic testing, just as       could be explained by the transient increase in cortisol
syndromic or familial Pheo does. SDHB, SDHD and vHL             disposal and transient corticotropin deficiency in early
gene mutations should be evaluated in the diagnosed PGL.        thyrotoxicosis.
Abnormal findings have significant impact on kindred.           	    Conclusion: Hypocortisolemia may be present in
                                                                patients with new onset hyperthyroidism and can resolve
Abstract #126                                                   with adequate treatment of hyperthyroidism.

HYPOCORTISOLEMIA IN A PATIENT
WITH NEWLY DIAGNOSED GRAVE’S                                    Abstract #127
THYROTOXICOSIS
                                                                CONGENITAL ADRENAL HYPERPLASIA
Ibrahim Mamoun Ibrahim, MD                                      PRESENTING AS AN ADRENAL
                                                                INCIDENTALOMA.
	    Objective: To report a case of hypocortisolemia in
a patient with Graves’ thyrotoxicosis resolved with the         Afokoghene Rita Isiavwe, MBBS, HC Wainwright, MD,
treatment of the underlying hyperthyroidism.                    NS Levitt, MD
	    Case	Presentation: A previously healthy 26-year-old
lady presented with palpitations, headaches, fatigue and        	    Objective: To highlight the fact that Congenital
intermittent dizziness and collapse when standing up. On        Adrenal Hyperplasia (CAH) may present as an adrenal
examination she was unwell, tachycardic with heart rate         incidentaloma.


                                                           – 15 –
                                         ABSTRACTS – Adrenal Disorders

	    Case	 Presentation: A 43 year old lady presented            interest that our patient’s adrenal tumor was mistaken for
with chronic lower backache. MRI showed a large right            a RCC. We were unable to relate her degree of virilisation
suprarenal mass and degenerative changes throughout              to her normal testosterone levels. We concluded that we
the spine, but no significant nerve root compression to          picked up the tumor in its degenerative state; as there was
explain the patient’s symptoms. CT abdomen showed a 53           histological evidence of both old and new hemorrhage,
x 50mm mixed density mass arising from the upper pole            areas of extensive necrosis, sclerosis and very scanty
of the right kidney. A renal cell carcinoma (RCC) was sus-       viable tumor remaining. Literature reports confirm hem-
pected. During preparation for radical nephrectomy, she          orrhage is more common in larger lesions – diameter > 10
was discovered to be virilized, with ambiguous genitalia.        mm, (our patient’s adrenal gland measured 68 x 53 x 45
History revealed primary amenorrhea, and she had never           mm and weighed 74g). Although the risk for developing
been sexually active. Examination revealed a BMI of 23           malignancy or hypersecretion is low in adrenal incinden-
kg/m2. Cardiovascular examination was normal. She had            talomas, it is important to exclude them.
ambiguous genitalia, with fully developed labia and a 6          	    Conclusion: There is a need to exclude CAH in
cm micro penis. There was no visible introitus, no testes        patients with adrenal incindentalomas. The role of hor-
were palpated. Chromosomal studies demonstrated a 46,            mone replacement therapy and inducing menstrual cycles
XX karyotype, and human chorionic gonadotrophic hor-             in CAH patients with primary amenorrhea needs further
mone stimulation test excluded the presence of testicular        evaluation. There is also a need for psychological support
tissue. Pelvic ultrasound scan showed normal internal            of these patients.
female genitalia and a uterus which was small for age.
Serum testosterone concentration as well as oestradiol           Abstract #128
were normal but there was a 20 fold elevated 17 OHP
concentration. In view of the large mass she underwent           CARCINOID AND DEXAMETHASONE
exploratory surgery, and a 7 x 7cm adrenal mass, with            SUPPRESIBLE CUSHING
normal kidneys was found; she subsequently had a right
adrenalectomy. Histology confirmed an adrenocortical             Timothy Kevin Jackson, MD, Sarah Sofka, MD
myelolipoadenoma.
	    Discussion: In South Africa, the most common cause          	    Introduction: Cushing Syndrome is a rare endocrine
of ambiguous genitalia in adulthood is true hermaphro-           condition with complex diagnostic pathways. High dose
ditism. CAH may present as an adrenal incidentaloma,             dexamethasone suppression testing is the main study used
and this is particularly common in the homozygous                to classify pituitary versus ectopic causes. Imaging is
form. Although mostly asymptomatic, adrenal myeloli-             also the mainstay of localizing ectopic sources. We pres-
poma can manifest as non-specific abdominal pain due to          ent the case of a patient with dexamethasone suppressible
mechanic compression of adjacent tissues from the tumor          Cushing syndrome from an ectopic source, namely bron-
bulk or due to development of the tumor necrosis. Our            chopulmonary carcinoid tumor. The tumor was only able
patient’s was discovered during investigation for back           to be localized on bronchoscopy.
pain. Adrenal myelolipomas are uncommon, benign and              	    Case	 Presentation: The patient was a 52 year old
hormonally inactive tumors; most commonly occurring in           female who presented with unilateral adrenal hemorrhage.
patients in their fourth to sixth decades of life. Prevalence    She also had the typical signs and symptoms of hyper-
of myelolipomas in adrenal incidentalomas is 7 – 15%,            cortisolism. Cortisol levels and ACTH levels were signifi-
with an equal sex distribution. Although rarely associ-          cantly elevated. Cortisol production was suppressed by 8
ated with endocrine disorders, there are isolated reports of     mg of dexamethasone. However, inferior pertrosal sinus
myelolipoma with Cushing syndrome and with CAH. It is            sampling and MRI failed to show a pituitary source. High
of interest that our patient successfully tolerated surgery,     resolution computed tomography and nuclear somatosta-
without the need for glucocorticoid cover, and the ques-         tin receptor imaging of the chest, abdomen and pelvis did
tion arises if there is need for glucocorticoid replacement      not localize a source. The patient continued to have high
in her. Some authors believe it is more prudent to provide       cortisol levels with resulting hyperglycemia, refractory
supplementary hydrocortisone on an intermittent basis            hypertension and hypokalemia, and depression. In order
for surgical and medical stress. The issue of her primary        to avoid adrenalectomy, a bronchoscopy was empirically
amenorrhea raises the question of the role of hormone            performed which revealed a small bronchopulmonary car-
replacement therapy to induce cyclical bleeding. Her risk        cinoid tumor which was partially resected.
for osteoporosis was considered little as her estrogen lev-      	    Conclusion: Since bronchopulmonary carcinoid
els were not low. Adrenal CT is generally thought to be          tumor is in the differential diagnosis of dexamethasone
none specific regarding the histology of adrenal incin-          suppressible Cushing syndrome if a pituitary source is not
dentalomas, except for myelolipomas; however it is of            localized, we suggest that bronchoscopy be added to the


                                                            – 16 –
                                         ABSTRACTS – Diabetes Mellitus

DIABETES MELLITUS                                                study include: small sample size (not yet FDA approved
                                                                 for patients receiving insulin), brief period of follow up
Abstract #200                                                    and inability to control the effect of diet and exercise on
                                                                 the study parameters. Future studies should include a
EFFECTS OF SITAGLIPTIN ON GLYCEMIC                               larger sample size and longer follow up.
CONTROL IN PATIENTS RECEIVING INSULIN
                                                                 Abstract #201
Amitha Padmanabhuni, MD, Daniel Rosenberg, MD,
Margot Boigon, MD                                                CONTINUOUS GLUCOSE MONITORING
                                                                 IMPROVED DETECTION OF HYPOGLYCEMIA
	    Objective: The purpose of this study was to evalu-          IN HOSPITALIZED PATIENTS
ate the benefits of adding sitagliptin to patients receiving
insulin in terms of glycemic control, lipids, and blood          Margaret Ryan, MD, Vincent Savarese, MD,
pressure.                                                        Brian Hipszer, PhD, Mary Kate McCullen, MD,
     Methods: This was a retrospective chart review              Tessey Jose, MD, Jeffrey Joseph, DO
comparing data at baseline and 3 months after starting
sitagliptin. All patients had follow up data for 3 months.            Objective: To determine whether the use of continu-
Patients who were receiving insulin and sitagliptin simul-       ous glucose monitoring (CGM) in hospitalized patients at
taneously with or without oral hypoglycemic agents were          high risk for hypoglycemia led to improved detection of
selected from a database at the outpatient endocrine clinic      hypoglycemic events.
between December 2006 and March 2009. Total of 25                     Methods: In an interim analysis of an ongoing study,
charts were selected. Fourteen, who met the inclusion            14 patients with a documented hypoglycemic event dur-
criteria, were included in the study. The only interven-         ing their hospitalization were recruited from the general
tion done was sitagliptin added to their regimen. Patients       floors of a tertiary care referral center. A CGMS® iProTM
served as their own controls. All patients in the study          Continuous Glucose Recorder (Medtronic Diabetes,
received 100mg of sitagliptin daily.                             Northridge, CA) was inserted on each patient and CGM
     Results: There was a significant decrease in HBA1c          data was collected until either the patients anticipated day
(1.1% ±1) (p =.002) and weight (9 lbs ±14) (p =.034), and        of discharge or completion of 144 hours of CGM data
an increase in HDL (5 mg/dl ± 6) (p = .011) after 3 months       collection. Point-of-care (POC) and laboratory blood glu-
of adding sitagliptin to a patients regimen regardless of        cose levels were monitored as per usual hospital protocol
the type of insulin they received. Although not statistically    throughout the study. The investigators, subjects, and hos-
significant there was a trend toward a decrease in systolic      pital staff were blinded to the results of the CGM. A recur-
blood pressure (8.7 mm ± 16) (p = .066), total cholesterol       rent hypoglycemic event was defined as a CGM-estimated
(13 mg/dl ± 45) (p =.304), LDL cholesterol (10 mg/dl ±           blood glucose of less than 70 mg/dL. CGM data was ana-
36) (p = .305) and triglycerides (23 mg/dl ± 58) (p =.15).       lyzed retrospectively.
13 out of 14 patients did not have a change in insulin                Result: Study participants included nine patients with
requirements. Two patients reported to have an episode           type 2, three with type 1, and two without diabetes. Ages
of hypoglycemia. 13 out of 14 patient’s renal status was         ranged from 31 to 79 (mean age 56). The average BMI was
unchanged after 3 months on sitagliptin.                         32 kg/m2 (SD +/- 9.4) The mean duration of diabetes was
     Discussion: The incretin effect is decreased in type        17 (+/-10 ) and 25 (+/- 1.7) years in the groups with type 2
2 diabetes. Sitagliptin (Januvia™) is a DPP-4 (Dipeptidyl        and type 1 diabetes, respectively. The overall mean hemo-
Peptidase enzyme) inhibitor that inhibits the breakdown          globin A1c was 7.6% (+/- 1.7). Nine subjects reported
of incretin hormones. Sitagliptin has multiple effects in        using insulin prior to admission. The CGM devices were
lowering blood glucose; it stimulates glucose–dependent          worn for an average of 47.15 hours and picked up a total of
insulin secretion by pancreatic beta cells, suppresses glu-      35 separate episodes of hypoglycemia with a mean dura-
cagon secretion, alters insulin resistance and restores first    tion of 68 minutes occurring in 10 patients. 8 episodes of
phase insulin response.                                          recurrent hypoglycemia, the highest number in the study,
     Conclusion: When compared to baseline there was             were noted in a single patient. POC testing detected only
statistically significant decrease in 3 primary outcomes         14 hypoglycemic episodes occurring in 8 patients, with
decrease in HBA1c, weight, and increase in HDL at the            no more than 3 episodes detected in any one patient. Of
end of 3 months when sitagliptin is added to insulin. There      hypoglycemic episodes detected by both CGM and POC
was a downtrend in systolic blood pressure and triglyc-          testing, these episodes were detected a mean 102 minutes
erides but was not statistically significant. The drug was       earlier with CGM. There were five instances in which
well tolerated by most of the patients. Limitations of the       POC testing documented a blood glucose of <70mg/dL,


                                                            – 18 –
                                         ABSTRACTS – Diabetes Mellitus

while CGM reported glucoses in the 70s but not dropping         	   Conclusion: Cost of oral hypoglycemics was per-
below 70 and there were 3 episodes in which the CGM             ceived to be very expensive in this study population. Poor
documented a hypoglycemic episode, but coincidental             glycemic control among adult diabetics in this study was
POC testing documented a blood glucose in the normal            found to be multi-factorial in origin.
range (85, 93 and 104mg/dL, respectively).
     Conclusion: In our study, CGM use in high risk hos-        Abstract #203
pitalized patients detected hypoglycemic episodes ear-
lier and more often than POC testing alone. Real-time           CARDIOMETABOLIC RISK BEHAVIORS
CGM use in hospitals could lead to earlier detection of         AMONG ADULTS LIVING WITH DIABETES IN
hypoglycemia and prevention of hypoglycemia related             TANZANIA: ROADMAP FOR INTERVENTIONS
complications.
                                                                Kelvin M. Leshabari, MD, Elizabeth Licoco, RN
Abstract #202
                                                                	    Objective: To assess practices on cardio metabolic
FACTORS INFLUENCING GLYCEMIC                                    risk behaviors among adults with type 2 diabetes attend-
CONTROL STRATEGIES AMONG ADULT                                  ing a tertiary diabetes clinic in Dar es Salaam, Tanzania.
DIABETICS IN SUB-SAHARAN AFRICA:                                	    Methods: A cross-sectional survey was done in
A CALL TO ACTION                                                July-Sept 2007 involving adult type 2 diabetes patients
                                                                attending a tertiary diabetes clinic at Muhimbili National
Kelvin M. Leshabari, MD                                         Hospital. Data were collected using semi-structured ques-
                                                                tionnaires. Data were analysed using epi-info version
	    Objective: To explore factors influencing glycemic         3.3.2. Statistical significance tests included the usage of
control strategies among adults with diabetes mellitus in a     X2 test to check for the association between different vari-
metropolitan area of sub-Saharan Africa.                        ables and P-value < 0.05 to account for the role of chance
	    Methods: A cross-sectional survey was conducted in         in findings.
Dar es Salaam, a business capital of Tanzania involving         	    Results: A total of 108 diabetes patients were sur-
adult diabetics attending municipal diabetes clinics. Thus      veyed. Out of whom, 66(61.1%) were females. Significant
the study considered Dar es Salaam to be representative of      amount (22.4%) of respondents declared to be regu-
a typical African metropolitan zone primarily based on its      lar alcohol drinkers with males outweighing females in
rich African ethnic varieties. A semi-structured question-      frequency (P=0.05) Almost 10% of male respondents
naire was the main tool used. Variables also included 10        revealed to have had smoked at least once within 24
likert items that were used to assess attitudes on exercise,    hours prior to the survey time (P=0.0000). None among
lifestyle modifications and oral hypoglycemics. Data were       the study respondents revealed to perform blood/urine
analyzed using epi-info version 3.3.2 with X2 test used to      sugar on a daily basis. Long duration of diabetes state was
check for the association between independent variables         strongly associated with higher frequency of blood/urine
and P-value <0.05 used to rule out chance in findings.          sugar tests (P=0.003). Significant number (87.75%) of
Chronbach’s alpha co-efficient was applied for determin-        respondents perceived eating practices to affect diabetes
ing internal consistency reliability test.                      and its outcomes.
	    Results: A total of 400 diabetes patients were sur-        	    Conclusion: Significant amount of respondents were
veyed out of whom 136 (34%) were males. Mean chron-             active smokers and alcohol users.
bach’s alpha score ( r ) was 0.725. Only 2% of the respon-
dents declared to have glucometers/urine dipstick kits          Abstract #204
at home. Almost all (92.5%) respondents declared oral
hypoglycemics to be very expensive (r=0.86). About a            PRIORITY SETTING FOR DIABETES MELLITUS
quarter (22%) revealed skipping meals to be an option in        INTERVENTION AND RESEARCH IN NIGERIA
maintaining glucose levels in a euglycemic state (r=0.68).
Significant amount (36.5%) perceived regular exercise           Bridget Akudo Nwagbara, MBBS,
to have limited/no role once a desirable body weight has        Chioma N. Unachukwu, MBBS, FWACP, FACE,
been achieved (r=0.71). About a third (33.75%) declared         Emmanuel Effa, MBBS
weight gain to be acceptable once a euglycemic state has
been achieved (r=0.66). The usage of traditional remedies            Objective: To identify priority issues on intervention
for glycemic control was inversely related to the level of      and research on Diabetes Mellitus in Nigeria. Diabetes
education of the respondent (P=0.0001).                         Mellitus is an emerging public health problem in Nigeria



                                                           – 19 –
                                          ABSTRACTS – Diabetes Mellitus

with substantial morbidity and premature mortality. To            Abstract #205
deliver evidence-based interventions in Nigeria, it is
important to ensure that national priority issues on this         A COMPARATIVE STUDY OF KNOWLEDGE,
disease are identified and addressed.                             ATTITUDES AND PRACTICES OF
	    Methods: Multi-disciplinary team developed and               COMPLICATIONS OF TYPE 2 DIABETES
piloted study methodology and tools. Collection of data           AND ASSOCIATED RISK FACTORS AMONG
relevant to burden of Diabetes Mellitus in Nigeria from           PATIENTS WITH TYPE 2 DIABETES IN DAR ES
the National Health Management Information Systems,               SALAAM, TANZANIA AND NEW HAMPSHIRE,
information from key informants (health professionals,            USA
researchers, NGOs and patients ) drawn from all six geo-
political zones in Nigeria and literature review. The key         Goodluck Willey Lyatuu, MD,
steps included compilation and ranking of a comprehen-            Mohammad Bakari, MD, MMed, PhD
sive list of cross cutting issues on the disease with refer-
ence to Nigeria; summary of existing strategies for disease       	    Objective: An analytical, cross-sectional study was
control in Nigeria; identification of gaps in existing sys-       done to compare the differences in Knowledge, Attitudes
tem for disease control; searching PUBMED, Cochrane               and Practices of complications of type-2 diabetes and
Library and other electronic databases for research done          associated risk factors, among patients with type 2 diabe-
on the identified priority areas using a defined search strat-    tes in Tanzania and USA.
egy. Analysis of search outputs to identify gaps in previ-        	    Methods: Swahili and English structured question-
ous research; and listing of new priority issues on inter-        naires were administered to 86 diabetic patients attend-
vention and research using predetermined criteria.                ing clinics in 3 hospitals in Dar es Salaam, Tanzania and
	    Results: Eight broad areas were identified as prior-         77 patients attending at Dartmouth Hitchcock Medical
ity for control and research of diabetes mellitus in Nigeria      Centre (DHMC) in New Hampshire, USA respectively.
addressing issues such as culturally appropriate health           Study participants were selected by simple random sam-
education, integration of Diabetes Mellitus control into          pling over a period of 6 weeks in each country. Data from
the primary health care system, treatment adherence, the          both study areas were analyzed using SPSS data analysis
use of treatment guidelines, follow up of patients, paucity       tool.
of epidemiological data, phyto- medications as treatment          	    Results: This study revealed no significant difference
adjuncts, management of infectious diseases in synergy            in proportion of patients knowledgeable of complications
with diabetes mellitus. 3 topics were identified for system-      of diabetes and associated risk factors in the two commu-
atic reviews. Specific intervention strategies and research       nities with both communities 84.9% in Dar es Salaam and
topics will be presented and discussed.                           92.2% in New Hampshire scoring high on knowledge, P
	    Discussion: A consultative approach including                = 0.15. There was also no significant difference in attitude
patients provided an equitable and bias free patient cen-         towards diabetes whereby majority had a positive health
tered and public health perspective to this research.             promoting attitude towards the disease, i.e. only 9.3% in
Despite adequate knowledge on pharmacological inter-              Dar es Salaam and 5.2% in New Hampshire considered
ventions among healthcare personnel, huge treatment               regular physical exercise to have little influence on dia-
gaps still persist in diabetes mellitus control in Nigeria.       betes management, P = 0.29, and 5.8% in Dar es Salaam
Findings draw attention on the need for researchers to            and 5.2% in New Hampshire considered weight manage-
shift from basic bio-medical research to other forms of           ment to have little influence on the management of their
research to facilitate informed decisions on the control of       Diabetes, P = 0.86. There were however significant differ-
diabetes mellitus in Nigeria                                      ences in practice whereby; only 11% of study participants
	    Conclusion: Prioritization of issues relevant to             in Dar es Salaam compared to 93.9% in New Hampshire
the management and research on diabetes mellitus will             reported to be doing blood glucose check-ups at least once
improve the opportunity to scale up interventions and             a week, P < 0.001; only 63% of study participants in Dar
deliver evidence-based and equitable healthcare to                es Salaam compared to all in New Hampshire reported
patients. These issues are likely to be also important for        to weigh themselves at least once a month, P < 0.001;
Diabetes Mellitus control in other resource-poor settings.        and 48% in Dar es Salaam compared to 69.4% in New




                                                             – 20 –
                                        ABSTRACTS – Diabetes Mellitus

Hampshire reported to be doing physical exercise at least      	    Discussion	and	Conclusion: The prevalence of both
4 to 6 times a week for at least 15 minutes, P = 0.02.         HIV and diabetes mellitus has reached a pandemic propor-
	    Conclusion: In conclusion, although knowledge on          tion. Sub-Sahara Africa bears the greatest burden of HIV
Diabetes Mellitus was high in both settings, and attitude      infection and non-communicable diseases such as obe-
positive, significant differences in practice were noted       sity and diabetes mellitus are emerging diseases of public
with Dar es Salaam scoring poorer compared to New              health importance in this region. The greater risk of occur-
Hampshire. More elaborate studies assessing multi-facto-       rence of type2 diabetes and other metabolic disorders such
rial of issues that influence positive health attitudes and    as atherogenic dyslipidemia, systemic hypertension and
behaviors towards Diabetes Mellitus should be conducted,       obesity associated with the use of highly active antiretro-
especially in less developed countries. Furthermore efforts    viral therapy may thus constitute a double tragedy in this
should be done to further expand the diabetes health edu-      low-resource region of the world. Previous studies have
cation being provided at the health care facilities in Dar     shown a higher prevalence of impaired fasting glucose,
es Salaam so as to reach out to more diabetes patients in      impaired glucose tolerance and overt diabetes mellitus in
other health facilities in the country.                        HIV positive patients on prolonged therapy with HAART
                                                               which this study has also clearly demonstrated. The man-
Abstract #206                                                  agement of HIV should therefore be holistic in approach
                                                               and metabolic parameters should be routinely assessed
PATTERN OF FASTING DYSGLYCEMIA AND                             and strategies such as lifestyle modification, early diag-
DYSLIPIDEMIA IN HIV POSITIVE PATIENTS ON                       nosis and prompt treatment should be employed in order
HIGHLY ACTIVE ANTIRETROVIRAL THERAPY                           to improve the overall survival and quality of life of HIV
                                                               positive patients.
Ayoola Olukunmi Oladejo, MBBS,
Jokotade O. Adeleye, MBBS, FWACP,                              Abstract #207
Yetunde A. Aken’ova, MBBS, FWACP, FMCPath
                                                               DIABETES RELATED KNOWLEDGE AMONG
	    Objective: To determine the pattern of fasting plasma     RESIDENTS AND NURSES: A MULTICENTER
glucose and lipid profile abnormalities in HIV positive        STUDY IN KARACHI, PAKISTAN.
patients on HAART and to compare with the pattern seen
in HAART naïve HIV positive patients.                          Asma Ahmed, MBBS, Lubna Zubairi, Abdul Jabbar,
	    Methods: One hundred and eighty HIV positive              Muhammad Islam, Khusro Shamim, MBBS
patients were selected by systematic random sampling.
Ninety-two were on HAART therapy while eighty-eight            	    Objective: To evaluate and compare the knowledge
were HAART naïve. Blood samples for fasting plasma glu-        related to the management of diabetes among nurses and
cose and fasting lipid profile were obtained after an over-    trainee residents of internal medicine, family medicine
night fasting. Fasting plasma glucose was determined in        and surgery at tertiary care hospitals of Karachi, Pakistan.
the chemical pathology laboratory by the glucose oxidase       	    Methods: A validated questionnaire consisting of
method using 4-aminophenazone as the oxygen acceptor           20 questions related to diabetes awareness was acquired
as described by Trinder while the fasting lipid profile was    through a study done at Thomas Jefferson University
determined by the enzymatic colorimetric method. Data          Hospital, Philadelphia with the permission of primary
obtained were analyzed using the SPSS 16.0 version.            author. The questionnaire was administered at 5 ter-
	    Results: The mean ages of the HAART and the               tiary care academic hospitals including The Aga Khan
HAART naïve groups were 40.1± 9.5 and 37.7± 9.3                University Hospital to residents and nurses.
respectively, p=0.081. The mean fasting plasma glucose         	    Results: 169 internal medicine residents (IMR), 27
was 125.5± 44.3 in the HAART group versus 88.3± 31.8 in        family medicine residents (FMR), 86 surgery residents
the HAART naïve group (p< 0.001). The mean serum tri-          (SR) and 99 nurses (RN) participated. The survey had
glyceride was 66.7± 31.6 and 112.7± 60.0 in the HAART          a good reliability coefficient (Cronbach α of 0.81).The
and HAART naïve group respectively (p< 0.001). The             overall mean correct percentage was 50% ± 21. There was
mean HDL-Cholesterol was lower in the HAART group              no difference in total scores of IM & FPM residents (64%
than the HAART naïve group but the difference was not          ± 14 vs. 60% ± 16, p= 0.47).The total scores of SR and
statistically significant( 42.3± 13.1 versus 44.1± 14.5, p=    RN were quite low (40 % ± 16 & 31% ± 15 respectively).
0.38).The overall prevalence of diabetes mellitus in the       Although FMR scored higher than IMR on items regard-
total study population was 25.6% being 45.7% in the            ing outpatient management of diabetes but that difference
HAART group and 4.5% in the HAART naïve group, p<              was not statistically significant (p=0.128).For inpatient
0.001.                                                         diabetes care the scores of IMR were higher than FMR but


                                                          – 21 –
                                          ABSTRACTS – Diabetes Mellitus

not statistically significant either(p-value 0.175).SR and        was not observed among female patients. Moreover, the
RN had profound deficit in both inpatient and outpatient          prevalence of HTN was found to be more among the
management. Surprisingly, despite of the fact that RN are         Pakistani female patients. The prevalence of IHD was
actively involved in in-patient management of diabetes,           similar among both groups. Retinopathy prevalence was
they didn’t answer correctly on most of the items regard-         higher with statistical significance only among Pakistani
ing in-patient management of diabetes (Mean score 40%).           males (p=0.037). As far as treatment was concerned South
	    Conclusion: Since the prevalence of diabetes has             Asians were more likely to be on oral hypoglycemic
been rapidly rising, it has become one of the major public        agents when compared to Europeans in our quoted UK
health problems. Pakistan is also one of those countries          based study. However, there was no significant difference
estimated to have the highest number of people with dia-          in treatment among Pakistani and UK based South Asians.
betes. To be able to face this enormous number of dia-            	    Conclusion: In conclusion, it appears that besides
betes cases, health care providers need to have adequate          environmental factors, genetic influence appears to be sig-
knowledge to deliver optimal care to these patients. There        nificant influencing the pattern and mode of presentation
are several studies that have examined the diabetes knowl-        of type 2 diabetes among South Asians and it should be a
edge of nurses, but the data assessing the knowledge of           focus of future research.
diabetes among trainee residents’ especially surgical resi-
dents is lacking. As there are no prior studies in our setting    Abstract #209
evaluating knowledge related to diabetes management
among residents and nurses, this study is quite significant.      RELATIONSHIP BETWEEN HBA1C AND
Based on these results, there are significant gaps in diabe-      2-HOUR PLASMA GLUCOSE
tes knowledge among residents and nurses. Due to high
burden of disease and considering the fact that our resi-         Abdullah Ndaman Adamu, MBBS
dents and nurses are actively involved in diabetes man-
agement this raises important concerns and needs to be                 Objective: There is paucity of existing studies on use
addressed.                                                        of HbA1c as a screening tool for type 2 diabetes among
                                                                  blacks, with high risk factor like systemic hypertension.
Abstract #208                                                     To evaluate the performance of HbA1c as a screening tool
                                                                  for type 2 diabetes among black people with systemic
COMPARISON OF PATTERNS OF TYPE 2                                  hypertension.
DIABETES BETWEEN NATIVE PAKISTANI AND                             	    Methods: Two-hundred and seven subjects attend-
UK IMMIGRANT SOUTH ASIANS                                         ing cardiology and renal out-patient department of Lagos
                                                                  University Teaching Hospital were recruited, out of which
Asma Ahmed, MBBS, Abdul Jabbar                                    131 of the subjects had OGTT done, 2hrs post glucose
                                                                  load plasma glucose assay was used as a gold standard
	    Objective: This study was designed to assess whether         for the diagnosis . Using random sampling of one out of
the pattern of diabetes in native South Asians is different       every four, thirty three of the subjects had HbA1c assess-
from immigrant South Asians.                                      ment using DCA2000® machine produced by Bayer®,
	    Methods: Data on Pakistan based South Asians                 USA. Two of the assay revealed error report and were
acquired from a sample of 100 type 2 diabetics attending          thus excluded from the analysis. The data was entered into
out- patient clinic of The Aga Khan University Hospital           Microsoft Excel, and transported to SPSS 11 for analysis.
(AKHU) at Karachi, Pakistan during year 2005 was col-             Glycated hemoglobin of <6.7% was considered to be neg-
lected for a cross sectional survey and compared with             ative while glycated hemoglobin of ≥6.7 was considered
the data from UK based South Asians acquired through a            to be positive for the screening. Two hour plasma glucose
study carried out at Ealing Hospital, London enrolling 889        of <11.1mmol/l (200mg/dl) was considered to be nega-
UK immigrant South Asians. This was done after gain-              tive while ≥11.1mmol/l (200mg/dl) was considered to be
ing approval for the inclusion of data from the author Dr.        positive for the diagnostic test. A 2x2 table was made to
H.M.Mather.                                                       calculate specificity, sensitivity, positive predictive value,
	    Results: The age of the native diabetic male patients        negative predictive value, efficiency of the test and preva-
was less 58 ± 11.6 as compared to the age of UK based             lence of the disease using HbA1c. Pearson correlation,
South Asians53 ± 13.3 (p=0.006) however, the age at               bivariate and Receiver Operative Characteristic Curve
diagnosis; the duration of diabetes as well as the BMI            was also plotted.
were similar among the two groups. Smoking was signifi-                Results: The mean age of the subjects that had
cantly more common among Pakistani male patients com-             HbA1c assay was 54.26 ± 6.6 years. The subjects were
pared to the UK counterparts. However, this difference            made up of 25 (80.6%) females and 6 (18.4%) males.


                                                             – 22 –
                                         ABSTRACTS – Diabetes Mellitus

Mean HbA1Cwas 6.6% and mean 2hour plasma glucose                 fasting glucoses and required a GTT to show that diabetes
was 169.47mg/dl. The sensitivity was 57.14%, specificity         was not “cured”.
of 62.5%, positive predictive value of 30.77%, negative          	    Conclusion: HbA1C and FBG are not sufficient cri-
predictive value of 83.33%, efficiency 61.29, prevalence         teria to establish DM2 “cure” after gastric bypass surgery.
of 41.94. The correlation of HbA1c to 2hrs post glucose          Measurement of postprandial blood glucoses, possibly
load was 0.42, y = -13.18 + 29.54x, P = <0.05.The area           GTT, or even continuous glucose monitoring should be
under ROC was 0.682 which was significant.                       considered postoperatively to provide a clear assess-
	    Conclusion: The performance of this screening test          ment of glycemic status specific to gastric bypass surgery
is low compare to the results of other studies among the         effects in those with established DM2. Many individuals
Caucasians.                                                      may need pharmacologic intervention, such as the pre-
                                                                 sented patient, to optimize glucose control. And certainly,
Abstract #210                                                    being told that a “cure” has taken place, when it has not,
                                                                 has significance for patients’ psychological well-being.
IS DIABETES MELLITUS REALLY CURED
BY GASTRIC BYPASS SURGERY?
                                                                 Abstract #211
Anna Leonidovna Marina, MD,
Dace Lilliana Trence, MD, FACE                                   THE MENOPAUSE AND THE METABOLIC
                                                                 SYNDROME IN TYPE 2 DIABETES MELLITUS
	    Objective: Gastric bypass surgery is increasingly
receiving attention as a potential “cure” for type 2 diabetes    Anthonia Okeoghene Ogbera, MBBS, FMCP, FACE,
mellitus (DM2). Mechanisms of action are not completely          Olufemi Fasanmade, MBBS, FWACP, FACE,
understood, but include improvement in insulin resistance        Sanjay Kalra
and insulin secretion, likely mediated by the action of
incretins and other hormonal factors. Surgical outcome           	     Objective: To determine the frequency and pattern
reports rely on fasting blood glucose (FBG) and normal           of the Metabolic syndrome (Mets), the age of onset and
hemoglobin A1C (HbA1C) as criteria for “cure”. We pres-          occurrence of menopausal symptomatology in Nigerian
ent a case where these criteria were present, but did not        women with type 2 DM.
support remission of diabetes on further evaluation.             	     Methods: This is a cross-sectional study in which
	    Case	 Presentation: 55-year-old male with BMI of            201 menopausal women with type 2 DM aged between
45.2 kg/m2 and 7-year history of DM2 underwent Roux-             40-85 years were studied. Anthropometric indices, fast-
en-Y gastric bypass (RYGB). Immediately after surgery,           ing lipid, glucose parameters, uric acid and HbA1c were
insulin requirement decreased from 100 to 30 units daily.        documented. The presence of the metabolic syndrome
In 4 months, with weight loss of over 100 lbs, FBG was           and menopausal symptoms were determined using the
90-150mg/dl, HbA1C decreased from 9 to 6.1%, and insu-           National cholesterol Panel -ATP definition and MENQOL
lin was discontinued. At 7 months’ follow-up, HbA1C was          questionnaire respectively. The tests statistics used include
6.2%. Patient reported unremarkable FBGs but sporadic            t test, chi square and correlation coefficient.
glucose excursions to 180mg/dl after meals. Subsequent           	     Results: The mean age (SD) of the onset, median age
three-day blinded continuous glucose monitoring (CGMS)           and age range of menopause was 50.3 (4.8) years, 50 years
revealed FBG of 65-102 mg/dl, but frequent postprandial          and 40-57 years respectively. The frequency of occurrence
glucoses in the 200s (up to 294 mg/dl), consistent with          of menopausal symptoms studied ranged from 14%-76%.
persistent diabetes mellitus.                                    Musculoskeletal symptoms were prominent with vasomo-
	    Discussion: Based on published surgical criteria,           tor symptoms of hot flushes, night sweats and dry skin
the patient’s FBG and HbA1C were indicative of com-              occurring in 38%, 31% and 30% respectively of the sub-
plete remission of DM2. However, diabetes could not be           jects. The pattern of occurrence of the menopausal symp-
considered cured. CGMS clearly documented spikes in              toms was comparable in subjects with and without the
blood glucose above 200 mg/dl after meals. Therapy with          Mets. The prevalence of the Mets was 69% and increased
repaglinide was required to reduce postprandial hypergly-        with increasing duration of the menopause. There was
cemia. Our observation is consistent with very recently          no risk factor of the Mets in 4 (7%) of the subjects. The
presented data by Roslin et al, who performed a glucose          prevalence of having at least two, three and four MetS
tolerance test (GTT) in 38 subjects after RYGB (more than        diagnostic criteria were met in 38.6%, 29.3% and 6.7% of
6 months post-op). 6 patients had had diagnosed diabetes         the cases, respectively. The most prevalent risk factor for
before surgery but were not on any prescribed glycemic           the Mets was abdominal obesity, affecting 75% of women.
modifying medications post-op. 5 out of the 6 had normal         The frequency of occurrence of hyperuricemia in the


                                                            – 23 –
                                        ABSTRACTS – Diabetes Mellitus

study population was 42% and proportion of subjects with       of patients at least once during the 16-wk study, with no
the Mets who had hyperuricemia was comparable to those         episodes of severe hypoglycemia. At Wk 16, the mean
without the Mets (47% vs 32 %, p-0.05). Plasma uric acid       daily basal, bolus, and total insulin doses were 66±36U,
levels did not increase with the number of MetS compo-         56±40U, and 122±72U (1.2U/kg), respectively. 90% of
nents present. There was however no significant correla-       patients were treated with 2 basal rates per day (1 basal
tion between the age of onset of menopause and the dura-       rate 80%; 2 basal rates 10%). Body weight increased by
tion of DM(r=0.06, p=0.3), waist circumference(r=0.05,         2.7±2.6kg (p<0.001). PRO measures improved signifi-
p=0.9) and body mass index (r=0.1, p=0.8).                     cantly from baseline (Treatment satisfaction: 65±15 vs
	    Conclusion: The age of onset of menopause in              81±15, p<0.001; Overall treatment preference: 58±14 vs
Nigerian women with type 2 DM is comparable to what            93±16, p<0.001; Scale of 0-100, Mean±SD).
is commonly reported and the Mets is highly prevalent in       	    Discussion:	 Insulin pump therapy is an important
this group of women. The pattern of occurrence of meno-        treatment option for patients with T2DM suboptimally
pausal symptoms is unaffected by the presence of the           controlled with MDI. Limited data exist about pump ther-
Mets. We conclude that the pathophysiological basis for        apy in this patient population. Though having multiple
the symptomatology of the menopausal state is most likely      basal rates and the ability to deliver very precise insulin
unrelated to that of the Mets.                                 increments is important for many patients with T1DM, it
                                                               is unlikely necessary for most patients with T2DM. The
Abstract #212                                                  improved PROs with pump therapy are important, since
                                                               improved patient medication experience may result in bet-
INSULIN PUMP THERAPY USING A SIMPLE                            ter compliance, ultimately improving long-term outcomes.
DOSING REGIMEN SAFELY IMPROVED                                 	    Conclusion: Insulin pump therapy using a simple
GLYCEMIC CONTROL AND PATIENT                                   dosing regimen significantly improved glycemic control
REPORTED OUTCOMES IN PATIENTS                                  in patients with T2DM who were suboptimally controlled
WITH TYPE 2 DIABETES SUBOPTIMALLY                              with MDI therapy. Patients experience moderate weight
CONTROLLED WITH MULTIPLE DAILY                                 gain, no severe hypoglycemia and preferred pump therapy
INJECTIONS                                                     to baseline treatment with insulin injections. Future con-
                                                               trolled trials are needed to further assess the benefits of
Juan P. Frias, MD, FACE, Steve V. Edelman, MD,                 insulin pump therapy in T2DM.
Bruce W. Bode, MD, Timothy S. Bailey, MD,
Mark S. Kipnes, MD, Xiaojing Chen, MS                          Abstract #213

	    Objective: To assess the efficacy, safety and patient     PENTOXYPHYLLIN IN DIABETIC
reported outcomes (PRO) of 16 wks of pump therapy in           NEPHROPATHY
patients with type 2 diabetes (T2DM) suboptimally con-
trolled with multiple daily injection (MDI) therapy.           Piyush Harshadrai Desai, MD, Shyamla N.,
	    Methods: In this sub-analysis of a 16-wk, open-label,     Ashwin Aiyangar, Sumedh Hoskote, MD, Bharat Shah,
multicenter study, 21 insulin pump naïve patients treated      Vijay Panikar, MD, MBBS,
with MDI±oral agents (9 male/12 female, age 57±13y,            Shashank Joshi, MD, FACP, FRCP, FACE
DM duration 15±6y, A1C 8.4±1.0%, FPG 165±58mg/dl,
body weight 98±20kg, BMI 34±5kg/m2, total daily insulin        	    Objective: Diabetic nephropathy is the leading cause
dose 99±65U [1.0U/kg], mean±SD) discontinued all DM            of chronic kidney disease in the world. Current therapeu-
medications except metformin and initiated pump therapy        tic targets in the management of diabetic nephropathy
(Animas® 2020) with one daily basal rate and bolus doses       are good glycemic control, BP control, lipid control and
at each meal. Insulin doses were titrated to safely achieve    reduction in the glomerular hypertension/hyperfiltration.
the best possible glycemic control. Outcomes included          In addition, there are measures to reduce proteinuria, e.g.
insulin dose and dosing patterns, A1C, FPG, weight, PRO        RAAS blockers and novel agents with various mecha-
(Insulin Delivery System Rating Questionnaire), and            nisms of reducing proteinuria. Among novel agents is
hypoglycemia.                                                  pentoxiphylline which is a nonselective phosphodiester-
	    Results: Glycemic control improved significantly          ase inhibitor. To analyze the effectiveness of Pentoxip-
after 16 wks of pump therapy: A1C 7.3±1.0% (-1.1±1.2%,         hylline in the reduction of proteinuria in patients of dia-
p<0.001) and FPG 129±37mg/dl (-36±74mg/dl, p<0.001).           betic nephropathy.
In patients with baseline A1C >8.5% (n=11, mean base-               Methods: 38 subjects were prospectively studied over
line A1C 9.1±0.5%), A1C was reduced by 1.9±1.3%                6 months. Subjects with DM and a urinary albumin to cre-
(p<0.005). Mild hypoglycemia was experienced by 81%            atinine ratio (UACR) greater than 0.03 (30mg/gm) were


                                                          – 24 –
                                       ABSTRACTS – Diabetes Mellitus

included. These subjects were started on Pentoxiphylline      sepsis-induced stress hyperglycemia. A higher percentage
1200mg/day in divided doses and followed up at 2 monthly      of septic patients with stress hyperglycemia died compared
intervals. BP, blood sugar and proteinuria was monitored      with patients with normal glucose levels (43.4% versus
at each visit. Proteinuric response was defined as a 25%      24.2%) and diabetics who had hyperglycemia at admis-
reduction in proteinuria as compared to baseline.             sion had higher mortality compared to patients with nor-
	    Results: 73.7% of the subjects experienced a response    moglycemia(37.5% versus 24.2%). All patients required
in UACR. Mean values of UACR obtained were 0.63               insulin for control of hyperglycemia. Majority of diabet-
at baseline and 0.55, 0.49 and 0.47 at 2, 4 and 6 months      ics were changed to diet and insulin (60%) at the time of
respectively. A reduction in UACR was observed even in        discharge. A positive correlation was detected between
those who were on RAAS blockers, suggesting an additive       the fasting blood glucose levels of Stress hyperglycemia
effect of PTX. UACR reduction was similar in both hyper-      group and the severity of sepsis indicated by sepsis-related
tensive and non-hypertensive subjects. Higher reduction       organ failure assessment score.
was seen with a higher baseline UACR and in those with        	     Discussion: Sepsis is the systemic inflammatory
a longer duration of DM.                                      response to severe infections with high morbidity and
	    Conclusion: Pentoxiphylline reduces proteinuria in       mortality rates, according to the disease state, by several
patients with diabetic nephropathy. It works well even in     clinical and laboratory markers, like age, severity scores
those in whom the RAAS is blocked, and hence a useful         (simplified acute physiology score, SOFA, acute physi-
agent in diabetic nephropathy.                                ology and chronic health evaluation, etc.), organ dys-
                                                              function, C-reactive protein, or procalcitonin levels. All
                                                              patients undergoing critical illness, including sepsis, are
Abstract #214                                                 at risk for stress induced hyperglycemia. Mortality rate in
                                                              patients with stress hyperglycemia in our study was 43.5%
STRESS HYPERGLYCEMIA AS PROGNOSTIC                            (24.2% in controls). A higher percentage of patients with
MARKER IN SEPSIS                                              stress-induced hyperglycemia died compared with con-
                                                              trols with severe sepsis.
Mukhyaprana M. Prabhu, MD, Hanumath Rao Madala,                     Conclusion: Baseline/ admission hyperglycemia,
Balasubramanian R., MD, Madhusudhan Sangar, MD,               including stress-induced hyperglycemia, is common in
Vishwanathan S., MD, Abdul Razak MD                           patients with severe sepsis. Stress-induced hyperglycemia
                                                              is related to a more severe disease and poorer prognosis.
     Objective: To study the clinical and laboratory char-
acteristics of patients with sepsis and baseline hypergly-        Abstract #215
cemia and investigate the impact of hyperglycemia on the
final outcome. Hyperglycemia has been noted in acute              SUCCESSFUL REMISSION OF TYPE –B
medical emergencies and stress hyperglycemia is asso-             INSULIN RESISTANCE WITH
ciated with increased mortality in myocardial infarction,         IMMUNOSUPPRESSIVE THERAPY
stroke and poisonings. There are no major studies regard-
ing stress hyperglycemia in sepsis patients.                      Bhanu Iyer, MD, Mariana Garcia Touza, MD,
     Methods: Prospective study done in Kasthurba                 Christos Paras, DO, Kyaw K. Soe, MD,
medical college hospital attached to Medical College in           Agnieszka Gliwa, MD
south India.150 patients admitted with severe sepsis dur-
ing a 2-years period were included in the study. Patients         	    Objective: To describe a case of type B insulin resis-
were divided in 4 groups according to their glycemic              tance (IRS-B) in a woman in whom normoglycemia was
profile at admission: patients with stress hyperglycemia          restored with immunosuppressive therapy.
(number 23) defined as random blood sugar at admission            	    Case	Presentation: A 21 year old black female pre-
> 200mg/dl and normal glycosylated hemoglobin (Hb                 sented in December 2008 with progressive weight loss,
A1C), with diabetes mellitus (number 24), (patients with          polyuria, polydypsia, darkening of the skin, severe acne,
history of diabetes / on treatment) with newly detected           amenorrhea, and was noted to have hyperglycemia.
diabetes (defined as no history of diabetes but HbA1c             She was placed on bolus-basal insulin 50 units a day,
>6.5 Gm%(number 8) and with normal glucose level and              but eventually required escalation of her insulin dosage
no diabetes (number 95). All patients were studied with           without gaining control over her blood glucose. Physical
respect to final outcome, duration of intensive care stay,        exam was significant for acanthosis nigricans, acne and
total duration of hospital stay and APACHE 2 score.               hirsutism. Work-up revealed extremely high serum insu-
	    Results: A total of 36.6% of patients with severe            lin levels 238 uU/ml (nl. <2.60), elevated c-peptide 4.5
sepsis had baseline hyperglycemia with 15.3% having               ng/ml (nl.0.8-3.1), negative islet cell antibodies, low


                                                         – 25 –
                                        ABSTRACTS – Diabetes Mellitus

triglycerides 33 mg/dl (nl. <150), elevated testosterone       hyperglycemia. The diagnosis of severe diabetic keto-
level at 916 ng/dl (nl.20-81), elevated hemoglobin A1C         acidosis was established and treatment was started with
(HgBA1C) 13.7% (nl. <6), and polycystic ovaries. ANA           intensive hydration, correction of electrolyte abnormali-
and all other autoimmune markers were negative. IRS-B          ties and insulin therapy. Further work up showed elevated
was suspected and confirmed with positive insulin recep-       hemoglobin A1c and the glutamic acid decarboxylase
tor auto antibodies (IR-Abs). Patient was placed on insulin    antibodies were negative. Glucose management in the
U-500 with maximum daily dose of 600U. She received            non-ICU setting included NPH and pre-meal regular insu-
2 cycles of rituximab along with dexamethasone in July/        lin. He was discharged from hospital with NPH insulin
August 2009 and cyclophosphamide 100 mg/day was con-           and metformin 850mg twice a day. After one month of the
tinued. There was a gradual resolution of her hyperglyce-      episode, he discontinued insulin, and after three months
mia and insulin was discontinued in October 2009. Her          he was treated only with metformin 850mg once a day.
HBA1C improved to 6.5 and testosterone normalized to           His last fasting blood glucose and hemoglobin A1c were
37.5 ng/dl by November 2009. Patient remains euglyce-          normal.
mic and continues to be on cyclophosphamide.                   	    Discussion: The prevalence of type 2 diabetes in
	    Discussion: Type B insulin resistance is rare and is      children and teenagers has increased the last decade. The
characterized by the presence of auto antibodies to the        clinical characteristics of our patient are typical of a type
insulin receptor. The majority of patients are women of        2 diabetes adult patient, with obesity, cervical acantosis
African American descent; with the mean age of onset           nigricans and familiar diabetes antecedent. Severe diabetic
at 40 yrs. Nonspecific autoimmune features are com-            ketoacidosis typical picture of a debut of a type 1 diabetes,
mon in these patients with the most consistent underlying      there are some publications that in certain afroamerican
syndrome complex being systemic lupus erythematosus            ethnias the diabetic ketoacidosis(DKA) is presented in the
(SLE). Signs of hyperandrogenism and insulin resistance        way of debut in young men , in our population the way of
are the prominent presenting features that disappear with      presentation of DKA in adult type 2 diabetes is frequent
the clearance of IR-Abs. Different immunosuppressive           and the presented the clinic characteristic that a 50% were
therapies like glucocorticoids, azathioprine, cyclophos-       a way of diabetes debut. At the beginning of the discus-
phamide, rituximab and plasmapheresis have been used in        sion we named the clinic characteristics associated to type
the past with variable results. Our patient presented with     2 diabetes and the antibodies anti GAD were negative , it
classical features of IRS-B in the absence of any systemic     is true that a 15% type 1 diabetes patients have negative
autoimmune condition, which to our knowledge is quite          antibodies but the phenotype of our patient is type 2 DM.
rare. Immunosuppressive therapy with rituximab and             	    Conclusion: Type 2 diabetes has traditionally been
cyclophosphamide was successful in achieving remission         viewed as a disorder of adults. However, as the prevalence
in our patient.                                                of obesity in youth is increasing, type 2 diabetes is now
	    Conclusion: In our patient treatment with cyclophos-      occurring in children and adolescents. Sustained hyper-
phamide, rituximab and glucocorticoids helped achieve          glycemia can impair the secretion of insulin by the beta-
remission of type B insulin resistance.                        cells of the pancreas. Glucose toxicity explains why some
                                                               patients newly diagnosed with type 2 diabetes have weight
Abstract #216                                                  loss, diabetic ketoacidosis, and low measured insulin and
                                                               C-peptide. Diabetic ketoacidosis in obese adolescents
DIABETIC KETOACIDOSIS IN OBESE                                 with new-onset diabetes does not imply the diagnosis of
ADOLESCENT, A CASE REPORT                                      type 1 diabetes.

Helard Andres Manrique, MD, Pedro Aro, MD,
Edith Hernandez, MD, Carlos Calle, MD,                         Abstract #217
Miguel E. Pinto, MD, Rubelio E. Cornejo, MD,
Jose Solis, MD                                                 NOT ALL SULFONYLUREAS ARE THE SAME.
                                                               TO REDUCE CARDIOVASCULAR MORBIDITY
	    Objective: To report a case of an obese adolescent        AND MORTALITY LETS SAY GOODBYE TO
presenting with diabetes and severe ketoacidosis.              GLYBURIDE.
	    Case	 Presentation: A 14 year-old obese male pre-
sented with a four weeks history of polyuria, polydipsia       Gauranga Chandra Dhar, MD
and weight loss. Physical examination at presentation
showed Kussmaul breathing, severe acanthosis nigricans,             Objective: To present 2 cases of T2DM patients under
and his left knee was swollen and tender. Laboratory           increased risk of cardiovascular (CV) events due to use of
tests showed severe metabolic acidosis, ketonuria, and         glyburide.


                                                          – 26 –
                                         ABSTRACTS – Diabetes Mellitus

	    CasePresentation: A 42-yo man presented with fre-          Abstract #218
quent episodes of hypoglycemia and left sided chest pain.
He is diabetic for 2 years, had no complaints when he was       HYPOGONADISM: A HIDDEN DANGER IN MEN
under metformin and statin except A1C >8.5% for which           WITH DIABETES MELLITUS
glyburide was added 6 months back after which his A1C
came down to 7% and lipids in normal limit. Ischemic            Anthonia Okeoghene Ogbera, MBBS, FMCP, FACE,
changes in ECG & ETT. CIMT & CT angiogram were non              Olufemi Fasanmade, MBBS, FWACP, FACE,
specific. Glyburide was changed to glimepiride. After 3         Sonny Chinenye
months, patient was free from chest pain and relieved from
hypoglycemic episodes and ECG found normal. A 63-yo             	    Objective: The relationship between hypogonadism
woman with T2DM presented with MI, died after 8 hours           (H) and the risk of development of cardiovascular diseases
of hospital admission. Retrospective analysis shows that        in men with diabetes mellitus (DM) has not been widely
after diagnosis of T2DM >20 years back she was noncom-          studied in sub-Saharan Africa. We set out to determine the
pliant, used to have A1C >9.5% and dyslipidemia which           frequency of occurrence of H, the prevalence and corre-
continued for approximately 5 years. Although she had no        lates of the metabolic syndrome (Mets) in Nigerian men
complaints, decided to go for proper control, started with      with type 2 DM who have H.
insulin, metformin and statin. A1C came down to 7% and          	    Methods: This was a cross sectional study of 200 men
lipids to normal in 2 years. Six months before her death, as    with type 2 DM aged 30-86 years receiving care at the DM
per her request glyburide was prescribed instead of insu-       Centre of the Lagos State University Teaching Hospital
lin. Blood glucose and lipid were normal 2 months before        (LASUTH), Ikeja. The clinical parameters that were
her death but felt symptoms of hypoglycemia.                    determined included history pertaining to DM and hyper-
	    Discussion: Increased CV morbidity and mortality           tension. The laboratory parameters that were assessed
due to use of glyburide can be explained by two different       included blood glucose, total testosterone (TT), uric acid,
mechanisms: First, Sulfonylureas (SUs) work by inhibit-         lipid parameters and highly sensitive CRP. Hypogonadism
ing KATP channels in beta cells causing cell membrane           (H) was determined by the combination of positive ADAM
to depolarize leading to voltage-dependent Ca2+ channel         score (clinical features of hypogonadism were determined
to open, causing increase in Ca2+ in beta cells leading to      by usage of the ADAM questionnaire) and TT less than
insulin secretion. Glyburide exerts non specific affinity       300ng/dl. The presence of the Mets was determined using
to SU receptors (SUR) e.g. acts on SUR-1 in beta cells,         the ATP III criteria. Test statistics used included logistic
SUR-2A and SUR-2B in cardiac myocytes and cells on              regression, correlation coefficient analysis, and t test. P
vascular bed respectively. Chronic inhibition of the KATP       values of <0.05 were considered statistically significant.
channel with glyburide abolishes ischemic precondition-         	    Results	and	Discussion: The overall prevalence of H
ing of explanted myocardium might be the reason of              was 70% and the mean (SD) age of the subjects with H
increased CV mortality. Such inhibition of the cardiac          was comparable to that of those without H (60.3± 11.8
KATP channel with glyburide has been shown to increase          vs 57.7± 12, p- 0.1). The proportion of H subjects with
ischemia-reperfusion damage. Second, Glyburide contin-          the Mets was higher than that of the non H group with
ues to stimulate insulin secretion to a greater extent than     the Mets (81% vs19%, p- 0.006). The mean TT level in
other SUs in the setting of profound hypoglycemia. In           subjects with the Mets was lower than in those without
addition, glyburide is known to accumulate in the beta          the Mets (200± 220ng/dl vs 290±300ng/dl, p-0.02). The
cells where it can prolong insulin secretion, whereas other     prevalence of high hs.CRP was 68% in subjects with, and
SUs do not. Sympatho-adrenal activation and counter-            32% in those without the Mets (p- 0.03). The occurrence
regulatory hormone secretion due to hypoglycemia lead           of the Mets was associated with low testosterone levels
myocardial ischemia and infarction. Additionally counter-       (OR: 0.3,95%CI: 0.148-0.647,p-0.004) which in turn
regulatory mechanisms may lead to prolonged cardiac             was significantly correlated with elevated hs CRP levels
repolarization causing “Torsade de pointes” and death.          (r=+0.3, p-0.001). The clustering of the components of
	    Conclusion: During selecting sulfonylurea for the          the Mets were in the following proportions: elevated TG
treatment of T2DM, better to go for selective SU having         (13%), reduced HDL- (84%) central obesity 41 (49%),
affinity only to SUR-1 and avoid glyburide, a non-selec-        and hypertension 58 (70%)). The overall prevalence of
tive SU.                                                        hyperuricaemia was 11% and this was noted in only 8% of
                                                                the subjects with the Mets. The frequency of occurrence of
                                                                hyperuricaemia in H and non H patients with the Mets was
                                                                comparable. LDL-C was the only lipid parameter that had
                                                                possible relationship with H. The mean level of LDL-C
                                                                was significantly higher in H than non H men (144mg%


                                                           – 27 –
                                         ABSTRACTS – Diabetes Mellitus

± 51 vs 108 mg % ± 48 , p-0.03) and LDL-C had a sig-            infusion was discontinued within 24 hours with the normal-
nificant correlation with testosterone levels (r = + 0.2,       ization of arterial pH, serum anion gap and disappearance
p-0.002).                                                       of urine ketones. However, large doses of subcutaneous
	    Conclusion: Given the more frequent occurrence             insulin (up to 130 units per day) were still needed to keep
of the Mets, prominence of elevated hs CRP levels and           serum glucose within normal range. In view of extremely
higher LDL levels in hypogonadal than non hypogonadal           high daily insulin requirements, tacrolimus was substi-
men, we conclude that testosterone deficiency in men with       tuted with cyclosporine A. Following this regime modi-
DM places them at greater cardiovascular risk compared          fication, his insulin requirements significantly reduced
with those without hypogonadism. Elevated hs-CRP but            (40 units per day). Complete insulin independence was
not hyperuricaemia is a dominant feature of the Mets in         achieved within 2 weeks and he has not required any insu-
hypogonadal men with type 2 DM. The underlying asso-            lin or oral hypoglycemic agents hitherto (approximately
ciation between testosterone deficiency and the Mets            1.5 years after his presentation with DKA). Serum fasting
remains unclear and needs to be studied.                        plasma glucose levels have remained within normal range.
                                                                Anti-GAD and islet cell antibodies were both negative in
Abstract #219                                                   this patient. Serum insulin levels and C-peptide levels
                                                                were, however, not checked.
TACROLIMUS INDUCED DKA IN A PATIENT                             	    Discussion: The diagnosis of drug induced DM in our
WITH RENAL TRANSPLANTATION AND                                  patient presented a diagnostic dilemma because of consid-
LAURENCE-MOON-BIEDL SYNDROME                                    eration for competing etiologies including DM second-
                                                                ary to LMBS and ketosis-prone type 2 DM. LMBS is an
Muhammad Qamar Masood, MD,                                      autosomal recessive condition characterized by rod-cone
Madiha Rabbani, MBBS                                            dystrophy, postaxial polydactyly, central obesity, mental
                                                                retardation, hypogonadism, and renal dysfunction. In a
	     Objective: To describe a case of new onset diabetes       large series of 109 patients, non-insulin dependent DM
mellitus with diabetic ketoacidosis (DKA) as initial pre-       (NIDDM) was described in 6% of the patients. In recent
sentation in a patient with Lawrence moon Biedl syn-            years, an increasing number of DKA cases have also been
drome receiving tacrolimus for renal transplantation.           reported in children, adolescents and adults without any
      Case	 Presentation: A 17-year-old Sudanese male           precipitating cause; these have been referred to as atypical
patient was brought to the Emergency Room (ER) with             diabetes or ketosis-prone type 2 DM. Increasing evidence
polyuria, nocturia, dry mouth, and poor appetite of three       indicates that this subtype of diabetes accounts for more
days duration and intractable vomiting, altered mentality       than half of newly diagnosed black and Hispanic patients
and irritability for one day. Although impaired fasting glu-    with DKA. These patients are usually obese, have a strong
cose (IFG) had been documented on a few prior occasions,        family history of diabetes, have a low prevalence of auto-
overt diabetes had never been present. The patient was a        immune markers, and lack a genetic association with
known case of Laurence-Moon-Biedl syndrome (LMBS).              HLA. While our patient was obese and had negative auto-
Deterioration in kidney function was noted at the age of        immune markers, he also didn’t have a family history of
12 years gradually progressed to end stage renal disease        DM. A diagnosis of drug induced DM leading to DKA is
(ESRD) leading to pre-emptive renal transplantation one         the most likely etiology in our patient because of the rapid
year prior to this presentation. He had been receiving          decline in insulin requirement and insulin independence
immunosuppressive treatment in the form of tacrolimus           after withdrawal of tacrolimus. Tacrolimus inhibits the
(6 mg bid), mycophenolate mofetil (1gram bid) and pred-         transcription of the insulin gene by inhibition of calcineu-
nisolone(5 mg qd) in the post-transplant setting. Physical      rin after binding to FK506-binding protein 12. Tacrolimus
examination showed moderate dehydration and without             as compared to is more commonly associated with post
any overt focus of infection. He was afebrile, had a heart      transplantation diabetes mellitus, in an open label, ran-
rate of 140 beats per min, blood pressure of 126/70 mm          domized trial the six month incidence of new onset dia-
Hg, respiratory rate of 30 per minute. His physical exam        betes after transplantation or impaired fasting glucose was
otherwise is significant for marked obesity, acanthosis         33.6% with tacrolimus and 26.0% with cyclosporine. In
nigricans, vision was limited to light perception only,         another study using the used data from the United States
polydactyly and absence of secondary sexual characteris-        Renal Data System, the three-year incidence of de novo
tics. His blood glucose was 702 mg/dl with large ketonu-        diabetic ketoacidosis was 1.56% in patients using tacro-
ria and high anion gap metabolic acidosis (pH-7.1, anion        limus vs. 0.35% in patients using cyclosporine. DKA is
gap 25 mEq/l, serum bicarbonate 06 mEq/l). The patient          usually sudden in onset in these individual and total insu-
was managed with intravenous fluids, insulin infusion and       lin independence was described in one case report after
potassium replacement as per standard protocols. Insulin        withdrawn from tacrolimus.


                                                           – 28 –
                                         ABSTRACTS – Diabetes Mellitus

	   Conclusion: Clinicians should be cognizant of the           0.19-0.59), PVD (OR 0.17 95%CI 0.06-0.47), and ulcers
possibility of hyperglycemic crisis presenting as sudden        (OR 0.20, 95%CI 0.06-0.63).
onset of diabetic ketocidosis in patients receiving tacroli-    	   Discussion: Despite a lower BMI and similar rates
mus. Substituting these patients to alternative calcineurin     of lab testing, Haitians have poorer glycemic and BP
inhibitor may provide a safer solution to minimize future       control than do African-Americans. Studies of Haitians’
morbidity.                                                      health care utilization and behavioral factors are indicated.
                                                                A strikingly lower rate of several diabetic complications
Abstract #220                                                   among Haitians may be due to under-diagnosis and under-
                                                                documentation or other factors.
DIABETES CONTROL AMONG HAITIANS                                 	   Conclusion: Haitians have poorer glycemic and
VERSUS AFRICAN-AMERICANS IN AN URBAN                            BP control, but equivalent rates of lab testing and
SAFETY-NET HOSPITAL                                             lower rates of many documented complications than do
                                                                African-Americans.
Varsha Vimalananda, MD, Karen E. Lasser, MD, MPH,
Howard Cabral, PhD, MPH, James Rosenzweig, MD                   Abstract #221

	    Objective: Haitians comprise 19% of the black popu-        IMPACT OF DIABETES EDUCATION ON
lation in Boston. We describe the burden of diabetes in this    HBA1C AND WEIGHT REDUCTION
ethnic subgroup.
	    Methods: We conducted a retrospective, cross-              Issac Sachmechi, MD, FACP, FACE, Saman Ahmed, MD,
sectional study of diabetes control, quality of care, and       Vincent Rizzo, MD, David Reich, MD, FACE,
complication rates among Haitian and African-American           Hildegarde Payne, RN, CDE,
patients at an urban safety-net hospital. Patients were         Betty Meenattoor, RN, CDE, Paul Kim, MD, FACE
>20 yo with two primary care visits over the past two
years. Self-identified Haitians (n=715) who spoke               	    Introduction: Diabetes education and dietitian coun-
English or Haitian Creole were compared to African-             seling are one of the most important components of dia-
Americans (n=1472). We defined poor glycemic control            betes management to improve the outcome of patients.
as A1C≥9%. Quality of care indicators were yearly test-         In spite of many clinical challenges by serving a largely
ing of A1C, LDL, and urine microalbumin(UMA), as well           uninsured population with generally poor health literacy
as LDL<100mg/dl and BP <130/80mmHg. Diagnoses of                at Queens Hospital Center (QHC), the outcome of referred
retinopathy, neuropathy, CAD, ischemic stroke, peripheral       patients to Diabetes Center of Excellence in term of weight
vascular disease (PVD), and lower extremity ulcers were         loss and Hemoglobin A1c (A1c) reduction has been above
on problem lists or billing codes. We defined nephropathy       the national average.
as GFR<60ml/min or renal transplant. We used chi-square         	    Objective: This study was designed to measure the
analyses and Student’s t-test. We used multiple logistic        sole effect of diabetes education and dietitian counseling
regressions to control for age, sex, BMI, BP, language,         without the intervention of an endocrinologist on glyce-
and payor group (insurance of poverty, Medicare, private,       mic control and weight on patients who were referred by
and other). For regression analysis of complication rates,      primary care physicians.
we also controlled for A1C.                                     	    Methods: This was a retrospective case control study.
	    Results: Thirty-two percent of Haitians spoke              The study group (n=150) was selected from those patients
English. Haitians had a lower mean BMI than African-            with type 2 diabetes (type 2 DM) who were referred by
Americans (30.8±6.0 vs. 33.8±6.0, p<0.0001), but rates of       their primary care physician to two diabetes educators and
hypertension were similar (80% vs. 83%). Haitians had a         a dietitian for counseling from the period of January 2007
higher mean A1C (8.2±1.9 vs. 7.8±2.0, p<0.0001), and a          to June 2008.The control group (n=150) was selected
higher proportion of A1C ≥ 9% (24% vs. 18%, p=0.003).           from those patients with type 2 diabetes in the primary
BP was more often >130/80 in Haitians (64% vs. 58%,             care clinic who were not seen by a diabetes educator and
p=0.009). In the adjusted model to identify predictors          a dietitian during the same period of time. A1c and weight
of A1C≥9%, only age (OR 0.97, 95%CI 0.96-0.98) and              were compared before and six months after diabetes edu-
Haitian ethnicity (OR 1.41, 95%CI 1.006-1.98) were sig-         cation and dietitian counseling in the study group as well
nificant. Rates of yearly testing for A1C, LDL or UMA           as in the control group.
were similar. Haitians had similar retinopathy and stroke       	    Results: In the study group, the mean A1c was
rates, but lower rates of diagnosed and documented              reduced by 1.02% (from 8.47% to 7.46%) with p< 0.01.
nephropathy (OR 0.52, 95%CI 0.35-0.76), neuropathy              In the control group the mean A1c was reduced by 0.59%
(OR 0.40, 95%CI 0.28-0.58), CAD (OR 0.34, 95%CI                 (from 7.8% to 7.24%) with p< 0.01. In the study group,


                                                           – 29 –
                                        ABSTRACTS – Diabetes Mellitus

the mean weight was reduced by 2 lb (from 175 lb to 173        Cglu <10 mmol>L) as assessed by CGM over standard 24
lb) with p < 0.05. In the control group, the mean weight       hour periods. Additional endpoints will include analysis
was reduced by 0.71 lb (from 190.48 lb to 189.77 lb),          of fructosamine, Glycomark, pharmacodynamics follow-
which was not statistically significant (p=0.365).             ing a meal challenge, insulin antibody data, hypoglycemia
	    Discussion: This study demonstrates that diabetes         and other adverse events.
education and dietitian counseling alone by three person-      	     Discussion: Nasulin is an ultra-rapid acting intrana-
nel were effective and resulted in an improvement in gly-      sal insulin formulation with a PK profile that more closely
cemic control and weight loss in the study group patients      mimics the onset of normal pancreatic secretion with a
compared to the control group patients although both           faster onset time at 5-10 min and a faster Tmax of ~15-20
groups received similar diabetes treatment from the physi-     min than current rapid acting mealtime insulins. This pro-
cians in the primary care clinic.                              file allows for more optimal pharmacodynamic activity at
	    Conclusion: This study demonstrates that diabetes         the time of caloric ingestion. In addition, this profile could
education and dietitian counseling by two diabetes educa-      potentially result in less hypoglycemia, less weight gain
tors and a dietitian without an endocrinologist’s interven-    and could replace the missing early phase insulin release
tion can improve glycemic control and promote weight           in Type 2 diabetic patients. CGM methodology was cho-
loss in patients with type 2 DM and poor health literacy.      sen as it will determine both the reduction of hyperglyce-
This is one of few study demonstrating a measurable            mia as well as the reduction of hypoglycemia.
improvement in diabetes control and weight loss which          	     Conclusion: This is an ongoing study. A total of 94
are solely due to diabetes education and diet counseling in    subjects have been randomized and enrollment is com-
a municipal hospital with limited resource.                    plete. The final efficacy and safety results will be pre-
                                                               sented for the 1st time at the meeting.
Abstract #222
                                                               Abstract #223
COMPARISON OF NASULIN VS. PLACEBO
THERAPY ON GLYCEMIC CONTROL IN                                 SERTRALINE INDUCED HYPOGLYCEMIA
TYPE 2 DIABETIC PATIENTS UTILIZING
CGM TECHNOLOGY                                                 Sol Virginia Guerrero, MD, Jennifer Pedersen-White, MD

Poul Strange, MD, Janet McGill, MD,                            	    Objective: To report the association between sertra-
Randall Severance, MD, Lance Berman, MD,                       line use and hypoglycemia
Robert Stote, MD                                               	    Case	 presentation: A 46 year old female with a 10
                                                               year history of type 2 diabetes (controlled with diet and
	    Objective: To compare the effect of Nasulin™ (intra-      glipizide) was admitted on 09/10/09 for evaluation of
nasal insulin) vs. Placebo on plasma glucose control in        recurrent, symptomatic hypoglycemia. During hospital-
subjects with Type 2 diabetes utilizing CGM technology.        ization, adrenal, hepatic and renal etiologies of hypogly-
	    Methods: This is a randomized, parallel design, dou-      cemia were excluded. Additionally, screening for MEN,
ble-blind, placebo-controlled, two arm, multi-center trial.    exogenous insulin and sulfonylurea was negative. A
Type 2 subjects with diabetes (≥18 years of age, HbA1c         symptomatic hypoglycemic episode occurred shortly after
between 6.5-10.0%, BMI ≤40.4 kg/m²) on OADs and                admission (blood glucose of 40mg/dl). Hypoglycemia
basal insulin were eligible for the study. After a single-     with associated Whipple’s triad first occurred in May of
blind, placebo run-in phase of 4 weeks during which diet       2009. At that time, glipizide was decreased from 5 mg to
and lifestyle counseling were given and glargine doses         2.5 mg daily. Despite this, hypoglycemic episodes per-
were optimized (target morning fasting plasma glucose          sisted. Three weeks later, glipizide therapy was discon-
between 90 and 120 mg/dl), patients entered a 6-week dou-      tinued after random blood work reported blood glucose of
ble-blind period and were randomized to placebo or 50 IU       36 mg/dL. Despite discontinuation of glipizide, hypogly-
Nasulin to be administered at the start of each of 3 meals.    cemic episodes continued for several months. Review of
Using a simple titration guideline based on postprandial       medication history revealed that Sertraline 100mg daily
glucose measurements, the blinded study medication dose        was prescribed on 05/04/09 with the first episode of hypo-
could be increased to 100 IU per meal. Doses of the back-      glycemia occurring 05/09/09. Sertraline was then discon-
ground long-acting insulin were to be kept constant during     tinued and patient was discharged home in stable condi-
the double-blind period. The primary analysis will assess      tion with no further episodes of hypoglycemia.
whether Nasulin™ achieves a larger increase from base-         	    Discussion: The prevalence of depression in diabetic
line compared with placebo in the percent of time spent in     patients is estimated to be between 8-27%. Depression
euglycemia (70 mg/dL<Cglu<180 mg/dL or 3.9 mmol/L<             can affect treatment and dietary compliance which can


                                                          – 30 –
                                         ABSTRACTS – Diabetes Mellitus

impact the development of long term complications. Little            significantly with HBA1c suggesting that poor glyce-
is known about the effect of selective reuptake inhibitors           mic control was a risk factor for the development of
on glycemic control. Here we report a case of sertraline             microalbuminuria.
induced hypoglycemia (SIH) which persisted despite dis-              	 Conclusion: Microalbuminuria is related to poor gly-
continuation of sulfonylurea therapy. To our knowledge,              cemic control in this study. Concerted efforts are therefore
there have been only 2 reported cases of SIH, one occur-             required to improve on glycemic control in our patients
ring in a non diabetic and the other in diabetic on sulfonyl-        to prevent microalbuminuria and possibly diabetic
urea therapy. Diabetic and non diabetic rat models have              nephropathy.
suggested several mechanisms for SIH including increased
insulin secretion, increased insulin uptake in muscle and
stimulation of insulin-like growth factor release. Others        Abstract #225
however, have reported a significant reduction in blood
glucose with no concomitant increased in insulin levels.         LIPID ABNORMALITIES IN ADULTS WITH
Furthermore, others suggest that the addition of sertraline      NEW-ONSET TYPE 1 DIABETES: ANALYSIS OF
to sulfonylurea therapy may predispose to hypoglycemia           BASELINE DATA FROM DEFEND
due to enzymatic competition of P 450.
	    Conclusion: There are currently no established treat-       Aoife M. Brennan, DR, Mark Christiansen, MD,
ment guidelines to assist practitioners in the medical man-      Richard Weinstein, MD, Bruce Belanger, PhD,
agement of depression in diabetic patients. We report an         Charlotte McKee, MD, Louis Vaickus, MD
association between sertraline use and persistent hypogly-
cemia. The potential impact of antidepressant medications        	     Objective: Examine relationships between fasting
on glycemic control should be considered prior to initia-        lipid levels, endogenous insulin secretion (C-peptide), and
tion of therapy in diabetic patients.                            glycemic control in new-onset type 1 diabetes mellitus
                                                                 (NOT1DM). Autoimmune T1DM is a risk factor for devel-
Abstract #224                                                    opment of cardiovascular disease and is associated with an
                                                                 atherogenic lipid profile. Glycemia mediates some of these
MICROALBUMINURIA AMONG DIABETIC                                  abnormalities, but whether fasting lipid levels are abnormal
PATIENTS IN ZARIA, NIGERIA.                                      at first diagnosis of T1DM and whether they are related to
                                                                 insulin secretion is unknown. DEFEND is a multinational
Adamu Girei Bakari, MBBS, FWACP,                                 placebo-controlled Phase 3 study of the safety and efficacy
Ahmad Bello Muhammed, BSc,                                       of an investigational targeted T cell immunomodulator, an
Fatima Bello-Sani, MBBS, FWACP,                                  anti-CD3 monoclonal antibody (otelixizumab), in subjects
Anaja P.O, BSc, MSc, PhD                                         with NOT1DM. Otelixizumab has been shown to preserve
                                                                 insulin secretion in a Phase 2 trial.
	 Background: Microalbuminuria reflects an abnor-                	     Methods: Subjects were enrolled within 90 days of
mal glomerular capillary permeability to protein and is an       diagnosis; had BMI < 32; screening stimulated C-peptide
early marker of diabetic nephropathy. It is also thought         > 0.20 and ≤ 3.50 nmol/l; at least one T1DM-associated
that microalbuminuria reflects generalized endothelial           autoantibody; and were otherwise healthy. Baseline data
dysfunction and is also considered a risk factor for cardio-     were examined for the percentage of subjects outside of
vascular morbidity and mortality among diabetic patients.        AACE targets for total cholesterol, LDL, HDL, and tri-
	 Objective: to determine the prevalence of microal-             glycerides. Stepwise regression was used to identify fac-
buminuria among diabetic patients attending the diabetic         tors associated with lipid levels. Gender, age, and BMI
clinic of Ahmadu Bello University Teaching Hospital,             were base explanatory variables; stimulated C-peptide
Zaria, Nigeria.                                                  time-normalized area under the curve (AUC; in response
	 Methods: A cross sectional study involving 170 dia-            to a mixed meal), unstimulated C-peptide, time from diag-
betic patients who did not have overt Proteinuria or urinary     nosis, and HbA1c were candidate variables for inclusion
tract infection and 100 control subjects. Urinary albumin        in the model.
was measured using immunoturbidimetric method on                 	     Results: Data were available from 124 adult subjects
spot urine samples. Serum and urinary creatinine, blood          (mean age 26 years, 34% female, mean BMI 24 kg/m2).
glucose and glycosylated hemoglobin (HBA1c), were                Excluding the 5% on lipid lowering therapy, analyses
measured using standard methods. Microalbuminuria was            included 118 subjects. Total cholesterol was > 200 mg/
defined as ACR of 3-30mg/mmol                                    dl in 18%, LDL was > 130 mg/dl in 14%, HDL was < 35
	 Results: The prevalence of microalbuminuria is 20%             mg/dl in 6%, and triglycerides were > 150 mg/dl in 6%.
among diabetic patients. Microalbuminuria correlated             In multiple regression analysis, age (p < 0.001), C-peptide


                                                            – 31 –
                                         ABSTRACTS – Diabetes Mellitus

AUC (p < 0.001), and HbA1c (p = 0.002) were indepen-             respectively, to 65 for the scorecard group and 62 for the
dently and positively associated with LDL. Adjusting for         control group.
age and C-peptide AUC, mean LDL increased 5.6 mg/dl              	    Conclusion: The use of diabetes scorecards to
(SE = 1.8) for every 1% increase in HbA1c. Adjusting for         improve risk factor control in adults with uncontrolled
age and HbA1c, mean LDL increased 15.1 mg/dl (SE =               Type II diabetes did not appear to be beneficial in addition
4.3) for every 1 nmol/l increase in C-peptide AUC.               to the standard care as measured by a scoring system at a
	    Conclusion: In NOT1DM, lower insulin secretion              subsequent visit. Further research is needed to study the
was associated with lower LDL levels. Possible explana-          use of scorecards over multiple visits over a longer period
tions include a) reduced LDL in subjects with severe insu-       of time and to see whether certain subgroups of patients
lin deficiency prior to diagnosis and b) elevated LDL in         could benefit from the use of diabetes scorecards.
subjects with higher insulin secretion due to insulin resis-
tance prior to diagnosis. Mechanistic studies are needed to      Abstract #227
explore these observations. The effect of otelixizumab on
serum lipid levels is being evaluated in DEFEND.                 FAMILIAL PARTIAL LIPODYSTROPHY
                                                                 COMPLICATED BY UNUSUAL LIVER LESIONS
Abstract #226
                                                                 Anders Carlson, MD, Muriel Nathan, MD, PhD
USE OF A SCORECARD TO IMPROVE RISK
FACTOR CONTROL IN PATIENTS WITH                                  	    Objective: To describe a case of familial partial lipo-
UNCONTROLLED TYPE II DIABETES                                    dystrophy with telangiectatic hepatocellular adenomas, a
                                                                 rare type of liver lesion.
Poonam Sood, MD, Tim Amass, Sheena Khurana, MD,                  	    Case	Presentation: A 35 year old female with a his-
Vimala Jayanthi, MD, Suzanne Adler, MD,                          tory of familial partial lipodystrophy, Dunnigan variety,
Alexander Rilling, MD, Michael Irwig, MD                         presented with abdominal pain and vomiting. Her diabe-
                                                                 tes is well controlled by insulin pump. She does not take
	    Objective: Type II diabetes mellitus (DM) has               oral contraceptives. She has a history of pancreatitis due
become a worldwide epidemic. Since education is essen-           to hypertriglyceridemia, and incidental liver lesions (up to
tial for patients to self manage their diabetes, our study       2 cm) were seen on MRI 2 years ago. Her physical exam
tested the use of diabetes scorecards during clinic visits to    shows marked fat atrophy of the limbs and chest, with sig-
see whether they improved glycemic control, BP control,          nificant fat deposits around the face, neck and abdomen.
LDL-cholesterol, aspirin usage, and amount of exercise.          Hirsutism is present. The largest liver lesion has grown to
	    Methods: 85 patients with type II DM from a univer-         over 5 cm. Lipase is normal. Biopsy of the largest liver
sity practice were recruited in clinic by endocrinologists       lesion shows necrotic tissue and fatty liver, worrisome for
and internists. Inclusion criteria were men and non-preg-        malignancy. Pathology from resection of the largest liver
nant women ≥ 40 years old with HbA1c levels ≥ 8%. In this        lesion reveals a telangiectatic hepatocellular adenoma
single-blinded controlled trial, patients were randomized        with peliosis, along with marked fatty liver changes in the
to receive a scorecard (n=42) or not (control group; n=43).      surrounding tissue.
At each clinic visit, providers reviewed with the patients       	    Discussion: Familial partial lipodystrophy type 2,
whether their HbA1c, BP, LDL-cholesterol, aspirin usage,         Dunnigan variety (FLP2), is an autosomal dominant
and exercise were at target. Points were assigned to each        mutation in the lamin A/C gene, encoding a nuclear
of the five previous variables, an overall total score (max-     envelope protein. The exact mechanism is unknown,
imum of 100) was calculated for each visit, and scores           but genes involved in adipogenesis are altered. FPL2
were provided to the patients in the scorecard group only.       patients have normal fat distribution until puberty, when
The primary endpoint was the change in total overall score       there is a spontaneous loss of subcutaneous fat from the
between the scorecard and control groups at a subsequent         upper and lower extremities, gluteal region and trunk.
visit 2-4 months after the initial visit.                        Accumulation of fat the face, neck and intraabdominal
	    Results: The patients in the scorecard and control          regions then occurs, resulting in a Cushingoid appearance.
groups were similar demographically. The average age             Hypertriglyceridemia is common; hirsutism and PCOS
was 56 years, 57% were women, and 69% were African-              are infrequent. While other forms of lipodystrophy are
American. The average education level was some col-              well known to have fatty liver, previous reports of FPL2
lege, 17% had CAD and the average duration of DM was             have not described a high prevalence of liver abnormali-
9.9 years. At baseline, the average total score was 59 for       ties. Treatment involves lifestyle modification and man-
the scorecard group and 55 for the control group. At the         agement of lipids and hyperglycemia. Leptin therapy in
subsequent visits, the scores increased by 6 and 7 points,       small trials has been effective. The type of liver lesion in


                                                            – 32 –
                                         ABSTRACTS – Diabetes Mellitus

this case is unusual. Formerly called telangiectatic focal       most prevalent pathogen isolated both with males and
nodular hyperplasia, telangiectatic hepatocellular adeno-        females.
mas are lesions with marked sinusoidal dilatation and            	   Conclusion: A significant percentage of subjects with
peliosis, without fibrosis. They also show a monoclonal          DM had asymptomatic bacteriuria and this was associated
pattern, raising concern for malignancy and distinguish-         with levels of hyperglycemia. We propose that patients
ing them from focal nodular hyperplasia. While most              with DM be routinely screened for AB in order to offer
commonly seen in young women on birth control pills,             appropriate and timely management.
their presence in lipodystrophic patients is not previously
reported.                                                        Abstract #229
	    Conclusion: Familial partial lipodystrophy, Dunnigan
variety, is a rare disorder of fat metabolism, with fatty        A CASE OF MATURITY ONSET DIABETES OF
liver as a known complication. In these cases, telangiec-        THE YOUNG PRESENTING WITH BLINDNESS
tatic hepatocellular adenomas are a possible type of liver
lesion.                                                          Marian Gaber Saad, MD,
                                                                 Faramarz Ismail-Beigi, MD, PhD
Abstract #228
                                                                 	    Objective: Understanding the different mutations
FREQUENCY OF OCCURRENCE AND                                      associated with maturity onset diabetes of the young
CORRELATES OF ASYMPTOMATIC                                       (MODY) and the resulting phenotypes can aid the clini-
BACTERIURIA IN DIABETES MELLITUS                                 cian in predicting the course of the disease, in counsel-
                                                                 ing the patient and other family members, deciding on
Adeleye Olufunmilayo Olubusola, MD,                              the treatment regimen and frequency of follow-ups. We
Anthonia O. Ogbera, FMCP, FACE, FACP,                            believe that better understanding of the pathophysiology
Ayotunde Oladunni Ale, MD, Ekere F., MD,                         of MODY at the molecular and genetic level through basic
Orolu MO, MD, Iyayi F., MD                                       science research will further our understanding of the opti-
                                                                 mal diagnostic and therapeutic approaches, and aid clini-
	    Objective: The diabetic state is associated with            cians in recognizing this disease entity.
immunosuppression hence the predisposition of persons            	    Case	 Presentation: We present a case of a 21 year
with diabetes to infections. Asymptomatic bacteriuria            old Caucasian male who presents to the outpatient
(AB) is a risk factor for pyelonephritis and renal dysfunc-      clinic with a chief complaint of progressive worsening
tion. This study sets out to determine the frequency of          of vision over months. He denies any other complaints.
asymptomatic bacteriuria in diabetic subjects attending          Ophthalmological testing confirmed diabetic proliferative
the diabetes centre, associated risk factors and the preva-      retinopathy resulting in legal blindness. Laboratory data
lent microorganisms.                                             confirmed diabetes mellitus of non-autoimmune origin.
	    Methods: 280 consecutive patients with type 2 DM            The patient responded to long acting secretagogue and
were recruited. The demographic and anthropometric               metformin and once HbA1c improved patient was man-
indices were obtained. Early morning urine samples were          aged solely with metformin with good control.
collected into sterile universal bottles for microscopy, cul-    	    Discussion: Maturity onset diabetes of the young
ture and sensitivity. Fasting blood samples were analyzed        (MODY) accounts for 1-5% of all cases of diabetes in the
for glucose and glycosylated hemoglobin. Subjects with           Western world. Several clinical characteristics distinguish
symptoms of urinary tract infection (UTI) and benign             MODY from type 2 diabetes mellitus. A presentation of
prostatic hypertrophy were excluded.                             non-ketotic diabetes mellitus, autosomal dominant mode
	    Results: The mean (SD) age of the subjects’                 of inheritance noted over several generations, absence of
59.8yrs±10.8 .Mean (SD) BMI 28.3±5.6. 69.3% were                 obesity and onset of diabetes before age 25, are all charac-
females, 30.4% were males. 31.4% of the study subjects           teristics of MODY. Mutations in at least 6 different genes
had positive urine culture (>105cfu). A higher proportion        account for the different types, presentations and ulti-
of females (33%) had positive cultures compared with             mately management modalities used for MODY patients.
males (24%).This was however not statistically significant       	    Conclusion: Since genetic testing for MODY muta-
p-value 0.51. There was positive correlation between level       tions is expensive and only available in select research lab-
of hyperglycemia and presence of infection and negative          oratories throughout the country, we emphasize through
correlation between duration of diabetes and presence of         this report the importance of recognition, early diagnosis
infection. Isolated organisms include, atypical coliforms,       and appropriate management that may prevent inevitable
Escherichia coli, Klebsiella species, proteus mirabilis,         complications with wrong or suboptimal management,
staphylococcus, and streptococcus spp. E coli were the           especially in primary care setting.


                                                            – 33 –
                                        ABSTRACTS – Diabetes Mellitus

Abstract #230                                                  	    Conclusion: These data demonstrate that salsalate, as
                                                               an anti-inflammatory agent, reduces insulin resistance and
SALSALATE IMPROVES GLYCEMIA AND                                glycemia in prediabetic patients. The optimal duration of
INSULIN RESISTANCE IN PREDIABETIC                              treatment and ability to prevent overt diabetes must fur-
PATIENTS                                                       ther be studied.

Elham Faghihimani, MD, Peyman Adibi, MD,                       Abstract #231
Hasan Resvanian, MD, Ashraf Aminorroaya, MD,
Masoud Amini, MD                                               SALSALATE IMPROVES GLYCEMIA IN
                                                               DIABETIC PATIENTS
	     Objective: Insulin resistance plays a primary role
in the development of type 2 diabetes mellitus and is a        Elham Faghihimani, MD, Peyman Adibi, MD,
characteristic feature of obesity, metabolic syndrome, pre-    Hasan Resvanian, MD, Ashraf Aminorroaya, MD,
diabetes and diabetes mellitus. The mechanism by which         Masoud Amini, MD
insulin resistance occurs is unknown but may be related
to a cascade of inflammatory process involving IKK-β.              	 Objective: chronic inflammation may contribute to
The aim of the present study is to evaluate the efficacy of        insulin resistance and type 2 diabetes mellitus through
salsalate as an inhibitor of IKK-β to decrease hyperglyce-         activation of the IKKβ/NF-κB pathway. The present study
mia and insulin resistance in prediabetic patients, before         investigated whether treatment with salsalate, an anti –
proceeding to overt diabetes mellitus.                             inflammatory medication, would improve glycemia and
	     Methods: In a double-blind, placebo controlled               insulin resistance in a group of diabetic naïve patients.
trial, we enrolled 120 prediabetic adults (40 to 70 years)         	 Methods: The study was a randomized, double – blind,
according to ADA criteria (fasting glucose level 100               placebo controlled clinical trial conducted at the Isfahan
mg/dl to 126 mg/dl or glucose level two hours after 75             Endocrine and Metabolism Research Center. Diagnosis of
gram oral glucose 140 mg/dl to 200 mg/dl). Participants            diabetes was based on ADA criteria if their diagnosis had
were first degree relatives of diabetic patients attend-           been established during the last 2 months before the study
ing in Endocrine and Metabolism Research Center. The               and they had not received any anti- glycemic agent. The
intervention was salsalate 3 g/day or identical placebo for        participants were 60 adults (21% men) 40 to 70 years old,
three month. Participants (20% men) were enrolled in the           all were enrolled in the project after a briefing session and
project after a brief informational meeting and giving a           signing written consent. They were randomized in two
signed written consent. We measured fasting plasma glu-            intervention and placebo groups. The intervention was
cose, HOMA-IR (fasting glucose× fasting insulin/22.5),             salsalate 3 g/day or placebo for 3 months. We measured
lipid profile, HbA1C and serum insulin level before and            fasting plasma glucose, glucose response two hours after
after intervention.                                                75 gram oral glucose, HbA1C, serum insulin, HOMA-IR
	     Results: Salsalate reduced fasting plasma glucose by         (fasting glucose× fasting insulin/22.5), lipid profile before
11% (from 129.8±28 mg/dl to 108.6±18 mg/dl) (p<0.03).              and after treatment.
There was no significant decrease in plasma glucose after          	 Results: Comparing with controls, salsalate reduced
an oral glucose tolerance test. HOMA-IR as an insulin              fasting glucose 14.5% (from 129.8±28 to 108.6±18)
resistance index changed from 5.1±3.0 to 3.0±1.5 in sal-           (P<0.01), glycemic response after an oral glucose toler-
salate group and from5.3±4 to 4.8±3 in placebo group               ance test 7% (from 198.4±45 to 156.9±66) (P<0.03), TG
(p<0.02). HbA1C, insulin level, triglycerides did not              12.5% (from 200.4±123 to 158.3±89) (P<0.04). HbA1c in
change after treatment with salsalate in the participants.         the placebo group increased during the study from 5.9±0.6
These were not age- or gender- dependent. There was no             to 6.4±1.8 but decreased in the intervention group from
serious complication, although some participants com-              5.8±1.2 to 5.6±0.8 (P<0.04), Total cholesterol, HDL and
plained of tinnitus which was not persistent after reducing        LDL cholesterol did not change after treatment with sal-
the dose of salsalate.                                             salate. HOMA-IR as an insulin resistance index did not
	     Discussion: Insulin resistance is at least in part a         reduce in the intervention group but insulin level increased
chronic inflammatory process. The direct role of the               25% (from 17.5±1.6 to 21.6±3.9) (P<0.02). Our patients
IKKβ/NF-κB pathway in development of insulin resis-                did not have any serious complications.
tance has been validated. Salsalate as an inhibitor of this        	 Discussion: Salsalate affects the IKKβ/NF-κB path-
pathway reduces insulin resistance and improves glyce-             way which supposed to be one of the causes of develop-
mia, though, can be used as a preventative intervention in         ing diabetes mellitus and the study demonstrates that it
diabetes mellitus.                                                 reduces fasting glucose level in diabetic patients and
                                                                   increases insulin possibly due to reduced clearance.


                                                          – 34 –
                                        ABSTRACTS – Diabetes Mellitus

	 Conclusion: These data show that an anti- inflamma-          16 had A1C ≥ 6.5. 4 of the 15 patients who survived (and
tory drug can decrease glucose level in diabetic patients.     had an A1C checked) had an A1C <6.5 while 11 had an
The optimal duration of treatment and sustainability of the    A1C ≥ 6.5. By Fisher’s Exact test this was not statistically
effect should further be studied.                              significant with a p value of 0.7. The OR was 0.75 (95%
                                                               CI 0.223 – 2.524) for the cohort of patients with A1C <6.5
Abstract #232                                                  while the OR was 1.091 (95% CI 0.749-1.588) for the
                                                               cohort with A1C ≥ 6.5.
COMPARISON OF MORTALITY AND                                    	     Conclusion: Patients with HF and a history of DM
READMISSION RATES OF HEART FAILURE                             did not show any difference from those without DM in
PATIENTS WITH AND WITHOUT                                      mortality or readmission rates including a sub analysis of
DIABETES MELLITUS                                              HbA1C. Our study is limited by the small sample size but
                                                               still has interesting results.
Vijay Gopal Eranki, MD, Marian Manankil, MD,
Sorin C. Danciu, MD, German Rossell, MD,
Michael Niaki, MD, Mercy Chandrasekaran, MD,                   Abstract #233
Efren Jason Jorge, MD, Claudius Mahr, DO
                                                               PREVALENCE OF METABOLIC SYNDROME
	     Objective: Patients with diabetes mellitus (DM) are      AND INSULIN RESISTANCE IN WESTERN INDIA
more likely to develop heart failure (HF) compared with
those without DM. Earlier studies showed increased risk        Piyush Harshadrai Desai, MD, K. N. Bhatt,
of HF with DM. We focused on mortality and readmission         Syamala Nadiminty, MD, Ashwin A., Lovleen Bhatia,
rates in HF patients with DM.                                  Niti Shah, Vijay Panikar, MD, MBBS,
	     Methods: Data from 100 patients admitted with HF         Shashank Joshi, MD, FACP, FRCP, FACE
at our facility from 01/2005 to 01/2006 was obtained ret-
rospectively from electronic records. Patients with limited    	    Background: Based on recent Adult Treatment Panel
information were excluded. HbA1C values ≥ 6.5 were             (ATP III) diagnostic guidelines, it has been estimated that
considered diabetic. The endpoints were readmission due        upwards of 50 million individuals in the United Stages
to HF 6 months after the index hospitalization and 3-year      older than 20 have the metabolic syndrome and this is
mortality data based on the Social Security Death Index.       likely to be a gross underestimate Not surprisingly, in
Statistical analysis was done and significant 2-tailed         the recent years there has been a tremendous increase in
p-value was set at <0.05.                                      interest in understanding the cause, consequences and
	     Results	and	Discussion: 91 of 100 patients had data      treatment of insulin resistance. Hence early detection of
on history of DM. 45 patients had DM while 46 did not. A       insulin resistance and its treatment can revolutionize the
total of 47 patients expired since discharge. Of these, 25     approach to primary prevention of the epidemic of coro-
had DM and 22 did not. 44 patients survived of which 20        nary artery disease and Type 2 Diabetes.
had DM and 24 did not. This was not statistically signifi-     	    Objective: To measure prevalence of metabolic syn-
cant with a p value of 0.461 with Pearson Chi – Square         drome and to calculate Insulin Resistance in apparently
analysis. The Odds ratio (OR) was 1.17 (95% CI 0.769-          normal population.
1.782) for the cohort of patients with DM who expired          	    Methods: The patients were above 18 yrs. of age. The
while the OR was 0.858 (95% CI 0.571-1.289) for the            total number of patients studied was 100 and all of them
cohort without DM. In patients with a past history of DM       were not previously known to have diabetes or hyperten-
and readmission rates, we had information on 92 patients.      sion or any significant disease or disorder. Known cases of
51 patients were readmitted, of these 28 had DM and 23         Ischemic Heart disease, renal disease, liver disease, preg-
did not. 41 patients were not readmitted and 18 patients       nancy, and women on contraceptives, were excluded from
among them had DM while 23 did not. This was not sta-          this study Detailed clinical and laboratory evaluation of all
tistically significant with a p value of 0.294 with Pearson    the patients was carried out and their Insulin Resistance
Chi – Square analysis. The OR was 1.251 (95% CI 0.817-         was calculated with the help of 4 methods, followed by
1.915) for the cohort of patients with DM who were read-       a comparative assessment of results obtained with each
mitted while the OR was 0.804 (95% CI 0.536-1.207) for         method. Prevalence of metabolic syndrome measured with
the cohort without DM. A further analysis on patients who      clinical criteria according to ATP III guidelines revised in
expired based on HbA1c data was performed. A1C was             2005. The four different insulin resistance scores used
checked on 35 patients, of these 8 patients had an A1C         were: Insulin Sensitivity Index (ISI), American Diabetes
< 6.5 and 27 had an A1C ≥ 6.5. 4 of the 20 patients who        Association Score (ADA), Finnish Diabetes Risk Score
expired (and had an A1C checked) had an A1C <6.5 while         and Indian Diabetes Risk Score (IDRS)


                                                          – 35 –
                                         ABSTRACTS – Diabetes Mellitus

	    Results: According to that criteria 26% patients were       a mercury sphygmomanometer in a standardized fashion.
having metabolic syndrome and 74% patients were not fit          All patients were divided into 3 sub-groups depending
into the criteria for metabolic syndrome. Insulin resistance     upon their blood pressure status according to the JNC
was calculated by 4 methods. Most important one is by            VII guidelines. The 3 sub groups were - hypertensives,
measuring Insulin sensitivity index through Normogram            Prehypertensives and Non hypertensives with blood pres-
developed by comparing gold standard hyperinsulinemic            sure level > 140 or > 90, 120-139 or 80-89, < 120 and
euglycemic clamp method. According to ISI 40% of the             < 80 mmHg respectively. Prevalence of metabolic syn-
patients had high Insulin resistance, While High insulin         drome measured with clinical criteria according to ATP
resistance was defined as ISI <6.3. According to ADA,            III guidelines revised in 2005, while prevalence of insu-
Finnish , Indian diabetic risk score insulin resistance were     lin resistance was calculated by Insulin Sensitivity Index,
found in 41%,24% and 33 % respectively.                          with high resistance defined by ISI<6.3
	    Conclusion: High insulin resistance is the predeces-        	    Results: According to JNC VII, 30% of our study
sor and precursor of the metabolic syndrome and can be           group were hypertensive, 47% were pre hypertensive and
and should be detected in normal individuals for imple-          23% were normotensive. Prevalence of metabolic syn-
menting effective preventive measures. Finnish score is          drome was high (73.33%) in hypertensive group while
more nearer to prevalence of metabolic syndrome, while           very low in pre hypertensive (9.09%) and normal 0%.
ADA score and Indian Diabetic Score results are compa-           Same way insulin resistance is also very high in hyperten-
rable to ISI results.                                            sive patients (73.33%) while only 15.3% in normotensive
                                                                 group. In prehypertensive group insulin resistance was
Abstract #234                                                    found slightly higher 31.8%.
                                                                 	    Conclusion: The presence of insulin resistance and
BLOODPRESSURE AND INSULIN RESISTANCE                             metabolic syndrome found higher in the hypertensive
IN WESTERN INDIA                                                 group as compare to pre hypertensive and non hyperten-
                                                                 sive group.
Piyush Harshadrai Desai, MD,
Syamala Nadiminty, MD, Ashwin A.                                 Abstract #235

	    Background: With the receding threats of commu-             MICROALBUMINURIA AND CORRELATES
nicable diseases, and looming over threats of Coronary           IN NEWLY DIAGNOSED DIABETICS-A
Artery Disease, Hypertension and Diabetes Mellitus, the          PRELIMINARY REPORT
research in the later has been focused on detection of their
preclinical stages i.e. detection of genetic, cellular, meta-    Adeleye Olufunmilayo Olubusola, MD,
bolic and biochemical mechanisms and processes so as to          Anthonia O. Ogbera, FMCP, FACE, FACP,
arrive at the ability to forestall their progress to clinical    Ayotunde Oladunni Ale, MD, DADA O, FMCP
illness. The changes associated with insulin resistance
that contribute to the increased risks are: dyslipidaemia,       	    Objective: Microalbuminuria (MA) is associated with
hypertension and inflammation, vascular endothelial dys-         increased cardiovascular risk in diabetic subjects and it
function; a prothrombotic state due to disturbance of the        is found to correlate with a cluster of other risk factors
clotting and fibrinolytic system, and platelet dysfunction.      such as dyslipidemia, retinopathy, left ventricular hyper-
Insulin Resistance is now considered as one of the caus-         trophy and hyperuricaemia. This study seeks to document
ative factor for development of essential hypertension and       the prevalence of MA and its associated factors in newly
hypetension is one of the important criteria for presence of     diagnosed diabetic subjects as there is insufficient data in
metabolic syndrome.                                              this subset of diabetics in our environment.
	    Objective: To measure prevalence of metabolic syn-          	    Methods: This is a prospective ongoing study involv-
drome and to calculate Insulin Resistance in hypertensive        ing people with newly diagnosed DM (of less than 4
prehypertensive and normotensive study group.                    months duration). The demographic and anthropometric
      Methods: The patients were above 18 yrs. of age.           indices and information pertaining to DM complications
The total number of patients studied was 100 and all of          and hypertension were documented. Early morning urine
them were not previously known to have diabetes or any           samples were collected and tested for MA. Subjects whose
significant disease or disorder. Known cases of Ischemic         urine samples tested positive (+vet) for MA had a repeat
Heart disease, renal disease, liver disease, pregnancy,          of same test after 2 weeks (wks) period. (MA was said to
and women on contraceptives, were excluded from this             be present if a positive result was obtained after the repeat
study. A complete physical and cardiovascular examina-           test). Fasting blood samples were obtained for glucose,
tion was performed. Blood pressure was measured with             uric acid, lipid profiles and glycosylated hemoglobin. 12


                                                            – 36 –
                                          ABSTRACTS – Diabetes Mellitus

lead electrocardiography was done. Subjects with urinary          insulin order sets, and 2 endocrine consultations at the dis-
tract infection, proteinuria, heart failure, renal failure and    cretion of the surgical team. Intervention Period. Results
sepsis were excluded. The test statistics used included t         of blood glucose (Glu), whether tested in the laboratory or
test and correlation coefficient. A p value of ≤ 0.05 indi-       by point of care, were obtained from the central lab com-
cated statistical significance.                                   puter and analyzed within 24 hours for all patients admit-
	    Results: 27 subjects so far have been recruited within       ted from 7/1/2008 through 6/30/2009 (FY09). Patients
a 4 month period. The Mean (SD) age was 51.8(12.2)                were selected for endocrine intervention when glucose
years. MA was present in 13 subjects (48%). Mean (SD)             <50 or >199. Comparisons were made between FY08
age of MA +ve individuals is 56.2(12.5), mean (SD) age            versus FY09, the presence (DM+) or absence (DM–) of
of MA negative 47.8(10.96) p value 0.075. Mean dura-              diabetes. Outcomes: length of stay (LOS), LOS in the ICU
tion of DM in MA +ve is 8.4 wks, MA negative 6.7wks.p-            (LOS-ICU) and hospital expenses (EXP). These data were
value 0.46. Mean (SD) BMI of MA +ve 30.6(5.9),                    obtained on a per case basis from the hospital accounting
MA –ve 27.03(3.6) p 0.06. Mean uric acid for MA +ve               system. Subgroup analyses and Contemporaneous Control
4.9(1.3)mg/dl, those without MA 5.3(1.7). Mean total              Groups. The subgroup of patients with Glu always >49 &
cholesterol, HDL, LDL, TGs for MA +ve are 201.9(50),              <200 served as a contemporaneous control (NORM) in
33.5(11.7), 144.5(44.0), 108(47) respectively. For MA –ve         both FY08 and FY09. Other factors considered were age,
184.8(50.8), 37.4(10.6), 128(45), 99(46)respectively with         sex and race. Statistics: Statistical analysis was performed
p-values of 0.40,0.40,0.37 and0.67 respectively. Mean             using SPSS 8.0 for Windows.
systolic and diastolic blood pressure of MA +ve individu-         	    Results: DM+ are older than DM– 60.7 v 49.7 (FY08)
als 143(16) and 86.15(11.3), for MA negative 124.7(17)            and 59.4 v 48.7 (FY09). Race and sex did not differ among
and 78.9(8.0) with pvalues of 0.009 and 0.066 respec-             groups. DM+ stay longer and cost more than DM –. ICU
tively. Only one individual had marginally elevated uric          days are similar. In FY08 (average values) for these were
acid level. All other subjects had normal uric acid values.       5.77, $9301, 0.90 for DM+ and 4.37, $7548, 0.87, for
	    Discussion/Conclusion: Subjects with MA were                 DM–. In FY09 these results were 5.04, $8009, 0.69 for
older, with higher BMI, higher total cholesterol, LDL and         DM+ and 4.05, $7440, 0.88, for DM– . While NORM
triglyceride levels, lowerHDL, and higher systolic and            showed improvement (FY09 v FY08) in both DM+ and
diastolic blood pressure than those without MA. A signifi-        DM– it was greater in DM+. For all patients the total sav-
cant proportion of the study subjects showed evidence of          ings (FY09 v FY08) in LOS & EXP was 1342 days and
constellation of cardiovascular risk. It is therefore impor-      $1.15M, of which 656 days and $1.06M occurred through
tant to screen all diabetic subjects adequately at diagnosis      improvements in DM+ patients.
to enable prompt intervention.                                    	    Conclusion: Endocrine intervention in surgical
                                                                  patients with diabetes and dysglycemia pays. Nearly 50%
Abstract #236                                                     of the savings year to year in days and over 90% of the
                                                                  savings in EXP was seen in DM+.
DIABETES AND DYSGLYCEMIA IN
HOSPITALIZED SURGICAL PATIENTS:                                   Abstract #237
DOES ENDOCRINE INTERVENTION PAY?
                                                                  PHYSICIAN COMPLIANCE WITH TRI-
Arthur Chernoff, MD, FACE                                         PRONGED ADA RECOMMENDATIONS IN AN
                                                                  ACADEMIC SETTING: BLOOD PRESSURE
	    Objective: The management of diabetes and dysgly-            CONTROL LAGS BEHIND
cemia in hospitalized patients remains controversial and
problematic. It is unclear whether intervention pays out-         Akshay Bhanwarlal Jain, MD, Leela Mary Mathew, MD
side the ICU. This study seeks to determine whether endo-
crine intervention in surgical inpatients with blood sugars            Objective: To examine the success rate of academic
< 50mg/dl or > 199 mg/dl affected economic outcomes.              physicians practicing in a resident-teaching clinic, in
	    Methods: Subjects: Adult patients over 18 years old          achieving the American Diabetes Association (ADA)
on the surgical service of an urban tertiary care hospital.       goals for reducing vascular disease risk in patients with
Historic Control Period: Patients from 7/1/2007 through           diabetes mellitus type 2 (DM-2).
6/30/2008 (FY08) served as the control group. Endocrine                Methods: As part of a quality improvement proj-
intervention in these patients was limited to 1. The use          ect, a retrospective chart review was performed on all
of previously deployed protocols for the management of            patients coded for diagnosed DM-2 in a seven-member
hyperglycemia in the ICU, hypoglycemia in all units and           faculty group practice of internists. Only adult patients



                                                             – 37 –
                                         ABSTRACTS – Diabetes Mellitus

with DM-2 who were in the practice for at least one year         presentation and severity of cardiovascular disease. This
were included. Levels of glycohemoglobin (HbA1c), low-           study is therefore set to determine the prevalence of
density lipoprotein (LDL) and blood pressure (BP) for 6          hypertension (HT) and its correlates among type 2 DM in
months preceding data collection were used for analysis.         Nigeria.
        Results: Of the 244 patients in the inclusion group      	    Methods: In this cross-sectional study 205 DM
(ages 25-96, mean age 64), 30 adults (12.3%) met ADA             patients were randomly selected in LASUTH. Their
recommendations on all three parameters, as compared             clinical characteristics and occurrence of cardiovascular
to the national estimate of 7.3%. Overall, 131(53.7%)            events(cv) were documented through interviewer-admin-
had HbA1c<7%, 145(59.4%) had LDL<100mg/dl and                    istered questionnaires. Fasting blood samples were col-
83(34.0%) had BP<130/80. Comparatively, the national             lected for biochemical analysis and urine samples for per-
average values were 37.0%, 49.2% and 35.8% respec-               sistent albuminuria. Test Statistics used were t-test, χ2 and
tively. In our study, 84.8% of the hypertensive patients         correlation coefficient to test for associations. A p value of
with DM-2 were either on an angiotensin converting               <0.05 denoted statistical significance.
enzyme inhibitor (ACEI) or angiotensin II receptor               	    Results/Discussion: The prevalence of hypertension
blocker (ARB).                                                   (HT) was 66%, the proportion of females (F) with HT
      Discussion:	 The National Health and Nutritional           was higher than males (M) (71.7% vs 28.3%, p=0.001).
Examination Survey(NHANES) 1999-2000 data showed                 The mean age of hypertensives & DM was 60.4 yrs ± 9.3.
that only 7.3% of adults in the United States with diabe-        The mean age of F and M were comparable (60.2 ± 8.8 vs
tes mellitus met ADA goals of: HbA1c <7%, LDL<100                61.2± 10.8, p=0.68). The mean age of the HT and duration
mg/dL and BP<130/80 mmHg. Subsequent studies have                of DM were significantly higher than without HT (60.4 ±
emphasized the importance of controlling these param-            9.3 vs 56.6 ± 11.6, p = 0.04 and 8.2 yrs ± 5.8 vs 4.9 yrs ±
eters for the prevention of microvascular and macrovascu-        3.8, p = 0.005.) Their mean BMI was 27.5 ± 5.0.BMI were
lar complications of diabetes.                                   comparable in both sexes (F = 28 ± 5.2 vs M = 26.1 ± 4.3,
      Conclusion: Being an academic clinic, we expected          p = 0.21). The mean BMI, Lipid parameters, blood glu-
greater adherence to the ADA recommendations than                cose and clinically evident non-fatal cv events were com-
the national average, six years after the data being first       parable in both groups. Proteinuria and microalbuminuria
published. Although HbA1c and LDL levels were better             were significantly higher in the HT than without HT only
controlled in this practice, BP was not. This led to a low       ( 68.85% vs 31.2% p=0.005 & 74.4% vs 25.6%, p=0.01).
proportion of patients with DM-2 meeting the tri-pronged         The overall prevalence of metabolic syndrome Mets using
ADA goals. With the nation veering towards a pay-for-            NCEP ATPIII criteria was higher(74%) in the HT group
performance model for healthcare, further efforts are            than without 52% p=0.04
needed to effectively control blood pressure in the study        	    Conclusion: The prevalence of hypertension in
population, to reduce vascular complications. We specu-          Nigerian DM is high and is associated with increasing
late that although physicians did prescribe the correct anti-    age, female sex, longer duration of DM and albuminuria.
hypertensive medication, they were less vigilant in follow-      The documented high prevalence of Mets lends credence
up monitoring and conclude that they need to adequately          to the great CVS risk posed by the presence of HTN in our
titrate blood pressure medication dosages. Faculty physi-        patients with DM.
cians and residents were informed of individual results as
part of quality intervention, with a subsequent follow-up        Abstract #239
study proposed after one year.
                                                                 ADMISSIONS TO A SAFETY-NET HOSPITAL
Abstract #238                                                    IN PATIENTS WITH DIABETES DURING
                                                                 ECONOMIC DOWNTURN ARE LARGELY
THE PREVALENCE OF HYPERTENSION AND                               PREVENTABLE
ITS CORRELATES AMONG TYPE 2 DIABETES
IN NIGERIA.                                                      Elizabeth Batcher, MD, Ana Uribe, MD, Eli Ipp, MD

Ayotunde Oladunni Ale, MD,                                       	    Objective: To test the hypothesis that largely prevent-
Anthonia Okeoghene Ogbera, MBBS, FMCP, FACE,                     able acute illnesses account for many hospital admissions
Adeleye Olufunmilayo Olubusola, MD, A.O. Dada                    in people with type 2 diabetes and are therefore an impor-
                                                                 tant target for cost reduction in health care delivery.
	    Background/Objective: Hypertension is more                  	    Methods: Cross sectional data on 100 patients
prevalent among blacks than Caucasians. The summa-               admitted to Harbor UCLA Medical Center in 2009 with
tion of hypertension and diabetic mellitus augment the           uncontrolled type 2 diabetes (A1C>8%) was obtained by


                                                            – 38 –
                                        ABSTRACTS – Diabetes Mellitus

questionnaire and electronic medical record. Potentially       DM from sub-Saharan Africa, hence this report sets out
preventable admissions were defined as glycemic crises         to bridge the gap. In an earlier preliminary analysis, we
and those associated with infection.                           reported the prevalence of hyperuriceamia to be 90% and
	    Results: Participants had a mean (+SD) age of 48+         this was found to have significant associations with hyper-
9.1years, 62% were male, 85% minority (59% Latino,             tension, high total cholesterol, high triglyceride and poor
26% African American). Mean A1C was 11.2+2.04%;                glycemic control. This study is to further evaluate other
diabetes duration was 6.4+6.5 years with 29% newly             clinical and biochemical correlates of hyperuricemia.
diagnosed. Potentially preventable illnesses accounted for     	    Methods: This is a prospective study involving 100
68% of admissions (infection 41%, glycemic crisis 27%)         patients with DM attending the Diabetes center of Lagos
and 19% cardiovascular events (13% other). Mean length         State University Teaching Hospital. A symptom –analyzed
of stay (LOS) was 6.6+6.2 days for all; LOS for glycemic       and macrovascular complications documented through
crises 4.3±2.5days, infections 7.8±7.3days and amputa-         interviewer administered questionnaire was carried out.
tions 11.7±10.7days. Patients without a primary care pro-      Glycosylated hemoglobin (HbA1c), urinary protein-
vider (PCP) accounted for 68% of admissions for glyce-         uria and ECG were carried out. 50-age and sex matched
mic crisis or infection. Most (58%) did not have a PCP         healthy controls were recruited into the research.
before admission, and on discharge 22% of patients had              Results/Discussion: The mean duration of DM and
neither appointment nor referral to a PCP or endocrinolo-      Hypertension (HT) was significantly higher in the hyper-
gist for diabetes care. Finally, 75% were uninsured, 42%       uricemia (p=0.03 and p=0.04 respectively). An appre-
unemployed, 41% new to the public hospital system and          ciable proportion of hyperuricemia group was on antihy-
15% recently lost insurance.                                   pertensive and oral hypoglycemic agents only 88.2% .The
	    Discussion: Hospitalizations make up 50% of the           mean HbAic was 7.2±3.6. The prevalence of albuminuria
direct costs of care for diabetes in the US. Glycemic cri-     was 79.8% of which Macroalbuminuria was 18.3% and
ses and infections are potentially preventable with regular    microalbuminuria was 61.5% in the hyperuricemia group
ambulatory care, yet comprised 68% of admissions and           compared with normal uric acid level of 14%,10% and 4%
65% of hospital days in this study. Considering the high       respectively (p=0.03,0.014 and 0.04). Non-fatal cardio-
percentage of preventable admissions in patients without a     vascular events were significantly higher in the hyperuri-
PCP (68%) in this study, we suggest that prevention of ill-    cemia subjects compared with normal uric acid level: 80%
ness may be enhanced and hospital usage mitigated in this      vs20% of total stroke p=0.04 ,90.9%vs9.1% chest pains
population by access to primary care. This is supported by     with significant ECG changes p=0.03 and 96.4% vs4 .6%
our finding that among those with a PCP 93% had seen           had intermittent claudication compared with normal uric
that provider in the last 6 months, suggesting that this       acid level. The mean age, uric acid, BMI and FBS of the
population will utilize primary care when made available.      healthy controls (44.4yrs ±11.7,5.1mg/dl ±0.7, 25.74kg/
     Conclusion: Public hospitals are assuming care for        m2 ±4.9 and 83.64mg/dl ±10.35) were significantly lower
diabetic patients with high burden of disease and poten-       than hyperuricemia group, p<0.05. None of the controls
tially preventable illnesses. We found that these admis-       had hyperuricemia.
sions are associated with poor access to ambulatory care       	    Conclusion: Hyperuricemia was significantly asso-
both before and after hospitalization. Interventions to        ciated with longer duration of DM and HT, albuminuria,
make affordable outpatient care available to uninsured         hypertension ,high total cholesterol ,high triglyceride
and ethnic minority patients with diabetes may diminish        levels as well as clinically evident cardiovascular events.
preventable admissions and thus have a major impact in         Uric acid level was significantly high in DM compared
reducing costs of care in this population.                     with the healthy controls.

Abstract #240                                                  Abstract #241

URIC ACID LEVEL IN TYPE 2 DIABETES IN AN                       DISEASE CONTROL AMONG ADULTS WITH
URBAN HOSPITAL IN NIGERIA                                      TYPE 2 DIABETES MELLITUS, HYPERTENSION
                                                               AND OBESITY
Ayotunde Oladunni Ale, MD,
Anthonia Okeoghene Ogbera, MBBS, FMCP, FACE                    Helena Wachslicht Rodbard, MD, FACP, MACE,
                                                               Kathleen M. Fox, PhD, Elise Hardy, MD,
	    Objective: Hyperuriceamia is a known cardiovas-           Susan Grandy, PhD
cular risk factor and it is a key feature of the metabolic
syndrome which has cardiovascular implications. There          	   Objective: To evaluate self-reported glycemic and
is a dearth of reports on uric acid levels in people with      blood pressure control among adults with type 2 diabetes


                                                          – 39 –
                                        ABSTRACTS – Diabetes Mellitus

mellitus (T2DM) alone and those with T2DM plus hyper-          Abstract #242
tension and obesity.
	    Methods: Respondents to the Study to Help Improve         THE IMPACT OF LY2189265 (GLP-1 ANALOG)
Early evaluation and management of risk factors Leading        ON GLYCEMIC CONTROL IN HISPANIC
to Diabetes (SHIELD), a large US survey, provided their        AND NON-HISPANIC CAUCASIANS WITH
most recent (past 12 months) HbA1c and blood pressure          UNCONTROLLED TYPE 2 DIABETES:
readings, height, weight, comorbid conditions and medi-        AN EGO STUDY ANALYSIS
cation list. Respondents reporting a diagnosis of T2DM
and hypertension with a body mass index (BMI) >30 kg/          Edward James Bastyr, III, MD, Julio Noriega,
m2 were identified and compared with respondents report-       Fady T. Botros, PhD, Rebecca Threlkeld, RD,
ing a diagnosis of T2DM and no self-reported diagnosis of      Jianfen Shu, MS, James H. Anderson, MD,
hypertension and BMI <30 kg/m2.                                Leonard C. Glass, MD
	    Results: For respondents with the triad comorbid con-
ditions of T2DM, hypertension, and obesity who reported             Objective: The US Hispanic population has a dispro-
an HbA1c (n = 593), 59.7% (354/593) reported hav-              portionately increased incidence and severity of type 2
ing achieved the American Diabetes Association (ADA)           diabetes mellitus. Little research has been conducted to
HbA1c goal of <7%, whereas 36.3% (215/593) reported            compare drug effectiveness between ethnicities. In this
achieving the AACE HbA1c goal of <6.5%; of the respon-         retrospective analysis of data from the EGO study we
dents with T2DM only (n = 117), 68.9% reported HbA1c           examine differences in metabolic outcomes comparing
<7% and 45.3% reported <6.5% (p = 0.10). A similar             Hispanic (H) versus non-Hispanic (NH) Caucasian popu-
proportion of respondents in each group reported HbA1c         lations following treatment with the long-acting glucagon-
<7% across different diabetes treatment regimens: oral         like peptide-1(GLP-1) analog (LY2189265).
antidiabetic therapy (70% of triad group vs. 73% of T2DM            Methods:	 262 patients were randomized to once-
alone, p = 0.61), insulin only (30% vs. 33%, p = 0.88), and    weekly subcutaneous injections of either placebo or 1 of
insulin and oral therapy (39% vs. 56%, p = 0.34). Fewer        3 LY dose regimens: 1) 1.0 mg for 16 weeks; 2) 0.5 mg
respondents with T2DM, hypertension, and obesity had           for 4 weeks then titrated to 1.0 mg for 12 weeks; or 3)
systolic blood pressure <130 mm Hg (56.0%) or diastolic        1.0 mg for 4 weeks then titrated to 2.0 mg for 12 weeks.
blood pressure <80 mm Hg (65.6%), despite the fact that        The 177 patients randomized to LY treatment (62 H and
92% of them were on anti-hypertensive medication, com-         115 NH) had similar baseline characteristics compared to
pared with respondents with T2DM only (72.7% <130              the entire randomized population. The primary metabolic
mm Hg and 78.8% <80 mm Hg; 48% on anti-hypertensive            measure for comparison between the 2 ethnic groups was
medication; p <0.001). Fewer respondents with the triad        glycemic control, as measured by HbA1c change from
comorbid conditions were in control for both HbA1c and         baseline at 16 weeks. Secondary measures were change
blood pressure (11.5%) compared with respondents with          in 1) fasting serum glucose (FSG), 2) glucose excur-
T2DM only (21.1%, p = 0.004). More respondents with            sion (AUC) response to a solid mixed meal test, and 3)
the triad conditions were on lipid-lowering medications        the homeostasis model assessment examining indices of
(62.5%) compared with respondents with T2DM only               beta cell function (HOMA2-%B), insulin resistance and
(53.5%, p =0.001).                                             sensitivity (HOMA2-%IR and HOMA2-%S). Differences
	    Conclusion: Respondents with the triad comorbid           between groups were tested using two-sample T-test using
conditions of T2DM, hypertension, and obesity did not          a nominal significance level of 0.05 for comparisons.
differ in their glycemic control but were more likely to            Results:	In all randomized patients, the H group had a
have uncontrolled blood pressure despite anti-hyperten-        statistically significantly higher baseline HbA1c compared
sive therapy than respondents with T2DM only. There is         to the NH group (8.44±0.97%, n=88 vs. 8.09±0.88%,
an unmet need for effective therapeutic strategies among       n=150, p=.006). In response to LY treatment, the H popula-
adults with this triad of comorbid conditions despite          tion experienced a larger reduction in HbA1c as compared
the availability of anti-hypertensive and anti-diabetic        to NH at endpoint (-1.47±0.99%, n=61 vs. -1.14±0.80%,
treatments.                                                    n=111, p=.020). There was also a 6-fold larger decrease
                                                               in postprandial AUC glucose excursion in the H group
                                                               compared to the NH group (-2.82 ± 3.78, n=56 vs. -0.46
                                                               ± 5.69, n=89, [mmol/L] hr, p=.003). Controlling for base-
                                                               line HbA1c (H 8.45±1.00%, n=62 vs. NH 8.55±0.84%,
                                                               n=82), the larger decrease in postprandial AUC glucose
                                                               excursion in the H group compared to the NH group



                                                          – 40 –
                                         ABSTRACTS – Diabetes Mellitus

was maintained (-2.82±3.78, n=56 vs. -0.05±6.17, n=66,          42% had alteration in ability to self report symptoms of
p=.003). Changes in FSG, HOMA2-%B, HOMA2-%IR,                   hypoglycemia.
or HOMA2-%S in response to LY treatment were not sig-           	    Discussion: Elderly patients with renal insufficiency
nificantly different between groups.                            admitted to ICU are at high risk of developing severe
     Conclusion: Treatment with LY is associated with           hypoglycemia. Steroids, prolonged admission, sepsis &
significantly greater reductions in HbA1c and postprandial      shock, altered mental status, altered route of nutrition,
glucose excursion in H compared to NH. Further studies          imaging and other inpatients procedures including sur-
are warranted to prospectively evaluate differential effects    gery, and insulin use, especially sliding scale increased the
of LY treatment in the Hispanic population with type 2          risk of hypoglycemia. Lastly, patients with prior history of
diabetes mellitus.                                              hypoglycemia were at risk of another episode during the
                                                                hospitalization.
Abstract #243                                                   	    Conclusion: Developing strategies to prevent or
                                                                reduce hypoglycemic events should include identifying
FACTORS ASSOCIATED WITH INPATIENT                               high risk patients, recognizing precipitating factors, use of
SEVERE HYPOGLYCEMIA                                             appropriate scheduled insulin, and appropriate nutritional
                                                                support in hospitalized patients.
Sunil Asnani, MD, FACE, Adrian Scaunasu, MD,
Taral Jobanputra, MD, Bhavikaben Babaria, MD                    Abstract #244

	    Objective: To identify factors associated with and         CLINICAL PRACTICE IMPROVED
likely causative of inpatient severe hypoglycemia.              GLYCEMIC CONTROL IN TYPE 2 DIABETES
	    Methods: Severe hypoglycemia was defined as hypo-          PATIENTS USING THE V-GO™
glycemia necessitating a rescue with intravenous dextrose.      AS INSULIN DELIVERY DEVICE
Pharmacy generated report on 50% dextrose (D50) utili-
zation from July-Dec 2007 was used to identify patients         Cheryl R. Rosenfeld, DO, FACE, Bruce Bode, MD,
with hypoglycemia. All code-blue and hyperkalemia               Nancy Bohannon, MD, Adam Kelman, MD,
associated use were excluded. Charts were reviewed for          Shari Mintz, MD, Sridhar Nambi, MD, Alan Schorr, DO,
labs, admitting service, medications, co-morbid illnesses,      Mark Sandberg, MD, Poul Strange, MD, Leon Shi, PhD
scheduled procedure or surgery and other variables affect-
ing glycemia.                                                   	    Objective: To retrospectively describe glycemic
	    Results: A total of 579 D50 orders were reviewed;          control before, during and after insulin delivery with the
105 orders were excluded (hyperkalemia, code-blue or            V-Go.
D50 not administered). 474 severe hypoglycemia were             	    Background: The V-Go is a disposable, continuous
confirmed. 268 patients had single episode while 72 had         subcutaneous insulin delivery device that delivers a pre-
multiple episodes during their admission; 12 had more           set basal infusion rate as well as on-demand insulin in 2U
than 3 episodes. The mean glucose level (serum or capil-        increments. 10 physicians treated 31 patients with diabe-
lary) was 41 mg/dl. The average age was 73.7 years; 54%         tes mellitus using the V-Go. The anecdotal information
were females. The average incidence rate was 4.5% in            regarding glucose control was positive.
medical admits and 4.2% in surgical admits. 258 episodes        	    Methods: After IRB approval, 8 physicians partici-
(54%) occurred in ICUs. 20% episodes occurred in Type 1         pated. Data were collected from before V-Go initiation,
DM patients & 52.5% in Type 2 DM; 27.5% patients had            after 12 weeks of use, at the end of V-Go treatment, and 12
no diagnosis of diabetes. 31% episodes occurred between         weeks after the patients discontinued the V-Go. Analyses
12AM and 6AM. The median hypoglycemia day of 8th                employed non-parametric statistical tests.
day of admission; the median A1C was 6.9%; the median           	    Results: 23 patients (15 white and 6 black) gave
Sr. Creatinine, AST and ALT were 1.4 mg/dl, 30 U/L and          informed consent. Patients were 61 (31-83) years old
24 U/L respectively. Oral hypoglycemic agents (except           (average range), with BMI of 30 (25-35) kg/m2, diabetes
SFU 4%) had minimal representation in this cohort.              for 16 (4-39) years and treated with insulin for 7 (0.5-23)
Sliding scale insulin was ordered for 71% patients; 34%         years. Baseline insulin use included 17 patients on insu-
had bolus and 32% had basal insulin ordered as well. 21%        lin glargine, 2 on NPH, and 4 on premix. 10 patients also
were on steroid taper; 38% were NPO, 21% on tube feeds          used rapid acting insulin. Concomitant diabetes medica-
and 4% on TPN. 9% had a procedure/imaging sched-                tions (baseline/V-Go/12 weeks after) included metformin
uled the day of hypoglycemia and had been transported           (10/7/8), pioglitazone (4/5/5), sulfonylureas/meglitinides
off their floor; 11% had surgery on the day of or the day       (7/4/4), sitagliptin (3/3/3), exenatide (2/1/1), and pram-
before the episode. 21% had sepsis; 17% were in shock;          lintide (1/1/1). Patients’ insulin was delivered using the


                                                           – 41 –
                                        ABSTRACTS – Diabetes Mellitus

V-Go for 194 (43-289) days. Total daily insulin dose was       administration, we observed a significant diminution in
50±14U (Mean±SD) at baseline, 46±13U while on V-Go,            the levels of insulin at 30 minutes of the test in patients
and 51±16U 12 weeks after stopping V-Go treatment.             with diabetes type 2.
A1C decreased from 8.8±2.8% at baseline, to 7.6±1.1 on         	    Discussion: With the presented results, it is evident
V-Go (p=0.005), increasing to 8.2±1.8 12 weeks after end       that although the plant has hypoglycemic properties, the
of treatment (p=0.021). Morning fasting glucose trended        unique dose with the used concentration did not get to
similarly from 205±117 mg/dl, down to 135±43 (p=0.055)         have statistically significant effect. On the other hand, still
while on V-Go, with increase to 164±77 mg/dl (NS) after        does not know the time of impregnating of the components
V-Go was stopped. Despite improvement in glycemic              of this plant, as well as the possible routes of their metabo-
control, weight was essentially unchanged from baseline        lism; reason why it is required to evaluate the answer to
201±35 pounds, to 202±37 (NS) on V-Go, and tended to           the administration of this type of infusions per prolonged
increase to 210±34 (NS) after V-Go was discontinued.           periods of time, and also greater doses and different con-
No differences in hypoglycemic events were found. 12           centration and furthermore in different stages from the
weeks after V-Go discontinuation, 0/19 (incomplete data)       disease. The significant diminution in the levels of insulin
patients were treated with premixed insulin and at least       at 30 minutes of the test in subjects with diabetes mel-
15/19 were treated with rapid acting insulin analogue.         litus in the presence of the Labiatae, could explain by the
	    Discussion: Glycemic control improved while               effect of the components of the Lepechinia caulescens on
patients were treated using the V-Go and deteriorated          the modification of sensitivity to the insulin of peripheral
when the V-Go was discontinued. The cause of this tem-         tissues.
porary improvement may be better matching of insu-                  Conclusion: In this work we found that the unique
lin delivery with demand and possibly, as suggested by         dose of watery extracts of Lepechinia caulescens prepara-
individual patient data (not shown), that the simplicity of    tions by means of infusion of 5 g of dry leaves in 200 ml
using the V-Go device enabled patients to achieve better       of water, in agreement with the popular practice, does not
compliance with therapy.                                       induce hypoglycemia in subjects with diabetes mellitus
                                                               type 2 of recent diagnosis. Although this plant has been
Abstract #245                                                  reported as having hypoglycemic properties, according
                                                               to this study design there was not a significant difference
HYPOGLYCEMIC EFFECT OF LEPECHINIA                              either with or without the infusion of Lepechinia caule-
CAULESCENS (LABIATAE) IN SUBJECTS WITH                         scens leaves using described doses.
TYPE 2 DIABETES MELLITUS
                                                               Abstract #246
Estanislao Ramirez Vargas, MD, PhD,
Maria del Rosario Arnaud Vinas                                 A CASE OF NEW ONSET DIABETES AND DKA
                                                               PRESENTING WITH DISSEMINATED MRSA
	     Objective: To investigate the effect hypoglycemic of
the Labiatae (Lepechinia	caulescens) - is a “purple flower     Daniel S. Hsia, MD
Bretonica”- in type 2 diabetic subjects with recently diag-
nosed pathology, according to the popular practice.            	    Objective: To describe a presentation of diabetic keto-
	     Methods: 20 subjects were divided in two groups,         acidosis complicated by disseminated MRSA infection in
whom were engaged in same clinical and laboratory tests.       an otherwise healthy adolescent.
One, control group included healthy subjects and the other     	    Case	 Presentation: A 14-year-old female with no
group, patients with type 2 diabetes mellitus. Both groups     significant medical history presented with complaints
were overloaded with 75 g of glucose for the tolerance         of multiple joint pain for 3 weeks (especially worsen-
test. Glucose and insulin were assayed for a period of four    ing right shoulder/arm pain not relieved with NSAIDS),
hours. Both groups had another glucose tolerance test (75      weight loss (50 lbs over the past 6 months), and fever for
g) plus 200 mL of a 5 g infusion of Lepechinia caulescens      2-3 days. She was taken to an outside ER due to bilateral
dry leaves. Glucose and insulin were assayed again for a       leg pain and a new facial rash. She also reported a 3-4
period of four hours.                                          day history of polyuria (10-12 times per day) and poly-
	     Results: The significant differences found when          dipsia. Her labs showed: pH 7.27; bicarb 9; glucose 475.
comparing both groups: the levels of glycemia, glycated        She was diagnosed with new onset diabetes with DKA
hemoglobin A1c, urea and systolic arterial pressure. The       and transferred to our hospital’s PICU. On exam her Temp
lowest levels were found in the group control (p < 0.05).      was 103°F; HR 130; RR 30; BP 120/60; wt 96.6 kg; BMI
In the test of tolerance with 75 grams of glucose, when        34. She was obese, tired appearing, and had dry mucous
we compared the effects of the Lepechinia caulescens           membranes. She did not have acanthosis nigricans, but


                                                          – 42 –
                                         ABSTRACTS – Diabetes Mellitus

she did have multiple pustular lesions on her face. She         in the World. This retrospective observational study was
had diffuse muscle tenderness with profound pain in her         carried out in Ras Al Khaimah emirate of UAE to assess
right shoulder and decreased range of motion. Her labs          & compare the clinico-epidemiological profile & glyce-
showed: pH 7.21; Na 132; K 3.6; Cl 107; bicarb 9; BUN           mic control in Arab / Nonarab T2DM population. The pre-
9; Cr 0.6; glucose 400; serum beta-hydroxybutyrate 4.1          dominant Nonarab population in UAE is the South Asian
mmol/L (<0.3); HbA1c 11.5%. Her U/A showed: 4+ glu-             population contributing to up to 70% of total country
cose and ketones. She was started on a regular insulin drip     population.
at 0.1 units/kg/hour and a 2 bag IV fluid system (LR/D10        	    Methods:	 392 subjects with T2DM were randomly
LR + KPhos 2mmol/100mL and KCl 1.5mEq/100mL) at                 selected and divided in Arab / Nonarab group. Their phe-
2500 mL/m2/day. Her acidosis corrected overnight, and           notypic features and relevant biochemical parameters
she was switched to SC insulin glargine/aspart BID. Her         were recorded.
peripheral blood culture as well as her right shoulder and      	    Results: Out of 392 subjects, 328 subjects were of
left ankle joint aspirates were positive for MRSA. MRI          South-Asian & 64 subjects were of Arab origin. The
showed: diffuse myositis throughout the body; osteomy-          mean age of the Nonarab & Arab group was 46.8+8.01
elitis in the proximal right humerus; cellulitis around the     & 47.50+9.18 yrs respectively. The mean duration of
left ankle, right wrist, and left forearm; and septic emboli    T2DM in Nonarab & Arab group was 5.35 + 5.13 yrs and
in the lungs. She is being treated with a prolonged course      4.55+4.96 yrs respectively. The mean BMI and WC in
of IV vancomycin for disseminated MRSA.                         Nonarab were 27+3.86kg/m2 & 96.05+9.20 cms whereas
	     Discussion: This patient presented with DKA, an           in Arab they were 31.2+5.47 kg/m2 &102.55+11.91 cms
entity most commonly associated with Type 1 diabetes.           respectively. Central obesity was seen in 87.6% of Nonarab
However, she is more typical of a Type 2 diabetes patient       subjects and 66.7% of Arab subjects.66.2% of Nonarab
given her obese body habitus, negative islet cell antibod-      & 87.5% of Arab subjects were overweight. The baseline
ies, and family history of Type 2 diabetes. Impaired host       HbA1c was 8.64+1.89% in Nonarab & 8.44+1.75% in
defense has been shown in diabetes patients with poor glu-      Arab group. 62.1% & 16.5% of Nonarab had post treat-
cose control, especially with ketoacidosis. Muller et al.,      ment HbA1c of ≤ 6.5% & 6.5-7% respectively while
Clinical Infectious Diseases 2005 41:281–8 showed that          56.3% & 25% of Arab subjects had achieved the same
patients with Type 1 and Type 2 diabetes are at increased       target HbA1c. 186/328 (56.70%) of Nonarab and 25/64
risk for lower respiratory tract infection, urinary tract       (39.1%) of Arab subjects had hypertension and more than
infection, and skin and mucous membrane infection.              2/3 of them required two or more drugs to control their BP.
However, it is unclear if the disseminated MRSA infec-          294/328 (91.9%) of Nonarab and 56/64 (87.5%) of Arab
tion unmasked her diabetes diagnosis; if diabetes put her       subjects had dyslipidemia with high LDL (≥100mg%)
at increased risk for severe infection; or both.                being the commonest lipid abnormality in both the groups.
	     Conclusion:	 Disseminated MRSA is a serious con-          167/328 (50.9%) of Nonarab & 34/64 (53.1%) of Arab
dition associated with a high complication rate and mor-        subjects had both HTN and dyslipidemia. 22% & 24.3%
tality. This case highlights the increased infection risk in    subjects had microalbuminuria in Nonarab & Arab group
diabetes patients and presents a pediatric patient with dis-    respectively. 31% subjects in Nonarab & 17.8% subjects
seminated MRSA and DKA.                                         in Arab group had abnormal ALT levels suggestive of Non
                                                                Alcoholic Fatty Liver Disease (NAFLD).
                                                                	    Discussion	 &	 Conclusion: An important observa-
Abstract #247                                                   tion was significantly higher prevalence of central obesity
                                                                in Nonarab & generalized obesity in Arab population.
CLINICO-EPIDEMIOLOGICAL                                         75-80% subjects in both groups had achieved satisfactory
CHARACTERISTICS & GLYCEMIC CONTROL                              glycemic control (HbA1c ≤7%). Prevalence of cardiovas-
IN ARAB /NONARAB DIABETIC                                       cular risk factors was similar in both the groups suggestive
POPULATION IN UAE                                               of higher risk of cardiovascular complications thus war-
                                                                ranting aggressive treatment of each risk factor. Though
Satendra Kumar Multani, MD, Meenakshi Jain, MD                  most of the clinico-epidemiological characteristics were
                                                                comparable in both populations, additional data on Arab
	   Objective: United Arab Emirates is having the 2nd           population (as group was small) will be helpful in under-
highest prevalence of Type 2 Diabetes Mellitus (T2DM)           standing significant differences if there are any.




                                                           – 43 –
                                        ABSTRACTS – Diabetes Mellitus

                                                               especially in cases with a new onset of a severe headache.
Abstract #248                                                  Delay in the diagnosis of this condition could be associ-
                                                               ated with permanent neurologic deficits which may be
SUPERIOR SAGITTAL SINUS THROMBOSIS                             mitigated with neuroimaging and anticoagulation in con-
SECONDARY TO DIABETIC KETOACIDOSIS                             firmed cases.
(DKA)
                                                               Abstract #249
Raaid Hassan Mannaa Mannah, MD,
John W. Kennedy, MD                                            CLINICAL EXPERIENCE WITH EXENATIDE IN
                                                               OBESE NORTH INDIAN PATIENTS WITH TYPE
     Objective: To present a case of a patient with Type 1     II DIABETES
Diabetes Mellitus (DM) who developed superior sagittal
sinus thrombosis as a complication of DKA.                     Ambrish Mithal, MD, DM, Tarunika Bawa, MBBS,
	    Case	 presentation: An 18 year old female patient         Vibha Dhingra, Niti Agarwal, MD, Nidhi Malhotra, MD
with a history of uncontrolled type 1 DM, due to non com-
pliance with prescribed insulin, presented to an outside       	     Objective: To share our clinical experience with the
hospital with lethargy, tachypnea and hypoxia. She was         use of exenatide in Indian patients.
found to have severe DKA: Glucose 863 mg/dL, CO2 5             	     Methods: We share our experience with use of exena-
mmol/L, Potassium 5.5 mmol/L, Sodium 135 mmol/L,               tide in 74 patients treated at a tertiary care centre in New
Chloride 100 mmol/L, anion gap 40, arterial pH 6.9, posi-      Delhi, India. Subjects included obese / overweight subjects
tive ketones in blood and urine. The patient was treated       (mean weight 97.67 kg) with known history of type 2 DM
for DKA with intravenous fluids and insulin. The DKA           (median duration 9 yrs) and maintaining suboptimal gly-
resolved and her mental status improved, but she devel-        cemic control (HbA1c >7.0)) on oral antidiabetic agents
oped a severe headache. She was discharged home in a           with or without basal insulin. TZDs and DPP4 inhibitors
stable condition. Over the next few days, her headache         were discontinued in view of weight gain and mechanism
became intractable. She returned to the outside hospital       of action respectively. At initiation, 69.77% of patients
and had a CT angiogram that showed possible sagittal           were on metformin, 67.44% on secretagogues, 13.95% on
sinus thrombosis. She was transferred to our Neurology         TZDs and 17.76% on basal insulin either in combination
service for evaluation. Further investigation with MRI –       or alone. 4 Patients discontinued exenatide before comple-
MRV showed findings of superior sagittal sinus thrombo-        tion of one month due to intolerance (severe nausea and
sis with extension into the transverse sinuses bilaterally.    vomiting). The dose of exenatide was increased to 10 mcg
She was started on heparin infusion and Coumadin. She          twice a day after 4 -12 weeks. Exenatide was discontinued
was discharged with no permanent neurologic deficits.          in 3 patients due to lack of response (glycemic or weight
	    Discussion: Cerebral sinus thrombosis is an uncom-        loss) and 6 patients discontinued due to cost factor. 56
mon condition. The risk factors include genetic pro-           patients completed a minimum of 3 months on therapy.
thrombotic conditions, pregnancy and puerperium, oral          42, 32 and 25 patients completed 6 months,9 months com-
contraceptives, infections, dehydration, hematologic           pleted 12 months respectively. We have analysed data
conditions, malignancies, and systemic diseases. There is      for patients who were able to complete at least 3 months
evidence suggesting that DKA promotes a pro-thrombotic         therapy.
state. Many hypotheses have been formulated for this           	     Results	&	Discussion: The decline in fasting and PP
mechanism but dehydration is probably the most impor-          blood sugars were significant from baseline at 3, 6, 9 and
tant factor. In our patient, her severe dehydration due to     12 months with p-value <0.05. The mean weight loss (kg)
diabetic ketoacidosis was most likely the cause of the         at one month, 3, 6, 9, 12 months was 1.75 ± 1.3, 3.86 ±
cerebral sinus thrombosis. She underwent extensive work        2.5, 6.26 ± 3.4, 7.75 ± 3.9 and 8.68 ± 4.1 respectively.
up looking for inherited and acquired pro-thrombotic con-      The mean HbA1c (%) at baseline was 8.63± 1.26, at 3
ditions but results were negative. Only a few cases have       months 7.81 ± 0.92, at 6 month 7.69 ± 0.86, at 9 months
been reported of a cerebral sinus thrombosis in association    was 7.53 ± 0.97 and at one year was 7.26 ± 0.81. The
with diabetic ketoacidosis in an adult.                        changes in HbA1c and weight loss from baseline were sta-
	    Conclusion: DKA is associated with dehydration            tistically significant with P value < 0.05. Nausea was the
and promotes a pro-thrombotic state. During an episode         major side effect which declined with the passage of time
of DKA, deterioration of the mental status due to cere-        (95% patients in first month, 73.8% at 6 months and 8%
bral edema or metabolic encephalopathy has been com-           at one year). Incidence of minor hypoglycemia was low
monly described, however, other less common conditions         in the first month (1.5%) which increased with improve-
such as cerebral sinus thrombosis should be considered,        ment in glycemic control (5.35%, 11.9%, 25% and 20%


                                                          – 44 –
                                         ABSTRACTS – Diabetes Mellitus

at 3, 6, 9, 12 months respectively), necessitating sulpho-      and 0.03). Mean LDL-C significantly correlated with
nylurea dose reduction. There was no incidence of major         abnormal proteinuria ( r-0.2,p=0.05). Non fatal clinically
hypoglycemia.                                                   evident cardiovascular events were comparable in both
	    Conclusion: There was a significant improvement in         groups (stroke 63.3% vs 36.4% p=0.8, chest pains 62.5%
glycemic control and major weight loss (mean 7.75 kg at         vs 37.5% p=0.4).
9 months) with the use of exenatide in obese North Indian            Conclusion: The prevalence of abnormal protein is
patients with Type 2 Diabetes. Nausea was the most com-         high in Nigerian DM and significantly associated with
mon side effect. Exenatide is a useful option for treatment     high total cholesterol, high LDL-C and ECG abnormali-
of diabetes for obese Indian diabetics.                         ties. Early elucidation would go a long way to reduce
                                                                cardiovascular complications. Limitation: Doppler,
Abstract #250                                                   Echocardiography, Brain CT Scan and CRP Studies.

ABNORMAL URINARY PROTEIN IN TYPE 2                              Abstract #251
DIABETES IN NIGERIA.
                                                                COST OF TREATING DIABETES IN A
Ayotunde Oladunni Ale, MD,                                      DEVELOPING ECONOMY
Anthonia Okeoghene Ogbera, MBBS, FMCP, FACE,
Adeleye Olufunmilayo Olubusola , MD, Dada, A.O.                 Babatope Kolawole, MD, Tomi Olugbodi

     Objective: Albuminuria is a strong independent pre-        	    Objective: The study set out to determine the out-of-
dictor of all-cause of CVD mortality in American Indians        pocket and indirect costs of treating diabetes mellitus in
with diabetes. Early assessment and targeted interventions      Nigeria with a developing economy and little or no health
are necessary to treat and prevent all risk factors associ-     insurance.
ated with diabetic complications. This study sets out to             Methods: The study was conducted at two tertiary
determine the prevalence of abnormal urinary protein and        health facilities that are 25 kilometers apart and operate
its correlates among DM patients in Nigeria.                    under the same management, the Wesley Guild Hospital
     Methods: This is cross-sectional study in which 200        (WGH) and the Ife Hospital Unit (IHU) both in southwest-
DM patients were randomly selected in LASUTH. Their             ern Nigeria. An interview-structured questionnaire and
clinical characteristics documented through interviewer         case note records were used to determine demographic
administered questionnaires. The laboratory parameters          variables, how much patients had expended on diabetes
assessed included serum lipid profile, uric acid, blood         care, sources of funds for care, ability to cope with paying,
glucose (FBS) and urine analysis for macro and micro-           number of clinic attendance and number of days spent on
albuminuria. All the study subjects had ECG done to             admission all in the preceding 12 months.
assess their cardiovascular status. Test Statistics used             Results: There were 94 patients in all (M: F= 1:1), the
were Student’s T-test, χ test and correlation coefficient to    average age was 62 years, 29 were retirees and 83 % of the
test for association. P value of <0.05 indicated statistical    patients were in the low socioeconomic class. The average
significance.                                                   clinic attendance was 8/12 months while the average dura-
     Results: The prevalence of proteinuria was 54%.            tion of hospital stay was 38 days. The total cost of insulin,
23% had macroalbuminuria and 31% microalbuminuria               oral hypoglycemics, other drugs and laboratory test was
. Females and males made up 62% and 38 %,p=0.01.                $51,986.00. Only six patients had their own glucometer.
More F were affected than M. The mean (SD) age of               With respect to the ability to cope with paying for care,
the subjects with proteinuria was 58.3±11.4 years. The          56% of the patients reported that they cope with difficulty
ages of the females (F) and male s(M) were comparable           or great difficulty while a third had to depend on relations
(56.5±11.5 vs. 61.2±10.8 years, p=0.16). The mean BMI           for diabetes care payment.
of the study subjects was 27.4±5.13. The mean BMI of                 Discussion: The prevalence of diabetes mellitus is
F were higher than M (28.5 ± 5.1 vs 25.4 ±4.8, p=0.02).         projected to continue to increase world wide and develop-
Their mean duration of DM was 8.0yrs ± 6.03. A high pro-        ing countries may bear the greater brunt of this increase.
portion of subjects (69%) were hypertensives. Their mean        Diabetes mellitus without doubt places a considerable eco-
FBS was 183.76 ± 101.56 and mean HbA1c 7.9 ±3.7.                nomic burden on individuals, families and even national
The mean BMI, duration of DM, uric acid levels, HbAic,          health systems. In some countries, including Nigeria, most
hypertension and FBS were comparable in both groups.            or at least a substantial proportion of healthcare costs are
However ECG abnormalities were significantly higher in          borne by individuals and their families and indirect costs
the proteinuria group. The TOTAL-C and LDL-C were               e.g. lost production may even be higher. Our study just
significantly higher in subjects with proteinuria (p=0.01       as in previous studies recorded a higher prevalence of


                                                           – 45 –
                                             ABSTRACTS – Diabetes Mellitus

diabetes in the elderly population. This group of individu-           whose insulin requirements exceed 200 units insulin/day.
als is particularly vulnerable to cost effects being mostly           The high concentration of U-500 regular insulin makes
retired and having no regular earnings. Majority of our               its pharmacokinetic profile more closely simulating NPH,
patients are from the lower socio economic strata with                and that helps in delivering high insulin doses in small
poor education further compromising their ability to make             volumes. Significant improvement in Hgb A1C level as
wealth and fund their own care. This results inevitably to            well as cost benefit was reported with using U 500.
poor outcomes hence creating a vicious circle for perpetu-            	    Conclusion: There is lack of experience in utilizing U
ating poverty.                                                        500 in hospital setting. Through our two cases we propose
     Conclusion: The out-of-pocket and indirect cost of               that U 500 regular insulin as an alternative option in treating
diabetes care appeared intolerably high to these mostly               hospitalized patients with high insulin resistance in appro-
indigent patients. An effective health insurance scheme               priate clinical settings providing that education and safety
might ameliorate this presently unacceptable situation.               measures are well undertaken. Ordering in mL/units and
                                                                      using TB syringes can eliminate confusion with dosing.
Abstract #252

UTILIZING U 500 INSULIN IN                                            Abstract #253
HOSPITAL SETTING
                                                                      A MULTIDISCIPLINARY PROTOCOL
Abdul-Razzak Alamir, MD, Joe Chehade, MD                              SPECIFYING A BASAL/BOLUS REGIMEN OF
                                                                      SUBCUTANEOUS INSULIN IN TRANSITION
	    Objective: Review the use of U 500 regular insulin               FROM CONTINUOUS INSULIN INFUSION IS
for highly insulin resistant patients in hospital setting.            EFFECTIVE FOR GLYCEMIC CONTROL IN
	    Case	Presentation: 52 year old male with HIV admit-              CARDIAC SURGERY PATIENTS.
ted with fever and confusion. Admission Blood glucose
(BG) 399 mg/dL, normal value a year ago. Patient was                  Agnieszka Gliwa, MD, Peter Terry, MD, Sarah Siu,
on HAART until a month earlier. Triglyceride 75 mg/dL,                Kathleen Salak, NP, Daniel Lee, MD, Vinay Tak, MD,
Hgb A1C 16.1%. ID evaluation & work up was negative,                  Haroon Kamran, Wilson Ko, MD
fever and confusion resolved in 24 hours. Despite very
high doses of insulin > 3000 units/day insulin IV (BG)                	    Objective: We investigated whether a protocol for
remained > 200 mg/dL . U 500 (800 U/daily) was effec-                 subcutaneous (SQ) insulin could maintain glycemic con-
tive in tapering off insulin infusion and lowering (BG) to            trol without prolonged continuous insulin infusion (CII) in
100 mg/dL range. Insulin requirement declined signifi-                patients after cardiac surgery.
cantly after 3 weeks and was discharged off insulin on                     Methods: We retrospectively analyzed consecutive
Pioglitazone 45 mg/d. 48 year old white female with his-              cardiac surgery patients enrolled for up to 5 days in the
tory of chronic pancreatitis and DM type 2 admitted with              Protocol between October 2008 and April 2009. Patients
abdominal pain and vomiting. Normal lipase, triglyceride              were treated as usual with CII with target glucose 120 mg/
928 mg/dL, Hgb A1C 7.8%. Her home regimen included                    dL until transition to SQ insulin at first oral feeding after
Glargine 24 units at bedtime and metformin 2000 mg/d.                 surgery, no earlier than the morning after surgery. Our
TPN 71 mL/hr (contained 156 gm/L dextrose; 40 units/L                 Protocol includes an algorithm calculating the initial dose
regular insulin) was started for severe GI symptoms, her              of basal insulin to be given on transition from CII, which
BG remained >400 despite insulin dose > 400 U/d IV                    occurs at the first post surgery oral feeding; as well as for
which persisted even after stopping TPN. U 500 (up to 0.4             ongoing prandial and supplemental dose insulin. Blood
ml = 200 U TID) was effective in lowering BG within 48                glucose (BG) is obtained at mealtimes, 10pm and 3am. An
hours. Triglyceride improved 212 mg/dL. The patient was               algorithm is used daily to titrate insulin doses according to
discharged on U 500 0.2 mL (100 units qac). Her insulin               BG results from the preceding 24 hours. The goal of the
requirement continued to decrease post discharge and she              protocol was to achieve a mean daily BG of ≤ 150 mg/dL.
was switched back to her old low dose insulin regimen. In             	    Results: We analyzed 31 diabetics and 59 nondia-
both cases work up for secondary causes for acute severe              betics. Mean duration of CII was 25.7±16 h (median and
insulin resistance was negative.                                      mode, 22 h). Of patients extubated after midnight on the
	    Discussion: Despite the fact that U 500 insulin has              day of surgery, 53% received SQ insulin within 6 hours of
been successful in treating patients with severe insulin              extubation. The dose of basal insulin was higher in diabet-
resistance, its clinical utilization is still limited. U 500 insu-    ics than nondiabetics at protocol initiation (0.56 vs 0.29
lin which is 5 times more concentrated than U-100 insu-               U/kg) (p<.000005). Over protocol days 1-5 the absolute
lin, is an alternative option for treating diabetic patients          doses as well as the difference in doses of diabetics and


                                                                 – 46 –
                                        ABSTRACTS – Diabetes Mellitus

nondiabetics decreased; on protocol day 5 doses were           decarboxylase antibodies (GADA). Subjects with
similar in diabetics and nondiabetics (0.24 vs. 0.16 U/kg)     CT2DM who were GADA positive had a lower mean
(p=ns). Mean BG in nondiabetics and diabetics was 129          BMI (25.64 kg/m2 vs. 26.59 kg/m2) and waist circumfer-
vs 145 mg/dL for Protocol Day 1 (p-ns), 127 mg/dL vs           ence (89.80 kg/m2 vs. 92.47 kg/m2) than GADA negative
138 for Protocol Day 2 (p=ns); and 122 vs 137 mg/dL for        subjects; however these differences did not attain statisti-
Protocol Days 1 – 5 (p=0.01). Efficacy rate in nondiabet-      cal significance. Subjects who were GADA positive had
ics vs diabetics was 83% vs 58% for protocol Day 1; 89%        higher mean fasting blood glucose (144mg/dl vs. 125mg/
vs 81% on day 2 (p=ns for both); and (95% vs 74%) for          dl, t=2.20, p=0.14), higher mean HbA1c levels (7% vs.
Days 1-5 (p = .01). Of 1868 BG results, 6.8% were below        6.1%, t=3.19 p=0.077) and a higher proportion on insulin
70 mg/dL, 0.7% were below 50 mg/dL, of which one epi-          therapy (31.6% vs. 22%, χ 2 = 0.07, p= 0.25) when com-
sode was symptomatic.                                          pared with GADA negative patients.
	    Discussion: Glycemic control after cardiac surgery             Conclusion: The prevalence of LADA amongst
reduces morbidity and mortality, but may require pro-          Nigerian patients clinically diagnosed as type 2 DM was
longed CII. A practicable SQ insulin protocol would be         11.9%. This high prevalence emphasizes the importance
a tool to study the benefit of defined glycemic control in     of GAD antibody testing in our practice settings, so as to
cardiac surgery patients who are not critically ill.           appropriately classify adult patients with diabetes melli-
     Conclusion: Our SQ insulin protocol is effective          tus. This would also help direct appropriate therapy so as
for glycemic control in cardiac surgery patients, without      to improve glycemic control and reduce the risk of long
excessive hypoglycemia. It can be initiated soon after         term complications of diabetes mellitus.
extubation and reduces the need for prolonged CII.

Abstract #254                                                  Abstract #255

PREVALENCE OF LATENT AUTOIMMUNE                                THE EFFICACY OF LIRAGLUTIDE IS NOT
DIABETES AMONGST ADULTS WITH                                   IMPACTED IN SUBJECTS POSITIVE FOR
TYPE 2 DIABETES                                                ANTI-LIRAGLUTIDE ANTIBODIES:
                                                               A POOLED ANALYSIS
Arinola Ipadeola, MBBS,
Jokotade Adeleye, MBBS, FWACP,                                 Alan J. Garber, MD, PhD, FACE,
Kehinde Akinlade, FMCP                                         Michel Marre, MD, PhD, Michael Nauck, MD, PhD,
                                                               David Russell-Jones, MD, PhD, Jason Brett, MD, PhD,
	    Objective: The aim of this study was to investi-          Maria During, PhD, Lawrence Blonde, MD
gate the frequency and characteristic features of Latent
Autoimmune Diabetes in Adults (LADA) based on the              	    Objective: Peptide drugs have the potential to induce
presence of Glutamic acid decarboxylase (GAD) antibod-         antibodies, based on homology to the native peptide or
ies in patients who had been clinically diagnosed as type 2    protein. Antibodies can bind to the effective peptide and
diabetes mellitus.                                             alter the pharmacokinetics and thereby decrease efficacy.
     Methods: One hundred and sixty patients who had           GLP-1 receptor agonists vary in their homology to human
been diagnosed clinically to have type 2 diabetes mellitus     GLP-1. Exenatide has 53% homology to human GLP-1;
(CT2DM) participated in the study following selection by       about 50% of subjects taking exenatide developed anti-
systematic random sampling. Anthropometric measure-            bodies to it during phase 3 trials, with 3-6% having high
ments (weight, height, waist circumference and hip cir-        antibody titers that were associated with decreased effi-
cumference) were taken and blood samples were obtained         cacy. Therefore, we evaluated if use of liraglutide, a once-
for analysis of fasting blood glucose, glycated hemoglo-       daily human GLP-1 analog with 97% homology to native
bin (HbA1c) and GAD antibodies from the patients with          GLP-1 would generate antibodies and, if so, whether this
CT2DM. The results obtained were analyzed using SPSS           would affect glycemic control.
package version 16.                                                 Methods: A pooled analysis from four phase 3 stud-
     Results: Out of the 160 patients with CT2DM, 65           ies was done to assess the prevalence of anti-liraglutide
(40.6%) were males while 95(59.4%) were females. The           antibodies by radioimmunoassay. All samples positive
mean age (SD) of the patients with CT2DM was 60.49             for anti-liraglutide antibodies were also tested for cross-
(10.37) years, the mean BMI (SD) was 26.47 (4.80)              reactivity to native GLP-1 and in vitro neutralizing effect
kg/m2 while the mean waist circumference (SD) was              on liraglutide. An analysis was also done to determine
92.16 (11.50) cm. Nineteen persons (11.9%) amongst             whether antibody generation affected efficacy based
patients with CT2DM were positive for Glutamic acid            on hemoglobin A1c [HbA1c]. Subjects included in the


                                                          – 47 –
                                         ABSTRACTS – Diabetes Mellitus

analysis had end-of-treatment samples taken off drug             team. Changes in diabetes outcomes were tracked through
(liraglutide 0.6mg, 1.2mg and 1.8mg) for at least 5 days,        a two year longitudinal study of all diabetic patients in the
ensuring that serum liraglutide levels did not interfere         clinic who had at least 2 visits each year following imple-
with the antibody assay.                                         mentation (n=560). Educational outcomes were assessed
     Result: Anti-liraglutide antibodies were detected in        for all 48 residents in the program through multi-source
8.3% of subjects treated with 1.8mg, 8.7% for 1.2 mg,            evaluations based on direct observations. Descriptive sta-
and 9.2% for 0.6 mg of liraglutide. Overall, 102 (8.6%)          tistics were used to report change in process of care and
subjects out of 1185 generated antibodies to liraglutide:        achievement of resident competencies. Paired t-tests were
and of those testing positive for liraglutide antibodies,        used to measure change in A1c levels. Since the method
12 (11.8%) subjects had neutralizing antibodies, and 56          of A1c measurement changed in 2009 with the addition of
(55%) subjects had antibodies that cross-reacted with            POC testing, change in A1c levels was only assessed for
native GLP-1. Antibody titers were in the range of 1.6-          2008.
10.7%B/T (% Bound/Total) and for subjects on liraglu-            	     Results: The percent of visits with current A1c results
tide, the mean was 3.28%B/T. In the liraglutide 1.8mg arm        increased from 62% in 2008 to 77% in 2009 after the
subjects positive for anti-liraglutide antibodies had a mean     introduction of POC testing. Treatment intensification for
HbA1c reduction of -1.1%, while those negative for anti-         appropriate patients occurred at a higher rate (65%) dur-
liraglutide antibodies had -1.2%, while in the 1.2mg arm,        ing visits with a completed POC test than during those
positive subjects had a mean HbA1c reduction of -1.3%            without a completed POC test (49%). Mean A1c levels
and those negative for liraglutide antibodies had -1.2%.         for patients not at goal at baseline significantly improved
There was also no difference in HbA1c reduction in the           during 2008 (9.6-9.0%; difference-0.6, 95% CI .29 to .81,
liraglutide 0.6mg arm in subjects positive or negative for       p<.001). Currently, 39% percent of the patients have A1c
liraglutide antibodies. Nine subjects testing positive for       levels <7.0 at their most recent visit. During 2008-2009,
liraglutide antibodies reported injection site reactions, and    the percentage of residents achieving “Competent” or
none were withdrawn from the trials due to these adverse         “Superior” ratings in interdisciplinary team related com-
events.                                                          petencies of Professionalism, Systems-Based Practice,
     Conclusion: Consistent with its high homology to            and Interpersonal and Communication Skills was 81%,
native GLP-1, the immunogenic potential of liraglutide           77% and 77% respectively.
is low. The prevalence of anti-liraglutide antibodies was        	     Discussion: Use of team-based services and
<10%, with low titers that did not affect efficacy.              enhanced decision support at visits significantly improves
                                                                 the quality of care provided by residents during training
Abstract #256                                                    and also improves clinical outcomes for their patients with
                                                                 diabetes.
ENDOCRINOLOGIST-SUPPORTED DIABETES                               	     Conclusion: This model for collaboration between
QUALITY IMPROVEMENT INITIATIVE IN                                endocrinologists and primary care physicians was shown
AN INTERNAL MEDICINE RESIDENCY                                   to be an effective quality improvement strategy in a resi-
CONTINUITY CLINIC                                                dency continuity clinic. The elements of the redesign are
                                                                 not specific to one institution and could be transferred
James K. Salem, MD, FACE, Ronald Jones, MD, FACP,                to others to improve patient care as well as resident
Sana Hasan, DO, David Sweet, MD, FACP,                           education.
Lynn Clough, PhD
                                                                 Abstract #257
	    Objective: To assess interdisciplinary team skills in
learners and improvements in diabetes outcomes follow-           ASSESSING GLYCEMIC CONTROL WITH
ing implementation of an endocrinologist-supported qual-         INSULIN PUMP THERAPY IN PATIENTS WITH
ity improvement initiative in an internal medicine resi-         TYPE 1 DIABETES MELLITUS
dency continuity clinic.
	    Methods: With the support and leadership of an endo-        Banshi Damodarlal Saboo, MD, Phatak Sanjiv R.,
crinologist, service delivery in the clinic was incremen-        Brahmkshatriya Priyanka P., Vyas C.,
tally redesigned for patients with diabetes to incorporate       Sanjiv J. Shah, MD, MBBS,
monthly endocrinologist-facilitated team meetings, team-         Shashank Joshi, MD, FACP, FRCP, FACE
based care visits (2008) and enhanced decision support
with point-of-care (POC) A1c testing (2009). The resi-                Objective:	 Glycemic control is very critical in
dency curriculum was also redesigned to include reviews          patients with Type 1 diabetes mellitus. Recent therapeu-
of practice patterns and optimal use of an interdisciplinary     tic interventions with regards to type 1 diabetes include


                                                            – 48 –
                                        ABSTRACTS – Diabetes Mellitus

Insulin pump therapy. Insulin pumps are used by diabetics      therapies were introduced to check the efficacy on these
to help manage their diabetes. An insulin pump mimics          complications as well as patient compliance.
the pancreas by giving out a basal rate of insulin, which           Conclusion:	 Prevention of hypertension and dys-
is a constant infusion of a small amount of insulin. Before    lipidemia would not only help in delaying the long term
each meal, a bolus dose (a burst of insulin) is taken based    complications of diabetes but also improve the lifestyle of
on the amount of carbohydrate to be eaten.                     diabetic patients.
     Methods:	The present study was aimed at assessing
the glycemic control in patients who are on insulin pump       Abstract #259
therapy. Patients with type 1 diabetes who were on insu-
lin pump therapy since last six months were included in        INCIDENCE OF FATTY LIVER IN A
the study. The blood sugar levels were monitored for 3         DIABETIC POPULATION
months to evaluate glycemic control. The parameter used
for evaluation was glycosylated hemoglobin (HbA1c lev-         Banshi Damodarlal Saboo, MD,
els). Glycemic control was compared among pump users           Sanjiv Jayantilal Shah, MD, MBBS,
and non users.                                                 Shashank Joshi, MD, FACP, FRCP, FACE,
     Results:	The study revealed that those on insulin pump    Brahmkshatriya Priyanka P., Vyas C.,
therapy were having better glycemic control (HbA1c lev-        Ladha M., Agrawal M.
els not more than 8.5) as compared to non users.
     Conclusion:	A significant proportion of pump users              Objective:	Nonalcoholic fatty liver disease (NAFLD)
had better optimum glycemic control than non users.            is the most common cause of abnormal liver function
Thus insulin pumps help in maintaining glycemic controls       tests among adults in Western countries. The spectrum
appreciably specially in patients with type 1 diabetes and     of NAFLD ranges from simple steatosis to nonalcoholic
are strongly recommended for achieving and maintaining         steatohepatitis (NASH), which can progress to end stage
optimum BSL and preventing diabetic complications.             liver disease. NAFLD is commonly associated with obe-
                                                               sity, type 2 diabetes, dyslipidemia and insulin resistance,
Abstract #258                                                  all of which are components of the metabolic syndrome,
                                                               strongly supporting the notion the NAFLD is the hepatic
EMERGING TRENDS FOR TREATMENT OF                               manifestation of the syndrome. The prevalence of NAFLD
DYSLIPIDEMIA AND HYPERTENSION IN                               has been reported to be in the 15-30% range in the general
PATIENTS WITH TYPE 2 DIABETES                                  population in various countries and is almost certainly
                                                               increasing. Compared with non diabetic subjects, people
Banshi Damodarlal Saboo, MD,                                   with type 2 diabetes appear to have an increased risk of
Sanjiv Jayantilal Shah, MD, MBBS,                              developing fibrosis and cirrhosis. It has been estimated
Brahmkshatriya Priyanka P., Chandarana H,                      that about 70-75% of type 2 diabetic patients may have
Sisodiya N, Vyas C., Vyas B.,                                  some form of NAFLD. However, the “precise” preva-
Shashank Joshi, MD, FACP, FRCP, FACE                           lence of NAFLD in type 2 diabetes is unknown. The few
                                                               available studies have been small and performed in highly
     Objective:	Diabetes is emerging as an epidemic in the     selected populations or have estimated only the preva-
developing as well as developed countries and is affecting     lence of abnormal aminotransferase levels, which are a
a large section of the health care sector. Along with the      poor proxy measure of NAFLD.
cardinal macrovascular and microvascular complications              Methods:	Hence the main purpose of this study was
observed in diabetes, a commonly observed manifestation        to determine the prevalence of NAFLD as diagnosed by
is the concomitant occurrence of hypertension and dys-         patient history, and liver ultrasound, which is the most
lipidemia. Abnormal lipid levels and hypertension are the      widely used imaging test for detecting hepatic steatosis,
indicators of cardiovascular diseases.                         and to establish whether there is an association between
     Methods:	The present study was aimed at prevention        NAFLD and CVD in a large cohort of type 2 diabetic
of cardiovascular disease in diabetic patients by introduc-    adults. Patients with type 2 diabetes specially associ-
ing newer drugs. The study was also aimed at establishing      ated with obesity and insulin resistance were included
the optimum time to start the drug therapy. Patients with      in the study and the fatty liver analyzed by sonographic
diabetes were screened for hypertension and dyslipidemia       techniques.
by observing their blood pressure and fasting total choles-         Results:	Studies revealed a significant proportion of
terol, HDL, LDL and triglycerides. The parameters stud-        patients with NFALD.
ied were total prevalence of hypertension and dyslipid-             Conclusion:	 Correct identification of NAFLD in
emia, gender ratio, current treatment and lifestyles. Newer    type 2 diabetes may help in CVD risk prediction with


                                                          – 49 –
                                         ABSTRACTS – Diabetes Mellitus

important management implications. Identifying people            is advantageous over SMBG as SMBG only gives blood
with NAFLD would also highlight a subgroup of diabetic           sugars at the different points of time when the patient
patients who should be targeted with more intensive ther-        chooses to test the blood sugar. Insulin Pump therapy and
apy to decrease their risk of future CVD events.                 CGMS has made the dream of the diabetologist to mea-
                                                                 sure glucose levels continuously a reality. As it is a new
Abstract #260                                                    technology, the health care professionals using CGMS
                                                                 have to become familiar with it and feel comfortable to
INSULIN PUMP THERAPY AND CONTINUOUS                              use it on patients.
GLUCOSE MONITORING SYSTEM (CGMS) IN                                   Conclusion:	 Reduction in the costs and further
PATIENTS WITH TYPE 1 DIABETES MELLITUS                           improvements in technology would ensure more wide-
                                                                 spread use of this potential method of continuously moni-
Banshi Damodarlal Saboo, MD, Phatak S.R.,                        toring glucose levels.
Shashank Joshi, MD, FACP, FRCP, FACE,
Brahmkshatriya Priyanka P., Vyas C.,                             Abstract #261
Sanjiv Jayantilal Shah, MD, MBBS
                                                                 INVESTIGATION OF PREVALENCE AND
     Objective:	An Insulin Pump is indicated for the con-        CHARACTERISTICS OF LATENT AUTOIMMUNE
tinuous delivery of insulin at set and variable rates for the    DIABETES IN ADULTS (LADA) IN
management of insulin dependant diabetes mellitus. They          A DIABETIC POPULATION
have become increasingly popular over the past several
years because of their convenience, flexibility, and ease        Banshi Damodarlal Saboo, MD, Goyal R.K.,
of use. The benefit of these pumps includes avoidance            Brahmkshatriya Priyanka P.
of following regimented meal plan that diabetics in the
past have had to follow. Additionally, insulin pumps are              Objective:	 Diabetes mellitus is one of the most
better than basal insulin injections because they deliver        commonly occurring metabolic disorders. One new
insulin at a very steady rate opposed to the basal injec-        form of diabetes that appears to have characteristics of
tions that deliver sporadic insulin dosages and allow users      both Type 1 and Type 2 diabetes is known as LATENT
to eliminate invasive injections. Hemoglobin A1c levels          AUTOIMMUNE DIABETES IN ADULTS (LADA).
are easier to monitor with a pump and the cost of diabetes            Methods:	The present study was aimed at determin-
management is reduced. Insulin pump therapy can achieve          ing the phenotypic characteristics of LADA patients and
near normal glycemia, minimize the risks of severe hypo-         establishing critical parameters like C-peptide levels and
glycemia and excessive weight gain, and prevent or delay         glutamic acid decarboxylase (GAD) autoantibodies as
microvascular complications in brittle type 1 diabetics.         diagnostic markers for LADA. The present study was
However, insulin pumps also have some unavoidable lim-           carried out to assess phenotypic characteristics of LADA
itations including high costs, round the clock use and an        patients.
increased need of monitoring to avoid hypoglycemia and                Results:	Results showed that the prevalence of LADA
ketoacidosis.                                                    patients was nearly equal to that of Type 1 diabetes.
     Methods:	 Along with Insulin pumps, patients with           LADA was observed to affect males more as compared to
IDDM should be recommended for CGMS to record                    females. Additionally, LADA patients showed lower basal
interstitial glucose. CGMS refers to the continuous, auto-       metabolic index (BMI) values; age of onset between type
matic monitoring of glucose in the subcutaneous tissue.          1 and Type 2 patients; higher glycosylated haemoglobin
Continuous Glucose Monitoring Systems (CGMS) act                 (HbA1c) and cholesterol levels; and optimum blood sugar
as “glycemic holters” to help the diabetologist and addi-        levels by a combined therapy of insulin and oral hypogly-
tionally have the ability to provide Real-time continuous        cemic agents. The most interesting observations in these
glucose monitoring. Some available devices approved or           patients were a significant presence of family history,
under review include Paradigm® 722 System, Guardian®             characteristically low C-peptide levels and a marked pres-
RT, MiniLink®, Dexcom® STS (3-day approved and                   ence of glutamate decarboxylase (GAD) auto antibodies.
7-day under review), Navigator® (Under FDA Review),              Since LADA patients constitute a noticeable proportion of
(CGMS, Medtronic MiniMed, Northridge, California)                a diabetic population, it is very essential to identify such
and GlucoWatch (Cygnus, Inc, Redwood City, California.           cases accurately.
The Continuous Glucose Monitoring System (CGMS) can                   Conclusion:	 The above characteristics can be uti-
help to achieve and improve metabolic control as a result        lized to correctly identify LADA patients and prevent their
of a balanced diet, physical activity and correct insulin. It    misdiagnosis as Type 2 diabetic patients. Determination



                                                            – 50 –
                                         ABSTRACTS – Diabetes Mellitus

of C-peptide and GAD autoantibodies is strongly recom-               Abstract #263
mended for differential diagnosis of LADA. Accurate
diagnosis can in turn lead to a better understanding of the          HUMAN MACRO AND MICRO-VASCULAR
underlying mechanisms which lead to development of                   ENDOTHELIAL CELLS DIFFER IN GENE
LADA and design of rational drug therapy for LADA.                   EXPRESSION WHEN EXPOSED TO HIGH
                                                                     GLUCOSE IN-VITRO
Abstract #262
                                                                     Sabyasachi Sen, MD, MRCP,
PRESCRIPTION PATTERN OF INSULIN                                      Abdulrahaman Alkabbani, MD, Saqib Inayatullah, MD
THERAPY IN A DIABETES CLINIC
                                                                     	    Objective: Literature on complications of diabetes
Banshi Damodarlal Saboo, MD,                                         suggests that micro and macrovascular outcomes sec-
Sanjiv Jayantilal Shah, MD, MBBS,                                    ondary to intensive control of diabetes favor microvas-
Shashank Joshi, MD, FACP, FRCP, FACE,                                culature. We decided to note if the effect of glycemia on
Chandarana H, Sisodiya N,                                            human micro and macrovascular endothelial cells (EC),
Brahmkshatriya Priyanka P, Vyas C, Vyas B                            differ as regards to their gene expression.
                                                                     	    Methods: We cultured commercially available
     Objective:	Diabetes is one the most commonly occur-             human cell lines such human umbilical vein endothelial
ring metabolic disorders characterized by dysfunction in             cells (HUVEC) as representative of macrovascular cells,
insulin secretion or insulin action or both. While certain           human retinal microvascular endothelial cells (HMEC), as
forms of diabetes are characterized by destruction of pan-           representative of microvascular cells and a non vascular
creatic beta cells, leading to failure of insulin secretion          human cell line such as human embryonic kidney cells
and insulin dependency, some forms like type 2 diabetes              (HEK) in monolayer. We exposed HUVEC and HMEC
are associated with insulin resistance and down regulation           to 5.5 mM (equivalent to 99mg% of glucose) and 25mM
of insulin receptors thus leading to dysfunctional insu-             (equivalent to 450mg% of glucose) and noted various
lin action. Thus optimal insulin therapy according to the            genes expression levels by real time PCR (RT-PCR).
onset of diabetes is very essential to maintain optimum              	    Results: On culturing HEK and HUVEC in 5.5mM
glycemic control.                                                    glucose media we identified genes that are clearly over-
     Methods:	The present study was aimed at establishing            expressed, in HUVEC rather than HEK, after 7 days of
a prescription pattern of insulin therapy according to the           culture in-vitro. These were CD-31 or PECAM (200-
duration of diabetes. Early initialization of insulin therapy        fold), VEGFR2 or KDR ( 20-fold), vonWillebrand’s fac-
can help in preventing or delaying the diabetic complica-            tor or VWR (205-fold), endothelial nitric oxide synthase
tions. Patients were screened according to their duration            or eNOS ( 134- fold). These genes were therefore most
of diabetes, following which optimum insulin therapy was             discriminatory between human endothelial and non-endo-
prescribed as per the requirement. The parameters used               thelial cells and may provide information of vasodilatory
to monitor glycemic control as well as efficacy of the               (eNOS) and coagulative (vWR) functions of endothelium.
treatment were Fasting Blood Sugar (FBS), Post Prandial              When we looked at expression of these identified genes in
Blood Glucose (PPBS), HbA1c levels and C-peptide lev-                HMEC and HUVEC after exposure to normal (NG) and
els in some of the patients.                                         high glucose (HG) for 7 days, we noted that that there was
     Conclusion:	 Appropriate initialization of insulin              almost no change in gene expressions in HMEC in HG
therapy with respect to the type of insulin prescribed, dose         however both VWR (4-fold) and eNOS (2.5 fold) gene
of insulin and most importantly the duration or stage of             expression were reduced in HUVEC in HG compared to
diabetes at which the therapy is prescribed can help in              NG. There was no cell death noted in either of the human
maintaining optimum glycemic control and delay the dia-              endothelial cell lines in HG by PI-dye staining using
betic complications thus improving the quality of life of            FACS analysis. FACS analysis using HUVEC cultured in
patients with diabetes.                                              HG and reactive oxygen species (ROS) responsive dye,
                                                                     such as DCFDA indicated ROS accumulation inside the
                                                                     cells.




                                                            – 51 –
                                        ABSTRACTS – Diabetes Mellitus

	    Discussion: These findings illustrate that macrovas-      Abstract #265
cular cells may be more susceptible to gene expression
deterioration than microvascular EC on short-term expo-        CASE SERIES OF FOUR YOUNG ADULTS
sure to HG. Exposure to HG leads ROS accumulation              WITH TYPE 1 DIABETES DIAGNOSED WITH
intracellularly, which may be the pathogenesis of gene         MOYAMOYA DISEASE
expression reduction. No obvious EC death was noted,
when exposed to HG up to 7 days. This observation of           Galina Smushkin, DR, Kalpana Muthusamy, MD,
gene expression suppression after a short exposure to HG       John M. Miles, MD
may indicate why reversal to normal function of EC may
prove to be difficult, even when hyperglycemic state is        	    Background: Moyamoya disease is a rare cerebro-
resolved, corroborating the data from the clinical trials.     vascular condition where progressive stenosis of intra-
	    Conclusion: Exposure to HG reduces synthetic gene         cranial internal carotid arteries and the resultant collateral
expression, of macrovascular EC, more, compared to             vasculature predispose patients to ischemic stroke or hem-
microvascular EC, even after a relatively short period of      orrhage. Associations with other conditions like sickle
exposure for 7 days.                                           cell disease or Down’s syndrome have been reported. We
                                                               report 4 cases of moyamoya disease in Caucasian young
Abstract #264                                                  adults with type 1 diabetes managed with insulin pump.
                                                               All four underwent STA-MCA bypasses in 2006-2009 at
PREVENTION OF DIABETES IN OBESE                                our institution.
PATIENTS WITH PHARMACOLOGICAL AND                                   Case	 presentation: 24 y.o. female w/ type 1 diabe-
NON-PHARMACOLOGICAL TREATMENT                                  tes and migraines, presented with transient visual loss
                                                               and headache. Cerebral angiogram demonstrated a near-
Banshi Damodarlal Saboo, MD,                                   total occlusion of the supraclinoid internal carotid artery
Sanjiv Jayantilal Shah, MD, MBBS,                              branches. There were many bihemispheric small ischemic
Shashank Joshi, MD, FACP, FRCP, FACE,                          infarcts. HgbA1C was 6.0; no microvascular complica-
Brahmkshatriya Priyanka P, Chandarana H,                       tions. 20 y.o. male w/ type 1 diabetes and poor glycemic
Sisodiya N, Vyas C, Vyas B                                     control (HgbA1C 9.0) developed aphasia, left hemiplegia
                                                               and DKA. MRI showed a right hemispheric infarct and
     Objective:	Obesity has assumed a great public health      cerebral angiogram revealed segmental narrowing of
and clinical significance in our country. Obesity affects      multiple intracranial arteries. He had microalbuminuria
more than 22 million Indians and central obesity leads to      but no retinopathy or neuropathy. 19 y.o. male w/ type 1
the classic epidemic of diabetes, hypertension, dyslipid-      diabetes and migraines, developed aphasia, disorientation
emia and CHD. Sedentary lifestyles, increased consump-         and headache. MRI demonstrated infarcts in caudate and
tion of junk foods and cola culture are one of the few fac-    basal ganglia. Cerebral angiogram showed severe bilat-
tors contributing to the increased prevalence of obesity.      eral MCA stenoses. HgbA1C was 9.6; no microvascular
Obesity is one of the key factors which play a substantial     complications or DKAs. 22 y.o. male w/ type 1 diabetes
role in the development of insulin resistance and diabetes.    and migraines, developed spells of morning confusion
     Methods:	The present study was aimed at screening         and headache. MRI showed a right frontal lobe infarct.
of obese patients for presence of IGT (Impaired Glucose        Cerebral angiogram showed bilateral high-grade stenoses
Tolerance) or IFG (Impaired Fasting Glucose). Patients         of the supraclinoid internal carotids. HgbA1C was 9.0; no
were characterized as obese based on their BMI values.         microvascular complications.
The parameters observed in the study were gender ratio,             Discussion: The remarkable aspect of these cases is
prevalence in different age groups, family history of obe-     the concurrence of type 1 diabetes and moyamoya dis-
sity and diabetes, current pharmacological treatment and       ease. This may be coincidental, but it is possible that type
lifestyle (diet, exercise, tobacco, smoking, alcohol).         1 diabetes can precipitate the emergence of moyamoya in
     Conclusion:	 Based on results appropriate lifestyle       susceptible persons. Dysregulated extra-cellular-matrix
modifications were recommended. Since obesity plays a          remodeling and angiogenesis is thought to underlie the
pivotal role in the development of diabetes, prevention        arteriopathy. In-vitro studies of smooth muscle cells from
of obesity will not only help prevent diabetes but also        patients with moyamoya show altered responsiveness to
decrease the incidence of cardiovascular complications         serum mitogens. Glycemic instability may contribute to
resulting from diabetes as well as obesity itself.             this altered responsiveness and to the dysregulation of the
                                                               involved enzymes.




                                                          – 52 –
                                        ABSTRACTS – Diabetes Mellitus

     Conclusion: This case series suggests that there may      Abstract #267
be an association between type 1 diabetes and moyamoya
disease, but formal studies are needed. In the meantime,       PULMONARY FUNCTION TESTS REMAIN
clinical endocrinologist should have a low threshold for       SIMILAR IN PATIENTS WHO RECEIVED
obtaining MRI/MRA in a young patient with type 1 diabe-        TECHNOSPHERE® INSULIN AND IN PATIENTS
tes and migraines, since early diagnosis of moyamoya is        CURRENTLY RECEIVING STANDARD
of paramount importance.                                       ANTIDIABETIC THERAPY

Abstract #266                                                  Campbell P. Howard, MD, FACE, Richard Petrucci, MD,
                                                               Nikhil Amin, MD, FCCP, Wen Yu, MD,
DIABETIC KETOACIDOSIS IN GESTATIONAL                           Paul Lovertin, BS, Anders H. Boss, MD, Peter C.
DIABETES. A CASE REPORT                                        Richardson, BMedSci, BM, BS

Miguel E. Pinto, MD, FACE, Milagros Ortiz, MD,                 	    Objective: Previous controlled clinical studies
Jaime E. Villena, MD                                           have demonstrated that regimens of basal insulin plus
                                                               Technosphere® Insulin (TI) were as effective as basal
     Objective: To report a case of a previously healthy       insulin plus rapid-acting sc insulin in patients with diabe-
woman who developed gestational diabetes and presented         tes. In previously reported studies, we have been unable
with severe ketoacidosis.                                      to detect a consistent change in pulmonary function tests
     Case	 presentation: A 21-year-old Hispanic woman          (PFTs). Small but clinically non-significant differences
with no previous history of diabetes, presented at 29          have been observed. This clinical trial was designed to
weeks’ gestation in her first pregnancy with a 6 weeks his-    assess the changes in pulmonary function after cessation
tory of polidypsia, polyuria, and lower abdominal pain.        of TI therapy and resumption of standard antidiabetic
In the previous week, she was diagnosed and treated for a      treatment in patients with type 1 or type 2 diabetes.
urinary tract infection. Two days before she presented at           Methods: Adults with diabetes who participated in
the Emergency Room, she developed dyspnea, nausea, and         any of 4 controlled clinical trials of TI were invited to par-
vomiting. At presentation, physical examination showed         ticipate in this follow-up trial to evaluate changes in PFTs
Kussmaul breathing and acanthosis nigricans. Laboratory        after completing the study and being switched to usual
test showed glucose of 371 mg/dl, arterial pH of 7.16,         antidiabetic therapy without TI. Patients were followed
bicarbonate of 2.7 mmol/l, and hemoglobin HbA1c of             for a total of 3 months after cessation of study therapy.
15%. Urine ketones and leukocyturia were positive. In          PFTs were assessed at the end of the parent trial and 1 and
the ICU, treatment was started with IV insulin infusion,       3 months after subjects completed the parent trial.
intensive hydration, correction of electrolyte abnormali-           Results: Of 649 patients in this study, 315 subjects
ties, and IV antibiotics. She developed some degree of         (121 with type 1 diabetes, 194 with type 2 diabetes)
transient diabetes insipidus associated with pregnancy         received TI and 334 subjects (129 with type 1 diabetes,
and mild hyperchloremic metabolic acidosis because of          205 with type 2 diabetes) received the antidiabetic regi-
renal tubular acidosis. Evolution was favorable, and she       men without prandial TI during the parent trials. Small,
was discharged with NPH insulin and pre-meal regular           non-progressive treatment group differences in mean
insulin. Her pregnancy is normal and she is continuing her     changes from baseline in forced expiratory volume in 1
controls in the outpatient setting.                            second (FEV1) and carbon monoxide diffusing capacity
     Conclusion: Gestational diabetes mellitus present-        (DLCO) observed during the comparative phase of the con-
ing with diabetic ketoacidosis is unusual. Case reports        trolled trials disappeared when comparing the 2 groups at
of diabetic ketoacidosis during pregnancy are related to       3 months after cessation of TI therapy and resumption of
undiagnosed type 1 diabetes, complication of previously        standard antidiabetic therapy (FEV1: -0.08 L in the ex-TI
diagnosed gestational diabetes by stress (prolonged labor      group, -0.11 L in the non ex-TI group [p=0.1388]; DLCO:
or infection), use of glucocorticoids, or O’ Sullivan test.    -1.29 mL/min/mm Hg in the ex-TI group, -1.37 mL/min/
Strict surveillance of glucose homeostasis and aggres-         mm Hg in the non ex-TI group [p=0.9360]), irrespective
sive diabetes management during pregnancy might reduce         of the duration of previous TI exposure. In addition, there
perinatal morbidity associated with diabetic ketoacidosis      was no statistical difference in FEV1 between the 2 groups
during pregnancy.                                              when examining subjects with type 1 and type 2 diabetes
                                                               (p=0.6158 and p=0.1795, respectively).




                                                          – 53 –
                                         ABSTRACTS – Diabetes Mellitus

     Conclusion: These data suggest that the pattern and         found to be non-adherent in this study. The rather high
magnitude of PFT changes associated with the use of TI in        proportion of poor adherence observed in this study is in
subjects with type 1 and type 2 diabetes are not likely due      keeping with findings from other similar studies despite
to any structural alterations in the lungs and are not clini-    wide variation in methods. The predominant factors that
cally meaningful.                                                strongly correlate to adherence to therapy as in most
                                                                 studies were quality of glycemic control, blood pressure
Abstract #268                                                    control, lifestyle measures and occurrence of drug side
                                                                 effects.
DETERMINANTS AND CORRELATES OF DRUG                              	    Conclusion: The population of our type 2 diabetics
ADHERENCE AMONG TYPE 2 DIABETES                                  who are non-adherent to therapy is unacceptably high and
PATIENTS IN NORTHERN NIGERIA                                     requires urgent intervention to prevent the growing conse-
                                                                 quences of uncontrolled diabetes mellitus. A large multi-
Andrew Enemako Uloko, MD,                                        centre study in Nigeria to truly determine the extent of
Aishatu A. Abubakar, FPC, Pharm,                                 adherence and its correlates is suggested.
Ayekame Tini Uloko, B. Pharm,
Fabian H. Puepet, MD, FMCP                                       Abstract #269

	    Objective: Data on adherence to therapy among               REDUCED INCIDENCE AND FREQUENCY
Nigerian type 2 diabetics is lacking hence the need for this     OF HYPOGLYCEMIA IN AN INTEGRATED
study. We aimed to determine the proportion of type 2 dia-       ANALYSIS OF POOLED DATA FROM CLINICAL
betic patients that adhere to drug therapy and associated        TRIALS OF SUBJECTS WITH TYPE 1 DIABETES
factors.                                                         USING PRANDIAL INHALED
	    Methods: In a descriptive cross sectional study of          TECHNOSPHERE® INSULIN
type 2 diabetics spanning twelve weeks at the diabetes
clinic of Aminu Kano Teaching Hospital, Kano, Nigeria,           Campbell P. Howard, MD, FACE, Hao Ren,
patient adherence to drug therapy was evaluated. A pre-          Alicia Rossiter, MD, FCP, Anders H. Boss, MD
tested interviewer-administered questionnaire was uti-
lized. A patient self-reporting model was applied to obtain      	    Objective: Technosphere® Insulin (TI) is an ultra
information on adherence. Data obtained include biodata,         rapid-acting insulin with a pharmacokinetic profile well
relevant information on adherence, blood pressure, fast-         suited for earlier control of postprandial plasma glucose
ing plasma glucose and glycated haemoglobin (HbA1c).             (PPG). This integrated analysis includes the pooled data
Spearman’s correlation coefficient was used to determine         from 3 phase 2/3 clinical trials in subjects with type 1 dia-
the correlates of adherence to therapy                           betes mellitus inadequately controlled (HbA1c >7.0% and
	    Results: A total of 41 type 2 diabetics were recruited      11.0%) with standard insulin regimens.
14 (34.1%) males and 27 (65.9%) females. The mean age                 Methods: Subjects were randomized to 1 of 3 treat-
of the patients was 52.20±11.93 years; males 49.00±10.08         ment regimens to achieve predefined glycemic goals: TI
years; females 53.85±12.64 years. A total of 11 patients         (n=614) plus a basal insulin; sc insulin (n=599), which
adhered to therapy with adherence rate of 26.8%. The             included insulin glargine plus aspart; or “usual care,” with
proportion of males and females adhering to therapy was          insulin adjustments according to investigator discretion.
28.6% and 25.9% respectively with a male:female adher-           A structured titration regimen was not enforced. When
ence ratio of 1.1:1. The mean HbA1c of the study popula-         experiencing hypoglycemic-like symptoms, subjects were
tion was 8.72±2.14% respectively. The mean HbA1c of              instructed to confirm the event with a blood glucose read-
the adherent compared to the non-adherent patients was           ing. Subjects experiencing a severe hypoglycemic episode
6.42±0.69% and 9.56±1.85% respectively. The main                 were required to report the details of third-party assistance
determinants of drug adherence included presence of drug         (if needed), the presence of neurologic symptoms, and the
side effects, pill burden, drug counseling at the pharmacy,      specifics of treatment.
and duration of consultation with the physician and the               Results: Mean baseline characteristics were similar
presence of co-morbidities. Correlates of adherence to           for TI and sc insulin (age 38.4, 38.5 years; disease time
therapy included quality of glycemic control (r = 0.91),         since diagnosis 16.5, 16.6 years; baseline HbA1c 8.59%,
blood pressure control (r = 0.76), life style measures (r =      8.56%; BMI 26.12, 26.03 kg/m2). Subjects treated with
0.51) and drug side effects (r = 0.83).                          TI experienced fewer hypoglycemic events with regard
	    Discussion: A significant proportion of type 2 dia-         to both incidence and frequency, compared with subjects
betics in our setting are non-adherent to therapy. This is       treated with other sc insulins. For incidence, fewer sub-
reflected in the poor mean glycemic control of the patients      jects reported hypoglycemia with TI: 75.9% vs 81.0%


                                                            – 54 –
                                         ABSTRACTS – Diabetes Mellitus

for total hypoglycemia (OR 0.749; p=0.0413), 75.6%               presence of neurologic symptoms, and the specifics of
vs 80.8% for mild/moderate hypoglycemia (OR 0.743;               treatment.
p=0.0354), and 24.3% vs 27.5% for severe hypoglyc-                    Results: Mean baseline characteristics were similar
emia (OR 0.826; p=0.1576), with the comparison p val-            for TI and sc insulin (age 56.2, 55.6 years; disease time
ues substantially in favor of TI for total hypoglycemia          since diagnosis 10.8, 12.4 years; baseline HbA1c 8.82%,
and mild/moderate hypoglycemia. For frequency, TI had a          8.84%; BMI 31.07, 31.07 kg/m2). Subjects treated with TI
comparable (not statistically different) number of events,       experienced statistically significantly fewer hypoglycemic
evaluated by event rate (number of events per 100 sub-           episodes in regard to both incidence and frequency com-
ject-months): 138.60 vs 124.06 for total hypoglycemia            pared with subjects treated with sc insulins. For incidence,
(p=0.9242), 133.16 vs 117.74 for mild/moderate hypogly-          significantly fewer subjects reported hypoglycemia with
cemia (p=0.9097), and 5.16 vs 6.03 for severe hypoglyc-          TI: 31.8% vs 49.6% for total hypoglycemia (OR 0.466;
emia (p=0.5901). When evaluated for those subjects with          p<0.0001), 31.6% vs 49.4% for mild/moderate hypoglyc-
blood glucose values ≤2 mmol/L, TI also was comparable           emia (OR 0.466; p<0.0001), and 2.8% vs 7.5% for severe
(not statistically different) to sc insulin treatment with a     hypoglycemia (OR 0.359; p<0.0001). For frequency, TI
lower event rate.                                                also had significantly fewer events, evaluated by event
     Conclusion: TI, in combination with a basal insulin,        rate (number of events per 100 subject-months): 23.87 vs
consistently reduced the incidence of total and mild/mod-        38.78 for total hypoglycemia (p<0.0001); 23.16 vs 37.32
erate hypoglycemic events and had a lower frequency of           for mild/moderate hypoglycemia (p<0.0001); and 0.66 vs
severe hypoglycemic events under conditions of compa-            1.37 for severe hypoglycemia (p<0.0184).
rable glycemic control.                                               Conclusion: TI, often in combination with a basal
                                                                 insulin, consistently reduced the incidence and frequency
Abstract #270                                                    of both mild/moderate and severe hypoglycemic events
                                                                 under conditions of comparable glycemic control.
REDUCED INCIDENCE AND FREQUENCY
OF HYPOGLYCEMIA IN AN INTEGRATED                                 Abstract #271
ANALYSIS OF POOLED DATA FROM CLINICAL
TRIALS OF SUBJECTS WITH TYPE 2 DIABETES                          AN UNUSUAL CASE OF EUGLYCEMIA
USING PRANDIAL INHALED                                           REQUIRING INSULIN
TECHNOSPHERE® INSULIN                                            Nagashree Gundu Rao, MD, Shuchita Gupta, MD

Daniel Louis Lorber, MD, FACP,                                        Objective: To recognize and differentiate diabetic
Campbell Howard, MD, FACE, Hao Ren,                              ketoacidosis (DKA) in euglycemia from starvation
Anders H. Boss, MD                                               ketoacidosis.
                                                                      Case	 Presentation: A 70 year old Korean woman
     Objective: Technosphere® Insulin (TI) is an ultra           with a history of diabetes mellitus was admitted for an
rapid-acting insulin with a pharmacokinetic profile that         elective intervertebral fusion for scoliosis. She was noted
may result in a lower rate of post-prandial hypoglycemia         to have anion gap metabolic acidosis in the post-operative
when used as a prandial insulin. We explored this hypoth-        period with normal lactate levels. Her blood glucose lev-
esis by carrying out an integrated analysis of the pooled        els remained below 150 mg/dl. She had altered conscious-
data from 6 phase 2/3 clinical trials in subjects with type      ness from excessive opioid administration, which neces-
2 diabetes mellitus inadequately controlled (HbA1c ≥6.6%         sitated intubation and mechanical ventilation. Her anion
and £12.0%) despite insulin with or without oral antihy-         gap continued to rise, while her lactate and blood glucose
perglycemic therapy.                                             levels remained normal. She had moderate ketonuria and
     Methods: Subjects were randomized to treat-                 was started on dextrose infusion for starvation ketosis.
ment regimens to achieve predefined glycemic goals:              However, her ketonuria and serum acetone levels contin-
TI (n=1795) or sc insulin (n=942), which included BPA            ued to worsen, while her blood glucose levels never went
70/30, or insulin aspart and “usual care,” with insulin          beyond 200 mg/dl. Her serum bicarbonate level dropped
adjustments according to investigator discretion in 5 trials     from 15 to 10 mg/dl. The patient was then diagnosed with
and forced titration in 1 trial. A structured titration regi-    euglycemic DKA and was started on insulin infusion
men was not enforced. When experiencing hypoglyce-               along with dextrose. Her anion gap of 25 closed com-
mic-like symptoms, subjects were instructed to confirm           pletely and she was subsequently transitioned to subcu-
the event with a blood glucose reading. Subjects experi-         taneous insulin. Later, her previous course was reviewed
encing a severe hypoglycemic episode were required to            and she was found to have markedly reduced oral intake
report the details of third-party assistance (if needed), the    after her surgery.

                                                            – 55 –
                                           ABSTRACTS – Diabetes Mellitus

     Discussion: Normoglycemia can occur in DKA due to              the patient but the patient remained unresponsive. A
fasting. Euglycemic DKA is uncommon, reported in asso-              venous blood glucose drawn at that time was found to be
ciation with diabetes type 1 and starvation, or pregnant            19 mg/dl. The patient was given 3 ampules of 50% dex-
women on insulin. This patient in contrast, is an elderly           trose and her mental status returned to her baseline. Her
type 2 diabetic with poor oral intake. In normal fasting            subsequent FS readings were 586 and 460 mg/dl with
state, glycogenolysis, gluconeogenesis and fat metabo-              serum glucose 392 mg/dl tested at same time. The Accu-
lism, help maintain glucose homeostasis. Accumulation               Check glucometer used for FS testing was checked and
of ketone bodies results in mild anion gap ketoacidosis.            there was no malfunction noted. We reviewed patient’s
The fasting state in diabetics leads to rapid depletion of          FS glucose readings with the laboratory supervisor and
glycogen stores and the observed lower glucose values.              attributed the discrepancy to patient’s edema in her fin-
Also, the inhibitory effect of insulin on lipolysis and keto-       gers. We recommended the use of “alternate site” testing
genesis is lost. Accelerated ketogenesis and higher anion           i.e. obtaining capillary blood from sites other than the fin-
gap metabolic acidosis is thus seen in DKA with fasting.            gertips concomitantly with venous blood glucose testing.
Euglycemic DKA can be differentiated from starvation                Alternate site testing was done at the palm where there
ketosis, by the presence of a precipitating cause, leading          was no edema. Alternate site testing at the palm correlated
to starvation and markedly lowered bicarbonate (less than           well with venous blood glucose testing.
18 mg/dl), as in this patient. High anion gap metabolic                   Discussion: In our case, we attributed finger edema
acidosis is not seen in isolated starvation ketoacidosis.           to be the primary reason for falsely elevated FS glucose
The failure of resolution of ketoacidosis till insulin and          values. The likely explanation is that due to edema, the
glucose are given, confirms the diagnosis of euglycemic             capillary blood was diluted with tissue fluid which low-
DKA. Management includes correction of fluid and elec-              ered the hematocrit resulting in falsely elevated FS glu-
trolyte abnormalities. Intravenous insulin with dextrose            cose readings. In our case, point-of-care glucose testing by
need to be administered till the acidosis resolves.                 alternate site method at palm correlated well with venous
     Conclusion: It is important to recognize the occur-            blood glucose readings.
rence of DKA without overt hyperglycemia, due to its                      Conclusion: We conclude that in a patient with fin-
lethal complications.                                               ger edema, glucose readings obtained from the fingertip
                                                                    are not reliable and alternate site testing method should
Abstract #272                                                       be considered to assess the magnitude of hyperglycemia
                                                                    before making important clinical decisions.
MAJOR DISCREPANCY IN FINGERSTICK
CAPILLARY GLUCOSE READINGS IN A                                     Abstract #273
PATIENT WITH FINGER EDEMA
                                                                    KETOSIS-RESISTANT DIABETES MELLITUS
Ankur Gupta, MD, Marina M. Charitou                                 TYPE I: CHRONIC ALCOHOLIC
                                                                    PANCREATITIS AS PROTECTION
     Objective: Monitoring of blood glucose by fingerstick          AGAINST DIABETIC KETOACIDOSIS
method is a key element in the management of diabetes.
We describe an interesting case of finger edema leading to          Brittany Bohinc, MD, John Parker, MD, FACE, ECNU
markedly inaccurate fingerstick glucose readings.
     Case	Presentation: An 80 year old woman with dia-                   Objective: To describe a case of a malnourished,
betes mellitus type 2 for 39 years with neuropathy and              alcoholic presenting with features consistent with hyper-
coronary artery disease was admitted for management of              osmolar hyperglycemic state (HHS), but shown to have
atrial fibrillation. During her hospital stay, her finger- stick    undetectable serum c-peptide and diagnosed with ketosis-
(FS) glucose readings varied from 24 to 586 mg/dl. On               resistant diabetes mellitus (DM) type I.
physical exam, she had mild edema on her finger tips but                 Case	 Presentation: This is a 50-year-old white
no edema in her lower extremities. On the day of evalu-             female with history of uncontrolled DM type 2 diagnosed
ation, the patient’s FS glucose reading before dinner was           11 years prior (treated with oral hypoglycemics, initial
245 mg/dl. At 10:17 pm, initial FS glucose reading was              c-peptide 3.0 ng/ml), chronic alcoholism, and anorexia
46 and repeat was 231 mg/dl. At 1:45 am, the patient was            nervosa (BMI 13), who presented with generalized weak-
found to be unresponsive. The initial FS glucose reading            ness, fatigue, polyuria, polydipsia, nausea and vomiting.
at that time was 426 mg/dl. The patient’s repeat FS glu-            She had no abdominal pain. Lipase was normal at 164 U/L.
cose readings within several minutes of each other were             Her blood glucose measured 1965 mg/dL. Initial anion
24, 204, and 272 mg/dl. The patient was not assumed to be           gap was normal at 13. Osmolar gap was 21. Serum and
hypoglycemic and all measures were taken to resuscitate             urine ketones were negative. Arterial blood gas revealed a


                                                               – 56 –
                                         ABSTRACTS – Diabetes Mellitus

pH of 7.309 secondary to respiratory acidosis with normal       were recommended. Subsequent HgbA1c readings were
serum bicarbonate at 23 mmol/L. Hemoglobin A1c was              3.5%, 3.4% and 3.7% (at 4, 10, and 16 months after diag-
14.3%. She was initially diagnosed with HHS and was             nosis, respectively). At time of consultation, blood glucose
placed on an insulin drip and aggressive IV hydration. She      readings demonstrated fasting hyperglycemia (glucose
had a history of ongoing alcohol use and elevated lipase,       105-120 mg/dL) and 2-hour post prandial measurements of
so consideration was given to pancreatic DM and chronic         120-200 mg/dL. Our laboratory evaluation demonstrated
alcoholic pancreatitis. Because she was so malnourished         a total glycosylated hemoglobin of 5.7% (healthy adult
with BMI of 13, a contributing diagnosis of malnutrition-       range of 3.9-7.3%), fructosamine of 255 µmol/L (normal
modulated DM (MMDM) was entertained. C-peptide was              up to 285) and 1-5 anhydroglucitol of 7.1 µg/mL (normal
<0.1 ng/ml. Anti-glutamic acid decarboxylase (anti-GAD)         adult reference range 10.7-32.0). Hemoglobin electropho-
and anti-islet cell antibodies were undetectable. Imaging       resis revealed 50.9% hemoglobin variant pattern consistent
of the pancreas by computed tomography showed no dila-          with hemoglobin Raleigh (substitution of acetylated ala-
tion of pancreatic ducts or pancreatic mass but did show        nine for valine as the N-terminal amino acid on the ß-chain
severe pancreatic atrophy and calcification consistent          of hemoglobin), with only 46.6% of the total hemoglobin
with chronic pancreatitis. A 2-hour glucose tolerance test      comprised of hemoglobin A.
showed low c-peptide levels that were unable to be stimu-            Conclusion: HgbA1c has been validated as an excel-
lated by glucose load and growth hormone levels that were       lent indicator of long-term glycemic control in diabetes
suppressed from baseline after 2 hours. Glucagon levels         mellitus, but there are several causes of misleading results,
after glucose load were low. The patient was diagnosed          including hemolytic anemia, medication effects, and hemo-
with ketosis-resistant DM type I with hormonal features         globinopathies. A specific etiology should be sought under
consistent with chronic alcoholic pancreatitis.                 these circumstances. In our case, erroneously low read-
     Discussion: Ketosis-resistant DM type I is an under-       ings for HgbA1c can be encountered because the ß-chain
recognized diagnosis in the developed world. There are          of hemoglobin Raleigh cannot be glycated. Alternative
two clinical considerations including pancreatic DM (both       methods of assessing glycemic control, such as measuring
alcoholic and nonalcoholic/fibrocalculous pancreatic DM)        1-5 anhydroglucitol, fructosamine, with ongoing reliance
and malnutrition-modulated DM (MMDM). Our patient               on accurate capillary blood glucose measurements, were
had clinical features consistent with both chronic alco-        recommended.
holic pancreatitis and MMDM. Clinical features and hor-
monal workup as means of distinction will be described.         Abstract #275
In this case, chronic alcoholic pancreatitis led to ketosis-
resistance because of destruction of both insulin and glu-      ANTIOXIDANT EFFECT OF VITAMIN D ON
cagon-producing cells of the islets of Langerhans.              THE BETA CELL MAY CONTRIBUTE TO ITS
                                                                BENEFIT IN DIABETES THERAPY
Abstract #274
                                                                Vasile Mihai Bota, MD, Zhengke Wang,
HEMOGLOBIN RALEIGH: AN UNUSUAL CAUSE                            Fang Xiong, Hussain Naseri, MD,
OF LOW HEMOGLOBIN A1C MEASUREMENTS                              Janet Cevallos-Brennan, MD, Kenneth A. Greer,
IN TYPE 2 DIABETES MELLITUS                                     Luo Luguang, MD, PhD

Brittany Bohinc, MD, John Parker, MD, FACE, ECNU                     Objective: To evaluate the role of Vitamin D in
                                                                preventing beta cell oxidative stress and in promoting cell
	    Objective: To describe a case of a patient with type       survival and function.
2 diabetes mellitus who, despite high capillary blood glu-           Methods: INS-1 cell line, rat pancreatic beta cells
cose readings, was found to have persistently low hemo-         obtained from an Xray induced insulinoma were cultured
globin A1c (HgbA1c) measurements secondary to a rare            using RPMI 1640 medium, enriched with glucose,
hemoglobin ß-chain variant, hemoglobin Raleigh.                 pyruvate, mercaptoethanol, HEPES, penicillin and
     Method: Case report and literature review.                 streptomycin. Streptozotocin (STZ) was administered to
     Case	 Presentation: A 62-year-old white male was           induce beta cell oxidative stress . We then explored whether
diagnosed with diabetes mellitus approximately 16 months        1,25-dihydroxyvitamin D at a physiologic concentration
prior to endocrinology consultation. Evaluation at diag-        can reverse beta cell oxidation in this model. Insulin levels
nosis included 2-hour oral glucose tolerance test (fasting      were checked with Rat/Mouse ELISA kit (Millipore,
glucose of 137 mg/dL, 1-hour glucose of 269 mg/dL, and          EZRMI-13K), and the oxidative stress level was checked
2-hour glucose of 263 mg/dL) and HgbA1c of 4.2% (refer-         by measuring the oxidation reduction potential (ORP)
ence range 4.1-5.7%). Dietary and exercise interventions        with a 6230N JENCO meter.


                                                           – 57 –
                                         ABSTRACTS – Diabetes Mellitus

     Results: The supernatant was collected and analyzed         acid decarboxylase antibodies 8.72 U/mL, IA-2 antibod-
after 48 hours STZ and 1,25-dihydroxyvitamin D                   ies <0.8, TSH 1.88 mIU/L, amylase 54 U/L, and lipase 26
treatment. STZ at 45uM decreased insulin levels by 74%           U/L. The patient was discharged on insulin glargine and
compared with control. Concomitant treatment with                insulin lispro.
1,25-dihydroxyvitamin D improved insulin secretion                    Discussion: Fulminant T1DM is a recently described
by 13.9% (n=3, p<0.05). 1,25-dihydroxyvitamin D was              presentation of T1DM with rapid beta cell destruction and
able to partially improve cell function after STZ induced        subsequent development of hyperglycemia and ketoaci-
oxidative stress. We found that STZ alone increased              dosis that has been predominately reported in Japan and
the oxidative stress measured through ORP by 22%                 other Asian countries. The classical presentation includes
compared to control. After concomitant treatment with            rapid onset of ketoacidosis within one week of symptoms
1,25-dihydroxyvitamin D at a physiological concentration,        of hyperglycemia, with a near normal HbA1c and very
the level of oxidative stress induced by STZ was reduced         low level of c-peptide (fasting <0.3 ng/mL or non-fasting
by half (n=4, p<0.05).                                           <0.5 ng/mL). With the majority of cases being reported
     Discussion: Our previous study shows that 1,25-             from Asia, it has been hypothesized that there is a genetic
dihydroxyvitamin D benefits pancreatic beta cell insulin         determinant that predisposes Asian individuals to develop
release and might improve diabetes outcome. We now               fulminant T1DM. In our patient, the rapid onset of keto-
demonstrated that 1,25-dihydroxyvitamin D prevents the           acidosis within one week, a near normal hemoglobin A1c,
oxidative stress induced by STZ in pancreatic beta cell          and low level C- peptide were consistent with fulminant
culture and improves pancreatic beta cell function after         T1DM. However, in our patient, the beta-cell destruction
STZ induced oxidative stress. More investigations are            was not complete at time of diagnosis, which thus failed
needed in order to clarify the involved mechanisms.              to meet the published criteria used in the Asian literature
     Conclusion: Correcting Vitamin D deficiency in              to diagnosis fulminant T1DM. The slightly higher level
diabetic patients is definitely beneficial for their clinical    of c-peptide, though still insufficient, may reflect genetic
outcome. The antioxidant effect of Vitamin D on the beta         differences between Hispanic and Asian population.
cell may contribute to its benefit in diabetes therapy.               Conclusion: Even though our patient did not fit the
                                                                 strict laboratory criteria set in the Asian literature, she
Abstract #276                                                    did have the clinical presentation mimicking fulminant
                                                                 T1DM. The addition of this case to the medical literature
ABRUPT ONSET TYPE 1 DIABETES MELLITUS                            supports the need for expanding research in the field of
IN A HISPANIC WOMAN                                              fulminant T1DM.

Robert Andrew McCauley, MD, Sundeep Dhillon, MD,                 Abstract #277
Xaingbing Wang, MD, PhD
                                                                 SQUAMOUS CELLCARCINOMACOMPLICATING
     Objective: To present a case of abrupt onset type 1         CHRONIC DIABETIC FOOT ULCER
diabetes mellitus (T1DM) mimicking fulminant T1DM in
a young healthy Hispanic female.                                 Innocent Onoja Okpe, MBBS, Muazu I. M. MBBS, FMCP,
     Case	Presentation: A previously healthy 18 year old         Felicia Anumah, MBBS, FMCP
Hispanic female with no recent history of infections pre-
sented with one week of fatigue, polydipsia, polyuria and        	   Objective: Malignant degeneration of ulcers and scars
weight loss. Routine blood work in the outpatient setting        has been recognized since the 19th century. Jean Nicholas
showed elevated blood glucose of 934 mg/dL. Evaluation           Marjolin first described an indolent ulcer arising in burns
in emergency department revealed the following labora-           scar in 1828. Malignant transformation of diabetic foot
tory values: sodium 133 mEq/L, potassium 3.9 mEq/L,              ulcer though rare has been documented in literature as
chloride 98 mEq/L, bicarbonate 10.5 mEq/L, blood urea            well. This is a case report showing occurrence of this
nitrogen 9 mg/dL, creatinine 1.1 mg/dL, with a calculated        malignant ulcer presenting as an ulceration of the foot.
anion gap of 24.5 mEq/L and arterial pH 7.24. Urinalysis             Case	Presentation: A 62 year old diabetic who was
showed 3+ ketones and 3+ glucose. The patient was diag-          diagnosed 2 years earlier was referred to our center with
nosed with diabetic ketoacidosis and started on IV hydra-        an 11 month old non-healing right planter ulcer, following
tion and an insulin infusion at 0.1units/kg/hr. Within 12        a minor penetrating injury he sustained while walking bare
hours her anion gap had closed and she was transitioned to       footed. On presentation he was chronically ill-looking
a basal/bolus insulin regimen. Additional laboratory eval-       and cachectic, had mild pallor and there was evidence of
uation showed: HbA1C 6%, C peptide 0.6 ng/mL, insulin            peripheral vascular disease. Glycemic control was fair. He
antibodies <0.4 U/mL, islet cell antibodies <1:4, Glutamic       had a Wagners grade iv ulcer. Concerned at the patient’s


                                                            – 58 –
                                        ABSTRACTS – Diabetes Mellitus

lack of response to conventional therapy, surgical evalua-     unclear and further research needs in order to determine
tion was requested. X-ray of the foot showed osteopenia        the clinical implications of our findings.
but no periosteal reaction to suggest osteomyelitis. The             Conclusion: Consequently Vitamin B12 measure
surgeons suggested wound debridement with incisional           should be considered as a screening test and the differen-
biopsies and culture. He developed regional lymphade-          tial diagnosis when managing diabetes comorbidities.
nopathy Biopsy results returned as a well differentiated
squamous cell carcinom.                                        Abstract #279
	    Discussion: The exact cause of marjolins ulcer is
not known, but chronic irritation has been suggested as        FLATBUSH DIABETES:
a major factor leading to the initiation of carcinomatous      NOT ALL DKA IS TYPE 1 DM
process . The exact duration of exposure to such irritation
required to cause a malignant transformation of a benign       Naga M. Yalla, MD, Nicole Dombrowski, DO,
ulcer is not clear, although most cases of malignant trans-    L. Raymond Reynolds, MD, FACP, FACE
formation reported in literature occur in long standing
ulcers of over 10 to 15 years. The patient reported here       	    Objective: To describe a case of ketosis-prone diabe-
had his ulcer for only 14 months before the diagnosis of       tes mellitus (KPD) in a South Asian male who presented
squamous cell carcinoma was made. The treatment option         with diabetic ketoacidosis but was able to discontinue
for this patient was surgery and radiotherapy but there was    insulin therapy five months later.
a delay in commencing either because of lack affordability     	    Case	 Presentation: A healthy 31 y/o male South
of the cost of treatment. He however finally had a BKA,        Asian graduate student presented to the student health
although he died a week after surgery from aneamia attrib-     clinic with an unexplained 50 lb. weight loss over 6
utable to the malignant condition.                             months, polyuria and polydipsia for 2 months, and fatigue
	    Conclusion: Malignancy should be considered in the        with minimal oral intake for 5 days. His father had type
diagnosis of foot ulcers in patients with diabetes espe-       2 diabetes. Physical exam revealed a BMI of 20 kg/m2
cially when they are chronic and refractory to conven-         and mild tachycardia. Blood glucose was 363 mg/dl, anion
tional treatment.                                              gap was elevated at 20, bicarbonate was 10 (23-31), and
                                                               urinalysis revealed 4+ ketones. HbA1c was 15.4%. The
Abstract #278                                                  patient was diagnosed with DKA and starvation ketosis.
                                                               Given his hemodynamic stability, the patient was treated
THE PREVALENCE OF VITAMIN B12 AND FOLIC                        as an outpatient with NovoLog 70/30®. Islet cell and glu-
ACID DEFICIENCY IN DIABETIC PATIENTS IN A                      tamic acid decarboxylase antibodies were negative, and
GENERAL HOSPITAL                                               C-peptide level was 7.1 ng/ml (1.0-4.4). Two months later,
                                                               the patient had markedly improved glycemic control and
Helard Andres Manrique, MD, Pedro Alberto Aro, MD,             occasional hypoglycemia requiring insulin dose reduc-
Rubelio Enrique Cornejo, MD, Miguel Pinto, MD,                 tion. At his five-month visit, insulin was discontinued
Jose Solis, MD, Angel Escalante, MD                            due to ongoing hypoglycemia and HbA1c of 6.1%. Three
                                                               months later, the patient remained euglycemic off insulin
     Objective: To determine the prevalence of vitamin         therapy.
B12 and folic acid in diabetic patients.                       	    Discussion: In 1994, Banerji et al. described a sub-
     Methods: A cross sectional study of 115 type 2 dia-       set of African-Americans who presented with DKA
betes outpatients was performed at Arzobispo Loayza            without autoimmune markers and were eventually able
Hospital during 2007. Deficiency of serum vitamin B12          to discontinue insulin. This presentation of KPD was
and folic acid were defined as <211 pg/ml and <5.38 ng/        termed Flatbush diabetes after the area in New York City
ml, respectively. Were excluded patients with kidney dys-      where the patients resided. KPD was thought to be preva-
function, ongoing antifolate drugs, and pregnancy.             lent only in African-Americans and Afro-Caribbeans.
     Results: The average age was 57.85 ± 8.51 years,          However, case series reveal that KPD can affect multiple
80% were female and the mean time of type 2 diabetes           ethnic groups, including South Asians. A widely utilized
was 7.52 ± 5.58 years; 64% were taken oral antidiabetic        classification scheme for KPD is the auto-immunity and
medication (sulfonylurea, biguanide or both), 73% had          b cell function system proposed by Maldanado et al in
serum glucose >110 mg/dl and 66% hemoglobin A1c                2006. Our patient was A-b+, indicating the absence of
>7%; 72% had vitamin B12 and 23% folic acid deficiency.        b cell autoimmunity and the preservation of b cell func-
     Discussion: Vitamin B12 deficiency in type 2 diabe-       tional reserve. Approximately 50% of these patients have
tes is very frequent in our population, the reason remains     new-onset diabetes and develop DKA without a clinically



                                                          – 59 –
                                         ABSTRACTS – Diabetes Mellitus

evident precipitating factor. Severe glucotoxic blunting of     mechanism of malabsorption, raising the question of
an intracellular pathway leading to insulin secretion may       whether there is a similar relationship between metformin
contribute to the reversible b cell dysfunction characteris-    and vitamin D levels in these patients. In addition, older
tic of A-b+ patients.                                           and elderly patients also suffer from diabetes mellitus type
	    Conclusion: It is important to remember that not all       2, and many are simultaneously afflicted with osteoporo-
patients presenting with DKA have type 1 DM. KPD,               sis. If vitamin D was affected similarly to vitamin B12
although previously rarely described in South Asians, is        by metformin, this population could be directly impacted.
increasingly being recognized in multi-ethnic populations.      Based on the results of this study, the relationship between
Often, these patients are able to discontinue insulin ther-     metformin use and vitamin B12 deficiency does not appear
apy over time making appropriate recognition and close          to extend to vitamin D.
follow-up extremely important.                                       Conclusion: This study confirms vitamin B12 defi-
                                                                ciency in metformin treated type 2 diabetic patients. This
Abstract #280                                                   study also suggests that vitamin D deficiency is not a clini-
                                                                cal concern among metformin treated type 2 diabetics. In
THE EFFECT OF METFORMIN THERAPY ON                              addition, metformin does not negatively impact treatment
VITAMIN D AND B12 LEVELS IN PATIENTS                            of vitamin D deficiency in these patients.
WITH DIABETES MELLITUS TYPE 2.
                                                                Abstract #281
Elizabeth Kos, MS, Mary Jo Liszek, MD,
Mary Ann Emanuele, MD, Ramon Durazo, PhD,                       THE ASSOCIATION OF ENDOTHELIAL
Pauline Camacho, MD                                             DYSFUNCTION AND LEFT VENTRICULAR
                                                                DIASTOLIC DYSFUNCTION AND THE
	    Objective: To determine the effect of metformin on         PRESENCE OF COMPLICATIONS IN PATIENTS
vitamin D and B12 levels in patients with diabetes mel-         WITH DIABETES MELLITUS TYPE 2
litus type 2.
     Methods: We conducted a retrospective chart review         Zarina Guevarra Lorenzo, MD,
of 706 consecutive patients with diabetes mellitus type 2       Maureen V. Valentin, MD,
treated at the Loyola University Medical Center between         Maria Honolina S. Gomez, MD
2003-2009. Statistical methods were used to show any
associations between various demographic, anthropomor-                Background/Objective: Endothelial and diastolic
phic, and biochemical measures.                                 dysfunctions are common in patients with diabetes melli-
     Results: A total of 706 patients ranging in age from       tus (DM) type 2 making them at higher risk for cardiovas-
20-93 with diabetes mellitus type 2 were identified for this    cular events. However, these 2 conditions may be clini-
study. The mean age was 63 +/- 13 and the mean BMI              cally silent thus early detection is important. Hence, the
was 33.1. 34% of these patients were on metformin with          determination of the association of these two conditions in
a mean dose of 1.5 g per day. 35% of these patients had         DM type 2 patients is relevant.The main objective of this
been diagnosed with osteoporosis or osteopenia. The             study was to determine the relationship between endothe-
results of previous studies regarding metformin use and         lial dysfunction and left ventricular diastolic function in
vitamin B12 deficiency were confirmed with statistically        patients with DM Type 2.
significant lower baseline vitamin B12 levels in those                Methods: A total of 56 Filipino patients with DM
on metformin therapy. This relationship was not shown           type 2 were included in the study who followed up at
with vitamin D levels, as we found no difference in vita-       the Department of Medicine, University of Santo Tomas
min D levels regardless of metformin use and dose when          Hospital, Espana, Manila from June-October 2008.
adjusted for age, sex, and BMI. Use of metformin also did       Endothelial function, measured by flow-mediated dilata-
not adversely affect treatment of vitamin D deficiency in       tion of the brachial artery using ultrasound, was calcu-
this patient subset. As a secondary endpoint, we found that     lated in the two groups. Left ventricular diastolic func-
those with osteoporosis had statistically significant lower     tion was assessed by classical methods of pulse and tissue
baseline vitamin D levels compared to those without when        doppler imaging. Peak early (E) and late (A) transmitral
adjusted for all variables, and metformin use did not affect    filling velocities, their ratio (E/A) and deceleration time
the treatment of vitamin D deficiency in these patients.        of the mitral E wave (DT), LV isovolumetric relaxation
     Discussion: Metformin is a widely used therapy for         time (IVRT) and pulmonary vein atrial flow reversal (Pa)
the treatment of diabetes mellitus type 2. Various studies      were all calculated by Doppler echocardiography. The
have demonstrated a causal relationship between met-            early diastolic mitral annular velocity (E’) and late dia-
formin use and vitamin B12 deficiency with a proposed           stolic mitral annular velocity (A’) were also measured


                                                           – 60 –
                                        ABSTRACTS – Diabetes Mellitus

using tissue Doppler imaging (TDI). The E’/A’ ratio was        level below 7%. There was no significant decline in body
calculated.                                                    weight (P 0.07; Fig. 2). The basal insulin dosage showed
	    Results: A total of 17 (30%) had endothelial dys-         a nonstatistical decrease (P 0.08; Fig. 3). Glycemic excur-
function. E’/A’ and Pa were positively correlated with         sions also declined significantly after patients were started
FMD with (r= 0.325, p =0.015) and (r= 0.248, p= 0.036),        on CSII (Fig. 4). Hypoglycemic episodes were noted in
respectively. FMD negatively correlated with HbA1c (r =        only two patients <60mg/dL. However, no episodes were
-0.374, p = 0.005) regardless of the presence or absence of    reported to required assistance or hospitalization.
microvascular complications.                                   	    Discussion	and	Conclusion: In our study, eight out
     Conclusion: Flow-mediated dilatation is negatively        of ten patients had an improvement in plasma glucose
associated with HbA1c regardless of the presence or            concentrations with a fall in A1c levels and three patients
absence of microvascular complications. It is likewise         achieved A1c goal of <7%. CSII resulted in improvement
correlated with several parameters of diastolic dysfunc-       of A1c and potential reduction in diabetes-related com-
tion such as E’/A’, Pa and IVRT.                               plications. CSII is an alternative option for patients with
                                                               T2DM who have not met glycemic control goals with use
Abstract #282                                                  of standard insulin regimen.

USE OF INSULIN PUMP IN TYPE 2 DIABETES                             Abstract #283

Nitin Trivedi, MD, Pearl Dy, MD,                                   HYPOGLYCEMIA IN PATIENTS WITH TYPE
Patachaya Boonchaya-anant, MD                                      1 DIABETES MELLITUS INCORPORATING
                                                                   PRANDIAL INHALED TECHNOSPHERE-INSULIN
     Objective: Despite availability of large numbers of           INTO THEIR USUAL ANTIHYPERGLYCEMIC
antidiabetic agents in the United States, about 67% of             REGIMEN VS CONTINUING THEIR USUAL
patients with type 2 diabetes mellitus (T2DM) are unable           ANTIHYPERGLYCEMIC CARE
to achieve glycosylated hemoglobin A1c (A1c) below the
American Diabetes Association target of less than 7%.              Philip Raskin, MD, FACE, Martin Phillips, MD,
Ideally the multiple dose insulin regimen should mimic             Ping-Chung Chang, MS, Alicia Rossiter, MD,
the physiologic insulin secretory pattern. Even after using        Peter C. Richardson, MD
basal bolus regimen with analogue insulin mimicking
endogenous insulin secretion may not be possible. Insulin      	    Objective: Technosphere® Insulin (TI) is an ultra
delivery using continuous subcutaneous insulin infusion        rapid-acting inhaled insulin with a pharmacokinetic pro-
(CSII) using insulin pumps is perhaps the closest to the       file well suited for control of postprandial plasma glucose.
physiological insulin secretion. CSII is well accepted way     This is to report the results of prespecified secondary
for insulin treatment in patients with type 1 diabetes mel-    safety endpoints from MKC-TI 030, a prospective, multi-
litus (T1DM). In this retrospective analysis we studied the    site parallel-group study comparing the efficacy and safety
efficacy of insulin pumps in patients with T2DM in an out-     of prandial TI vs usual diabetes care (UC) in patients with
patient setting who are unable to achieve optimal glucose      type 1 diabetes mellitus and inadequate glycemic control
control despite multiple subcutaneous doses of insulin.        (HbA1c 6.6% and £12.0%) despite subcutaneous insulin
	    Methods: In this study we preformed analysis of data      therapy.
by reviewing patient charts. From the database of our          	    Methods: Subjects with type 1 diabetes were ran-
patients we found that 10 patients T2DM (6 men and 4           domly assigned to a 2-year diabetes treatment regimen
women) were started on an insulin pump. All oral antidia-      consisting of prandial TI plus subcutaneous basal insulin
betic medications were discontinued with the exception of      (TI group, n=267) or usual diabetes treatment regimens
metformin when the patients were started on CSII. During       of any insulin (subcutaneous basal and/or prandial), the
the first 4-8 weeks, the pump settings were adjusted every     UC group (n=271). Insulin doses were adjusted accord-
1-2 weeks. Thereafter the patients were encouraged to          ing to investigator discretion to achieve glycemic goals
follow every 2-3 months with their endocrinologist. The        established by the American Diabetes Association and the
pump adjustment was performed only by one endocri-             American Association of Clinical Endocrinologists; they
nologist for all the patients. Efficacy was assessed using     were not instructed to follow a protocol-specified insulin
HbA1c values and blood glucose profiles. Glycemic              dose titration regimen. Prespecified endpoints included
excursions and hypoglycemic episodes before and up to 6        change in HbA1c, change in body weight, and frequency
months of starting on an insulin pump were analyzed.           of defined mild, moderate, and severe hypoglycemia.
	    Results: A1c showed significant decline from base-        	    Results: Mean baseline characteristics were similar
line (P 0.03; Fig. 1). Three patients achieved HbA1c           between the TI and UC groups: mean age 40.0, 39.4 years;


                                                          – 61 –
                                         ABSTRACTS – Diabetes Mellitus

diabetes duration 15.7, 15.1 years; baseline HbA1c 8.7%,        SNP with aspirin non-responder was assessed by compar-
8.5%; and BMI 26.3, 26.3 kg/m2, respectively. The aver-         ing the allele frequencies of each SNP using chi-square
age daily dose in the TI group was 138.3±61.6 U (roughly        analysis. Then the associated SNPs from test cohort were
20% bioavailability relative to rapid-acting analog). Basal     confirmed in the validation cohort. All subjects received at
insulin therapies were similar in both groups. At the 2-year    least 60 mg of ASA.
time point, there was comparable reduction in HbA1c (by         	    Results:	Six subjects in the test cohort were aspirin
0.29% and 0.31% in the TI and UC groups, respectively).         responders (6.2%), and 66 subjects were non-responders
TI resulted in weight loss, while UC resulted in weight         (68%). Most of the subjects with aspirin non-respond-
gain (-0.59 vs +1.38 kg, respectively; p=0.0007). Overall       ers were male (83.3%vs48.8%, p=0.04), and had higher
event rates were 0.86/subject-month for the TI group (2.36      hemoglobin levels (14.2+0.5vs12.9+0.1 g/dl, p=0.03), and
severe events/100 subject-months) vs. 0.70 for the UC           greater waist to hip ratio (0.96+0.02vs0.90+0.01, p=0.02).
group (3.76 severe).                                            Higher frequency of T allele of c.1138T>C of TBXA2R
	    Conclusion: Diabetes treatment regimens containing         was found in subjects with ASA non-responder defined by
prandial TI resulted in HbA1c reductions that were compa-       AA criteria (0.97vs0.80, p=0.03) in test cohort. This find-
rable, weight loss, and less hypoglycemia in patients with      ing was subsequently confirmed in the validation cohort
type 1 diabetes mellitus and inadequate glycemic control        (0.86vs0.74, p=0.02). Subjects with TT genotype had
compared with conventional diabetic regimens utilizing          significantly greater platelet aggregation induced by AA
subcutaneous prandial insulin.                                  than those with CT and CC genotype. TBXA2R encodes
                                                                thromboxane receptor, therefore our finding was biologi-
Abstract #284                                                   cal plausible.
                                                                	    Conclusion: We demonstrate the association of
ASSOCIATION OF GENETIC POLYMORPHISMS                            higher hemoglobin levels, male gender, central obesity
OF THE PLATELET GLYCOPROTEINS AND                               and T allele of c.1138T>C of TBXA2R gene with aspirin
PLATELET RECEPTORS WITH ASPIRIN                                 resistant state in Thais. This finding may be useful for the
RESPONSIVENESS IN THAI TYPE 2 DIABETES                          pharmacogenetic test before prescribing aspirin to the
                                                                high risk patients.
Wallaya Jongjaroenprasert, MD,
Aruchalean Taweewongsoontorn, Napatorn Artchararit,                 Abstract #285
Katcharin Ar-urachai,
Boonsong Ongphiphadhanakul, MD                                      PROFILE OF NIGERIANS WITH
                                                                    DIABETES MELLITUS
     Objective:	Underlying genetic background has been
proposed for aspirin responsiveness. This study was to              Andrew Enemako Uloko, MD, Esther Ofoegbu, FWACP,
examine the genetic susceptibility to aspirin response in           Anthonia O. Ogbera, FMCP, FACE,
Thai type 2 diabetes patients.                                      Sunday Chinenye, MBBS, FWACP,
     Methods: Two cohorts of subjects from Ramathibodi              Olufemi Fasanmade, MBBS, FWACP, FACE,
Hospital were recruited; the test and the validation group.         Adesoji Fasanmade, FWACP,
Ninety seven of diabetic patients were recruited as the test        Ogugua Osi-Ogbu, FWACP
cohort and 204 subjects with coronary disease were the
validation cohort. All received aspirin for at least 2 weeks             Objective: Diabetes mellitus (DM) is the commonest
prior entering our study. Response to aspirin was assessed          metabolic condition and one of the most prevalent non-
using the optical platelet aggregation test induced by 10           communicable diseases in Nigeria. There is paucity of
µM adenosine diphosphate (ADP) and 0.5 mg/ml arachi-                data on the actual prevalence of DM, its complications,
donic acid (AA). From the aggregation results, responder,           and quality of care. We aimed to assess the clinical and
semi-responder and non-responder to aspirin were defined            laboratory profile, and evaluate the quality of care of
according to Gum’s cut-off criteria (% aggregation by               Nigerian diabetics.
ADP >70%, % aggregation by AA >20%). Four single                         Methods: In a multicentre study spanning 6 months
nucleotide polymorphisms (SNPs) of platelet glycopro-               across seven tertiary health centers (diabetes clinics) in
teins and platelet receptors (c.893C>T of P2Y1 gene, the            Nigeria, the clinical and laboratory parameters of dia-
Kozak T>C polymorphism at -5 position, and variable                 betics were evaluated. Some clinical parameters studied
number of tandem repeats of GP1BA, and c.1138T>C of                 include type of diabetes, anthropometry, history of hyper-
TBXA2R) were genotyped individually in test cohort. The             tension, dyslipidaemia, blood pressure (BP), chronic com-
correlation of clinical parameters and aspirin responsive-          plications of DM and treatment types. Laboratory data
ness was analyzed by unpaired t-test. The association of            assessed included fasting plasma glucose (FPG), 2-hour


                                                           – 62 –
                                         ABSTRACTS – Diabetes Mellitus

post-prandial (2-hr pp) glucose, glycated hemoglobin                  Methods: A total of 289 newly diagnosed T2D sub-
(HbA1c), urinalysis, serum lipid profile, electrolytes, urea     jects (male 46%, female 54%, age 45+9 years, mean +SD)
and creatinine.                                                  were selected from different health care centers of Capital.
     Results: A total of 531 patients; 39.5% males and           Data were collected by a pre-designed, pre-tested, inter-
60.5% females enrolled. The mean age of the patients             viewer-administered questionnaire. The responses regard-
was 57.1±12.3 years with mean duration of DM 8.8±6.6             ing all knowledge and practice were coded as 1 (correct
years. Majority had type 2 DM (95.4%) compared to type           ans) and 0 (wrong ans). Five point Likert scale was used
1 DM (4.6%), p < 0.001. The mean FPG, 2-hr pp glu-               to assess attitude.
cose and HbA1c were 8.1±3.9 mmol/L, 10.6±4.6 mmol/L                   Results: The score of kAP among the study subjects
and 8.3±2.2 % respectively. Only 170 (32.4%) and 100             were 23±5, 126±9 and 11±3 (mean ±SD) respectively.
(20.4%) patients achieved the ADA and IDF targets                KAP scores did not differ in various age, sex and habi-
respectively. Most of the patients do not have glucom-           tat groups. Compared to the illiterate group (19.02±4.3)
eters (72.8%) and never practice self monitoring of blood        the knowledge score was higher in primary (21.7±4.3,
glucose (73.2%). Concomitant hypertension was found in           p<0.0001), secondary (24.3±4.5, P<0.0001) and gradu-
322 (60.9%), mean systolic BP 142.0±23.7 mmHg, dia-              ate (25.7±3.7, p<0.0001) groups. Practice score of illit-
stolic BP 80.7±12.7 mmHg. Chronic complications of               erate group (9.5±3.3) was lower than the graduate group
DM found were peripheral neuropathy 59.2%, retinopathy           (11.4±3.1, p<0.01). Attitude did not differ between any
35.5%, cataract 25.2%, stroke 4.7%, diabetes foot ulcers         two of the four educational groups. The score of knowl-
16.0%, and nephropathy 3.2%.                                     edge regarding diabetes were significantly positively
     Discussion: Diabetes mellitus in Nigeria is now an          correlated with attitude (r= 0.18, p=0.002) and practice
epidemic with numerous clinical and social consequences.         (r=0.42, p=0.0001) score. Age, sex, education, occupa-
The poor quality of glycemic control observed in this study      tion, monthly income, location and family history of
is not different from other parts of the world where similar     diabetes and acquisition of information were tested in
studies were carried out recently. As in most resource-con-      a multiple regression model with the KAP score values
strained third world countries, availability and ownership of    as dependent variables entered separately. None of the
personal glucose meters by our ever-increasing number of         independent variables, except education and acquisition
diabetic patients for their self monitoring of blood glucose     of information, showed any significant association with
remains a practical challenge. More advocacies by profes-        KAP scores. Education (ß= 0.39, p=0.0001 and ß= 0.17,
sional bodies and non-governmental organizations as well         p=0.007 respectively) showed a significant positive asso-
as funding for diabetes care and education will improve the      ciation with knowledge and practice score. Acquisition of
quality of life of Nigerian diabetics substantially.             information had also significant association with knowl-
     Conclusion: Most Nigerian diabetics have sub-               edge (ß= 0.18, p=0.001) and attitude score (ß= 0.14,
optimal glycemic control, concomitant hypertension               p=0.01). A significant association was found between total
and chronic complications of DM. Improved quality of             practice and knowledge score (β= 0.42, p= 0.0001) in this
care and treatment to target is recommended to prevent           model.
DM-related morbidity and mortality.                                   Conclusion: Education and acquisition of infor-
                                                                 mation seem to be the most important determinants of
Abstract #286                                                    knowledge which, in turn, is the main factor behind good
                                                                 attitude and practice. A coordinated development policy
KNOWLEDGE, ATTITUDE AND PRACTICE                                 is required to promote knowledge and attitude on healthy
AMONG NEWLY DIAGNOSED BANGLADESHI                                lifestyle and to translate those into practice.
T2D SUBJECTS ATTENDING VARIOUS
DIABETES CARE CENTERS
                                                                 Abstract #287
Fazlarabbi Khan, MBBS, Prof, MD,
Faruque Pathan, MBBS, MD, FACE,                                  PREVALENCE OF DIABETIC NEUROPATHY IN A
Anisur Rahman, MD                                                HOSPITAL POPULATION OF 2,031 PATIENT FOR
                                                                 A PERIOD OF 18 YEARS
     Objective: Evidence based design of diabetes educa-
tion programs need an understanding of the knowledge,            Zdravko Asenov Kamenov, MD, PhD,
attitude and practice (KAP) of the respective community.         Rumyana Parapunova, MD, Rumyana Georgieva
The aim of the present study was to study the levels of
KAP of the newly diagnosed type 2 diabetic subjects in           	    Objective: To evaluate the prevalence of diabetic neu-
the context of demographic and socioeconomic factors             ropathy DN in a hospital population with diabetes (DM) in
associated with the subjects.                                    a time course of 18 years.
                                                            – 63 –
                                         ABSTRACTS – Diabetes Mellitus

      Methods: This retrospective study was carried out          Abstract #288
in a University clinic of endocrinology in the Medical
University in Sofia. Analysis of the patient hospital records    EFFICACY OF SALSALATE IN BRACHIAL
was applied. The time interval covered 1990-2007 years           FLOW-MEDIATED DILATION IN DIABETES
divided in four periods, starting every 5 years and lasting
for 3 years. The patients were included in the electronic        Noushin Khalili Boroujeni, MD,
database only during their first admission to the hospi-         Elham Faghih Imani, MD, Masoud Amini, MD,
tal. Presence of DN was accepted if one of the following         Shaghayegh Haghjoo, MD, Mohamad Saadatnia, MD
was present: final diagnosis “DN” and/or symptoms of
DN and/or positive instrumental investigation including          	    Objective: Obesity and fat deposition in tissues along
EMG.                                                             with inflammatory response may induce insulin resistance
      Results: 2,031 records were analyzed - DM2/DM1 =           and finally type 2 diabetes mellitus Salsalate, a prodrug
83.9/16.1%; female/male = 1130/901; mean age (mean ±             form of salicylate can inhibit IKKβ and NF-kappaB
SD) = 55,6 ± 15,7 (DM2 = 60,0 ± 11,9; DM1 = 32,9 ± 13,4)         inflammatory pathway as a potential pharmacologic tar-
years; mean diabetes duration of 9,9 ± 8,8 (9,9 ± 8,4 and        get in diabetes. The aim of this study was to determine
10,2 ± 10,9 respectively) years. There was no difference in      the efficacy of salsalate as an anti-inflammatory drug to
HbA1c by gender and type of diabetes. The prevalence of          resolve endothelial dysfunction in diabetic patients.
DN was 75.7% (DM2 = 78.8; DM1 = 59.2; p<0.001), dif-             	    Methods: This was a double blind controlled trial
fering in the course of the periods, and correlating signifi-    study. Forty newly diagnosed type 2 diabetic patients (30
cantly with the rate of application of EMG and semi-quan-        to 45 years of age) were randomized in the drug and pla-
titative instrumental somatic neuropathy diagnostic tests        cebo groups. The drug group received 3g Salsalate per day
(modified Neuropathy Disability Score) and/or the test           (two 750 mg tablets every 12 hours orally) for one month.
for sudomotor autonomic dysfunction - Neuropad. When             The placebo group received identical placebo. Fasting
analyzing the abnormal results of EMG we found out that          plasma glucose level was assessed in two groups before
the sensory disturbances were most common (91,2%), fol-          and after treatment period. Endothelial function was
lowed by the motor ones (77,0%) and the combination of           assessed via flow mediated dilation (FMD) of the brachial
sensory and motor disturbances (76,3%). Least common             artery following reactive hyperemia before and after treat-
was the mononeuropathy (8%). Patients with DM2 and               ment period in two groups.
DN were about 4 years older (60.8 ± 11.5), compared to           	    Results: Thirteen patients in the drug group and 15
those without DN (56.8 ± 13.2; p<0.001). This age differ-        ones in the placebo group finished the study. At baseline,
ence was 8.8 years in patients with DM1 (36.5 ± 14 vs.           there was no significant difference in mean fasting plasma
27.7 ± 10.6; p<0.001). Groups with and without DN did            glucose level (120 vs. 122 mg/dl, P = 0.621) and FMD
not differ in HbA1c (9.0 ± 2.1 vs. 9.2 ± 2.4%).                  (10.5 ± 5.2 vs. 10.2 ± 5.4%, P= 0.19) between drug and
      Discussion: Data about prevalence of DN worldwide          placebo groups, respectively. Salsalate reduced the fasting
differ from 10 to 90% depending on the population and            glucose level in the drug group (18mg/dl) significantly, in
diagnostic criteria. The prevalence of DN in our study was       comparison with the placebo group (P < 0.05). At the end
in the higher range because of the broad diagnostic criteria     of the trial, FMD in the salsalate and placebo group was
including EMG, hospital population, poor diabetes con-           11.5 ± 5.6 vs. 10.1 ± 5.3%, respectively (P = 0.09).
trol. In the community DN is largely neglected by both the       	    Discussion: This study showed that daily use of 3
physician and the patient, complaining usually on posi-          grams salsalate for one month reduced 15.5% of baseline
tive symptoms like pain, but not on the loss of sensation,       blood glucose level in diabetic cases. However, endothe-
which represents the actual risk for amputation. Careful         lial dysfunction did not change significantly. It might be
neurological examination is essential for early recognition      because of the short duration of the study. We suggest fur-
and more effective treatment of DN.                              ther studies with longer treatment duration and control-
      Conclusion: DN has a high prevalence, but for its          ling other factors of insulin resistance, should be done to
identification a complex diagnostic approach including           investigate the role of salsalate in resolving the endothelial
instrumental methods, is necessary.                              dysfunction in diabetic patients.
                                                                 	    Conclusion: These data demonstrate that salsalate
                                                                 improves glucose homeostasis, but endothelial dysfunc-
                                                                 tion did not change.




                                                            – 64 –
                                         ABSTRACTS – Diabetes Mellitus

Abstract #289                                                        cell function. We conclude that A1c overestimates glyce-
                                                                     mic burden in black subjects, and may be inappropriate for
HBA1C AS A PREDICTOR OF GLYCEMIC                                     diagnosis of diabetes in that population.
BURDEN IN AFRICAN AMERICANS AND
CAUCASIANS                                                           Abstract #290

Samuel Dagogo-Jack, MD, FACE,                                        IMPACT OF A NIGERIAN TERTIARY DIABETES
Chimaroke Edeoga, MD, MPH,                                           CENTER ON PSYCHOSOCIAL DISTRESS IN
Nonso Egbuonu, MD, Emmanuel Chapp-Jumbo, MD                          TYPE 2 DIABETES MELLITUS PATIENTS

	     Objective: There is emerging data on ethnic dispari-           Itunuoluwa Yewande Oshungbohun, MBCHB,
ties in the relationship between A1c and glycemic burden             Adekunle Adeyemi-Doro, MBBS,
among subjects with diabetes or pre-diabetes. However,               Olufemi Fasanmade, MBBS, FWACP, FACE
it is not known whether such disparities extend to healthy
nondiabetic subjects or whether genetic risk for diabetes            	    Objective: To assess the level of impact of a tertiary
plays a role. We therefore analyzed A1c levels in relation           diabetes centre on the psychosocial distress of patients
to glycemia and glycemic predictors in our unique cohort             with type 2DM
of nondiabetic African Americans (AA) and Caucasians                      Methods: A Cross sectional study was carried out in
(C) who are offspring of diabetic parents.                           the DM clinic of the Lagos University Teaching Hospital
	     Methods: We studied 234 subjects (104 C, 130 AA),              Nigeria, a tertiary health care centre with two sample
all of whom have a parental history of type 2 diabetes.              groups of 25 patients each (T2DM patients). The first
None of the subjects had a history of diabetes or predia-            group comprised of newly referred patients (NRP) and
betes, or use of medications that alter glucose metabo-              the second of patients with regular clinic attendance for
lism. Each subject underwent standard anthropometric                 > 1year (RCA). Baseline demographic data: age, gender,
measurements (weight, height, waist circumference) and               and duration of DM were obtained. The Diabetes Distress
completed a 75g Oral Glucose Tolerance Test (OGTT)                   Scale questionnaire assessing DM specific psychosocial
after an overnight fast and had a second measurement of              burden with four subscales “emotional burden, physician-
fasting plasma glucose (FPG) ~45 days from the date of               related distress, regimen-related distress and interpersonal
OGTT. Blood glucose and insulin levels were assessed at              distress” was administered to both groups. The data was
fasting, 30min and 120min, and HbA1c levels were also                analyzed using SPSS version 16. Statistical significance
measured. The area-under-the-curve (AUC) for glucose                 was set at p < 0.05.
during OGTT was determined by the trapezoidal rule, and                   Results: Demographic properties between the two
insulin resistance and b-cell function were assessed using           groups were similar. The NRP group had a mean age of
the homeostasis model (HOMA) method.                                 55.3 (+\- 8.25) while the RCA group had mean age of 57.1
	     Results: The mean (+ SD) HbA1c level was 5.63                  (+\- 7.4) p=0.42. The mean duration of diabetes in years
+ 0.48% in African Americans and 5.45 + 0.33% in                     in both groups was 8 (+\-6.9) and 7 (+\-6) respectively
Caucasians (P <0.0001). The African American and                     (p=0.6). The Diabetes distress score (polonsky et al 2005)
Caucasian subjects had similar FPG values (mean + SD:                was assessed, the overall mean score for the NRP group
91.9 + 6.20 mg/dl vs. 93.6 + 6.00 mg/dl, P = 0.12), BMI              was 2.0 (+\- 1.03) the RCA group had a distress score of
(BMI AA 31.2 + 7.30 vs. C 28.2 + 6.50 kg/m2, P = 0.10)               1.8 (+\-1.2) (p=0.5). In the sub-analysis of the four sub-
and waist circumference (94.6 + 14.4 vs. 91.3 + 15.3 cm,             scales the RCA group had higher mean “emotional bur-
P = 0.081). Both groups also were similar in age (AA 42.8            den” (RCA 2.7 (+/-1.1) vs. NRP 2.3 (+/- 1.5), P=0.29) and
+ 9.5 y, C 47.3 + 10y, P=0.06) and had identical values              “regimen-related distress” (RCA 2.3 (+/-1.5) vs. NRP 2.1
for HOMAR-IR (AA 2.03 + 1.78, C 2.04 + 1.66] and                     (+/- 1.4), P=0.6), mean “physician-related distress” was
HOMA-B (AA 1.87 + 1.35, C 1.86 + 1.54), Notably, the                 higher in the NRP population (NRP 2.0(+/-1.4) vs. RCA
Glucose AUC was significantly lower in black than white              1.8(+/-1.2),P=0.6), while “interpersonal distress” was
subjects (14,882 + 1847 mg/dl/T vs. 15,651 + 1908mg/                 equal in both sample groups (NRP 2.0 (+/-1.3), RCA 2.0
dl/T, p = 0.016). In a multivariate model, the racial differ-        (+/-1.2) P =1), with no statistical difference between the
ence in A1c remained significant (P = 0.0006) after adjust-          two groups in any of the subscales.
ing for BMI, age, FPG, HOMA-IR, and HOMA-B.                               Discussion: Tertiary centers are expected to have
	     Conclusion: Among healthy subjects at similar                  more effective diabetes care in comparison to primary and
genetic risk for diabetes, we found that African Americans           secondary centers. However in this study overall distress
had significantly higher A1c levels than Caucasians,                 in the NRP and RCA had no statistical significant dif-
despite similar FPG, 2hPG, insulin sensitivity and beta              ference. Overall it may be possible that different factors


                                                            – 65 –
                                         ABSTRACTS – Diabetes Mellitus

cancel out against each other resulting in the non-signifi-      	    Conclusion: This case illustrates a very important
cant differences in distress.                                    point. The first line management of insulin allergy is to
     Conclusion: This study shows no significant differ-         switch insulin to a different preparation. In this case, most
ence in diabetes related distress between new and older          allergic reactions were most likely IgE mediated. Whether
patients of a tertiary DM clinic in Nigeria. Evaluating the      this new onset reaction was triggered by pancreatic cancer
effect of different care system components on diabetes           or chemotherapy is unknown. However, the timeframe of
distress between primary and secondary clinics against           the events may suggest some association. To our knowl-
tertiary clinics may shed further light on the causes of psy-    edge, this is the first case of a new onset insulin allergy in
chological distress in diabetes patients.                        the setting of a newly diagnosed pancreatic adenocarci-
                                                                 noma treated with anti-MUC1 Humanized Antibody and
Abstract #291                                                    Gemcitabine.

ALLERGIC REACTION TO INSULIN IN A                                Abstract #292
TYPE 2 DIABETIC WITH NEWLY DIAGNOSED
PANCREATIC CARCINOMA TREATED WITH                                THE PHENOTYPE OF NEWLY-DIAGNOSED TYPE
ANTI-MUC1 HUMANIZED ANTIBODY AND                                 2 DIABETES MELLITUS AMONG FILIPINOS
GEMCITABINE.
                                                                 Gerry H. Tan, MD, FACP, FACE,
Juan Pablo Brito, MD, Anup Sabharwal MD, CCD                     Evangeline P. Costelo, MD, Roselyn E. Sialongo, MD

	     Objective: Insulin is the mainstay of therapy in Type      	    Objective: The study aimed to know the phenotype of
1 diabetics and more resistant Type 2 diabetics. Insulin         newly-diagnosed type 2 diabetes mellitus among Filipinos
allergy is one of the most serious reactions associated          using HOMA-IR index to determine insulin resistance and
with insulin therapy. After the introduction of recombinant      using C peptide to determine beta cell function or insulin
human insulin preparations, insulin allergy became very          secretion.
uncommon, particularly in patients with Type 2 diabetes.         	    Methods: A cross sectional study conducted at a dia-
Multiple endogenous and exogenous risk factors have              betes center in a tertiary hospital from January 2006 to
been associated with insulin allergy; however, there is no       March 2009.
medical literature about the possible association between        	    Results: There were 209 newly-diagnosed type 2 dia-
solid tumors, chemotherapy and insulin allergy. We report        betes patients in this study (145 female and 64 male; mean
a case of a Type 2 diabetic that developed an allergic reac-     age 56 years; 107(51%) with normal BMI and 103(49%)
tion to insulin after being diagnosed with pancreatic can-       were overweight to obese). All patients were drug-naïve.
cer and treated with anti-MUC1 Humanized Antibody and            The mean HbA1c was 8.7% at the time of diagnosis.
Gemcitabine.                                                     Fasting insulin and glucose were used to compute for
	     Case	 Presentation: This is a case of a 64-year-old        HOMA index of insulin resistance. The C peptide level
woman with a past medical history of asthma, and Type            determination was also used to assess the insulin secretion
2 diabetes since 1997. She was initially treated with            of pancreatic beta cell. Four (2%) subjects had a C peptide
Metformin and Glipizide, as well as Pioglitazone, and            < 1 ng/ml, 12 (6%) subjects had a C peptide > 5 ng/ml
then had to be transitioned to subcutaneous insulin ther-        and 193(92%) of the subjects with newly-diagnosed dia-
apy in 2007. In June 2008, she was found to have a non-          betes have normal C peptide level (1 to 5 ng/ml) suggest-
resectable pancreatic carcinoma and since then, received         ing adequate normal insulin secretion. Among the subjects
anti-MUC1 humanized antibody and Gemcitabine.. After             with normal C peptide, 141 of the subjects (67%) were
week number one post completion of cycle#1, she started          insulin resistant based on HOMA index on diagnosis and
to develop subcutaneous nodules, urticaria, and pharyngi-        52 subjects (25%) remained insulin sensitive.
tis to insulin Glargine injections. She was also challenged           Conclusion: This study shows that most Filipinos
with Novolin R, Novolog, Novolin N, Insulin 70/30, and           with newly diagnosed type 2 diabetes are insulin resistant
found to have similar reactions. Finally, she was placed on      but has adequate insulin reserve. The study has major clin-
regular insulin before meals and at bed time, and had an         ical implication in the way we approach and select medi-
excellent response. During this time, she has maintained         cations for our newly diagnosed patients.
an acceptable glycemic control with an A1c of 7, and
without microvascular or macrovascular complications.




                                                            – 66 –
                                       ABSTRACTS – Adrenal Disorders

diagnostic algorithm when conventional imaging studies        epinephrine, urine: 5 mcg/24 hours (2-24) Norepinephrine,
fail to reveal the ectopic source. This may result in cure    urine: 807 mcg/24 hour (12-86) Dopamine, urine: 319
of the Cushing syndrome and avert the need for bilateral      mcg/24 hours (88-420) Catecholamine, total: 813 mcg/24
adrenalectomy or the use of poorly tolerated medical ther-    hours (14-110) Metanephrines: 0.135 mg/24 hours (0.052-
apy, such as keotconazole.                                    0.341) Normetanephrine: 6.021 mg/24 hours (0.88-.444)
                                                              Metanephrine, total: 6.156/24 hours (0.140-0.785) CT
Abstract #129                                                 Scan: left adrenal mass: 5.2X3X4.4cm with heteroge-
                                                              neous enhancement. Patient had laproscopic removal of
PROTRACTED RECOVERY DURING THE                                the pheochromocytoma. Post-operatively, patient had
POST-OPERATIVE COURSE IN A PATIENT                            severe orthostatic hypotension which lasted for 3 months.
WITH ATYPICAL PRESENTATION OF                                 This gradually improved within 6 months.
PHEOCHROMOCYTOMA                                              	    Discussion: It is commonly understood that pheo-
                                                              chromocytoma is associated with either sustained or epi-
Wei-An Lee, DO                                                sodic hypertension in 80% of patients. Episodic spells is
                                                              also described as a common presentation. In our case, we
	    Objective: To demonstrate a complicated follow-          have a patient with two hypotensive presyncopal hypoten-
up course in a patient with an atypical presentation of       sive episodes without any history of hypertension. With a
Pheochromcytoma.                                              significantly large adrenal of 5 cm and virtually asymp-
	    Case	 Presentation: 24 year old male referred for        tomatic, the patient most likely developed catecholamine
consultation regarding fatigue with associated dizziness      resistance over time. Due to this, the patient developed
and weakness. He has had previous episodes of irregular       severe hypotension after surgery and had persistent ortho-
heart beat in the lasting 5 years. Workup by cardiologist     static hypotension for over 3 months.
had been unremarkable. He was placed on beta blocks           	    Conclusions: Pheochromocytoma should be sus-
empirically. He stated that he has never “felt right.”        pected in patients with unexplained cardiovascular hypo-
Patient reported a presyncopal episode at Disneyland 1        tensive episodes. Significant pheochromocytomas can
month prior to consultation. During that episode, he had      present without hypertension and severe palpitations. In
palpitations, hypotension, and dizziness. Since that epi-     this case, this patient had developed desensitization to the
sode, he had been feeling extremely fatigued with nau-        catecholamines over time. In patients with mild symptoms
sea. He had a cardiology workup again which was unre-         with pheochromocytomas, the post operative course can
markable. Family history remarkable with mother with a        be very protracted.
prolactinoma. Weight: 151, Ht: 64 inches, BP: 125/68, P:
75. Physical exam unremarkable. 24 hour urine studies:




                                                         – 17 –
                  ABSTRACTS – Hypoglycemia

None submitted.




                            – 67 –
                                          ABSTRACTS – Lipid Disorders

LIPID DISORDERS                                                 Abstract #401

Abstract #400                                                   THE IMPACT OF STATIN THERAPY ON
                                                                CANDIDA COLONIZATION OR INFECTION
LDL-C GOAL ACHIEVEMENT IN DIABETIC                              AMONG PATIENTS WITH DIABETES TYPE 2
PATIENTS WITH AND WITHOUT ESTABLISHED
CARDIOVASCULAR DISEASE                                          Ilias Spanakis, MD, T. Kourkoumpetis, MD,
                                                                A. Peleg, MD, G. Livanis, PhD, E. Mylonakis, MD
Pendar N. Farahani, MD, Gray Ellrodt, MD
                                                                     Objective: Experimental studies have proposed that
	     Objective: Diabetic patients are at high risk for car-    statins can inhibit the growth of fungi by interfering with
diovascular (CV) events and are two to four times more          the ergosterol synthesis pathway. We evaluated the impact
likely to develop CV disease due to CV risk factors. This       of statin therapy against Candida colonization or infection
purpose of this study is to compare LDL-C goal achieve-         in high-risk hospitalized diabetic type-2 (DM2) patients.
ment with pharmacotherapy in clinical practice in groups        	    Methods: A retrospective cohort study was per-
of patients with/without diabetes and previous CV events.       formed analyzing the records of all DM2 patients who
	     Methods: Demographic, CV risk factors, drug pro-          were admitted at the Massachusetts General Hospital for
files, clinical and laboratory variables from a cross-sec-      lower gastrointestinal tract surgery between 01/01/2001
tional study on patients filling a prescription for a lipid-    and 05/01/2008. We defined statin exposure as the filling
lowering drug in selected pharmacies across Canada were         of at least 1 prescription of statins during the last 6-months
obtained. LDL-C goal attainments according to Canadian          prior to and/or during hospitalization. The primary out-
guidelines were compared between groups. [Group (A)             come was the presence of any positive culture for Candida
primary prevention in patients without diabetes, group (B)      spp. during the hospitalization. Clinical information on a
diabetic patients with no previous cardiovascular events,       wide range of covariates was collected which included
group (C) secondary prevention in patients without diabe-       comorbidities, as measured by the Charlson comorbidity
tes and group (D) diabetic patients with no previous car-       index (CCI), length of stay, use of antibiotics, intravas-
diovascular events]                                             cular catheter use, total parenteral nutrition and immuno-
	     Results: The number of patients [N (% in the cohort)]     suppressant use. Logistic regression analysis was used to
in each group (A, B, C and D) were 585 (53%), 162               adjust for appropriate confounders.
(14%), 241 (22%) and 115 (11%), respectively. The aver-         	    Results: From the total of 1019 patients that were
age age in each group (A, B, C and D) was 62.3 (10.8)           included, 493 of them (48%) received statin therapy and
[mean (SD)], 62.5 (10.6), 68.4 (10.9) and 67.2 (10.3)           526 (52%) did not. Those exposed to statins were older
years-old, respectively. The proportions of male patients       (67.83 ± 10.98 vs. 64.91 ± 13.67, p<0.001) and had a
were 50%, 43%, 68% and 66% in each group (A, B, C and           higher modified CCI. After adjusting for important con-
D). Patients on average had 2.1 (0.8), 3.5 (0.8), 3.4 (0.8)     founders the use of statins was associated with a statis-
and 4.7 (0.8) CV risk factors in each group, respectively       tically significant 40% reduction in the development of
(p<0.0001). LDL-C values were 4.6 (1.1), 4.0 (1.0), 4.0         Candida colonization (p= 0.031, Odds Ratio (OR) 0.60;
(1.0) and 3.8 (1.1) mmol/L at the baseline (p<0.0001) and       95% Confidence Interval (CI) 0.38-0.96). Other covariates
LDL-C was reduced by 1.8 (1.0), 1.7 (0.9), 1.6 (1.0) and        that were independently associated with Candida coloni-
1.8 (1.1) mmol/L in each group, respectively (p=0.05).          zation or infection included length of stay (p<0.001, OR
LDL-C goals were attained in 81%, 61%, 58% and 71%              1.05; CI 95% 1.03-1.07), intensive care unit stay (p=0.002,
of patients in each group (A, B, C and D), respectively         OR 2.37; CI 1.39-4.05) colonization of central venous
(p<0.0001).                                                     catheters (p<0.001, OR 3.15; CI 95% 1.78-5.58) and prior
	     Conclusion: This study demonstrated that patients         antibiotic use (p=0.005, OR 2.98, CI 95% 1.39-6.42). The
using statins as primary prevention attained the LDL-C          benefit of statins against Candida colonization or infec-
goal more often than patients with diabetes or previous         tion was more prominent in DM2 patients with greater
CV events (p<0.001). However, goal attainment was equal         co-morbidities (CCI ≥ 2) (53% reduction, p=0.008, OR
between diabetic patients and patients on treatment as sec-     0.47; CI 95% 0.27-0.79). The effect of statins did not dif-
ondary prevention (p>0.05). LDL-C goal achievement              fer among the different types or dose of statins. However,
was significantly higher in diabetic patients who received      these subgroup analyses were limited by small patient
treatment as secondary prevention compared to those dia-        numbers.
betic patients who received the treatment as primary pre-       	    Discussion: Candida colonization represents one
vention (p<0.01).                                               of the most important factors for invasive candidiasis.
                                                                Our results underline that exposure to statin therapy may


                                                           – 68 –
                                         ABSTRACTS – Lipid Disorders

decrease the incidence of Candida colonization or infec-       practice in the absence of genetic or more obvious second-
tion among high-risk hospitalized patients. Being the first    ary causes, a paraproteinemia should be suspected.
clinical study in this field, future studies are inevitably    	    Conclusion: Circulating monoclonal proteins may
needed in order to deepen knowledge in this issue.             interfere with one of more laboratory tests performed on
	    Conclusion: Statin therapy significantly reduced the      liquid-based automated analyzers. Inaccurate measure-
risk for Candida colonization or infection among high-risk     ment of HDL can lead to misclassification and unneces-
DM2 patients undergoing gastrointestinal tract surgery.        sary treatment. Clinicians should be aware of interferences
                                                               in the clinical laboratory and techniques such as dilution,
Abstract #402                                                  using a solid-based assay or semiquantitative electropho-
                                                               reseis, if available, should be employed to distinguish
A PATIENT WITH ARTIFACTUALLY LOW HDL                           between purely in vitro artifacts and real alterations.
CHOLESTEROL DUE TO WALDENSTROM
MACROGLOBULINEMIA                                              Abstract #403

David M. Reich, MD, FACE, Hammad Bhatti, MD,                   COLESEVELAM HCL IMPROVES BOTH
Paul Kim, MD, FACE, Issac Sachmechi, MD, FACE, FACP            HYPERCHOLESTEROLEMIA AND
                                                               HYPERGLYCEMIA IN PREDIABETES:
	    Objective: To report a case of an artifactually low       A RANDOMIZED, PROSPECTIVE STUDY
measured HDL cholesterol (HDL) leading to a diagnosis
of Waldenstrom macroglobulinemia.                              Yehuda Handelsman, MD, FACP, FACE,
	    Case	Presentation: A 68-year-old man presented for        Ronald B. Goldberg, MD, W. Timothy Garvey, MD,
well health maintenance. He had a past medical history of      Vivian A. Fonseca, MD, Julio Rosenstock, MD,
vitamin B12 deficiency. He had no complaints, appeared         Michael R. Jones, PhD, Yu-Ling Lai, RNC, MSN,
well, and physical exam was unremarkable. Lipid panel          Xiaoping Jin, PhD, Soamnauth Misir, PharmD,
showed total cholesterol (TC) 144 mg/dl, triglyceride          Sukumar Nagendran, MD, Stacey L. Abby, PharmD
(TG) 79mg/dl, HDL 5 mg/dl and LDL 123 mg/dl. HDL
done three years prior to his presentation was 41 mg/dl.       	    Objective: Prediabetes (impaired glucose toler-
The patient was prescribed extended release nicotinic          ance and/or impaired fasting glucose) increases the risk
acid (niaspan®) 500 mg at bedtime. Three months later,         of developing microvascular/macrovascular disease and
his HDL rose to 20 mg/dl, but 1 year later his lipid panel     progression to type 2 diabetes. This study assessed the
revealed TC 225 mg/dl, TG 69 mg/dl, HDL 6 mg/dl and            lipid- and glucose-lowering effects of colesevelam HCl in
calculated LDL 205 mg/dl. At this point, the patient’s         patients with hypercholesterolemia and prediabetes.
niaspan dose was raised to 1000 mg at night and pravas-        	    Methods: This 16-week randomized, double-blind,
tatin 40 mg at bedtime was added on. The patient was           placebo-controlled study included patients aged 18-79
also referred to the Endocrinology Clinic. Further work        years with untreated prediabetes (2-hr post-OGTT ≥140
up revealed serum apolipoprotein A1 97 mg/dl( 94-176),         mg/dL to <200 mg/dL and/or fasting plasma glucose
apolipoprotein B 35 mg/dl (52-109), ratio of apo B/apo         [FPG] ≥110 mg/dL to ≤125 mg/dL), LDL-cholesterol
A1 0.36, and direct LDL 28 mg/dl. Serum protein electro-       (LDL-C) ≥100 mg/dL and triglyceride levels <500 mg/
phoresis showed normal IgG and IgA and an abnormally           dL. Patients were randomized 1:1 to unmarked, active
high IgM at 3510 mg/dl (57-266). A bone marrow biopsy          colesevelam HCl (3.75 g/day) or matching placebo. The
revealed Waldenstrom macroglobulinemia.                        primary efficacy endpoint was percent change in LDL-C
	    Discussion: The artifactually low HDL in this patient     from baseline to Week 16 with last observation carried
was caused by paraprotein interference in vitro with the       forward (LOCF). Secondary efficacy endpoints included
liquid homogenous HDL assay, but a diagnostic work             changes in FPG, HbA1c, 2-hr post-OGTT glucose, lipid
up for an isolated low HDL unmasking the diagnosis             parameters from baseline to study end/Week 16 LOCF,
of Waldenstrom macroglobulinemia has been rarely               and attainment of LDL-C target level. Patients participat-
reported. Since the values of Apo A1 and Apo B did not         ing in a weight loss program with ongoing weight loss, or
correlate with the high total and LDL cholesterols or the      starting an intensive exercise program were excluded.
low HDL, suspicion of an interfering substance became          	    Results: In total, 216 patients were randomized (cole-
obvious. Prior observations suggest that some parapro-         sevelam HCl [n=108] and placebo [n=108]). Treatment
teins may associate with and alter the physicochemical         with colesevelam HCl vs placebo resulted in significant
characteristics of HDL particles, affecting their behavior     changes in both lipid and glycemic variables: LDL-C
in assays designed to measure HDL. When a very low or          (-13.9% vs +1.7%; mean treatment difference: -15.6%;
undetectable HDL cholesterol is encountered in clinical        P<0.001), non-HDL-C (-8.4% vs +0.7%; mean treatment


                                                          – 69 –
                                         ABSTRACTS – Lipid Disorders

difference: -9.1%; P<0.001), apoB (-7.5% vs +0.6%; mean        activity by anandamide requires a previously identi-
treatment difference: -8.1%; P<0.001), HbA1c (-0.12%           fied nuclear receptor binding site designated as site A.
vs -0.03%; mean treatment difference: -0.10%; P=0.02),         Furthermore, anandamide-treatment inhibited protein-
and FPG (-4.0 mg/dL vs -2.0 mg/dL; median treatment            DNA complex formation with the site A probe. Exogenous
difference: -2.0 mg/dL; P=0.02), from baseline to end of       over expression of cannabinoid receptor one (CBR1) in
study. Treatment with colesevelam HCl compared with            HepG2 cells suppressed apo A-I promoter activity, while
placebo did not significantly change 2-hr post-OGTT glu-       in Caco-2 cells, exogenous expression of both CBR1 and
cose (mean treatment difference: -1.9 mg/dL; P=0.75).          cannabinoid receptor two (CBR2) could repress apo A-I
Significantly more patients receiving colesevelam HCl          promoter activity. Treatment of HepG2 or Caco-2 cells
vs placebo attained LDL-C <100 mg/dL (29% vs 11%;              over-expressing CBR1 or CBR2 with anandamide had no
P<0.001) at Week 16. More patients receiving cole-             additional suppressive effect on promoter activity.
sevelam HCl vs placebo had HbA1c <6.0% (37% vs 25%;            	    Conclusion: These results indicate that endocannabi-
P=0.05) and normalization of glucose with an FPG <100          noids directly suppress apo A-I gene expression in both
mg/dL (40% vs 23%; P=0.06) at Week 16. Colesevelam             hepatocytes and intestinal cells. This effect may contrib-
HCl was weight neutral and well-tolerated. One case of         ute to the decrease in serum HDLc in obese individuals.
hypoglycemia was reported in each treatment group.
	    Conclusion: The use of colesevelam HCl is an option
for managing hypercholesterolemia and may help with the        Abstract #405
normalization of glucose in patients at high cardiometa-
bolic risk such as those with hypercholesterolemia with or     LOW SERUM 25(OH) VITAMIN D LEVELS
without statins and prediabetes. Further study is warranted    (<32NG/ML) ARE ASSOCIATED WITH
to determine whether colesevelam HCl slows or prevents         REVERSIBLE MYOSITIS-MYALGIA
the progression to type 2 diabetes.                            IN STATIN-TREATED PATIENTS

Abstract #404                                                  Waqas Ahmed, MD, Naseer A. Khan, Ping Whang, PhD,
                                                               Naila Goldenberg MD, Charles J. Glueck MD
INHIBITION OF APOLIPOPROTEIN A-I GENE
EXPRESSION BY OBESITY-ASSOCIATED                                    Objective: Our specific aims were to determine
ENDOCANNABINOIDS                                               whether low serum 25(OH) vitamin D (D2+D3) (<32ng/
                                                               ml) was associated with myalgia in statin-treated patients
Senan Sultan, MD, Arshag D. Mooradian, MD,                     and whether the myalgia could be reversed by vitamin D
Michael J. Haas                                                supplementation while continuing statins.
                                                                    Methods: In the temporal order of their referral to our
	    Objective: Diabetes and obesity are frequently asso-      outpatient cholesterol center and after excluding subjects
ciated with increased serum endocannabinoid (EC) lev-          taking corticosteroids or supplemental vitamin D, serum
els and decreases in high-density lipoprotein cholesterol      25 (OH) D was measured in 942 statin-treated patients,
(HDLc). Apolipoprotein A-I (apo A-I), the primary pro-         221 with myalgia at entry, and 721 asymptomatic. Vitamin
tein component of HDL is expressed primarily in the liver      D therapy was then given to those patients who had myal-
and to a lesser amount in the small intestine.                 gia and low vitamin D.
	    Methods: In order to determine if ECs have a direct            Results: The 221 myalgic patients had lower mean ±
effect on expression of the apo A-I gene, the effect of the    SD serum vitamin D than the 721 asymptomatic patients
obesity-associated ECs anandamide and 2-arachidonylg-          (26.4±12.2 vs. 30.4±13.3 ng/ml, p ≤0.0001), were more
lycerol on apo A-I gene expression was examined in the         likely to be black (11% vs. 6%, p=0.013) and female (63%
hepatocyte cell line HepG2 and the intestinal cell line        vs. 42%, p<0.0001). By analysis of variance, adjusted for
Caco-2.                                                        race, gender and age, least square mean (±SE) serum vita-
	    Results: Apo A-I protein secretion was suppressed         min D was lower in the 221 patients with myalgia than in
nearly 50% by anandamide and 2-arachidonoylglycerol in         the 721 asymptomatic patients, 23.5±1.1 vs. 27.5±0.9 ng/
a dose-dependent manner in both cell lines. Anandamide         ml, p<.0001. Serum 25 (OH) D was low (<32 ng/ml) in
treatment suppressed both apo A-I mRNA and apo A-I             165/221 (75%) patients with myalgia vs. 439/721 (61%)
gene promoter activity in both cell lines suggesting that      asymptomatic patients (χ2=13.9, p=0.0002). Of the 155
anandamide inhibits apo A-I gene expression at the tran-       vitamin D deficient, myalgic patients, while continuing
scriptional level.                                             statins, 88 were given vitamin D (50,000 units/week for
	    Discussion: Studies using apo A-I promoter deletion       4.3±2.5 months), with a resultant increase in serum vita-
constructs indicated that repression of apo A-I promoter       min D from 20.4±7.0 to 43.7±17.1 ng/ml (p<0.0001). In


                                                          – 70 –
                                         ABSTRACTS – Lipid Disorders

these 88 patients, 84 (95%) had no myalgia at their last       concentration was 36% in urban subjects and 18% in rural
visit, and 67 (76%) had normalized vitamin D.                  subjects. The most frequent dyslipidaemia was abnor-
     Discussion: We speculate that symptomatic myalgia         mally low HDL-C (17%) which was more common in the
in statin-treated patients with concurrent vitamin D defi-     urban subjects (22%) than in rural subjects (12%). There
ciency may reflect a reversible interaction between vita-      was no significant difference in the frequency of dyslipi-
min D deficiency and statins on skeletal muscle.               daemia between the males and the females (p=0.178).
	    Conclusion: We suggest that patients with statin          	    Conclusion: This study demonstrated a significant
induced myalgias should be screened and treated for vita-      difference in urban versus rural lipid levels and the preva-
min D deficiency.                                              lence of dyslipidaemia. Dietary changes and less physical
                                                               activity resulting from urbanization may be the causes for
Abstract #406                                                  the urban-rural difference. The results underline the need
                                                               to increase public screening and to emphasize the value of
RURAL-URBAN DIFFERENCE IN LIPID                                preventive measures.
LEVELS AND PREVALENCE OF
DYSLIPIDEMIA: A COMMUNITY-BASED                                Abstract #407
STUDY IN SOKOTO, NIGERIA
                                                               PROFILE OF LIPID ABNORMALITIES IN
Anas Ahmad Sabir, MBBS, Efedaye Ohwovoriole, FMCP,             OLDER NIGERIANS WITH TYPE 2
Olufemi Fasanmade, MBBS, FWACP                                 DIABETES MELLITUS (T2DM)

	    Objective: To determine the serum lipids levels and       Akinyele Taofiq Akinlade, MBBS,
compare the serum lipids levels and the prevalence of          Anthonia Okeoghene Ogbera, MBBS, FMCP, FACE
dyslipidemia of rural versus urban dwellers in Sokoto,
Nigeria.                                                       	    Objective: To describe the lipid abnormality patterns
	    Methods: A cross-sectional study was conducted            in older Nigerians with type 2 DM
in both rural and urban areas of Sokoto, Nigeria. One               Methods: The anthropometric indices, the serum
hundred subjects (50 urban; 50 rural) were recruited for       lipid profile and other characteristics of 203 consecutive
the study using a multi-stage sampling method. Using a         patients, aged ≥60 years, attending our out-patient clinic
modification of the WHO STEPS, information on socio-           were studied.
demographic data and anthropometric measurements                    Results: The mean age of the study was 66 years, with
were obtained. After a 12-hour fast, blood was drawn for       a male-female ratio of 1:1. The men were older, but this
assessment of total cholesterol (TC), triglyceride (TG),       is not statistically significant (p=0.237). Mean duration of
high-density lipoprotein (HDL-C) and low-density lipo-         DM was 8 years, ranging between 1 month and 40 years.
protein (LDL-C) cholesterol. The classification of dyslipi-    Co-morbidities include systemic hypertension in 68% and
daemia was based on the NCEP ATP III guidelines. Data          lipid abnormalities in 12% of the subjects. Central obe-
was analysed using Epi Info version 3.3.2.                     sity was present in 74% of the women but only in 23% of
     Results: The mean (SD) age of the sample popula-          the men (using waist circumference of 88cm and 102cm
tion was 39.9 (13.9) years. The mean (SD) age of the           respectively). The mean BMI of this study was 27.7kg/
rural subjects was 38.7(14.3) years and that of the urban      m2. More women (39%) were obese than men (16%). The
was 40.6(13.6) years (p> 0.05). The urban subjects were        difference in BMI was statistically significant (p=0.000).
significantly heavier [64.9 vs. 59.4 kg (p=0.038)] and         Most of the study subjects do not smoke cigarette (84%)
had higher BMI [23.5 vs. 22.2 kg/m2 (p=0.08)] than the         or take alcohol (71%). Mean T-cholesterol of this study
rural subjects. The mean waist circumference of the urban      was 196mg/dl, with 48% having values ≥200mg/dl. Most
subjects [83.8 (9.5) cm] was significantly higher than the     subjects (74%) had an LDL-C ≥100mg/dl with a mean
mean waist circumference of the rural subjects [79.2 (11.2)    of 131mg/dl. HDL-C values ≥40mg/dl was seen in 63%
cm] (p=0.030). The mean TC was significantly higher in         of the men, with mean value of 46mg/dl. However, the
urban [175.9(49.6) mg/dl] than rural subjects [148.3(24.3)     women had a lower mean HDL-C value of 47mg/dl, with
mg/dl] p < 0.001. Mean serum LDL-C, and TG concentra-          most (64%) having values ≤50mg/dl. Only 9% had tri-
tions were increased in urban than in rural subjects but       glyceride values ≥159mg/dl and the mean value was
not statistically significant. The mean serum HDL-C was        89mg/dl.
higher in the rural [51.1(7.9) mg/dl] than in urban sub-            Conclusion: Raised LDL-C is a common finding in
jects [50.2(11.7) mg/dl] but not statistically significant     older Nigerians with type 2 DM. In addition, low HDL-C
(p=0.64). The prevalence of at least one abnormal lipid        is more prevalent in the female older T2DM Nigerians.



                                                          – 71 –
                                          ABSTRACTS – Lipid Disorders

Abstract #408                                                   to ARVs and HIV status is no longer necessarily a death
                                                                sentence in our environment.
FAMILIAL COMBINED HYPERLIPIDEMIA (FCH)
IN AN HIV-POSITIVE PATIENT-COULD THIS                           Abstract #409
BE DUE TO A PROTEASE INHIBITOR? CASE
REPORT AND REVIEW OF LITERATURE                                 INHIBITION OF HEPATIC APOLIPOPROTEIN
                                                                A-I SECRETION BY ENDOPLASMIC
Adeleye Olufunmilayo Olubusola, MD,                             RETICULUM STRESS
Anthonia Okeoghene Ogbera, MBBS, FMCP, FACE, FACP,
Abioye I.A., MBBS                                               Emad Naem, MD, Abdul-Razzak Alamir, MD,
                                                                Rosalyn R. Alcade, Senan Sultan, MD,
	    Objective: To describe the presentation of an HIV-         Norman C.W. Wong, Arshag D. Mooradian,
positive patient with FCH after commencing antiretroviral       Michael J. Haas
therapy.
     Case	 Presentation: A 47-year-old man HIV-                      Objective: Apolipoprotein A-I (apo A-I), the primary
positive presenting with polyuria, polydipsia ,extreme          protein component of high-density lipoprotein cholesterol
weakness and dysuria about 3 years after commencing             (HDLc), is reduced in diabetes, obesity, and metabolic
antiretroviral(ARVs),including a protease inhibitor(PI).        syndrome and is an important risk factor for coronary
No history suggestive of angina He had no family history        artery disease. Endoplasmic reticulum stress (ER stress)
of sudden death or heart attack and no significant alcohol      has been shown to be an important mechanism involved
ingestion. Clinical examination revealed an acutely ill man     in regulating glycemia and lipidemia in experimental ani-
dehydrated with bilateral arcus corneas. No xanthomas,          mals and humans. Therefore, we determined whether or
no remarkable findings on cardiovascular and abdominal          not ER stress regulates apo A-I gene expression and high-
examination. Lab results revealed a Random Blood Glucose        density lipoprotein cholesterol synthesis in hepatocytes.
of 685 mg/dl, urinalysis –glycosuria++,ketones++, fasting       	    Methods: HepG2 cells were treated with 0, 0.1, 1.0,
lipid profile- Total Cholesterol 404mg/dl, HDL-c 39mg/dl,       and 10-mM tunicamycin (TM) and 0.1, 1.0, and 10-mg/ml
LDL-c 191mg/dl, triglycerides 872mg/dl, VLDL 174mg/             thapsigargin (TG), two potent inducers of ER stress, and
dl.CD4 count 174cells/µl. Liver function tests were nor-        apo A-I and albumin secretion and apo A-I promoter activ-
mal. Electrocardiography was essentially normal. He was         ity were measured. ER stress was measured using the ER
treated with insulin, as well as combination of fibrates and    stress-responsive alkaline phosphatase (ES-TRAP) assay
a statin, and was discharged home on same with instruc-         and a plasmid containing the secreted human placental
tion on dietary modification.                                   alkaline phosphatase gene. TM and TG induced ER stress
	    Discussion: Familial combined hyperlipidemia is            in HepG2 cells, as measured by ES-TRAP, in a dose-
a common disorder of unknown genetic cause which is             dependent manner. Apo A-I and albumin protein secre-
associated with glucose intolerance, obesity, and hyper-        tion also decreased in a dose-dependent manner, similar to
uricemia. Hyperlipidemia is also recognized sequelae            total protein measured in the conditioned medium.
of antiretroviral treatment, leading to increased cardio-            Results: Unexpectedly, apo A-I gene promoter activ-
vascular risk in HIV infected individuals. HIV infection        ity increased with TM- and TG-treatment. Intracellular
has been found to induce proatherogenic lipid changes.          albumin levels increased in cells treated with TM and TG
Combination of PIs and nucleoside reverse transcriptase         (similar to total intracellular protein content), while intra-
inhibitors increase the levels of cholesterol and triglycer-    cellular apo A-I levels decreased in TM and TG-treated
ides in patients treated with these agents. The increase in     cells. At low TM and TG concentrations, the ER stress
risk of cardiovascular disease was found in patients who        inhibitors dimethylsulfoxide (DMSO) and 4-phenylbutyr-
have been on these agents (PIs and NRTIs) for over 3            ate (4-PB) suppressed ER stress in HepG2 cells, as mea-
years. Negative association has also been found between         sured by ES-TRAP. Also at low TM and TG concentra-
the time on PI therapy and HDL-c levels and a trend to          tions, DMSO and 4-PB reversed the effects of TM and TG
positive correlation between viral load and cholesterol         on apo A-I and albumin secretion.
levels.                                                         	    Discussion: ER stress was a potent inhibitor of apo
	    Conclusion: The features of FCH in this patient            A-I secretion, but not gene promoter activity, in hepato-
underscores the need to properly assess HIV positive indi-      cytes. Therefore, induction of ER stress by exposure to
viduals on antiretroviral(ARVs) therapy for the presence        free-fatty acids and hyperglycemia, both of which have
of cardiovascular risk factors to reduce the mortality and      been shown to induce ER stress, may lead to significant
morbidity associated now that more patients have assess         declines in plasma HDLc.



                                                           – 72 –
                                           ABSTRACTS – Lipid Disorders

	    Conclusion: These results suggest that apo A-I secre-       medication. This could imply a role of exenatide in treat-
tion is inhibited by ER stress and that therapeutic strate-      ment of fatty liver disease and possibly NASH .To extend
gies targeting the ER stress response may represent a new        our findings and delineate the effect of exenatide on liver
approach to treating hypoalphalipoproteinemia.                   we tried to study the effect of exenatide on the liver in a rat
                                                                 model of fatty liver disease. The aim of the current study
Abstract #410                                                    was to evaluate at the effects of exenatide on rat model of
                                                                 NASH.
IS EXENATIDE THE ANSWER FOR NON                                       Methods: Twenty 8-week-old outbred Sprague-
ALCOHOLIC FATTY LIVER DISEASE?                                   Dawley male rats were used for this study. Rodents fed
                                                                 a methionine and choline deficient (MCD) diet have been
Deepti Bulchandani, MD, Jagdish S. Nachnani, MD,                 extensively studied as a model of fatty liver disease. All
Betty Herndon, PhD, Agostino Molteni, MD, PhD,                   the 20 animals were fed a MCD diet for a period of 75
Laura M. Alba, MD                                                days. During that time period, ten animals served as base-
                                                                 line and ten were treated with exendin-4. At day 75, the
	    Objective: Non-alcoholic fatty liver disease                animals were euthanized, tissues and serum were har-
(NAFLD), the most common chronic liver disease in the            vested, and livers were formalin fixed for histology.
Western world, associated with obesity and metabolic syn-             Results: The diet was exceptionally efficient at pro-
drome. NAFLD can further develop into non alcoholic              ducing fatty livers in MCD control animals, which had a
steatohepatitis which in turn can lead to liver cirrhosis and    liver steatosis score of 38 ± 6.7 (of 50 possible). Treatment
liver failure. At present, there is no definitive treatment      with exendin-4 was not associated with a significant
for reversing NASH, however evidence does suggest that           reduction of steatosis (44 ± 5.16, p=0.07). Treatment with
controlling the risk factors including, obesity, diabetes as     exendin-4 was also associated with significantly lower
well as insulin resistance can delay progression of NAFLD        adiponectin levels in MCD animals. Exendin-4 had no
to NASH and cirrhosis. There is no approved treatment            effect on the liver enzymes.
for fatty liver disease and NASH. Exenatide (exendin-4),              Conclusion: In an animal model of NAFLD, exen-
a GLP1 agonist is approved for treatment of diabetes.            din-4 therapy was not associated with significant improve-
Another beneficial effect of exenatide is weight loss. We        ment in hepatic steatosis; though it has shown improve-
originally presented results of beneficial effects of exena-     ment of liver enzymes in human studies.
tide on the liver enzymes in diabetic patients treated the




                                                            – 73 –
                                    ABSTRACTS – Metabolic Bone Disease

METABOLIC BONE DISEASE                                         Abstract #501

Abstract #500                                                  THE PREVENTION AND TREATMENT OF
                                                               GLUCOCORTICOID-INDUCED OSTEOPOROSIS
VITAMIN D DEFICIENCY INDUCED                                   IN PULMONARY CLINIC PATIENTS
HYPOCALCEMIA IN INTENSIVE CARE UNIT
PATIENTS: A CASE SERIES                                        Melissa Roether Piech, MD, Marc J. Laufgraben, MD

Vanessa Escobar Barboza, MD,                                   	    Objective: Patients treated with glucocorticoids are
Myriam Lagunas-Fitta, MD, Cristina Gutierrez, MD,              at high risk of fracture due to rapid bone loss that occurs
Jean-Paul Menoscal, MD, Tazneem Zahra, MD                      within six months of steroid treatment. The American
                                                               College of Rheumatology guidelines address the manage-
	     Objective: To report 5 cases of hypovitaminosis D        ment of glucocorticoid-induced osteoporosis (GIOP) with
induced hypocalcemia in critically ill patients.               lifestyle risk factor modification, vitamin supplementa-
      Case	 Presentation: We report a case series of five      tion, and bone mineral density testing. The guidelines also
patients with hypocalcemia who were admitted to the            recommend bisphosphonates for any patient beginning
Medical Intensive Care Unit from September 2008 to             therapy with a glucocorticoid equivalent to prednisone
March 2009. The group consisted of three women (62.5%)         5mg per day or greater for ≥ 3 months. The goal of this
and two (37.5%) men. We selected all patients with calcium     study was to evaluate guideline adherence for the preven-
levels < 8 mg/dl. In hypocalcemic patients, we measured        tion and treatment of GIOP in pulmonary clinic patients at
PTH, phosphate, mg, and 1, 25 vitamin D. In addition,          an academic teaching hospital.
comorbidities such as diabetes, CHF, HTN, osteoporosis         	    Methods: A retrospective chart review was performed
were evaluated. Finally, length of hospital stay, days of      of all patients seen at the Rhode Island Hospital Pulmonary
intubation, and mortality rate were also reviewed. Our         Clinic between January 1, 2007 and December 31, 2007.
first patient is a 47 years old female with no past medical    Eligible patients included men and women ≥ 18 years old
history was admitted with acute pancreatitis. Her ionized      who received glucocorticoids at a dose equivalent to pred-
calcium level was 3.2 mg/dl, 25 hydroxyvitamin D level         nisone 5mg or higher for ≥ 3 months. The charts of study
17 ng/ml, and PTH <3.0 pg/ml. Our second patient was a         subjects were reviewed for evidence of lifestyle risk fac-
39 years old female with no past medical history admitted      tor modification, vitamin supplementation, bone mineral
with sepsis. Her ionized calcium level was 4.64 mg/dl, 25      density testing, and bone-specific pharmacologic therapy
hydroxyvitamin D levels was 34 ng/ml, and PTH 197 pg/          within two years prior to the index visit.
ml. Our third patient was a 55 years old diabetic female       	    Results: Of the 30 eligible patients, 15 (50%)
admitted with DKA. Her ionized calcium was 4.6 mg/dl,          received calcium and vitamin D supplementation and 12
25 hydroxyvitamin D level 19 ng/ml, and PTH 93.7 pg/           (40%) received a bisphosphonate. Bone mineral density
ml . Our fourth patient is a 53 years old female admitted      measurements were ordered or assessed in only 3.3%
with symptomatic bradycardia. Her ionized calcium level        of study participants. Younger patients (men or women
was 4.88 mg/dl, 25 hydroxyvitamin D level 19 ng/ml, and        < 50 yrs. old) were more likely to receive treatment with
PTH 200 pg/ml. Our fifth patient was a 38 years old dia-       calcium and vitamin D (91%) than older patients (26%)
betic male admitted with DKA. His ionized calcium level        (P value 0.001). In addition, younger patients had higher
was 3.92 mg/dl, 25 hydroxyvitamin D level 12 ng/ml, and        rates of bisphosphonate treatment (64% vs. 26%, P value
PTH level was 300 pg/ml. The Majority of these patients        0.04). When analyzed by age/sex cohorts, the highest rate
were Hispanic females with no previous medical histories.      of bisphosphonate treatment was found in premenopausal
The length of hospital stay was longer in patients with vit    women (80%), followed by men < 50 (50%), postmeno-
D levels below 20 ng/ml. Three out of the five vitamin D       pausal women (30.8%), and men ≥ 50 (16.7%). There was
deficient patients died                                        no significant difference in the prevention or treatment of
	     Conclusion: Hypovitaminosis D can be an important        GIOP when analyzed by race or gender.
cause of hypocalcemia. Greater awareness of this com-          	    Discussion: The overall rate of guideline adherence
plication could reduce the incidence of poor outcomes          for the prevention and treatment of GIOP in pulmonary
related to hypocalcemia and hypovitaminosis D.                 clinic patients was low, most strikingly for the performance
                                                               of bone densitometry. Subjects younger than age 50 were
                                                               significantly more likely to receive calcium/vitamin D
                                                               supplementation and/or treatment with a bisphosphonate.




                                                          – 74 –
                                    ABSTRACTS – Metabolic Bone Disease

	    Conclusion: GIOP guideline adherence was low in           The etiology is unknown and it is postulated that it may
the pulmonary clinic at an academic hospital, particularly     be a vasomotor response or an early precursor to osteo-
for patients older than 50 years old.                          necrosis. It is also called algodystrophy or Bone marrow
                                                               edema syndrome and is characterized by focal osteopenia
Abstract #502                                                  and increased signal on T2 images. The biopsy of the bone
                                                               usually shows marrow edema, thin seams of woven bone
TRANSIENT REGIONAL OSTEOPOROSIS OF                             and active osteoblasts. Early differentiation from other
THE HIP SUPERIMPOSED ON METABOLIC                              chronic conditions with increased fracture risk is essential
BONE DISEASE                                                   to avoid unnecessary treatment.
                                                               	    Conclusion: Transient regional osteoporosis is a
Prasanna Santhanam, MBBS, Padma Venkatraman,                   self limiting condition and should be differentiated from
Tipu F. Saleem, MD, FACE                                       osteonecrosis, infection and true osteoporosis.

	     Objective:	 To underscore the need to look for other     Abstract #503
uncommon conditions when there is sudden worsening of
the bone mineral density.	To present a case where a female     AN UNUSUAL RECURRANCE OF
with osteopenia and increased fracture risk secondary          HYPERCALCEMIA DUE TO CONCURRENCE
to metabolic bone disease developed transient regional         OF PARATHYROID ADENOMA AND
osteoporosis of the hip.                                       PARATHYROID SARCOIDOSIS
	     Case	 Presentation: A 56-year-old female with a
history of menopause since age 36 (induced after total         Leila Chaychi, MD, Sushela Chaidarun,
abdominal hysterectomy and bilateral oophorectomy)             Allan Golding, Alan Siegel, Vincent Memoli
and surgical hypoparathyroidism that occurred after total
thyroidectomy for enlarging non-toxic multinodular goi-        	    Objective: To describe a patient presenting with the
ter (performed few years ago) presented with left leg          rare constellation of synchronous parathyroid adenoma
and hip pain of 4 months duration. She had been initially      and parathyroid sarcoidosis.
treated with bisphosphonate therapy for a year before she      	    Methods: We describe the clinical history, physical
developed hypoparathyroidism after the surgery. She was        examination, laboratory values, imaging findings and
found unsuitable for hormone replacement therapy due           pathologic data of a man who developed recurrent severe
to active smoking. Her lab values were; 25, OH, Vitamin        hypercalcemia after a successful parathyroidectomy.
D 35.5(32-100 ng / ml), 24 hr urine calcium 87 mg/24           	    Results: Initial biochemical findings were: calcium
hr (<250), calcium 8.2 (8.6-10.2 mg /dl),and PTH was 9         11.1 mg/dl (reference range 8.5-10.6), albumin 4.0 mg/
(10-69 pg/ml). The Dual X-Ray Absorptiometry (DXA)             dl (reference range 3.2-5.2), intact parathyroid hormone
had shown worsening T scores in both the lumbar verte-         (iPTH) 166 pg/ml (reference range10-69), creatinine 1.9
bra ( a decrease from -1.8 to -2.0 within 1 year) and the      mg/dl, 25(OH)D 15 pg/ml (reference range 30-80) and 1,
left femoral neck (a fall from -1.8 to -2.3 during the same    25(OH)2 D 44 pg/dl (reference range 16-72). The chest
time frame). The 25-Hydroxy Vitamin D level was within         x-ray was normal and delayed images from a Tc-99m ses-
normal limits of the reference range. The patient under-       tamibi scan showed increased activity in the right lower
went an MRI of the hip for evaluation of the pain and it       pole of the thyroid. Two months after successful parathy-
showed an abnormal edema pattern within the left femoral       roidectomy the patient was admitted to the hospital with
neck and the left intertrochanteric area along with a small    serum calcium of 17 mg/dl. Pathology of the resected
amount of joint fluid. The right hip was unremarkable. The     gland confirmed the diagnosis of parathyroid adenoma
DXA scan was repeated and it showed a further reduction        and subsequent review disclosed the presence of non-
in T score of the left femoral neck from -2.3 to -2.8 while    caseating granulomas within the adenoma.
the T scores in the right hip were unchanged. It was a case    	    Conclusion: Sarcoidosis with parathyroid involve-
of transient osteoporosis of the hip superimposed on pre-      ment causing severe hypercalcemia is unique to this case.
existing osteopenia.                                           Recurrent after successful resection of a parathyroid ade-
	     Discussion: Transient regional osteoporosis is a rare    noma may require consideration of potential causes other
condition that affects the hip, knee, and ankle in middle-     than the initial diagnosis.
aged men and women and is usually self limiting in nature.




                                                          – 75 –
                                     ABSTRACTS – Metabolic Bone Disease

Abstract #504                                                   may prevent development of calcifications however care
                                                                must be maintained to avoid overzealous correction of
POST SURGICAL HYPOPARATHYROIDISM                                hypocalcemia. Attention to mental status exam and close
WITH EXTENSIVE INTRACRANIAL                                     monitoring of calcium levels, are essential in the long term
CALCIFICATION PRESENTING WITH                                   follow up of post-surgical hypoparathyroidism patients.
DEMENTIA SYNDROME
                                                                Abstract #505
Gina Gerardine Santos Fernandez, MD,
Alexander Sy, MD, Maria Paliou, MD,                             PARATHYROID CARCINOMA PRESENTING
Shobhana Chaudhari, MD                                          AS HIP FRACTURE IN A 27 YEAR OLD WOMAN

	    Objective: To describe a case of post surgical hypo-       Pallavi Guddeti, MD, Socorro Vargas, MD,
parathyroidism with extensive intracranial calcification        Andrew Arnold, MD
who presented with symptoms of dementia.
	    Case	Presentation: A 66 yo lady, with post-surgical        	    Objective: To describe unusual presentation of para-
hypoparathyroidism since 1959, presented with progres-          thyroid carcinoma (PC) associated with HRPT2 mutation
sive decline in mental status. On examination, she was          in a young woman.
noted to be alert but oriented only to person with mild         	    Case	 Presentation: A 27-year-old woman presented
slurred speech and hand tremors. Attention span was             with 2 week history of bilateral hip pain triggered by min-
noted to be short with decreased concentration and short/       imal trauma. Radiographs showed bilateral hip fractures
long term memory. Brain CT showed multiple calcifica-           and subperiosteal bone resorption. Labs showed elevated
tions in the basal ganglia, thalamus, and subcortical white     iCal at 2.52 mmol/l (1.19–1.35); PTH 1407 pg/ml(24-91);
matter. Later, laboratory data showed elevated levels of        alkaline phosphatase 1084 U/L (38-126); Phosphorus 2.8
Serum Calcium (17.5mg/dl). Parathyroid hormone (<3.00           mg/dL (2.5- 4.5); 25OH D 6.1 ng/mL(25-80); 1,25(OH)2D
pg/ml) and PTHrP (12 pg/ml) were low. On review of              66 pg/ml (18-78); PTH-rP <0.2 and normal SPEP.
medications, she was on long standing replacement ther-         Parathyroid scan and thyroid U/S showed an adenoma
apy for post-surgical hypoparathyroidism with Calcitriol        near the right lower pole of the thyroid. Pre-operative
0.75 mcg/day and Ca Carbonate 2500 mg/day however it            management included calcitonin, pamidronate and cina-
was unclear if she could have overmedicated herself. She        calcet. She then underwent right hemithyroidectomy and
was treated initially with hydration and diuretics. Initial     right inferior parathyroidectomy – en bloc resection with
symptoms and mental status improved as the calcium              sacrifice of the involved recurrent laryngeal nerve and
levels trended down. Calcium and Vit D were eventually          ipsilateral lymph nodes. Intra-op PTH level decreased
restarted.                                                      from 1500 to 50 pg/ml. Histology of the 6 cm, 12 g speci-
	    Discussion: Chronic hypoparathyroidism has been            men revealed perineural, capsular and vascular invasion
associated with the development of intracranial calcifica-      indicating parathyroid carcinoma. Hospital course was
tions. Although the mechanism for development of brain          complicated by hypocalcemia requiring IV calcium infu-
calcifications remains unclear, prior studies have sug-         sions and calcitriol. She subsequently underwent bilateral
gested that its presence is associated with neuronal loss,      hip repair. Germline DNA testing was positive for HRPT2
cognitive decline and plausibly reversible dementia in          mutation in exon 7.
affected patients. Microscopic analysis of the brain calci-     	    Discussion: PC is a rare disease encompassing <1-5%
fications of postsurgical hypoparathyroidism patients has       of primary hyperparathyroidism (HPT) cases. Prevalence
shown that these were mainly located in the vascular and        of germline or acquired HRPT2 mutations is 77% in PC vs
perivascular regions of the brain. If such is the case, then    0.8% in adenomas, with increased risk of malignancy in all
these calcifications can lead to abnormalities in neuropsy-     4 glands when germline-positive i.e. in the hyperparathy-
chological function akin to a vascular type of dementia. In     roidism-jaw tumor syndrome, associated with ossifying
this patient, her brain calcifications were noted 50 years      jaw fibromas, various renal lesions, and uterine tumors.
post surgery. It is unclear if her mental status changes        Clinical manifestations of PC are related to severe hyper-
resulted from pre-existing extensive intracerebral calcifi-     calcemia. Local recurrence rate is 50%, with late metas-
cations from long standing hypoparathyroidism versus an         tases to cervical nodes, lung and liver. Calcimimetics and
overshoot in treatment of her Ca replacements leading to        bisphosphonates can be used to control hypercalcemia.
hypercalcemic dementia or both.                                 	    Conclusion: This case represents unusual presenta-
	    Conclusion: Brain calcifications can be seen in post-      tion of PC at young age with dramatic onset of bilateral
surgical hypoparathyroidsim and can lead to cognitive           hip fractures. She was positive for HRPT2 mutation,
decline. Prompt treatment with calcium and vitamin D            which puts her at increased risk for malignancy in all 4


                                                           – 76 –
                                     ABSTRACTS – Metabolic Bone Disease

parathyroid glands and emphasizes the need to screen             been taking for several months before surgery. Because
family members. Pre-operative suspicion and intra-oper-          of the elevated PTH a parathyroid scan was performed,
ative recognition are of great importance in the manage-         which showed a left superior parathyroid adenoma. We
ment of these patients.                                          are following him closely for HPT and are contemplating
                                                                 parathyroidectomy.
Abstract #506                                                    	    Conclusion: Although hypercalcemic HPT is a well
                                                                 known complication of long term phosphate therapy, co-
AN UNUSUAL CASE OF TUMOR INDUCED                                 existent primary HPT has not been reported with TIO.
HYPOPHOSPHATEMIC OSTEOMALACIA                                    Hypercalcemia in our patient may have been masked
(TIO) AND NORMOCALCEMIC PRIMARY                                  because of severe osteomalacia. Reason(s) for the co-
HYPERPARATHYROIDISM (PHPT):                                      existence remains unclear.
A COINCIDENCE OR ASSOCIATION?
                                                                 Abstract #507
Kevin L. Borst, DO, Sudhaker Rao, MD, FACE
                                                                 IS THE PREVALENCE OF PRIMARY
	    Objective: Although hypercalcemic HPT is a well             HYPERPARATHYROIDISM (PHPT) INCREASED
known complication of long-term oral phosphate therapy           IN MORBIDLY OBESE INDIVIDUALS?
in patients with TIO or hypophosphatemic rickets and             IMPLICATIONS FOR PATHOGENESIS OF PHPT
osteomalacia, co-existent PHPT has not been reported. We
report a case of TIO that resolved following tumor resec-        Kevin L. Borst, DO, Sudhaker Rao, MD, FACE,
tion despite the presence of normocalcemic PHPT.                 Arti Bhan, MD
	    Case	Presentation: A 57-year-old man was referred
for evaluation of “Paget’s disease” because of progres-          	    Objective: To determine if the prevalence of PHPT is
sive rise in serum alkaline phosphatase (AP) and diffuse         increased in morbidly obese patients, since an increased
bone pain. He noticed severe pain beginning in his feet,         BMI has been reported in patients with PHPT.
ultimately progressing to ribs and back over 2 years.            	    Methods: Retrospective chart review for the pres-
He developed severe lower extremity muscle weakness,             ence of PHPT in morbidly obese patients seeking bariatric
waddling gait, and fatigue, which became debilitating.           surgery.
Extensive biochemical testing and imaging studies were           	    Results: 1,472 obese patients sought bariatric sur-
done at an outside facility prior to referral. At presenta-      gery between 2002 and 2008 at our institution. PHPT was
tion, he had a profound symmetrical proximal muscle              defined as ≥3 consecutive albumin adjusted serum calcium
weakness and waddling gait. Neurological examination             (Ca) >10.2 mg/dl with elevated or non-suppressed PTH
was otherwise normal. Biochemical data showed a nor-             and normal renal function (serum creatinine <1.5 mg/dl).
mal serum calcium and creatinine, but high serum AP of           The necessary biochemical data to unambiguously diag-
370 IU/L (with a bone specific AP 165 IU/L). Both serum          nose PHPT was available in the Bone & Mineral Research
25-hydroxyvitamin D and 1,25-dihydroxyvitamin D were             Laboratory computerized database in 875 (59%) patients.
normal. However, serum PTH was elevated at 239 pg/ml             Of these, 127 had serum Ca >10.2 mg/dl, but only 15
with concomitant albumin adjusted calcium of 9.5 mg/             patients had PHPT as defined. The mean (SD) serum Ca
dl and phosphorus of 1.5 mg/dl. Maximum tubular reab-            and PTH in these 15 cases were: 10.5 (0.4) mg/dl and
sorption of phosphorus was very low at 0.48 mg/dL GFR            105 (57) pg/ml respectively. This resulted in an estimated
(2.48-4.15 mg/dL GFR), indicating severe phosphate               PHPT prevalence of 1.7 %, or 1 in 59 patients. Assuming
wasting. A serum FGF-23 was elevated at 218 RU/ml.               that none of the remaining 597 patients, in whom com-
Bone scan revealed multiple rib fractures and an octreotide      plete data was unavailable, did not have PHPT, the esti-
scan showed focal uptake in the left supraclavicular fossa       mated prevalence is still 1% or 1 in 98 patients. This is a
consistent with possible tumor. CT of the upper extremity        2-10 fold higher prevalence of PHPT depending upon the
displayed 3.2 x 2.0 x 2.0 cm lesion behind the left clavicle.    population studied.
A transiliac bone biopsy after in vivo double tetracycline       	    Discussion: A recent meta-analysis has demonstrated
labeling confirmed severe osteomalcia. Patholgic exami-          an association between PHPT and obesity. Proposed mech-
nation of the resected sub-clavicular tumor was consistent       anisms for this association include: the effects of increased
with mesenchymal tumor – mixed connective tissue vari-           intracellular Ca leading to insulin resistance, inhibition of
ant. Following resection of the tumor serum P normalized         lipolysis, and direct effects of PTH on adipocyte differenti-
despite high PTH levels. His bone pain and muscle weak-          ation. If the two conditions are “truly related”, we hypoth-
ness resolved over a period of a few months and he no lon-       esized that there would be a higher prevalence of PHPT in
ger required phosphorus or calcitriol therapy, which he had      patients with obesity, just as higher BMI in patients with


                                                            – 77 –
                                    ABSTRACTS – Metabolic Bone Disease

PHPT. Our findings confirm the hypothesis that obesity         bisphosphonate treated patients with remarkable decrease
and PHPT might be pathogenetically linked. An inverse          in subsequent fractures.
relationship between serum 25-hydroxyvitamin D level,          	    Discussion: This study describes the varying presen-
the best available index of vitamin D nutrition, and BMI is    tation of fibrous dysplasia with various endocrinopathies
well established. Prolonged stimulation of PTH secretion       and successful use of bisphosphonates in these patients.
due to chronic vitamin D depletion might lead to clonal        The diagnosis of FD is based on classical radiological
tumors arising in the setting of hyperplasia, resulting in     findings substantiated with bone scans and characteris-
hypercalcemic PHPT. Alternatively, obese patients may          tic pathological findings on histopathology. Most com-
have susceptible vitamin D receptor gene polymorphisms,        mon endocrine abnormality documented in our series was
which have been implicated in parathyroid tumorigenesis.       hypersomatotropism (20%), followed by hyperthyroidism
	     Conclusion: Our preliminary results suggest, for the     (8%) hyperprolactinemia (20%), hypophosphatemia(4%)
first time, an increased prevalence of PHPT in morbidly        and precocious puberty (4%). However, in one of the pedi-
obese patents, and are consistent with the recent meta-        atric series of fibrous dysplasia, asymptomatic hypophos-
analysis showing increased BMI in PHPT. Further studies        phatemia was the most common endocrine abnormality
are needed to determine the pathophysiologic mechanisms        (38.5%) followed by sexual precocity (16.5%). The acro-
responsible for this association.                              megaly associated with MAS differs from classical acro-
                                                               megaly by its presentation at younger age, facial asym-
Abstract #508                                                  metry, hyperprolactinemia and lack of demonstratable
                                                               adenoma on imaging in majority of patients, however 4 out
FIBROUS DYSPLASIA AND MCCUNE-ALBRIGHT                          of 5 patients with acromegaly had pituitary adenoma and
SYNDROME: AN AUDIT FROM A TERTIARY                             all had hyperprolactinemia in our series. Hyperthyroidism
CARE CENTRE                                                    associated with MAS is due to autonomous thyroid nod-
                                                               ule with constitutive activation of GS alpha subunit of
Sambit Das, MBBS, MD, Sanjay Bhadada, Anil Bhansali            TSH receptor. Ablative therapy is the treatment of choice
                                                               as was done in our patients. Patient who had precocious
	    Objective: Fibrous dysplasia (FD) is a rare metabolic     puberty was gonadotropin independent as described in
bone disease and reported as anecdotal case reports. We        literature and later developed hyperthyroidism emphasiz-
describe the clinical profile and therapeutic outcome of 25    ing the fact that these patients need constant follow up for
patients with FD observed over 14 years.                       evolving endocrinopathies. Patients with FD may pres-
     Case	 Presentation: The diagnosis of fibrous dys-         ent with manifestation of rickets and osteomalacia dur-
plasia was based on either classical radiological features     ing childhood and adolescence. Hypophosphatemia is the
and/or histological evidence on bone biopsy. Associated        characteristic abnormality and is attributable to increased
endocrinopathies if any were evaluated. The diagnosis of       secretion of FGF23 (fibroblast growth factor 23), a phos-
McCune Albright syndrome was established by two of the         phatonin secreted from dysplastic bone lesions, hence
following abnormalities: fibrous dysplasia, Café au lait       leading to phosphaturia. Only one of our patients had low
macules and endocrinopathies. The clinical presentation,       serum phosphate and florid features of hypophosphatemic
biochemical parameters and imaging were analyzed. A            rickets in contrast to the findings of others. Till recently the
total of seven patients received bisphosphonate therapy.       treatment of FD was only restricted to symptomatic ortho-
The final outcome and side effects were noted. Age of the      pedic management. Various medical therapies like calcito-
studied patients ranged from 7 to 48 years (mean + SD,         nin and mithramycin have been tried with poor outcome.
24.2 + 11.4 yrs) with lag time ranging from 1 to 20 years      The use of bisphosphonate (intravenous pamidronate ) as
(mean ± SD, 6.6 ± 6.2 years). The mean duration of fol-        a potential therapy for FD came with a great success with
low up was 3.5±2.1 years. Eighteen (72%) patients had          many studies showing 60-70% improvement in bone pain
polyostotic disease while rest had monostotic FD. Eight        and up to 50% radiological improvement. Similar effects
patients had endocrinopathies: five had acromegaly, one        were later shown by oral alendronate and intravenous
each had gonadotropin independent precocious puberty           potent bisphosphonates like palmidronate and, zoledro-
(GIPP), hyperthyroidism and hypophosphatemic rick-             nate. The possible mechanism of action of bisphospho-
ets. One child with GIPP later developed hyperthyroid-         nates in FD is related to suppressed osteoclastic activation
ism. McCune Albright Syndrome (MAS) was observed               which are activated in FD due to constitutive activation
in 10 (40%) patients. Majority of the patients (23 out of      of GS alpha subunit in the bone tissue. All had marked
25) received various minor and major surgical procedures       symptomatic improvement in bone pain and reduction of
and seven patients received bisphosphonates for recur-         fracture incidence, although there was no improvement in
rent pathological fractures. Bone pain was reduced in all      bony deformities, a finding similar to other studies.



                                                          – 78 –
                                    ABSTRACTS – Metabolic Bone Disease

	   Conclusion: Fibrous dysplasia is a rare disease with       was made postmortem. In our case the diagnosis, albeit
varying presentations and usually requires combined            late, was made antemortem.
medical and surgical treatment. Medical treatment with              Conclusion: In an elderly patient with unexplained
bisphosphonates is potentially rewarding.                      hypercalcemia, suppressed PTH and 1,25-di(OH)vitamin
                                                               D and a negative SPEP and UPEP with immunofixation,
Abstract #509                                                  the possibility of NSM should be considered. Serum FLC
                                                               are a facile and rapid noninvasive test that can then be
A PUZZLING CASE OF HYPERCALCEMIA                               ordered.

Ranjani Ramanathan, MD, Dwight Towler, MD                      Abstract #510

	    Objective: To describe a case of non-secretory            ORBITAL INFLAMMATORY DISEASE IN A
myeloma (NSM) whose sole presenting feature was                PATIENT TREATED WITH ZOLEDRONATE
hypercalcemia for almost ten years.
     Case	Presentation: An 88-year-old man was admitted        Harpreet Kaur, MD, Christopher Bruno, MD,
with recurrent hypercalcemia of 13-14 mg/dl. Historical        Jennifer Kelly, MD, Nicolas Uzcategui, MD,
laboratory data revealed elevated serum calcium of 11.2        Timothy Riccardi, MD, Arnold Moses, MD
mg/dl first noted in 1999. An extensive work up during
2 prior admissions had been unrevealing. The work up           	     Objective: To report a rare complication of treatment
revealed a normal 25-(OH)vitamin D level of 30 ng/ml,          with a bisphosphonate.
PTH suppressed at 6 pg/ml, normal bone scan and CT             	     Case	 Presentation: A 57-year-old postmenopausal
scan of the chest, abdomen and pelvis, negative SPEP and       female with a history of esophageal, breast and lung can-
UPEP with immunofixation, normal TSH, PTHrp, 24 hr             cer, currently in remission for 3 years, who has been fol-
urine Ca, PSA and ACE level and low 1, 25-di(OH)vita-          lowed for postmenopausal osteoporosis, was treated with
min D. Long bone plain radiographs were unrevealing.           IV ibandronate every 3 months for a total of 6 doses. No
ESR was elevated at 54 mm/hr and CRP at 10.8 mg/l. ANA         adverse effects were reported. Recently, she received a
was negative. Peripheral smear was normal. No associated       5mg infusion of zoledronate in the morning and that night
drugs were implicated. A cosyntropin stimulation test was      she developed a painful, swollen left eye with photopho-
abnormal with a 30 minute cortisol of 12.9 mcg/dl. The         bia. Ophthalmologic exam revealed intraocular pressures
hypercalcemia was thus attributed to adrenal insufficiency     of 18 mm Hg in the right eye and 45 mmHg in the left eye.
and the patient was discharged on prednisone. However          Her visual acuity was 20/25 without correction in both
he did not improve and we saw him during his third             eyes. There was 3+ edema of the left upper lid. On slit
admission. In this setting, with suppressed PTH AND            lamp examination, she had 2-3 + conjuctival infection in
1,25-di(OH)vitamin D, elevated ESR yet normal SPEP             the left eye. The remainder of the exam was normal. An
and UPEP on immunofixation, malignancy remained the            orbit CT scan showed a hazy, increased density of the fat
primary consideration. However, long-standing hypercal-        in the left orbital, preseptal and retroseptal spaces along
cemia is not characteristic of most malignancies, although     with thickening of the globe wall indicative of inflamma-
described for multiple myeloma. A simple and rapid             tion. A diagnosis of orbital inflammatory disease was made
serum test, the serum free light chain (FLC) assay, was        and she was started on oral prednisone 20 mg daily and
performed to look for rare NSM. This was indeed abnor-         azithromycin. The orbital and eyelid swelling responded
mal with a κ/λ FLC ratio of 47.27 (normal-0.26 - 1.65), κ      partially to treatment but dull ache and photophobia per-
FLC 52.00 (normal-0.33 - 1.94 mg/dl), λ FLC 1.10 (nor-         sisted. She was then started on two Medrol dose packs on
mal-0.57 - 2.63 mg/dl). β -2-Microglobulin was elevated        the 9th day after the initial episode, and the swelling and
at 6.9 (normal-0.7 - 3.4 mg/L). A bone marrow biopsy           erythema of the left eye disappeared completely over a
confirmed the diagnosis. The patient had a rapidly down-       period of next 2 weeks. She has remained symptom free
hill course and expired shortly thereafter.                    since then. Follow up CT will be repeated at 3 months.
     Discussion: NSM was first described in 1958 and a         Upon questioning the patient after the recent episode, she
large review suggested that < 1% do not secrete immuno-        recalled having mild edema of the left eye after the prior 2
globulin in serum or urine. Screening elderly patients with    infusions of ibandronate. She did not seek medical help.
hypercalcemia using only SPEP and UPEP is occasionally         	     Discussion: Zoledronate is a bisphosphonate which is
fallible, even with immunofixation. Bone scans are insen-      widely used for treatment of osteoporosis and Paget’s dis-
sitive for myeloma, and skeletal surveys can miss small        ease. Rarely, ocular inflammation including uveitis, scle-
lesions. We found only one case report of NSM presenting       ritis, conjunctivitis, episcleritis, and photophobia has been
with hypercalcemia alone and in that report the diagnosis      reported after use of this medication as well as with oral


                                                          – 79 –
                                    ABSTRACTS – Metabolic Bone Disease

bisphosphonates. Onset may occur immediately, weeks or         was a negative association between BMI and 25OHD for
even months after therapy. To our knowledge, only 3 cases      OB AAMV (r = -0.16) and CAMV (r = -0.16) groups. There
of diffuse orbital inflammatory disease have been reported     was also a negative association between 25OHD and PTH
following use of zoledronate. The mechanism is unknown         (AAMV: r= -0.16; CAMV: r= -0.24).
but may be due to the release of acute-phase reactants and     	    Discussion: Our study is one of a few studies evalu-
cytokines.                                                     ating relationship of vitamin D insufficiency and obesity
	    Conclusion: Physicians should be aware of this rare       to include a large group of AA males with detailed health
complication of zoledronate and it should be used with         habits. Similar to previous observation, our data shows a
caution in patients with either a positive or even negative    higher overall prevalence of vitamin D insufficiency in
history of inflammatory eye disease, or even, as in our        AA compared with CA males. Contrary to the previous
case, mild ocular symptoms following use of a different        data, our results show similar prevalence of vitamin D
bisphosphonate.                                                insufficiency and dietary vitamin D intake for obese AA
                                                               and CA males. Our data shows similar level of PTH in
Abstract #511                                                  AAMV and CAMV despite differences in 25OHD levels.
                                                               This observation is different from the majority of previous
THE PREVALENCE OF VITAMIN D                                    studies and remains poorly understood although magne-
INSUFFICIENCY AND SECONDARY                                    sium deficiency may be a contributing factor.
HYPERPARATHYROIDISM IN OBESE                                   	    Conclusion: Vitamin D insufficiency is highly preva-
MALE VETERANS                                                  lent in both obese AAMV and CAMV. The negative asso-
                                                               ciation of 25OHD to BMI and PTH is similar in obese
Terri Washington, MD, Joel Brooks,                             veterans of both races.
Valeriu Neagu, MD, Olga Cherepanova,
Lipi Sekhadia Patel, Elena Barengolts, MD                      Abstract #512

	    Objective: In a prospective cohort study we examined      RENAL FUNCTION IN PRIMARY
the relationship between obesity and prevalence of vita-       HYPERPARATHYROIDISM
min D insufficiency (25-hydroxyvitamin D [25OHD] < 30
ng/ml) in males.                                               Giorgio Borretta, MD, Chiara Giulia Croce, MD,
	    Methods: Male veterans (n=878) were recruited at          Laura Gianotti, Valentina Borretta, MD,
VA Medical Center in Chicago. Serum levels of 25OHD            Flora Cesario, MD, Claudia Baffoni, MD,
and parathyroid hormone (PTH) were obtained. Surveys           Ignazio Emmolo, MD, Micaela Pellegrino, MD,
and chart reviews were completed. Subjects with body           Francesco Tassone, MD
mass index (BMI) < 35 and ≥ 35 kg/m2 were considered
non-moderately obese (non-OB) and moderately obese             	    Objective: Renal insufficiency (RI) is a complica-
(OB), respectively. Vitamin D insufficiency was defined as     tion of the primary hyperparathyroidism (PHPT) and it
25OHD < 30ng/ml. Data is presented as mean (Standard           can negatively affect the clinical presentation of PHPT
Deviation) or number (%).                                      and increase the risk of mortality. In asymptomatic PHPT
     Results: Overall African-American male veterans           a Glomerular Filtration Rate (GFR) less than 60 ml/min
(AAMV) (n=629) and Caucasian-American Male Veterans            represents the precise level below which surgery is rec-
(CAMV) (n=249) were of similar age and BMI [61 (11) vs         ommended; however the prevalence of renal insufficiency
63 (13) years and 29 (6) vs 29 (6) kg/m2, respectively] and    (RI) in asymptomatic PHPT is unknown. Thus we sought
similar proportion of AAMV (17%) and CAMV (17%)                to investigate the prevalence of RI in a large case series of
had BMI ≥ 35 kg/m2. The overall prevalence of 25OHD            PHPT patients mostly asymptomatic.
insufficiency was 86% in AAMV and 71% in CAMV,                 	    Methods: In 294 consecutive PHPT patients (M/F
while it was 90% and 85% in OB and non-OB AAMV and             = 76/218; asymptomatic/symptomatic = 151/143; age =
93% and 66% in OB and non-OB CAMV, respectively.               59.1 ± 13.7 yrs; BMI = 25.5 ± 4.9kg/m2; PTH = 215.3 ±
Obese AAMV (n=104) compared with obese CAMV                    221.1pg/ml; ionized calcium = 1.46 ± 0.17mmol/l; serum
(n=43) had lower 25OHD level, 16.0 (9.1) vs 20.1 (8.9)         creatinine = 0.88 ± 0.3mg/dl) renal function estimated by
ng/ml, and lower calcium 256 (194) vs 368 (306) mg/day,        means of MDRD (Modification of Diet in Renal Disease)
but not vitamin D dietary intake [98 (80) vs 104 (111) IU/     equation was evaluated. A GFR <60ml/min represent the
day, respectively]. Similar results were seen in non-OB        threshold of moderate-to-severe RI definition.
males but dietary vitamin D intake was lower in AAMV                Results: In the whole group mean (±S.D.) GFR
vs CAMV. PTH level was similar in AAMV and CAMV                was 92.3±31.6ml/min, with a RI prevalence of 17.4 %.
[66.6 (47.8) and 67.6 (43.0) pg/ml, respectively]. There       Patients were subdivided according to their median age


                                                          – 80 –
                                       ABSTRACTS – Metabolic Bone Disease

(i.e. 60 years): younger patients showed higher GFR than            1.54 mg/dL (0.6-1.2 mg/dL), Phosphorus 2.5 mg/dL (2.5-
older ones (98.7±32.1 vs 85.5±29.6 ml/min, respectively,            5.0 mg/dL) and Alkaline Phosphatase 2154 U/L (34-104
p<0.0003) with a RI prevalence of 11.2% vs 23.9 %                   U/L). Radiographs showed “salt and pepper” appearance,
(p<0.00001). Asymptomatic patients compared to symp-                bone cysts and brown tumors on bones. Neck ultrasound
tomatic did not differ both for mean GFR (92.1±31.3 vs              revealed a 2.6 cm parathyroid adenoma. Primary hyper-
92.5±31.9ml/min, respectively, p=n.s.) and for RI prev-             parathyroidism was considered as the etiology. Intact
alence (14.7% vs 17.9 % , p=n.s.). Patients with kidney             Parathyroid Hormone levels were ordered and results
stones, also, did not differ from those without kidney              were 1634 pg/mL (10-65 pg/mL). Patient was taken to
stones in terms of GFR (93.1±31.3 vs 91.5±31.7m l/min,              surgery for parathyroid adenoma resection.
p=n.s.) and for RI prevalence (16.7% vs 17.9 %, p=n.s.).            	    Discussion: Osteitis fibrosa cystica was first described
Male patients showed a lower GFR compared to females                in the 19th century. Before 1950 around half of patients
(59.4±17.4 vs 103.8±27.0 ml/min, p<0.001), and also                 diagnosed with hyperparathyroidism in the United States
higher RI prevalence (56.6 % vs 3.7 %, p<0.00001). These            presented with it. Today, it appears in only 2% of indi-
findings persisted also adjusting the statistical tests for age,    viduals diagnosed with primary hyperparathyroidism.
serum calcium and PTH levels. In the whole group GFR                It usually results from an overproduction of parathyroid
was negatively associated with age (R=-0.25, p<0.00002)             hormone that causes increase in bone turnover. Symptoms
and with ionized serum calcium levels (R=-0.13, p<0.04).            are the consequences of both the general softening of the
      Conclusion: In a large contemporary PHPT case                 bones and the excess calcium. It is characterized by bone
series a lower than previously reported prevalence of               pain and radiographically by subperiosteal bone resorp-
moderate to severe renal insufficiency was observed. No             tion on the radial aspect of the middle phalanges, tapering
significant differences were found between asymptomatic             of the distal clavicles, and a “salt and pepper” appearance
and symptomatic patients and also between patients with             of the skull, bone cysts, and brown tumors of the long
kidney stones and those without. A sharp difference of RI           bones. Brown tumors result from excess osteoclast activ-
prevalence was found between sexes (independently of                ity and consist of collections of osteoclasts intermixed
the activity of the disease). Finally, the negative relation-       with fibrous tissue and poorly mineralized woven bone.
ship of GFR with serum calcium would confirm the patho-             The usual route of treatment is parathyroidectomy.
genetic link between PHPT and RI.                                   	    Conclusion: Although Osteitis fibrosa cystica has
                                                                    long been a rare disease it still can be seen on patients
Abstract #513                                                       with unchecked primary hyperparathyroidism.

OSTEITIS FIBROSA CYSTICA IN A PATIENT                               Abstract #514
WITH SEVERE HYPERCALCEMIA
                                                                    AN UNUSUAL CASE OF ZOLEDRONIC ACID
Jorge Rohena, MD,                                                   INDUCED SEVERE HYPOCALCEMIA IN A
Myriam Allende, MD, MBA, FACP, FACE,                                TRANSITIONAL BLADDER CANCER PATIENT
Maragarita Ramirez, MD, Marielba Agosto, MD,                        WITH OSTEOBLASTIC METASTASES
Meliza Martinez, MD
                                                                    Sanjit S. Bindra, MBBS, Walaa A. Ayoub, MD, PhD
	    Objective: Describe a patient with osteitis fibrosa cys-
tica, a now very rare in the United States manifestation of         	    Objective: To report the first case of transitional blad-
primary hyperparathyroidism.                                        der cancer and extensive osteoblastic metastases with
	    Case	 Presentation: A 42-year-old female with past             zoledronate induced severe hypocalcemia and to discusses
medical history of hypertension and hypercalcemia first             precautions and potential serious implications following
noticed 2 years ago. She was hospitalized due to a femoral          zoledronate therapy.
fracture and consulted to endocrinology for hypercalce-             	    Case	Presentation: A 64-year-old female with blad-
mia. Fracture was found after she experienced left thigh            der cancer and extensive osteoblastic metastases admitted
pain while sitting in a chair at her house, without trauma.         with excruciating left femoral pain after left femoral neck
She also had acute renal insufficiency. Two years prior             fracture status post surgical repair. One day before the sur-
she was told of elevated calcium levels but she did not to          gery, she received 4 mg of zoledronate for bone pains and
seek further evaluation. She also complained of nausea,             prevention of further skeletal complications with calcium
abdominal pain, constipation, polyuria and polydipsia. No           of 8.1 mg/dL (nl.8.5-10.4) prior to IV zoledronate therapy.
history of nephrolithiasis, bone pain prior to the fracture,        Two days later, the patient was found to have calcium of
confusion or renal insufficiency. Laboratories showed               4.9 with feet parasethesia but no perioral parathesia or
calcium at 17.4 mg/dL (8-10 mg/dL), serum creatinine                tetany. Patient had vitamin D deficiency on vitamin D and


                                                               – 81 –
                                    ABSTRACTS – Metabolic Bone Disease

calcium therapy, normal magnesium and creatinine, and          ache worse with activity and alleviated by aspirin and rest.
no history of parathyroid disease. Intact PTH elevated at      The patient endorsed symptoms of weakness but main-
1167 and 25- hydroxyvitamin D was low at 20.8 ng/mL (nl        tained full range of motion. Physical exam demonstrated
30-70). Patient received IV and oral calcium and vitamin       swelling and tenderness to palpation of the ulnar aspect of
D with calcium of 8.6 gm/dl corrected for albumin after        the left wrist but did not demonstrate tenosynovitis. She
2 weeks. Patient was maintained on therapeutic doses of        was started on ibuprofen and wrist splints and followed up
vitamin D and calcium supplementation.                         after three weeks without resolution of symptoms. On fol-
	    Discussion: Zoledronate is a highly potent bisphos-       low up, the possibility of a ganglion cyst was entertained,
phonate shown to reduce skeletal-related events in can-        and the patient was referred to orthopedic hand surgery
cer patients with bone metastases. Severe hypocalcemia         for evaluation. X-rays of the wrist obtained prior to this
requiring IV calcium therapy is increasingly seen with         appointment showed sclerosis of the ulnar head with
wider adoption of bisphosphonate therapy. Several reports      lucency in the ulnar corner of the lunate. The exam by the
of severe zoledronate induced hypocalcemia have been           orthopedist was positive for ulnar compression and “ulno-
published among cancer patients with osteoblastic metas-       carpal impaction syndrome” was diagnosed. An MRI was
tases particularly advanced prostate, and rarely among         ordered for evaluation prior to surgical correction and con-
breast and gastric cancers. However, upon careful review       firmed ulnocarpal impaction, but also showed underlying
of the literature, we report the first case of zoledronate     bony changes of the distal ulna. The radiologist recom-
induced severe hypocalcemia in a patient with bladder          mended a bone scan for further evaluation. The bone scan
cancer with osteoblastic metastases. Hyplacemia in our         showed increased homogenous uptake throughout the
case is likely due to unopposed osteoblastic activity with     enlarged left ulna, which was pathognomonic for Paget’s
a preexisting vitamin D deficiency. This case underscores      disease. Surprisingly Bone Specific Alkaline Phosphatase
the need for calcium and vitamin D monitoring and ade-         obtained at the time of diagnosis was within normal limits
quate supplementation prior to bisphosphonate therapy to       at 17.2 and thought to be secondary to the localized nature
avoid severe hypocalcemia particularly among patients          of the disease and possibly low disease activity at that
with osteoblastic metastatses which could alone cause or       time. There were no prior Alkaline Phosphatase labs avail-
at least aggravate hypocalcemia secondary to Zoledronate       able for comparison. The patient started treatment with
therapy.                                                       Zoledronic Acid to ease pain and reduce risks of bleeding
	    Conclusion: Our case buttresses the current literature    secondary to increased bone vascularity prior to surgical
concerning severe hypocalcemia as a potential adverse          correction of ulnocarpal impaction.
outcome of zoledronate therapy. We report the first case            Discussion: Paget’s disease of the bone, also known
of severe Zoledronic acid induced hypocalcemia in blad-        as osteitis deformans, is a localized bone disorder that
der cancer patient with osteoblastic metastasis. Our case      affects the skeleton through increased bone remodeling.
highlights the need for greater awareness and precaution-      Paget’s disease is typically diagnosed during the evalua-
ary measures prior to the institution of IV zoledronate to     tion of pain in the weight baring bones of the axial skel-
prevent potentially life threatening hypocalcemia.             eton or after discovery of abnormally elevated alkaline
                                                               phosphatase. Paget’s disease primarily affects the axial
Abstract #515                                                  skeleton, pelvis, and skull with proximal long bones fre-
                                                               quently involved. Paget’s disease is predominately a poly-
PAGET’S DISEASE OF THE ULNA: A RARE                            stotic process rather than involving only one bone. Our
LOCATION OF MONOSTOTIC DISEASE                                 case is unique, as Paget’s disease is not typically found in
                                                               the upper limbs or as a monostotic process. The presenta-
Blake Elkins, MD, Sarah Fackler, MD                            tion of Paget’s in the forearm is exceedingly rare with very
                                                               few cases cited in the literature.
	   Objective: To describe a rare presentation of Paget’s           Conclusion: Paget’s disease of the bone is a meta-
disease in the ulna of a 52 year old female.                   bolic disease of abnormal bone turnover characterized by
    Case	 Presentation: The patient is a 52-year-old,          increased osteoclastic activity and disorganized bone for-
white female of Irish descent who presented to her pri-        mation. It generally affects the axial skeleton and weight
mary care doctor with a nine month history of left wrist       bearing long bones. Here we presented a case of mono-
pain and swelling without history of trauma. The pain was      stotic disease of the ulna, a rare location for Paget’s dis-
described as intermittent, then progressed to a chronic        ease of the bone.




                                                          – 82 –
                                     ABSTRACTS – Metabolic Bone Disease

Abstract #516                                                        	    Conclusion: Due to lack of renal lymphoid tissue, the
                                                                     existence of a primary renal NHL has been questioned.
HYPERCALCEMIA AND RENAL MASS                                         This presentation emphasizes its inclusion in the work
RECOGNIZING AN UNUSUAL DIAGNOSIS                                     up of a patient presenting with hypercalcemia and a renal
                                                                     mass.
Shuchi Gulati, MD, Harris Taylor, MD, Hamed Daw, MD
                                                                     Abstract #517
	    Objective: Hypercalcemia, an unusual complication
of Non Hodgkin Lymphoma (NHL) usually occurs late                    OSTEOGENESIS IMPERFECTA IN A
in the course of the disease. We discuss an unusual case             PREPUBERTAL GIRL TREATED WITH
of primary renal NHL presenting with hypercalcemia and               PAMIDRONATE - CASE PRESENTATION
acute renal failure.
	    Case	 Presentation: A 66-year-old male presented                Otilia Marginean, MD, Dana Bucuras, MD, Pavel
with a six week history of progressively worsening gait              Ecaterina, Ioan Simedrea MD, Maria Florea MD
instability, fatigue, unintentional weight loss of 20 lbs and
abdominal discomfort. Physical examination revealed no               	    Objective: Osteogenesis imperfecta (OI) is a congeni-
lymphadenopathy or hepatosplenomegaly. Total and ion-                tal disorder of bone fragility caused by mutations in genes
ized serum calcium were 15.5mg/dL and 1.73mmol/L                     that code for type I procollagen. Osteogenesis is an inher-
respectively (nl.8-10mg/dL and 1.15-1.35mmol/L). BUN                 ited disorder with severe damage of bone structure.
and creatinine were 38 and 3.3mg/dL, respectively. PTH               	    Case	Presentation: We present a case of a 14 years
was suppressed to 12pg/mL (nl.14-72 pg/mL) and PTHrP                 old female patient, L.V. transferred in July 2007 (at
was 1.8pmol/L (nl.<2 pmol/L). Calcitriol was not drawn               age 12 years) in our service from the Pediatric Surgery
on admission. Serum LDH was 399U/L (nl.100-220U/L).                  Department in a good and stabile state of health but with
Abdominal CT revealed a heterogeneous hyper-dense                    a full immobility, being incapable to walk because of ter-
right renal mass measuring 15x16x20 cm. with normal                  rible muscular and bone pain and because she felt anxi-
spleen, liver and left kidney. CT/PET/bone scan ruled out            ety being afraid of a new fracture. She was usually car-
involvement of other extra renal organs including lymph              ried by her mother or she used a wheel chair. Anamnesis
nodes. IV hydration, furosemide and bisphosphonates                  reveals 3 fractures of the right thighbone and 2 fractures
normalized serum calcium to 9.5mg/dl. Nephrectomy                    of the right tibia with approximately 4 cm shortness of the
was aborted due to excessive bleeding. Biopsy, however,              right foot, a mild postural ciphosis, toracal scoliosis, and
revealed a diffuse large B-cell lymphoma, non germinal               hiperlordosis. L.V. is the second child of a non-consan-
cell type. Immunohistochemical stains for CD 20, bcl-6               guineous couple, burst weight were 3100g, height 51cm,
and MUM-1 were positive; those for bcl-2, cyclin D1 and              APGAR is not known. Even from her first month of life
TDT were negative. Bone marrow aspirate was normo-                   the patient was registered in the Children Surgery Clinic
cellular. The international prognostic index of 5 put him            right hip dislocation. In our clinic the physical examina-
at high risk of CNS involvement. Chemotherapy was                    tion reveal short stature 143 cm (under percentile 5), bone
therefore started with intrathecal methotrexate along with           pain, anxiety, incapable to walk. The lab analysis reveals
CHOP and Rituxan. One year later repeat PET/CT showed                normal Calcium metabolism, (Ca, Ca++, alkaline phos-
no evidence of recurrence. Serum calcium was 9.6mg/dL.               phatases, calciuria, fosphaturia, PTH) were normal. The
	    Discussion: NHL may cause and can manifest solely               arms X-Ray detected fragility and poor bone quality and
as severe and symptomatic hypercalcemia. It is mediated              the legs’ X-Ray showed the deforming of the thighbone’s
by an increased serum concentration of PTHrP or cal-                 axe on both sides, deforming of the Coxa Vara, callous
citriol. Since calcitriol level was not measured and PTHrP           vicious, in the inferior third part of the thighbone diaphy-
was close to the upper limit of normal it is not possible            sis and in the half part of tibia and the right fibula, diffuse
to determine the relative contributions of each to hyper-            osteoporosis. The initial spine Dual X-Ray reveal spine
calcemia. Primary renal NHL is an unusual malignancy                 T score -4.7 and Z score -2.9, and hip t score -3.9. The
accounting for 0.7% of all extranodal lymphomas in North             patient received i.v. treatment with Aredia in a dose of
America and for 3% of all renal masses. Lesions which                0.5 mg/kg for 2 consecutive days. The cure treatment was
lack the typical radiologic features of the more common              repeated every three months, when the patient returns to
renal cell carcinoma should be considered for CT guided              the hospital. Between the pamidronate administrations the
percutaneous biopsy. This may prevent unnecessary                    girl received Calcium and Vitamin D daily. The control
nephrectomy since treatment of NHL is primarily sys-                 spine Dual X-ray (after 1 year of treatment) reveals a T
temic chemotherapy.                                                  score of -2.9 and Z score -2.3; on hip the T score were
                                                                     -3.3.


                                                            – 83 –
                                       ABSTRACTS – Metabolic Bone Disease

The clinical evolution was good L.V. can walk and go to            difference is more important at lumbar spine level. In the
school alone.                                                      36 month follow-up period, the hypogonadal patients had
	    Conclusion: Osteogenesis Imperfecta is a disease              higher bone loss at spine level: 8,47 ± 6,8% as compared
underdiagnosed in our country. Careful following the case          with eugonadal cases: -5.71 ± 5,51%. The risk of having
history, clinical and imagistic exams can sustain the diag-        bone demineralization is higher in hypogonadal patients,
nostic but it is necessary to have a national registry for this    at spine level (OR = 1,038) or osteoporosis (OR = 3,98),
disease. It is imperative necessary to have a high standard        compared with hip level (osteopenia: OR = 1,3, osteopo-
level genetic laboratory in order to establish the exact type      rosis OR = 1,904).
of this disorder. Bisphosphonates therapy that slows dawn          	    Conclusion: Physiological or secondary hypogonad-
bone resorption is well tolerated by children.                     ism impairs BMD in patients with secondary hyperpara-
                                                                   thyroidism. The effect is independent of age of the subject,
Abstract #518                                                      BMI, or lengths of hemodialysis.

HYPOGONADISM - AN ADDITIONAL RISK                                  Abstract #519
FACTOR FOR BONE LOSS, IN CASES WITH
SECONDARY RENAL HYPERPARATHYROIDISM                                PARATHYROID FUNCTION IN TUMOR-
                                                                   INDUCED OSTEOMALACIA (TIO)
Otilia Marginean, MD, Dana Bucuras, MD,
Simedrea Ioan, Pavel Ecaterina, MD,                                Zinnia San Juan, MD, Raymond Grenfell, III, MD,
Dragsineantu Daiana, MD                                            Brandy Panunti, MD, Allan Burshell, MD

	    Objective: Hypogonadism is associated with low bone           	    Objective: To describe serum phosphorus response to
mass, in men and women. ESRD associates multifactorial             hyperparathyroidism and hypoparathyroidism in TIO.
hypogonadism due to uremia, chronic illness, hyperpro-             	    Case	 Presentation: A 76-year-old female initially
lactinemia or dialysis process. We studied the relationship        presented in 1976 with osteopenia with a previous his-
between hypogonadism - BMD - bone turnover and bone                tory of hip fracture, persistently low phosphorus (1.1-2.3
loss in patients with secondary hyperparathyroidism.               mg/dl; normal 2.7-4.5 mg/dl), renal phosphate wasting
	    Methods: The study group comprised of patients                (TmPO4/GFR 1.2), undetectable 1,25-OH vitamin D3
diagnosed with secondary hyperparathyroidism form                  and elevated PTH (1600-1900 pg/ml; normal 12-72 pg/
all of the chronic hemodialised patients treated in the            ml). Medical treatment with calcitriol and phosphate sup-
Haemodialysis and Renal Transplantation Center form                plements was ineffective, hypophosphatemia worsened
the County Hospital nr.1. We diagnosed secondary                   and she developed hypercalcemia. At parathyroid sur-
hyperparathyroidism by means of repeated iPTH values               gery, three glands appeared abnormal and were removed,
(> 3xUNL), increased bone turnover markers. We also                except for 50 mg of the left lower gland. Following sur-
measured LH, FSH, PRL, Total testosterone and estradiol            gery, PTH, phosphorus and calcium levels normalized. In
levels. Gynecological and urological evaluations were              1998 she again presented with hyperparathyroidism and
also done. BMD was measured with DXA (anteroposte-                 underwent a second surgery which revealed growth of
rior technique, Delphi W device, Hologic Inc.).                    the remnant gland to 900 mg as well as fifth parathyroid
	    Results: From the total of 131 (66 men, 65 women)             gland in the left carotid sheath, which were both resected.
cases with secondary hyperparathyroidism, with a mean              She then developed hungry bone syndrome (undetectable
age 44,32 years, being in the hemodialisis treatment for a         PTH, calcium of 6.2 mg/dl, phosphorus of 1 mg/dl, ele-
period of 49,6 ± 43,72 months, 61 (46,5%) had hyponon-             vated alkaline phosphatase) and then hypoparathyroidism
adism. 39,4% of men had secondary partial testosterone             (undetectable PTH, calcium of 8 mg/dl, phosphorus of 3.7
deficiency, 27,7% of the females had secondary amenor-             mg/dl). TIO was suspected, an octreotide scan was posi-
eea due to hyperprolactinemia and uremia, and 9 women              tive, and MRI of the head confirmed two right-sided extra-
were in natural menopause. We observed significant dif-            cranial masses, consistent with meningiomas. Fibroblast
ference both in initial bone mass and bone loss speed, in          growth factor-23 (FGF23) was elevated at 4850 RU/mL
the hypogonadal group as compared with the eugonadal               (0-180). The patient refused neurosurgery. PTH gradually
group. There were no significant differences regarding             increased and phosphorus declined.
age, length of disease, type of disease, coexisting risk           	    Discussion: TIO is a rare syndrome characterized by
factors, BMI between the two subgroups. Initial BMD at             hypophosphatemia due to renal phosphate wasting, low
spine level was 0,811 ± 0,117 g/cm2 versus 0,918 ± 0,154,          serum 1,25-OH D3 levels, and osteomalacia. The proposed
T score = -4,298, p = 0,00006, total hip: 0,720 ± 0,13 ver-        mechanism is paraneoplastic secretion of phosphatonins,
sus 0,844 ± 0,113, T = -4,101, p=0,00011. Fig 1 and 2. The         such as FGF23, which inhibits phosphate transport and


                                                              – 84 –
                                    ABSTRACTS – Metabolic Bone Disease

reduces calcitriol production in the renal tubule usually      and malignancy. Among patients with severe hypercalce-
from mesenchymal or mixed connective tissue tumors.            mia (calcium level>14mg/dL) it is more common than
It may present with secondary and even tertiary hyper-         malignancy. It consists of a triad: hypercalcemia, renal
parathyroidism and tumor resection has been reported to        failure and metabolic alkalosis. The “modern version”
be curative. This is the 3rd case of TIO with a radiologic     was described in the setting of greater awareness of osteo-
diagnosis of a meningioma. Tertiary hyperparathyroid-          porosis and increased availability of over the counter
ism developed on at least two occasions which may be           calcium carbonate supplements for prevention. Daily ele-
related to the low calcitriol and phosphate replacements.      mental calcium intake of no more than 2 g/d is considered
On both occasions parathyroidectomy led to improvement         safe, but lower doses should be recommended for those
in serum phosphorus.                                           patients who have predisposing factors for hypercalcemia.
	    Conclusion: TIO may be associated with tertiary           The treatment for milk-alkali syndrome implies limit-
hyperparathyroidism. Induction of hypoparathyroidism           ing calcium and alkali ingestion and volume expansion.
improves the phosphorus levels in FGF23-mediated TIO.          Bisphosphonates contribute to hypocalcaemia.
Parathyroid function modulates phosphate levels in TIO.              Conclusion: This case illustrates that milk-alkali syn-
                                                               drome is also seen in patients self-treated for dyspepsia.
Abstract #520                                                  Its recognition remains very important for patient care. We
                                                               emphasize the importance of a good history taking, includ-
MILK-ALKALI SYNDROME IS A MAJOR                                ing over the counter medications and other remedies in
CAUSE OF SEVERE HYPERCALCEMIA                                  order to make an accurate diagnosis and treat accordingly.

Mona Shimshi, MD, FACE, Ramona Dadu, MD                        Abstract #521

	    Objective: To increase awareness of the milk-alkali       PRIMARY HYPERPARATHYROIDISM (PHP)
syndrome as a major cause of severe hypercalcemia and to       WITH NEURASTHENIC DEBUT
stress the importance of inquiring about over the counter
medication use.                                                Cristina Iuliana Bejnariu, MD, Pavel Suciu, MD, PhD
	    Case	 Presentation: We present a 59-year-old white
male who was admitted to our hospital for acute encepha-       	    Objective: To highlight the significance of parathy-
lopathy, severe hypercalcemia, metabolic alkalosis and         roids scintigraphy for every case with PHP.
acute on chronic renal failure. The patient had two hos-       	    Case	 Presentation: A 46-year-old woman with no
pitalizations in the previous year for severe hypercalce-      family history of MEN, monthly menstruation, no his-
mia of unknown etiology, although extensive workup has         tory of cervical irradiation presented with: asthenia, nau-
been performed. His past medical history was significant       sea, arrhytmia, depression, hypertension, polyuria and
for HTN, CKD, GERD, nephrolithiasis s/p JJ stent, but          polydipsia. The symptoms had appeared 6 months ago.
no nephrocalcinosis, and chronic alcoholism. Laboratory        Laboratory: persistent elevated total and ionized calcium,
data revealed macrocytic anemia, serum bicarbon-               hypercalciuria, hypophosphatemia, elevation of the alka-
ate=32 mmol/L, BUN=41 mg/dL, creatinine=3.35 mg/               line phosphatase, helicobacter pylori positive, euthyroid-
dL, GFR=19, Ca=15.4 mg/dL, Phoshorus=3.4 mg/dL,                ism, ATPO negative which leaded to PHP diagnose con-
Alb=4.5 g/dL. A review of old records demonstrated an          firmed by the elevated PTH level. Radiology: salt and
elevated calcium level, low-normal phosphorus level, a         pepper skull; subperiostal resorption of index finger; bone
suppressed PTH and low 25 vitamin D and 1,25 vitamin           cysts. Cervical ultrasonography (US): mixt nodule in the
D levels. Vitamin A, PTHrP, ACE, SPEP/UPEP, TSH, 24            lower pole of right thyroid lobe confirmed also by the
h urine calcium levels were all within normal range. The       computed tomography (CT). DXA: osteoporosis. Were
patient also had a normal skeletal survey, a 4 mm lung         performed right thyroid lobectomy and right parathy-
nodule on CT chest and a 7 mm non-obstructive left kid-        roidectomy (RP). Final pathology revealed lymphocytic
ney calculus. He underwent aggressive hydration, natri-        thyroiditis and one huge solid/cystic right inferior para-
uresis and biphosphonate treatment. By day 4 of hospi-         thyroid mass. Post-op the symptoms persisted beside the
talization his calcium level was 10.4 mg/dL, bicarbonate       hypercalcemia (HC) and elevated PTH level. Thyroid US:
level was 22 mmol/L and serum BUN/creatinine steadily          nodule hypoechogen in the lower pole of left thyroid lobe.
trended down to 16/1.81 mg/dL. On further questioning          An FNA biopsy was nondiagnostic. Because a parathyroid
he did admit to taking over the counter antacids for severe    adenoma (PA) was suspected in this location, PTH was
dyspepsia.                                                     measured in the aspirate. The decrease level of PTH in
     Discussion: Milk-alkali syndrome is the third leading     the aspirate of remaining nodule from the left thyroid lobe
cause of hypercalcemia after primary hyperparathyroidism       post right thyroid lobectomy infirmed source of PTH at


                                                          – 85 –
                                     ABSTRACTS – Metabolic Bone Disease

this level and we indicated a technetium Tc 99m sestamibi       49 mg/dL (6-22 mg/dL), creatinine of 2.5 mg/dL (0.8-1.4
parathyroid scan (TPS) which was negative. The patient          mg/dL), and albumin of 4.8 g/dL (3.5-5.0 g/dL). Her acute
refused other surgery. We initiated treatment with cinacal-     renal failure and hypercalcemia improved with hydration.
cet 30mg/day.                                                   Further work up for the etiology of the hypercalcemia
	    Discussion: The debut of PHP was atypical with             revealed a parathyroid hormone concentration of 22 pg/
neuropsychic, cardiovascular and gastrointestinal distur-       mL (10-55 pg/mL) and a vitamin D concentration of 338
bances (GID) at a middle - aged woman. DXA modifica-            ng/mL (32-100 ng/mL) (D2 component was 331.6 ng/mL).
tions are characteristic for PHP especially at forearm, the     The patient stated that vitamin D therapy had been started
favorite situs in PHP. Even the US and CT were typical for      6 months earlier during her rehabilitation following her
PA, the evolution after RP put in appearance parathyroid        pacemaker placement. Closer examination of the vitamin
hyperplasia. The cinacalcet decreased the HC but a few          D pill bottle revealed a dose of 50 international units (IU)
initially symptoms are still persistent after one month of      twice daily for maintenance therapy which was filled by
treatment the PTH level is still high which means that a        the pharmacy as 50,000 IU twice a day. The patient had
part of PHP symptoms are induced by the excess of PTH           been taking this dose of ergocalciferol for approximately
not by HC.                                                      six months. The vitamin D was held and hydrocortisone
	    Conclusion: Each US and CT has a sensitivity of            10 mg twice a day was started. Over the next four days the
60-70% and can mislead the localization of PA. TPS is           patient’s calcium concentration normalized.
the most successful procedure for a sensitive localiza-              Conclusion: Medication errors are the most frequent
tion (sensitivity 80%) for parathyroids. The GID of PHP         type of medical error associated with poor clinical events.
can be indistinct or superpose with GID induced by the          More practitioners are checking vitamin D in their patients,
cinacalcet. For low doses and in the initially stages of the    and errors in vitamin D prescriptions can lead to serious
treatment with cinacalcet the decrease of HC cannot be          adverse outcomes. Restricting the number of refills, and
accompanied by the decrease of PTH level.                       communication and sharing of information between the
                                                                physician, community pharmacists and patient remain an
Abstract #522                                                   important safeguard for preventing such errors.

MEDICATION ERROR- RISE OR FALL                                  Abstract #523

Harkesh Arora, MBBS, David C. Lieb, MD,                         COEXISTANCE OF PRIMARY
Joseph A. Aloi, MD                                              HYPERPARATHYROIDISM AND ACROMEGALY
                                                                ASSOCIATED WITH EMPTY SELLA SYNDROME
	    Objective: To describe the events that resulted in a
case of vitamin D toxicity.                                     Brittany Bohinc, MD, John Parker, MD, FACE, ECNU
     Case	 Presentation: 82-year-old Caucasian female
presented to her primary care physician after an acute epi-     	    Objective: To describe the case of hypercalcemia
sode of nausea and vomiting. She reported two weeks of          (HC) diagnosed with primary hyperparathyroidism (PHP)
worsening anorexia, decreased energy and polyuria. She          and acromegaly associated with empty sella (ES).
denied any mental status changes, fever, chills, dyspnea,       	    Case	Presentation: This is the case of a 59-year-old
abdominal pain or constipation. Past medical history was        black female with type 2 diabetes and stage III chronic
significant for mild congestive heart failure secondary         kidney disease (CKD) who was referred for evaluation
to an arrhythmia that was treated seven months earlier          of persistent HC, despite discontinuation of hydrochlo-
with atrioventricular junction ablation and pacemaker           rothiazide. She had been diagnosed with PHP18 months
placement. This necessitated a prolonged hospitalization        earlier, with calcium (Ca) of 11.1 mg/dL (normal, 8.4-
and rehabilitation. The patient’s primary care physician        10.2), parathyroid hormone (PTH) of 166 pg/mL (normal,
ordered a basic metabolic panel that revealed a calcium         17.3-72.9), 1,25-di-hydroxy vitamin D [1,25(OH)D] of
concentration of 14.1 mg/dL (8.4-10.5 mg/dL). Repeat test-      56.8 pg/mL (normal, 15.9-55.6), and 25-hydroxy vita-
ing showed persistent hypercalcemia (15mg/dL). She was          min D [25(OH)D] of 9.6 ng/mL. As treatment of HC, she
admitted to the hospital and aggressive intravenous fluids      had been given cinacalcet. At our evaluation, she noted
were given. Her medications included warfarin, aspirin,         bone pain, myalgias, fatigue, and poor glycemic control.
calcium, vitamin D, simvastatin, metoprolol, ibandronate,       Physical exam demonstrated mildly coarsened features
furosemide and a daily multivitamin. Physical examina-          and a nodular goiter. Neck sonography confirmed het-
tion revealed a normal neurological exam. The remainder         erogenous multinodular goiter and probable parathyroid
of her metabolic panel was significant for hyponatremia         adenoma. Laboratory investigation revealed an elevated
at 132 mmol/L (136-145 mmol/L), blood urea nitrogen of          insulin-like growth factor-I (IGF-I) of 316 ng/mL [age/


                                                           – 86 –
                                    ABSTRACTS – Metabolic Bone Disease

sex-matched reference range 81-225] and was elevated           the lowest recorded level being 10.7 ng/mL. Another 15
at 510 ng/mL upon repeat testing. Glucose tolerance            patients were classified as insufficient. In total, 24 of the
testing did not appropriately suppress growth hormone          29 (82.7%) were deficient or insufficient in vitamin D.
(GH). Magnetic resonance imaging (MRI) of the pituitary        All Hispanic and African American patients were insuf-
discovered ES, with no evidence of pituitary adenoma.          ficient or deficient, with the lowest levels seen in these
Prolactin was normal. Based upon these clinical data, a        populations.
diagnosis of acromegaly was made.                                   Discussion: DVD has recently been recognized as a
	    Discussion: In our case, HC was mediated by a com-        contributor to beta cell dysfunction and decreased insu-
bination of PHP and acromegaly. PTH induces increased          lin sensitivity in type 2 diabetes.2 It has also been linked
Ca entry from the intestine and kidney via increase in         to an increased risk of GDM.3 The prevalence of DVD
the production of 1,25(OH)D at the proximal convo-             among pregnant women in the North has been previously
luted tubule. GH also activates 25(OH)D conversion to          reported.4 We wished to describe the prevalence of vita-
1,25(OH)D at the site of the renal tubules, leading to         min D deficiency among young women with GDM living
concomitant increase in serum Ca. Our patient had intrin-      in the sunny climate of coastal North Carolina (latitude
sic elevation in PTH and GH, but only minor elevation          34.22 N). Although we were expecting a good percentage
in 1,25(OH)D (accounting for vitamin D deficiency and          of our patients to have DVD, we were surprised to find
CKD); despite this, the combined effects of PTH and GH         that 82.7% are vitamin D deficient/insufficient. DVD in
excess resulted in HC. Coexistence of acromegaly and           this population is problematic, with profound implications
ES is another interesting facet of this case. Acromegaly       for both the mother and the newborn. Since a newborn’s
is most commonly caused by a GH-secreting pituitary            25(OH)D concentration is approximately half that of its
adenoma and its association with ES is rare. It is likely      mother’s5, it is not surprising that there is an increasing
that the ES resulted from clinically silent infarction of a    frequency of childhood rickets and other autoimmune
pituitary adenoma.                                             disease. Although a single-center, small cohort study, the
	    Conclusion: HC has numerous causes. One should            high prevalence of DVD in this population may help raise
pursue specific etiology, considering acromegaly. While        awareness among endocrinologists seeing young patients
coexistence of PHP and acromegaly has been described           with GDM. Whether the degree of DVD has confounding
(notably in multiple endocrine neoplasia type 1), to our       effects on glycemic control, complications of pregnancy,
knowledge this is the first case description of PHP in the     development of other autoimmune pathology, or effect on
setting of acromegaly, diagnosed without pituitary ade-        the vitamin D status of the breastfeeding infant is subject
noma, but with ES.                                             for further research.
                                                               	    Conclusion: At our coastal North Carolina practice,
Abstract #524                                                  82.7% of our GDM cohort seen between August 2008 and
                                                               December 2009 were vitamin D deficient, despite sunny
HIGH PREVALENCE OF HYPOVITAMINOSIS D                           weather and supplementation with prenatal vitamins.
IN YOUNG, GESTATIONAL DIABETICS LIVING
IN THE SOUTH                                                   Abstract #525

Brittany Bohinc, MD, John Parker, MD, FACE, ECNU               SEVERE HYPERCALCEMIA IN A YOUNG
                                                               PATIENT WITH “THYROIDALIZED”
     Objective: To characterize the prevalence of vitamin      PARATHYROID ADENOMA
D deficiency (DVD) in a cohort of women with gesta-
tional diabetes (GDM) living in the southern US.               Shadi Barakat, MD, Stephen Brietzke, MD
     Case	 Presentation: Retrospective chart review of
all patients with GDM referred to our practice August          	    Objective: Parathyroid adenoma is the most com-
2008-December 2009. Those with co-morbid conditions            mon cause of Primary hyperparathyroidism. Most patients
predisposing to DVD, including sprue, history of gastric       with primary hyperparathyroidism presents with mild, if
bypass surgery, malabsorption syndromes, chronic kidney        any, symptoms of hypercalcemia because they usually
disease, or liver disease were excluded. All patients were     present with modest increase with serum calcium level.
taking prenatal vitamins (400 IU vitamin D3). Sufficient       Conversely, severe symptomatic hypercalcemia, espe-
25-hydroxyvitamin D (25(OH)D) levels were character-           cially in a young patient, should raise concern for parathy-
ized as > 32 ng/mL, insufficient levels were classified as     roid carcinoma.
20-31 ng/mL, and deficient levels were < 20 ng/mL.1            	    Case	Presentation: A 23-year-old, otherwise healthy,
     Results: Twenty-nine patients met inclusion crite-        Caucasian male, sought medical attention for evaluation of
ria, and of these, 9 were vitamin D deficient (31%) with       severe abdominal pain. On one occasion, it was associated


                                                          – 87 –
                                     ABSTRACTS – Metabolic Bone Disease

with vomiting of a blood clot, and two episodes of melena.      phlebotomy with varying compliance. His father & two
Laboratory tests revealed elevated alkaline phosphatase of      sisters also suffered from hemochromatosis. Laboratory
242U/L, and calcium of 14.2 mg/dl. He was treated with          studies showed calcium of 12.5 mg/dL (normal 8.6-10.2)
intravenous normal saline infusion, calcium remained            with intact PTH value of 32.5 (normal 10-65) pg/mL, cho-
elevated and iPTH was 407 pg/ml. An ultrasound of the           lesterol 254 mg/dL, LDL 184 mg/dL, TSH 1.0 uU/mL.
neck revealed a 1.9 x 1.2 x 1.4 cm hypoechoic nodule            US of the thyroid revealed normal sized thyroid with a
with internal vascularity inferior to the left thyroid lobe,    4mm right nodule. A DEXA scan was compatible with
and a Sestamibi scan showed increased uptake in the same        osteopenia. The patient underwent a Minimally Invasive
region. The patient was taken to the operating room for         Radioguided Parathyroidectomy of a left upper adenoma.
parathyroidectomy with limited neck exploration. The            The procedure involved a high resolution sestamabi scan
endocrine surgeon found a large pale colored lesion adher-      on the morning of surgery. In the OR, a hand held gamma
ent to the inferior pole of the thyroid. An excision of 5       radiation detecting probe was used to map radioactivity in
lymph nodes, parathyroidectomy and left thyroid lobec-          all quadrants of the neck and detected a left upper para-
tomy was performed, and an intra-operative iPTH level           thyroid adenoma. PTH production was found to be 320 (nl
dropped from 329 pg/ml to 45.8 pg/ml. Patient recovered         30-80) units and was diagnostic of parathyroid adenoma.
well after the surgery with calcium level of 9.5 mg/dl on       The other glands were anatomically normal & physiologi-
post-op day #1. Gross pathology was normal appearing            cally dormant. The patient’s calcium level was 9.5 with
thyroid with parathyroid tissue. The microscopic evalua-        PTH of 5 a month after surgery.
tion showed 5 out of 5 benign lymph nodes, parathyroid               Discussion: The endocrine manifestations of hemo-
adenoma without evidence of carcinoma, and nodular              chromatosis usually lead to hypofunction of different
hyperplasia of the thyroid with one microscopic focus of        endocrine glands including pancreas, gonads and thyroid.
parathyroid tissue.                                             Primary hyperparathyroidism in a patient with hemochro-
	    Conclusion: Sporadic primary hyperparathyroidism           matosis has not been reported in the literature, to the best
is usually caused by parathyroid adenomas. Ectopic and          of our knowledge. One of the most common confusion
super numeracy parathyroid glands are common. Entirely          areas in the diagnosis of primary hyperparathyroidism is
thyroidal parathyroid adenomas have been described.             hypercalcemia with a “normal” PTH. Normal parathyroid
Severe hypercalcemia (≥ 14 mg/dl) was found in 65 –             glands should stop production of PTH in a setting of non-
75 % of the cases of parathyroid carcinoma and should           PTH mediated hypercalcemia. Review of literature sug-
always prompt diligent search to exclude this probability.      gests that about 15% of cases of primary hyperparathy-
The histopathological distinction between an adenoma            roidism show “normal” PTH levels.
and a carcinoma is sometimes challenging and usually is              Conclusion: Primary hyperparathyroidism in a patient
based on the basis of local invasion of contiguous struc-       with hemochromatosis is extremely rare. Detectable PTH
tures, or lymph nodes or distant metastasis. The coinci-        in the face of hypercalcemia should be considered primary
dence of a thyroid adenoma with non-invasive intra-thy-         hyperparathyroidism until proven otherwise.
roidal parathyroid island without pathological evidence of
malignancy is a unique aspect of this case.                     Abstract #527

Abstract #526                                                   FUNCTIONAL HYPOPARATHYROIDISM AND
                                                                TETANY IN CELIAC DISEASE
PRIMARY HYPERPARATHYROIDISM
IN A PATIENT WITH HERIDITARY                                    Nagashree Gundu Rao, MD, Ricardo Balestra, MD
HEMOCHROMATOSIS
                                                                	    Objective: To recognize the etiology of hypocalcemia
Richard W. Pinsker, MD, FACE,                                   and functional hypoparathyroidism in celiac disease.
Neil Pathak, Mohan Sharma, MD                                        Case	Presentation: A 39-year-old African-American
                                                                woman with a history of recently diagnosed celiac dis-
	    Objective: To describe an unusual occurrence of pri-       ease and pernicious anemia, presented with sudden onset
mary hyperparathyroidism in a patient with hereditary           of painful muscle spasms involving the hands, feet and
hemochromatosis. To describe a ‘normal’ PTH level in a          face with symptoms of jaw locking. Physical examination
patient with primary hyperparathyroidism.                       revealed hypertension (no prior history of hypertension)
     Case	 Presentation: A 37-year-old male with a his-         and a positive Trousseau’s sign. She was found to have
tory of hemochromatosis, hyperlipidemia, and GERD,              serum calcium of 5.5 mg/dl (8.5-10.6), ionized calcium of
presented for a routine visit. His hemochromatosis was          0.73 mmol/l (1.1-1.4) and magnesium level of 0.3 mg/dl
diagnosed several years ago and was treated with regular        (1.7-2.8) Additional laboratory tests showed phosphorus


                                                           – 88 –
                                     ABSTRACTS – Metabolic Bone Disease

of 3.6 mg/dl (2.5-4.5), low 25-hydroxy-vitamin D of             	    Case	Presentation: A 56-year-old male with abdomi-
<7 ng/ml (35-55), low 1,25-dihydroxy-vitamin D of 10            nal pain and nausea was found to have serum a calcium of
pg/ml (15.9-55.6) and normal thyroid function tests. The        14.2 mg/d (albumin 3.7g/dL) with an appropriately sup-
intact parathyroid hormone (iPTH) level of 36 ng/dl (12-        pressed parathyroid hormone (<3 pg/mL), a low 25-OH
65) was inappropriately low for her calcium. The patient’s      Vitamin D (26 ng/mL) and normal 1,25-(OH)2D3 (57
symptoms of tetany and hypertension resolved with intra-        pg/mL). Twenty-four hour urine collection revealed the
venous repletion of calcium and magnesium. With the             presence of calciuria. SPEP and UPEP were negative
correction of hypomagnesemia, iPTH increased to 111 ng/         for monoclonal gammopathy. An elevated PTHrP of 3.6
dl. The corresponding calcium was 8.2 mg/dl. The patient        pmol/L prompted a work up for malignancy. CT scan of
was then started on oral magnesium, calcium and vitamin         the chest revealed numerous pulmonary parenchymal
D supplements. Her low magnesium levels were likely             nodules bilaterally and marked diffuse lymphadenopathy.
related to her gastrointestinal losses secondary to underly-    An excisional biopsy of a large right axillary lymph node
ing celiac disease                                              demonstrated non-necrotizing granulomatous inflam-
     Discussion: Hypocalcemia in celiac disease can be          mation consistent with sarcoidosis with no evidence of
caused by vitamin D deficiency, autoimmune hypopara-            malignancy. Histochemical stains for fungal organisms
thyroidism or concomitant hypomagnesemia. Vitamin               and acid-fast bacilli were negative. Immunohistochemical
D deficiency however, is characterized by low phospho-          testing for PTHrP within the granulomatous tissue was
rus and elevated PTH. The classic sign of severe hypo-          positive. After treatment with IV hydration and steroids,
magnesemia (<1.2 mg/dl) is hypocalcemia. One-third of           the hypercalcemia resolved and PTHrP levels were found
the dietary magnesium is absorbed in the small bowel.           to have normalized to 0.5 pmol/L.
Hypomagnesemia and hypocalcemia are seen in celiac              	    Discussion: Hypercalcemia is a well established met-
disease due to gastrointestinal losses and malabsorptive        abolic abnormality associated with sarcoidosis. The com-
state. There is an intricate interplay between calcium and      monly accepted mechanism of hypercalcemia in sarcoid-
magnesium metabolism. Hypomagnesemia is known to                osis involves elevated levels of hydroxylated vitamin D
cause hypocalcemia by decreasing the secretion of PTH,          from sarcoid activated macrophages. Only two case reports
inducing end-organ resistance to PTH and impaired               have previously noted immunohistochemical detection of
1-hydroxylation of 25-hydroxy vitamin D. This explains          PTHrP antigen in sarcoid granulomata. PTHrP has been
the blunted response of PTH to the low vitamin D and low        shown to stimulate renal 1-α hydroxylase resulting in
calcium in this patient. Further, the increase in iPTH after    increased production of 1-25(OH)2D3. Increased levels
the correction of hypomagnesemia goes against autoim-           of PTHrP in sarcoid tissue suggest a possible additional
mune hypoparathyroidism. Interestingly, hypomagnese-            source for vitamin D hydroxylation and hypercalcemia.
mia has also been implicated in the pathogenesis of hyper-      Although the source of PTHrP in sarcoidosis is unclear,
tension by potentiating vasoconstriction. This is supported     it has been shown that PTHrP production in human squa-
by the resolution of hypertension with the correction of        mous cell lung cancer is stimulated by tumor necrosis fac-
hypomagnesemia, as seen in this patient.                        tor alpha (TNF-α) and interleukin (IL)-6. Elevated levels
     Conclusion: Functional hypoparathyroidism can lead         of TNF-α and IL-6 have been demonstrated in bronchoal-
to lethal complications, unless promptly recognized and         veolar lavage fluid in sarcoidosis, suggesting a possible
treated.                                                        mechanism of elevated PTHrP. Furthermore, it has been
                                                                demonstrated that glucocorticoid use inhibits PTHrP
Abstract #528                                                   expression in vitro which could explain the sustained reso-
                                                                lution of hypercalcemia and elevated PTHrP after steroid
PARATHYROID HORMONE RELATED                                     therapy.
PROTEIN: AN UNUSUAL MECHANISM FOR                               	    Conclusion: PTHrP may be a possible mediator of
HYPERCALCEMIA IN SARCOIDOSIS                                    hypercalcemia in sarcoidosis. The differential diagnosis of
                                                                PTHrP-induced hypercalcemia should include sarcoidosis
Armand Ara Krikorian, MD, Sapna S. Shah, MD,                    and further research is needed to establish the incidence
Jay K. Wasman, MD, Abdallah Kamouh, MD                          and source of PTHrP in sarcoidosis.

	   Objective: To describe parathyroid hormone related
protein (PTHrP) as a mediator of hypercalcemia in
sarcoidosis.




                                                           – 89 –
                                     ABSTRACTS – Metabolic Bone Disease

Abstract #529                                                    and can be used as an initial screening tool. These are
                                                                 simple to use and can help identify which patients should
SCREENING FOR OSTEOPOROSIS IN                                    undergo DXA scans.
MALE VETERANS: PERFORMANCE OF
OSTEOPOROSIS SCREENING TOOLS                                     Abstract #530

Soe Naing, MD, MRCP, Tin Tin Kyaw, MD,                           MULTI-FACTORIAL RESISTANT
Jian Huang, MD                                                   HYPOCALCEMIA IN AN ONCOLOGY PATIENT
                                                                 BEING TREATED FOR BONE METASTASIS:
	    Objective: To determine whether the Osteoporosis            WHEN BISPHOSPHONATE USE AND VITAMIN D
Self -assessment Tool (OST) and Men Osteoporosis Risk            DEFICIENCY MEET GLUCOCORTICOIDS
Estimation Score (MORES) can be used as initial screen-
ing tools to predict osteoporosis in male veterans.              Isabelle Zamfirescu, MD, Harold E. Carlson, MD,
	    Methods: This study is a retrospective cross sectional      Herman Katz, MD
study. Male veterans who underwent dual x-ray absorpti-
ometry (DXA) scan from 12/01/2004 to 11/30/2006 were             	    Objective: This case illustrates the potential danger of
studied. They were considered to have at least one risk          hypocalcemia occurring in routine treatment for oncologic
factor for osteoporosis when they were selected for bone         complications of bone metastasis.
density scan. OST index and MORE scores were calcu-              	    Case	 Presentation: Oncology patients with meta-
lated in these patients. General Electrics, Lunar Prodigy        static bone lesions commonly receive frequent bisphos-
Advance DXA scan was used to measure bone density in             phonate administration in treatment of bone metastasis
all patients. Osteoporosis was defined as a DXA T score          and at times require high dose glucocorticoids for spinal
of –2.5 or less in the spine, total hip, or femoral neck. OST    cord compression. As with many chronic illnesses, onco-
index was calculated as 0.2x (weight in Kg-age in years).        logic patients also have high rates of vitamin D deficiency.
The MORES included 3 variables—age, weight, and his-             We present a case of resistant hypocalcemia in a patient
tory of chronic obstructive pulmonary disease.                   with unrecognized vitamin D deficiency who had been
	    Results: 132 (31%) of 421 men, with a mean age              receiving monthly bisphosphonate infusions for treatment
of 71.3 years (26-91) and a mean weight of 85.0 kg (47-          of metastatic colon cancer in whom the hypocalcemia
154), had osteoporosis. 316 (75%) were White, 57(13.5%)          began after initiation of high dose glucocorticoids for cord
Hispanic, and 20(4.8%) African-American. The OST                 compression. Treatment with high doses of oral calcium,
index ranged from –8 to 20. Using an OST cutoff index            calcitriol and ergocalciferol had little effect in correction
of 3, we predicted osteoporosis with a sensitivity of 80%,       of hypocalcemia in the patient who required intravenous
a specificity of 45% and the area under the curve (AUC)          calcium for several days. Ultimately the hypocalcemia
of 67%. The MORE scores ranged from 0 to 13. Using a             improved as glucocorticoids were reduced and continued
MORE cutoff score of 6, we predicted osteoporosis with a         therapy with high doses of calcium and vitamin D.
sensitivity of 75%, a specificity of 55% and the area under      	    Discussion: This case demonstrates resistant hypo-
the curve of 70%. Using both OST cutoff index of 3 and           calcemia caused by multiple factors in combination. We
MORE cutoff score of 6, sensitivity improved to 89%,             hypothesize that there were three main interrelated causes
specificity to 61% and the area under the curve to 89%.          for the patient’s hypocalcemia. First, the patient had
	    Discussion: Several screening tools have been stud-         received treatment with intravenous bisphosphonate on a
ied to help clinicians determine the risk of osteoporosis        monthly basis. Several cases of hypocalcemia associated
in women. Relatively few screening tools have however            with bisphosphonate use have been reported in oncology
been suggested in men. Simple and effective tools are            patients due to suppression of bone resorption by osteo-
needed to identify men at risk for osteoporosis. OST and         clasts and a resulting inability to respond to hypocalcemia
MORES have been proposed as initial screening tools for          by liberation of skeletal calcium. In the current patient,
men but there were very limited information on their per-        the hypocalcemia began shortly after the initiation of
formance in male veterans. Their sensitivity, specificity        high dose glucocorticoid therapy for treatment of cord
and the area under the curve in our study were lower than        compression symptoms and improved only as the gluco-
that was reported in other studies. However these results        corticoids were tapered, thus indicating a critical role for
significantly improved when both OST and MORES crite-            glucocorticoids in the development and persistence of the
ria were applied.                                                hypocalcemia. While glucocorticoids are known to lead to
	    Conclusion: Combined use of OST and MORES                   negative calcium balance they rarely cause hypocalcemia
improves the prediction of osteoporosis in male veterans         when given alone. Finally, our patient was also found to



                                                            – 90 –
                                     ABSTRACTS – Metabolic Bone Disease

be profoundly vitamin D deficient and this proved difficult           Discussion: Little over 100 cases of mediastinal para-
to correct. This vitamin D deficiency may have impacted          thyroid cysts have been reported with some detail in the
skeletal bone resorption. It is also possible that high doses    literature. Parathyroid cysts are quite rare, representing
of glucocorticoids also led to decreased vitamin D absorp-       0.6% of all parathyroid and thyroid lesions. Only 10%
tion or metabolism and ultimately decreased intestinal cal-      of all parathyroid cysts are found in the mediastinum.
cium absorption. We explore the causes of hypocalcemia           Parathyroid cysts associated with raised serum intact PTH
in this patient based on current literature.                     and calcium and low phosphate are classified as functional
	    Conclusion: Glucocorticoid use for spinal cord com-         cysts. It remains unknown how cystic PTH enters the cir-
pression in this patient with a history of bisphosphonate        culation to raise serum PTH. Confirming elevated PTH
use and vitamin D deficiency led to the development and          levels on FNA can make the preoperative diagnosis of a
persistence of a dangerous degree of hypocalcemia.               parathyroid cyst. Surgical resection is the treatment of
                                                                 choice for functional mediastinal parathyroid cysts.
Abstract #531                                                         Conclusion: Functioning mediastinal parathyroid
                                                                 cysts are a rare cause of hypercalcemia. In order to avoid
FUNCTIONING MEDIASTINAL                                          unnecessary surgery, it is important to include ectopic
PARATHYROID CYST                                                 sources of parathyroid hormone in the differential diagno-
                                                                 sis of hypercalcemia.
Janna Cohen-Lehman, MD, Stuart Weinerman, MD,
Ageliki Valsamis, DO                                             Abstract #532

	    Objective: Hypercalcemia due to a functioning para-         HYPERCALCIURIA ASSCOCIATED
thyroid cyst is rare, and when located in the mediastinum        OSTEOPOROSIS: ARE WE MISSING THE BOAT?
can present a diagnostic challenge to the treating physi-
cians. We describe the case of a 79-year-old female who          Sunil Asnani, MD, FACE, Romil Patel, Reema Salat,
presented with hypercalcemia due to a functioning medi-          Ushir Patel, MD, Neena Penagaluru, MD
astinal parathyroid cyst, the identification of which was
elusive.                                                         	    Objective: To present a case of severe pre-menopausal
     Case	 Presentation: A 79-year-old female presented          osteoporosis in a young woman.
to another institution with altered mental status. She was       	    Case	Presentation: A woman in her 40s was evalu-
diagnosed with primary hyperparathyroidism with serum            ated for back pain and loss of 2 inches in height. She
calcium of 18.2 mg/dL (8.4 – 10.5 mg/dL) and parathyroid         denied depression and was menstruating regularly. She
hormone (PTH) level of 2115 pg/mL (15 – 65 pg/mL), and           had a history of primary hypothyroidism and nephrolithia-
right superior parathyroidectomy was performed. Calcium          sis. Family history was remarkable in that her mother had
and PTH levels remained elevated postoperatively, and            severe osteoporosis. Physical examination was unremark-
the patient was transferred to our institution. A computed       able; she was lean. Bone densitometry (DEXA) revealed
tomographic (CT) scan of the chest revealed a simple cys-        T and Z scores of -3.2 and -3.1 respectively at the lum-
tic structure in the anterior mediastinum measuring 6.9 x        bar spine, and -1.5 and -1.2 respectively at the right hip.
4.0 cm, which was thought to represent either a thymic or        Pertinent labs: Serum Calcium 10.1 mg/dl (8.5-10.6);
pericardial cyst. Sestamibi scintigraphy suggested a pos-        25(OH) Vitamin D 36.2 ng/ml (32-100); intact PTH 38 pg/
sible single parathyroid lesion extending posteriorly from       ml (15-65); and TSH 2.6 µIU/ml (0.45-4.5); Endomysial
the lower pole of the left thyroid lobe. It also demonstrated    Antibody IgA was negative. The 24-hour-urine calcium
a nonspecific large photopenic area with a thin irregular        excretion was elevated at 618.8 mg (100-300); a repeat
rim of activity in the anterior mediastinum correspond-          24-hour study confirmed the elevated excretion at 537.5
ing to the simple cystic structure identified on CT scan.        mg (100-300). A diagnosis of Idiopathic Hypercalciuria
She underwent cervical re-exploration, which was again           was made and treatment with hydrochlorothiazide was
unsuccessful at localizing the source of PTH. The patient        initiated. Follow-up assessment has documented improve-
finally underwent fine needle aspiration (FNA) of the            ment in hypercalciuria.
mediastinal cyst, which resulted in a PTH of 364,800 pg/         	    Discussion: A case series of osteoporotic, premeno-
mL. Median sternotomy was performed, and the pathol-             pausal women found that 56% had idiopathic osteoporosis
ogy was consistent with a parathyroid cyst. Calcium and          and 44% had secondary osteoporosis. Almost 30% of these
PTH levels normalized, and her calcium levels remain             women had vertebral fractures. Hypercalciuria was seen in
stable 5 months after surgery.                                   nearly 40% of patients with idiopathic osteoporosis. It has




                                                            – 91 –
                                       ABSTRACTS – Metabolic Bone Disease

been suggested that idiopathic hypercalciuria is transmit-         malnutrition, infusion of iron dextran, use of vitamin D
ted as an autosomal dominant trait with gene defects local-        and calcium based phosphate binders and insulin use in
ized to chromosomal areas 9q33.2-q34.2 and 1q23-q24. It            patients with diabetes mellitus. All these are very com-
is likely that the common form of hypercalciuria is a com-         mon in patients with ESRD; obesity and diabetes are
plex genetic disorder that is influenced by environmental          other common co-morbidities. Our patient was interest-
factors such as dietary intake. A family history of osteopo-       ing due to her lean habitus, normoglycemia and normal
rosis is frequently associated with this disorder. Patients        calcium, phosphate and PTH levels, a scenario that has
with idiopathic hypercalciuria should be advised to adhere         been reported with increasing frequency of late and which
to a low calcium diet; hydrochlorothiazide is the treatment        raises the possibility that other unknown abnormalities of
of choice if there is evidence of bone demineralization or         mineralization could also be involved in the development
recurrent renal stones despite dietary modification.               of calciphylaxis in ESRD patients.
      Conclusion: It is critical to identify patients with this    	    Conclusion: Elevated levels of parathyroid hormone
condition as a distinct, treatable subset of idiopathic osteo-     (PTH) and a high calcium-phosphorous product were
porosis given both the potential for renal dysfunction due         initially thought to be pivotal in the pathogenesis of cal-
to recurrent nephrolithiasis and the potential for bone dis-       ciphylaxis. The case described herein demonstrates that
ease due to worsening mineralization.                              such laboratory abnormalities are not invariably present.

Abstract #533                                                      Abstract #534

NORMOCALCEMIC CALCIPHYLAXIS: A NEED                                OSTEOPOROSIS SCREENING IN WOMEN
TO REEXAMINE THE PATHOGENESIS OF                                   ABOVE THE AGE OF 65 YEARS IN A
UREMIC ARTERIOLOPATHY                                              TEACHING PRACTICE

Sunil Asnani, MD, FACE, Ezinne Nwotite, MD,                        Abeer W. Anabtawi, MD, Mohammad Titi, MD,
Nduche Onyeaso, MD, Elizabeth Onyeaso, MD,                         Leela Mathew, MD
Swaleha Mahpara, MD
                                                                   	    Objective: Study aims at evaluating compliance rate
	    Objective: To describe a case of normocalcemic                of primary care physicians in a teaching clinic based with
calciphylaxis.                                                     osteoporosis screening based on United States Preventive
	    Case	Presentation: A 70-year-old woman with end-              Services Task Force (USPSTF) guidelines for screening
stage renal disease on hemodialysis for 5 years presented          females above the age of 65 years for osteoporosis using
with extremely tender skin lesions, distributed all over the       DEXA scan.
lower abdomen and lower extremities. The lesions were              	    Methods: A retrospective review of electronic medi-
2-5 cm extremely tender ischemic/necrotic ulcers with              cal records (EMR) of all females between the age of 65
eschars. Laboratory evaluation showed corrected calcium            and 75 years who were followed for at least 1 year or more
of 9.7 mg/dl (8.5-10.5), phosphate 2.7 mg/dl (2.5-4.6) and         by one of seven primary care physicians (PCP). Multiple
PTH 54.5 pg/ml (14-72). She had been on prophylaxis                categories were reviewed including physician recommen-
against hypercalcemia and secondary hyperparathyroid-              dation for osteoporosis screening with DEXA scan; nota-
ism with paricalcitol and cinacalcet. A clinical diagnosis         tion that DEXA is inappropriate based on co-morbidities;
of calciphylaxis was made and was confirmed by punch               patient refusal of screening; documentation of osteoporo-
biopsy of the skin. She was treated with high dose sodium          sis screening in the health care maintenance sections by
thiosulfate.                                                       scanning DEXA scan results in the EMR.
	    Discussion: Calciphylaxis, also known as calcific             	    Results: The records of 143 female patients were ana-
uremic arteriolopathy, is a rare but serious disorder of           lyzed. A total of 104 patients had their risk for osteoporosis
vascular calcification that leads to ischemia and necro-           and the need for screening addressed by their PCP [over-
sis of skin and soft tissue, and occurs in about 1-4% of           all 73% (range 56-82%)]. DEXA scan was performed on
ESRD patients. The pathophysiology of calciphylaxis is             98 patients while 6 patients refused. Twenty five patients
poorly understood. Putative mechanisms of pathogenesis             had a DEXA scan, but there was no documentation at the
include abnormalities in coagulation, defects in inhibi-           Health Care Maintenance (HCM) section in the EMR
tors of mineralization (Fetuin-A and Matrix Gla protein)           (24%).
and an increased calcium-phosphate product (hypercal-              	    Discussion: Little and variable data are available on
cemia, hyperphosphatemia and secondary hyperparathy-               the national compliance rate for osteoporosis screening in
roidism). Associated trigger factors include weight loss,          a primary care setting. A recent study estimated the mean



                                                              – 92 –
                                    ABSTRACTS – Metabolic Bone Disease

compliance rate to be 56% [1]. Comparatively, our study        volume depletion may worsen the hypercalcemia. PTH is
shows improved compliance rate of 73%. However, our            further suppressed by hypercalcemia. This cyclic patho-
study was based on USPSTF guidelines, newer guide-             physiology maintains hypercalcemia and alkalosis as long
lines of the National Osteoporosis Foundation advocates        as calcium and alkali are taken in by mouth.
screening to include males above the age of 70 years, all      	    Conclusion: MAS is making a resurgence. A com-
postmenopausal females and males above the age of 50           plete history remains the key to the diagnosis. Restoration
years with risk factors for osteoporosis.                      of normal renal function depends on the duration of hyper-
	    Conclusion: Since morbidity, mortality and health         calcemia with acute cases having a better prognosis. If
care cost of osteoporosis are rising; prevention, detection    unrecognized and left untreated, MAS can lead to meta-
and treatment of osteoporosis should be a mandate for pri-     static calcification and renal failure.
mary care offices. More emphasis on the importance of
adequate patient education and physician documentation         Abstract #536
is needed.
                                                               INADEQUEATE VITAMIN D LEVELS IN
Abstract #535                                                  AN OSTEOPOROTIC WOMAN WITH
                                                               CELIAC DISEASE
MILK ALKALI SYNDROME:
OLD DISEASE, MODERN VERSION                                    Jose Guillemo Jiménez-Montero, MD, FACE,
                                                               Alexandra Rosabal-Arce
Danielle Erin Lann, MD, Sunil Asnani, MD,
Anup Ohri, MD                                                  	    Objective: To present a case of secondary osteoporo-
                                                               sis in a middle age woman due to with celiac disease and
	    Objective: To describe Milk Alkali Syndrome (MAS)         chronic steroid treatment.
as a re-emerging etiology of hypercalcemia                     	    Case	 Presentation: A 51-year-old female patient
	    Case	Presentation: A 62-year-old woman presented          with past history of myalgias, lumbar pain, and fatigue
with altered mental status, nausea and vomiting. She had       was referred because of osteoporosis. She was treated
thyroidectomy 2 weeks prior to admission for a multi-          with analgesics and steroids during the last 5 years with-
nodular goiter with compressive symptoms. She was dis-         out relieve of her skeletal symptoms. The patient had no
charged home on tapering doses of Tums. However, she           thyroid, hepatic or renal dysfunction. For many years she
continued to take high dose calcium, and also increased        had suffered of abdominal discomfort, chronic diarrhoea
her dietary calcium intake with milk and yogurt daily.         presumable due to lactose intolerance. At age 42, estro-
Admission calcium was 16.8 mg/dl (8.5-10.5), phos-             gens replacement therapy was initiated because of prema-
phorus 3.9 mg/dl (2.5-4.6), parathyroid hormone (PTH)          ture menopause. In 2007 a bone mineral density showed
<1pg/ml (12-88), creatinine 1.8 mg/dl (0.44-1.00).             osteopenia; alendronate was prescribed, but the patient
Calcium supplements were immediately discontinued and          discontinued the medication because of gastrointestinal
the patient was hydrated aggressively with intravenous         intolerance. When she was seen in the endocrine clinic, in
normal saline. Her mental status markedly improved and         September 2009, she complained of muscle aches, fatigue
her serum calcium level normalized over the next 3 days.       and flatulence. At physical examination, she appeared
Phosphorus decreased from 3.9 mg/dl to 2.1 mg/dl. She          depressed, was pale, weighted 50 kg, her height was 157
was discharged in stable condition.                            cm, and the blood pressure was 100/80 mmHg. The abdo-
	    Discussion: MAS is caused by the ingestion of more        men was soft, no masses were palpated; pain was elicited
than 2 grams per day of elemental calcium with absorbable      in the sacral region on palpation; the rest of the physi-
alkali. Inability to suppress calcitriol and impaired cal-     cal examination was unremarkable. Laboratory test were:
cium excretion increase susceptibility to the development      haemoglobin 11.5 g/dl; hematocrit 36.4 %; serum calcium
of this syndrome and likely play a pathophysiological role.    9.7 mg/dl; phosphorous 3.5 mg/dl; magnesium 3.5 mg/
Avid absorption of large doses may lead to suppression of      dl; parathyroid hormone 32.7 pg/ml (15-68.3 reference
PTH, which then produces enhanced bicarbonate reten-           range); vitamin D3 levels 27 nmol/L (80-374 reference
tion by the kidney. Continuing ingestion of calcium car-       range). Antitransglutaminase and endomyseal antibodies
bonate and bicarbonate retention leads to alkalosis, which     were negative. In a new bone densitometry performed in
causes increased calcium resorption in the distal collect-     August 2009 osteoporosis was found. A small intestine
ing system of the kidney. Also, hypercalcemia produces a       biopsy showed lymphocytic infiltrate (MARSH 1). A glu-
renal concentrating defect that can be considered a form of    ten free diet, vitamin D and calcium supplements were
nephrogenic diabetes insipidus. Resultant dehydration and      initiated; three months later the patient had had no muscle



                                                          – 93 –
                                     ABSTRACTS – Metabolic Bone Disease

pain, does not have fatigue and the abdominal symptoms           	    Conclusion: Five cases of iatrogenic hypercalcemia
disappeared. However, she still complains of mild sacral         or vitamin D intoxication are described. This experience
pain.                                                            casts doubt on the conclusion that doses of vitamin D
	    Discussion: The clinical manifestations, laboratory         which greatly exceed RDA are safe in most persons.
and histological findings were consistent with celiac dis-
ease. Vitamin D insufficiency or deficiency can occur            Abstract #538
in this condition and can cause metabolic bone disease.
Nonspecific musculoskeletal symptoms associated with             A CASE OF END-STAGE PRIMARY
inadequate vitamin D levels lead other physicians treat          HYPERPARATHYROIDISM (PHPT) WITH
this patient with steroids, which in turn, increased the risk    MARKEDLY ELEVATED PARATHYROID
of osteoporosis.                                                 HORMONE LEVELS DUE TO
	    Conclusion: Premature menopause, chronic use                SUPERNUMERARY PARATHYROID GLANDS
of steroids and vitamin D insufficiency, associated with
celiac disease, were the main causes associated with the         Andrea Marcela Sosa Melo, MD,
development of osteoporosis in this middle aged woman.           Ana Cecilia Apaza-Concha, Hermes Florez

Abstract #537                                                    	     Objective: To report a case of end-stage PHPT caused
                                                                 by supernumerary parathyroid glands in a man with previ-
IATROGENIC HYPERCALCEMIA AND                                     ous amputation of a suspected brown tumor.
HYPERVITAMINOSIS D IN                                                  Case	 Presentation: A 41-year-old Hispanic male
MIDDLE-AGED WOMEN                                                admitted with acute pancreatitis. The patient had h/o
                                                                 RUE amputation secondary to “giant cell osteosarcoma”
John David Faichney, MD                                          in Cuba in 2006. In 2008 he had a left pathologic femur
                                                                 fracture. On admission he had abdominal pain, vomit,
	    Objective: To describe an experience in which com-          extreme fatigue, and inability to stand. Imaging studies
monly prescribed doses of vitamin D and calcium were             including CT-scan of the abdomen and skeletal survey
associated with hypercalcemia or hypervitaminosis D.             demonstrated: acute pancreatitis and diffuse lytic lesions
	    Case	 Presentation: Five women, middle-aged or              in the iliac bones as well as multiple lytic rib lesions and
older, menopausal and with another endocrine diagno-             punched-out lytic calvarial and vertebral lesions respec-
sis: Addison’s, thyroiditis or diabetes mellitus. All were       tively. Biochemical studies showed severe hypercalcemia
receiving doses of vitamin D which greatly exceeded              (corrected calcium: 15 mg/dL) and markedly elevated
(RDA) of 400 IU, calcium supplementation. Vitamin                PTHi: 2,381 (5-65 pg/mL). SPEP and UPEP showed no
D dose range: 1600-4400 IU/day. Calcium supplement               monoclonal band. PTH-RP <2.1 pmol/L. Sestamibi scan
range: 1000-2400 mg/day. Significant hypercalcemia               showed abnormal accumulation below the lower pole of
(10.8-12.3 mg/dl) observed in 4 of 5 cases. Significant          the left lobe of the thyroid gland, as low as within the
hypervitaminosis D (154, 214 ng/ml) observed in 2 of 5           thymus gland. The patient was taken to surgery where
cases. Detectable but low PTH (23 pg/ml, 31 pg/ml) in 2          six hyperplastic parathyroid glands and a left mediastinal
cases when hypercalcemic. One woman did not manifest             mass consistent with parathyroid tissue were found. Five
hypercalcemia despite persistent hypervitaminosis D.             and a half glands and the mediastinal mass were resected.
	    Discussion: These women shared some common                  Post-op evolution was remarkable for hungry bone syn-
demographic features (age, gender, menopause, endocrine          drome that resolved. The patient was discharged in good
disease) and all received generous vitamin D and calcium         condition and is followed up as outpatient. Current PTHi:
supplements with physician blessing. For diverse reasons,        32 pg/mL.
all became either hypercalcemic or vitamin D intoxicated.              Discussion: PHPT is a disease which has evolved
The two women with vitamin D intoxication could have             from its classic presentation to a one quite different and
been exposed to toxic concentrations of D in supplements.        now most patients have few symptoms and mild hyper-
A discordance between vitamin D levels and hypercalce-           calcemia. Skeletal manifestations of PHPT are rare nowa-
mia was also observed and as well relatively low parathy-        days since the early detection of the disease has been pos-
roid hormone levels, though detectable, in 2 with normal         sible by the introduction of serum calcium determination
vitamin D and high calcium. The safety of high dose vita-        in the routine biochemical screening. In some countries,
min D and calcium therapy without monitoring must be             however, overt manifestations of PHPT including oste-
questioned.                                                      itis fibrosa cystica are still present. This case describes




                                                            – 94 –
                                    ABSTRACTS – Metabolic Bone Disease

perfectly the complications associated with PHPT when is           Conclusion: BTs are pathognomonic of end-stage
misdiagnosed: this patient suffered of repeated attacks of    PHPT. The fact that they are very rarely observed make
pancreatitis most likely secondary to chronic hypercalce-     their diagnosis challenging to the physician. Histologically,
mia. He underwent amputation of his RUE with a pathol-        BT may be indistinguishable from giant cell tumors of the
ogy report consistent with “giant cell osteosarcoma,” con-    bone and the diagnosis requires clinical, biochemical and
sidered the main differential diagnosis of brown tumor        radiological correlation.
(BT).




                                                         – 95 –
                                                ABSTRACTS – Obesity

OBESITY                                                          This study shows improvements in health-related quality
                                                                 of life, both in the physical and mental components, at 4
Abstract #600                                                    and 12 weeks, in obese patients participating in a multi-
                                                                 disciplinary weight management program while using a
EFFECT OF MULTIDISCIPLINARY SUPERVISED                           VLCD, behavior therapy and nutrition counseling.
WEIGHT LOSS ON QUALITY OF LIFE
                                                                 Abstract #601
Christopher Case, MD
                                                                 THE PATTERN OF OBESITY IN HIV
	     Objective: The purpose of this study is to evaluate the    POSITIVE PATIENTS ON HIGHLY ACTIVE
changes in health-related quality of life in obese individu-     ANTIRETROVIRAL THERAPY
als utilizing a very low-calorie diet (VLCD) with multi-
disciplinary supervision, behavior therapy, and nutrition        Ayoola Olukunmi Oladejo, MBBS,
counseling.                                                      Jokotade Oluremilekun Adeleye, MBBS, FWACP,
	     Methods: Consecutive obese individuals (n=65)              Yetunde A. Aken’ova, MBBS, FWACP, FMCpath
enrolling in a weight loss program were asked to complete
the SF-36 version 2TM Health Survey form at baseline             	    Objective: To determine the pattern of Obesity in
prior to weight loss and at 4 weeks and 12 weeks after           HIV positive patients on highly active antiretroviral ther-
starting the VLCD to evaluate health-related quality of          apy (HAART) and to compare with the pattern seen in
life. Weight reduction was supervised weekly by physi-           HAART naïve HIV positive patients.
cians, dietitians, and behaviorists in both a clinic setting     	    Methods: One hundred and eighty HIV positive
and group classes. All participants had a body mass index        patients were selected by systematic random sampling.
(BMI) greater than 30 at baseline. The diet was an indi-         Ninety-two were on highly active antiretroviral therapy
vidually prescribed protein-sparing VLCD (average 800            while eighty-eight were HAART naïve. Anthropometric
kcal) with meal replacement products. No supplements             measurements such as the weight, height, body mass
or medications were prescribed, and participants were            index (BMI) and waist circumference were all done by
advised to begin physical activity (less than 45 minutes         standard methods. Obesity was defined as BMI greater
weekly) after 4 weeks. Norm-based scores were calcu-             than 30Kg/m2 and abdominal obesity was defined by the
lated using QualityMetric Health OutcomesTM scoring              cut off value for Europeans as defined by the International
software. Paired t-tests were used to compare the eight          Diabetes Federation criteria for the diagnosis of the meta-
domains of the SF-36, as well as mental and physical             bolic syndrome. The fasting plasma glucose and the lipid
composite summaries, from baseline to 4 and 12 weeks.            profile were also assayed.
Patients and the investigator were not aware of calculated       	    Results: The mean ages of the HAART and the
scores during active weight loss.                                HAART naïve group were 40.1± 9.5 and 37.7± 9.3 respec-
	     Results: At baseline, participants had SF-36 scores in     tively (p= 0.081). The mean BMI in the HAART group
all domains below the general population norm. Scores            and the HAART naïve group was 26.3± 11.0 and 23.1±
improved in all eight domains of health-related quality of       4.2 respectively, p=0.012. The mean waist-circumference
life at 4 and 12 weeks compared to baseline (all P<0.001),       between the HAART group and the HAART naïve group
and in both the physical and mental composite summa-             was 86.8± 10.4 and 80.0± 9.5 respectively, p= 0.0001. The
ries. All domains showed improvements to greater than            overall prevalence of generalized obesity was 12.8% being
the mean.                                                        19.6% in the HAART group and 5.7% in the HAART naïve
	     Discussion: Obesity can have a significant impact          group, p=0.002 while the overall prevalence of abdominal
on the mental and physical aspects of quality of life.           obesity was 46.1% being 54.3% in the HAART group and
Unfortunately, very few treatments in medicine objec-            37.5% in the HAART naïve group, p< 0.05.
tively improve health-related quality of life. VLCDs may         	    Discussion: The human immunodeficiency virus is
lead to significant and rapid weight loss, which often           the etiologic agent for human immunodeficiency virus
results in many improvements in the metabolic abnor-             infection and acquired immunodeficiency syndrome
malities associated with obesity. The findings in this           (AIDS) which is the end of the spectrum of HIV infection.
study show that the medical treatment of obesity through         AIDS is characterized by profound immune-suppression
a coordinated clinic can also robustly improve quality of        with increased susceptibility to opportunistic infections
life, providing endocrinologists, bariatrians, and patients      and certain malignancies. Individuals with advanced
important options.                                               disease suffer from the wasting syndrome which has a
	     Conclusion: Individuals enrolling in multispecialty        multifactorial pathogenetic factors such has anorexia,
weight loss centers have low health-related quality of life.     malabsorption states and cytokine induced cachexia. The


                                                            – 96 –
                                               ABSTRACTS – Obesity

advent of HAART has revolutionized the management of            the etiopathogenesis of adolescent obesity. Thus with the
HIV infection with a dramatic reduction in morbidity and        strong association between obesity and insulin resistance,
mortality frequently associated with untreated advanced         prevention and treatment of adolescent obesity appears to
disease and improvement in the general well being of            be essential to prevent the development of insulin resist-
patients. However, this therapy is often associated with        ance and the associated complications.
some untoward metabolic complications which may
increase the risk of cardiovascular disease. These meta-        Abstract #603
bolic complications such as systemic hypertension, dys-
glycemia, dyslipidemia and lipodystrophy syndrome have          ENDOGENOUS CUSHING SYNDROME IN
all been described in various studies.                          SEVERELY OBESE POPULATION
	    Conclusion: This study has shown a higher preva-
lence of both generalized obesity and abdominal obes-           Simona Vasilica Fica, MD, PhD, FACE, Anca Sirbu, MD,
ity in HIV positive on HAART therapy than the HAART             Sorina Martin, MD, Carmen Barbu, MD, PhD,
naïve group. Both generalized and abdominal obesities           Catalina Poiana, MD, PhD, FACE, Suzana Florea,
have been strongly linked with increased insulin resist-        Claudia Lenghen, MD
ance and increased risk of type 2 diabetes and atheroscle-
rotic cardiovascular disease.                                   	    Objective: To evaluate the prevalence of Cushing syn-
                                                                drome in severely obese patients before bariatric surgery.
Abstract #602                                                   	    Methods: In a prospective study that we have con-
                                                                ducted in the last 2 years, we exhaustively evaluated (per-
TO STUDY THE ROLE OF LEPTIN,                                    sonal and heredocollateral history, psychological param-
RESISTIN, AND ADIPONECTIN IN AN                                 eters and eating behavior disturbances, clinical exam,
ADOLESCENT OBESE GROUP                                          biochemistry: inflammation, lipid profile, glycemia, oral
                                                                glucose tolerance test, insulinemia, hormonal tests: stress
Sanjay Ganesh Godbole, MD, Chinmay Godbole,                     hormones profile, ghrellin, leptin and other adipocito-
Bhagyashri Shah, Sujata Mahadik                                 kines plasma level) a total of 176 obese subjects (65.3%
                                                                female), aged 18-67 (mean 40.29), with BMI 36-74.20
	    Objective: Global epidemic of obesity is well              Kg/m2 (mean 48.38) and indication for bariatric surgery.
described in the adult population but not much data is          They all completed 1 mg overnight dexamethasone sup-
available regarding the prevalence of childhood obesity         pression test ( DST) (cut-off level<1.8 μg/dl). If any result
in developing countries. Adipose tissue derived adipocy-        was abnormal, tests were repeated and completed with
tokines attract an increasing attention due to the important    other tests (high-dose dexamthasone suppression test,
role they play in the pathogenesis of obesity and diabetes.     ACTH)
Hence in this study we have determined the prevalence           	    Results: 14.2% (25 patients) had falsely abnormal
of adolescent obesity in urban population, and studied the      1 mg overnight DST, but 4 patients were diagnosed with
role of adipocytokines like leptin, resistin and adiponectin    Cushing syndrome (3 Cushing diseases, 1 adrenal cor-
in adolescent obesity.                                          tisol secreting adenoma), rendering the prevalence of
	    Methods: A total of 50 overweight and obese sub-           the endogenous syndrome to 2.27%. We compared the
jects were recruited in this study. Fasting insulin, leptin,    patients with falsely elevated cortisol after 1 mg dexa-
resistin and adiponectin levels were measured by RIA &          methasone overnight with the others with suppressible
ELISA method. Insulin Resistance index was calculated           cortisol. The obese patients with falsely elevated cortisol
by the Homeostasis Model Assessment (HOMA-IR). The              >1.8μg/dl after 1 mg overnight DST were older (p=0.047),
relation between these variables was studied by univariate      had higher basal glycemia (p=0.008) and higher morning
regression analysis.                                            basal cortisol (p=0.002), but there was not statistical sig-
	    Results: Overall Prevalence of obesity is 7.7% in          nificant difference in BMI, waist, HOMA-IR or choles-
our study population. Main findings of the present study        terol, triglycerides. In this group neither basal morning
were high prevalence of obesity in girls compared to            plasma cortisol nor cortisol after 1 mg DST correlated
boys. In addition girls exhibited higher fasting plasma         with age, BMI, waist, basal glycemia or HOMA-IR. The
glucose, serum insulin, HOMA-IR and leptin levels com-          prevalence of previous known hypertension, diabetes mel-
pared to boys. In linear regression analysis we found that      litus, ischemic heart disease and dyslipidemia was not dif-
among the Adipocytokines leptin is a strong predictor of        ferent in those two groups.
HOMA-IR in our adolescent obese group.                          	    Discussion: Classic endogenous syndrome is a rare
	    Discussion: Elevated leptin levels and its associa-        disease with an estimated incidence of 10 cases/million
tion with insulin resistance support the role of leptin in      person/year. Recent reports suggest a higher prevalence


                                                           – 97 –
                                               ABSTRACTS – Obesity

(1–5%) of Cushing syndrome in certain patient popula-           hyperparathyroidism. The pouch created to serve as a
tions (e.g., uncontrolled diabetes and/or hypertension), but    stomach in RYGB produces less acid than a normal stom-
the prevalence in an obese population is not known. We          ach, thus calcium citrate is the recommended calcium
evaluated severely obese patients with BMI > 40kg/m2 or         preparation to be used in these patients (1). Relatively
BMI ≥ 35kg/m2 and one or more severe comorbidities,             large doses of calcium citrate, calcitriol and vitamin D
who were referred to the endocrinologist with indication        may be required to treat hypocalcemia in RYGB patients.
for bariatric surgery, without specific clinical suspicion      	    Conclusion: Bariatric surgery patients undergoing
of Cushing’s syndrome, and found a high prevalence of           thyroid surgery are at increased risk of hypocalcemia and
endogenous Cushing’s syndrome (2.27%).                          require aggressive supplementation to maintain normal
	    Conclusion: Although current bariatric surgery             serum calcium levels. Preoperative supplementation with
guidelines do not consider cost-effective and neither           calcium and vitamin D is recommended. Intra-operative
recommend routine laboratory testing to screen for rare         PTH measurements should be considered.
causes of obesity, our data support screening for Cushing’s
syndrome in this category of obese patients, before bariat-     Abstract #605
ric surgery.
                                                                ATTIVA, A NOVEL SUPERABSORBENT
Abstract #604                                                   BIODEGRADABLE HYDROGEL, INCREASES
                                                                THE FEELING OF SATIETY IN HUMANS
PRIOR GASTRIC BYPASS SURGERY
COMPLICATING TOTAL THYROIDECTOMY                                Hassan Massoud Heshmati, MD, Roberto Tacchino, MD,
                                                                Eyal Ron, PhD, Alessandro Sannino, PhD, Yishai Zohar
Bianca Alfonso, MD, Michael Via, MD
                                                                	    Objective: To assess the effect of single adminis-
	    Objective: To describe a case of profound hypocalce-       tration of Attiva, a novel superabsorbent biodegradable
mia occurring after total thyroidectomy in a patient with a     hydrogel obtained from cellulose derivatives, on satiety in
prior gastric bypass surgery.                                   humans.
	    Case	Presentation: A 58-year-old female with a his-        	    Methods: Ninety-five subjects (73 females, 22 males)
tory of Roux-en-Y gastric bypass surgery (RYGB) pre-            with a mean age ± standard deviation (SD) of 41 ± 12
sented with dysphagia secondary to multinodular goiter.         years (range, 19-67 years) and a mean body mass index
She underwent total thyroidectomy. All parathyroid glands       (BMI) ± SD of 31.1 ± 7.5 (range, 18.0-55.9) were studied.
were identified and preserved. The patient’s baseline cal-      Twenty-one subjects had normal (or subnormal) BMI, 22
cium was 8.4 mg/dL, creatinine 0.6 mg/dL, albumin 4.2 g/        were overweight, and 52 were obese. Subjects received
dL, parathyroid hormone (PTH) 72.9 pg/mL and thyroid            2 g of Attiva (5 oral capsules) versus placebo before
stimulating hormone (TSH) 1.99 mIU/L. PTH decreased             breakfast, lunch, and dinner, in a double-blind, cross-over
intra-operatively to 7.1 pg/mL and subsequently became          fashion. There was a 3-day interval between each admin-
undetectable. Postoperatively, she developed symptom-           istration of Attiva to the same subject. Meals consisted
atic hypocalcemia that required large doses of intravenous      of habitual intake of each subject and were consumed
calcium gluconate (2 g daily), oral calcium carbonate (7.5      at home. Satiety was assessed using a self-administered
g daily), calcium citrate (2 g daily), calcitriol (up to 4 g    questionnaire immediately, and 30 and 60 minutes after
daily) and ergocalciferol (50,000 IU daily). Serum cal-         meal. The questionnaire included 5 options to score the
cium levels remained normal on this regimen after hospi-        feeling of satiety: not at all (score 0), a little (score 1),
tal discharge despite persistent hypoparathyroidism.            enough (score 2), very (score 3), and very much (score 4).
	    Discussion: Bariatric surgery drastically and posi-        Statistical analysis was performed with a paired t-test.
tively changes the lives of obese individuals. Despite          	    Results: Attiva significantly increased the feeling of
significant improvements in obesity associated condi-           satiety at 30 minutes after breakfast and dinner, and at 60
tions and mortality, there are potential complications          minutes after lunch and dinner. The mean ± SD for the
and numerous metabolic and dietary sequelae associated          satiety scores with Attiva versus placebo at 30 minutes
with RYGB. Manipulation of the parathyroid glands dur-          were 1.85 ± 0.93 versus 1.63 ± 0.95 (P = 0.037), 1.84 ±
ing thyroidectomy can result in transient or permanent          1.14 versus 1.66 ± 0.87 (P = 0.071), and 1.98 ± 0.97 ver-
hypoparathyroidism. Bariatric surgery patients are at high      sus 1.70 ± 1.01 (P = 0.004), for breakfast, lunch, and din-
risk of severe hypocalcemia following thyroidectomy             ner, respectively. The mean ± SD for the satiety scores
due to diminished intestinal calcium absorption, long-          with Attiva versus placebo at 60 minutes were 2.13 ± 1.00
standing vitamin D deficiency and prolonged secondary           versus 2.12 ± 0.83 (P = 0.960), 2.35 ± 1.06 versus 2.07 ±



                                                           – 98 –
                                                 ABSTRACTS – Obesity

0.86 (P = 0.007), and 2.46 ± 1.12 versus 2.15 ± 0.99 (P =         cholesterol showed a statistical significance difference in
0.006), for breakfast, lunch, and dinner, respectively. The       both groups.
administration of Attiva was safe and well tolerated.                 Conclusion: Metabolic syndrome serves a useful
	    Discussion: Attiva is able to swell in the stomach in        purpose in that it draws attention to the fact that some
the presence of water and gastric fluids. By occupying the        CVD risk factors tend to cluster in predisposed patients.
gastric and intestinal cavities, Attiva can induce a feel-        The essential point in this study is that the identification of
ing of satiety that lasts until the hydrogel is degraded in       one risk variables in a patient should prompt a search for
the colon and expelled in the feces. The overall results of       others.
this study demonstrating increased feeling of satiety with
Attiva are in agreement with the physical properties of           Abstract #607
Attiva.
	    Conclusion: Single administration of Attiva, a               VISFATIN, ADIPONECTIN, LEPTIN AND
novel superabsorbent biodegradable hydrogel, to humans            MACROPHAGE MIGRATION INHIBITORY
increases the post-meal feeling of satiety. The treatment is      FACTOR (MIF) IN SEVERE OBESE WOMEN
well tolerated. This effect of Attiva on satiety, if confirmed    WITH NORMAL AND IMPAIRED
by long-term studies, will support Attiva as a potential          GLUCOSE TOLERANCE
anti-obesity product.
                                                                  Mirjana Sumarac-Dumanovic, MD, PhD,
Abstract #606                                                     Micic Dragan, MD, PhD,
                                                                  Stamenkovic-Pejkovic Danica, MD
PREVALENCE AND RISK FACTORS OF
METABOLIC SYNDROME IN NIGERIANS                                   	    Objective: Hyperglycemia could increase plasma
WITH TYPE 2 DIABETES MELLITUS                                     visfatin in patients with T2DM. This increase gets more
                                                                  prominent as the glucose intolerance worsens. Macrophage
Rosemary Temidayo Ikem, MD, David Soyoye, MD,                     Migration Inhibitory Factor (MIF) is elevated in obesity
Adebayo Joseph Olorunfemi, MD,                                    and it was shown that metformin suppresses plasma MIF
Babatope A. Kolawole, MD                                          in the obese. The aim of the study was to determine level
                                                                  of plasma visfatin, adiponectin and leptin as well as MIF
	    Objective: The clustering of metabolic abnormalities         in severely obese women with normal and impaired glu-
in people with metabolic syndrome confers substantial             cose tolerance.
and additional cardiovascular risk over and above the sum         	    Methods: Ten obese women (age: 35.46±2.21yrs;
of the risks associated with each abnormality. For non-           BMI 34.11±0.75 kg/m2) with normal glucose tolerance
diabetics with metabolic syndrome, the risk for develop-          (NGT) and 10 age and BMI matched obese women (age:
ing type 2 DM is increased five times. The inclusion of           35.80±2.54 yrs; BMI 36.98±1.66 kg/m2) with normal
type 2 DM as part of the definition of MS thus seems to           fasting and impaired glucose tolerance (OGTT-75 gr of
overwhelm other risk factors in some populations since            glucose) (IGT) were included in the study. Fasting plasma
DM by itself is a strong CVD risk factor. To determine            visfatin (EIA Phoenix, ng/ml), adiponectin (Linco RIA,
the prevalence of MS using IDF criteria and to compare            ng/ml), leptin (Linco RIA, ng/ml) and insulin (RIA Inep,
the Anthropometric and Metabolic (Lipids) features of             mU/l), MIF (ELISA, ng/l) were measured. Insulin sen-
patients Type 2 DM with and without metabolic syndrome.           sitivity (M index: mg/kgBW/min) was determined using
	    Methods: All type 2 DM patients attending out patient        euglycemic 2hr clamp.
diabetic clinic of Obafemi Awolowo University Teaching            	    Results: There was no difference in fasting visfa-
Hospital Complex Ile-Ife were recruited. This study was           tin between NGT and IGT (72.66±4.11 vs. 69.80±5.55,
carried out over a three month period. Their demographic          p>0.05), fasting leptin (33.53±2.98vs.30.70±3.88, p>0.05)
and metabolic parameters were noted and analysed.                 fasting adiponectin (8.84±1.61vs.9.65±4.59, p>0.05) and
	    Results: One hundred and thirty four subject with type       plasma MIF (2456.75±428.91 vs. 2344.80±481.80, p
2 diabetes were seen, 62(46.3%) males and 72 (53.7%)              >0.05). Insulin senstitivity was reduced in obese women
females. Their mean age was 57.65 ± 10.0 years with a             with IGT (6.55±0.51vs.2.74±0.38, p<0.05).
range of 31 – 90 years. The mean BMI was 26.13 ± 4.3 Kg/          	    Discussion: There were no significant correlations
M2. The prevalence of metabolic syndrome was 44.8% i.e.           among investigated parameters neither with insulin sensi-
60/134 M: F = 18 (30%): 42 (70%). Comparison of demo-             tivity index. No significant difference among investigated
graphic and metabolic parameters in patients that exhib-          adipocytokines was found in women with IGT in compar-
ited feature of met syndrome and those without showed             isson with women with NGT.
that, waist circumference, blood pressure; HDL and LDL


                                                             – 99 –
                                                 ABSTRACTS – Obesity

	    Conclusion: In conclusion, our data suggest that               GLP-1 and its co-synthesized partner, Oxyntomodulin, are
impairment in insulin sensitivity precede change in adi-            quite potent anorexigenic peptides through both periph-
pocytokines and MIF during development of type 2 diabe-             eral and central actions. Hypothalamic, dorsomedial and
tes in obesity.                                                     paraventricular nuclei are also sites of GLP-1 action.
                                                                    Activation of these areas leads to production of anorexi-
Abstract #608                                                       genic precursors like Pro-opiomelanocortin (POMC).
                                                                    By far the highest brain levels of GLP-1 are found in the
THE EFFECT OF EXENTIDE ON BODY WEIGHT                               hypothalamus, where it is present in nerve endings and the
AND GLYCEMIC CONTROL IN A PATIENT WITH                              NST acts as an important relay and amplification site for
HYPOTHALAMIC SYNDROME UNDERGOING                                    GLP-1 signals.
BARIATRIC SURGERY                                                   	    Conclusion: The dramatic weight loss that we report
                                                                    in this case of hypothalamic obesity is a clear pointer to
Ibrahim Mamoun Ibrahim, MD, Jeevan Mettayil, MD                     the potential of using the anorectic actions of gut hor-
                                                                    mones in the management of obesity.
     Objective: The anorectic gut hormones GLP-1 (glu-
cagon-like peptide 1) and co-secreted peptides such as              Abstract #609
Oxyntomodulin and Peptide YY are among prime candi-
dates for manipulation in the development of new thera-             DEXA MORE ACCURATELY PREDICTS
pies for obesity. We report the effect of Exenatide on body         OBESITY COMPARED TO BMI UTILIZING
weight and blood glucose control in a morbidly obese                AMERICAN BARIATRIC SOCIETY CRITERIA
patient with hypothalamic syndrome.                                 FOR OBESITY IN 1,234 ADULTS IN A PRIMARY
     Case	Presentation: A 37-year-old male with a history           CARE OUT-PATIENT FACILITY.
of type 2 diabetes mellitus on insulin for five years and
a background of midline cerebral angioma, treated with              Eric Braverman, MD, Mallory Kerner, Stanley Huang,
stereotactic high dose radiotherapy, complicated with               Stella Savarimuthu, Uma Damle, Jennifer Quon,
panhypopituitarism and hypothalamic state. He also had              Kenneth Blum, PhD, Nirav R. Shah, MD, MPH
obstructive sleep apnoea, deep vein thrombosis (DVT),
depression and morbid obesity. He had evidence of severe                 Objective: Obesity has been recognized as an epi-
insulin resistance, needing more than 300 units of insulin          demic in the United States with approximately 23% of
per day. He was maintained on insulin and Pioglitazone.             Americans determined to be obese by the commonly
However his insulin requirements were going up with a               used body mass index (BMI). However, a direct measure-
BMI of 55 and he was subsequently referred for bariat-              ment of adiposity by dual X-ray absorptiometry (DEXA)
ric surgery. Three months before his surgery we decided             is a more precise body fat indicator than BMI. To date,
to add in GLP-1 analogue based therapy (Exenatide) to               no large-scale comparison has been made between BMI
help him lose some weight before the surgery. On the                and DEXA to directly measure percentage body fat. As
initiation of Exenatide he lost a total of 16 kilograms in          the prevalence of overweight and obesity is increasing
weight, came off Pioglitazone and NovoRapid and was                 and resulting in a larger burden to society, this study has
maintained only on 18 units of Glargine. Gastric banding            important implications for policymakers, clinicians, and
was the bariatric surgery of choice because he had had a            patients.To investigate and compare the differences and
recent DVT. Following the gastric banding, Exenatide was            descriptive properties of obese classification by BMI mea-
stopped and he was discharged on 10 units of Glargine per           surement and percentage body fat as measured by DEXA.
day. However, four months following the surgery he only                  Methods: In a retrospective study, we reviewed
had very minimal weight loss of about 3 kilograms and his           medical records from 2003 to 2009 to obtain BMI (from
blood glucose levels had deteriorated significantly and he          height and weight) and percentage body fat (from Hologic
needed more basal and meal insulin. Exenatide (Byetta)              DEXA). Subjects were classified as obese or non-obese,
was restarted in addition to basal insulin and his blood            using the American Bariatric Society’s classification
glucose levels responded very well to this, but it is still too     (BMI: 30+, Body Fat %: 25%+ males, 30%+ females).
early to comment on any further weight reduction.                   The 1,234 patients from a private outpatient medical prac-
	    Discussion: This case report highlights emerging data          tice were of age 18+ with BMI and DEXA data available.
that GLP-1 is in fact both a gut hormone and a cerebral             All subjects provided approved IRB written informed
neuropeptide with a very limited site of production in the          consent form, and this study was approved by the PATH
brain. It is produced by alpha cells of the pancreas, L cells       Institutional Review Board.
of the gut as well as by neurons chiefly located in the cau-        	    Results: Using BMI, 20% (n = 249) were classified
dal section of the nucleus of the solitary tract (NST). Both        as obese. Of these 249: 95% (n = 237) were obese based


                                                              – 100 –
                                                ABSTRACTS – Obesity

on body fat percentage while 5% (n = 12) were non-obese.          based study with an age range of 5-20 years. The subjects
Using body fat percentage, 56% (n = 689) were classified          were divided into two groups based on their ALT levels
as obese. Of these 689: 34% (n = 237) were obese based            (ALT>40 IU/L was defined as elevated).
on BMI while 66% (n = 452) were non-obese. The per-               	    Results: Out of total 156 children, 56 were less than
cent identified as obese by BMI (20%) compared to that            11 years old and remaining were between 11-20 years.
by DEXA (56%) was highly divergent (P < 0.01). 37%                The mean BMI of the group was 34.3±7.7. The prevalence
(452/1234) of patients were misclassified by BMI.                 of elevated ALT was 19% in the overall group, higher in
	    Discussion: Our measurement of obesity with BMI              boys (27%) than in girls (13%). The frequency of ALT
was nearly equal to the national percentage. However, we          elevation increased with age in boys, 13.4% at 5-10 years
have shown that BMI is a highly insensitive measure of            of age, 15 % at 11-15 years and 53 % at 16-20 years of
obesity and under-diagnoses. Extrapolating our data on a          age. But inverse trend was noted in girls with increasing
global scale, it is very likely that obesity is a much bigger     age (15.1%, 14.7%, 7.1% at 5-10, 11-15 and 16-20 years
epidemic than is currently acknowledged.                          age group respectively). TG levels correlated positively
	    Conclusion: In light of the importance of the global         (r=0.39, P< 0.001) while HDL correlated negatively with
obesity epidemic, the use of BMI should be greatly cur-           ALT levels (r= - 0.29, p < 0.001). Ratio of TG/HDL cor-
tailed, and direct measure of adiposity should be used            related positively with ALT (r= 0.37, p < 0.001) and AST
on large subgroups of patients often misclassified by this        (r=0.27, p< 0.001). No significant difference was seen in
measure. Further analysis should help to identify which           fasting blood glucose, fasting insulin, homeostatic model
patients may need DEXA analysis in addition to standard           assessment of insulin resistance (HOMA-IR), blood pres-
BMI measurement, and which patients may be mislabeled             sure, BMI or age between the groups with normal and
as obese when using BMI. We urge additional studies to            elevated ALT levels.
confirm these important results especially to more accu-          	    Discussion: NAFLD is highly prevalent in obese
rately determine the true nature of the global obesity            children based on elevated ALT levels. To our knowl-
epidemic.                                                         edge, this is the first study which looks at the variation in
                                                                  prevalence of NAFLD in children according to different
Abstract #610                                                     age groups in both the genders. The explanation for higher
                                                                  prevalence of NAFLD in boys and specially with increas-
GENDER AND AGE DIFFERENCES IN THE                                 ing age could be related to higher visceral fat in males.
PREVALENCE OF NONALCOHOLIC FATTY                                  Also puberty in boys is associated with increase in insulin
LIVER DISEASE IN OBESE CHILDREN                                   resistance whereas high estrogen levels in girls could be
                                                                  protective. No difference in HOMA-IR was seen between
Rishi Gupta, MD, Nicole A.V. Matthews, MD,                        the two groups. But HOMA-IR is a marker of peripheral
Amrit Bhangoo, MD, Henry Anhalt, DO,                              insulin resistance, so it might not represent the insulin sen-
Gracilla Wetzler, MD, Shivinder Narwal, MD,                       sitivity at the level of liver and portal circulation. A high
Svetlana Ten, MD                                                  TG/HDL ratio can also be used as an additional marker
                                                                  for detection of NAFLD along with elevated ALT in obese
	    Objective: Alanine aminotransferase (ALT) eleva-             children.
tions are considered a surrogate marker of NAFLD. Aim             	    Conclusion: These findings have implications for
of present study is to evaluate the prevalence of elevated        increased NAFLD and metabolic profile screening in
ALT (>40 IU/L) levels in obese children and to study              obese children, especially boys so that we can prevent the
the correlation between their ALT levels and metabolic            long term complications of NAFLD such as liver failure in
profile.                                                          the beginning.
	    Methods: We studied 156 obese (BMI >95% for
age and sex) children (86 girls and 70 boys) in a clinic




                                                            – 101 –
                                                ABSTRACTS – Other

OTHER                                                            	    Conclusion: Dysregulation of RAAS influences the
                                                                 development of increased LVM in normotensive AA ado-
Abstract #700                                                    lescents. Our findings suggest that non suppressible Ang
                                                                 II levels in AA may contribute directly and/or indirectly to
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM                             increased LVM and earlier cardiovascular damage.
CONTRIBUTION TO RACIAL DIFFERENCES
IN CARDIOVASCULAR RISK IN                                        Abstract #701
NORMOTENSIVE ADOLESCENTS
                                                                 THE BEST APPROACH FOR MANAGEMENT
Prashanth Chandra Sekhar, MD,                                    OF A CASE WITH COMPLETE ANDROGEN
Jennifer Pedersen-White, DO, Greg Harshfield, PhD                INSENSITIVITY SYNDROME

	    Background/Objective: To evaluate RAAS (renin-              Ali Hasan Dhari Al-Jumaili, MD
angiotensin-aldosterone system) contribution to racial dif-
ferences in blood pressure (BP) in normotensive adoles-          	    Objective: To discuss the best approach of a child
cents. Hypertension (HTN) in adults is more prevalent in         with complete androgen insensitivity syndrome (CAIS)
African Americans (AA) than in Caucasians (CA) and is            and to drop light on increase of the incidence of pediatric
a major public health problem. The prevalence of “adult”         endocrinology disorders that demand more attention from
diseases in children is increasing; an estimated 4.5% of         the high health authorities.
children are hypertensive, also with a greater prevalence             Case	 Presentation: 2.5-year-old female baby
in AA than CA. Little is known about the mechanism(s)            appeared normal at birth, during childhood growth was
underlying racial differences in HTN in children and ado-        normal and the karyotypic incongruity remained unsus-
lescents. 	                                                      pected until an inguinal lump had been discovered to be
	    Methods: We examined 84 normotensive adoles-                a testis during surgical repair of an inguinal hernia at
cents, age 15–18 years (47 AA, 37 CA). After 3 days on           age of 8 months for that the surgeon referred her to our
a controlled sodium diet (4000 mg/day), resting BP was           clinic before 2 months. The pregnancy and delivery were
measured (an average of BP taken by Dynamap every 15             unremarkable. She is the only child for the family with
minutes for two hours). Urinary sodium excretion (UnaV),         deceased mother consanguinity positive. The grandmother
plasma renin activity (PRA), plasma angiotensin-II (Ang          mentioned that two married women relative to the father
II) and plasma aldosterone (Aldo) were collected after two       are sterile with amenorrhea. O/E: she is 13 kg weight and
hours of rest. A 2-D echocardiogram was performed on all         92 cm height with female external genitalia (clitoris, labia,
subjects to calculate left ventricular mass (LVM).               vaginal opening and urethral orifice) with big Rt. inguinal
	    Results: In CA subjects, systolic BP (SBP) corre-           hernia and a scar in the left inguinal region for previous
lated negatively with Ang II (r = -0.389, p = 0.017) and         herniotomy and palpable testis. The rest of her examina-
positively with UnaV (r = 0.384, p = 0.019), indicating          tion is unremarkable. Ultrasound shows shallow vagina
appropriate RAAS suppression and pressure natriuresis.           (20mm length), bilateral testes in the Inguinal canals
In AA subjects, SBP was not associated with Ang II sup-          confirmed by biopsy, no uterus nor ovaries. Bone age 3
pression (r = 0.090, p = 0.548) and correlated negatively        years. Karyotype 46 XY, Photos, FSH 2.6 mIU/ml (con-
with UnaV (r = -0.309, p = 0.034), indicating a lack of          trol 1.o14.0) for male, LH 2.1mIU/ml (control 0.7-7.40 for
RAAS suppression and inappropriate pressure natriuresis.         male, Testosterone 0.03ng/ml (female 0.2-0.9,male 3-10),
Overall, SBP correlated positively with LVM (r = 0.380,          Estradiol less than 9.0 pg/ml (control less 62) for male,
p = 0.000), a correlation which was accounted for by a           Serum Electrolytes normal, Serum cortisol normal.
highly significant relationship seen in AA subjects only              Discussion: From the history, physical examination,
(r = 0.449, p = 0.002).                                          and investigations, this is a case of complete androgen
	    Discussion: It is well known that BP contributes to         insensitivity syndrome (CAIS) confirmed by 46XY karo-
the development of LVM. Twenty percent of the variance           type, shallow vagina, testes with no cervix, ovaries nor
of LVM in our AA subjects was accounted for by SBP. Our          uterus. Gonadotropin results are uninterruptable/ irrel-
data supports that the lack of Ang II suppression (which         evant as the child is 2.5 years old. The incidence of (AIS)
can affect BP through arteriolar constriction, enhanced          is 1:20,000-1:64000. A person with (CAIS) has a female
tubular sodium retention and augmentation of sympa-              external appearance despite a 46XY karyotype and unde-
thetic activity) and inappropriate pressure natriuresis both     scended testes. The Androgen Insensitivity Syndrome
affect BP and contribute to early target organ damage in         is x-liked recessive condition. Management of this case
AA adolescents.                                                  and other DSD require an experienced multidisciplinary



                                                           – 102 –
                                                 ABSTRACTS – Other

team, which is generally found in tertiary care centers.          an ethnically mixed group from a tertiary health facility
The team should develop a plan for clinical management            in Lagos, Nigeria. Heights, weights and waist girths for
with respect to diagnosis, gender assignment, and treat-          each subject were determined using standard techniques.
ment options before making any recommendation. For                Adiposity was classified using the body mass index (BMI)
that I include my colleagues in the hospital and in the U.K       and waist circumference (WC). Socio- demographic vari-
and U.S.A, who are members of BSPED & AACE, for the               ables were obtained using a modified WHO steps ques-
best plan to manage this case as team work the decision           tionnaire. The questionnaire was also used to determine
for all is (no benefit in keeping the testes as there good        previous diabetes diagnosis, family history of diabetes,
hormone replacements available for the child to be given          smoking habits, and alcohol consumption.
in a pubertal age rather than retaining a hernia/malignancy            Results: Mean BMI and waist circumference were
potential, etc., so it is better to remove the testes. Family     23.1 kg/m2 and 79.6 cm, respectively, for men and 23.5
made aware that the child will need estrogen supplements          kg/m2 and 77.2 cm, respectively, for women. The overall
from age of 12 years, sterile, may need vaginal dilators          prevalence of obesity was 9.8% and the prevalence was
in puberty/later due to small vagina (with psychological          higher in females (15.7%) than in males (4.4%) and the
support for the family), so arrangement with pediatric sur-       difference was statistically significant (P<0.05). The over-
geon about that has been done.                                    all prevalence of overweight and obesity was 38.1%. The
     Conclusion: It is clear that management of DSD               prevalence of central obesity was 4.6% in men and 20% in
requires an experienced multidisciplinary team, which is          women. Subjects who took salted meals were three times
generally found in the tertiary care centers, which is not        more likely to be obese (Odds Ratio =3.479, P=0.001) and
applied in our hospitals for that and due to the increase         those with hypertension were four times more likely to
in the no. of pediatric endocrinology disorders (pituitary,       be obese (Odds Ratio =4.308, P=0.001). Lifestyle factors
hypothyroidism, adrenal, puberty, intersex, type 1 diabe-         were the most important risk factors to explain the dif-
tes….etc.) that exceed thousands registered in the pediat-        ferences in overweight and central obesity between males
ric endocrinology clinic with diabetes in Central Teaching        and females. Among females, lifestyle, occupation and
Hospital for Children with discovering more rare cases            diet were the most important risk factors to explain the
related to intersex (six cases during the past few months).       differences whereas lifestyle and diet were all important
So the need for a specialized centre supplied with all labo-      among men.
ratory facilities, trained staff, and therapy has become               Conclusion: The prevalence of obesity is high among
an urgent demand to be a centre for teaching, research            health workers, and more so in females than males.
studies, consultation and promotion of the health services
qualitatively and quantitatively, especially there is no          Abstract #703
such a centre in the country. In this direction, a project to
develop the pediatric endocrinology with diabetes clinic          A CASE OF GIANT INSULINOMA IN A PATIENT
in Central Teaching Hospital to a center including all the        WITH TYPE 2 DIABETES
current and future vision had been sent through the hospi-
tal and the Al Karkh directorate to Iraqi MOH and also had        Seshadrinathan Pramodh, MD, Dominic Parsons, MBBS,
been presented in the MOH. We hope the Minister and all           Alex Bickerton, MBBS, DPhil
in the high health authorities will support that.
                                                                       Objective: To demonstrate that hypoglycemia in type 2
Abstract #702                                                     diabetes outside of insulin, sulphonylurea and metiglinide
                                                                  analogue use is unusual and needs to be investigated.
OBESITY AND SOCIO-DEMOGRAPHIC                                          Case	Presentation: An 81-year-old man with a past
VARIABLES OF HEALTH WORKERS IN A                                  history of diet controlled type 2 diabetes was investigated
TERTIARY INSTITUTION IN LAGOS, NIGERIA                            in our hospital as an inpatient for chest pain. Whilst in hos-
                                                                  pital he had frequent episodes of hypoglycemia. He gave
Ofem Egbe Enang, MBBCh,                                           a 12 month history of episodes of drowsiness, disorienta-
Olufemi Fasanmade, MBBS, FWACP, FACE,                             tion and palpitations, which occurred whenever he went
Augustine Ohwovoriole, MBBS, FMCP, FWACP, FNSEM                   for over 3 hours without food, and resolved with carbohy-
                                                                  drate intake. He had gained 12 kg in weight over the pre-
    Objective: To assess the prevalence of obesity in an          ceding 2 years. He was diagnosed with Impaired Glucose
urban Nigerian population from different ethnic groups,           Tolerance in 2003 on the basis of a 75g oral glucose toler-
and to identify lifestyle risk factors for obesity.               ance test (oGTT) in 2003 (fasting glucose 70 mg/dL, 2
    Methods: This was a cross-sectional study using               hour post glucose 164 mg/dL). A repeat 75g oGTT in 2006
an opportunity sample of health workers who make up               confirmed type 2 diabetes (fasting 59mg/dL; 2 hour post


                                                            – 103 –
                                                ABSTRACTS – Other

glucose 205 mg/dL). He was managed with dietary regu-            and OctreoScan, did not localize the tumor. A 3, 4-dihy-
lations alone, and achieved HbA1c levels between 5.9 and         droxy-6-18F-fluoro-phenylalanine (18F-FDOPA).
6.6% over the subsequent 3 years. Blood tests performed                PET scan showed the presence of a small tumor adher-
on 2 occasions during episodes of hypoglycemia (27mg/            ent to the right side of the bladder that was removed surgi-
dL & 29mg/dl) in hospital demonstrated very high lev-            cally. Genetic testing was negative. The patient showed no
els of insulin (81.7 & 92.2 µU/mL) and C-peptide (5793           evidence of pheochromocytoma three years after his last
pmol/L & 5793 pmol/L). CT scan revealed a 10cm tumor             surgery.
of the pancreas, confirming insulinoma. He was treated           	     Discussion: Pheochromocytoma and paraganglioma
with diazoxide and octreotide, which stabilized the hypo-        are a catecholamine-secreting tumor arising from the
glycemic episodes. Unfortunately he died from an acute           adrenal glands and the sympathetic ganglia respectively.
MI while awaiting surgery. Post-mortem examination con-          About 25% of tumors harbor a gene mutation predispos-
firmed the presence of a pancreatic tumour 98mm in size,         ing to an inherited condition. Confirming pheochromo-
with histology confirming neuroendocrine differentiation.        cytoma by biochemical testing, then localizing the tumor
The mitotic count was <2/hpf, with no marked nuclear             using imaging is the best strategy. Several imaging types
pleomorphism and the Ki67 index was <5%. There was               are available, some (CT, MRI) are sensitive but not spe-
evidence of local vascular invasion, but no evidence of          cific while other (MIBG imaging) are specific but less sen-
local or distant metastasis.                                     sitive, only PET scan with 18F-FDOPA shown high sensi-
     Discussion: Insulinomas are the most common type            tivity and specificity; beside, 18F-FDOPA PET scan does
of tumors affecting the endocrine pancreas, usually under        not interfere with the medications and is less time con-
20mm in size at diagnosis. There have been very few              suming when compared with the MIBG imaging. Genetic
reports of benign giant insulinomas (>9cm diameter).             testing is indicated in the presence of paraganglioma,
The coincidental occurrence of type 2 diabetes and insuli-       bilateral adrenal pheochromocytoma, unilateral adrenal
nomas is well recognized, but rare. We report an unusual         pheochromocytoma with positive family history or with
case of a benign giant insulinoma in association with type       age of onset < 20 years, presence of pheochromocytoma-
2 diabetes, which, to our knowledge, is unique. It is likely     associated syndrome, and an asymptomatic person with
that the coincidental insulin resistance from type 2 diabe-      positive family history with identified genetic mutation.
tes masked the clinical features of hyperinsulinemia for a       	     Conclusion: The optimal approach for catecho-
considerable length of time and promoted tumor growth.           lamine-secreting tumors is debatable. The lack of guide-
     Conclusion: It is important to look for other causes of     lines and the evolution of the biochemical, radiological,
hypoglycemia in type 2 diabetes, especially if not on medi-      and genetic testing are making the diagnosis expensive,
cations that are associated with hypoglycemia. Insulinoma        clear guidelines are needed to make such diagnosis less
is well recognized but rare cause of hypoglycemia in both        expensive. 18F-FDOPA PET scan is not widely available
type 1 and type 2 diabetes.                                      yet, but it seems to improve the localizing accuracy, in
                                                                 patients with small tumors, that are not localized with
Abstract #704                                                    the conventional techniques. When available, we recom-
                                                                 mend considering an 18F-FDOPA PET scan if an MRI or
THE ROLE OF 18F-FDOPA PET SCAN IN A                              CT scan of the abdomen and an I123MIBG scintigraphy
CHALLENGING CASE OF PARAGANGLIOMA                                fail to localize the tumor with a biochemically-confirmed
                                                                 diagnosis.
Georges Chehade Elhomsy, MD, Brian E. Michael, MD,
Karel Pacak MD, PhD                                              Abstract #705

	    Objective: Describe pheochromocytoma and the new            POSTPRANDIAL HYPOGLYCEMIA AFTER
diagnostic modalities.                                           LAPROSCOPIC NISSEN FUNDOPLICATION
     Case	 Presentation: A 59-year-old man with asyn-            IN ADULTS
chronous bilateral adrenal pheochromocytoma treated
with bilateral adrenalectomy presented with recurrent            Pooja Singal, MD, Amale A. Lteif, MD,
episodes of diaphoresis, paroxysmal hypertension, and            Melissa K. Cavaghan, MD
palpitations of several months duration. He had a positive
family history of pheochromocytoma. Physical exam was            	   Objective: To describe two cases of postprandial hypo-
normal. Serum metanephrines and 24-hour urine meta-              glycemia following Laparoscopic Nissen Fundoplication
nephrines and urine catecholamines confirmed the diag-           (LNF) in adults.
nosis of recurrent pheochromocytoma. A work-up, includ-              Case	Presentation: A 51-year-old woman presented
ing abdominal MRI and CT scan, I123MIBG scintigraphy,            with postprandial hypoglycemia occurring weeks after


                                                           – 104 –
                                                 ABSTRACTS – Other

LNF procedure for prolonged GERD. Following an epi-               Abstract #706
sode of mild confusion 3 hours after eating at work in a
medical office, she had an Accucheck of 52mg/dL. A veni-          DAILY PHYSICAL ACTIVITY, FASTING
puncture revealed a blood glucose of 43 mg/dL with an             GLUCOSE, URIC ACID AND BODY MASS
insulin level of 76 IU/ml (normal range 4 - 30mcU/ml) and         INDEX ARE INDEPENDENT FACTORS
C-peptide of 12.6mg/dl (0.8-4.2 mg/ml). A 72-hour fast            ASSOCIATED WITH SERUM FIBROBLAST
was normal. She responded well to a low glycemic index            GROWTH FACTOR 21 LEVELS
diet. Our second case was a 35 year-old male presenting
with similar episodes two hours after meals occurring a           Daniel Cuevas-Ramos, MD,
month after LNF. His symptoms were associated with                Paloma Almeda-Valdes, MD,
blood glucose readings as low as 50mg/dl. Gastric empty-          Francisco J. Gomez-Perez, MD, FACE,
ing was noted to be accelerated. A 72-hour fast and mixed         Clara Elena Meza-Arana, Ivette Cruz-Bautista, MD,
meal tolerance test was normal. He had poor response to           Olimpia Arellano-Campos, Mariana Navarrate-López,
diet changes; medications such as dicyclomine, octreotide         Carlos A. Aguilar-Salinas, MD
and acarbose as well as revision of his fundoplication.
Repeat gastric emptying studies were normal; however,                  Objective: FGF21 have been linked with benefi-
there was only marginal relief of his symptoms.                   cial effects on glucose and lipid metabolism in animals.
	    Discussion: Postprandial hypoglycemia following              Recently, it has been found elevated in humans with meta-
LNF may be explained by accelerated gastric emptying              bolic syndrome. This study aimed to investigate indepen-
resulting in early hyperglycemia and increased release            dent factors associated with serum FGF21 levels.
of incretin hormones (GLP-1, GIP), which may result in                 Methods: This was a cross-sectional study. A clinical
augmented insulin release as well as reduced glucagon             and biochemical evaluation was done to detect the meta-
response in these patients. Miholic et al. Surg Endosc.           bolic syndrome in a never-treated cohort. A total of 210
2007; 21:309-314 studied the relationship of gastric emp-         individuals with (n=81) and without (n=129) metabolic
tying and plasma concentration of gut hormones such               syndrome were included.
as GLP-1, GIP and Peptide-YY in 10 adults, before and                  Results: Serum FGF21 levels correlated positively
after fundoplication and showed greater and earlier rise in       with body mass index (BMI) (r=0.23, P=0.001) and age
GLP-1 and GIP secretion with accelerated gastric empty-           (r=0.17, P=0.01). After adjusting for these parameters and
ing in the first 30 minutes after meal ingestion 3 months         gender, FGF21 correlated positively with fasting glucose
following fundoplication. In our first patient, the diagnosis     (r=0.19, P=0.04), uric acid (r=0.29, P=0.04) and physical
of postprandial hypoglycemia was made following docu-             activity (r=0.18, P=0.01). In addition, FGF21 also corre-
mentation of a low serum blood glucose level associated           lates negatively with RBP4 (r=-0.35, P=0.02), total (r=-
with increased insulin and C-peptide levels 3 hours fol-          0.23, P=0.01) and HMW adiponectin (r=-0.34, P=0.03).
lowing routine meal ingestion. An oral glucose tolerance          A multiple linear regression model analysis identified that
test was performed only in our second patient with incon-         BMI (standardized beta (SB) = 0.247; P=0.008), glucose
clusive results despite having documented delayed gastric         (SB=0.226; P=0.003), uric acid (SB=0.191; P=0.04)
emptying.                                                         and physical activity (SB=0.223; P=0.004) are indepen-
	    Conclusion: Postprandial hypoglycemia has been               dent factors influencing serum FGF21 levels (F=10.05,
described following LNF mostly in the pediatric popu-             r2=0.19, P<0.001). In addition, fasting hyperglycemia
lation with only two case reports in adults. A proposed           ≥100mg/dl, excess body weight with BMI ≥25 kg/m2,
mechanism for this disorder is increased insulin surge in         and uric acid ≥5.5 mg/dl predicted higher serum FGF21
response to hyperglycemia in the immediate postprandial           levels in comparison of subjects without the abnormality.
period due to accelerated gastric emptying. An important          Moreover, a further increment in serum FGF21 levels was
component of this pathophysiology is the dysregulated             observed when the clinical or biochemical abnormality
secretion of incretin hormones.                                   coexisted with higher intensity of daily physical activity
                                                                  (F=5.9, r2=0.26; P=0.001).
                                                                       Conclusion: Serum FGF21 levels are influenced by
                                                                  BMI, fasting glycemia, uric acid and physical activity.




                                                            – 105 –
                                                 ABSTRACTS – Other

Abstract #707                                                     attacks. 24 hour urine metanephrine and catecholamine as
                                                                  well as plasma free metanephrine levels were significantly
RELATIONSHIP BETWEEN TWO-HOUR                                     elevated, CT scan imaging revealed bilateral adrenal mass,
ORAL GLUCOSE TOLERANCE TEST PLASMA                                consistent with adrenal pheochromocytoma. Laparoscopic
GLUCOSE AND URINALYSIS AS SCREENING                               bilateral adrenalectomy for pheochromocytoma was per-
METHOD FOR DIABETES IN HYPERTENSIVE                               formed which resulted in normalization of metanephrine
PATIENTS                                                          levels and improvement of symptoms. Genetic testing for
                                                                  RET Protooncogen showed mutation of 634 codon TGC
Abdullah Ndaman Adamu, MBBS                                       to CTC consistent with MEN 2A. She was diagnosed with
                                                                  type 1 diabetes mellitus at age 43. Her c-peptide level is
	     Objective: To evaluate random urine samples a               undetectable and GAD -65 antibody is elevated at 27 U/
screening test for type 2 diabetes mellitus among people          mL. She is currently being treated with multiple daily
with systemic hypertension.                                       doses of insulin, but reports frequent hypoglycemic and
	     Methods: Between January and May 2004, screening            hyperglycemic episodes. At age 47 she developed symp-
for type 2 diabetes was conducted among people known to           toms of diplopia and was diagnosed with ocular myasthe-
have systemic hypertension and who were regular attend-           nia gravis. Her HLA genotype is consistent with A1, A25,
ees of medical out-patient clinic of the Lagos University         B8, B17, DR3, DR4, compatible with myasthenia gravis
Teaching Hospital. Screening was done using random                and type 1 diabetes mellitus. Of special interest, she has
urine sample. Oral glucose tolerance test was carried out         typical marfanoid habitus with high arched palate and arm
on all the subjects as the standard for the diagnosis of dia-     span exceeding height.
betes. Subjects were classified as screen positive if the         	    Discussion: MEN 2 A is characterized by medul-
urinalysis result is positive, World Health Organisation          lary thyroid carcinoma, pheochromocytoma and primary
(WHO) criteria is used to interpret the OGTT result.              hyperparathyroidism. Mutation at codon 634 is strongly
	     Results: We recruited 206 persons to give room for          associated with pheochromocytoma and hyperparathy-
attrition, out of which 131 (participation rate of 63.41%)        roidism (1). In our case even though genetic mutation is in
of them had OGTT and urinalysis done; 87 were females             codon 634 suggestive of MEN 2A, she has classic pheno-
constituting 65.64% while males were 44 in number                 typic feature of MEN 2B- marfanoid habitus. In addition
constituting 34.35%. A sensitivity of 25%, specificity of         presence of autoimmune diseases, type 1 diabetes mellitus
97.19%, positive predictive value of 66.66%, negative             and myasthenia gravis with MEN2A has not been reported
predictive value of 85.24% was reported. The correla-             in the literature. If this specific mutation in codon 634 is
tion of random urinalysis to two-hour plasma glucose of           related to increased autoimmunity or this is just coexis-
OGTT was 0.55 and the r2 was 30%.                                 tence remains unclear.
	     Conclusion: Urinalysis is a poor screening tool for              Conclusion: MEN 2A can be associated with
type 2 diabetes mellitus among people with systemic               Marfanoid features, and clinicians should be vigilant to
hypertension.                                                     look for other hallmark clinical features and confirma-
                                                                  tory diagnosis with genetic testing. Association of other
Abstract #708                                                     autoimmune diseases, type 1 diabetes mellitus and
                                                                  myasthenia gravis can exist with MEN2A.
INTERESTING CASE OF MULTIPLE
ENDOCRINE NEOPLASIA (MEN) 2A WITH                                 Abstract #709
MARFANOID HABITUS AND MULTIPLE
AUTOIMMUNE DISORDERS                                              MALE HYPOGONADISM AND TRANSDERMAL
                                                                  TESTOSTERONE REPLACEMENT THERAPY -
Grishma Parikh, MD, Augustin Busta, MD                            PERSONAL EXPERIENCE

	    Objective: To describe an interesting case of Multiple       Corina H. Galesanu, MD, PhD, Luminita Apostu,
Endocrine Neoplasia (MEN) 2A presenting with features             Petronela Iovita
of MEN 2B, type 1 diabetes mellitus and myasthenia
gravis.                                                                Objective: Male hypogonadism is usual associated
     Case	 Presentation: A 64-year-old female with a              with sexual dysfunction, particularly diminished libido, as
known history of medullary thyroid carcinoma diagnosed            well as mood disturbances, reduced lean body mass and
at age 24, underwent a total thyroidectomy. At age 36, she        increased adipose - tissue mass. The aim of Testosterone
was diagnosed with HTN, two years later her hypertension          Replacement Therapy (TRT) is to restore serum testos-
worsened, associated with increased anxiety and panic             terone (T) to eugonadal levels and minimize signs and


                                                            – 106 –
                                                ABSTRACTS – Other

symptoms of hypogonadism. Hydroalcoholic T-gel (1%)              1%, 50 mg/daily. Larger number of patients treated lon-
(AndroGel)have been approved for male hypogonadism.              ger periods of time may help to evaluate the efficacy, tol-
	    Methods: Eleven men with primary or secondary               erability and safety profiles of transdermal testosterone
hypogonadism aged 18-68 years were treated with T-gel            treatment.
50 mg/daily. Six patients had primary hypogonadism and
five had secondary hypogonadism. The limits of serum             Abstract #710
total T for establishing the diagnosis of hypogonadism in
our clinic are 8-12 nmol/L. Our study was a clinical, open       TOTAL AND HIGH MOLECULAR WEIGHT
label, non randomized trial, screening examinations had          ADIPONECTIN HAVE SIMILAR UTILITY FOR
been completed before the first application of T-gel. Well-      THE IDENTIFICATION OF
being and sexuality were investigated by standardized            METABOLIC ABNORMALITIES
questionnaires. Serum concentrations of FSH, LH, SHBG,
prolactin, PSA were analyzed by immunofluorometric               Paloma Almeda Valdes, MD,
assays. Serum testosterone was measured by enzyme                Daniel Cuevas-Ramos, MD, Roopa Metha, MD,
- linked immunosorbent assay. Free T (FT) was calcu-             Francisco J. Gomez-Perez, MD, FACE,
lated with Vermeulen formula. Biochemical parameters             Ivette Cruz-Bautista, MD, Olimpia Arellano-Campos,
were: glucose, alkaline phosphatase, creatinine, uric acid,      Mariana Navarrete-Lopez,
sodium, potassium, aspartate amino transferase (ASAT)            Carlos A. Aguilar-Salinas, MD
alanine amino transferase (ALAT), lipids. Hematological
parameters: hematocrit values and hemoglobin. Prostate                Objective: To evaluate and compare the utility of total
examinations included determination of volume, by digi-          and HMWA for the identification of insulin resistance (IR)
tal rectal examination (DRE). Monitoring are required to         and related metabolic conditions.
evaluate the efficacy by TT and FT and safety by PSA,                 Methods: A cross-sectional analysis was performed
hemoglobin, hematocrit, serum lipid panel ALAT, ASAT,            in a group of ambulatory subjects, aged 20 to 70 years, in
prostate related symptom, sleep apnea, before the treat-         Mexico City. Area under the receiver operator characteris-
ment at six and at twelve months.                                tic (ROC) curve for total and HMWA were plotted for the
	    Results: During T-gel applications body weight              identification of metabolic disturbances. Sensitivity and
increased slightly with 2.3% (from 72.3±3.5 to 74±3.8 kg)        specificity, positive and negative predictive values and
after one year. TT levels increased from 5.16±0.7 nmol/L         accuracy for the identification of IR were calculated.
to 7.8±0.3 nmol/L (6 months) and to 22.22±2.4 nmol/L                  Results: The study included 101 men and 168 women.
(12 months). Calculated FT levels who were 74.83±8.1             The areas under the ROC curve for total and HMWA for
pmol/L at the beginning, increased to 171.6±36.5 pmol/L          the identification of IR (0.664 vs. 0.669, P = 0.74), obesity
at six months and to 326.6±39.6 pmol/L after a year of           (0.592 vs. 0.610, P = 0.32), hypertriglyceridemia (0.661
treatment (Normal FT >250 pmol/L). Biochemical param-            vs. 0.671, P = 0.50) and hypoalphalipoproteinemia (0.624
eters: glucose, creatinine, uric acid, alkaline phosphatase,     vs. 0.633, P = 0.58) were similar. A total adiponectin level
sodium, potasium, ASAT; ALAT remained unchanged                  of 8.03 μg/ml was associated with a sensitivity of 57.6%,
during the treatment. No statistically significant changes       a specificity of 65.9%, a positive predictive value 50.0%,
for hemoglobin and hematocrit. Compared with base-               a negative predictive value 72.4% and accuracy of 62.7%
line a small increased with 6.2% of hemoglobin (13.65            for the diagnosis of IR. The corresponding figures for a
to 14.5 ng/dL) and hematocrit increased with 7.4% (40.3          HMWA level of 4.25 μg/dl were 59.6%, 67.1%, 51.8%,
to 43.3%) after one year treatment. The lipid parameters         73.7% and 64.2%.
did not change during the treatment compared with base-          	    Discussion: IR and related metabolic disturbances
line levels; a slight decrease in HDL-C (4.1%) and LDL-C         are characterized by low levels of adiponectin. HMWA
(3%) were observed. No changes in prostate volume or             is considered the active form of adiponectin and a better
significant changes of PSA; a slight increase in PSA was         marker of IR than total adiponectin. IR is a treatable pre-
observed but insignificant 0.8±0.5 ng/L before the treat-        cursor of diabetes; its identification is therefore desirable
ment to 1.9±0.6 ngL at the end of first year of treatment.       in clinical practice. Established direct methods to quantify
	    Conclusion: Male hypogonadism is associated                 insulin sensitivity, such as the hyperinsulinemic euglyce-
with potentially distressing symptoms and signs, many            mic clamp, are relatively complex and time consuming.
of which are reversible under TRT. Serum T levels ≥ 12           Surrogate indexes are available but there are no universal
nmol/L and FT levels ≥ 250 pmol/L reduced symptoms               cutoff points to define IR. For this reason we attempted
of hypogonadism. In our study normal levels of TT and            to estimate an adiponectin threshold for the identifica-
FT were obtained after one year of treatment with T-gel          tion of IR. The cutoff points identified had a reasonable



                                                           – 107 –
                                                ABSTRACTS – Other

sensitivity and specificity. At present one of the disadvan-     normal saline as her sensorium improved. She developed
tages of adiponectin is that the assay for its measurement       tremors and rigidity over the next few days and EPM was
is not widely available and is expensive.                        suspected. An MRI scan confirmed the same.
     Conclusion: Adiponectin may be a useful marker for               Discussion: Osmotic Demyelination Syndrome
IR. Total adiponectin and HMWA had similar utility for           (ODS) is a life threatening complication that manifests
the identification of IR and metabolic disturbances.             several days after aggressive therapy of hyponatremia. In
                                                                 CPM there is dissolution of myelin sheaths within the cen-
Abstract #711                                                    tral aspect of basis pontis. CPM and EPM are usually the
                                                                 complications of rapidly corrected hyponatremia, espe-
CENTRAL PONTINE MYELINOLYSIS IN                                  cially in chronically debilitated and bed ridden patients,
SPITE OF GRADUAL CORRECTION OF                                   but there are always exceptions to the rule. ODS may
HYPONATREMIA: 2 CASE REPORTS                                     occur when serum sodium levels are normal or high and
                                                                 even if serum sodium levels are corrected within “safe”
Mukhyaprana M. Prabhu, MD,                                       limits Laureno and Karp et al study, 21% of patients in
Masdhusdhan Sangar, MD, Vishwanathan S., MD,                     study group developed myelinolysis after correction of
Abdul Razak MD, Balasubramanian R., MD                           hyponatremia with so-called safe guidelines. There is
                                                                 enough evidence to say that chronicity of hyponatremia is
      Objective: Central pontine myelinolysis (CPM) is           the precipitating factor to myelinolysis. The initial inten-
a demyelination disease of pons often associated with            sity of hyponatremia and also absolute increase in serum
the demyelination of extrapontine areas of central ner-          sodium levels has a vital role in this dramatic condition.
vous system. Although the etiology and pathogenesis are               Conclusion: Medical literature recommendations for
unclear, CPM is usually associated with hyponatremia or          management of hyponatremia are controversial. Both of
its rapid correction, and chronic alcoholism is also a com-      our cases were treated gradually as per “safe” guidelines
mon underlying condition. We describe here 2 cases of            but still developed ODS. So further research is still required
CPM occurring in non alcoholic ladies in spite of gradual        regarding the question how much to correct and how slow
correction of hyponatremia                                       to correct and till then carefulness and close monitoring is
      Case	Presentation: Case 1: A 54 year-old non alco-         warranted to prevent this dreaded complication
holic lady presented with a 10 day history of abdominal
pain, dysuria with altered sensorium. Her vitals were sta-       Abstract #712
ble and Glasgow Coma Scale (GCS) was 4/15 on presen-
tation. At admission her serum sodium was 101mEq/l. A            SEX STEROID-DEPENDENT INHIBITION OF
diagnosis of hyponatremic encephalopathy with Syndrome           HYPERGLYCEMIA-INDUCED ENDOPLASMIC
of Inappropriate Anti Diuretic Hormone (SIADH) was               RETICULUM STRESS IN ENDOTHELIAL CELLS
made. 1.6% saline was infused and a gradual correction of
serum was done. On the 2nd hospital day, 1.6% saline was         Mae Sheikh-Ali, MD, Prafull Raheja, MD,
replaced with normal saline as her sensorium improved            Michael J. Haas, PhD, Arshag D. Mooradian, MD
and she became fully conscious and oriented. 3rd day, she
was again found to be drowsier with papillary asymmetry          	    Background: Elevated plasma glucose levels induce
was intubated and hyperventilated in view of possible con-       endoplasmic reticulum stress (ER stress) in endothelial
ing. 4th hospital day, she was comatose with no response         cells. As a result, changes in endothelial cell function may
to painful stimuli and no spontaneous breaths. Magnetic          promote atherogenesis and increase vascular permeabil-
resonance Imaging (MRI) scan was normal. Patient con-            ity. Estradiol regulates vascular tone by enhancing nitric
tinued to be comatose. Repeat MRI done later showed              oxide-dependent vasodilation of the endothelium. It is
features of central pontine and extrapontine myelinolysis        not clear however if estradiol or other sex steroids influ-
(EPM). She remained in vegetative state until death on the       ence other aspects of endothelial cell function, such as ER
40th post admission day.                                         stress. Therefore, we measured the effects of sex steroids
      Case 2: A 70-year-old hypertensive, non-alcoholic          on hyperglycemia-induced ER stress.
woman was brought to emergency department in altered             	    Methods: To determine if sex steroids inhibit ER
sensorium. She was diagnosed to have hyponatremia                stress, we measured ER-stress in endothelial cells, a cell
due to SIADH. At presentation her serum sodium was               type that is prone to damage and is important in athero-
110mEq/l. 1.6% saline was started and her sodium levels          sclerosis and cardiovascular disease. Human umbilical
were frequently monitored. A gradual correction of hypo-         vein endothelial cells (HUVEC) were treated with physio-
natremia was done. 2nd day she was started on dextrose           logical (5 mM) or supra-physiological (27.5 mM) dextrose



                                                           – 108 –
                                                ABSTRACTS – Other

concentrations in the presence or absence of 100 nM estra-       and three had persistence of medullary carcinoma.
diol (E), 100 nM testosterone (T), 100 nM dihydrotestos-              Discussion: MEN is a rare autosomal dominant dis-
terone (DHT), and 100 nM 5-methyl-testosterone (meT).            ease caused by activating mutations in the RET proto-
	 	 	 	 	 Results: After 24 hours, ER stress was determined      oncogene. It is characterized by thyroid, adrenal and para-
by measuring secreted alkaline phosphatase activity with         thyroid tumors. In this case series we were able to identify
a chemiluminescent substrate. Supra-physiological dex-           the causal mutations, in agreement with the literature all
trose concentrations increased ER stress, however, in the        the MEN 2B cases were due to a mutation in codon 918.
presence of E or T, ER stress was significantly reduced.         With regard to MEN 2A, the most frequent mutation was
However, in contrast to T-treated cells, DHT and meT             in codon 634 as expected.
were ineffective at alleviating ER stress. Since DHT and              Conclusion: Appropriate diagnosis of MEN and
meT cannot be metabolized to E by endogenous aroma-              identification of the causal mutations are essential. A
tase activity, we hypothesize that E is the primary sex ste-     search for affected family members is mandatory, with
roid possessing ER stress normalizing activity.                  prophylactic thyroidectomy and appropriate screening of
	        Conclusion: These results indicate that hypergly-       other manifestations.
cemia-induced ER stress is alleviated by E and T (pos-
sibly after conversion to E by aromatase). These obser-
vations suggest that sex differences, menopause, and the         Abstract #714
age-related decline in T levels in males may have roles in
regulating ER stress in vascular cells, enhancing the risk       PREVALENCE AND METABOLIC
of cardiovascular disease.                                       CHARACTERISTICS OF LIPOATROPHY
                                                                 IN PATIENTS ON HIGHLY ACTIVE
Abstract #713                                                    ANTIRETROVIRAL THERAPY IN A
                                                                 NIGERIAN OUTPATIENTS HIV CLINIC
MULTIPLE ENDOCRINE NEOPLASIA TYPE 2.
EXPERIENCE IN A REFERENCE CENTER IN                              Sandra Omozehio Iwuala, MBBS,
MEXICO CITY                                                      Olufemi Fasanmade, MBBS, FWACP, FACE,
                                                                 Olufunmilayo Lesi, FMCP
Edgar Avendaño Vazquez, MD,
Alfredo Reza-Albarran, MD,                                       	    Background: Lipoatrophy is an adverse effect of
Paloma Almeda-Valdes, MD,                                        highly active antiretroviral therapy (HAART). It has the
Daniel Cuevas-Ramos, MD, Roopa Mehta, MD,                        potential of influencing long term adherence to medica-
Francisco Gomez-Perez, MD, Juan Rull, MD                         tion. As part of the lipodystrophy syndrome in HIV infec-
                                                                 tion, it can be associated with metabolic abnormalities,
	    Objective: To describe the clinical characteristics,        potentially increasing morbidity and mortality in HIV
evolution and treatment of patients with multiple endo-          infection. Nucleotide reverse transcriptase inhibitors
crine neoplasia type 2 (MEN 2).                                  (NRTI) which often form the backbone of HAART in
     Methods: We analyzed the clinical records of all            resource poor settings are frequently implicated in its cau-
patients with diagnosis of MEN 2 in the Instituto Nacional       sation. This study set out to determine the prevalence of
de Ciencias Medicas y Nutricion Salvador Zubiran in              lipoatrophy in patients on HAART attending an outpatient
Mexico City from 1987 to 2008.                                   HIV clinic in a tertiary health care centre in Nigeria.
     Results: We identified seven cases with MEN 2B and          	    Methods: HAART experienced patients (6 months)
thirteen with MEN 2A. The mean age at diagnosis was              were recruited for the study. The study protocol involved
13.5 years (6-63). Medullary thyroid carcinoma was pres-         administration of a questionnaire, physical examination
ent in all patients. MEN 2B cases had marfanoid appear-          (including anthropometric indices and skin fold thick-
ance and neuro-dermatological tumors. In addition, three         ness), bioelectrical impedance analysis measurements
(42.8%) had pheochromocytoma, of which two were bilat-           and biochemical investigations (fasting plasma glucose,
eral. A mutation of codon 918 in the RET proto-oncogene          lipogram and serum insulin. Lipoatrophy was defined
was identified in 5 patients, three of which appeared to be      clinically (patients report on questioning supported by
de novo mutations. Three patients died during follow-up.         findings on physical examination. The case notes were
With regards to MEN 2A cases, three patients had hyper-          also reviewed for drug history and retrieval of recent CD4
parathyroidism and five pheochromocytoma. In seven               count and viral load values.
cases a mutation in codon 634 of the RET proto-oncogene          	    Results: There were 145 patients studied, compris-
was detected, and in four a mutation in codon 620 was            ing 84 (57.9%) females and 61 (42.1%) males. The mean
observed. At follow-up, ten patients were free of disease        (SD) age of the study population was 40.3 (8.9) years.


                                                           – 109 –
                                                ABSTRACTS – Other

Lipoatrophy was present in 48 (33.1%) HAART experi-                   Discussion: Nesidioblastosis is the most common
enced patients. It was associated with significantly lower       cause of persistent hypoglycemia in infancy, but is rare
body circumferences, skin fold thickness and lower body          in adults accounting for 0.5-7% of all cases of hyperin-
fat (p< 0.05) but with preservation of skeletal muscle           sulinemia and tends to be more common in adult males
mass. Clinical lipoatrophy was not associated with glu-          than in females. These patients experience predominantly
cose intolerance or dyslipidemia or insulin resistance (p>       postprandial hypoglycemia and have nesidioblastosis with
0.05).                                                           islet cell hypertrophy in close contact with acinar ducts,
     Conclusion: Lipoatrophy is a frequently encountered         findings different from those in patients with insulinomas.
adverse effect of HAART in Nigerian HAART treated                During episodes of hypoglycemia, patients with NIPHS
patients. Its characteristics in this cohort of patients are     have biochemical findings similar to those of insulinoma,
similar to those observed elsewhere.                             including elevated plasma insulin, C-peptide, and proin-
                                                                 sulin concentrations, low plasma beta-hydroxybutyrate,
Abstract #715                                                    and a negative sulfonylurea screen. Our patient’s his-
                                                                 tory and findings were compatible with a diagnosis of
A CASE OF NESIDIOBLASTOSIS ASSOCIATED                            nesidioblastosis.
WITH NONINSULINOMA PANCREATOGENOUS                                    Conclusion: Nesidioblastosis is a very rare condi-
HYPOGLYCEMIA SYNDROME (NIPHS) IN AN                              tion in adults overall and even more rare in females, but it
ADULT FEMALE                                                     should be considered as a differential diagnosis in patients
                                                                 presenting with hyperinsulinemic hypoglycemia. In the
Yanira Ivelisse Marrero Mcfaline, MD,                            majority of these patients partial pancreatectomy relieves
Margarita Ramirez, MD,                                           hypoglycemic symptoms.
Myriam Allende, MD, MBA, FACP, FACE,
Meliza Martinez, MD, Marielba Agosto, MD,                        Abstract #716
Alejandra Santiago, MD
                                                                 WATER INTOXICATION WITH DESMOPRESSIN
     Objective: To describe a case of nesidioblastosis in an     USED FOR NOCTURNAL POLYURIA.
adult female patient in Puerto Rico.
     Case	 Presentation: A 38-year-old female with his-          Harsha Karanchi, MD, Eric J. Mueller, MD,
tory diabetes mellitus type 2 and high blood pressure was        Jose A. Perez, Jr., MD
referred to our institution due to three months history of
hypoglycemia despite no use of oral hypoglycemics and/           	     Objective: Desmopressin is a synthetic analog of
or insulin. Patient refers that since three months ago, had      arginine vasopressin. Water intoxication and severe water
been experiencing weight gain, dizziness, and blurred            retention is a rare but alarming side effect of this drug and
vision, which were relieved with carbohydrate ingestion.         it is important to educate patients regarding restriction of
The episodes of hypoglycemia occurred both at fasting            fluid intake when taking this medication.
and postprandial. Medical history was negative for peptic              Case	Presentation: The patient is a seventy-nine year
ulcer disease or gastrointestinal surgical procedures and        old Hispanic man with history of hypertension and benign
family history was negative for endocrine tumors. Physical       prostatic hyperplasia treated three years previously with
examination was unremarkable. Fasting blood sugar was            a transurethral resection of prostate. Three weeks prior to
36 mg/dL (60-100 mg/dL), with concomitant insulin lev-           admission the patient was prescribed oral desmopressin for
els in 19.28 uIU/L (3-28 uIU/L), C-peptide 2.79 ng/mL            progressively worsening nocturnal polyuria by his urolo-
(0.81-3.85 ng/mL), proinsulin levels 21.2 pmol/L (1.8-           gist. The patient presented with a two week history of pro-
18 pmol/L), beta-hydroxybutyrate 0.17 mmol/L (> 2.7              gressive bilateral leg edema and a weight gain of twenty
mmol/L), and negative sulfonylurea screen. Abdominal             pounds. Two days prior to admission, the patient devel-
sonogram and computed tomography with pancreatic pro-            oped progressive dyspnea and palpitations. On physical
tocol were negative. In exploratory laparotomy a lesion          examination, irregularly irregular muffled heart sounds
in distal pancreas was found by palpation and distal pan-        and bilateral symmetric pitting leg edema was noted.
createctomy was done. A fragment of pancreas of 4 x 3.7          The electrocardiogram showed arterial fibrillation with
x 1.5 cm was removed and sent to pathology. Pathology            rapid ventricular response and low voltage. Chest radio-
report revealed findings consistent with adult form of           graph demonstrated bilateral massive pleural effusions.
nesidioblastosis. One month after surgery patient contin-        Laboratory testing showed mild hyponatremia and normal
ues with stable blood glucose between 130 and 150 mg/            cardiac enzymes. An echocardiogram was consistent with
dL.                                                              pericardial tamponade showing a moderate anterior and



                                                           – 110 –
                                                ABSTRACTS – Other

posterior pericardial effusion with RV diastolic collapse        and 31.08% had triple vessel disease. CAG positive sub-
and normal LV function. A pericardiocentesis was done            jects, 62.1% had waist circumference above normal, and
and drain left in place for two days. Desmopressin was           about 90% have dyslipidemia and dysglycemia (DM/IGT/
stopped and the patient treated with furosemide. Pleural         IFG). In the group undergone CAG 83.9 % of diabetic and
and pericardial effusions and arterial fibrillation resolved     69.76% of non diabetic had positive angiographic finding.
and the patient improved symptomatically. On further             	    Results:	 It was observed that hypertriglyceridemia,
questioning, the patient revealed that he habitually drank       waist circumference, hypertension (metabolic parameters)
large amounts of fluid in an effort to cleanse his body and      are significantly related with positive angiographic find-
continued this practice while on the desmopressin.               ing. Among the demographic parameters aging, male sex,
	    Discussion: Several cases of severe hyponatremia            smoking habit and family history of cardiovascular disease
and associated seizures have been reported with desmo-           is related to angiographic positivity. Peripheral vascular
pressin use, particularly in the pediatric population and        disease (PVD) as measured by low ankle brachial index
especially with the intranasal formulation previously            (ABI) (<0.9) (palpatory method is applied for assessing
used for primary nocturnal enuresis. However, the severe         peripheral vascular disease) is not significantly higher in
volume overload seen in this case has not been reported.         CAG positive subjects and it was also not evident that
Desmopressin use for nocturnal polyuria in adults is non-        metabolic syndrome is influencing the occurrence of PVD
FDA approved.                                                    in association of CAD.
     Conclusion: Caution should be used when prescrib-           	    Conclusion: Using the IDF criteria waist circum-
ing desmopressin and it is prudent to educate patients           ference, hypertension and hypertriglyceridemia are sig-
especially pediatric and geriatric populations to avoid          nificantly predicting cardiovascular event in this study
excessive fluid intake when taking desmopressin to pre-          subjects and presence of metabolic syndrome does not
vent this life threatening but preventable complication.         influencing the relationship between cardiovascular and
                                                                 peripheral vascular disease.
Abstract #717
                                                                 Abstract #718
CHARACTERISTICS OF DIFFERENT
PARAMETERS OF METABOLIC SYNDROME                                 RARE INTERVENTION TO DEAL WITH
IN SUBJECTS UNDERGOING CORONARY                                  A RARE DISEASE- INSULINOMA
ANGIOGRAM AND THEIR ASSOCIATION WITH
PERIPHERAL VASCULAR DISEASE                                      Khurshid Ahmad Khan, MD

Faria Afsana, MBBS                                                    Objective: To describe non-conventional treatment of
                                                                 insulinoma in a patient who was poor candidate for surgi-
     Objective: Metabolic syndrome (MetS) is associated          cal treatment based on co-morbidities.
with an increased risk of cardiovascular disease events.              Case	Presentation: An 85-year-old female presented
The present study was undertaken to identify the predict-        with episodic complaints of sweating, palpitations, gener-
ing parameters of metabolic syndrome that can associate          alized weakness and confusion for last one month mostly
with cardiovascular and peripheral vascular disease.             around early morning in a fasting state. She was admitted
	    Methods: A total of 360 subjects were selected pur-         to the hospital for work up. Next morning in fasting state
posively in this study. Two hundred and sixty subjects           she had similar symptoms; blood glucose was 48 mg/dl.
(group1) were selected from Ibrahim Cardiac Hospital and         Her blood was also drawn for C-peptide, proinsulin and
Research Institute (ICHRI), who reported for coronary            insulin levels. She was given IV dextrose and symptoms
angiogram (CAG) for the first time having either a car-          subsided with that. Test results came back as insulin 10
diac event in the past or enough clinical or investigational     µU/ml, C-peptide 6 pg/ml and proinsulin 21pmol/L.
evidence of coronary artery disease. One hundred subjects        Abdominal CT showed 2 cm mass in head of the pan-
were selected from outpatient department of, BIRDEM              creas. A diagnosis of insulinoma was made. Other tests
coming for routine follow up with no past history, docu-         were done and possibility of multiple endocrine neopla-
ment/evidence of CAD or of CAG. About two thirds of the          sia (MEN 1) was ruled out. Patient did have history of
subjects of both the groups had MetS (64.6% in group 1           CAD, HTN and CHF with EF of 20%. Based on her age
and 66% in group 2). In group 1, 79.2% had positive angi-        and co-morbidities she was considered poor candidate
ographic finding and 20.8 % had normal CAG indicating            for surgery. Trial of oral diazoxide failed to control her
that a good percentage of subjects who were suspected to         symptoms. As a last resort decision to do selective embo-
have CAD had normal coronary arteries. Among the CAG             lization of tumor was made. She was treated by repeated
positive subjects 38.83% had single, 30.09% had double           embolization using spherical polyvinyl alcohol particles,


                                                           – 111 –
                                                ABSTRACTS – Other

resulting in shrinkage of the tumor leading to cure of her       stroke and 3 (6%) had both. All the subjects with ABG
hypoglycemic events and improvement of quality of life.          200mg/dl or more had an infarctive stroke. However, of
     Discussion: Insulinoma is a rare neuroendocrine             those with ABG less than 200mg/dl, 36% had hemorrhagic
tumor, most commonly originating from the pancreas,              stroke, 58% had infarctive stroke while 7% had both. No
which is either sporadic or familial as a component of           statistically significant relationship between the ABG and
MEN1. It is characterized by inappropriately increased           stroke types (p=0.13). Also, mean ABG was higher in
insulin secretion leading to hypoglycemia. For localiza-         infarctive than in hemorrhagic stroke (138 Vs 130mg/dl)
tion purposes transabdominal ultrasonography and CT              but difference is not statistically significant (p=0.064).
abdomen are preferred initial tests, followed by endo-           	    Conclusion: Patients with ABG ≥200mg/dl are more
scopic ultrasonography or arterial stimulation with hepatic      likely to have an infarctive stroke.
venous sampling. Surgical removal is considered the treat-
ment of choice, with limited side effects and relatively low     Abstract #720
morbidity and mortality. For patients whose insulinoma
cannot be located during pancreatic exploration or those         A COMPARATIVE STUDY OF TIGHT GLYCEMIC
who are not candidates for or refuse surgery, diazox-            PROTOCOLS AND THEIR RISK OF INDUCING
ide therapy for the medical management of hypoglycemia           HYPOGLYCEMIA IN CRITICALLY ILL
is another option. Some rarely used treatment options for        PATIENTS
these patients include embolization, chemoembolization,
RFA, and cryoablation.                                           Abeer W. Anabtawi, MD, Margaret Hurst, RN,
     Conclusion: Embolization as an alternative treatment        Umarshanker Doss, MD, Shashi Patel,
of insulinoma in a patient, who was poor surgical candi-         Carlos Palacio, MD, Krishna Kumar Rajamani, MD
date and had failed medical treatment with diazoxide, was
very effective in improving hypoglycemic episodes as             	    Objective: Comparison of the incidence of hypogly-
well as quality of life.                                         cemia among the different tight glycemic control (TGC)
                                                                 protocols is a crucial aspect that has not been addressed
Abstract #719                                                    in previous trials. This study compared the incidence of
                                                                 hypoglycemia using three TGC protocols in critically ill
TACROLIMUS-INDUCED DKA IN A PATIENT                              patients.
WITH RENAL TRANSPLANTATION AND                                   	    Methods: In this 18 months prospective study; 420
LAURENCE-MOON-BIEDL SYNDROME                                     patients were divided into three groups by TGC proto-
                                                                 col: A (Modified Leuven Protocol), B (Georgia Hospital
Muhammad Qamar Masood, MD,                                       Association (GHA) Protocol, target Blood glucose (BG)
Madiha Rabbani, MBBS                                             80-110 mg/dl), and C (Modified GHA Protocol, target BG
                                                                 90-140 mg/dl). Groups were similar in age, gender, dia-
	    Objective: To determine if there is a relationship          betes history, body mass index, admission type, and ICU
between the admitting blood glucose (ABG) and the types          length of stay. End points included differences in the inci-
of stroke in patients with stroke.                               dence of hypoglycemia (BG ≤ 60 mg/dl), severe hypogly-
     Methods: Fifty-one subjects admitted into the emer-         cemia (BG ≤ 40 mg/dl), and hyperglycemia (BG ≥ 180
gency ward of a tertiary hospital in Lagos, Nigeria, for         mg/dl). BGs are presented as mg/dl.
acute stroke, confirmed with brain computerized tomogra-         	    Results: A total of 34,497 BG samples were analyzed
phy (CT) scan were studied over a year period. Subjects’         [A: 11,202 (32.47%), B: 9,627 (27.91%), and C: 13,668
clinical history and blood glucose were recorded at admis-       (39.62%)]. Hypoglycemia was significantly more frequent
sion and analyzed.                                               in group A [348 episodes (3.11%)] compared to B [209
     Results: Mean age (and standard deviation, SD) of           episodes (2.17%)] [OR 1.45, 95% CI 1.25-1.172, p=0.001]
study subjects was 60 (12) years, ranging between 28 and         and C [266 episodes (1.95%)] [OR 1.66, 95% CI 1.37-1.89,
85 years. The male-female ratio was 1:1. No statistically        p=0.001]. Severe hypoglycemia was significantly more
significant difference in the ages of the male and female        frequent in group A [131 episodes (1.17%)] compared
subjects (p=0.20). Nine (18%) of the subjects were had           to B [62 episodes (0.64%)] [OR 1.83, 95%CI 1.22-1.72,
prior history of diabetes mellitus (DM) with a mean dura-        p=0.001] and C [58 episodes (0.42%)] [OR 2.77, 95%CI
tion (SD) of 7(6) years. Most subjects (65%) had prior           2.04-3.79, p=0.001]. No significant differences in hypo-
history of systemic hypertension with an average duration        glycemia and severe hypoglycemia when group B and C
(SD) of 8 (7) years. The mean ABG was 134 (58)mg/dl,             were compared (p=0.10 and p=0.06). Hyperglycemia was
ranging between 37 and 320mg/dl. While 32 (63%) of the           significantly more common in group A [2,175 episodes
subjects had infarctive stroke, 16 (31%) had hemorrhagic         (19.42%)] compared to B [1,333 episodes (13.83%)] [OR


                                                           – 112 –
                                                 ABSTRACTS – Other

1.49, 95% CI 1.39-1.62, p=0.001], although it was not             Measure (SLAM) score and Systemic Lupus International
significantly more frequent when A was compared to C              Collaborating Clinics Damage Index (SLICC/ACR) were
[2,560 episodes (18.73%), p=0.17]. Group B had a sig-             used for assessment of disease activity and organ damage.
nificantly lower incidence of hyperglycemia compared to           	    Results: The metabolic syndrome was present in 51.4
C [OR 0.69, 95% CI 0.65-0.75, p=0.001].                           % of SLE patients and in 16.7 % of controls (p<0.05)
	    Discussion: Although the optimum intensity of BG             using the WHO definition that requires direct determina-
control in critically ill patients remains controversial, the     tion of insulin resistance, and in 38.6 % of patients and
avoidance of hypoglycemia appears to be of significant            in 10 % of controls (p<0.05) using the NCEP definition.
importance to obtain the maximum benefit of TGC pro-              WHO definition has higher sensitivity, while NCEP defini-
tocols. This study shows that TGC protocols vary signifi-         tion has higher specificity. Among patients with SLE, both
cantly in their efficacy and risk of inducing hypoglycemia.       definitions were significantly associated with higher insu-
Both protocols B and C significantly lowered incidence            lin resistance, higher concentrations of C reactive protein
of hypoglycemia compared to A. Using columnar insulin             (CRP), higher triglycerides levels, and lower high density
dosing charts in both protocols may contribute to these           lipoproteins (HDL)levels (p<0.05). Disease duration and
findings.                                                         type of medication used were not associated with the met-
	    Conclusion: TGC protocols vary in their risk of              abolic syndrome (p>0.05), while SLE disease activity and
inducing hypoglycemia and this should be a key factor             damage scores were associated with the metabolic syn-
when selecting a specific protocol. Future studies may            drome (p<0.05). Patients with metabolic syndrome had
determine if these variations result in differences in clini-     higher levels of proteinuria and more aggressive nephritis
cal outcome such as mortality or adverse effects.                 (p <0.05).
                                                                  	    Conclusion: Patients with SLE have a higher preva-
Abstract #721                                                     lence of insulin resistance and metabolic syndrome than
                                                                  controls. In patients with SLE, the metabolic syndrome
METABOLIC SYNDROME IN EGYPTIAN                                    is associated with higher levels of C reactive protein,
PATIENTS WITH SYSTEMIC LUPUS                                      higher disease activity and damage scores. The metabolic
ERYTHEMATOSUS                                                     syndrome may provide a link between inflammation and
                                                                  increased cardiovascular risk.
Aziza Abdel Moez Hammad, MD,
Mohamad Salah Eldin Abdel-Baky, MD,                               Abstract #722
Dalia Abdel-Mohsen, MD, Eman Ahmed Hafez, MD,
Noran Osama El-Aziz, MD                                           THE VALUE OF INSULINE-LIKE GROWTH
                                                                  FACTOR 1 LEVEL IN PREDICTING RESPONSE
	    Background/Objective: To study the prevalence of             TO LEVOSIMENDAN TREATMENT IN PATIENTS
the metabolic syndrome in Egyptian patients with SLE              WITH SEVERE HEART FAILURE
and compare with the controls, and to evaluate its asso-
ciation with cardiovascular risk factors and disease char-        Serhat Isik, MD, Mustafa Cetin, MD,
acteristics. Patients with systemic lupus erythematosus           Hulya Cicekcioglu, MD, Ozgul Ucar, MD,
(SLE) have accelerated atherosclerosis but the causes are         Zehra Guven Cetin, MD, Ufuk Ozuguz, MD,
not clear. The metabolic syndrome is an independent risk          Fatih Bakir, MD, Dilek Berker, MD, Serdar Guler
factor for ischaemic heart disease. SLE provides a unique
model to identify mechanisms that are common to both              	    Objective: In spite of entire improvements achieved
inflammation and cardiovascular disease; however there            in treatment, heart failure (HF) has still had high rate of
are no controlled studies of the metabolic syndrome in            mortality. Levosimendan has positive inotropic, antistun-
Egyptian patients with SLE.                                       ning and cardioprotective effects during episodes of acute
	    Methods: Seventy patients with SLE who satisfied             HF. Among the studies on the treatment of HF, those based
the American College of Rheumatology (ACR) criteria,              on growth hormone (GH) are of interest. Besides, clini-
aged ≥16 years and had disease duration ≥ 1 year and              cal studies of patients with HF have demonstrated that
thirty age and sex matched healthy controls were studied.         insulin-like growth factor 1 (IGF-I) levels were low and
The prevalence of the metabolic syndrome was compared             correlate with the severity of HF. In the present study, we
in patients and controls using the National Cholesterol           aimed to investigate the usefulness of basal IGF-I levels in
Education Program Adult Treatment Panel III (NCEP)                levosimendan treatment.
and the World Health Organization (WHO) definitions.                   Methods: Thirty patients under standard HF treat-
Associations with cardiovascular risk factors and SLE             ment who presented with functional capacity NYHA class
disease characteristics were examined. Lupus Activity             III-IV and left ventricular ejection fraction (LVEF) less


                                                            – 113 –
                                               ABSTRACTS – Other

than 35% were enrolled in the study. The patients were         dehydration, seizures and hepatic encephalopathy during
initiated on infusion of levosimendan loading dose of 12       a Rotavirus infection. Metabolic workup showed evidence
µg/kg/min for 10 minutes and subsequently, infusion of         of medium chain dicarboxylic acids in the urine. Plasma
0.1 µg/kg/min 24 hours was administered as maintenance         acylcarnitine profile disclosed a large peak for octanoyl-
dose. Pre- and post-treatment symptoms of patients (72         carnitine and elevations of C6, C8, and C10. Her carnitine
hours after the completion of infusion) echocardiographic      level was low and was started on carnitine supplementa-
parameters were evaluated and blood samples were               tion and an appropriate diet and did well. Genetic testing
collected.                                                     confirmed MCCAD. In our office, she was asymptomatic.
	    Results: The mean age of patients was 62.6 ±10.1          Her total Carnitine was 25umol/L (31-78). We discontin-
years, 83.3% of patients were male and 16.7% were              ued the supplementation and two months later she contin-
female. Mean basal IGF-I level was 106.9± 47.0 µg/L.           ued to be asymptomatic. However, there was a drop in her
A statistically significant improvement was detected in        Free Carnitine to 4 umol/L (22-63) and total Carnitine to
NYHA class, brain natriuretic peptide (BNP) levels and         7umol/L. We decided to restart carnitine supplementation
average LVEF levels of patients following the treatment        in the patient.
when compared to those of pre-treatment. However, no                Discussion:	 MCADD is a mitochondrial fatty acid
significant difference was observed in IGF-I levels. There     oxidation (FAO) disorder that results from inactivity or
was no correlation between pre-treatment IGF-I levels and      deficiency of the medium chain acyl-COA dehydroge-
LVEF, BNP levels and NYHA classes of patients. On the          nase protein, coded by the ACADM gene on chromosome
other hand, post-treatment changes in IGF-I and BNP lev-       1p31. Fasting or stress in MCADD can lead to hypoke-
els and baseline IGF-I levels were found to be correlated.     totic hypoglycemia, hypotonia, seizures, encephalopathy,
	    Discussion: In the present study, we detected an          coma and death due to accumulation of toxic metabolites.
improvement in HF symptom scores and LVEF measure-             Frequent carbohydrate rich meals and avoidance of fasting
ments and a decrease in BNP levels with levosimendan           prevents the accumulation of FAO intermediates and their
treatment. This is a predictable finding consistent with       COA esters. Carnitine plays an essential role in the trans-
previous studies. In individuals with HF, high amount          fer of fatty acids into mitochondria for beta-oxidation.
of GH/IGF-I deficiency and diminished renal clearance          Biologic effects of low carnitine levels may not be clini-
of BNP due to decreased renal perfusion in heart fail-         cally significant until they reach less than 10-20% of nor-
ure may contribute to increased BNP levels in patients         mal. Although MCADD patients may exhibit secondary
with decompansated HF. Both increased renal clearance          carnitine deficiency, routine supplementation in MCADD
of BNP and decreased ventricular wall tension may be           is controversial. Upon reviewing literature we found, that
uncovering direct suppressive effect of GH/IGF-I system        there was increase in FAO and carnitine biosynthesis dur-
on BNP. Therefore, individuals with high basal IGF-I lev-      ing exercise.
els may show a greater decrease in BNP after levosimen-             Conclusion: MCADD patients transitioning to adult-
dan treatment.                                                 hood typically do not need carnitine supplementation. If a
     Conclusion: Basal IGF-I levels may be used to pre-        decision to stop supplementation is made, it is important
dict responses of hospitalized patients with decompen-         to follow up carnitine levels to identify small subset of
sated HF to levosimendan treatment.                            patients with extremely low levels. Given relatively low
                                                               cost and lack of significant side effects, carnitine replace-
Abstract #723                                                  ment can be considered in this subset of patients.

MEDIUM CHAIN ACYL-COA DEHYDROGENASE                            Abstract #724
DEFICIENCY WITH SECONDARY CARNITINE
DEFICIENCY                                                     CASE OF SUCCESSFUL PREGNANCY
                                                               AND BIRTH OF A NEWBORN IN A
Jaya Reddy Kothapally, MD, Andjela Drincic, MD                 WOMAN WITH AUTOSOMAL DOMINANT
                                                               PSEUDOHYPOALDOSTERONISM TYPE 1
	    Objective: To study the need of carnitine supplemen-
tation in adult patients with MCADD and secondary car-         Rishi Anand, MD, Chandana Konduru, MD,
nitine deficiency.                                             Rosemaria Alappat, DO, Monica Schwarcz, MD
	    Case	 Presentation: We saw a 19-year-old female,
with a history of MCADD and secondary carnitine                	    Objective: To describe a successful pregnancy and
deficiency transitioning from pediatric to adult endo-         birth of a newborn in a woman with autosomal domi-
crine clinic. She was diagnosed with MCADD at two              nant pseudohypoaldosteronism type 1 (adPHA1 or Renal
years of age. She presented with severe hypoglycemia,          PHA1).


                                                         – 114 –
                                                 ABSTRACTS – Other

     Case	 Presentation: A 26-year-old female G2P0100,            Abstract #725
was referred to our endocrine clinic at 17 weeks gesta-
tion for management of pseudohypoaldosteronism type 1             ESTIMATION OF TOTAL BODY FAT AND
and hypothyroidism. The patient, diagnosed with adPHA1            CORRELATION WITH PERIPHERAL INSULIN
as infant, required aggressive sodium (NaCl) supplemen-           RESISTANCE: DOES THE METHODOLOGY
tation and cation exchange resins during childhood, and           MATTER?
was maintained only on cation exchange resins during
her adult life to maintain normokalemia. She reported a           Donna Lawson, MD, Csava Kovesdy, MD,
prior intra uterine fetal death at 31 weeks of gestation sec-     Barbara Dunn, PA, Ali Iranmanesh, MD
ondary to heart defect. Family history is significant and a
brother is also affected with adPHA1. The patient’s preg-              Objective: Dual-energy X-ray absorptiometry (DXA)
nancy progressed without complication during the first            is a validated method for the assessment of body compo-
and second trimester with close monitoring of electro-            sition. With fat mass as the prime objective, more acces-
lytes. During the third trimester when serum sodium per-          sible and less expensive methods have been used, but
sisted below 130mg/dl, NaCl supplementation was added             there is concern about their level of sensitivity, accuracy
to cation exchange resin regimen. The patient delivered a         and reproducibility. Such concerns become more relevant,
preterm male infant at 34 weeks gestation, despite docu-          when the study population is heterogeneous, as it relates
mented electrolytes within normal range. The newborn              to age, physical fitness and muscle mass. In the present
baby had transient hyponatremia on day 1of life, which            study, measures of body fat estimated by skin fold thick-
subsequently normalized in 24 hours.                              ness, bioelectrical impedance analysis (BIA), and near-
	    Discussion: Aldosterone, by acting on the mineralo-          infrared interactance (NIR) techniques were compared to
corticoid receptor in the distal nephron, plays a crucial         the values obtained by DXA.
role in regulation of volume and electrolyte homeostasis.         	    Methods: Study population consisted of 29 healthy
Pseudohypoaldosteronism type 1 is a rare inherited con-           men ranging in age (19-78 yrs), BMI (21-38 kg/m2), and
dition that is characterized by renal insensitivity to the        Appendicular Muscle Mass Index (AMMI: 7.2-12 kg/m2).
action of mineralocorticoids. Patients manifest neonatal          To correct for height, Fat Mass Index (FMI: Kg/m2) was
salt wasting, hypotension, hyperkalemia and metabolic             used for statistical analysis. SF, BIA and NIR were com-
acidosis despite elevated aldosterone levels. The disorder        pared to DEXA by performing receiver operator curve
may be inherited by autosomal recessive or autosomal              (ROC) analyses and by calculating Pearson correlation
dominant forms via either epithelial Na channel muta-             coefficients (r; a measure of precision), bias correction
tion or mineralocorticoid receptor mutation respectively.         factors (C_b; a measure of accuracy) and concordance
Analysis of few extended adPHA1 pedigrees suggest no              correlation coefficients (rho_c; the product of r and C_b).
obvious impairment of fertility or failure to transmit the        Bland-Altman plot analysis, Pitman’s variance ratio tests
disease allele but the impaired reproductive fitness and          and the F test of equality of means and variances between
disease transmission is most likely due to high infant mor-       DEXA and each of the other three methods were used for
tality who were at risk for adPHA1.                               the comparative analysis between methods.
	    Conclusion: Pregnancy and infancy are periods char-               Results: Mean (± SD) of FMI for SF (6.33±3.07), BIA
acterized by intrinsic aldosterone resistance and patients        (5.60±2.57), and NIR (5.46±2.45) were not significantly
with adPHA1 may be at risk for further electrolyte imbal-         different from DXA (5.56±2.82), and were highly corre-
ance during these two phases, so careful monitoring and           lated with R of 0.93 (SF), 0.93 (BIA), and 0.90 (NIR). Bias
treatment is crucial for good outcomes. This is the first         correction factors (C_b) and concordance correlation coef-
reported case of pregnancy resulting in a live birth to a         ficients (rho_c) were 0.96 (SF), 0.99 (BIA), 0.99 (NIR),
mother with adPHA1.                                               and 0.89 (SF), 0.92 (BIA), & 0.90 (NIR). Concordance
                                                                  correlation coefficients for all three methods were similar,
                                                                  but the paired differences vs. DEXA (SF: -0.744±1, BIA:
                                                                  -0.043±1.004, NIR: -0.043±1.004) and F test for equal-
                                                                  ity (p values: SF=0.003, BIA=0.42, NIR=0.87) indicated
                                                                  better concordance for BIA and NIR. FMI obtained by all
                                                                  methods were significantly and similarly correlated with
                                                                  measures of peripheral insulin resistance (HOMA-IR).




                                                            – 115 –
                                                 ABSTRACTS – Other

      Conclusion: In healthy men skin fold, bioelectrical         cases. Frequently, it is an incidental finding during sur-
impedance, and infra-red methods provide accurate esti-           gery. There are few cases related to pregnancy. The issues
mates of total body fat, which is highly correlated with the      in these cases are the therapy during pregnancy, if the
DXA findings. Considering the cost and technical skills,          pregnancy should continue and if there is any fetal risk.
these methods, namely skin fold measurement or BIA can            The acute appendicitis picture caused by the tumor needs
be of significant value in clinical studies of body fat meas-     to be differentiated by a complicated or uncomplicated
urement, particularly involving large number of partici-          pregnancy. A retrospective diagnosis of carcinoid tumor
pants. Applicability of these methods for body fat meas-          as revealed by the histological exam does not necessar-
urement to female and non-healthy subjects and reproduc-          ily complicate a pregnancy prognosis because of the low
ibility after intervention require future investigation.          aggressive profile. The pathological exam brings out the
                                                                  major aspects regarding the spreading potential, and the
Abstract #726                                                     future necessary procedures. The interaction between car-
                                                                  cinoid tumor of the appendix and pregnancy is not yet elu-
THE CARCINOID OF APPENDICLE IN A YOUNG                            cidated. Serial tests of the neuroendocrine markers are the
PREGNANT WOMAN – CASE REPORT                                      most useful tool in follow-up and imaging scans are not
                                                                  necessary.
Raluca-Alexandra Trifanescu, MD,                                  	    Conclusion: The case shows the important role of dif-
Mara Carsote, MD, Corina Chirita, MD,                             ferential diagnosis of acute abdominal pain in women of
Dana Terzea, MD, Cristina Ene, MD,                                childbearing age, considering this rare pregnancy-related
Ramona Samoila, MD, Adina Croitoru, MD,                           appendicle pathology.
Catalina Poiana, MD, FACE
                                                                  Abstract #727
	    Objective: We report the case of a young female
diagnosed with appendicle carcinoid tumor related to              AN UNUSUAL PRESENTATION OF PAPILLARY
pregnancy.                                                        THYROID CANCER AND PARATHYROID
	    Case	Presentation: A 27-year-old female patient suf-         CARCINOMA
fered an emergency appendectomy. There were no symp-
toms suggestive for a carcinoid syndrome prior to surgery,        Leila Chaychi, MD, Allan Golding, Kathleen Belbruno
so neuroendocrine markers were not assessed. Pathology
exam revealed a tumor of less than 1 cm in diameter, at           	    Objective: To describe a rare presentation of para-
the top of the appendix, with neither base nor middle por-        thyroid carcinoma in association with papillary thyroid
tion invasion, or into the lymph nodes. These suggested           carcinoma.
a carcinoid tumor. The immunochemistry revealed posi-             	    Methods: We describe the clinical history, physical
tive reaction for chromogranin A and synaptophysin, with          examination findings, laboratory values, imaging findings,
undetectable Ki-67 levels. One month after the surgery,           and pathologic findings of a woman with two previously
pregnancy was confirmed. Based on the low aggressive              palpable thyroid nodules and mild hypercalcemia in line
type of the tumor the patient was not at any risk. But the        with the pertinent literature review.
patient did not choose to keep the pregnancy. Soon after          	    Results: The patient is a 79-year old woman who pre-
surgery (3 months later), the neuroendocrine markers              sented for reevaluation of two thyroid nodules and long
were normal: chromogranin A= 40 pg/mL (normal values:             standing parathyroid adenoma that was initially evaluated
40 -100), serotonin= 186 ng/mL (normal values: 40-200),           six years ago with the intact parathyroid hormone (iPTH)
the urinary 5-hydroxy indol-acetic acid= 5.2 mg/24h (nor-         level of 89 pg/ml (10-69) and calcium of 10.4 mg/dl (8.5-
mal values: 2-9). The neuronal specific enolase was also in       10.6) in the setting of normal alkaline phosphatase, creati-
normal ranges: 3.5µg/dl (normal value< 18.3). According           nine and 25(OH)2 D3. She was found to have a 2.5 and 1.8
to the patient’s option, because no guide indicates it, the       cm papillary thyroid cancer in the right thyroid lobe, upper
111 Indium Octreotide scan was performed and it was neg-          and lower poles respectively as well as 4.9 cm parathyroid
ative. 6 months later, the serum markers were still normal        carcinoma in the left side.
(chromogranin A= 36 ng/mL, serotonin= 183 ng/mL). No              	    Conclusion: Synchronous parathyroid and thyroid
colonoscopy or computed tomography scan was necessary             carcinomas are extremely rare. To our knowledge, our
up to this point. A long time follow-up by measurement of         case is the first patient with parathyroid carcinoma with
serum neuroendocrine markers is planned in this case.             clinical presentation of long standing mild adenoma in
	    Discussion: The appendicle carcinoid tumor is a fre-         addition to synchronous papillary thyroid carcinoma.
quent type of carcinoid with a good prognostic in many



                                                            – 116 –
                                               ABSTRACTS – Other

Abstract #728                                                   diagnostic. It is often associated with increased hepatic
                                                                glycogen stores.
AN UNUSUAL CASE OF NON-ISLET CELL                                    Conclusion: Hypoglycemia should be considered in
TUMOR INDUCED HYPOGLYCEMIA IN A                                 differential diagnosis of altered mental status in patient
PATIENT WITH CEREBRAL PALSY                                     with cerebral palsy. NICTH, though rare, should be
                                                                included in the differential for intractable hypoglycemia.
Deepti Rawal, MD, Ajay Varanasi, MD,
Sandeep Dhindsa, MD, Teekam Lohano, MD,                         Abstract #729
Ajay Chaudhuri, MD, Paresh Dandona, MD
                                                                NEW-ONSET DIABETES AND HYPERTENSION
     Objective: We report an unusual case of non-islet          ATTRIBUTABLE TO ECTOPIC CUSHING’S
cell tumor-induced hypoglycemia (NICTH) presenting as           SYNDROME SECONDARY TO METASTATIC
hypoglycemia in a patient with cerebral palsy.                  PANCREATIC NEUROENDOCRINE TUMOR
     Case	 Presentation: A 36-year-old female with his-
tory of cerebral palsy with limited communication abili-        Haidee David Zamora, MD, Delia Stefan, MD,
ties, group home resident was admitted to the hospital          Debra Simmons, MD
after she had recurrent episodes of confusion, blank stare
and slurred speech in early morning hours. She would get        	    Objective: To report a case of metastatic pancreatic
back to her normal self after drinking orange juice. During     neuroendocrine tumor presenting as new-onset diabetes
several of these episodes her blood sugar was found to          and hypertension.
be below 40. This was confirmed on lab tests. She was           	    Case	 Presentation: 60-year-old white female with
then hospitalized for further investigation. During her         new-onset diabetes and hypertension presents with poorly
hospital stay she continued to have early morning hypo-         controlled diabetes. She was fairly healthy, until 11/08,
glycemia. During hypoglycemia her insulin level was <2,         when she was found to have hypertension. Three months
c-peptide<0.1 on two separate occasions. Proinsulin level       later, she was diagnosed with diabetes. She had no signs
was 6.8 pmol/L (<18.9), β-hydroxybutyrate β-OH (B)              and symptoms of diabetes, no history of Gestational DM
0.11mmol/L (< 0.29 mmol/L), cortisol 19.5 mcg/dl and            or a macrosomic baby. She had easy bruising and easy
GH 0.2 ng/ml (>10 ng/ml). Sulfonylurea screen was nega-         fatigability. Positive family history of hypertension and
tive. TSH was 1.22 (0.4-5) and Free T4 was 0.78 (0.8-           diabetes, and no history of cancer. Physical examina-
1.8). Cortisol stimulation test was normal. Hypoglycemia        tion revealed a thin woman, with no cushingoid charac-
responded to 1 mg glucagon by an increase in blood              teristics. Labs showed hypokalemia, in the absence of a
glucose by more than 100 mg/dl. Serum IGF-l level was           potassium-wasting medication. Initial work-up demon-
28 ng/ml (109-284 ng/ml), and serum IGF-ll level was            strated absence of autoimmune antibodies to beta cells,
1134 ng/mL (460-1240 ng/mL), Insulin receptor anti-             no evidence of primary hyperaldosteronism; however,
body <0.2. Pt was given a trial of prednisone and octeo-        24-hr urine free cortisol was elevated. Overnight 1-mg
tide which failed to resolve hypoglycemia. Pituitary MRI        oral Dexamethasone suppression test showed an elevated
was normal. CT of the abdomen showed a solid pelvic             cortisol. Eight-milligram dexamethasone suppression test
mass 15 cm in transverse dimension. She continued to            revealed a non-suppressed ACTH consistent with an ecto-
have hypoglycemic episodes in spite of dextrose infusion.       pic source. CRH test was likewise consistent with ectopic
Hypoglycemia resolved after surgical resection of the           source of hypercortisolism. CT scan showed a mass lesion
tumor. Histopathology of the tumor demonstrated a high          involving the neck and proximal body of the pancreas and
grade endometrial sarcoma.                                      a solitary mass within hepatic segment VI/VII. Octreotide
     Discussion: An uncommon cause of hypoglycemia is           scan findings correlated with the CT scan. Liver mass
the secretion of partially processed precursors of IGF-II       biopsy showed neoplastic cells, with neuroendocrine dif-
by sarcomatous tumors, also known as non islet cell tumor       ferentiation, which stained for synaptophysin, but nega-
hypoglycemia (NICTH). NICTH is associated with insu-            tive for ACTH and Chromogranin A. KI-67 was positive
lin secretion, lipolysis and ketogenesis, leading to a low      in 20% of the neoplastic cells. Patient subsequently had
C-peptide, and inappropriately low GH and β-OH(B) con-          partial pancreatectomy and right hepatectomy.
centrations in the circulation. The diagnosis of NICTH          	    Discussion: Pancreatic neuroendocrine tumors have
can be confirmed by a combination of suppressed serum           been reported to be the cause of ectopic ACTH syndrome
insulin, c-peptide and suppressed GH levels in setting          in up to 16% of patients. The ectopic ACTH syndrome can
of hypoglycemia along with elevated IGF-ll levels. An           follow an acute or chronic course. The acute syndrome
IGF-ll/ IGF-l ratio of greater than 10 is believed to be        is associated with rapid onset of hypertension, weakness,



                                                          – 117 –
                                                  ABSTRACTS – Other

edema, hypokalemia, glucose intolerance, anorexia                  carcinoid tumors are strongly associated with chronic
and weight loss, all of which except for the edema, our            atrophic gastritis, as can occur in autoimmune gastritis.
patient had at presentation. The chronic syndrome is often         Enterochromaffin-like (ECL) cells of the stomach are part
clinically indistinguishable from pituitary-dependent              of the gastric neuroendocrine cell system. Condition caus-
hypercortisolism. Hassan et al., observed an association           ing loss of parietal cells, as in atrophic gastritis, results in
between recent-onset diabetes and pancreatic neuroendo-            reduced gastric acid secretion, and ultimately, achlorhy-
crine tumors (PNET), in 55% of the patients, but long-             dria. Achlorhydria leads to hypergastrinemia due to nega-
term diabetes were unrelated to PNET.                              tive feedback inhibition. Gastrin is trophic to ECL cells.
	    Conclusion: This case demonstrates the association            Hypergastrinemia can lead to ECL hyperplasia and ulti-
between new-onset diabetes and hypertension and the                mately gastric carcinoid tumor. The average age of type 1
diagnosis of pancreatic neuroendocrine tumor, underscor-           gastric carcinoid is between 50-60 years. Our patient with
ing the importance of determining temporal relationships           type 1 diabetes mellitus developed a 1.1 cm gastric carci-
between disease entities.                                          noid tumor complicating autoimmune gastritis at the age
                                                                   of 26. The high prevalence of autoimmune gastritis in type
Abstract #730                                                      1 diabetes, and the occurrence of gastric carcinoid tumors
                                                                   in such patients, even in young adults, provides rationale
GASTRIC CARCINOID TUMOR COMPLICATING                               for enhanced awareness, and possibly even screening in
AUTOIMMUNE GASTRITIS IN A YOUNG ADULT                              such patients.
WITH TYPE 1 DIABETES MELLITUS                                      	    Conclusion: Autoimmune gastritis is associated
                                                                   with type 1 diabetes mellitus and can predispose to type
Rachanon Murathanun, MD,                                           1 gastric carcinoid tumors. T ype 1 diabetic patients may
Charles Berkelhammer, MD, FACG,                                    develop gastric carcinoid tumor even as a young adult.
Tahira Yasmeen, MD, FACE
                                                                   Abstract #731
	    Objective: To describe a rare case of a type 1 gastric
carcinoid tumor complicating autoimmune gastritis in a             A RARE CASE OF INSULINOMA WITH LOW
young adult with type 1 diabetes mellitus.                         C-PEPTIDE CONCENTRATIONS.
	    Case	Presentation: A 26-year-old female with type1
diabetes mellitus was found to have a 1 cm hypervascu-             Mehul Ratilal Vora, MBBS, Sandeep Dhindsa, MD,
lar gastric mass as an incidental finding on CT scanning           Paresh Dandona, MD, Teekam Lohano, MD,
to evaluate unrelated symptoms. The gastric mass was               Ajay Chaudhuri, MD
asymptomatic. She denied gastrointestinal symptoms,
flushing, diarrhea, wheezing, melena, hematochezia, or             	    Objective: To describe a case diagnosed with insuli-
weight loss. Physical examination revealed no hepato-              noma with low C-peptide concentrations.
megaly, skin lesions, or signs of right-sided heart failure.            Case	Presentation: A 48-year-old Caucasian female
Stool was negative for occult blood. Liver biochemistry            with no significant past medical history was referred to our
was normal. An upper endoscopy revealed gastric atrophy            clinic for low blood glucose of 29mg/dl on routine blood
and a 1 cm submucosal gastric polyp in the mid body of             work. Her blood glucose during the clinic visit was 31.
the stomach. Endoscopic polypectomy was performed.                 She was asymptomatic and denied any symptoms of hypo-
Pathology revealed a 1.1 cm carcinoid tumor with posi-             glycemia. Laboratory blood revealed blood glucose of
tive margins. Tumor stain was strongly positive for chro-          45mg/dl, HgA1c 4.6%, insulin concentration 22mc Unit/
mogranin and synaptophysin, but negative for serotonin             ml (2-20), c-peptide 0.7ng/ml (0.8-6), Plasma Proinsulin
and gastrin. 24-hour urine for 5- Hydroxyindoleacetic acid         26.9 pmol/L (<18.9), Sulfonylurea screen Negative,
(5-HIAA) was normal. Plasma chromogranin A level was               Glucagon <50pg/ml (<61pg/ml), Beta-Hydroxybutyrate
140 ng/ml (0-50 ng/ml). Plasma gastrin level was 866 pg/           0.17 mmol/L (<0.29mmol/L) Growth Hormone 2.3 ng/
ml (0-100 pg/ml). Antibody to intrinsic factor was posi-           ml (>10), IGF-1 121 ng/ml (94-252), cortisol 20.9 mcg/
tive. Serum vitamin B12 was normal. T he patient under-            dl (5-25) TSH 1.890 mcUnit/ml ( 0.5-5) Free T4 0.85ng/
went partial gastrectomy. No intraoperative spread was             dl (0.8 -1.8), insulin autoantibody Negative. Our patient’s
found. Surgical pathology revealed a focus of residual             chemistry was consistent with insulinoma, except a low
gastric carcinoid tumor and severe autoimmune chronic              C-peptide level. She had a CT-scan of the abdomen and
atrophic gastritis.                                                pelvis, which showed 3 enhancing lesions in the tail of
	    Discussion: The prevalence of autoimmune gastritis            the pancreas in close proximity to each other measuring
in type 1 diabetes mellitus is 5-10%, compared with 2% in          from 0.5cm to 2cm in diameter. An MRI of the abdomen
the general population, a 3 to 5 fold increase. Type 1 gastric     also confirmed them. She had an octreoscan for tumor


                                                             – 118 –
                                                 ABSTRACTS – Other

localization and was found to have lesion distally at the         (288-736), Insulin antibody 4.1uU/ml (0-5), Beta hydroxy-
tail of the pancreas corresponding to the abnormality seen        butyrate: 0.4, Glucagon stimulation test increased blood
in the CT scan. The patient continued to monitor her blood        sugar from 46 mg/dl to 106mg/dl. Abdomen/ pelvic CT
glucose at home and had low blood glucose frequently but          showed very large and heterogeneous pelvic mass. Patient
remained asymptomatic. She underwent distal pancreatec-           was started on stress dose of I/V steroids and responded
tomy. Two well differentiated endocrine neoplasms 1.2cm           favorably. PPN and I/V synthroid were discontinued.
and 0.8cm in greatest dimensions and multiple endo-               Hypoglycemia reappeared when steroids were tapered
crine microadenomas limited to pancreas were found.               down to physiological dose. Patient was maintained with-
All stained positive for insulin and chromogranin A. Her          out hypoglycemia on prednisone 40 mg daily and under-
blood sugars were elevated post-operatively but became            went surgery for pelvic mass. Pathology revealed multiple
normal a month after surgery.                                     large cellular leiomyomatas, largest weighing 2896 grams
      Discussion: Our patient with insulinoma showed low          and measuring 22x20x14cm. Hypoglycemia completely
c-peptide levels, compared to the proinsulin and insulin          resolved after surgery.
levels. Both insulin and c-peptide are normally produced               Discussion: Hypoglycemia can be caused by several
by cleavage of the proinsulin in equimolar amounts.               tumors including islet and non islet cell tumors (NICTH).
Exogenous insulin and insulin antibodies both affect the          NICTH is usually associated with tumors of mesenchy-
insulin levels but the c-peptide levels are not affected by       mal, vascular or epithelial cell types. Most common cause
them. Our case demonstrates a low c-peptide level, which          of NICTH is tumoral overproduction of incompletely pro-
is generally considered inconsistent with insulinoma. One         cessed IGF2 (Big IGF2) resulting in stimulation of insulin
previous case report and a few in-vitro studies in rats and       receptors and increased glucose utilization. Other possible
humans have shown low c-peptide levels due to enhanced            causes include insulin receptor antibodies and tumor infil-
intracellular protein degradation by cathapsin B a cyseine        tration of liver or adrenal glands. Our case clearly demon-
proteinase, in insulinoma cells.                                  strates the correlation of the massive leiomyomatas, IGF2
      Conclusion: In summary our case demonstrates a              and recurrent hypoglycemia. In contrast to insulinoma, C
rare case of insulinoma with decreased c-peptide concen-          peptide and insulin levels are low. Beta hydroxybutyrate
trations presumably due to enhanced c-peptide degrada-            level is also low and glucagon stimulation test is normal
tion. Thus careful interpretation of blood tests and clinical     or near normal. Treatment includes complete removal of
features in needed in a case of hypoglycemia to rule out          tumor. When it is not possible, medical therapy includes
insulinoma.                                                       use of steroids, diazoxide or long term glucagon infusion.
                                                                       Conclusion: Though rare, NICTH associated with
Abstract #732                                                     increase production of IGF2 can be the cause of recurrent
                                                                  hypoglycemia in the presence of a tumor.
A RARE CASE OF NON ISLET CELL
TUMOR HYPOGLYCEMIA                                                Abstract #733

Faiza Aziz, MD, Zewge Shiferaw, MD                                METABOLIC SYNDROME:
                                                                  GAMMA-GLUTAMYLTRANSFERASE VS.
     Objective: To demonstrate rare association of hypo-          ALT/AST?
glycemia with tumoral production of IGF2
     Case	 Presentation: Our patient is an 80-year-old            Maria del Pilar Serra, MD, Mercedes Pineyro, MD,
female with history of diabetes mellitus (not on any hypo-        Gabriela Sosa, MD, Maria Zeballos, MD,
glycemic agents), HTN, hypothyroidism and history of              Cristina Belzarena, MD
progressively growing mass in abdomen for last one year.
She presented in ER with history of fall and feeling dizzy        	    Background/Objective: To evaluate the hypothesis
for last few weeks. Blood sugar in ER was found to be 26          that ggt alterations are more prevalent in the metabolic
mg/dl. She was started on Dextrose 10% infusion and was           syndrome than those of alt or ast. Studies have reported
consuming about 2/3rd of her meals but continued to have          ggt levels in association with oxidative stress, also sug-
recurrent episodes of symptomatic hypoglycemia. Patient           gesting a relationship with metabolic syndrome and car-
was transferred to ICU and started on PPN and I/V syn-            diovascular risk factors. High levels of this enzyme have
throid for severe hypothyroidism. Lab results are as fol-         been linked with increased risk of diabetes and metabolic
lows TSH: 47, FT4:0.42. Concomitant with blood sugar of           syndrome (ms). Some studies have shown the previous to
36, C-peptide: 0.1ng/ml (0.8-3.85), Insulin level: <2uIU/         be true for ggt but not for alt or ast. Liver enzymes have
ml (0-24.9). Cosyntropin test revealed adequate adre-             been linked to metabolic syndrome variables in large rep-
nal response. IGF1:72ng/ml (59-177), IGF2: 782ng/ml               resentative samples of the general population.


                                                            – 119 –
                                                 ABSTRACTS – Other

	    Methods: A retrospective case-controls study was             low urine and serum osmolarities. The hyponatremia was
performed. We identified 86 patients with ms (group 1)            corrected with fluid restriction and dextrose solution 5%
and 84 patients without ms (group 2) followed in our              was used to slow the correction rate of Na levels. Once
department. Patients without liver function tests, reported       Na returned to a level of 122mmol/Lt the patient became
excess alcohol drinking, or known liver disease of any eti-       responsive again and was easily extubated. The history
ology were excluded. Metabolic syndrome was defined in            revealed the presence of significant polydipsia for the few
accordance with atpiii criteria as the occurrence of three or     days prior to presentation, with a daily intake of water
more of the following risk factors: (1) waist circumference       around 4 gallons, that the patient attributed to the newly
(wc) ≥102 cm. In men and ≥88 in women; (2) blood pres-            started psychotropic medications. All the laboratory eval-
sure (bp) ≥130/85 mmhg; (3) triglycerides (tg) ≥150 mg/           uation for seizures came back normal apart from the above
dl; (4) hdl cholesterol < 40 mg/dl (men) and < 50 mg/dl           mentioned values and the diagnosis of psychogenic poly-
(women) and (5) fasting plasma glucose ≥100 mg/dl. Data           dipsia was confirmed. The patient’s regimen was changed
on last year lfts was obtained.                                   and the patient has stayed asymptomatic on follow-up.
     Results: patients with ms were significantly older than           Discussion: Psychogenic polydipsia is a syndrome
those without ms (62.13±12.38 (n=83) vs. 56.91±17.78              caused by the interaction of several psychotropic medica-
(n=47) p=0.001). There was no difference in sex ratio             tions with the brain osmostat, leading to a derangement
between groups. No significant differences in diet and exer-      of the thirst mechanism. The clinical effect of that, is a
cise between groups 1 and 2 was seen (61.3% _vs._ 61.5%           feeling of excessive thirst and increased water intake,
_p=0.983_y_34.3% _vs. 35._3%_p=0.919,respectively).               which in turn leads to electrolytes and fluid imbalances.
Median ggt levels were significantly higher in g1 com-            The water intake could be increased to such an extent that
pared to g2 (24.0 (7,699) vs. 20 (6,162) (n = 131)                could cause an acute drop of serum Na levels and lead to
p=0.014)); in contrast, there were no differences in ast (22      acute hyponatremia symptoms, sometimes severe enough
(8,75) vs. 23 (4,103) (n = 134) p=0.206) or alt levels (17.5      to warrant clinical investigation.
(6,125) vs.16 (6,191) (n = 134) p=0.200). Linear regres-               Conclusion: Our case demonstrates the wide spec-
sion analysis showed that glycemia ≥100 mg/dl and bmi             trum of symptoms that could be attributed to this clinical
were significantly associated with higher levels of ggt (r 2)     entity and points to the well-known problem of polyp-
(0.13 p = 0. 023), with no other ms components entering           harmacy as a major risk factor for serious and potentially
the model.                                                        lethal effects.
     Conclusion: Levels of ggt are significantly higher
in patients with Ms. However, no differences in ast or alt        Abstract #735
were found. Conversely, in multivariate analysis ggt ele-
vations were significantly linked only with bmi and glyc-         PANCOAST TUMOR: AN UNSUALLY
emia. It may be cost-effective to measure only ggt instead        AGGRESSIVE PRESENTATION OF A
of all liver enzymes to assess patients with ms.                  NEUROENDOCRINE TUMOR

Abstract #734                                                     Sunil Asnani, MD, FACE, Reema Salat, MD,
                                                                  Abdel Alsharif, MD, Neena Penagaluru, MD
A CASE OF NEW ONSET SEIZURES
                                                                  	    Objective: To present an unusually aggressive and
Rodis Paparodis, MD, Dimitra Bantouna, MD,                        metastatic case of bronchial carcinoid with further atypi-
Renee Schickler, MD                                               cal presentation.
                                                                  	    Case	Presentation: A 70-year-old male with 55-pack-
     Objective: Review the pathogenesis and the spectrum          years smoking history was admitted with loss of sensa-
of clinical manifestations of psychogenic polydipsia.             tion below the nipples, and falls. This had been progres-
     Case	 Presentation: This is a case of a 42-year-old          sive over the last one week. He denied any bowel/bladder
female, resident of a psychiatric long term care facility         complaint. On exam, he had a sensory level at T4 derma-
that presented with seizures. Her medications were started        tome; there was no motor deficit. Systems review revealed
a few days prior to presentation and were valproate, chlor-       upper back pain for the last year, treated with NSAIDs.
promazine, quetiapine and haloperidol. She was found to           Chest X-ray revealed a right upper lobe mass, and chest
have generalized seizures, after which she was minimally          CT showed a 7.4 x 5.1 cm irregular mass with invasion
responsive and was intubated for airway protection. The           of right posterior second rib and T2 vertebral body with
laboratory evaluation revealed a significant hyponatre-           direct extension into the spinal canal, cord compres-
mia of 107mmol/Lt with undetectable urine Na and very             sion, and multiple parenchymal lung nodules. Bone scan



                                                            – 120 –
                                               ABSTRACTS – Other

showed abnormal tracer activity in T3, T4 and multiple         follicle stimulating hormone (FSH) 2.6 mIU/mL, prolac-
posterior ribs. Pathology revealed intermediate grade neu-     tin 7.3 ng/mL, IGF-I 56 ng/mL (age and sex-matched ref-
roendocrine carcinoma (atypical carcinoid).                    erence range 81-225). Overnight polysomnography was
	    Discussion: Bronchial carcinoid tumors are a rare         diagnostic of obstructive sleep apnea (OSA). Continuous
group of pulmonary neoplasms characterized by neuro-           positive airway pressure (CPAP) therapy was provided.
endocrine differentiation and relatively indolent clini-       Intramuscular testosterone was delivered biweekly, with
cal behavior. They account for 1-2% of lung malignan-          favorable levels achieved (trough testosterone 632.0, peak
cies in adults and 20-30% of carcinoid tumors. Typical         testosterone 734.4.). He had 35 pounds weight loss after
carcinoids are low-grade, slowly-growing and rarely            dietary and exercise interventions. IGF-I increased (98
metastasize. High-grade, typical for small cell lung can-      ng/mL). Physical examination 12 months following onset
cers, behave aggressively with rapid tumor growth and          of whitening of hair demonstrated darkening at the base
early dissemination. Atypical carcinoids are intermediate.     of the white hairs on his scalp, as well as new growth of
Immunohistochemical identification is the most reliable        dark hairs on his arms and legs. Visual images of hair are
method to confirm neuroendocrine differentiation. They         shown.
are thought to arise from specialized bronchial cell (the      	    Discussion: Sudden whitening of hair may involve
Kulchitsky cell) and have low serotonin content. Typical       simultaneous lengthening of white hair or selective loss of
bronchial carcinoids have excellent prognosis with five-       dark hair. Androgens exhibit a moderate effect on extrem-
year survival rates of 87-100%. Despite their low malig-       ity hair, with a stronger effect noted on facial and pari-
nant potential, long-term follow-up is warranted because       etal hair. Increased growth of androgen-dependent hair
local or distant recurrence may occur years after initial      likely occurred as a consequence of testosterone therapy,
treatment. Further, it is uncommon for carcinoids to pres-     and as such a repopulation by dark hairs may have been
ent as a pancoast tumor. Lastly, spinal canal invasion and     manifested as resolution of whitened hair. A low level of
compression is another rarity of this case. Treatment is       IGF-I in obesity has been characterized and may relate to
typically surgical resection or debulking with radiation.      OSA syndrome. IGF-I accelerates growth of hair and hair
	    Conclusion: Our patient is interesting for present-       follicles. It is interesting that improvement in IGF-I fol-
ing with an atypical carcinoid. Physicians must always         lowing weight loss and appropriate treatment of OSA has
keep this diagnosis in the differential given its superior     occurred in concert with resolution of hair whitening.
prognosis.                                                     	    Conclusion: While sudden whitening of hair has
                                                               been described in vitiligo, and alopecia areata, a strong
Abstract #736                                                  association with hypogonadism or low IGF-I has not been
                                                               described, per se. Apparent resolution of our patient’s
SUDDEN WHITENING OF HAIR ASSOCIATED                            findings raises the possibility of the ameliorating contri-
WITH HYPOGONADISM AND LOW IGF-I                                bution of eugonadism and normalization of IGF-I.

John Charles Parker, MD, FACE,                                 Abstract #737
Brittany Noel Bohinc, MD,
Paul Caldwell Whitesides, Jr., MD                              METASTATIC NEUROENDOCRINE TUMOR
                                                               WITH PRIMARY ALDOSTERONISM
	     Objective: To describe a case of rapid-onset of hair
whitening with newly-diagnosed hypogonadism and                Muthukrishnan Jayaraman, MD
decreased insulin-like growth factor-I (IGF-I), with sub-
sequent resolution within 12 months.                           	    Objective: To describe a case of refractory hypokale-
	     Case	Presentation: A 57-year-old white male noted        mia in a patient with neuroendocrine tumor.
fatigue, labile hypertension, headaches, and rapid-onset       	    Case	Presentation: A woman with severe refractory
whitening of his hair occurring over approximately             hypokalemia was evaluated. Arterial blood pH, bicarbon-
8 weeks time. He also had lighter beard growth and             ate and spot urinary potassium was done. Plasma aldoste-
had lost hairs on his arms and legs. Physical examina-         rone and renin were done at baseline and after IV saline
tion demonstrated androgenic alopecia (which had been          suppression. Serum cortisol was estimated after overnight
long-standing), but the remaining scalp hairs were white.      dexamethasone suppression. A liver tissue sample was
Moustache was white. Eyelashes appeared normal. No             evaluated for histopathology and immunohistochemistry
vitiligo. Investigations for thyroid dysfunction and adre-     for Chromogranin A and Neuron Specific Enolase was
nal insufficiency were unrevealing. Additional evaluation      done. Metabolic alkalosis with high urinary potassium
included total testosterone of 276 ng/dL, free testoster-      and high plasma Aldosterone to Renin ratio, which was
one 7.8 pg/mL, luteinizing hormone (LH) 4.5 mIU/mL,            non suppressible with Isotonic Saline infusion was noted.


                                                         – 121 –
                                               ABSTRACTS – Other

Serum cortisol was normally suppressible after overnight        	    Discussion: The suggestive clinical characteristics of
dexamethasone suppression test. Ultrasonography and a           hyperandrogenism are very common problems in women
computerized tomogaphic scan of her abdomen showed              and have been related with excessive androgen production
multiple hepatic space occupying lesions but were nega-         from ovaries, suprarenal glands or both. The most com-
tive for an adenoma in the adrenal glands or a tumor            mon identifiable cause of androgen excess is the polycystic
elsewhere in the abdomen. On histopathology of liver            ovary syndrome. The virilizing tumors are rare. Ovarian
tissue, metastases were detected, which were positive for       steroid cell tumors secrete great quantities of testosterone
Chromogranin A and Neuron Specific Enolase.                     or androstenedione and differ from Leydig cell tumors in
	    Discussion: Aldosterone excess in the setting of a         that they lack crystals of Reinke. Usually, they are benign,
neuroendocrine tumor may be due to renin secreting              but 20% of malignancy has been reported. They can pro-
tumors causing hyperreninemic hyperaldosteronism or             duce different substances.
rarely ACTH secreting tumors which may lead to aldos-           	    Conclusion: Ovarian steroid cell tumors are rare.
terone excess with low renin and present as Cushing’s           Diagnosis depends on androgens levels. The election
syndrome (ectopic ACTH secretion). We documented                treatment is oophorectomy. Androgens levels are normal-
aldosterone excess with low renin and cortisol, which           ized after surgery.
ruled out these two possibilities.
	    Conclusion: Primary aldosterone excess was docu-
mented in this patient with metastatic neuroendocrine
tumor, which we presume was the likely source of
aldosterone.

Abstract #738

OVARIAN STEROID CELL TUMOR

Edith Jacqueline Luque Cuba, MD,
Freddy García Ramos, MD

	    Objective: To describe the behavior and features of an
ovarian steroid cell tumor in a post menopausal woman.
     Case	 Presentation: We report the case of a post-
menopausal woman with virilizing signs and a left anexial
mass. Testosterone 4.3ng/mL (0.2-0.95); DHEAS 56ug/
dL (35-430); androstenedione: 10ng/ml (0.4-2.7); Cortisol
16ug/dL. Testosterone post dexamethasone suppression
test 3.5ng/mL. An oophorectomy was performed in this
patient. Androgen levels were normalized after surgery.




                                                          – 122 –
                                           ABSTRACTS – Pituitary Disorders

PITUITARY DISORDERS                                                   no	 significant	 difference	 regarding	 the	 response	 to	 GH	
                                                                      therapy	between	sex	difference	(male/female	ratio	range	
Abstract #800                                                         in	 GHD	 patients	 range	 2.3:1	 &	 in	 control	 group	 1:1.03	
                                                                      respectively),	consanguinity	(3:1	among	patients	group&	
EFFICACY OF GROWTH HORMONE THERAPY                                    1:1.63	 in	 control	 group	 respectively),	 delay	 in	 bone	 age	
ON PATIENTS WITH GROWTH HORMONE                                       and	degree	of	GHD	respectively.
DEFICIENCY TREATED WITH RECOMBINANT                                   	    Discussion:	It	is	obvious	from	this	study	that	there	is	
GROWTH HORMONE                                                        a	significant	response	in	the	linear	growth	after	treatment	
                                                                      with	 recombinant	 GH	 therapy	 in	 patients	 with	 GHD	 by	
Ali Hasan Dhari Al-Jumaili, MD, Qasim Rahi                            increment	 of	 height	 velocity	 from	 3.5	 ±	 1.2/year	 before	
                                                                      treatment	 to	 8.5	 ±	 3.6	 cm/year	 after	 6	 months	 of	 treat-
	    Objective:	 This	 study	 was	 conducted	 to	 determine	          ment.	 This	 response	 is	 approximately	 similar	 to	 those	
the	growth	velocity	response	to	recombinant	growth	hor-               reported	previously.	The	majority	of	patients	included	in	
mone	(rGH)	therapy	in	growth	hormone	deficient	children	              this	study	with	GHD	79%	(126	from	160)	were	considered	
(GHD).	The	effects	 of	 factors	such	 as	 age,	gender,	 birth	        normal	 for	 gestational	 (NGA)	 and	 because	 birth	 weight	
weight	and	chronological	bone	age	were	also	evaluated	in	             has	been	shown	to	have	a	great	influence	on	the	response	
these	patients.                                                       of	growth	hormone	therapy	in	this	study	(P	value	0.007)	
	    Methods:	A	prospective	study	was	conducted	in	160	               which	is	similar	to	the	study	of	Lassare	C.	et	al	1991.	The	
patients	 (age	 range	 3-12	 years).	 These	 growth	 deficient	       explanation	is	that	children	with	SGA	could	be	relatively	
patients	 were	 selected	 from	 a	 cohort	 of	 1400	 patients	        insensitive	 to	 the	 action	 of	 either	 endogenous	 GH	 or	 to	
originally	 presented	 for	 evaluation	 of	 short	 stature.	 All	     IGf-1.	The	percentage	of	small	for	gestational	age	to	nor-
subjects	underwent	complete	history	and	physical	exami-               mal	for	gestational	age	13%	to	79%	respectively	approxi-
nation	 including	 measurements	 of	 height	 and	 weight.	            mately	similar	to	John	C.	et	al	1998	result	were	19%	to	
In	 all	 patients	 mid	 parental	 heights	 were	 calculated	 to	      81%	respectively	and	similar	to	control	group.	Reference	
exclude	normal	short	stature	(genetic	and	constitutional).	           to	the	criteria	of	this	study	the	significant	response	to	the	
Following	 this	 patients	 were	 screened	 to	 exclude	 sys-          therapy	 was	 achieved	 by	 85%	 (136	 from	 160)	 and	 15%	
temic	 causes	 of	 short	 stature	 (celiac	 disease,	 renal	 fail-    (24	from	160)	fail	to	achieve	adequate	response.	This	may	
ure).	Patients	were	also	screened	for	genetic	disorders	and	          be	 explained	as:	 SGA	 patients	need	 higher	 doses	 of	 GH	
also	underwent	a	detailed	evaluation	for	hypothyroidism,	             0.48mg/kg/week	 in	 divided	 doses	 (1,2,3),	 The	 patients	
Cushing’s	 syndrome	 and	 growth	 hormone	 deficiency.	               may	not	follow	the	proper	instructions	regarding	the	dose,	
After	confirming	growth	hormone	deficiency	patients	were	             frequency	or	the	cooling	chain.	Wrong	diagnosis	because	
treated	 with	 growth	 hormone.	A	 control	 group,	 matched	          lack	 of	 many	 hormonal	 assay	 e.g.:	 IGF-1,	 GHBP,	 etc.	
for	sex	distribution,	age	and	other	variables	(n=160)	were	           Intercurrent	 illnesses	 during	 therapy	 period	 might	 inter-
also	included	in	this	study.	                                         fere	with	the	response.	
	    Results:	The	patients	with	growth	hormone	deficiency	            	    Conclusion:	 This	 study	 indicates	 a	 significant	
included	 160	 patients	 with	 112	 males	 and	 48	 females.	         response	in	linear	growth	in	patients	with	GHD	after	treat-
Control	 group	 consisted	 of	 76	 male	 and	 84	 female	 chil-       ment	with	recombinant	GH	with	positive	relationship	with	
dren.	The	 incidence	 of	 consanguinity	 was	 40/120	 in	 the	        birth	weight	so	effort	&	resources	needed	to	achieve	avail-
study	group	in	comparison	to	61/99	in	control	group.	The	             ability	of	the	drug,	related	equipments,	laboratory	tests	&	
type	of	delivery	(normal	vaginal	vs	cesarean	section)	was	            trained	personnel.	This	study	is	a	preliminary	one	and	we	
24/136	 in	 the	 patients	 and	 34/126	 in	 control	 group.	The	      hope	for	further	expanded	studies	in	this.
birth	weights	were	adjusted	according	to	gestational	age	
divided	as*	normal	for	gestational	age	(NGA),	*small	for	             Abstract #801
gestational	 age	 (SGA)	 and	 *small	 with	 unknown	 gesta-
tional	age.	The	result	was	126.21	and	13	in	patients	group	           ANEURYSMAL SUBARACHNOID HEMORRHAGE
and	 130,	 18,	 and	 12	 in	 control	 group.	 Height	 velocity	       COMPLICATING TRANS-SPHENOIDAL
increased	 from	 3.5±1.2	 cm/year	 before	 treatment	 to	 8.5	        SURGERY FOR A PITUITARY ADENOMA
±3.6	cm/year	after	6	months	of	treatment	with	significant	
P	value.	This	significant	increment	in	height	velocity	was	           Subramanian Kannan, MD, Tarun Rustagi, MD,
compared	in	different	age	group	(range	3-12	y)	,different	            Patrick Senatus
bone	 age	 (range	 1-10	 y)	 ,	 and	 different	 degree	 in	 delay	
of	bone	age	(range	2-8)	,degree	of	GHD	either	partial	or	             	    Objective:	To	emphasize	the	vascular	complications	
complete	 and	 the	 degree	 of	 response	 in	 relation	 to	 birth	    of	pituitary	surgery	with	special	emphasis	on	aneurysmal	
weight	 correlated	 with	 gestational.	 The	 result	 shows	           bleeding.


                                                                – 123 –
                                          ABSTRACTS – Pituitary Disorders

	     Case	Presentation:	39-year-old	male	presented	with	           Abstract #802
headache,	 intermittent	 photophobia	 and	 left	 sided	 visual	
field	defect	of	3	month	duration.	Physical	exam	was	sig-            POSTPARTUM GRANULOMATOUS
nificant	for	bitemporal	hemianopia.	Subsequently,	MRI	of	           HYPOPHYSITIS WITH SPHENOID SINUS
the	brain	revealed	a	contrast	enhancing	macroadenoma	of	            INVOLVEMENT: A CASE STUDY
size	3.5	x	3	x	3	cm	extending	from	the	sella	into	the	supra-
sellar	region	causing	a	mild	mass	effect	on	the	optic	chi-          Charalambos Demetri, DO, Kamal Shoukri, MD,
asm	with	no	invasion	into	the	carotids.	A	CT-angiogram	             Sherry Taylor, MD, J. Enrique Silva, MD
did	 not	 reveal	 any	 intracranial	 aneurysm.	 His	 endocrine	
evaluation	 was	 suggestive	 of	 a	 non-secretory	 adenoma.	        	     Objective:	To	 report	 an	 unusual	 case	 of	 granuloma-
A	transcranial	craniotomy	and	tumor	debulking	was	per-              tous	 hypophysitis	 with	 sphenoid	 sinus	 involvement	 in	 a	
formed.	A	post	operative	CT	showed	reduction	in	size	of	            woman	presenting	with	headaches	and	visual	field	deficits	
tumor	 to	 1.8cm.	 Immunochemical	 stains	 were	 negative	          2	weeks	after	a	normal	delivery.
for	 functionality.	 Post-operative	 anterior	 pituitary	 evalu-    	     Case	 Presentation:	A	 29-year-old	 female	 presented	
ation	 was	 normal.	A	 follow	 up	 MRI	 with	 MRA	 showed	          with	 headache	 and	 visual	 disturbances	 11	 days	 postpar-
a	residual	tumor	with	no	evidence	of	aneurysm.	A	trans-             tum.	MRI	revealed	a	sellar	mass	with	suprasellar	exten-
sphenoidal	 surgery	 was	 performed	 for	 removal	 of	 the	         sion,	 invasion	 of	 cavernous	 sinuses	 and	 optic	 chiasm,	
residual	 tumor.	 There	 was	 a	 significant	 intra-operative	      along	 with	 sinus	 mucosal	 thickening.	 A	 subtotal	 resec-
epistaxis.	Despite	achieving	adequate	hemostasis,	patient	          tion	 was	 performed	 via	 transphenoidal	 route.	 Histology	
did	not	recover	post-operatively.	CT	scan	of	head	showed	           demonstrated	extensive	non	vasculitic	granulomatous	tis-
intraventricular	hemorrhage	with	hydrocephalus.	A	cere-             sue	in	pituitary	and	sphenoid	mucosa	samples.	Serology	
bral	CT	angiogram	showed	a	6mm	anterior	communicat-                 for	 infectious	 causes	 and	 autoimmunity	 were	 negative.	
ing	 artery	 aneurysm	 which	 was	 successfully	 embolized.	        Fungal,	 bacterial,	 and	 tuberculosis	 staining	 and	 culture	
Patient	was	closely	monitored	in	the	ICU,	but	his	mental	           were	all	negative	as	well.	She	required	desmopressin	and	
status	never	improved	and	he	underwent	a	tracheostomy	              thyroxine	 replacement	 after	 surgery.	 The	 patient’s	 head-
and	a	feeding	tube	placement.	Post-operatively	he	devel-            aches	and	visual	field	defects	resolved	rapidly.	Sequential	
oped	Diabetes	insipidus,	hypothyroidism,	and	hypoadre-              follow	up	revealed	spontaneous	resolution	of	the	residual	
nalism	for	which	he	was	started	on	hormone	replacement	             mass	in	5	months	without	further	intervention.
therapy.                                                            	     Discussion:	Hypophysitis	is	an	inflammatory	condi-
	     Discussion:	 Arterial	 bleeding	 during	 transsphenoi-        tion	 of	 the	 pituitary	 gland	 that	 can	 be	 difficult	 to	 distin-
dal	surgery	for	pituitary	adenoma	usually	happens	due	to	           guish	from	other	pituitary	lesions.	There	are	3	histopatho-
rupture	 of	 intracavernous	 carotid	 or	 carotico-cavernous	       logical	categories	of	hypophysitis,	namely	granulomatous,	
fistula	 and/or	 pseudoaneurysm.	 A	 large	 series	 failed	 to	     lymphocytic,	 and	 xanthomatous.	 The	 granulomatous	
demonstrate	 any	 link	 between	 aneurysm	 formation	 and	          form	 has	 been	 described	 in	 the	 setting	 of	 tuberculosis,	
pituitary	 tumors.	 Pituitary	 apoplexy	 and	 fatal	 epistaxis	     syphilis,	Takayasu’s	disease,	Crohn’s	disease,	Wegener’s	
have	also	been	reported.	In	this	poster	we	present	a	patient	       granulomatosis,	 sarcoidosis,	 Langerhans’	 histiocytosis,	
with	a	non	functioning	pituitary	macroadenoma	and	ante-             rheumatoid	arthritis	and	Rathke’s	cleft	cyst	rupture.	The	
rior	communicating	artery	aneurysm,	which	caused	signif-            term	 primary	 granulomatous	 hypophysitis	 is	 reserved	 to	
icant	hemorrhage	during	the	surgery.	Retrospective	analy-           those	cases	where	the	investigation	fails	to	reveal	a	cause.	
sis	 of	 MRI	 and	 CT	 angiograms	 revealed	 no	 evidence	 of	      Primary	 granulomatous	 hypophysitis	 was	 first	 described	
aneurysm.	We	presume	that	the	initial	bleeding	was	from	            by	Simmonds	in	1917	who	reviewed	2000	pituitary	glands	
the	 internal	 carotid	 artery	 with	 subsequent	 formation	 of	    at	autopsy.	We	feel	our	case	represents	a	primary	granu-
pseudoaneurysm.                                                     lomatous	 process	 given	 the	 absence	 of	 any	 associated	
	     Conclusion:	 A	 thorough	 evaluation	 for	 intracranial	      systemic	or	infectious	granulomatosis.	It	remains	unclear	
vascular	 malformation	 should	 be	 undertaken	 before	 sur-        whether	 the	 lesion	 was	 primarily	 hypophyseal	 or	 due	 to	
gery	 for	 pituitary	macroadenomas	and	 invasive	 pituitary	        local	extension	from	the	adjoining	sphenoidal	sinusitis.
tumors	with	special	precautions	in	patients	who	have	had	           	     Conclusion:	Unique	features	of	this	case	include	the	
prior	surgeries	in	the	sellar	region.                               simultaneous	 presence	 of	 granulomatous	 lesions	 in	 the	
                                                                    pituitary	 and	 sphenoidal	 sinus,	 its	 presentation	 in	 early	
                                                                    postpartum	period,	as	well	as	the	spontaneous	resolution	
                                                                    of	the	residual	granulomatous	lesions	in	both	the	sphenoid	




                                                              – 124 –
                                            ABSTRACTS – Pituitary Disorders

sinus	and	sella	turcica.	Our	case	demonstrates	that	com-               Abstract #804
plete	resolution	of	granulomatous	hypophysitis	can	occur	
in	a	postpartum	patient	without	the	use	of	glucocorticoids.            A CASE OF REVERSIBLE VALVULOPATHY
                                                                       ASSOCIATED WITH CABERGOLINE THERAPY
Abstract #803
                                                                       Troy Dillard, MD, Maria Fleseriu, MD,
SEVERE HYPONATREMIA INDUCED BY                                         Kevin S. Wei, MD, Chris Yedinak, NP
INTRANASAL DDAVP
                                                                       	     Objective: To	highlight	reversibility	of	valvulopathy	
Rakhi Shah, MD, Fariba Rahnema, MD,                                    associated	with	high	dose	cabergoline	(CAB)	therapy.
Mrinalini Kulkarni-Date, MD                                            	     Case	 Presentation:	 A	 21-year-old	 male	 presented	
                                                                       with	delayed	puberty	and	headache.	Hormonal	evaluation	
	     Objective:	Central	diabetes	insipidus	is	recognized	by	          revealed	 hyperprolactinemia	 (PRL=1000)	 and	 hypopitu-
inability	to	secrete	ADH	in	response	to	high	plasma	osmo-              itarism.	MRI	showed	a	2.2	cm	pituitary	tumor.	CAB	was	
lality.	This	leads	to	polyuria	with	compensatory	polydip-              titrated	 to	 6	 mg/wk	 over	 4	 years	 without	 normalization	
sia,	 if	 thirst	 mechanism	 is	 intact,	 resulting	 in	 euvolemic	    of	 prolactin	 or	 adequate	 tumor	 shrinkage.	 His	 hypopitu-
state.	 Some	 patient	 smay	 have	 detectable	 plasma	 vaso-           itarism	was	appropriately	replaced.	After	a	total	cumula-
pressin	level,	which	represents	partial	form	of	the	disorder.          tive	dose	of	814	mg,	an	echocardiogram	(echo)	revealed	
	     Case	Presentation:	A	50-year-old	female	with	history	            normal	LV	function,	mild	apical	displacement,	and	mild	
of	partial	diabetes	insipidus	(DI)	was	admitted	after	MVA.	            non-coaptation	of	the	mitral	leaflets	with	associated	mild	
Pt	 was	 diagnosed	 with	 partial	 DI	 at	 age	 12	 and	 records	      mitral	regurgitation.	CAB	was	discontinued	and	replaced	
from	past	could	not	be	obtained.	Patient	reported	having	              with	bromocriptine.	Repeat	echo	(reviewed	by	same	car-
headaches	associated	with	low	serum	Na.	After	starting	on	             diologist)	 8	 months	 later	 showed	 resolution	 of	 all	 prior	
her	home	dose	of	DDAVP	of	2	nasal	spray	(10mcg)	bid,	                  abnormal	 findings.	 Clinical	 exam,	 including	 vitals	 signs	
her	 serum	 Na	 was	 decreased	 to	 115mmol/l,	 with	 serum	           was	unchanged	between	these	two	visits.
osmolality	240	and	urine	osmolality	357.	When	DDAVP	                   	     Discussion: While high	cumulative	doses	of	CAB	are	
was	held	Na	increased	to	132mmol/l,	with	serum	osmo-                   a	clear	risk	factor	for	valvulopathy	in	Parkinson’s	patients,	
lality	 280	 and	 urine	 osmolality	 75.	 Decreasing	 DDAVP	           the	true	risk	of	valvulopathy	at	doses	used	in	prolactino-
to1	 spray	 bid	 Na	 dropped	 to	 125mmol/l,	 with	 serum	             mas	is	unknown	and	studies	show	conflicting	results.	In	
osmolality	253	and	urine	osmolality	510.	MRI	brain	was	                our	patient,	a	definitive	causal	relationship	between	CAB	
unremarkable.	 TSH,	 LH,	 FSH	 levels	 and	 her	 cosyntro-             use	and	valvulopathy	could	not	be	established	without	a	
pin	stimulation	test	were	normal.	Her	DDAVP	dose	was	                  true	baseline	echo.	However,	causality	is	likely	since	no	
titrated	based	on	her	urine	output	and	serum	Na.	Serum	Na	             other	etiology	for	his	valvular	abnormalities	were	identi-
remained	stable	when	0.1mg	DDAVP	was	given	if	urine	                   fied	and	cessation	of	CAB	resulted	in	complete	resolution	
output	>300ml/hr	x	3	hrs.	Patient	was	discharged	with	oral	            of	 these	 findings.	 There	 were	 no	 hemodynamic	 changes	
DDAVP	at	dose	of	0.1mg	in	morning	and	0.1mg	at	around	                 between	 echo’s	 to	 explain	 this	 resolution.	 This	 implies	
5pm	if	her	urine	output	is	high.	With	this	dose	of	DDAVP	              that,	in	specific	cases,	CAB	may	induce	valvulopathy	at	
patient’s	Na	remained	stable	and	headaches	resolved.                   much	lower	doses	than	previously	thought.	It	is	possible	
	     Discussion:	Patients	with	DI	are	treated	with	DDAVP	             that	higher	doses	in	the	first	2	years	of	treatment	at	a	rela-
in	 doses	 to	 normalize	 urine	 osmolality	 and	 flow.	 After	        tively	young	age,	rather	than	total	cumulative	dose,	played	
urine	output	normalizes,	it	produces	increase	in	total	body	           a	role	in	the	development	of	valvulopathy	in	this	patient.	
water	and	subsequent	decrease	in	plasma	osmolality	and	                While	reversible	dopamine	agonist-induced	valvulopathy	
Na	concentration.	Eventually	water	balance	is	maintained	              is	documented	in	only	a	few	patients	with	Parkinson’s	dis-
and	hyponatremia	does	not	develop.	But	in	some	patients	               ease,	this	is	the	first	case	described	in	a	patient	treated	for	
abnormal	 thirst	 persists	 and	 they	 develop	 hyponatremia.	         a	prolactinoma.
In	 these	 patients,	 administering	 DDAVP	 based	 on	 UOP	            	     Conclusion: Increased	 risk	 of	 valvulopathy	 should	
(>300ml/hr	x	3hrs.)	may	be	an	optimal	way	of	treating.                 be	 considered	 in	 patients	 requiring	 higher	 cumulative	
	     Conclusion:	 In	 DI,	 after	 initiation	 of	 therapy	 with	      CAB	 doses.	 Echocardiography	 should	 be	 performed	 in	
DDAVP	serum	Na	should	be	monitored	closely.	In	some	                   these	 high-risk	 patients,	 drug	 holidays	 implemented	 and	
patients,	 DDAVP	 dose	 should	 be	 adjusted	 depending	 on	           patients	withdrawn	from	these	agents	if	possible.	This	case	
urine	output	to	prevent	rare	complication	of	hyponatremia.             highlights	the	potential	reversibility	of	mild	valvulopathy	




                                                                 – 125 –
                                          ABSTRACTS – Pituitary Disorders

associated	with	CAB	therapy	if	treatment	is	discontinued	            any	medications	known	to	cause	hyperprolactinemia.	INH	
before	 the	 onset	 of	 the	 severe	 structural	 abnormalities.	     therapy	 not	 reported	 causing	 subclinical	 hypothyroidism	
Prospective	studies	are	required	to	better	characterize	the	         and	hyperprolactinemia.	Only	three	cases	of	galactorrhea	
clinical	significance	of	these	valvulopathies,	their	natural	        associated	 with	 subclinical	 hypothyroidism	 have	 been	
history	and	the	potential	for	reversibility.                         reported.	Similar	to	the	reported	cases	in	the	literature,	our	
                                                                     patient’s	TSH	and	prolactin	levels	returned	to	normal	with	
Abstract #805                                                        levothyroxine	therapy.	A	case	of	sterility	associated	with	
                                                                     increased	 prolactin	 and	 subclinical	 hypothyroidism	 have	
HYPERPROLACTINEMIA WITH                                              been	reported.
GALACTORRHEA DUE TO                                                  	    Conclusion:	 Hyperprolactinemia	 with	 galactorrhea	
SUBCLINICAL HYPERTHYROIDISM                                          can	 occur	 in	 subclinical	 hypothyroidism.	 Treatment	 of	
                                                                     subclinical	 hypothyroidism	 and	 follow	 up	 of	 prolactin	
Issac Sachmechi, MD, FACP, FACE,                                     level	should	be	done	in	order	to	avoid	ordering	an	unnec-
Hammad Bhatti, MD, David Reich, MD, FACE,                            essary	MRI	of	the	sella	tursica.
Paul Kim, MD, FACE
                                                                     Abstract #806
	    Objective:	Hyperprolactinemia	is	a	common	finding	
in	primary	hypothyroidism	but	increased	prolactin	in	the	            XANTHOMA DISSEMINATUM:
setting	 of	 subclinical	 hypothyroidism	 has	 been	 scarcely	       A CASE REPORT
reported	in	the	literature.
	    Case	Presentation:	We	describe	a	case	of	a	48-year-             Miguel E. Pinto, MD, FACE, Glenda Escalaya, MD,
old	 female.	 Her	 past	 medical	 history	 was	 significant	 for	    María E. Escalaya, MD, Jose L. Pinto, MD
hypertension	 and	 sciatica.	 Because	 of	 her	 positive	 PPD	
status	in	June	of	2006,	she	was	started	on	isoniazid	(INH)	          	    Objective:	 To	 report	 a	 case	 of	 a	 young	 normolipe-
and	 vitamin	 B6.	 However,	 the	 patient	 only	 took	 her	          mic	woman	with	cutaneous	and	mucosal	xanthomas	who	
medication	 for	 a	 few	 months	 and	 was	 lost	 to	 follow-up.	     developed	neurogenic	diabetes	insipidus	and	hyperprolac-
Subsequently,	her	INH	treatment	had	to	be	restarted	again	           tinemia	because	of	inflammatory	pituitary	stalk	lesion.
in	January	of	2007.	She	presented	with	painful	galactor-             	    Case	Presentation:	A	23-year-old	woman	presented	
rhea	for	two	to	three	weeks.	Her	last	menstrual	period	was	          with	nine	months	history	of	polydipsia,	polyuria,	galactor-
3	weeks	prior	to	her	presentation,	and	the	patient	denied	           rhea,	secondary	amenorrhea,	and	weight	gain.	Her	previ-
any	use	of	tobacco,	marijuana,	alcohol,	illicit	drugs,	over	         ous	 medical	 history	 included	 chronic	 anemia,	 and	 wide-
the	 counter	 medications,	 or	 prescription	 medications	           spread	 cutaneous	 and	 mucosal	 xanthomas.	 Laboratory	
with	 the	 exception	 of	 her	 anti-hypertension	 medications	       tests	 showed	 hyperprolactinemia,	 but	 serum	 electrolytes	
(HCTZ	25MG	daily	and	losartan	50mg	daily)	as	well	as	                and	lipid	profile	were	normal.	The	water	deprivation	test	
INH	 and	 B6.	 Her	 physical	 examination	 was	 within	 nor-         was	 compatible	 with	 neurogenic	 diabetes	 insipidus.	The	
mal	limits,	except	for	diffuse	non-tender	enlargement	of	            cerebral	 magnetic	 resonance	 imaging	 showed	 pituitary	
her	 thyroid	 gland	 which	 has	 remained	 unchanged	 over	          stalk	enlargement.	Histologic	examination	of	a	skin	biopsy	
the	 past	 one	 year.	 Her	 breasts	 were	 tender	 to	 palpation	    showed	diffuse	infiltration	of	the	dermis	with	histiocytes,	
with	 milky	 yellow	 discharge	 bilaterally.	The	 visual	 field	     which	exhibited	central	nuclei	and	clear,	vacuolated	cyto-
exam	was	normal.	Labs	showed:	negative	pregnancy	test,	              plasm.	Biopsy	results	were	consistent	with	xanthoma	dis-
TSH	 level	 5.63	 (0.7-5mIU/ml),	 free	 thyroxine	 (free	 T4)	       seminatum.	Treatment	was	started	with	cabergoline,	nasal	
0.75	ng/dL	(0.58-1.64	ng/dL),	total	T4	6.96	mcg/dL	(6.09-            desmopressin,	and	dermabrasion	for	skin	lesions.
12.2mcg/dL),	total	triiodothyronine	(T3)	91.4	ng/dL	(87-             	    Conclusion:	 Xanthoma	 disseminatum	 is	 a	 rare,	
178	 ng/dL)	 and	 prolactin	 55.42	 (3.34-26.74	 ng/ml).	 Her	       benign	proliferative	disorder	in	children	and	adults	char-
mammogram	was	normal	and	an	MRI	failed	to	show	any	                  acterized	 by	 disseminated	 xanthomatous	 lesions	 in	 nor-
pituitary	disease.	The	patient	finished	her	course	of	INH	           molipemic	patients.	Central	nervous	system	involvement	
and	she	was	started	on	levothyroxine	50mcg	daily.	Three	             is	rare	and	usually	occurs	in	the	systemic	variety.	Pituitary	
months	later	her	galactorrhea	and	breast	pain	was	relieved	          stalk	 disease	 commonly	 causes	 hyperprolactinemia,	 dia-
and	labs	showed	TSH	level	of	1.4	mIU/ml	and	prolactin	               betes	 insipidus,	 and	 varying	 degrees	 of	 hypopituitarism.	
level	of	13.44ng/mL.                                                 Natural	 history	 of	 xanthoma	 disseminatum	 usually	 is	
	    Discussion:	This	is	a	rare	case	of	hyperprolactinemia	          benign,	 but	 lesions	 in	 critical	 anatomical	 locations	 may	
due	to	subclinical	hypothyroidism	that	resolved	with	thy-            result	in	morbidity	and	mortality.
roid	hormone	replacement	therapy.	The	patient	was	not	on	



                                                               – 126 –
                                           ABSTRACTS – Pituitary Disorders

Abstract #807                                                         assist	 in	 defining	 extent	 of	 disease.	 Molecular	 profiling,	
                                                                      and	possible	treatment	with	tyrosine	kinase	inhibitors,	are	
METASTATIC PROLACTINOMA; DIAGNOSIS,                                   areas	needing	further	study.
AND TREATMENT WITH TYROSINE
KINASE INHIBITORS                                                     Abstract #808

Stanley Edward Von Hofe, MD, FACE,                                    RATHKE CLEFT CYST AND PITUITARY
Jeff Edenfield, MD                                                    DYSFUNCTION: MEDICAL AND SURGICAL
                                                                      TREATMENT OPTIONS
	     Objective:	To	report	a	case	of	man	with	pituitary	car-
cinoma	with	metastatic	disease.	                                      Simona Ioja, MD, Victor Ciofoaia, MD, Rob Sandhu, MD, MPH
	     Case	Presentation:	A	37-year-old	man	presented	with	            Mark Kulaga, MD, Nancy J. Rennert, MD, FACE, FACP
hypopituitarism	 and	 a	 prolactin	 of	 1727	 ng/dl.	 Pituitary	
MRI	 revealed	 a	 2.5	 x	 2.0	 x	 2.8	 cm	 intrasellar	 mass.	        	     Objective: We	present	two	cases	of	Rathke	cleft	cysts	
Bromocriptine	(up	to	10	mg	orally	tid),	followed	by	trans-            (RCC)	with	pituitary	dysfunction	and	we	review	the	natu-
sphenoidal	surgery	(TSS),	yielded	a	post-op	prolactin	of	             ral	history	and	management	of	this	disorder.
153	ng/dl.	Therapy	was	changed	to	pergolide,	and	over	the	            	     Case	 Presentation: A	 23-year-old	 male	 presented	
next	4	years	prolactin	decreased	to	33,	and	MRI	revealed	             with	headache	and	bradycardia	and	was	found	to	be	hypo-
no	obvious	tumor.	The	prolactin	rose	to	>200,	and	there	              natremic,	normokalemic,	hypothermic	and	hypoglycemic.	
was	regrowth	of	pituitary	tumor	(MRI)	to	2.2	x	2.2	x	1.8	             Lab	evaluation	revealed	panhypopituitarism	[cortisol	0.9	
cm	over	the	next	four	years,	and	pergolide	was	changed	to	            ug/dl,	ACTH	49	pg/ml	(nl.7-50),	TSH	3.35uU/ml	(nl.0.49-
cabergoline	 and	 a	 second	TSS	 performed.	 Prolactin	 was	          4.67),	 FT4	 0.44	 ng/dl	 (nl	 0.71-1.85),	 Total	 Testosterone	
29	 post-op,	 and	 the	 patient	 had	 radiation	 therapy	 to	 the	    20	 ng/ml	 (nl260-1000),	 Free	 Testosterone	 1.1pg/ml(nl	
pituitary.	The	 prolactin	 rose	 over	 the	 next	 year	 to	 1622,	    50-210),	FSH/LH	3.7/1.4	mIU/ml	(nl),	Prolactin	4.8nh/ml	
despite	 a	 change	 from	 cabergoline	 to	 quinagolide.	 MRI	         (nl)].	MRI	showed	a	14	x7.5	x5.2	mm	non-enhancing	pitu-
showed	 questionable	 tumor	 recurrence	 within	 the	 sella	          itary	cyst,	projecting	the	pituitary	upwards	into	the	ante-
and	clivus,	and	a	third	TSS	was	performed,	but	no	tumor	              rior	aspect	of	the	suprasellar	cistern.	He	had	no	visual	field	
tissue	was	found.	Spine	MRI	suggested	wide-spread	met-                deficits.	He	was	treated	with	hydrocortisone	with	normal-
astatic	 disease,	 and	 PET	 scan	 revealed	 diffuse	 uptake	 in	     ization	 of	 sodium	 level,	 levothyroxine	 and	 testosterone.	
the	 liver	 and	 multiple	 bony	 lesions.	 The	 prolactin	 level	     A	 25	 year	 old	 female	 presented	 with	 intermittent	 head-
was	 now	 20,517.	 Liver	 biopsy	 confirmed	 metastatic	              aches	 and	 6	 months	 of	 secondary	 amenorrhea.	 Prolactin	
neuroendocrine	 carcinoma	 with	 positive	 immunostains	              level	was	elevated	at	207	ng/ml	(nl	6-29.9),	however	TSH,	
for	 prolactin.	 Molecular	 profiling	 (Molecular	 Profiling	         gonadotropins,	and	cortisol	were	all	within	normal	ranges.	
Institute,	 Phoenix,	 Arizona)	 demonstrated	 up-regulation	          MRI	 showed	 a	 1	 cm	 cyst	 with	 mildly	 deviated	 pituitary	
of	 c-kit,	 epidermal	 growth	 factor	 receptor,	 and	 platelet-      stalk.	She	had	no	visual	field	deficits.	The	patient	wanted	
derived	growth	factor,	among	other	gene	targets(all	tyro-             to	preserve	future	fertility	if	possible.
sine	kinase-driven	processes).	Treatment	was	begun	with	              	     Discussion: RCC	 are	 fairly	 common	 non-neoplas-
sunitinib	50	mg	qd	and	high	dose	cabergoline	(5	mg	bid)	              tic	 epithelial	 cysts	 derived	 from	 remnants	 of	 the	 Rathke	
continued.	Over	7	months	PET	scan	showed	progression	                 pouch,	 found	 in	 20%	 of	 pituitaries	 at	 autopsy.	 Rarely,	
of	metastatic	disease,	and	sunitinib	and	cabergoline	were	            RCCs	 can	 result	 in	 pituitary	 dysfunction.	A	 spectrum	 of	
discontinued	and	dasatinib	(70	mg	bid)	begun.	One	week	               endocrine	 dysfunction	 has	 been	 reported	 in	 a	 large	 case	
later	the	prolactin	level	was	228,000,	and	the	patient	was	           series:	 57%	 presenting	 with	 hypocortisolism,	 43%	 with	
hospitalized	with	acute	renal	failure,	thought	possibly	due	          hypogonadism,	39%	with	hyperprolactinemia,	35%	with	
to	tumor	lysis	syndrome.	Within	6	weeks	of	starting	dasat-            hypothyroidism,	35%	with	GH	deficiency,	13%	with	GH	
inib	the	prolactin	had	decreased	to	12.7,	and	it	remained	            excess	 and	 9%	 with	 diabetes	 insipidus.	 Accurate	 diag-
in	the	normal	range	thereafter.	The	patient,	however,	expe-           nosis	 and	 differentiation	 from	 craniopharyngiomas	 is	
rienced	much	bone	pain	and	progression	of	disease	(PET/               important	for	both	treatment	selection	and	outcome	pre-
CT)	 and	 died	 from	 metastatic	 disease	 13	 months	 after	         diction.	 Management	 of	 RCCs	 with	 endocrine	 dysfunc-
starting	dasatinib	and	16	½	years	after	his	initial	diagnosis.        tion	should	be	individualized.	Treatment	options	include	
	     Discussion:	Pituitary	carcinoma	with	metastatic	dis-            medicine,	 surgical	 drainage,	 alcohol	 injection	 and	 radia-
ease	is	rare,	about	140	cases,	with	only	47	being	prolacti-           tion	 (gamma	 knife)	 and	 will	 be	 discussed	 in	 detail	 with	
nomas,	reported	prior	to	2006.	Typically	patients	demon-              attention	 to	 risks,	 benefits	 and	 outcomes	 as	 documented	
strate	 escape	 from	 dopamine	 agonist	 therapy	 during	 the	        in	the	literature.	In	our	first	case,	the	patient	was	offered	
course	of	their	disease.	Imaging	with	MRI	and	PET	may	                surgery	but	declined	and	is	being	monitored.	In	the	second	


                                                                – 127 –
                                           ABSTRACTS – Pituitary Disorders

case,	 medical	 therapy	 was	 given,	 but	 surgery	 is	 being	        not	correct	even	after	surgery.	Our	patient	had	a	very	rare	
contemplated.                                                         presentation	 of	 secondary	 hypothyroidism,	 growth	 hor-
	    Conclusion: RCCs	 can	 be	 associated	 with	 variable	           mone	 deficiency	 which	 corrected	 post	 surgery	 and	 pos-
pituitary	 dysfunction.	 Treatment	 should	 be	 individual-           sibly	diabetes	insipidus	at	presentation.
ized	 to	 address	 the	 specific	 endocrine	 dysfunctions	 with	      	    Conclusion:	 Anterior	 communicating	 artery	 aneu-
consideration	of	risks	and	benefits,	including	postsurgical	          rysms	 causing	 hypopituitarism	 are	 rare	 and	 this	 should	
recurrence	rates	that	are	close	to	20%.                               be	considered	in	the	differential	diagnosis	of	any	patient	
                                                                      who	present	with	hypopituitarism	and/or	persistent	head-
Abstract #809                                                         ache.	In	this	modern	age	with	CT	scan	technology	early	
                                                                      detection	and	treatment	of	this	condition	can	be	life	saving	
HYPOPITUITARISM SECONDARY TO                                          without	significant	neuroendocrine	sequelae.
INTRASELLAR ANEURYSM
                                                                      Abstract #810
Sailatha Padmanabhan, MD, Allison Galloway, DO,
Mary Zoe Baker, MD                                                    TEMOZOLOMIDE FOR CORTICOTROPH
                                                                      ADENOMAS REFRACTORY TO SURGERY
	    Objective:	To	describe	a	young	patient	with	anterior	            AND RADIATION: A CASE OF RAPID
communicating	artery	aneurysm	causing	hypopituitarism.                TUMOR REGRESSION
	    Case	Presentation:	A	23-year-old	woman	presented	
to	the	emergency	department	with	progressively	worsen-                Troy Dillard, MD, Maria Fleseriu, MD,
ing	headache,	nausea,	vomiting	and	double	vision.	She	had	            Johnny B. Delashaw, MD, Edward A. Neuwelt, MD,
had	polyuria,	polydypsia,	fatigue	and	alopecia	for	several	           Chris Yedinak, NP
weeks	 prior	 to	 presentation.	 On	 physical	 exam,	 she	 had	
weakness	 of	 her	 left	 third	 cranial	 nerve.	 Her	 laboratory	     	    Objective:	 To	 highlight	 the	 potential	 for	 temozolo-
studies	 were	 as	 follows:	 Sodium	 128meq/L	 (134-144),	            mide	(TMZ)	to	induce	rapid	tumor	regression	in	patients	
TSH	0.072	μ	IU/mL	(0.350-4.940),	free	T4	0.5	ng/dL	(07-               with	aggressive	corticotroph	adenomas	(CA)	refractory	to	
1.5),	random	cortisol	27	mcg/dL	(6.0-30.0),	LH	0.2	mIU/               surgery	and	radiation	therapy.
mL	(1.6-70),	FSH	1.07	mIU/mL	(0.9-16)	(she	had	taken	                 	    Case	Presentation:	We	present	a	case	of	a	56-year-
depot	 medroxy	 progesterone	 injection	 4	 months	 ago),	            old	male	with	a	3	cm	CA	diagnosed	in	1996,	treated	with	
prolactin	 21.70	 ng/mL	 (1.2-29.9),	 and	 IGF1-104	 ng/mL	      	    transphenoidal	 surgery	 (TSS)	 and	 radiotherapy.	 His	 dis-
(116-358).	A	 CT	 scan	 of	 the	 brain	 and	 a	 CT	 angiogram	        ease	recurred	11	yrs	later	with	rapid	tumor	growth	to	4.2	
confirmed	 the	 presence	 of	 a	 1.6	 x	 1.5	 x	 1.5	 cm	 bilobed	    x	2.5	cm,	multiple	Cushing’s	symptoms	and	he	underwent	
saccular	aneurysm	emerging	from	the	inferior	margin	of	               2nd	TSS.	His	tumor	recurred	after	6	mos,	this	time	without	
the	junction	of	distal	right	A1	and	anterior	communicating	           florid	Cushing’s	symptoms	but	with	ophthalmoplegia.	He	
artery	 with	 subarachnoid	 hemorrhage.	 She	 subsequently	           required,	over	16	mos,	an	additional	3	surgeries	(2	TSS,	1	
underwent	 microsurgical	 dissection	 and	 clipping	 of	 the	         craniotomy)	and	repeat	radiation	therapy	to	control	hyper-
anterior	 communicating	 artery	 aneurysm.	 She	 tolerated	           cortisolemia.	The	highest	ACTH	during	this	interval	was	
the	procedure	well	except	for	postoperative	diabetes	insip-           306	pg/mL.	Ki67	staining	index	on	his	surgical	specimens	
idus.	 She	 was	 discharged	 on	 desmopressin	 and	 levothy-          was	5-6%.	Due	to	large	residual	tumor	and	visual	defects,	
roxine.	A	cosyntropin	(0.25mg)	test	one-month	post	sur-               the	patient	was	started	on	TMZ	at	150mg/m2,	titrated	to	
gery	showed	a	baseline	cortisol	level	of	9.2	mcg/dL,	19.7	            190mg/m2	per	dose	taken	5	days	monthly.	The	only	sig-
mcg/dL	 at	 30	 min	 and	 24.9mcg/dL	 at	 60	 min.	A	 repeat	         nificant	 side	 effect	 was	 moderate	 nausea.	After	 only	 10	
IGF1	was	211	ng/ml.                                                   weeks	of	TMZ,	the	patient’s	tumor	showed	a	remarkable	
	    Discussion:	Intrasellar	aneurysms	are	a	rare,	but	rec-           60%	 regression	 in	 size	 with	 objective	 improvement	 in	
ognizable	cause	of	hypopituitarism	accounting	for	0.17%	              ophthalmoplegia.
cases	 of	 hypopituitarism,	 with	 anterior	 communicating	           	    Discussion:	Treatment	of	aggressive	CAs	represents	
artery	 aneurysms	 being	 much	 less	 common	 than	 those	            a	therapeutic	challenge.	They	are	often	invasive,	incom-
arising	from	the	internal	carotid	artery.	At	least	one	pitu-          pletely	resected	and	recurrence	is	common.	Conventional	
itary	hormone	deficiency	seems	to	occur	more	commonly	                treatment	options	(surgical	debulking	and	radiation)	are	of	
than	 previously	 thought	 after	 a	 year	 from	 subarachnoid	        limited	success	and	few	options	remain.	TMZ	is	an	oral	
hemorrhage	 related	 to	 aneurysms.	 Adrenal,	 thyroid	 and	          alkylating	agent.	Tumors	that	express	O-6-methyluanine-
gonadal	deficiencies	were	the	deficiencies	in	the	order	of	           DNA	methyltransferase	(MGMT)	are	resistant	to	its	effects.	
decreasing	frequency	in	a	Mayo	Clinic	retrospective	study	            Thus,	low	expression	of	MGMT	predicts	responsiveness.	
of	 hypopituitarism	 and	 intrasellar	 aneurysms.	They	 may	          A	series	of	88	pituitary	adenomas	revealed	low	levels	of	


                                                                – 128 –
                                          ABSTRACTS – Pituitary Disorders

MGMT	expression	in	13%	of	tumors.	Prolactinomas	were	                levels	 ranged	 between	 9.8-10.7	 mg/dL,	 PTH	 23	 pg/mL,	
most	likely	to	have	low	MGMT,	but	there	was	no	differ-               and	calcitriol	remained	high	of	81.3	pg/mL.
ence	between	invasive	and	noninvasive	or	recurrent	and	                   Discussion:	 Approximately	 10%	 of	 acromegalic	
non-recurrent	tumors.	Small	series	suggest	that	aggressive	          patients	were	reported	to	have	hypercalciuria	and	nephro-
CAs	(especially	Crooke’s	cell	variants)	have	low	MGMT	               lithiasis,	but	hypercalcemia	without	elevated	PTH	in	acro-
expression.	Only	a	few	cases	of	CAs	responsive	to	TMZ	               megaly	has	never	been	reported.	Proposed	mechanisms	of	
have	 been	 reported.	 Our	 case	 is	 the	 only	 case	 reported	     hypercalciuria	include	parathyroid	hyperplasia,	increased	
with	such	a	rapid	and	robust	response	in	tumor	size.	It	is	          Ca	absorption,	renal	tubular	acidosis	or	calcitriol	overpro-
unclear	if	radiation	pre-treatment	may	have	enhanced	our	            duction.	Normalization	of	IGF-1	with	GH	receptor	antag-
patient’s	response	to	TMZ.                                           onist	 reduces	 urinary	 Ca	 clearance	 and	 calcitriol	 level.	
	    Conclusion:	 TMZ	 shows	 significant	 promise	 in	 the	         Alternatively,	GH	replacement	has	been	shown	to	increase	
treatment	 of	 aggressive	 pituitary	 adenomas.	 Our	 case	          serum	Ca	level	from	baseline.	We	present	2	cases	of	cal-
highlights	 its	 potential	 effectiveness	 even	 after	 multiple	    citriol-dependent	 hypercalcemia	 correlating	 with	 acro-
surgical	interventions	and	radiation	therapy.	After	only	10	         megaly	 activity.	 Biochemical	 remission	 of	 acromegaly	
weeks	of	TMZ,	a	60%	decrease	in	tumor	size	was	noted	                resulted	in	normalization	of	Ca	and	calcitriol	levels,	while	
with	 improvement	 in	 ophthalmoplegia.	 Further	 clinical	          incomplete	 resection	 was	 associated	 with	 persistent	 cal-
trials	of	TMZ	in	the	treatment	of	aggressive	pituitary	ade-          citriol-dependent	 hypercalcemia.	 GH	 may	 activate	 renal	
nomas	are	warranted.                                                 1-α-hydroxylase	resulting	in	increased	calcitriol	produc-
                                                                     tion	 and	 subsequent	 hypercalcemia	 and	 hypercalciuria,	
Abstract #811                                                        but	further	studies	are	needed	to	clarify	the	mechanism.
                                                                          Conclusion:	Hypercalcemia	rarely	occurs	in	patients	
ACROMEGALY AS A CAUSE OF CALCITRIOL-                                 with	acromegaly,	likely	due	to	increased	calcitriol	levels	
DEPENDENT HYPERCALCEMIA                                              by	GH,	either	by	increased	synthesis	or	decreased	clear-
                                                                     ance	of	the	vitamin.
Reshma Shah, MD, Angelo Licata, MD, PhD,
Nelson M. Oyesiku MD, PhD, FACS,                                     Abstract #812
Adriana G. Ioachimescu MD, PhD
                                                                     DIABETES INSIPIDUS IN A PATIENT WITH
	    Objective:	We	describe	2	cases	of	calcitriol	dependent	         METASTATIC SMALL CELL LUNG CANCER
hypercalcemia	associated	with	growth	hormone	excess.
	    Case	 Presentation:	 A	 50-year-old	 female	 with	 1	           Alina Khan-ghany, MD, Vitor Pastorini, MD,
year	 h/o	 hypercalcemia	 presented	 with	 features	 of	 acro-       Seth Sclair, MD, Reyan Ghany, MD,
megaly.	 Serum	 calcium	 (Ca)	 was	 10.9	 mg/dL	 (8.6-               Bresta Miranda-Palma, MD
10.2),	 parathyroid	 hormone	 (PTH)	 20	 pg/mL	 (10-65),	
25-hydroxyvitamin	 D	 33	 ng/mL	 (20-100),	 urine	 Ca	 388	          	    Objective:	 To	 report	 a	 case	 of	 diabetes	 insipidus	
mg/day,	PTH-related	peptide	undetectable,	and	calcitriol	            (DI)	in	a	patient	with	metastatic	Small	Cell	Lung	Cancer	
(1,25-(OH)2	 vit	 D)	 119	 pg/mL	 (15-75).	 She	 had	 nega-          (SCLC)	to	the	pituitary	stalk.
tive	 PPD,	 chest	 x-ray,	ACE	 level,	 and	 gadolinium	 scan.	            Case	Presentation:	A	49-year-old	male	smoker,	with	
Insulin-like	growth	factor-1	(IGF-1)	was	911	ng/mL	(49-              recently	diagnosed	SCLC,	presented	to	the	ER	with	a	post-
292)	and	growth	hormone	(GH)	14.5	ng/mL	(0.03-10),	not	              obstructive	 pneumonia.	 Radiographic	 staging	 showed	
suppressed	after	OGTT.	MRI	showed	a	1.7	cm	pituitary	                metastases	to	the	mediastinum;	bone;	and	pituitary	stalk,	
tumor.	 Transsphenoidal	 adenomectomy	 (TSA)	 resulted	              which	was	a	well-defined	enhancing	6	x	6	mm	lesion	on	
in	normalization	of	IGF-1	(197	ng/mL),	GH	(1.4	ng/mL),	              brain	 MRI.	 On	 day	 8	 of	 hospitalization,	 he	 developed	
Ca	(10.0	mg/dL),	and	calcitriol	(50	pg/mL).	At	3	months,	            superior	vena	cava	syndrome	and	received	emergent	radi-
GH	 suppressed	 after	 OGTT	 and	 MRI	 showed	 complete	             ation	 and	 chemotherapy	 with	 etoposide	 and	 carboplatin.	
tumor	 resection,	 while	 Ca	 remained	 normal.	A	 52	 y/o	 F	       The	day	after	chemotherapy,	he	was	noted	to	have	a	urine	
was	diagnosed	with	visual	field	deficits	on	routine	exam.	           output	of	12	L	with	an	oral	intake	of	7	L.	A	history	of	ice-
MRI	showed	a	3	cm	pituitary	macroademona.	IGF-1	was	                 cravings	 and	 the	 urge	 to	 wake	 up	 at	 night	 to	 drink	 cold	
416	 ng/mL	 and	 GH	 75.8	 ng/mL.	 Incidentally,	 she	 was	          water	 was	 elicited.	 He	 denied	 symptoms	 of	 orthostasis,	
found	with	Ca	of	10.8	mg/dL	associated	with	PTH	19	pg/               headaches,	 or	 visual	 changes.	 Laboratory	 data	 revealed	
mL	 and	 calcitriol	 66	 pg/mL.	TSA	 resulted	 in	 immediate	        a	 urine	 osmolality	 of	 123	 mOsm/kg	 with	 correspond-
reduction	of	GH	(18.6	ng/mL),	IGF-1	(246	ng/mL),	&	Ca	               ing	serum	sodium	of	140	mmol/L.	The	patient	remained	
(8.4	mg/dL).	At	3	months,	IGF-1	was	440	ng/mL,	GH	9.9	               eunatremic	 despite	 polyuria	 so	 a	 water	 deprivation	 test	
ng/mL,	 while	 MRI	 showed	 parasellar	 tumor	 residue.	 Ca	         was	performed.	After	4	hours	of	water	deprivation,	serum	


                                                               – 129 –
                                           ABSTRACTS – Pituitary Disorders

sodium	 increased	 from	 142	 to	 148	 mmol/L	 with	 a	 urine	        one	 more	 month	 after.	 Pregnancy	 was	 confirmed.	 Based	
osmolality	that	remained	hypotonic	(88	-118	mOsm/kg).	                on	 high	 dimensions	 of	 the	 macroprolactinoma,	 estrogen	
During	hour	5	of	water	deprivation,	a	desmopressin	chal-              stimulus	 associated	 with	 pregnancy	 was	 considered	 to	
lenge	produced	an	increase	in	the	urine	osmolality	to	363	            be	 dangerous,	 so	 early	 pregnancy	 termination	 was	 per-
mOsm/kg,	 confirming	 the	 diagnosis	 of	 central	 DI.	 The	          formed.	Six	months	later,	the	CT	scan	of	pituitary	showed	
patient	 was	 subsequently	 started	 on	 intranasal	 desmo-           an	important	shrinkage	of	the	tumor	to	2.1	by	1.2	cm,	with	
pressin	 with	 improved	 polyuria	 and	 polydipsia.	Anterior	         prolactin	level	of	30.13ng/mL.	During	the	following	3	yrs,	
pituitary	function	was	normal	as	assessed	by	ACTH,	LH,	               bromocriptine	 was	 progressively	 reduced	 while	 normal-
FSH,	testosterone	and	IGF-1	levels.	Prolactin	was	18	ng/              ization	 of	 the	 visual	 field	 and	 shrinkage	 of	 the	 pituitary	
ml.	TSH,	free	T4,	anti-TPO	antibody	were	11	uIU/ml,	0.8	              adenoma	to	1.3/0.9	cm	(prolactin:	4.02	ng/mL).	Low	dose	
ng/dl	 and	 431	 IU/mL,	 respectively,	 consistent	 with	 pri-        bromocriptine	(7.5	mg/day)	was	continued	for	2	yrs	when	
mary	autoimmune	hypothyroidism.                                       the	tumor	became	a	microadenoma	(of	0.87/0.71	cm)	and	
      Discussion:	 Pituitary	 metastases	 (PM)	 occur	 in	 1-4	       remained	so	till	present.	At	the	age	of	45,	the	breast	exam	
%	of	patients	with	malignancy	on	autopsy	with	non-small	              revealed	a	nodule	in	the	upper-outer	quadrant	of	the	left	
cell	 lung	 cancer	 as	 one	 of	 the	 leading	 causes.	There	 are	    breast	 associated	 with	 orange	 like	 skin.	 The	 ultrasound	
few	reports	of	metastatic	SCLC	to	the	pituitary	gland	in	             showed	a	nodule	of	1.5	cm.	The	surgical	approach	of	the	
the	 literature.	 PM	 are	 typically	 asymptomatic,	 however,	        nodule	was	recommended	and	intra-operator	pathological	
when	they	are	symptomatic,	60-70	%	of	patients	present	               exam	revealed	a	mammary	carcinoma.	Total	mastectomy	
with	DI.	It	is	hypothesized	that	since	the	posterior	pituitary	       and	axillary	lymph	nodes	excision	was	performed.	There	
receives	 its	 blood	 supply	 from	 the	 systemic	 circulation,	      was	 a	 T1G1N0,	 mucinoid	 carcinoma.	 The	 immunohisto-
the	probability	of	metastatic	seeding	is	greater	than	seed-           chemistry	was	positive	for	estrogen	and	prolactin	recep-
ing	to	the	anterior	pituitary,	which	receives	its	blood	sup-          tors.	External	irradiation	and	total	histerectomy	with	bilat-
ply	from	the	portal	system.	Treatment	modalities	include	             eral	 anexectomy	 were	 performed.	 Further	 chemotherapy	
chemotherapy,	surgery,	and	radiation	therapy.	In	our	case,	           or	immunotherapy	is	under	consideration.
the	patient	received	whole	brain	radiation.                           	    Discussion:	 The	 prolactin	 induces	 changes	 at	 the	
      Conclusion:	DI	is	a	rare	complication	of	metastatic	            level	 of	 the	 mammary	 gland,	 regardless	 of	 normal	 or	
SCLC.	DI	often	is	unrecognized,	but	once	identified	and	              pathological	context.	Hyperprolactinemia	in	women	with	
treated,	quality	of	life	is	improved.	Mean	survival	rates	of	         breast	cancer	is	of	poor	prognosis	for	the	breast	disease,	
metastatic	SCLC	range	from	6	to	22	months	independent	                probably	by	a	direct	autocrine	production	by	cancer	cells	
of	treatment	strategy.                                                themselves.	 The	 prolactin	 receptors	 in	 the	 tumor	 in	 a	
                                                                      long	 standing	 case	 of	 hyperprolactinemia	 due	 to	 a	 pitu-
Abstract #813                                                         itary	macroadenoma	may	be	responsible	of	tumor	growth.	
                                                                      Controlled	prospective	studies	 would	 be	 useful	 to	 deter-
BREAST CANCER WITH NEUROENDOCRINE                                     mine	 the	 risk	 of	 breast	 cancer	 (if	 any)	 for	 women	 with	
PHENOTYPE: THE ROLE OF PITUITARY                                      chronic	high	prolactin.
TUMOR INDUCED HYPERPROLACTINEMIA                                      	    Conclusion:	The	mucinoid	breast	cancer	may	gain	a	
                                                                      neuroendocrine	profile,	with	a	more	rapid	growth	induced	
Catalina I. Poiana, MD, PhD, FACE,                                    by	prolactin	receptors	in	a	context	of	hyperprolactinemia.
Mara Carsote, MD, Madalina Musat, MD, PhD,
Dana Terzea, MD, Corina Chirita, MD,                                  Abstract #814
Dan Hortopan, MD, PhD, Anda Dumitrascu, MD, PhD
                                                                      AN UNUSUAL CASE OF HYPOGLYCEMIA IN
	     Objective:	 We	 report	 a	 case	 of	 macroprolactinoma	         TYPE 1 DIABETES
diagnosed	with	breast	cancer	at	age	of	45.
	     Case	Presentation:	Woman	of	47	has	a	6	year	history	            Seshadrinathan Pramodh, MD, Dominic Parsons, MBBS,
of	 prolactinoma.	At	 diagnosis,	 she	 had	 hypo-menorrhea	           Alex Bickerton, MBBS, D. Phil
and	 intense	 headaches.	 Prolactin	 levels	 were	 very	 high:	
>1000	ng/mL	(normal	<	20ng/mL)	with	low	FSH	and	LH	                   	     Objective:	To	demonstrate	the	possible	multi-factorial	
levels.	 The	 pituitary	 CT	 scan	 revealed	 a	 macroadenoma	         potentially	reversible	causes	of	hypoglycaemia	in	Type	1	
of	4	/4.45/	4.25	cm,	with	suprasellar	extension	and	inva-             Diabetes,	aside	exogenous	insulin.
sion	into	the	left	cavernous	sinus	and	left	temporal	lobe.	           	     Case	Presentation:	A	55-year-old	woman	with	a	40	
High	 dose	 therapy	 with	 dopamine	 agonist,	 (bromocrip-            year	history	of	Type	I	DM,	primary	hypothyroidism	and	
tine	 30	 mg/day)	 was	 started.	Three	 months	 later	 prolac-        a	 2	 year	 history	 of	 severe	 hypoglycemic	 episodes	 and	
tin	 decreased	 to	 52.29	 ng/mL,	 but	 the	 menses	 stopped	         weight	 loss,	 presented	 following	 hypoglycemic	 collapse	


                                                                – 130 –
                                            ABSTRACTS – Pituitary Disorders

to	our	hospital.	She	had	1-2	episodes	of	severe	hypogly-               (goserelin)	 and	 androgen	 receptor	 antagonist	 (flutamide)	
cemia	a	week,	with	minimal	warning	symptoms,	requiring	                for	prostate	cancer	treatment.
frequent	 glucagon	 administration.	 She	 exercises	 heavily,	               Case	 Presentation:	 A	 68-year-old	 man	 developed	
cycling	6	miles	a	day,	whilst	consuming	handfuls	of	glu-               excruciating	right	sided	headache	and	diplopia	one	week	
cose	 tablets	 to	 avoid	 hypoglycemia.	 She	 also	 has	 a	 his-       after	 receiving	 goserelin	 and	 flutamide.	 Physical	 exam	
tory	 of	 anorexia	 in	 the	 past	 and	 continues	 to	 be	 heavily	    showed	 third	 nerve	 palsy	 and	 bitemporal	 hemianopsia.	
obsessed	 about	 her	 weight.	 She	 was	 on	 multiple	 daily	          Magnetic	resonance	imaging	(MRI)	of	the	brain	showed	a	
doses	 of	 insulin	 with	 Glargine	 and	 Aspart.	 Admission	           large	sellar	mass	(2.6	cm	x1.9	cm)	compressing	the	optic	
plasma	 glucose	 level	 was	 25.2	 mg/dL.	 She	 received	 80	          chiasm	 and	 extending	 to	 right	 cavernous	 sinus	 without	
g	 of	 glucose	 intravenously	 over	 3	 hours	 before	 eventual	       hemorrhage.	 Initial	 assessment	 revealed	 FSH	 104(1-18	
recovery	and	achieving	euglycemia.	She	was	investigated	               mIU/ml),	 LH	 10	 (1-9	 mIU/ml),	 α	 subunit	 51.3	 (<0.6ng/
for	 adrenal	 insufficiency	 and	 was	 found	 to	 have	 a	 low	        mL),	TSH	0.19	(0.35-5.50	uIU/mL),	Free	T4	0.73	(0.89-
morning	 cortisol	 (6.74	 μg/dL)	 and	 inadequate	 response	           1.80ng/dL),	Free	T3	1.7	(2.3-4.2	pg/mL),	total	testoster-
to	 250	 μg	 ACTH	 stimulation	 (17.6	 μg/dL	 at	 30	 mins).	          one	 (TT)	 591	 (241-827	 ng/dL),	 free	 testosterone	 (FT)	
An	ACTH	of	26	pg/mL	(NR	0-40)	and	renin	of	18	mu/L	                    133.3	 (35.0-155.0	 pg/mL),	 somatomedinC	 230	 (71-290	
(NR	 2-30)	 excluded	 primary	 adrenal	 insufficiency.	 An	            ng/mL),	 GH	 1.4	 (0-10	 ng/mL),	ACTH	 8	 (7-50	 pg/mL),	
insulin	 stress	 test	 confirmed	 secondary	 hypoadrenalism	           cortisol	9.94	(4.30-22.40	mcg/dL)	and	prolactin	20	(2-18	
(peak	cortisol	of	14	µg/dL).	Appropriate	GH	response	on	               ng/ml).	A	repeat	MRI	four	weeks	later	showed	no	interval	
insulin	stress	test	(peak	GH	rise	of	12	μg/L),	and	normal	             changes	but	visual	field	defect	worsened.	He	then	under-
post-menopausal	levels	of	LH	(33.9	U/L)	and	FSH	(52.0	                 went	transsphenoidal	debulking	of	the	tumor.	Post-op	MRI	
U/L)	and	prolactin	(22.35ng/mL)	confirmed	normal	func-                 showed	decreased	pituitary	tumor	size	and	decompression	
tion	of	other	anterior	pituitary	hormones.	She	was	slightly	           of	the	optic	chiasm.	FSH&LH	levels	decreased	to	42&3	
over	replaced	with	Thyroxine	(TSH	0.03mu/L;	fT4	23.5	                  respectively.	 His	 visual	 field	 improved	 within	 the	 next	
pmol/L).	A	 pituitary	 MRI	 scan	 was	 normal	 leading	 to	 a	         six	months.	Immunohistochemical	staining	of	tumor	was	
diagnosis	 of	 isolated	ACTH	 deficiency.	 She	 was	 started	          strongly	positive	for	LH.	No	tissue	necrosis	was	noted.	He	
on	steroid	replacement	and	the	dosage	of	Thyroxine	was	                had	prostectomy	two	weeks	later	and	flutamide	was	dis-
reduced.	This	reduced	the	episodes	of	severe	hypoglyce-                continued.	No	more	goserelin	was	given.	Five	years	later,	
mia,	but	not	mild	and	moderate	episodes.                               LH/FSH/TT/FT	were	12/32/366/38.5	and	no	changes	on	
	     Discussion:	Isolated	ACTH	deficiency	is	an	unusual,	             MRI.
but	 well-recognized	 cause	 of	 hypoglycemia	 in	 Type	 1	                  Discussion:	We	are	presenting	a	case	of	gonadotro-
Diabetes	 characterized	 by	 low	 cortisol	 production,	 nor-          pin	 producing	 tumor	 with	 sudden	 growth	 coincide	 with	
mal	secretion	of	pituitary	hormones	other	than	ACTH.	It	               the	administration	of	goserelin	and	flutamide.	While	con-
is	 usually	 autoimmune	 in	 origin	 In	 this	 case,	 there	 were	     tinuous	GnRH	agonist	therapy	is	known	to	decrease	LH	
several	 factors	 contributing	 to	 hypoglycemia	 including	           and	FSH	in	normal	pituitary,	it	may	have	acute	stimula-
exercise,	 anorexia	 and	 hypoglycemia	 unawareness.	 The	             tory	effect	on	gonadotropin	adenoma,	resulting	in	sudden	
prolonged	 episode	 of	 severe	 hypoglycaemia	 prompted	               enlargement	of	tumor.	Pituitary	apoplexy	after	GnRH	ago-
investigation	for	cortisol	insufficiency.                              nist	therapy	had	been	reported	before.	But,	no	hemorrhage	
	     Conclusion:	It	is	important	to	look	for	unusual	and	             or	necrosis	noted	on	imaging	or	pathology	in	our	patient.	
reversible	 causes	 of	 hypoglycemia	 in	 Type	 1	 Diabetes.	          His	symptoms	occurred	a	week	after	receiving	GnRH	ago-
Adreno-cortical	insufficiency	must	always	be	considered	               nist	fit	the	time	window	for	cell	proliferation	to	generate	
as	a	possible	cause	of	hypoglycemia,	prompting	appropri-               a	significant	growth	of	the	pituitary	adenoma.	This	is	the	
ate	investigation.                                                     fourth	reported	case	of	increased	intrasellar	pressure	with-
                                                                       out	 pituitary	 apoplexy	 following	 GnRH	 agonist	 therapy.	
Abstract #815                                                          In	 the	 last	 three	 cases,	 patients’	 symptoms	 occurred	 at	
                                                                       10,	12	and	7	days	after	GnRH	agonist	administration.	In	
ACUTE INCREASED INTRACELLAR PRESSURE                                   addition,	our	patient	received	flutamide	which	is	known	to	
SHORTLY AFTER RECEIVING GNRH AGONIST                                   increase	LH	and	FSH	production.	It	may	also	contribute	to	
& ANDROGEN RECPTOR ANTAGONIST FOR                                      the	growth	of	the	pituitary	adenoma.
PROSTATE CANCER TREATMENT                                                    Conclusion:	 We	 reported	 a	 patient	 with	 sudden	
                                                                       symptoms	 of	 increased	 intrasellar	 pressure	 shortly	 after	
Lee Hong, MD, Nasrin Azad, MD                                          receiving	 goserelin	 and	 flutamide	 without	 any	 evidence	
                                                                       of	pituitary	apoplexy.	We	hypothesize	the	acute	growth	of	
     Objective:	 To	 describe	 a	 case	 of	 acute	 increased	          the	 adenoma	 was	 due	 to	 the	 administration	 of	 goserelin	
intrasellar	pressure	shortly	after	receiving	GnRH	agonist	             and	possibly	flutamide.


                                                                 – 131 –
                                           ABSTRACTS – Pituitary Disorders

Abstract #816                                                         Coexistence	 of	 hypogonadism	 as	 in	 this	 case	 is	 well	
                                                                      described	in	literature.
RECALCITRANT PITUITARY ADENOMA                                             Conclusion:	The	 management	 of	 pituitary	 adenoma	
PRESENTING AS ACROMEGALY AND                                          in	Nigeria	is	challenging	for	myriad	of	reasons.	Recurrent	
HYPOGONADISM IN A NIGERIAN MALE                                       tumors	 are	 very	 likely	 if	 surgery	 alone	 (not	 first	 line	 of	
                                                                      treatment)	is	used	for	treatment.
Andrew Enemako Uloko, MD, Fabian H. Puepet, MD,
FMCP, Shehu M. Yusuf, FWACP,                                          Abstract #817
Ayekame Tini Uloko, BPharm
                                                                      OUTCOME STUDY OF TRANSSPHENOIDAL
      Objective:	 Reports	 of	 recurrent	 pituitary	 adenoma	         SURGERY FOR ACROMEGALY:
in	Nigeria	remain	scanty	probably	due	to	diagnostic	and	              UNIVERSITY EXPERIENCE
therapeutic	 challenges.	 Our	 objective	 is	 to	 report	 a	 case	
of	 recalcitrant	 pituitary	 adenoma	 with	 Acromegaly	 and	          Adriana Gabriela Ioachimescu, MD, PhD,
hypogonadism	in	a	Nigerian	male.                                      Diana M. Pimentel, Vaninder S. Chhabra,
      Methods:	The	case	records	of	a	32-year-old	Nigerian	            Nelson M. Oyesiku, MD, PhD
male	with	suspected	Acromegaly	and	hypogonadism	was	
reviewed.	Hormonal	assays,	screening	for	diabetes	melli-              	    Objective:	 To	 determine	 the	 biochemical	 outcome	
tus,	neuro-imaging	were	performed	and	review	of	relevant	             of	acromegaly	patients	treated	by	transsphenoidal	adeno-
literature	undertaken.                                                mectomy	(TSA).
      Case	 Presentation:	 A	 32-year-old	 male	 referred	            	    Methods:	We	reviewed	all	acromegaly	cases	(N=61)	
from	the	urology	clinic	to	the	endocrine	clinic	of	AKTH	              of	TSA	by	a	single	neurosurgeon	between	1998	and	2009.	
in	 April	 2009	 had	 a	 3-year	 history	 of	 excessive	 body	        We	excluded	8	patients	with	follow-up	<	3	months	and	5	
growth,	 recurrent	 headaches,	 impaired	 vision,	 loss	 of	          patients	with	prior	pituitary	surgery	by	a	different	surgeon.	
libido	 and	 erectile	 weakness.	 He	 had	 trans-frontal	 pitu-       Criteria	for	remission	were:	normalized	age-	and	gender-
itary	adenomectomy	15	months	earlier	at	a	Saudi	hospital	             matched	IGF-1	and	fasting	growth	hormone	(GH)	<	2.5	
with	initial	improvements.	His	clinical	features	however	             ng/mL	(or	GH	<1	ng/mL	during	OGTT).
recurred	 10	 months	 ago	 mainly	 with	 progressive	 body	           	    Results:	 Twenty	 two	 men	 and	 26	 women,	 age	
growth,	 difficulties	 with	 appropriate	 shoe	 and	 cap	 sizes,	     45.7±11.9	were	followed	for	a	median	of	1.5	years	after	
bilateral	gynecomastia,	greasy/oily	skin,	hyperpigmenta-              TSA	 (0.33-8	 years).	 At	 3	 months	 postoperatively,	 the	
tion,	recurrent	headaches	and	impaired	vision	(blindness	             remission	 rate	 was	 70%	 in	 patients	 with	 non-invasive	
left	 eye,	 cataract	 right).	 Laboratory	 evaluation	 revealed	      (N=23)	and	16%	for	invasive	tumors	(N=25).	The	remis-
normal	 fasting	 plasma	 glucose	 and	 OGTT.	 Hormonal	               sion	rate	was	77%	for	microadenomas	(N=13)	and	31.4%	
assays:	FSH	1.7IU/L	(1.0-19.0IU/L),	LH	1.1IU/L	(1.0-9.0	              for	 macroadenomas	 (N=35).	 In	 the	 remission	 group,	 the	
IU/L),	 Prolactin	 3.8	 ng/ml	 (2.6-13.1ng/ml),	Testosterone	         tumor	 size	 was	 smaller	 (1.4±1.0	 cm)	 vs.	 no-remission	
0.76nmol/l	 (9.5-35	 nmol/l).	Thyroid	 function	 tests	 (Free	        group	(2.2±1.0	cm,	p	0.007).	Although	preoperative	GH	
T3,	T4,	TSH)	were	normal.	Basal	growth	hormone	(GH)	                  and	IGF1	were	lower	in	the	remission	group,	there	was	no	
assay	 >	 96μIU/ml	 (normal	 up	 to	 13.5	 Μiu/ml)	 and	 fail-        significant	difference	vs.	no-remission	group.	GH	on	post-
ure	to	suppress	GH	after	a	2-hour	75g	OGTT	(>96	μIU/                  operative	days	1-5	was	lower	in	the	remission	(1.6±1.7)	
ml	30mins,	>96	μIU/ml	60mins,	>96	μIU/ml	90mins,	>96	                 vs.	non-remssion	group	(53±197,	p=0.1).	Immediate	post-
μIU/ml	120mins	and	>96	μIU/ml	180mins).	Recent	brain	                 operative	GH	was	<3	ng/mL	in	90%	of	patients	in	remis-
CT	 scan	 showed	 a	 huge	 pituitary	 macroadenoma	 with	             sion	 group	 and	 in	 37%	 of	 patients	 who	 did	 not	 achieve	
some	 frontal	 lobe	 infarcts.	 A	 diagnosis	 of	 Recalcitrant	       postoperative	remission.	MRI	at	3	months	postoperatively	
Pituitary	Adenoma	with	Acromegaly	and	Hypogonadism	                   showed	tumor	residue	in	9.5%	of	patients	in	the	remission	
was	made.	He	is	yet	to	commence	medical	treatment	for	                group	and	81.5%	of	patients	who	did	not	achieve	remis-
the	adenoma	due	to	logistic	and	social	constraints.                   sion.	 Thirty	 three	 patients	 were	 followed	 for	 more	 than	
      Discussion:	 The	 main	 treatment	 for	 pituitary	 mac-         1	year	(median	2.5).	Recurrence	occurred	in	one	patient	
roadenoma	 is	 by	 use	 of	 drugs	 depending	 on	 the	 tumor	         (3%)	at	8	months	post	TSA.	Among	the	19	who	did	not	
type	 and	 the	 predominant	 hormone	 secreted.	 Surgery	 is	         achieve	 postoperative	 remission,	 5	 (26%)	 normalized	
considered	 when	 medical	 therapy	 is	 not	 successful	 or	          IGF1	 and	 GH	 during	 somatostatin	 analog	 therapy	 and	 5	
when	pressure	symptoms	are	very	prominent	due	to	tumor	               (26%)	after	radiation	therapy	while	taking	medical	treat-
size.	As	in	this	case,	there	is	high	chance	of	recurrence	of	         ment.	The	median	time	from	radiation	to	remission	was	2	
tumor	 growth	 if	 surgery	 alone	 is	 used	 in	 the	 treatment.	     years	(1	to	5).



                                                                – 132 –
                                           ABSTRACTS – Pituitary Disorders

	     Discussion:	 Remission	 rate	 for	 acromegaly	 varies	          found	in	systemic	LCH.	Chemotherapy	was	started.
greatly	among	studies	due	to	different	remission	criteria,	           	    Discussion:	 LCH	 is	 a	 rare	 entity	 that	 results	 from	
changes	 in	 hormonal	 assays	 and	 surgeon’s	 experience.	           pathological	 proliferation	 and	 infiltration	 by	 Langerhans	
Proposed	predictors	of	postoperative	biochemical	remis-               cells,	with	an	incidence	of	3-5	cases	per	million	per	year	in	
sion	 include	 tumor	 size	 and	 invasiveness,	 incomplete	           pediatric	population.	Adults	are	rarely	affected	(1.8	cases	
tumor	 resection	 and	 preoperative	 GH	 levels.	 Our	 study	         per	 million	 per	 year).	 It	 shows	 predilection	 for	 the	 HPA	
supports	the	predictive	value	of	tumor	size,	invasiveness	            leading	to	CDI	in	about	17-30%	of	the	cases.	In	the	pres-
and	incomplete	tumor	resection.	Some	studies	suggested	               ence	of	other	pituitary	deficiencies,	the	prevalence	of	CDI	
that	low	GH	immediately	after	TSA	is	a	predictor	of	long-             can	be	as	high	as	94%.	The	pathogenesis	has	been	attrib-
term	 remission.	 However,	 we	 found	 that	 37%	 patients	           uted	to	LC-infiltration	as	well	as	scarring	lesions	in	HPA.	
who	did	not	achieve	remission	had	GH	<	3	ng/mL	in	the	                MRI	shows	typically	a	thickening	of	the	pituitary	stalk	or	
first	few	days	after	surgery.                                         loss	of	the	pituitary	spot.	Hypothalamic	masses	are	found	
	     Conclusion:	Tumor	size,	dural	invasion	and	incom-               in	8-18%	of	cases.	Biopsies	from	certain	delicate	regions	
plete	resection	are	important	prognostic	factors	of	surgi-            such	as	the	hypothalamus	are	controversial.
cal	outcome	in	acromegaly.	Immediate	postoperative	GH	                	    Conclusion:	LCH	should	be	in	the	differential	diag-
levels	should	not	be	used	alone	to	predict	long-term	bio-             nosis	of	adult	patients	presenting	with	CDI,	anterior	pitu-
chemical	remission.                                                   itary	 hormone	 abnormalities	 and	 hypothalamic	 lesions.	
                                                                      Endocrinologists	need	to	develop	high	clinical	suspicion	
Abstract #818                                                         of	endocrine	abnormalities	associated	with	systemic	dis-
                                                                      eases	such	as	LCH.	This	recognition	could	avoid	unneces-
LANGERHANS CELL HISTIOCYTOSIS IN AN                                   sary	and	risky	invasive	procedures	such	as	brain	biopsy.
ADULT PATIENT MANIFESTED AS DIABETES
INSIPIDUS AND HYPOTHALAMIC LESION                                     Abstract #819

Ana Cecilia Apaza Concha, MD,                                         EXPRESSIVE APHASIA: A RARE
Andrea Marcela Sosa-Melo, MD,                                         MANIFESTATION OF UNTREATED
Luz Marina Prieto Sanchez, MD                                         HYPOPITUITARISM

	    Objective:	To	report	a	case	of	an	adult	patient	newly	           Richard W. Pinsker, MD, FACE, Kaushik Doshi, MD,
diagnosed	 with	 Langerhans	 Cell	 Histiocytosis	 (LCH)	              Kelly L. Cervellione, MA, MPh, Danny Guillen, MD,
complicated	with	Central	Diabetes	Insipidus	(CDI).                    Birju Shah, MD, Pooja Kanth, BS
	    Case	 Presentation:	 46-year-old	 Hispanic	 female	
presented	 with	 a	 6-month	 history	 of	 progressive	 confu-         	     Objective:	To	 describe	 a	 case	 of	 expressive	 aphasia	
sion,	 memory	 problems	 and	 incoherent	 speech	 associ-             caused	by	untreated	hypopituitarism.
ated	 to	 polyuria,	 polydipsia.	After	 an	 episode	 of	 loss	 of	    	     Case	 Presentation:	 A	 73-year-old	 male	 with	 HTN,	
consciousness	she	was	admitted	to	a	tertiary	care	Hospital	           DM	 and	 depression	 was	 admitted	 due	 to	 an	 episode	 of	
where	 a	 brain	 MRI	 (Magnetic	 Resonance	 Imaging)	                 syncope.	 He	 had	 been	 diagnosed	 with	 meningioma	 in	
showed	a	1.6	X	3cm	hypothalamic	lesion.	She	was	trans-                2001,	and	underwent	a	craniotomy	in	2001	and	again	in	
ferred	for	possible	mass	resection.	Her	mental	status	wors-           2004.	 He	 subsequently	 received	 gamma	 knife	 treatment	
ened.	She	developed	polyuria	with	severe	hypernatremia	               for	 invasion	 of	 the	 cavernous	 sinus.	 Since	 then,	 he	 had	
of	176mmol/L	and	inappropriately	low	urine	osmolality.	               experienced	 progressive	 weakness,	 lethargy,	 and	 mul-
The	 patient	 was	 treated	 with	 desmopressin	 with	 good	           tiple	episodes	of	hypoglycemia	and	syncope.	In	2008	he	
response.	 Other	 pituitary	 evaluation	 showed	 central	             became	 non-verbal	 and	 was	 diagnosed	 with	 ‘expressive	
hypothyroidism,	 hypogonadotrophic	 hypogonadism,	 low	               aphasia’	 by	 neurologists,	 thought	 to	 be	 caused	 by	 isch-
IGF-1	levels	and	prolactin	levels	slightly	elevated.	After	           emia	from	past	treatments.	A	few	weeks	prior	to	current	
stabilization,	 she	 underwent	 craniotomy	 and	 hypotha-             hospitalization,	he	was	admitted	due	to	an	episode	of	diz-
lamic	biopsy.	Pathology	result	showed	“astrocytosis	and	              ziness	 with	 loss	 of	 consciousness.	 Mild	 hypothyroidism	
perivascular	lymphocytic	infiltration”.	In	additional	medi-           was	diagnosed;	l-thyroxine	was	started.	CT	scan	showed	
cal	record	review	it	was	found	that	she	had	chronic	vul-              a	large,	hyper-dense	pituitary	mass	invading	the	sella	and	
var	and	major	labia	lesions	that	were	biopsied	5	months	              eroding	 into	 the	 sphenoid	 sinus.	 At	 current	 admission,	
prior	to	this	episode.	Pathology	result	was	consistent	with	          the	 patient	 was	 non-verbal	 and	 unable	 to	 walk;	 his	 BP	
Histiocytes	and	Langerhans	cells	with	positive	cD1a	and	              =	 80/60	 and	 pulse	 =	 60bpm.	 He	 was	 taking	 l-thyroxine	
S100	stain.	It	was	concluded	that	the	hypothalamic	lesion	            50mcg/day.	 Due	 to	 CT	 results	 from	 last	 admission	 and	
was	 compatible	 with	 the	 type	 of	 pathology	 that	 can	 be	       history	of	gamma	knife	surgery	involving	the	cavernous	


                                                                – 133 –
                                           ABSTRACTS – Pituitary Disorders

sinus,	 endocrine	 function	 work-up	 was	 ordered.	 Results	         The	patient	underwent	a	left	pterional	and	subfrontal	cra-
included:	 Cortisol	 2.72	 ug/dL	 with	 post-cosyntropin	 of	         niotomy	with	gross	total	resection	of	the	mass.	Pathology	
12.6	ug/dL,	prolactin	14.2	ng/mL,	TSH	3.99	mlU/mL,	free	              revealed	pituitary	cells	with	intermediate	mitotic	activity	
T4	0.44	ng/dL	(onl-thyroxine),	total	T3	90	ng/dL,	ACTH	               and	positive	immunostaining	for	MIB-1	and	p53.	No	areas	
6.0	 pg/mL,	 FSH	 0.9	 ng/mL,	 LH	 0.1	 ng/ml,	 total	 testos-        of	metastasis	were	identified.
terone	 120	 ng/dL	 (N	 260-1000	 ng/dL).	 Hypopituitarism	           	    Discussion:	 The	 definition,	 diagnosis,	 therapy,	 and	
was	 diagnosed	 and	 hydrocortisone	 100	 mg	 IV	 q8h	 was	           prognosis	of	pituitary	carcinomas	are	controversial	due	to	
started.	On	day	two	of	steroid	treatment	the	patient	began	           a	paucity	of	reports	that	exist	in	the	English	literature.	The	
to	respond	verbally	and	provide	information	on	his	con-               case	above	illustrates	the	difficulty	encountered	when	try-
dition.	 He	 also	 began	 walking	 with	 assistance.	 He	 was	        ing	to	discern	between	invasive	pituitary	macroadenoma	
started	on	cortisone	25mg	BID	orally	along	with	l-thyrox-             and	primary	pituitary	carcinoma.	Most	cases	of	pituitary	
ine	50	mcg	daily.	At	one-week	follow-up,	the	patient	was	             carcinomas	are	believed	to	arise	from	the	malignant	trans-
doing	very	well	with	complete	resolution	of	his	expressive	           formation	 of	 benign	 macroadenomas.	 Differentiating	
aphasia.                                                              between	 the	 two	 has	 clinical	 significance	 for	 the	 patient	
	    Discussion:	 Development	 of	 signs	 and	 symptoms	              due	to	the	substantial	difference	in	the	morbidity	and	mor-
of	 hypopituitarism	 is	 sometimes	 insidious.	 Patients	 fre-        tality	of	pituitary	carcinomas.	The	currently	accepted	defi-
quently	 have	 modest	 hyperprolactinemia	 with	 GH	 and	             nition	 of	 primary	 pituitary	 carcinoma	 requires	 the	 pres-
gonadotropin	 failure.	 TSH	 and	 ACTH	 deficiencies	 are	            ence	of	metastatic	spread	at	discovery.	The	World	Health	
much	 less	 common.	As	 in	 our	 patient,	 radiation	 therapy	        Organization	 further	 differentiates	 pituitary	 neoplasms	
eventually	 results	 in	 a	 50%-60%	 incidence	 of	 pituitary	        with	 the	 classification	 of	 atypical	 adenomas:	 exhibiting	
insufficiency.	Once	the	hypopituitarism	was	realized	and	             high	mitotic	activity,	an	increased	(>3%)	Ki-67%	LI,	and/
treated,	our	patients	expressive	aphasia	quickly	and	com-             or	p53	immunoreactivity.	The	goal	of	this	subdivision	is	
pletely	resolved,	evidently	due	to	improved	adrenal	status.           to	 clarify	 the	 adenomas	 with	 the	 greatest	 likelihood	 of	
	    Conclusion:	 Untreated	 hypopituitarism	 can	 cause	             transformation.	 This	 intermediate	 stage	 could	 confound	
numerous	complications	that	can	greatly	depreciate	quality	           the	diagnosis	by	suggesting	that	the	course	of	an	invasive	
of	life,	including	a	wrong	diagnosis	of	“expressive	apha-             adenoma	 is	 more	 indolent	 which	 may	 lead	 to	 delays	 in	
sia”.	 Proper	 endocrine	 replacement	 therapy	 can	 greatly	         treatment	and	increased	risk	of	metastases.
improve	a	patient’s	quality	of	life	in	such	circumstances.                  Conclusion:	 Dismal	 survival	 rates	 exist	 after	 docu-
                                                                      mentation	 of	 metastatic	 disease.	 To	 improve	 the	 overall	
Abstract #820                                                         response	rate	and	stop	initial	progression	to	metastatic	dis-
                                                                      ease,	efforts	should	be	made	to	look	for	more	conclusive	
DIAGNOSTIC DILEMMA: REVISITING THE                                    histological	discernment	between	invasive	adenomas	and	
DIAGNOSIS OF PITUITARY NEOPLASMS                                      carcinomas.

Dana Patrick Houser, MD,                                              Abstract #821
Elena A. Christofides, MD, FACE
                                                                      RAPID EFFICACY OF BROMOCRIPTINE IN A
	     Objective:	To	 reexamine	 the	 difficulty	 that	 exists	 in	    MALE WITH MACROPROLACTINOMA AND
a	 diagnosis	 of	 pituitary	 neoplasm	 illustrated	 with	 a	 case	    VISUAL LOSS
presenting	 as	 a	 non-metastasized	 lesion	 exhibiting	 inter-
mediate	histopathologic	features.                                     Ajay Varanasi, MD, Manav Batra, MD,
      Case	Presentation:	A	27-year-old	African	male	with	             Deepti Rawal, MD, Teekam Lohano, MD,
a	 five-year	 history	 of	 intermittent	 periorbital	 headaches	      Jody Leonardo, MD, Paresh Dandona, MD
presents	 with	 new-onset	 visual	 field	 deficits.	 Family	
history	 was	 positive	 for	 long-standing	 headaches	 in	 his	       	    Objective:	We	report	an	interesting	case	of	macrop-
mother	which	prompted	a	workup	of	the	patient’s	symp-                 rolactinoma	 in	 which	 we	 documented	 a	 dramatic	 reduc-
toms.	 The	 patient	 declined	 to	 be	 evaluated	 at	 that	 time,	    tion	in	prolactin	levels	in	less	than	two	days	after	starting	
but	 consented	 now	 due	 to	 the	 visual	 field	 changes.	 On	       bromocriptine.
physical	 exam,	 visual	 field	 testing	 revealed	 bitemporal	             Case	 Presentation:	 A	 63-year-old	 Caucasian	 male	
hemianopsia	 and	 rotational	 nystagmus.	 MRI	 revealed	 a	           with	 type	 2	 diabetes	 mellitus,	 coronary	 artery	 disease,	
4cm	sellar	mass	with	suprasellar	extension	and	significant	           and	 hypertension	 presented	 with	 deterioration	 in	 vision	
deviation	 of	 the	 optic	 chiasm.	 Laboratory	 studies	 done	        over	a	period	of	four	months,	starting	with	the	right	eye	
pre-op	did	not	reveal	any	pituitary	hormone	abnormalities.	           and	progressing	to	the	left.	On	physical	exam	patient	had	



                                                                – 134 –
                                          ABSTRACTS – Pituitary Disorders

bitemporal	hemianopsia.	Hematological	and	biochemical	               headache	and	nausea	in	the	36th	week	of	her	first	otherwise	
profiles	 were	 normal.	 He	 had	 an	 elevated	 prolactin	 con-      uneventful	pregnancy.	She	was	not	hypotensive	or	ortho-
centration	of	1800ng/dl	(0-17	ng/dl),	a	low	testosterone	of	         static	 and	 there	 were	 no	 signs	 of	 diplopia,	 cranial	 nerve	
<20ng/dl	(150	–	400	ng/dl)	and	a	low	growth	hormone	con-             dysfunction	 or	 papilledema.	 MRI	 brain	 showed	 recent	
centration	<0.1ng/ml	(>10	ng/ml).	MRI	of	brain	revealed	a	           hemorrhage	 within	 pituitary	 gland	 and	 adenoma	 could	
3.5	x	2.3	x	2.3	(cm)	pituitary	mass	with	suprasellar	exten-          not	be	ruled	out.	Hormonal	evaluation	did	not	show	any	
sion	and	compression	of	optic	chiasm.	He	was	admitted	to	            pituitary	dysfunction.	Because	of	the	potential	worsening	
the	 neurosurgical	 unit	 for	 possible	 surgical	 intervention,	    of	 pituitary	 hemorrhage	 into	 apoplexy,	 she	 was	 treated	
for	 deteriorating	 vision	 and	 large	 pituitary	 mass.	 While	     with	oral	hydrocortisone	50	mg	and	closely	observed.	She	
awaiting	 surgery,	 the	 patient	 was	 started	 on	 bromocrip-       remained	 clinically	 stable	 and	 was	 discharged	 on	 main-
tine	5	mg	twice	daily.	Prolactin	concentration	fell	within	          tenance	 dose	 of	 steroids	 which	 were	 continued	 through	
36	hours	and	his	vision	improved	dramatically	within	48	             the	 rest	 of	 the	 pregnancy.	 She	 successfully	 delivered	 a	
hours	of	starting	bromocriptine.	His	prolactin	levels	had	           baby	via	C-Section	at	40	weeks;	stress	dose	steroids	were	
dropped	 down	 to	 598	 ng/dl	 at	 36	 hours	 and	 to	 76.4	 ng/     given	at	delivery.	Her	repeat	MRI	pituitary	after	delivery	
dl	on	day	7	of	treatment.	As	his	symptoms	improved	and	              showed	a	non	functional	macroadenoma.
prolactin	levels	improved,	plan	for	surgery	was	cancelled.	          	     Discussion:	 While	 post	 partum	 hypopituitarism	
The	size	of	tumor	on	MRI	was	reduced	to	2.5	1.5	x	1.5	               (Sheehan’s	syndrome)	is	well	known,	there	are	not	many	
(cm)	3	months	after	initiation	of	bromocriptine.                     case	reports	of	pituitary	hemorrhage	during	pregnancy.	It	
      Discussion:	Macroroprolactinomas	cause	endocrino-              is	likely	that	in	patients	with	pre	existing	adenomas,	pitu-
logical	 symptoms	 due	 to	 hyperprolactinemia	 and	 neuro-          itary	enlargement	during	pregnancy	increases	the	risk	of	
logic	symptoms	due	to	space	occupation	and	compression.	             pituitary	hemorrhage/infarction.	The	presentation	of	pitu-
This	case	presented	with	neurological	symptoms	in	spite	             itary	hemorrhage	may	range	from	asymptomatic	to	cata-
of	extremely	high	prolactin	concentrations.	Bromocriptine	           strophic	 pituitary	 apoplexy.	 In	 its	 most	 dramatic	 presen-
and	other	dopamine	agonists	are	the	most	effective	drugs	            tation	 apoplexy	 causes	 the	 sudden	 onset	 of	 excruciating	
for	 treating	 both	 micro	 and	 macro-prolactinoma,	 since	         headache,	diplopia,	and	mental	status	changes	and	can	be	
they	suppress	prolactin	secretion	while	also	causing	rapid	          fatal	if	untreated.	Pituitary	dysfunction	is	often	seen	with	
tumor	 shrinkage.	 The	 fall	 in	 serum	 prolactin	 and	 the	        apoplexy	and	pituitary	hemorrhage	and	may	be	transient	
reduction	in	tumor	size	typically	occur	within	the	first	two	        or	 permanent.	 Nevertheless,	 once	 pituitary	 hemorrhage	
to	three	weeks	of	such	therapy.	This	report	shows	for	the	           is	 diagnosed	 it	 is	 imperative	 to	 treat	 patients	 with	 glu-
first	time	that	the	reduction	in	prolactin	concentrations	can	       cocorticoids	 because	 of	 the	 potential	 fatality	 from	 acute	
occur	within	two	days	of	bromocriptine	treatment.                    adrenal	insufficiency.	These	patients	also	need	supportive	
      Conclusion:	 Our	 case	 re-emphasizes	 the	 fact	 that	        management,	 close	 monitoring	 and	 if	 necessary,	 surgi-
bromocriptine	 or	 dopamine	 agonists	 should	 be	 tried	 as	        cal	decompression.	It	is	especially	important	to	consider	
first	 line	 agents	 in	 treatment	 of	 macroadenomas,	 even	 if	    the	 possibility	 of	 pituitary	 hemorrhage	 in	 pregnancy	 in	
the	patient	has	neurological	symptoms	like	loss	of	vision	           the	right	setting	as	it	can	potentially	lead	to	apoplexy	and	
and	headache,	with	close	clinical	assessment	for	signs	of	           place	both	the	mother	and	fetus	at	risk.
further	compression	or	deterioration	in	which	case	surgery	          	     Conclusion:	Clinicians	need	to	be	aware	of	the	situ-
may	be	necessary.                                                    ations	 where	 pituitary	 hemorrhage	 should	 be	 suspected	
                                                                     and	evaluated,	especially	during	pregnancy	and	the	need	
Abstract #822                                                        for	emergent	management	with	glucocorticoids	in	such	a	
                                                                     scenario.
PITUITARY HEMORRHAGE DURING
PREGNANCY AS THE PRESENTING FEATURE                                  Abstract #823
OF A PITUITARY MACRODENOMA
                                                                     A RARE CASE OF PITUITARY APOPLEXY
Madhuri Devabhaktuni, MD, Praveena Gandikota, MD,                    RESULTING FROM MICROPROLACTINOMA
Jeanine Albu, MD                                                     EXPANSION DURING PREGNANCY

	    Objective:	To	present	a	case	of	pituitary	hemorrhage	           Nitasha Bakhru, MD, Matthew Levine, MD, FACE
during	pregnancy	as	the	presenting	feature	of	a	pituitary	
macroadenoma.                                                        	   Objective:	To	illustrate	a	case	highlighting	the	impor-
     Case	 Presentation:	A	 34-year-old	 woman	 with	 his-           tance	of	detecting	expanding	microprolactinomas	during	
tory	 of	 hemochromatosis	 trait	 was	 admitted	 with	 severe	       pregnancy.



                                                               – 135 –
                                         ABSTRACTS – Pituitary Disorders

      Case	Presentation:	A	25-year-old	female	13	months	           Abstract #824
post-partum	 presented	 with	 spontaneous	 galactorrhea	 4	
months	after	cessation	of	breast-feeding.	History	notable	         CENTRAL DIABETES INSIPIDUS IN A
for	oligomenorrhea	prior	to	pregnancy.	Prolactin	level	was	        PATIENT WITH ACUTE MYELOID LEUKEMIA
128	ng/mL,	estradiol	<28	pg/mL,	FSH	1.8	mIU/mL,	LH	                ASSOCIATED WITH CHROMOSOME 3
0.7	 mIU/mL,	 qualitative	 B-HCG	 negative.	 Initial	 MRI	         INVERSION AND CHROMOSOME 7 MONOSOMY
Brain	was	unremarkable.	Given	suspicion	of	microprolac-
                                                                   Ana Cecilia Apaza Concha, MD,
tinoma	unidentified	on	initial	imaging,	a	focused	MRI	of	
                                                                   Andrea Marcela Sosa-Melo, Maria del Pilar Solano
the	sella	was	pursued.	A	0.6cm	microadenoma	sparing	the	
optic	chiasm	and	sphenoid	sinus	was	found.	Cabergoline	            	    Objective:	 To	 report	 a	 case	 of	 Central	 Diabetes	
was	 initiated	 with	 resultant	 cessation	 of	 galactorrhea.	     Insipidus	(CDI)	in	a	21-year-old	African	American	male	as	
Prolactin	decreased	to	2	ng/mL.	Patient	was	educated	that	         a	complication	of	Acute	Myeloid	Leukemia	(AML).
if	she	became	pregnant	again,	she	may	discontinue	caber-           	    Case	 Presentation:	 21-year-old	 African	 American	
goline	given	a	<5%	chance	of	microadenoma	expansion	               male	 admitted	 with	 weakness,	 fever,	 pleuritic	 chest	 pain,	
during	pregnancy.	Unfortunately,	she	failed	to	follow-up	          CBC	 showed	 a	 white	 count	 of	 138	 000,	 Hemoglobin	 of	
thereafter.	 In	 the	 interim,	 pregnancy	 was	 confirmed	 and	    6.6g%	 and	 normal	 platelets.	 Bone	 marrow	 (BM)	 biopsy	
cabergoline	 stopped.	 Within	 months,	 she	 experienced	          showed	 AML-M1.	 He	 had	 a	 complicated	 hospitalization	
worsening	headaches	and	visual	impairment.	MRI	Brain	              with	pericardial	effusion	requiring	pericardial	window.	The	
revealed	increase	in	size	of	adenoma	to	1.5cm	with	inter-          disease	was	refractory	to	induction	chemotherapy.	During	
nal	 hemorrhage	 and	 encroachment	 on	 the	 optic	 chiasm.	       his	admission	he	developed	pulmonary	nodules	and	broad	
Prolactin	 had	 risen	 to	 93.2	 ng/mL.	 C-section	 was	 per-      antibiotic	therapy	was	started	including	liposomal	ampho-
formed	at	32	wks	gestation	with	subsequent	transsphenoi-           tericin	B.	On	day	60	of	hospitalization	he	presented	signifi-
dal	tumor	resection.	Post-partum,	her	vision	improved	and	         cant	polyuria	of	7	liters/24	hours.	His	metal	status	deterio-
prolactin	decreased	to	9.3	ng/mL	with	continued	preserva-          rated,	had	a	seizure	and	needed	to	be	transferred	to	intensive	
                                                                   care	 unit.	 Serum	 Sodium	 level	 was	 185	 mmol/L,	 Serum	
tion	of	other	pituitary	hormones.
                                                                   Osmolality	 284	 mmol/L,	 Urine	 osmolality	 139mOsm/
      Discussion:	Symptomatic	enlargement	of	micropro-             kg.	He	was	started	on	desmopressin	intravenously	twice	a	
lactinomas	 during	 pregnancy	 has	 been	 reported	 in	 1.6%	      day	and	dextrose	5%	infusion.	Antidiuretic	hormone	level	
of	cases.	It	is	a	rare	phenomenon	necessitating	heightened	        was	3.4pg/mL.	A	cytogenetic	BM	study	showed	chromo-
clinical	 suspicion.	 Prolactinomas	 are	 the	 most	 common	       some	3	inversion	(q21q26)	and	chromosome	7monosomy.	
hormone-secreting	pituitary	tumors	with	incidence	being	           Brain	MRI	showed	unremarkable	hypothalamus	and	pitu-
four-fold	 greater	 in	 women.	 Microadenomas	 are	 three	         itary	gland.	After	medical	treatment,	his	sodium	decreased	
times	more	common	than	macroadenomas.	These	tumors	                to	156mmol/L	and	the	urine	osmolality	to	498	mOsm/Kg	
are	an	important	cause	of	infertility.	Treatment	with	dopa-        in	a	period	of	36	hrs.	Mental	status	recovered	completely.	
mine	agonist	therapy	results	in	the	resumption	of	ovula-           Amphotericin	 was	 discontinued	 after	 an	 8	 week-course.	
tory	menses	in	80-90%	of	females.	Bromocriptine	exhib-             When	stable,	the	patient	was	treated	with	salvation	chemo-
its	the	most	clinical	safety	data	for	use	during	pregnancy.	       therapy	but	unfortunately	he	failed.	The	patient	was	sent	to	
Resuming	 bromocriptine	 is	 the	 treatment	 of	 choice	 for	      Hospice.
pregnant	patients	with	a	microprolactinoma	who	develop	            	    Discussion:	CDI	presents	as	a	result	of	deficient	secre-
signs	suggesting	tumor	expansion.	The	decision	for	con-            tion	of	antidiuretic	hormone.	It	is	most	often	idiopathic	in	
tinuation	of	the	medication	perinatally	needs	to	be	individ-       origin	30-50%.	Other	etiologies	include	trauma	and	malig-
                                                                   nancies.	From	the	hematological	neoplasias,	AML	and	spe-
ualized,	taking	into	account	such	factors	as	prenatal	sellar	
                                                                   cially	the	one	related	with	chromosome	3	inversion	and/or	
extension	and	clinical	symptoms.	Asymptomatic	microp-
                                                                   chromosome	 7	 monosomy	 is	 the	 most	 commonly	 associ-
rolactinoms	do	not	necessitate	serial	imaging	or	prolactin	        ated	with	CDI.	The	latter	can	present	before,	during	or	after	
measurement	during	pregnancy.                                      the	diagnosis.	Pathogenesis	is	still	unclear,	but	appears	to	
      Conclusion:	Although	enlargement	of	microprolacti-           be	secondary	to	leukemic	infiltration	of	the	posterior	lobe	
nomas	during	pregnancy	is	rare,	devastating	effects	such	          and	pituitary	stalk.	Inappropriate	activation	of	EVI-1	gene	
as	pituitary	apoplexy	can	occur.	This	case	underscores	the	        is	suspected	to	play	a	key	role.	Some	reports	did	not	dem-
importance	of	early	clinical	detection	of	such	patients	in	        onstrate	any	gross	CNS	abnormality	in	neuroimaging	as	in	
ensuring	the	health	of	the	mother	and	fetus.                       the	case.
                                                                   	    Conclusion:	 AML	 associated	 to	 CDI	 is	 a	 rare	 syn-
                                                                   drome	and	the	association	with	chromosome	7	monosomy	
                                                                   and	 chromosome	 3	 inversion	 carries	 worse	 prognosis.	
                                                                   Diabetes	Insipidus	is	a	hazardous	clinical	presentation	that	
                                                                   needs	to	be	suspected	and	recognized	in	order	to	be	appro-
                                                                   priately	managed.

                                                             – 136 –
                                     ABSTRACTS – Reproductive Endocrinology

REPRODUCTIVE ENDOCRINOLOGY                                             and testosterone levels. Present study also demonstrated
                                                                       that serum PSA levels correlated negatively with sperm
Abstract #900                                                          count. The reason for our observations is not clear. In men,
                                                                       inhibin B is secreted from the testis as a product of Sertoli
CORRELATION OF PROSTATE-SPECIFIC                                       cells involved in the regulation of FSH secretion. Previous
ANTIGEN WITH LUTEINIZING HORMONE,                                      studies have reported inhibin B to be positively correlated
FOLLICLE-STIMULATING HORMONE,                                          with sperm concentration and negatively correlated with
PROLACTIN, TESTOSTERONE, INHIBIN B,                                    serum FSH. Patients with a larger testicular volume also
SPERM COUNT AND MOTILITY IN                                            have a higher serum inhibin B concentration. Since this
NIGERIAN MALES                                                         present study showed PSA to be positively correlated with
                                                                       inhibin B, one would have expected PSA to be positively
Abraham Adewale Osinubi, MBBS, MSc,                                    correlated with sperm count. The reason for the negative
Godwin O. Ajayi, Prof., Sunday A. Omilabu, Prof.,                      correlation between serum PSA and sperm count in our
J.O. Wellington, BSc                                                   study remains unclear. One previous study had reported
                                                                       a positive correlation between seminal PSA and sperm
	    Objective: This present study sought to investigate               motility, in contrast to ours. The disparities (one of the
the relationship between PSA and LH, FSH, prolactin,                   main reasons for bringing this study to the knowledge of
testosterone, Inhibin B, sperm count and sperm motility in             colleagues) in the results of these earlier studies and ours
Nigerian males.                                                        could be due to the fact that we assayed the serum PSA,
	    Methods:	 Subjects were adult Nigerian males (30-45               while they largely assayed seminal PSA. The free PSA
years), whose wives were attending the Prenatal Diagnosis and          molecule represents a very heterogeneous population,
Therapy Centre of the College of Medicine of the University            including pro-PSA, cleaved (“nicked”) PSA, PSA that can
of Lagos. Subjects with prostatic disease, chromosomal                 complex with α1-antichymotrypsin (ACT), and PSA that
abnormalities, undescended testes, obstructive syndromes               cannot complex with ACT but complexes with α2- mac-
of the genital tract, and hypogonadism secondary to surgery,           roglobulin. In addition, heterogeneity in the carbohydrate
trauma, or chemotherapy were excluded from this study.                 part of the PSA molecule results in several isoforms, rang-
Patients on hormones, steroids and fertility drugs were also           ing from nonglycosylated to fully glycosylated. These
excluded. Serum levels of PSA, LH, FSH, prolactin, testos-             variations of the free PSA molecule also affect its immu-
terone and inhibin B were evaluated concomitantly in                   nological characteristics, and for that reason, results of
all the subjects using ELISA (enzyme-linked immune                     comparison studies done with mixtures of free PSA from
assay) method. Seminal fluid analysis was carried out                  seminal plasma do not compare favorably with results that
using standardized laboratory protocols. The correlations              would be obtained with serum. Similar observations have
among the variables were analyzed using Pearson’s correla-             been made in spinal cord injury patients in whom dispari-
tion coefficients (r). Statistical significance was defined as         ties were recorded in the serum and seminal PSA levels.
p<0.01, except where otherwise stated.                                 A second source of disparity could be the sample studied.
	    Results: Our results show that PSA correlates positively          Most of the other studies used subjects from the general
with inhibin B (r=+0.60; t= 3.21) and this is statistically sig-       population while we used a selected group (i.e., husbands
nificant (p< 0.01). In addition, there is a statistically signifi-     of women attending a prenatal clinic). Other plausible rea-
cant (r = -0.5; p< 0.01) negative correlation between serum            sons for the differences between previous studies and ours
PSA levels and sperm count, and a weak negative correla-               could be racial, genetic or environmental. Clinical inter-
tion between serum PSA concentration and sperm motility                pretation of PSA concentrations is further confounded by
(r= -0.3; p<0.1). No linear relationship could be established          the wide range of PSA concentrations encountered in nor-
between PSA and FSH level (r between the two =+0.08;                   mal men. For example, PSA ranged from 0.30 to 15.00 ng/
SE= 0.11; t= -0.76). The correlation coefficient between the           ml in our subjects (mean value of 2.90 ± 2.88 ng/ml), all of
values of PSA and those of prolactin is -0.09 (SE= 0.11; t =           whom have no history of prostatic disease.
0.85), while that of PSA levels and testosterone was +0.03                  Conclusion: Serum levels of PSA correlate positively
(SE= 0.11; t= 2.64). Since these values are not statistically          with serum levels of inhibin B and negatively with sperm
significant, there is probably no linear relationship between          count in Nigerian males, whose wives are attending a pre-
serum concentrations of PSA and prolactin and testosterone             natal clinic in Lagos, Nigeria. Present study further high-
levels.                                                                lights the heterogeneity of PSA, and that interpretation of
     Discussion: The results of present study showed that              results should be made with some caution. PSA is prob-
serum levels of PSA correlated positively with serum                   ably more than a tumor marker. Further studies, are neces-
inhibin B levels. However, there was no linear relation-               sary to further elucidate the importance, mechanism and
ship between serum levels of PSA and LH, FSH, prolactin                implication of the observed correlations, especially those


                                                                 – 137 –
                                   ABSTRACTS – Reproductive Endocrinology

between PSA and inhibin B, sperm count and motility in            indicating a possible anti-apoptotic effect of the two HT
subjects under varying conditions.                                regimens investigated.
                                                                       Conclusion: The decrease in sFas/sFasL ratios
Abstract #901                                                     among postmenopausal women receiving either E2/DSP
                                                                  or E2 /NETA suggests a decrease in apoptosis associated
ESTROGEN PLUS PROGESTIN TREATMENT:                                with the above pathway. However, cyt-c levels were not
EFFECT OF DIFFERENT PROGESTIN                                     even detected in the study groups suggesting an absence
COMPONENTS ON SERUM MARKERS OF                                    of mitochondria-associated apoptosis. Further studies are
APOPTOSIS IN HEALTHY                                              necessary to elucidate the effect of different progestins
POSTMENOPAUSAL WOMEN                                              included in HT regimens on apoptotic products.

Maria Karaflou, MD, George Kaparos, PhD,                          Abstract #902
Demetrios Rizos, PhD, Emanuel Logothetis, MD,
Andreas Alexandrou, MD, Leon Aravantinos, MD, Maria               EFFECT OF HT AND TIBOLONE ON ADAM-8
Creatsa, MD, George Christodoulakos, MD,                          AND CD40L
Irene Lambrinoudaki, MD
                                                                  Maria Karaflou, MD, Irene Lambrinoudaki, MD, George
	    Objective: To investigate the effect of two hormone          Kaparos, PhD, Odysseas Grogoriou, MD, Andreas
therapy (HT) regimens differing only in their progestin           Alexandrou, MD, Constantinos Panoulis, MD, Emanuel
component on serum markers of apoptosis.                          Logothetis, MD, Maria Creatsa, MD,
	    Methods:	 Randomized, double-blinded, clinical               George Christodoulakos, MD, Evangelia Kouskouni, MD
study at the University Menopause Clinic, involving one
hundred healthy, naturally menopaused women, aged                 	    Objective: The role of neutrophils and platelets in
44-54.	 Patients were randomized to either 17b-estradiol          atherothrombotic disease is well established. The aim of
1mg/drosperinone 2 mg (E2 /DSP) or 17b-estradiol 1mg/             our study was to investigate the effect of hormone therapy
norethisterone acetate 0.5 mg (E2 /NETA) for 6 months.	           (HT) and tibolone on the soluble markers of neutrophil
Serum soluble Fas (sFas), soluble Fas Ligand (sFasL) and          and platelet activation, a member of the disentigrin and
cytochrome-c (cyt-c) at baseline and at 6 months.                 metalloproteinase domain family-8 (ADAM-8) and CD40
	    Results: Serum sFas significantly decreased in both          Ligand (CD40L) respectively, in healthy postmenopausal
groups (E2 /DSP group: 6997.4 ± 681.8 pg/mL at base-              women.
line vs 5842.1 ± 1386.0 pg/mL at 6 months, p=0.021; E2 /          	    Methods: 106 healthy postmenopausal women were
NETA group: 7634.3 ± 2446.6 pg/mL at baseline vs 6454.1           randomly allocated to: estradiol plus drospirenone (E2/
± 1981.7 pg/mL, p= 0.040). Serum sFasL significantly              DSP), estradiol hemihydrate 1mg plus norethisterone
decreased in both groups (E2 /DSP group: 62.82 ± 19.22            acetate (E2/NETA) 0.5mg and tibolone 2.5 mg. Serum
pg/mL at baseline vs 54.3 ± 12.99 pg/mL at 6 months, p=           ADAM-8 and CD40L were measured at baseline and at 6
0.038; E2 /NETA group: 62.25 ± 36.12 pg/mL at baseline            months.
vs 52.79 ± 28.37 at 6 months, p= 0.010). sFas/sFasL ratios        	    Results: Baseline values of ADAM-8 and CD40L
decreased from 111 at baseline to 108 at 6 months in the          were similar between groups. No significant correlation
E2 /DSP group and from 123 at baseline to 122 at 6 months         was revealed between ADAM-8 or CD40L and param-
in the E2 /NETA group. Serum cyt-c levels were under the          eters related to cardiovascular risk factors in each group.
detection limit (<0.05 ng/mL) at baseline and at 6 months         No significant changes were observed between baseline
in both groups. For this reason, statistical analysis on cyt-c    values and values at 6 months (E2/DSP group: ADAM-8
levels was not feasible.                                          levels: 267.4 ± 71.3 pg/mL at baseline vs 270.7 ± 42.8 pg/
	    Discussion: Currently, there is an increasing interest       mL at 6 months, p= 0.86, CD40L levels: 6.43 ± 3.13 at
in identifying accessible molecular markers, which may            baseline vs 6.79 ± 2.70 ng/mL at 6 months, p= 0.67), (E2/
aid in the diagnosis of various conditions and in the evalu-      NETA group: ADAM-8 levels: 308.3 ± 64.3 at baseline vs
ation of therapeutic efficacy. The apoptotic products sFas,       294.7 ± 57.7 pg/mL at 6 months, p= 0.40, CD40L levels:
sFasL, cyt-c may serve as useful clinical markers for the         9.68 ± 2.81 at baseline vs 8.59 ± 5.13 ng/mL at 6 months,
detection of diseases whose pathophysiology involves              p= 0.51), (tibolone group: ADAM-8 levels: 307.5 ± 87.5
apoptosis. Nadal et al, Clin Cancer Res 2005; 11:4770-            at baseline vs 289 ± 48.1 pg/mL at 6 months, p=0.48,
4, computed sFas/sFasL ratios and suggested that these            CD40L: 9.46 ± 4.30 vs 9.26 ± 4.60 ng/mL, p= 0.99).
values were related to chemotherapy-induced apoptosis             	    Discussion: ADAM-8 is a protein abundantly pres-
in cancer patients. In our study sFas/sFasL ratios have           ent in human neutrophils, which is reported to be released
decreased in both groups from baseline to 6 months,               into circulation during neutrophil activation. According to


                                                            – 138 –
                                  ABSTRACTS – Reproductive Endocrinology

Sriraman et al, Biol Reprod 2008, 78:1038-48, ADAM-8             	    Discussion: SRD5A2 catalyzes the conversion of tes-
seemed to be hormonally regulated, under the coordi-             tosterone into DHT. This isoenzyme (type 2) is expressed
nate action of progesterone and LH in ovulating follicles.       in high levels in the prostate and other androgen-sensitive
Furthermore, CD40L is considered a critical link between         tissue. The SRD5A2 is located on chromosome 2, region
inflammation, atherosclerosis and thrombosis. However,           p23 and is comprised of five exons and four introns (Labrie
Oviedo et al, Gynecol Endocrinol 2008, 24:354-7, have            et al 1992). Various studies have demonstrated that any
shown that therapeutic dosages of oral or transdermal            single base mutation of the SRD5A2 gene may result in
estradiol did not modify sCD40L levels in postmeno-              reduced enzymatic activity (Andersson et al 1991) and
pausal women.                                                    incomplete virilization.A second isoenzyme (SRD5A1 or
	    Conclusion: Our study did not detect an association         type 1) with 50% sequence identity also exists. Mutations
between HT or tibolone and serum ADAM-8 or CD40L                 in the SRD5A2 gene associated with male pseudoher-
in healthy postmenopausal women. Despite a plausibly             maphroditism were first described by Thigpen et al (1992).
important role of neutrophil and platelet activation in the      At least 50 different mutations in the SRD5A2 gene have
pathophysiology of atherothrombosis, pre-analytical or           been compiled by the Human Gene Mutation Database.
analytical sources of variation may have limited the clini-      Of these reported cases, about 60% were homozygous.
cal application of ADAM-8 and CD40L. Larger prospec-             	    Conclusion: We describe a novel missense mutation
tive studies are needed to elucidate the effect of low-dose      of the SRD5A2 in an extremely premature, genetically
HT or tibolone on serum markers of neutrophil and plate-         male infant. This mutation underscores the importance of
let activation.                                                  the stability of the gene in order to achieve full enzymatic
                                                                 activity. Early identification allowed timely genetic coun-
Abstract #903                                                    seling for the family in addition to providing a framework
                                                                 for future care of the patient. Molecular analysis of the
IDENTIFICATION OF A NOVEL MISSENSE                               SRD5A2 gene should be pursued in genetic males born
MUTATION IN THE 5-ALPHA REDUCTASE TYPE                           with clinical evidence of hypovirilization and abnormal T:
2 GENE IN AN EXTREMELY PREMATURE 46,                             DHT ratio regardless of gestational age.
XY MALE INFANT
                                                                 Abstract #904
Cayce Jehaimi, MD, Patrick G. Brosnan, MD,
Nunilo I. Rubio, MD                                              HYPERANDROGENISM IN A
                                                                 POSTMENOPAUSAL WOMAN: A DIAGNOSTIC
	    Objective: To describe the clinical and biochemical         CHALLENGE
features in a very premature male infant with confirmed
5-alpha reductase type 2 deficiency (SRD5A2).                    Vicky Cheng, MD, Krupa Doshi, MD,
	    Case	Presentation: A 46, XY male infant born at 26          Tommaso Falcone, MD, Charles Faiman, MD
weeks of gestation presented at day of life 1 with micro-
penis and severe hypospadias. Family history was lack-           	    Objective: To describe a postmenopausal woman with
ing for consanguinity or genetic diseases. At day of life 3,     marked hyperandrogenism in whom a dramatic response
Endocrine service was consulted for evaluation of ambig-         to gonadotropin-releasing hormone agonist (GnRHa)
uous genitalia. Physical examination revealed a small            administration fails to delineate the source.
penile length measured at 1.2 cm (-2.2 SD), penoscrotal          	    Case	 Presentation: A 53-year-old postmenopausal
hypospadias, bifid scrotum, cryptoorchid testes and blind        woman with end-stage renal disease status-post kidney
vaginal pouch. Pelvic ultrasonography confirmed bilateral        transplant was referred because of high serum testosterone
testicular structures present in the superior aspect of the      levels. She presented with worsening acne and hirsutism
inguinal canal. No Mullerian structures were identified.         for the previous two years. She denied any deepening of
Persistently elevated testosterone to dihydrotestosterone        her voice or baldness. Medications included prednisone
(T: DHT) ratio lead to direct sequencing of the SRD5A2           7.5mg every other day. On examination, she was thin (BMI
gene using exon specific polymerase chain reaction. DNA          14.5 kg/m2). Mild acne and facial hirsutism but no fronto-
comparative studies revealed a novel missense mutation           temporal balding, cushingoid features, palpable masses or
within exon 1 of the first allele, with a G>T change alter-      clitoromegaly were noted. Lab results: total testosterone,
ing codon 69 from Alanine to Serine [Ala69Ser]. A sec-           224 ng/dL (normal 20-70); free testosterone, 30 pg/mL
ond previously reported G>A base change was detected             (1-9); FSH, 192 mU/mL (>20); LH, 194 mU/mL (>20);
in exon 4, changing the encoded amino acid Glycine to            DHEAS, 86 µg/dL (10-152); androstenedione, 7.6 ng/
Serine at codon 196 [p.Gly196Ser] in the other allele. Both      mL (0.5-2.7); 17-α hydroxyprogesterone, 1.3 ng/mL (0.9-
mutations are predicted to be functionally significant.          3). Two-day low-dose dexamethasone failed to suppress


                                                           – 139 –
                                  ABSTRACTS – Reproductive Endocrinology

testosterone levels. Transvaginal ultrasonography: right          to determine ovarian volume, and total antral follicle
ovary measured 5.5 cm3 with non-visualization of the left         count (AFC) and their serum FSH levels were assessed on
ovary. CT scan without contrast showed a normal right             the same day. The number of antral follicles <10 mm in
adrenal, minimal left adrenal thickening and normal ova-          each ovary was counted.
ries. GnRHa (Depo-Lupron) 3.75mg IM administration,               	    Results: Means ± SD for the age, disease duration and
after one month, resulted in a marked decline in FSH and          body mass index (BMI) among women in the present study
LH levels and testosterone became undetectable.                   were 37.4±6.9 years, 6.0±4.6 years, and 35.9±8.9 kg/m2,
	    Discussion: The source of marked hyperandrogen-              respectively. A significant difference was found in terms of
ism, ovarian versus adrenal, in postmenopausal women              FSH values (IU/L) (Group 1: 7.8±0.9 vs 5.0±1.0; Group 2:
represents a diagnostic challenge particularly if no obvi-        8.2±1.1 vs 7.2±1.8; Group 3: 9.5±3.2 vs 6.4±2.4, respec-
ous tumor is seen on diagnostic imaging. Moreover, the            tively) and AFC [Group 1: 21.1±4.8 vs 25.0±9.1; Group
inability to perform venous catheterization studies in our        2: 10.4±5.2 vs 23.0±9.5; Group 3: 6.0±3.5 vs 21.7±2.1,
patient, in whom contrast media represented an unwar-             respectively] between patient and control groups for each
ranted risk, confounds the problem. Suppression of andro-         decade group (p<0.001 for all). However, only difference
gen levels with low-dose dexamethasone has been used to           was observed in Group 1 between the groups of T2DM
screen for a non-tumorous adrenal source. As in the pres-         and the healthy controls in terms of total ovarian volumes
ent case, this failure coupled with the fact that the patient     (cm3) (9.7±3.0 vs 16.3±4.7, respectively) (p=0.002). A
was on long-term prednisone points to a tumorous adrenal          negative correlation was determined between the values
or ovarian source. We reasoned that a clear response to           of AFC and FSH, age, glycolized hemoglobin and fast-
a GnRHa would discriminate between the two potential              ing blood glucose levels ((r=-0.406, p<0.001; r=-0.618,
sources. Regrettably, the literature has described cases          p<0.001; r=-0.505, p<0.001; r=-0.687, p<0.001, respec-
of adrenal adenomas which suppressed paradoxically                tively). In regression analysis, it was observed that the
on GnRHa administration. Although our patient refused             effects of age and FSH on AFC were continuous.
surgery to document the source of hyperandrogenism,               	    Discussion: Up to day ovarian reserve has not to
GnRHa affords a favorable long-term therapeutic option.           be evaluated in type 2 diabetic patients. In our study,
	    Conclusion: The dramatic improvement in a post-              we detected higher FSH levels and lower AFC values
menopausal woman with marked hyperandrogenism by                  that would point to a decrease in ovarian functions when
means of GnRHa therapy demonstrates its potential use in          compared to healthy individuals. We think that insulin
poor surgical candidates without necessarily delineating          resistance and frequently comorbid polycystic ovary syn-
the source of androgen excess.                                    drome, which are involved in pathogenesis of T2DM and
                                                                  which are known to cause deterioration in ovarian func-
Abstract #905                                                     tions, are responsible for this difference.
                                                                  	    Conclusion: We, for the first time, showed in this
HORMONAL AND SONOGRAPHIC EVALUATION                               study that ovarian reserve decreases in T2DM patients
OF OVARIAN RESERVE IN PATIENTS WITH                               compared to the nondiabetics at the same age group.
TYPE 2 DIABETES MELLITUS                                          Attention should be paid to preventive approaches for dia-
                                                                  betes from early ages because of both fertility problems
Serhat Isik, MD, Hatice Nursun Ozcan, MD,                         and the fact that early menopause may increase the risk
Dilek Berker, MD, Yasemin Ates Tutuncu, MD,                       of cardiovascular disease, which is already elevated in
Ufuk Ozuguz, MD, Ayse Gul Alimli, MD,                             diabetics.
Gulhan Akbaba, MD, Mehmet Alp Karademir, MD,
Serdar Guler, Assoc. Prof.                                        Abstract #906

	    Objective: Chronic diseases such as diabetes mellitus        ISOLATED LEYDIG CELL DEFICIENCY IN A
(DM) may determine premature ovarian failure by vari-             74-YEAR-OLD MAN
ous mechanisms. We studied the parameters of ovarian
reserve in women with type 2 DM (T2DM).                           Hema Padmanabhan, MD, MBBS, Ali Iranmanesh, MD
	    Methods: Eighty-nine women with T2DM and 73
healthy women were evaluated through categorization               	    Objective: To describe a case of isolated leydig cell
in age groups [Group 1 (20-29): 7/18; Group 2 (30-39):            deficiency in a 74-year-old man.
35/35; Group 3 (40-49): 47/20, T2DM/control, respec-              	    Case	Presentation: A 74-year-old married male with
tively]. On the third day of the menstrual period, fertile        history of seizure disorder, primary hypothyroidism,
women with regular monthly cycles and no history of               osteopenia, colon cancer, type 2 diabetes mellitus and
ovarian surgery underwent a transvaginal ultrasonography          hypertension was referred to endocrine clinic for erectile


                                                            – 140 –
                                 ABSTRACTS – Reproductive Endocrinology

dysfunction and decreased libido. He denied history of         inhibin-B concentrations are consistent with seminiferous
tobacco, or illicit drug, but indicated social consumption     tubule damage, most probably due to radiation exposure.
of alcohol. His medications included Metformin, Dilantin,      Normal serum testosterone and LH concentrations over
Metoprolol, Glipizide, calcium and vitamin D. Patient had      a period of several years indicate preserved function of
never fathered a child. He denied visual symptoms, diz-        Leydig cells, which are known to be more resistant to the
ziness, headache, nausea or vomiting. Rest of systemic         effect radiation.
review and physical examination was unremarkable.
Testes were descended and measured 18 ml bilaterally           Abstract #908
without palpable masses. Laboratory findings included
within the normal range values for estradiol (24.7 pg/         BIOLOGICAL VARIATION OF TESTOSTERONE
mL; normal: 7.6-42.6), inhibin-B (173.6 pg/mL; normal:         IN MEN, WOMEN, AND CHILDREN OF VARYING
60-260), cortisol, TSH, prolactin and IGF-1, with gonadal      AGES AND ETHNICITIES: A REVIEW
function over the follow-up period summarized in the fol-
lowing table.                                                  Vin Tangpricha, MD, PhD, FACE, Brittany E. Butler,
	    Conclusion: Decreased circulating total and free tes-     Julianne Cook Botelho, PhD, Hubert W. Vesper PhD
tosterone concentrations associated with increased LH
levels are consistent with compromised testosterone bio-            Objective:	Studies have shown associations between
synthesis. This along with normal testicular size and nor-     altered testosterone levels and a wide range of adverse
mal serum concentrations of FSH and inhibin-B is indica-       health conditions such as obesity, cardiovascular disease,
tive of a primary defect in Ledig cell function. Although      metabolic syndrome, and autism. In order to distinguish
unlikely, defective LH bioactivity could be an alternative     between clinically significant pathological changes in
possibility.                                                   hormone levels and the normal fluctuations observed
                                                               in healthy individuals, it is important to understand the
Abstract #907                                                  biological variability of testosterone and the factors that
                                                               affect it. The aim of this research was to review the bio-
ISOLATED SEMINIFEROUS TUBULE DAMAGE                            logical factors affecting testosterone levels and to identify
IN A 53-YEAR-OLD MAN                                           gaps in current knowledge.
                                                                    Methods: We used Pub Med to perform a literature
Hema Padmanabhan, MD, MBBS, Ali Iranmanesh, MD                 search that identified scientific publications addressing
                                                               the biological variability of human testosterone levels
	    Objective: To describe a 53-year-old man with iso-        in the entire population, including both genders and all
lated seminiferous tubule damage.                              ages. Studies measuring total testosterone, calculated free
	    Case	Presentation: A 53-year-old male with history        testosterone, and/or bioavailable testosterone were evalu-
of depression, and hypertension was referred for evalu-        ated. Initial search terms included combinations of the fol-
ation of hypogonadism. Current medications included            lowing words: men, women, children, testosterone levels,
Fluoxetine, clonazepam, Quetiapine and Mirtazapine. He         pre-analytical, biological variability, and biological varia-
denied tobacco, alcohol or illicit drug use. He was not        tion. Only studies published within the last 25 years were
married, has never fathered a child, and past semen analy-     considered, but most included studies that had been pub-
sis had shown azoospermia. No history of mumps, chemo-         lished within the last 20 years.
therapy, or trauma to the groin. He had history of working          Results:	Major biological factors associated with tes-
with depleted uranium in the past. Physical examination        tosterone levels in men included diurnal (levels peak in the
revealed normal vital signs and normal systemic exami-         morning and decrease by at least 43% by the evening), age
nation. Testes were descended in scrotum and were              (decrease with increasing age), polymorphisms in andro-
soft, measuring 4 cm in diameter and without masses.           gen-related genes, and disease states (anemia, cardiovas-
Circulating concentrations of TSH, ACTH, cortisol, and         cular disease, diabetes, and hypertension). Findings on
IGF-1 were normal. Monitoring of gonadal function over         seasonal variations were inconclusive. Excluding diurnal
a period of 11 years revealed normal serum concentrations      variation, these factors were also related to testosterone
of total testosterone (273-620 ng/dL; normal: 241-827),        levels in women as were use of oral contraceptives (47%
and LH (6.4-15.1 µIU/mL; normal: 1.5-9.3), but increased       decrease in levels) and oophorectomy (23% decrease in
FSH (22.5-38 µIU/mL; normal: 0.9-15). Circulating con-         levels).
centration of inhibin-B was significantly decreased at 6.7     	    Conclusion: The relationship between testosterone
pg /mL (normal: 60-260).                                       and cardiovascular disease, diabetes, and hypertension has
     Conclusion: Defective spermatogenesis associated          not been well studied in women. Race/ethnicity seem to
with increased circulating FSH and markedly decreased          affect testosterone levels with Asian and African-American


                                                         – 141 –
                                 ABSTRACTS – Reproductive Endocrinology

men having lower and higher levels, respectively, com-          Abstract #910
pared to Caucasian men and African-American women
having higher levels than Caucasian women. Other factors        SUCCESSFUL TWIN PREGNANCY IN A WOMAN
that affect testosterone in individuals include preeclamp-      WITH PANHYPOPITUITARISM
tic pregnancies, prenatal environment, body weight, diet,
and exercise. More well designed studies are needed to          Praveena Gandikota, MD, Martin Ketlz, MD,
identify factors affecting testosterone in healthy people,      Jeanine Albu, MD
especially in women and children.
                                                                	    Objective: To report a case of successful pregnancy in
Abstract #909                                                   a patient with panhypopituitarism.
                                                                	    Case	 Presentation: A 12-year-old patient with cra-
SERUM AND SEMINAL INHIBIN B AND                                 niopharyngioma underwent three surgical resections and
ANTI-MÜLLERIAN HORMONE AS NON-                                  subsequently developed panhypopituitarism including
INVASIVE MARKERS OF PERSISTENT                                  diabetes insipidus (DI). She was treated with cortef, syn-
SPERMATOGENESIS IN MEN WITH NON-                                throid, desmopressin and oral contraceptive pills. Human
OBSTRUCTIVE AZOOSPERMIA:                                        growth hormone (GH) was added at age 15. At 34 years,
A SYSTEMATIC REVIEW AND META-ANALYSIS                           she underwent controlled ovarian hyperstimulation with
OF DIAGNOSTIC ACCURACY STUDIES                                  human menopausal gonadotropin (hMG) and human cho-
                                                                rionic gonadotropin (HCG) and intrauterine insemina-
Konstantinos A. Toulis, MD, MSC,                                tion (COH/IUI), resulting in a triplet pregnancy that was
Paschalia K. Iliadou, MD, MSc, Christos Tsametis, MD,           reduced to twins. During pregnancy GH was discontin-
Basil C. Tarlatzis, MD, PhD, Ioannis Papadimas, MD,             ued and cortef, synthroid, and desmopressin doses were
PhD, Dimitrios G. Goulis, MD, PhD                               increased. She successfully delivered twins via C-section
                                                                at 36 weeks, with no complications or postpartum hemor-
	    Objective: A non-invasive test that could predict the      rhage (PPH); stress-dose steroids were given at delivery.
presence of sperm during a testicular sperm extraction          	    Discussion: Pregnancy after loss of both anterior and
(TESE) procedure in men with non-obstructive azoosper-          posterior pituitary function is uncommon. More cases are
mia would be of profound clinical importance. Inhibin B         now being reported using artificial reproductive techniques
(Inh-B) and anti-Müllerian hormone (AMH) have been              (ART), though miscarriage up to 39% has been described.
proposed as direct markers of Sertoli cell function and         We speculate that, in our patient, use of GH with hMG and
indirect markers of spermatogenesis.                            HCG played a significant role in the successful outcome
     Methods: A search was conducted in the electronic          of the pregnancy. It is now recognized that GH/ IGF-1
databases MEDLINE, EMBASE and Cochrane Central                  have an active role in gametogenesis as well as follicu-
Register of Controlled Trials from inception through June       lar maturation. There are reports of successful pregnancy
2009. Thirty-five different studies reported data on the        after sequential co-treatment with GH and gonadotropins
predictive value of one or more index markers (serum Inh-       after failed ovarian response to only gonadotropins. It thus
B: 31 studies, seminal Inh-B: four studies, serum AMH:          seems prudent, that women with hypopituitarism seek-
two studies, seminal AMH: three studies) were included          ing pregnancy be initiated on GH replacement to aid in
in the systematic review. Eight studies, which had serum        improving pregnancy rate with ART. Safety of GH dur-
Inh-B as an index marker, met the predefined criteria and       ing pregnancy is not determined and is discontinued dur-
was included in the meta-analysis.                              ing pregnancy. There have been few cases where GH has
     Results: Serum Inh-B demonstrated a sensitivity of         been continued until the second trimester. Pregnancies in
0.67 (95% confidence interval [CI]: 0.56 – 0.76) and a          hypopituitary patients are high risk with high rates of both
specificity of 0.84 (CI: 0.61 – 0.94) for the prediction of     fetal and obstetric complications [small for gestational age
the presence of sperm in TESE. The pre-test probability         (SGA), fetal malpresentation and PPH]. The hypothesis
of 40% was incorporated in a Fagan’s nomogram, and              for these complications is utero-placental dysfunction
resulted in a positive post-test probability of 73% and a       due to deficient pituitary hormones and neuroendocrine
negative post-test probability of 21% for the presence of       feedback mechanisms. Patients need stress dose steroids
sperm in TESE.                                                  during delivery and thyroid supplementation needs to be
     Conclusion: Inh-B cannot serve as a stand-alone            increased during pregnancy.
marker of persistent spermatogenesis in men with NOA.                Conclusion: Pregnancy in a patient with loss of both
                                                                anterior and posterior pituitary function through utilization




                                                          – 142 –
                                 ABSTRACTS – Reproductive Endocrinology

of ART is feasible but uncommon. These patients need            Biallelic means of CAG repeats did not differ significantly
close antenatal as well as peri-natal monitoring due to         between PCOS and control groups (22.73 vs. 23.07).
high risk of complications for both mother and fetus. More      X-inactivation analysis was possible in 148 subjects (87
research is needed regarding the role/utilization/safety of     PCOS and 61 controls). No significant distribution differ-
GH prior and during pregnancy.                                  ences were observed between PCOS and control groups,
                                                                with non-random inactivation in 52.87% vs. 54.1% and
Abstract #911                                                   skewed inactivation in 10, 34% vs. 16.39% of subjects,
                                                                respectively. In the non-random subset of PCOS and con-
ASSOCIATION STUDY OF CAG REPEAT                                 trols, both biallelic means (22.46 vs. 23.55, p= 0.0016)
POLYMORPHISM OF THE ANDROGEN                                    and X-weighted biallelic means (22.46 vs. 23.43, p=0.011)
RECEPTOR WITH POLYCYSTIC OVARY                                  were significantly lower in PCOS. There was no evi-
SYNDROME (PCOS) IN THE ROMANIAN                                 dence of preferential allele inactivation in favor of shorter
POPULATION                                                      alleles in PCOS. We observed a significant positive cor-
                                                                relation between total plasma testosterone values and AR
Mihail Gr. Coculescu, MD, PhD, FRCP, FACE, Nicoleta             X-weighted biallelic means (r-square=0.18, p=0.015)
Baculescu, MD, Daniela Aflorei, MD,                             which was lost in PCOS subjects. Ferriman-Gallwey hir-
Andra Caragheorgheopol, PhD, Ilinca Gussi, MD, PhD,             sutism scores were not influenced by AR alleles.
Florin Grigorescu, MD, PhD, Serban Radian, MD, PhD              	    Discussion: Our results support the view that shorter
                                                                AR alleles for the CAG polymorphism are associated
	    Objective: To assess association of androgen receptor      with PCOS, at least in the subgroup of patients with non-
alleles and their degree of inactivation (by DNA methyla-       random X-inactivation. While in normal control women,
tion) with PCOS and its phenotypic traits.                      shorter alleles are associated with lower total testosterone
	    Methods: Case-control association study. We                values this “protective” association is not seen in PCOS
recruited 112 PCOS patients (Rotterdam criteria) and 72         subjects.
control subjects of Romanian descent. Androgen recep-           	    Conclusion: We demonstrate that in Romanian
tor genotyping, X-chromosome methylation analysis, and          women (Eastern Europe) the CAG polymorphism of the
phenotyping for PCOS were performed.                            androgen receptor plays a role in the genetics of PCOS.
	    Results: Median CAG repeat numbers were 23
(range 11-30) in PCOS and 23 (range 15-30) in controls.




                                                          – 143 –
                                             ABSTRACTS – Thyroid Disease

THYROID DISEASE                                                      presented	 with	 constipation	 or	 ileus	 and	 also	 advice	
                                                                     administering	levothyroxine	alone	on	empty	stomach,	fol-
Abstract #1000                                                       lowed	by	rest	of	the	medications	an	hour	later.

A CASE OF MEGACOLON SECONDARY TO                                     Abstract #1001
SEVERE HYPOTHYROIDISM
                                                                     REVIEW OF A SERIES OF THYROIDECTOMY
Amitha Padmanabhuni, MD                                              PATIENTS - PREDICTIVE VALUE OF
                                                                     SONOGRAPHY AND CYTOLOGY
	     Objective:	 To	 describe	 the	 effect	 of	 malabsorbtion	
of	 levothyroxine	 leading	 to	 development	 of	 ileus	 and	         Nishanth Sanalkumar, MBBS, Mathew John, Ragi KV,
megacolon.                                                           Aniyan Poulose
	     Case Presentation:	A	74-year-old	white	male	with	a	
history	of	hypothyroidism,	type	2	diabetes	mellitus,	CVA	                 Objective: To	 review	 a	 series	 of	 thryroidectomy	
with	 left	 hemiparesis,	 s/p	 peg	 tube,	 neurogenic	 bladder,	     patients	 with	 a	 predictive	 value	 of	 sonography	 and	
ambulatory	dysfunction,	was	admitted	to	the	hospital	for	            cytology.
decrease	in	urine	output.	Apparently	he	had	been	experi-                  Methods:	Clinical,	imaging	and	fine	needle	aspiration	
encing	diarrhea	at	home	for	the	past	four	months,	passing	           (FNA)	biopsy	data	of	all	patients	who	underwent	thyroid-
lot	of	gas	but	no	vomiting	or	abdominal	pain.	On	physi-              ectomy	 over	 a	 3	 year	 period	 at	 a	 tertiary	 referral	 centre	
cal	examination	no	thyromegaly	was	noted,	abdomen	was	               in	India	was	reviewed.	Accuracy	of	FNA	and	other	pre-
distended	 but	 soft	 and	 non	 tender	 with	 decreased	 bowel	      operative	data	on	predicting	the	final	histopathology	was	
sounds.	 Obstructive	 series	 done	 in	 the	 hospital	 showed	       examined.
ileus	with	diffuse	dilatation	of	the	entire	colon	about	14	               Results:	136	patients	underwent	thyroidectomy	over	
cm	in	size	with	air	fluid	levels.	During	the	workup,	TSH	            a	period	of	32	months.	Mean	age	(±SD)	of	this	population	
was	108.	On	further	history	taking,	although	patient	had	            was	44.26	(±12.6)	years.	There	were	105	women	(77%)	
peg	tube	for	the	past	four	years,	he	started	to	receive	oral	        and	 31	 men	 (23%).	 Only	 a	 minority	 of	 patients	 (12%)	
diet	since	last	four	months	and	was	administering	all	his	           were	 on	 levothyroxine	 prior	 to	 surgery.	 Ultra	 sonogram	
medications	 at	 the	 same	 time,	 crushed	 in	 apple	 sauce.	       was	done	in	63%	of	patients.	Solitary	thyroid	nodule	was	
We	 started	 him	 on	 IV	 levothyroxine	 considering	 malab-         present	in	31%,	multi-nodular	goitre	in	65%	and	diffuse	
sorption.	After	the	first	dose	patient	had	two	large	bowel	          goitre	 in	 4%.	 Presence	 or	 absence	 of	 calcification	 was	
movements	 and	 subsequently	 over	 the	 next	 couple	 of	           reported	 in	 38%,	 vascularity	 in	 34%,	 echo	 characteris-
days	patient	had	several	large	solid	bowel	movements	and	            tics	in	50%	and	LN	status	in	55%.	FNA	data	was	avail-
felt	 better.	 Repeat	 obstructive	 series	 showed	 decrease	 in	    able	in	124	patients	and	was	classified	as	benign	(60.5%),	
colonic	dilatation	and	air	fluid	levels.                             malignant	(14.5%),	indeterminate	(17.7%)	or	inadequate	
	     Discussion:	 Constipation	 is	 a	 problem	 that	 can	 be	      (7.3%).	Majority	of	the	patients	underwent	total	or	near-
particularly	troublesome	for	people	with	hypothyroidism.	            total	thyroidectomy	(65%).	Histopathology	was	benign	in	
Hypothyroidism	slows	down	many	of	the	body’s	systems,	               70%	 and	 malignant	 in	 30%.	 The	 malignant	 pathologies	
including	 digestion	 and	 elimination.	 With	 lower	 levels	        were	papillary	carcinoma	in	28%	and	follicular	variant	in	
of	thyroxin	there	is	an	abnormal	bowel	movement	which	               2%.	The	benign	lesions	were	nodular	colloid	goitre	(40%),	
leads	to	chronic	constipation	and	overtime	progresses	to	            lymphocytic	thyroiditis	(15%),	follicular	neoplasm	(13%)	
ileus	and	megacolon.	In	occasional	patients,	marked	ileus	           and	others.	Although	a	STN	was	more	likely	to	be	malig-
may	be	confused	with	intestinal	obstruction.	Though	ileus	           nant	(59%)	as	compared	with	a	MNG	(32%),	a	malignant	
in	this	patient	could	be	multifactorial	the	fact	that	patient	       lesion	 had	 almost	 equal	 probability	 of	 being	 reported	 as	
had	several	bowel	movement	soon	after	starting	iv	levo-              STN	or	MNG	in	ultrasound.	Presence	of	lymph	nodes	was	
thyroxine	displays	the	fact	that	hypothyroidism	played	a	            a	significant	predictor	of	malignancy	(p	0.01).	The	FNA	
major	role	in	causing	chronic	constipation	and	ileus.                result	also	significantly	predicted	the	histopathology	with	
	     Conclusion:	Simple	treatment	of	hypothyroidism	in	             a	 good	 specificity	 (98.5%)	 but	 lower	 sensitivity	 (63%).	
patients	with	constipation	can	substantially	improve	their	          The	positive	predictive	value	was	94.4%	and	negative	pre-
quality	 of	 life	 and	 prevent	 complications	 like	 ileus	 and	    dictive	value	87%.	Of	the	22	patients	with	indeterminate	
megacolon.	As	per	our	case	report	malabsorbtion	of	levo-             FNA,	15	were	benign	and	7	were	malignant.
thyroxine	might	be	due	to	fact	that	it	was	taken	together	           	    Discussion:	 Ours	 is	 a	 retrospective	 review	 of	 data	
with	 multiple	 medications,	 drug	 interaction	 or	 due	 to	        from	 a	 relatively	 small	 population.	 Ultrasound	 data	 was	
crushing	in	applesauce.	Therefore	we	recommend	routine	              available	 in	 a	 limited	 number	 of	 patients	 and	 suffered	
screening	 of	 hypothyroidism	 with	 TSH	 for	 all	 patients	        from	inter-observer	variability	in	reporting.	FNA	had	good	


                                                               – 144 –
                                             ABSTRACTS – Thyroid Disease

specificity	but	less	sensitivity	compared	with	that	reported	        commonly	 found	 in	 connection	 with	 propylthiouracil	
in	literature.	Sensitivity	might	be	improved	by	doing	more	          (PTU)	than	with	methimazole	(MMI).	There	are	previous	
ultrasound	guided	FNA.                                               reports	of	patients	with	MPO-ANCA-associated	vasculi-
                                                                     tis	 syndromes	 caused	 by	 MMI	 and	 PTU.	 The	 incidence	
Abstract #1002                                                       was	 reported	 to	 be	 between	 0.53	 and	 0.79	 patients	 per	
                                                                     10,000,	and	the	ratio	of	the	estimated	incidences	for	MMI	
VASCULITIS IN A PATIENT WITH                                         and	PTU	was1:39.2.	The	clinical	features	of	antithyroid-
AMIODARONE-INDUCED THYROTOXICOSIS                                    associated	 vasculitis	 include	 myalgia,	 arthritis,	 hemop-
TREATED WITH METHIMAZOLE                                             tysis,	 acute	 renal	 dysfunction,	 skin	 ulceration,	 and	 vas-
                                                                     culitic	 rash.	 Although	 this	 syndrome	 generally	 resolves	
Rachanon Murathanun, MD, Mais Trabolsi, MD,                          after	 drug	 cessation,	 high-dose	 corticosteroid	 therapy	 or	
Tahira Yasmeen, MD, FACE,                                            cyclophosphamide	may	be	needed	in	severe	cases.	By	far	
Farah Hasan, MD, FRCP, FACE                                          the	previous	reports	of	antithyroid	medication	associated	
                                                                     vasculitis	were	described	in	patients	with	Graves’	disease.	
	     Objective:	To	report	a	case	of	vasculitis	in	a	patient	        Our	 patient	 developed	 vasculitis	 syndrome	 with	 nega-
being	 treated	 with	 methimazole	 for	 amiodarone-induced	          tive	ANCA	and	presented	with	a	vasculitic	rash	and	acute	
thyrotoxicosis.                                                      renal	 dysfunction	 while	 being	 treated	 with	 methimazole	
	     Case Presentation:	 A	 57-year-old	 man	 with	 a	 past	        for	AIT.	The	absence	of	MPO-ANCA	in	our	patient	may	
history	of	type	2	diabetes	mellitus,	congestive	heart	fail-          reflect	a	different	pathogenesis.
ure,	 and	 ventricular	 tachycardia	 presented	 to	 our	 clinic	     	     Conclusion:	Vasculitic	rash	in	patients	being	treated	
for	 follow-up	 of	 his	 diabetes.	 He	 had	 been	 treated	 with	    with	antithyroid	drugs	could	be	an	early	sign	of	a	serious	
amiodarone	for	the	past	one	year.	His	physical	examina-              vasculitis	syndrome	and	clinical	awareness	of	this	compli-
tion	revealed	fine	tremors	of	the	upper	extremities	but	no	          cation	should	be	of	considerable	importance.	To	the	best	
exophthalmos	 or	 thyroidomegaly.	Thyroid	 function	 tests	          of	our	knowledge	we	report	the	first	case	of	vasculitis	in	a	
were	ordered	and	the	results	were	as	followed:	TSH	<0.01	            patient	with	AIT	treated	with	methimazole.
(0.35-5.00),	 FT4:	 2.4	 (0.7-1.5),	 FT3:	 5.9	 (2.3-4.2).	 The	
patient	 was	 diagnosed	 with	 amiodarone-induced	 thyro-            Abstract #1003
toxicosis	(AIT).	Due	to	his	poor	glycemic	and	the	type	of	
AIT	was	not	yet	clear,	amiodarone	was	discontinued	and	              EVALUATION OF HEARING LOSS IN PATIENTS
methimazole	(MMI)	15	mg	BID	was	started	empirically.	                WITH GRAVES’ HYPERTHYROIDISM
Further	 investigations	 revealed	TSI	 level	of	 109	 (0-109)	
and	 IL-6	 level	 was	 9.4	 (≤3.6).	Thyroid	 ultrasound	 dem-        Dilek Berker, MD, Hayriye Karabulut, MD,
onstrated	 a	 normal	 thyroid	 with	 no	 nodules.	Two	 weeks	        Serhat Isik, Yasemin Tutuncu, MD, Ufuk Ozuguz, MD,
later,	he	developed	a	hemorrhagic	palpable	purpuric	rash	            Muharrem Dagli, MD, Gonul Erden, MD,
mainly	 on	 the	 trunk	 and	 lower	 extremities.	 The	 patient	      Yusuf Aydin, MD, Serdar Guler, MD
denied	fever,	weight	loss,	hemoptysis,	hematuria,	myalgia	
or	joint	pain.	Due	to	the	suspicion	of	vasculitis,	methima-          	    Objective:	Hearing	loss	is	commonly	associated	with	
zole	was	discontinued	and	further	serologic	investigations	          thyroid	 disorders,	 and	 during	 propilthiouracil	 treatment.	
were	 performed.	 ANA,	 myeloperoxidase	 (MPO),	 and	                However,	 the	 relationship	 between	 hyperthyroidism	 and	
proteinase-3	 antineutrophilic	 anticytoplasmic	 antibodies	         auditory	system	has	not	been	investigated.	The	aim	of	this	
(ANCA)	were	all	negative.	However,	his	serum	creatinine	             cross-sectional,	case–control	study	is	to	investigate	hear-
rose	 from	 1.17	 to	 2.51	 mg/dL.	 Urinalysis	 was	 positive	       ing	loss	in	patients	with	Graves’	disease	(GD).
for	 pyuria	 and	 microscopic	 hematuria	 with	 10-20	 eryth-        	    Methods:	Twenty-two	patients	with	newly	diagnosed	
rocytes,	20-40	leukocytes.	Skin	biopsy	revealed	damaged	             GD	and	22	healthy	control	subjects	were	included.	Pure	
dermal	blood	vessels	with	perivascular	neutrophilic	infil-           tone	audiometry	at	250,	500,	1000,	2000,	4000	and	8000	
tration,	karyorrhectic	debris	and	erythrocytes	which	were	           Hz	 and	 immittance	 measures,	 including	 tympanometry	
consistent	 with	 leukocytoclastic	 vasculitis.	 In	 order	 to	      and	 acoustic	 reflex	 tests,	 were	 performed	 in	 the	 patients	
treat	AIT	 type	 2,	 prednisone	 was	 started	 at	 40	 mg	 daily	    and	controls.
initially	 and	 was	 tapered	 subsequently.	Approximately	 2	        	    Results:	 There	 were	 no	 statistically	 significant	 dif-
weeks	later,	the	purpuric	rash	resolved	and	his	creatinine	          ferences	 between	 the	 ages	 and	 genders	 of	 the	 patient	
decreased	 to	 the	 baseline.	The	 patient	 became	 euthyroid	       and	control	groups	(p=0.567	and	p=0.757,	respectively).	
after	2	months	of	treatment	with	prednisone.                         No	 significant	 difference	 was	 observed	 between	 hear-
	     Discussion:	 Vasculitis	 is	 a	 rare	 but	 major	 toxic	       ing	 threshold	 of	 right	 and	 left	 ears	 in	 GD	 and	 control	
reaction	 seen	 with	 antithyroid-drug	 treatment,	 more	            groups	(Bonferroni	corrected	p>0.0042).	When	only	one	


                                                               – 145 –
                                             ABSTRACTS – Thyroid Disease

ear	 was	 taken	 into	 account	 (44	 ears),	 hearing	 thresholds	    samples;	these	results	were	reviewed	and	adjudicated	by	
of	 GD	 group	 were	 significantly	 higher	 than	 controls	 at	      a	subset	of	the	authors	according	to	the	Bethesda	System	
all	 frequencies	 (p<0.05).	 Although	 no	 significant	 effect	      for	Reporting	Thyroid	Cytopathology.	Local	histopathol-
of	 thyrotoxicosis	 was	 observed	 on	 hearing	 loss	 at	 250,	      ogy	 diagnoses	 were	 obtained	 for	 816	 samples	 from	 607	
500,	1000	and	2000	frequencies,	a	significant	effect	was	            patients.	Histopathology	slides	were	over-read	by	2	thy-
detected	at	4000	and	8000	frequencies.	In	GD	group,	odds	            roid	 pathology	 experts	 without	 knowledge	 of	 the	 initial	
ratio	for	hearing	loss	at	8000	frequency	was	14.97	(95%	             interpretation,	 and	 results	 listed	 according	 to	 the	 WHO	
confidence	interval	4.03-55.64)	compared	to	controls.	The	           criteria,	 with	 the	 addition	 of	 the	 recommendations	 from	
pure	tone	average	(PTA)	thresholds	of	patients	and	con-              the	Chernobyl	Pathologists	group.
trols	were	significantly	different	in	all	three	PTA	groups	          	     Results:	 1420	 FNA	 samples	 had	 cytopathology	
(p<0.05).	 Right	 and	 left	 pure	 tone	 audiometric	 findings	      results:	827	(58%)	Benign	(B),	350	(25%)	Indeterminate	
were	positively	correlated	with	FT3,	FT4	and	negatively	             (I),	 189	 (13%)	 Malignant	 (M),	 and	 54	 (4%)	 Non-
correlated	with	TSH	in	GD	at	8000	frequency.	                        Diagnostic	(ND).	Of	the	848	prospectively	collected	FNA	
	     Discussion:	We	detected	a	decrease	in	hearing	ability,	        samples,	625	(74%)	were	B,	110	(13%)	I,	74	(9%)	M,	and	
particularly	at	high	frequencies,	in	patients	with	GD.	The	          39	(4%)	ND.	816	FNA	samples	had	local	histopathology	
correlation	 between	 thyroid	 hormone	 levels	 and	 hearing	        results:	59%	B,	41%	M,	0%	Uncertain	Malignant	Potential	
thresholds	at	high	frequencies	may	suggest	that	increased	           (UMP).	141	cases	had	expert	over-reads	with	the	follow-
hearing	thresholds	in	GD	may	be	due	to	metabolic	effects	            ing	results:	Expert	1	–	50%	B,	47%	M,	3%	UMP;	Expert	
of	 high	 thyroid	 hormones.	 It	 is	 known	 that	 some	 of	 the	    2	-	51%	B,	46%	M,	3%	UMP.	The	two	experts	concurred	
clinical	 findings	 of	 hyperthyroidism	 result	 from	 sympa-        in	134	cases	(96%)	but	reclassified	the	local	specific	his-
thetic	over-activity	due	to	up-regulated	adrenergic	recep-           topathology	diagnosis	in	32%	of	the	cases	and	generically	
tors	 in	 some	 tissues.	 Another	 possible	 mechanism	 for	         from	B	to	M	or	from	M	to	B	in	9%	of	the	cases.	Malignant	
hearing	 loss	 in	 patients	 with	 GD	 is	 vascular	 mechanism	      histopathology	rates	for	cytopathologically	indeterminate	
as	seen	in	autoimmune	diseases	resulting	in	sensorineural	           nodules	were	36%	local	and	34%	expert.
hearing	loss.                                                        	     Discussion:	 Post-operatively	 almost	 2/3	 of	 nodules	
	     Conclusion:	 Our	 results	 revealed	 that	 hearing	 abil-      with	 indeterminate	 cytology	 proved	 to	 be	 benign,	 a	 fig-
ity	decreases,	mostly	at	high	frequencies,	in	patients	with	         ure	 comparable	 to	 recently	 published	 retrospective	 FNA	
GD.	Further	studies	are	needed	to	explain	the	cause	and	             series.	In	addition,	expert	histopathology	over-read	had	a	
mechanism	of	hearing	loss	in	patients	with	GD.                       significant	9%	B	to	M	or	M	to	B	reclassification.	The	pro-
                                                                     spective	sub-cohort	in	this	study	is	the	largest	prospective,	
Abstract #1004                                                       multicenter	evaluation	of	thyroid	FNA	pathology	to	date.
                                                                     	     Conclusion:	False	positive	results	remain	a	concern	
A LARGE MULTICENTER CORRELATION                                      in	 thyroid	 cytopathology.	 Molecular	 testing	 studies	 to	
STUDY OF THYROID NODULE                                              more	accurately	diagnose	FNA	results	are	needed,	espe-
CYTOPATHOLOGY AND HISTOPATHOLOGY                                     cially	in	the	cytology	indeterminate	group	where	66%	of	
                                                                     cases	 are	 benign	 post-operatively	 and	 surgery	 could	 be	
Richard Burnham Lanman, MD,                                          avoided.	These	studies	should	incorporate	expert	surgical	
Chung-Che Charles Wang, MD,                                          pathology	interpretation	in	their	study	design,	given	local	
Lyssa Friedman, RN, MPA, Giulia Kennedy, PhD,                        to	expert	histopathology	variation.
Electron Kebebew, MD, Martha Zeiger, MD,
Juan Rosai, MD, Virginia LiVolsi, MD                                 Abstract #1005

	    Objective:	To	correlate,	in	a	large	multicenter	study,	         CLINICAL CHARACTERISTICS OF PAPILLARY
indeterminate	thyroid	nodule	fine	needle	aspiration	(FNA)	           THYROID MICROCARCINOMA: BASED ON THE
cytopathology	 diagnoses	 with	 histopathology	 diagnoses	           SIZES OF PRIMARY TUMORS
by	local	and	expert	histopathologists	in	the	corresponding	
surgically	resected	specimens.                                       Ufuk Ozuguz, MD, Serhat Isik, MD,
	    Methods:	848	FNA	samples	were	prospectively	col-                Yasemin Ates Tutuncu, Gulhan Akbaba, MD,
lected	from	708	patients	in	clinic	or	pre-operatively	from	          Ayse Arduc, MD, Dilek Berker, MD, Serdar Guler
16	 community-based,	 3	 academic	 U.S.	 and	 2	 non-U.S.	
sites.	An	 additional	 572	 banked	 FNA	 samples	 from	 444	         	    Objective:	In	recent	years,	the	diagnosis	of	papillary	
patients	 were	 obtained	 from	 2	 academic	 U.S.	 centers.	         microcarcinoma	 (PMC)	 has	 increased	 with	 widespread	
Initial	 cytopathology	 diagnoses	 were	 obtained	 for	 all	         use	 of	 ultrasound-guided	 fine-needle	 aspiration	 biopsy,	



                                                               – 146 –
                                             ABSTRACTS – Thyroid Disease

particularly	by	endocrinologists.	However,	consensus	has	             Abstract #1006
been	established	yet	on	treatment	of	PMC.	In	the	present	
study	we	aimed	to	assess	the	relationship	between	clini-              PULMONARY METASTASIS IN WELL
cal	and	pathological	features	of	PMC	patients	with	tumor	             DIFFERENTIATED THYROID TUMOR OF
size.                                                                 UNKNOWN MALIGNANT POTENTIAL: A CASE
	     Methods:	 One	 hundred-fifteen	 patients	 diagnosed	            PRESENTATION AND REVIEW OF LITERATURE
with	PMC	from	2003	to	2009	were	evaluated	retrospec-
tively.	Papillary	microcarcinoma	was	defined	as	a	tumor	              Asma Ahmed, MBBS, Najmul Islam
of	 10	 mm	 or	 less	 in	 greatest	 diameter	 using	 the	 histo-
logical	classification	criteria	of	thyroid	tumors	of	WHO.	                  Objective:	To	report	a	case	of	a	metastatic	well	dif-
Tumor	sizes,	histopathologic	characteristics,	extrathyroi-            ferentiated	thyroid	tumor	of	unknown	malignant	potential.
dal	spread,	lymph	node	(LN)	involvement,	distant	metas-               	     Case Presentation:	We	describe	the	case	of	a	40-year-
tases	 and	 surgical	 procedures	 are	 recorded.	The	 patients	       old	female	with	history	of	multinodular	goiter.	Ultrasound	
were	divided	two	groups	according	to	tumor	sizes	(Group	              revealed	two	large	nodules	in	left	lobe	of	thyroid,	largest	
1:	 tumor	 size	 5	 mm	 and	 above,	 67	 patients;	 Group	 2:	        one	being	4	x	1.3	x	1.2	cm,	and	the	right	lobe	had	three	
tumor	size	less	than	5	mm,	48	patients).                              small	nodules.	Technetium	scan	showed	a	cold	nodule	in	
	     Results:	One	hundred-five	of	the	patients	were	female	          the	left	lobe.	Chest	X	ray	revealed	large	soft	tissue	mass	
and	 10	 were	 male.	 The	 mean	 age	 was	 45.6±12.3	 years.	         in	neck	displacing	trachea.	FNAC	of	dominant	nodules	in	
Total	thyroidectomy	had	been	performed	on	107	patients,	              the	 left	 lobe	 was	 consistent	 with	 benign	 pathology.	 U/S	
subtotal	thyroidectomy	in	6	patients	and	lobectomy	in	2	              repeated	 after	 one	 year	 revealed	 complete	 replacement	
patients.	 Lymph	 node	 dissection	 had	 been	 performed	 on	         of	 left	 lobe	 with	 large	 solid	 cum	 cystic	 nodule	 measur-
24	patients.	Tumor	was	multifocal	in	28/115	(24.3%)	and	              ing	 6.1	 x	 4.4	 x	 2.8	 cm,	 which	 subsequently	 increased	
bilateral	in	13/115	(11.3%)	of	the	patients.	One	patient	had	         after	another	year	to	7.4	 x	 4.4	 x	 2.8cm.	.	 Repeat	FNAC	
vascular	invasion,	7	had	capsule	invasion,	2	had	extrathy-            subsequently	didn’t	show	any	evidence	of	malignancy.	In	
roidal	involvement,	7	had	LN	involvement	and	1	had	dis-               view	 of	 the	 fact	 that	 the	 size	 of	 her	 thyroid	 nodule	 was	
tant	metastases.	Seven	of	the	16	patients	with	tumor	>0.5	            progressively	 increasing	 and	 displacement	 of	 trachea,	 it	
mm	had	LN	involvement	while	there	was	no	LN	inolve-                   was	decided	on	clinical	grounds	to	perform	total	thyroid-
ment	in	group	2	(p=0.026).	No	significant	difference	was	             ectomy.	 Histopathology	 showed	 well	 differentiated	 thy-
found	with	regard	to	general	demographic	characteristics,	            roid	tumor	with	unknown	malignant	potential.	One	month	
multifocality,	 vascular	 invasion,	 capsule	 invasion,	 extra-       after	 her	 thyroidectomy,	 TSH	 stimulated	 thyroglobulin	
thyroidal	spread	and	distant	metastases	between	the	two	              was	 13.90ng/ml	 by	 chemiluminescence	 with	 TSH	 of	
groups.                                                               65.44Uiu/ml	 (0.27-4.2)	 and	 negative	 thyroglobulin	 anti-
	     Discussion:	 Papillary	 microcarcinomas	 are	 slow-             bodies.	 After	 involving	 multidisciplinary	 teams	 it	 was	
growing	tumors	that	spread	commonly	by	lymphogenous	                  decided	to	manage	her	with	radioactive	iodine.	Her	post	
way.	The	main	poor-prognostic	factors	include	tumor	size,	            ablation	131I	whole	body	scan	(WBS)	showed	uptake	in	
LN	involvement,	advanced	age,	male	gender,	multifocal-                thyroid	bed	with	pulmonary	metastasis.	Subsequently,	C.T	
ity	 and	 extrathyroidal	 spread.	 However,	 these	 factors	 do	      scan	with	contrast	after	WBS	showed	no	evidence	of	pul-
not	 suffice	 to	 predict	 tumor	 recurrence,	 metastases	 and	       monary	 metastasis	 suggestive	 of	 iodine	 avid	 pulmonary	
tumor-	 related	 deaths.	 On	 the	 other	 hand,	 there	 exists	 a	    micrometastasis.	At	six	months	of	follow-up	patient	was	
relationship	 between	 LN	 involvement	 and	 locoregional	            found	 to	 be	 completely	 tumor	 free	 with	TSH	 stimulated	
reccurrence	 and	 distant	 metastases.	 In	 the	 present	 study	      thyroglobulin	of	0.30ng/ml	and	negative	neck	ultrasonag-
LN	metastases	were	significantly	higher	in	patients	with	             raphy	and	low	dose	(2mci)	I131	WBS.	Patient	has	been	
tumor	size	5	mm	and	larger.                                           started	 on	 suppressive	 dose	 of	 thyroxine	 and	 is	 planned	
	     Conclusion:	Papillary	microcarcinoma	patients	with	             for	strict	follow-up	according	to	guidelines	for	papillary	
tumor	size	5	mm	and	larger	should	be	evaluated	in	terms	              or	follicular	thyroid	carcinoma.
of	LN	involvement.                                                          Discussion:	 Due	 to	 the	 vagueness	 of	 the	 clinical	
                                                                      behavior	 of	 these	 tumors,	 clinicians	 and	 surgeons	 are	
                                                                      often	 puzzled	 regarding	 the	 treatment	 of	 these	 tumors.	
                                                                      Moreover,	 there	 are	 no	 guidelines	 for	 the	 management	
                                                                      of	these	tumors.	In	the	management	of	our	case,	we	also	
                                                                      encountered	the	similar	problem	of	treatment	uncertainty	
                                                                      but	ultimately	decided	to	treat	the	patient	with	I131	RAI	
                                                                      post	 thyroidectomy.	 This	 clinical	 decision	 of	 131	 RAI	
                                                                      ablation,	later	on	proved	to	be	a	sensible	one,	due	to	the	


                                                                – 147 –
                                              ABSTRACTS – Thyroid Disease

finding	of	pulmonary	metastasis	on	post	RAI	whole	body	                over	papillae	is	complete.	The	difference	between	follicu-
scan.                                                                  lar	 carcinoma	 and	 follicular	 variant	 of	 papillary	 thyroid	
     Conclusion:	On	the	basis	of	the	reported	findings,	it	            carcinoma	has	significant	clinical	implications.	Follicular	
is	tempting	to	speculate	that	these	new	entities	should	be	            carcinomas	 usually	 metastasize	 hematogenously,	 on	 the	
treated	 with	 total	 thyroidectomy	 followed	 by	 RAI	 until	         other	 hand	 FVPTC	 behaves	 like	 usual	 PTC	 with	 rare	
more	long	term	data	is	available	documenting	the	outcome	              hematogenous	spread	and	similar	survival	rates.	There	are	
of	these	lesions.                                                      case	reports	of	this	entity	in	literature	presenting	as	bone	
                                                                       metastasis,	 but	 this	 is	 not	 a	 very	 common	 feature.	 Our	
Abstract #1007                                                         patient	didn’t	have	any	history	of	thyroid	lump	or	swelling	
                                                                       in	neck.	Since	histopathology	of	the	bone	lesion	suggested	
FOLLICULAR VARIANT OF PAPILLARY                                        thyroid	or	prostate	being	the	primary,	we	had	to	search	for	
THYROID CARCINOMA PRESENTING                                           thyroid	nodule	which	was	ultimately	found	on	C.T	scan.	
AS BONE METASTASIS                                                     Furthermore,	 after	 thyroidectomy	 this	 patient	 received	
                                                                       RAI	 131	 and	 subsequent131I	 whole	 body	 scan	 revealed	
Asma Ahmed, MBBS, Najmul Islam, MBBS                                   multiple	areas	of	increased	uptake	including	lumbar	and	
                                                                       pulmonary	 metastasis	 suggestive	 of	 widespread	 meta-
      Objective:	 To	 report	 a	 case	 of	 follicular	 variant	 of	    static	disease.
papillary	thyroid	carcinoma	(FVPTC)	initially	presenting	              	     Conclusion:	 This	 case	 highlights	 the	 fact	 that	
as	spinal	metastasis.                                                  although	FVPTC	are	very	much	similar	to	classic	PTC	but	
	     Case Presentation:	 A	 45-year-old	 male	 presented	             a	subset	of	it	may	behave	as	follicular	carcinoma	and	can	
with	 history	 of	 pain	 and	 numbness	 over	 lateral	 aspect	         also	present	initially	with	bone	metastasis.
of	 right	 thigh.	 MRI	 demonstrated	 a	 lesion	 involving	 L2	
vertebra	measuring	approximately	3.5	×2	cm.	Bone	scan	                 Abstract #1008
showed	 increased	 tracer	 uptake	 at	 L2	 vertebrae	 &	 right	
shoulder	 joint.	 FNA	 of	 the	 L2	 bone	 lesion	 was	 sugges-         THYMIC ENLARGEMENT—A FEATURE OF
tive	of	metastasis	carcinoma	with	primary	in	prostate	vs.	             GRAVES DISEASE
thyroid.	 Transrectal	 U/S	 of	 the	 prostate	 and	 PSA	 were	
normal	which	ruled	out	prostate	being	the	primary	focus.	              Madhavi Yarlagadda, MD, Colleen Veloski, MD
Further	 focusing	 on	 to	 find	 out	 primary	 etiology,	 US	 of	
thyroid	 was	 done	 which	 was	 normal.	 C.T	 scan	 revealed	          	    Objective:	 To	 increase	 the	 awareness	 of	 the	 usual	
small	 nodules	 in	 the	 left	 lobe	 of	 thyroid	 gland	 and	 both	    benign	 course	 of	 thymic	 enlargement	 in	 patients	 with	
lungs.	Furthermore,	thyroglobulin	level	was	found	to	be	               Graves’	 disease	 and	 recommend	 close	 radiologic	 obser-
extremely	high	at	2858ng/ml.	FNAC	of	left	thyroid	nod-                 vation	 and	 reevaluation	 after	 treatment	 of	 Graves	 as	 an	
ule	 revealed	 scanty	 benign	 tissue.	 The	 patient	 received	        alternative	to	surgical	excision.
radiation	 therapy	 for	 his	 bone	 metastasis	 at	 L2	 site.	 In	          Case Presentation:	 We	 present	 a	 case	 series	 of	 six	
view	of	extremely	raised	thyroglobulin	levels	and	FNAC	                subjects	seen	in	our	practice	in	the	past	year,	with	Graves’	
of	 bone	 lesion	 suggestive	 of	 primary	 lesion	 possibly	 in	       disease	and	an	incidentally	discovered	enlarged	thymus	on	
thyroid,	 it	 was	 decided	 to	 proceed	 with	 total	 thyroidec-       imaging	studies.	Among	the	six	patients,	five	had	active	
tomy.	 Histopathology	 of	 excised	 thyroid	 gland	 was	 in	           Graves’	 disease	 at	 the	 time	 of	 discovery	 of	 the	 thymic	
keeping	 with	 the	 diagnosis	 of	 FVPTC.	Two	 weeks	 after	           mass,	 and	 one	 had	 a	 history	 of	 Graves’	 disease	 20	 yrs	
thyroidectomy,	thyroglobulin	levels	were	5056ng/ml	indi-               prior.	Two	patients	had	thymectomy	due	to	suspicion	for	
cating	high	tumor	load.	Patient	received	200	mci	of	radio-             thymoma	 and	 both	 histopathologic	 evaluations	 revealed	
active	iodine	followed	by	I131	whole	body	scan	showing	                thymic	 hyperplasia.	The	 other	 four	 patients	 were	 sched-
multiple	 areas	 of	 increased	 uptake	 in	 lumbar	 vertebrae,	        uled	 for	 thymectomy	 pending	 evaluation	 by	 endocrinol-
right	shoulder	region	and	pulmonary	region.                            ogy.	 Based	 on	 our	 recommendations,	 the	 planned	 thy-
      Discussion:	 Several	 subtypes	 of	 papillary	 thyroid	          mectomies	 were	 postponed	 and	 those	 patients	 are	 being	
carcinoma	(PTC)	exist	which	constitute	for	approximately	              followed	by	serial	CT	scans	while	being	treated	for	hyper-
20%	of	all	PTCs.	The	follicular	variant	of	papillary	thyroid	          thyroidism.	 Thyroid	 stimulating	 immunoglobulins	 are	
carcinoma	was	first	described	by	Lindsay	and	later	Chen	               also	being	followed	as	markers	of	disease	activity.
and	Rosai	reported	the	detailed	morphologic	description	of	            	    Discussion:	 Association	 of	 thymic	 hyperplasia	
this	tumor.	The	tumor	is	designated	as	a	follicular	variant	           with	 Graves’	 disease	 was	 recognized	 decades	 ago,	 but	
of	PTC	when	the	lining	cells	have	nuclear	features	charac-             was	 not	 usually	 detected	 clinically.	 Initially,	 the	 thymus	
teristic	of	papillary	thyroid	carcinoma	(Nuclear	clearing,	            was	thought	to	play	a	role	in	autoimmune	hyperthyroid-
overlapping	and	grooves)	and	the	follicular	predominance	              ism,	 but	 thymectomy	 was	 found	 to	 have	 no	 effect	 on	


                                                                 – 148 –
                                              ABSTRACTS – Thyroid Disease

hyperthyroidism.	In	1996,	a	study	by	Mukarami	et	al	dem-               calcitonin	levels,	plasma	parathyroid	hormone,	24-h	uri-
onstrated	that	thyrotropin	receptors	(TSH-R)	were	present	             nary	 excretion	 of	 catecholamines	 and	 metabolites,	 and	
in	normal	thymus	tissue	suggesting	that	TSH-R	auto	anti-               DNA	analysis.	Genomic	DNA	was	isolated	from	periph-
bodies	may	cause	thymic	hyperplasia	in	Graves’	disease	                eral	blood	leucocytes	using	standard	procedure.	Exons	10,	
in	the	same	manner	that	TSH-R	auto	antibodies	stimulate	               11,	13,	14	and	16	of	the	RET	proto-oncogene	were	ana-
thyroid	 growth.	The	 study	 also	 demonstrated	 a	 decrease	          lyzed	by	single	strand	conformation	polymorphism	analy-
in	 thymic	 mass	 size	 and	 density	 along	 with	 a	 concomi-         sis,	 direct	 DNA	 sequencing	 and/or	 restriction	 enzyme	
tant	decrease	in	TSH-R	antibodies	following	treatment	for	             analysis.
Graves’	disease	with	antithyroid	medications.                                Results:	Among	the	78	individuals,	a	total	of	46	indi-
	     Conclusion:	Thymic	enlargement	in	the	past	was	an	               viduals	with	hereditary	MTC	were	enrolled	in	this	study.	
under	 recognized	 feature	 of	 Graves’	 disease	 prompting	           Thirty	(aged	12–65	y),	patients	had	previously	y	for	MTC.	
the	publication	of	many	case	reports.	In	recent	years,	the	            In	 addition;	 molecular	 screening	 identified	 another	 16	
routine	use	of	CT	angiogram	to	rule	out	pulmonary	embo-                individuals	without	clinical	evidence	of	disease	but	at	risk	
lism	has	led	to	an	increase	in	detection	and	many	poten-               because	of	an	affected	relative.	From	this	MTC	group	10	
tially	 avoidable	 thymectomies.	 In	 most	 cases,	 Graves’	           patients	had	been	operated	on	for	PHEO	and	4	for	HPT.	
related	 thymic	 enlargement	 regresses	 with	 treatment	 of	          The	 diagnosis	 of	 MTC,	 PHEO	 and	 parathyroid	 hyper-
the	 Graves’	 disease.	 Often	 patients	 are	 not	 referred	 to	       plasia	 was	 confirmed	 by	 pathological	 examination	 post-
endocrinology	until	after	surgical	resection	of	the	thymic	            operatively.	Among	 10	 families	 with	 hereditary	 MTC,	 5	
mass.	Cardiothoracic	surgeons	and	other	physicians	must	               diagnosed	with	MEN	2A	and	5	with	FMTC.	Two	from	5	
be	made	aware	of	the	association	between	benign	thymic	                MEN	2A	family’s	mutation	was	located	at	codon	618	in	
hyperplasia	and	Graves’	disease	in	order	to	avoid	unnec-               exon	10.	The	incidence	of	MTC,	PHEO	and	HPT	in	the	25	
essary	surgery.	We	also	recommend	screening	all	patients	              MEN2A	patients	was	100%,	52%	and	16%,	respectively.	
with	thymic	enlargement	for	hyperthyroidism	prior	to	sur-              In	our	series,	the	most	frequent	phenotype	was	the	MEN	
gical	removal.                                                         2A	 syndrome	 with	 codon	 618	 mutations	 (46.6%),	 fol-
                                                                       lowed	by	634	mutation	44.2%.	In	1	of	10	families,	screen-
Abstract #1009                                                         ing	of	exons	10,	11,	13,	14	and	16	was	negative	for	RET	
                                                                       mutations.	Of	the	5	families	classified	as	MEN2A,	three	
RET CODON 618 MUTATIONS IS THE MOST                                    had	a	mutation	at	codon	634,	exon	11while	the	other	two	
FREQUENT PHENOTYPE IN SAUDI FAMILIES                                   families	had	a	mutation	at	codon	618.
WITH MULTIPLE ENDOCRINE NEOPLASIA                                      	     Discussion:	Mutations	that	cause	activation	of	RET	
TYPE 2A                                                                have	 been	 well	 characterized	 and	 several	 groups	 have	
                                                                       studied	 the	 disease	 phenotype–genotype.	 Differences	 in	
Dr. Tariq Abdulrahman Nasser, Prof. Faiza Qari,                        the	frequency	of	specific	RET	mutations	in	MEN	2A	phe-
Dr. Abdulah Karawagh, Dr. Jumana AlAama                                notypes	have	been	found	in	series	from	different	countries,	
                                                                       suggesting	that	the	occurrence	of	these	mutations	may	be	
     Objective:	 To	 evaluate	 the	 prevalence	 of	 the	 RET	          influenced	by	genetic	background.	We	analyzed	the	RET	
mutation	in	Saudi	families	with	multiple	endocrine	neo-                proto-oncogene	from	79	patients	from	10	unrelated	Saudi	
plasia	 type	 2A	 (MEN	 2A)	 or	 familial	 medullary	 thyroid	         families.	A	 total	 of	 46	 individuals	 with	 hereditary	 MTC	
carcinoma	(FMTC).                                                      were	enrolled	in	this	study.	Our	study	analyzed	the	RET	
	    Methods:	A	total	of	10	unrelated	Saudi	families	with	             proto-oncogene	from	79	patients	from	10	unrelated	Saudi	
germline	 mutation	 of	 the	 RET	 protooncogene	 and/or	               families.	A	 total	 of	 46	 individuals	 with	 hereditary	 MTC	
immunohistochemistry	diagnosis	of	MTC	were	identified.	                were	enrolled	in	this	study.	The	nature	of	the	mutations	in	
Before	 undergoing	 genetic	 testing,	 all	 patients	 and	 their	      our	MEN	2A	families	is	618	found	in	46.6%	of	all	cases	of	
family	 members	 had	 given	 their	 written	 informed	 con-            MEN	2A,	which	is	interestingly	different	from	the	results	
sent	in	accordance	with	institutional	ethic	guidelines	and	            of	the	International	RET	mutation	consortium	analysis
national	regulations.	The	presence	of	pheochromocytoma	                	     Conclusion:	 We	 showed	 the	 frequency	 profile	 of	
(PHEO)	or	hyperparathy-	roidism	(HPT)	was	excluded	by	                 RET	 proto-oncogene	 mutations	 in	 a	 sample	 of	 10	 unre-
extensive	 testing	 of	 all	 affected	 individuals	 and	 their	 at	    lated	Saudi’s	families	with	hereditary	MTC.	The	most	fre-
risk	family.	Seventy-eight	family	members	were	evaluated	              quent	RET	proto-oncogene	mutations	in	Saudi’s	families	
by	 medical	 history,	 physical	 examination	 and	 biochemi-           with	MEN	2A	and	familial	medullary	thyroid	carcinoma	
cal	measurements	of	fasting	serum	calcium,	basal	plasma	               (FMTC)	is	mutation	in	codon	618.




                                                                 – 149 –
                                             ABSTRACTS – Thyroid Disease

Abstract #1010                                                       Abstract #1011

THE VALUE OF ON-SITE PATHOLOGIC                                      UNEXPECTED OUTCOMES OF SELF-IMPOSED
ASSESSMENT FOR DETERMINING SAMPLE                                    DIETARY RESTRICTIONS AND DIETARY
ADEQUACY DURING ULTRASOUND GUIDED                                    PREFERENCES: CASE REPORT OF IODINE
BIOPSY OF THYROID NODULES                                            DEFICIENCY INDUCED GOITER IN CENTRAL
                                                                     NEW JERSEY
Bhakti Paul, MD
                                                                     Amy Chow, MD, Sun Wei, MD, Xiangbing Wang, MD
      Objective:	The	purpose	of	this	study	is	to	determine	
whether	 having	 on	 site	 pathologic	 evaluation	 of	 speci-              Objective:	 Iodine	 deficiency	 induced	 goiters	 have	
mens	 improved	 the	 adequacy	 rate	 for	 ultrasound	 guided	        generally	 been	 eliminated	 with	 iodized	 salt	 in	America.	
(US)	fine	needle	aspiration	(FNA)	of	thyroid	nodules                 However,	sporadic	cases	of	euthyroid	goiter	due	to	iodine	
      Methods:	Retrospective	review	was	conducted	for	all	           deficiency	have	been	reported,	even	in	New	Jersey,	a	sup-
patients	 referred	 for	 US-FNA	 of	 thyroid	 nodules	 in	 our	      posedly	 iodine-replete	 state.	 We	 report	 the	 cases	 of	 two	
institution	 since	 2007.	 Data	 from	 200	 US	 guided	 FNAs	        patients	in	central	New	Jersey	who	suffered	from	iodine	
done	 in	 the	 presence	 of	 an	 attending	 pathologist	 (group	     deficiency-induced	euthyroid	goiters.
1)	who	inspected	the	specimen	from	each	pass	as	it	was	              	     Case Presentation:	A	47-year-old	female	with	hyper-
obtained	for	adequacy	was	compared	with	200	US	guided	               tension	 presented	 with	 goiter.	 Examination	 was	 notable	
FNAs	done	at	an	off-site	clinic	(group	2)	without	on-site	           for	diffused	enlarged	thyroid.	CBC,	CMP,	TSH,	free	T4,	
specimen	evaluation.	The	number	of	passes	made	per	nod-              total	 T3	 and	 thyroid	 perioxidase	 (TPO)	 antibody	 level	
ule	in	group	1	was	contingent	on	feedback	from	the	pathol-           were	normal.	Sonogram	showed	diffusely	enlarged	homo-
ogist.	A	standard	of	3	passes	were	made	for	each	nodule	in	          geneous-appearing	thyroid	gland.	A	24-hour	urine	iodine	
group	2.	This	group	contained	37	males,	163	females	with	            collection	showed	subnormal	level	of	42ug.	Further	dis-
a	mean	age	of	53.	3	passes	were	made	for	each	nodule	in	             cussion	 revealed	 that	 she	 refrained	 from	 consuming	 salt	
group	2.	This	group	contained	23	males,	177	females	with	            for	 her	 hypertension	 and	 avoided	 seafood	 by	 choice.	
a	mean	age	of	52.	FNAs	in	both	groups	were	performed	                She	was	diagnosed	with	goiter	secondary	to	iodine	defi-
using	 23G	 needles	 with	 ultrasound	 guidance	 using	 the	         ciency	 and	 was	 advised	 to	 use	 iodized	 salt	 and	 eat	 sea-
same	 suction	 method,	 and	 final	 interpretation	 was	 made	       food.	Six	months	later,	the	goiter	resolved.	A	36-year-old	
by	the	same	board	certified	cytopathologists.                        female	with	hypertension	presented	with	thyroid	nodules.	
	     Results:	5%	of	FNAs	performed	in	group	1	with	on	              Examination	 was	 notable	 for	 BMI	 of	 46	 and	 diffused	
site	 pathology	 evaluation	 were	 inadequate,	 compared	 to	        enlarged	thyroid.	CBC,	CMP,	TSH,	free	T4,	total	T3	and	
13.5%	in	the	group	2	without	on	site	pathology.	(p=0.005,	           TPO	were	normal.	She	had	5	children	including	one	year	
Fisher’s	 Exact	 test).	 Group	 1	 contained	 37	 males,	 163	       old	twins.	Fine	needle	aspiration	was	negative	for	malig-
females	with	a	mean	age	of	53.	Mean	nodule	size	was	2.4	             nancy	cells.	An	I123-uptake	and	scan	showed	a	24-hour	
cm.	 The	 final	 diagnosis	 was	 146	 benign,	 38	 indetermi-        uptake	of	37	%	and	a	diffusely	enlarged	gland.	A	24	hour	
nate	 and	 6	 malignant.	 Group	 2	 contained	 23	 males,	 177	      urine	iodine	collection	revealed	an	iodine	level	of	<	10ug.	
females	with	a	mean	age	of	52	with	a	mean	nodule	size	as	            She	 also	 avoided	 salt	 for	 hypertension,	 cut	 down	 dairy	
2.8	cm.143	nodules	were	benign,	22	were	indeterminate,	              products	 and	 bread	 for	 weight	 loss	 and	 refrained	 from	
and	8	malignant.	The	median	number	of	passes	was	equal	              consuming	 seafood	 by	 choice.	 She	 was	 diagnosed	 with	
in	both	groups	and	was	3	with	the	number	of	passes	rang-             iodine	 deficiency	 induced	 goiter	 and	 started	 on	 iodized	
ing	from	2	to	8	in	group	1.                                          salt.	Six	months	later,	patient’s	nodules	resolved.
      Discussion:	 Ultrasound	 guided	 Fine	 Needle	 aspira-         	     Discussion:	Our	cases	of	iodine-deficiency	occurred	
tion	biopsy	is	a	standard	procedure	for	diagnostic	evalu-            in	an	iodine-abundant	environment.	Given	the	culture	and	
ation	 of	 thyroid	 nodules.	 Our	 study	 found	 that	 the	 inad-    dietary	history	of	these	patients,	the	possible	mechanisms	
equacy	 rate	 is	 reduced	 by	 more	 than	 half	 with	 on-site	      of	iodine	deficiency	includes:	1)	avoidance	of	salt	due	to	
pathology.	This	in	turn	decreases	patient	burden,	cost	of	a	         medical	conditions	like	hypertension.	2)	avoidance	of	sea-
repeat	biopsy	and	potentially	prevents	delay	in	treatment.           food	 due	 to	 personal	 preferences.	 These	 cases	 highlight	
      Conclusion:	The	presence	of	on-site	pathology	eval-            the	 importance	 of	 obtaining	 specific	 dietary	 information	
uation	significantly	improves	diagnostic	yield.	This	has	to	         on	the	intake	of	iodized	salt	and	seafood	routinely	during	
be	balanced	against	the	costs	of	providing	this	coverage.            evaluation	of	patients	with	goiter.	Measurement	of	urinary	




                                                               – 150 –
                                             ABSTRACTS – Thyroid Disease

iodine	excretion	is	warranted	in	suspicious	cases.	If	iodine	        either	 through	 imaging	 or	 surgery	 is	 playing	 an	 increas-
deficiency	induced	goiter	is	diagnosed,	dietary	iodine	sup-          ingly	important	role	in	the	older	population.
plementation	 can	 have	 a	 profound	 antigoitrogenic	 effect	       	    Conclusion:	 Patients	 with	 PTC	 are	 growing	 older	
and	lead	to	dramatic	resolution,	thereby	avoiding	unwar-             which	 has	 important	 prognostic	 and	 treatment	 implica-
ranted	 thyroxine	 suppression	 therapy	 and	 fine	 needle	          tions.	PTC	tumor	size	is	decreasing	and	older	patients	are	
aspiration.                                                          being	 treated	 for	 an	 increasing	 number	 of	 small	 tumors	
                                                                     perhaps	 reflecting	 the	 increased	 detection	 of	 these	 inci-
Abstract #1012                                                       dental	 thyroid	 nodules	 because	 of	 the	 proliferation	 of	
                                                                     imaging	studies.
THE CHANGING FACE OF PAPILLARY
THYROID CANCER: IS 50THE NEW 30?                                     Abstract #1013

David T. Hughes, MD, Megan R. Haymart, MD,                           LARGE NEEDLE ASPIRATION BIOPSY FOR
Barbra S. Miller, MD, Paul G. Gauger, MD,                            PREOPERATIVE SELECTION OF HURTHLE
Gerard M. Doherty, MD                                                CELL NODULES

     Objective:	The	incidence	of	papillary	thyroid	cancer	           Angelo Carpi, MD, Giuseppe Rossi, PhD,
(PTC)	 is	 growing	 at	 a	 faster	 rate	 than	 any	 other	 malig-    Jeffrey Mechanick, MD, Andrea Nicolini, MD,
nancy,	yet	it	is	unknown	what	role	the	aging	population	             Giancarlo di Coscio, PhD
has	on	PTC	incidence	rates.	With	the	goal	of	understand-
ing	the	role	of	age	in	thyroid	cancer	incidence,	this	study	              Objective:	 We	 reported	 that	 large	 needle	 aspiration	
sought	to	analyze	the	changing	demographics	of	patients	             biopsy	 (LNAB)	 histology	 distinguishes	 nodules	 with	
with	PTC	over	the	past	three	decades.                                indeterminate	follicolar	structure	by	fine	needle	aspiration	
	    Methods:	Retrospective	cohort	evaluation	of	patients	           biopsy	(FNAB)	cytology	into	two	groups:	pure	microfol-
with	papillary	thyroid	carcinoma	from	1973-2006	using	the	           licular	nodules	with	increased	likelihood	of	postoperative	
National	 Cancer	 Institute’s	 Surveillance,	 Epidemiology,	         malignancy	 and	 mixed	 micro-macrofollicular	 nodules	
and	End	Results	(SEER)	database.                                     with	decreased	risk	of	postoperative	malignancy.
	    Results:	From	1973-2006	the	incidence	of	PTC	has	               	    Methods:	We	compared	FNAB	(23-22	gauge	needles)	
increased	for	all	age	groups,	but	has	escalated	the	most	in	         and	LNAB	(20-18	gauge	needles)	diagnostic	accuracy	in	
patients	older	than	age	45.	Over	the	last	three	decades,	the	        Hürthle	cells	nodules	(HCN;	Hürthle	cell	found	in	>60%	
peak	incidence	of	PTC	has	shifted	from	the	30-40	year-               of	all	cells	examined)	at	FNAB	which	were	excised	fol-
old	age	group	to	the	40-50	year-old	age	group.	Until	1999	           lowing	preoperative	examination	with	FNAB	and	LNAB	
most	 cases	 of	 PTC	 were	 found	 in	 patients	 younger	 than	      (4	men	and	20	women;	nodule	size	range	1-4	cm).
45,	however	in	2006	the	majority	(61%)	are	now	found	in	             	    Results:	 FNAB	 demostrated	 7	 benign	 HCN	 (which	
patients	older	than	age	45.	From	1988	to	2003	there	has	             were	 considered	 as	 negative	 preoperative	 findings),	 8	
been	an	increasing	incidence	of	all	sizes	of	PTC	in	all	age	         HCN	 with	 atypia	 (positive	 preoperative);	 7	 suspected	
groups;	however	the	largest	increase	has	been	in	tumors	             cancers	 with	 HC	 (positive	 preoperative);	 and	 2	 cancers	
less	than	1	cm	in	patients	older	than	45	years.	Forty-three	         with	Hürthle	cells	(positive	preoperative).	LNAB	showed	
percent	of	tumors	in	older	patients	are	now	1cm	or	less,	            a	microfollicular	structure	in	14	nodules	(positive	preop-
while	only	34%	are	1	cm	or	less	in	younger	patients.	The	            erative)	and	a	mixed	micro-macrofollicular	feature	in	10	
rates	 of	 invasion	 and	 the	 presence	 of	 distant	 metastasis	    nodules	 (negative	 preoperative).	 Postoperative	 findings	
have	remained	relatively	stable	from	1988	to	2003	in	both	           were:	 benign	 (negative)	 16,	 carcinoma	 (positive)	 8.	The	
age	 groups,	 but	 the	 relative	 incidence	 of	 multifocal	 dis-    sensitivity	 and	 specificity	 for	 FNAB	 were	 87.5%	 (7/8,	
ease	 has	 increased	 10%	 and	 is	 now	 present	 in	 approxi-       95%	C.I.:	64.5-100%)	and	37.5%	(6/16,	95%	C.I.:13.7-61,	
mately	25%	of	all	cases	of	papillary	thyroid	cancer.                 2%)	respectively;	and	for	LNAB	were	87.5%	(7/8,	95%	
	    Discussion:	The	demographics	of	patients	with	PTC	              C.I.:64.5-100%)	and	75.0%	(12/16,	95%	C.I.:53.8-96.2%),	
are	evolving	with	the	peak	incidence	shifting	from	the	3rd	          respectively.	 FNAB	 results	 were	 significantly	 different	
decade	to	the	4th	and	5th	decades	of	life.	Since	under	the	          from	post-operative	result	(McNemar’s	test,	Exact	2-sided	
current	AJCC	staging	system,	only	patients	older	than	age	           p=0.012),	while	LNAB	results	were	not	(McNemar’s	test,	
45	can	be	classified	as	stage	III	or	IV,	the	increasing	age	         Exact	2-sided	p=0.375).	Youden’s	index,	a	global	measure	
of	patients	with	PTC	will	have	important	implications	for	           of	 accuracy,	 was	 high	 for	 LNAB	 (0.62,	 95%	 C.I.:	 0.31-
staging	 and	 subsequent	 treatment.	 The	 increasing	 inci-         0.94)	but	not	for	FNAB	(0.25,	95%	C.I.:	-0.08-0.58).
dence	of	tumors	less	than	1	cm	in	the	older	age	groups	also	              Conclusion:	 These	 data	 confirm	 previous	 findings	
leads	to	speculation	that	the	incidental	discovery	of	PTC	           that	LNAB	is	more	specific	than	FNAB	and	can	be	used	


                                                               – 151 –
                                             ABSTRACTS – Thyroid Disease

for	 preoperative	 selection	 of	 thyroid	 nodules	 containing	       	    Conclusion:	Iodine	intake	from	fast	food	restaurants,	
Hürthle	cells.                                                        a	 major	 source	 of	 nutrition	 for	 many	 Americans,	 may	
                                                                      be	 low	 unless	 milk	 shakes,	 iodinated	 bread,	 or	 fish	 are	
Abstract #1014                                                        consumed.

IODINE CONTENT IN FAST FOODS:                                         Abstract #1015
COMPARISON BETWEEN TWO US FAST FOOD
CHAINS                                                                SIMULTANEOUS DIAGNOSIS OF MULTIFOCAL
                                                                      METASTATIC PAPILLARY THYROID
Sun Lee, MD, Angela M. Leung, MD, Xuemei He, MD,                      CARCINOMA AND FOLLICULAR LYMPHOMA
Lewis E. Braverman, MD, FACE,
Elizabeth N. Pearce, MD, MSc                                          Sandra L. Weber, MD, FACE, Christopher Woody,
                                                                      John Neuffer
	    Objective:	 To	 determine	 the	 iodine	 content	 in	 food	
items	from	popular	fast	food	chains	in	the	US.                        	    Objective:	To	describe	a	case	of	simultaneously	diag-
	    Methods:	 Use	 of	 iodized	 salt	 in	 food	 preparation	         nosed	thyroid	cancer	and	lymphoma.
was	 determined	 by	 phone	 calls	 and	 emails	 to	 various	          	    Case Presentation:	A	previously	healthy	55-year-old	
fast	food	chains	in	the	US.	Burger	King	and	McDonald’s	               woman	 with	 recently	 diagnosed	 osteopenia,	 taking	 cal-
were	 selected	 for	 further	 evaluation	 of	 food	 iodine	 con-      cium	and	Vitamin	D,	presented	with	a	new	palpable	left	
tent,	as	Burger	King	endorses	use	of	iodized	salt	whereas	            neck	mass.	She	also	complained	of	multiple	lumps	in	both	
McDonald’s	 does	 not.	 Seven	 comparable	 items	 were	               breasts.	 She	 underwent	 left	 neck	 lymph	 node	 resection	
selected	from	each	venue.	Two	restaurants	for	each	venue	             and	multiple	breast	biopsies.	The	breast	biopsies	were	all	
in	the	Boston	area	were	selected	at	random,	and	two	items	            benign.	 The	 neck	 mass	 was	 diagnosed	 as	 papillary	 thy-
per	 category	 from	 each	 restaurant	 were	 purchased.	 The	         roid	 carcinoma	 metastatic	 to	 a	 lymph	 node.	 She	 under-
iodine	content	of	two	samples	of	each	homogenized	item	               went	near	total	thyroidectomy	and	lymph	node	dissection.	
was	 measured	 spectrophotometrically	 by	 the	 method	 of	           Multifocal,	papillary	thyroid	carcinoma	of	the	thyroid	was	
Benotti	et	al.                                                        found	in	both	lobes.	The	largest	focus	was	in	the	left	lobe,	
	    Results:	The	average	iodine	content	per	item	was	as	             0.8	 cm	 and	 extending	 into	 the	 perithyroidal	 soft	 tissue.	
follows:	 for	 McDonald’s;	 Big	 Mac	 with	 cheese	 16.7mg,	          Nine	of	39	lymph	nodes	were	positive	for	metastatic	pap-
small	 French	 Fries	 2.7mg,	 Filet-o-Fish	 69.9mg,	 Southern	        illary	 thyroid	 cancer.	 Some	 of	 the	 16	 left	 jugular	 lymph	
Style	Chicken	Sandwich	5.3mg,	Happy	Meal	Hamburger	                   nodes,	none	with	evidence	of	metastatic	papillary	thyroid	
4.3mg,	 Chicken	 McNuggets	 3.0mg,	 12-oz	 Vanilla	 Shake	            cancer,	showed	partial	effacement	of	architecture.	Several	
163.7mg;	for	Burger	King;	Whopper	with	cheese	25.8mg,	                of	the	follicles	were	atypical	showing	a	monotonous	popu-
small	French	Fries	4.3mg,	BK	Big	Fish	43.5mg,	Original	               lation	of	centrocytes	without	polarization	or	lingibis	body	
Chicken	 Sandwich	 163.6mg,	 BK	 Kids	 meal	 hamburger	               macrophages.	Immunohistochemical	staining	showed	that	
3.9mg,	 4-piece	 Chicken	 tenders	 2.1mg,	 12-oz	 Vanilla	            the	 atypical	 follicles	 were	 positive	 for	 CD20	 and	 CD10	
Shake	147.8mg.	Further	analysis	of	Burger	King’s	chicken	             (strong)	 and	 overexpressed	 Bcl-2.	 Kappa	 and	 lambda	
sandwich	showed	that	the	source	of	high	iodine	was	the	               light	chain	staining	did	not	show	plasmacytic	differentia-
bread	and	not	the	chicken	patty.	                                     tion.	 These	 findings	 are	 consistent	 with	 in	 situ	 localiza-
	    Discussion:	 NHANES	 III	 (1988-1994)	 reported	 a	              tion	of	follicular	lymphoma.	She	completed	an	evaluation	
decrease	 in	 the	 median	 urinary	 iodine	 from	 320	 mg/L	 to	      for	lymphoma	including	Positron	Emission	Tomography	
145	mg/L	compared	to	NHANES	I	(1971-1974).	Adequate	                  (PET)	scan	and	bone	marrow	biopsy	which	did	not	show	
iodine	 intake	 is	 especially	 important	 in	 pregnant	 and	         any	 evidence	 of	 lymphoma.	 She	 underwent	 radioactive	
lactating	 women	 for	 normal	 fetal	 and	 neonatal	 neurode-         iodine	 therapy	 with	 post	 treatment	 uptake	 in	 the	 thyroid	
velopment.	Given	the	high	consumption	of	fast	foods	in	               bed	and	neck	area	right	of	midline.	There	was	no	abnor-
America,	 two	 fast	 food	 chains	 were	 selected	 to	 assess	        mal	distant	uptake.	At	one	year	after	resection	she	is	with-
iodine	content.	Despite	the	difference	in	the	use	of	iodized	         out	evidence	of	lymphoma	or	papillary	thyroid	cancer.
salt	in	food	preparation,	the	iodine	contents	appear	to	be	           	    Discussion:	 According	 to	 The	 National	 Cancer	
similar	 between	 comparable	 items	 of	 McDonald’s	 and	             Institute,	 in	 2009	 there	 were	 an	 estimated	 37,200	 new	
Burger	King	except	for	Burger	King’s	chicken	sandwich,	               cases	of	thyroid	cancer,	27,200	in	women	and	74,490	new	
most	 likely	 due	 to	 the	 high	 iodine	 content	 in	 the	 bread	    cases	of	lymphoma,	33,860	in	women	with	29,900	identi-
from	iodate	used	as	a	dough	conditioner.	Items	containing	            fied	as	Non-Hodgkin	lymphoma.	The	incidence	of	thyroid	
milk	and	fish	had	the	highest	iodine	content.                         cancer	 is	 15	 per	 100,000	 white	 women.	 The	 incidence	



                                                                – 152 –
                                             ABSTRACTS – Thyroid Disease

of	 lymphoma	 is	 19.8	 per	 100,000	 white	 women,	 17.2	            goiters,	11	follicular	adenomas	and	5	oxifilic	adenomas).	
per	 100,000	 for	 Non-Hodgkin	 lymphoma.	 The	 inciden-              The	 highest	 sensitivity	 of	 ultrasound	 characteristics	 to	
tal	 identification	 of	 follicular	 lymphoma	 in	 this	 woman	       identify	 thyroid	 carcinoma	 were:	 microcalcifications	
prompted	an	extensive	evaluation	for	lymphoma	in	other	               84%,	hypoechogenicity	76%	and	irregular	margins	94%.	
locations.	 Because	 the	 neck	 lymphoma	 overexpressed	              Independent	 risk	 factors	 to	 predict	 thyroid	 carcinoma	
Bcl-2,	 bone	 marrow	 PCR	 (polymerase	 chain	 reaction)	             were:	microcalcifications	(OR	13.24,	IC	95%	5.52-27.59,	
testing	for	Bcl-2	major	break	point	region	and	microclus-             p=0.0001)	 irregular	 margins	 and	 local	 invasiveness	 (OR	
ter	region	was	performed.	PET	scanning	which	can	distin-              3.71,	 IC,	 95%	 1.44-9.58,	 p=0.007).	 Hypoechogenicity	
guish	metabolically	more	active	cells	like	thyroid	cancer	            with	 microcalcifications	 had	 the	 greatest	 associated	 risk	
and	lymphoma	cells	is	also	helpful	in	determining	extent	             (OR	12.69,	p<0.0001).	In	addition,	hypoechogenicity	and	
of	disease.                                                           irregular	 margins	 and	 local	 invasiveness	 predicted	 also	
	     Conclusion:	The	simultaneous	diagnosis	of	two	can-              thyroid	carcinoma	(OR	3.05,	p<0.002).
cers	is	distinctly	unusual.	As	part	of	the	therapeutic	inter-         	    Conclusion:	Sonographic	findings	significantly	asso-
vention	of	papillary	thyroid	cancer,	lymph	node	dissection	           ciated	with	differentiated	thyroid	cancer	were:	hypoecho-
is	 a	 standard	 process	 with	 the	 possibility	 of	 identifying	    genicity,	microcalcifications,	irregular	margins	and	inva-
simultaneous	lymphoma	as	described	here.                              sion	to	adjacent	tissue.	The	presence	of	hypoechogenicity	
                                                                      associated	with	microcalcifications	and	hypoechogenicity	
Abstract #1016                                                        associated	 with	 irregular	 margins	 and	 invasion	 were	 the	
                                                                      most	 useful.	 Sonographic	 characteristics	 of	 thyroid	 nod-
UTILITY OF HIGH RESOLUTION ULTRASOUND                                 ules	 are	 useful	 to	 suspect	 malignancy	 and	 help	 to	 guide	
IN THE CHARACTERIZATION AND                                           further	 evaluation	 with	 fine	 needle	 aspiration	 biopsy	 or	
IDENTIFICATION OF DIFFERENTIATED                                      surgery.
THYROID CARCINOMA
                                                                      Abstract #1017
Kenny Sofía Joya Péñate, MD,
Bernardo Pérez Enriquez, MD, Paloma Almeda,	MD                        A GENOMIC TEST FOR ACCURATE
                                                                      IDENTIFICATION OF BENIGN THYROID
	    Objective:	 To	 identify	 ultrasonographic	 characteris-         NODULES
tics	for	recognizing	differentiate	thyroid	carcinoma	from	
benign	lesions.	Due	to	the	high	prevalence	of	thyroid	nod-            Richard Burnham Lanman, MD,
ules,	and	its	association	with	thyroid	carcinoma	in	about	            Giulia C. Kennedy, PhD, Nusrat Rabbee, PhD,
5%	 of	 cases,	 it	 is	 important	 to	 develop	 a	 cost-effective	    Jonathan Wilde, PhD, Hui Wang, PhD,
strategy	for	its	evaluation.	Neck	ultrasound	is	a	noninva-            Darya Chudova, PhD, Eric Wang, PhD,
sive	and	relatively	inexpensive	tool	that	can	be	useful	for	          Camila Friedlander, PhD, Jessica Reynolds,
evaluation	of	thyroid	nodules.                                        Ed Tom, Morita Pagan, PhD, Charles Wang, MD,
     Methods:	Cross-sectional	study	to	evaluate	the	util-             Lyssa Friedman, RN, MPA, Martha Zeiger, MD,
ity	of	neck	ultrasound	to	identify	thyroid	carcinoma.	We	             Electron Kebebew, MD, Juan Rosai, MD,
studied	 147	 patients	 whom	 underwent	 thyroid	 surgery	            Virginia LiVolsi, MD
between	January	2005	and	December	2007.	All	patients,	
before	surgery,	had	neck	ultrasound	and	fine	needle	aspi-             	    Objective:	 To	 develop	 a	 molecular	 test	 on	 thyroid	
ration	 biopsy	 performed.	 For	 each	 sonographic	 sing,	 we	        nodule	 fine	 needle	 aspirates	 (FNAs)	 that	 provides	 accu-
established	 sensitivity,	 specificity,	 positive	 and	 negative	     rate	diagnostic	information	on	nodules	with	indeterminate	
predictive	values	considering	the	final	pathology	report.	In	         cytopathologic	features.	The	literature	reports	that	~	20%	
addition,	odds	ratio	was	estimated.	The	ultrasound	charac-            of	thyroid	nodules	aspirated	by	FNAs	result	in	indetermi-
teristics	were	evaluated	by	two	blinded	endocrinologists.	            nate	cytopathology	diagnoses.	Due	to	the	ambiguity	of	the	
Also,	 fine	 needle	 aspiration	 biopsies,	 when	 performed,	         results,	many	of	these	patients	undergo	hemi-	or	total	thy-
were	evaluated	considering	the	final	pathology	diagnosis.             roidectomy,	yet	only	30%	of	these	cases	are	subsequently	
	    Results:	Mean	age	was	42.8±14.89	years	(18-77)	and	              shown	to	be	malignant	on	histopathology.	More	definitive	
129	(87.8%)	cases	were	women.	In	92	(62.6%)	cases	mul-                diagnostic	 tests	 performed	 on	 thyroid	 FNAs	 would	 be	
tiples	nodules	were	found.	In	81	cases	final	diagnosis	was	           desirable,	as	this	would	reduce	the	number	of	patients	with	
papillary	thyroid	carcinoma,	6	of	which	were	reported	as	             benign	 conditions	 subjected	 to	 surgery	 and	 its	 sequelae,	
microcarcinomas	(67	classic,	13	follicular	and	1	tall-cell	           such	as	dependence	on	life-long	thyroid	hormone	replace-
type).	 Twelve	 cases	 were	 follicular	 thyroid	 carcinomas	         ment.	 Many	 studies	 have	 used	 molecular	 analysis	 to	 try	
and	in	54	cases	benign	lesions	were	diagnosed	(38	colloid	            to	determine	which	“indeterminate”	cytology	samples	are	


                                                                – 153 –
                                             ABSTRACTS – Thyroid Disease

malignant.	We	use	a	different	approach,	i.e.,	we	identify	            any	 intervention.	 A	 73-year-old	 woman	 with	 no	 H/O	
those	indeterminate	nodules	which	are	benign.                         thyroid	disease	developed	new	onset	Afib	with	dyspnea.	
	    Methods:	 We	 used	 genome-wide	 mRNA	 expres-                   Pulmonary	embolism	was	ruled	out	by	CT	angiography.	
sion	 analysis	 to	 measure	 >247,186	 transcripts	 including	        Additionally,	she	needed	amiodarone	for	controlling	Afib.	
alternatively-spliced	 genes	 in	 849	 thyroid	 nodules	 com-         TFTs	showed	TSH	0.19	mU/L,	freeT4	2.4	ng/dL	with	fur-
prising	subtypes	which	result	in	indeterminate	cytopathol-            ther	worsening	over	next	few	days.	She	was	successfully	
ogy.	Machine-learning	algorithms	utilizing	expert	surgical	           treated	 with	 both	 methimazole	 (60	 mg/day)	 and	 predni-
pathology	 over-reads	 as	 the	 gold	 standard	 were	 com-            sone	(40	mg/day)	to	control	thyrotoxicosis	over	5	months	
bined	 to	 develop	 a	 multi-gene	 molecular	 classifier	 that	       while	 amiodarone	 was	 discontinued.	A	 58-year-old	 man	
accurately	 distinguishes	 benign	 from	 malignant	 thyroid	          with	 H/O	 cardiomyopathy	 (ejection	 fraction	 20%),	 post	
lesions.	We	also	developed	improved	laboratory	protocols	             AICD	 on	 amiodarone	 since	 2007	 developed	palpitations	
for	collection	of	thyroid	fine-needle	aspirates	and	subse-            10	 days	 prior	 to	 admission	 and	 was	 found	 to	 have	TSH	
quent	extraction	of	nucleic	acid	from	these	specimens.	We	            0.014	mU/L,	freeT4	>7.7	ng/dL	and	freeT3	23.1	pg/dL	.	
successfully	employed	these	protocols	across	21	academic	             Methimazole	was	started	but	symptoms	persisted	and	he	
and	community-based	sites	in	the	U.S.                                 was	admitted	with	wide	complex	tachycardia	(150	beats/
	    Results:	The	multi-gene	classifier	utilizes	~200	gene	           min).	Since	it	was	difficult	to	determine	the	type	of	AIT,	
transcripts	 and	 multi-dimensional	 analytical	 methods	             patient	was	started	on	both	methimazole	and	steroids	and	
to	 achieve	 an	 overall	 cross-validated	 accuracy	 of	 >95%	        amiodarone	was	discontinued.	He	continued	to	have	recur-
when	 tested	 on	 prospectively	 collected	 thyroid	 FNAs.	           rent	 ventricular	 tachycardia	 (VTach)	 despite	 maximal	
Large	 numbers	 of	 genes	 are	 necessary	 to	 achieve	 high	         doses	of	methimazole,	intravenous	steroids,	and	multiple	
performance	across	the	myriad	of	thyroid	nodule	subtypes	             anti-arrhythmics	 and	 thus,	 lithium	 and	 cholestyramine	
encountered	in	clinical	practice.	Preliminary	performance	            were	added	to	try	and	control	thyrotoxic	state.	Despite	all	
characteristics	of	this	test	show	ROC	curve	AUC	values	               efforts,	he	had	uncontrolled	VTach	and	died.
of	 0.94,	 indicating	 reasonable	 sensitivity	 as	 a	 function	      	    Discussion:	The	above	cases	highlight	the	spectrum	
of	 specificity.	 Furthermore,	 the	 false	 negative	 rate	 we	       of	 presentation	 and	 the	 complexity	 of	 managing	 AIT.	
observe	 with	 our	 molecular	 classifier	 is	 no	 greater	 than	     Though	 radioactive	 iodine	 uptake	 scan,	 cytokines	 like	
that	of	FNAs	diagnosed	as	benign	by	cytopathology.	                   interleukin-6	and	color	flow	doppler	of	thyroid	have	been	
     Conclusion: Using	 several	 different	 classifiers	 we	          proposed	to	distinguish	type	I	and	II	AIT,	many	times,	it	is	
have	identified	a	subset	of	samples	whose	surgical	pathol-            difficult	to	clearly	determine	the	type.	This	prompts	treat-
ogy	diagnoses	are	highly	inconsistent	with	their	molecular	           ment	 with	 both	 thionamides	 and	 steroids.	 A	 diagnostic	
profiles.	 These	 discordant	 calls	 are	 counted	 as	 classifier	    modality	that	would	clearly	distinguish	the	2	types	would	
errors,	but	in	fact	may	be	due	to	inadequate	sampling	of	             be	 beneficial	 and	 more	 research	 is	 needed	 in	 this	 area.	
the	thyroid	nodule	during	the	FNA	process	or	to	ambigu-               Finally,	whether	amiodarone	should	be	continued	or	not	is	
ous	surgical	pathology	diagnoses.                                     a	matter	of	contention	as	well.
                                                                      	    Conclusion:	The	presentation	of	AIT	can	range	from	
Abstract #1018                                                        asymptomatic	 to	 severe	 thyrotoxicosis	 and	 is	 associated	
                                                                      with	 significant	 morbidity	 and	 potential	 mortality.	 It	 is	
BEWARE OF THE SPECTRUM OF AMIODARONE                                  essential	 that	 amiodarone	 be	 used	 judiciously	 and	 when	
INDUCED THYROTOXICOSIS (AIT)                                          used,	thyroid	status	be	monitored	periodically.

Praveena Gandikota, MD, Sandra Foo, MD,                               Abstract #1019
Lynn Allen, MD
                                                                      GRAVES’ DISEASE PRESENTING AS
	    Objective:	 To	 describe	 varied	 presentations	 of	 AIT	        INTRACTABLE VOMITING
ranging	from	benign	to	fatal	outcomes	and	challenges	of	
management.                                                           Mohsen Eledrisi, MD, FACE, Fayez Bishara, MD, MRCP
	    Case Presentation:	A	61-year-old	woman	with	H/O	
atrial	 fibrillation(Afib),	 aortic	 and	 mitral	 valve	 replace-     	    Objective:	To	 describe	 a	 patient	 with	 thyrotoxicosis	
ments,	 no	 thyroid	 disease,	 on	 amiodarone	 for	 >5	 years	        due	to	Graves’	disease	who	had	an	unusual	presentation	
was	 evaluated	 due	 to	 abnormal	 thyroid	 function	 tests	          with	predominantly	vomiting.
(TFTs):	TSH	<0.03	mU/L,	freeT4	3.1	ng/dL	and	totalT3	                      Case Presentation:	A	20-year-old	unmarried	female	
192	 ng/dL.	 Since	 she	 had	 no	 symptoms/signs	 of	 thyro-          was	evaluated	for	persistent	vomiting	for	3	months	along	
toxicosis,	she	was	closely	monitored	without	discontinu-              with	unintentional	weight	loss	of	about	9	kilograms.	Her	
ing	amiodarone.	Over	3	months,	TFTs	normalized	without	               past	medical	history	was	not	significant	and	she	was	not	


                                                                – 154 –
                                             ABSTRACTS – Thyroid Disease

taking	 any	 medications.	 On	 physical	 examination,	 she	          for	 the	 last	 five	 years.	 He	 presented	 with	 complaints	 of	
looked	cachectic,	her	weight	was	35.5	kg,	body	mass	index	           generalized	 weakness	 and	 weight	 loss	 of	 fifteen	 pounds	
was	14.6	kg/m2	,	blood	pressure	was	130/80	mmHg,	and	                over	the	last	three	months,	diarrhea	and	palpitations	over	
pulse	was	130	beats	per	minutes.	She	had	no	fever.	Her	              the	 last	 four	 weeks.	 On	 physical	 exam	 he	 was	 found	 to	
thyroid	was	mildly	enlarged	with	no	palpable	nodules	or	             be	in	atrial	fibrillation	and	thyroid	exam	was	normal.	His	
lymph	nodes.	Examination	of	the	eyes	and	cardiovascular,	            labs	 showed	 TSH	 0.01	 µIU/mL,	 free	 T4	 5.6	 ng/dL	 and	
respiratory,	gastrointestinal	and	neurological	systems	was	          T3	421	ng/dL.	An	ultrasound	of	the	thyroid	was	normal	
normal.	 Laboratory	 data	 showed	 a	 normal	 hemoglobin,	           without	 any	 nodules.	 A	 technetium	 99M-pertechnetate	
electrolytes,	 and	 liver	 function	 tests.	 Because	 of	 intrac-    scan	obtained	because	of	inability	to	get	an	iodine	uptake	
table	 vomiting,	 the	 patient	 was	 admitted	 to	 the	 hospital	    due	to	recent	use	of	iodinated	contrast	showed	no	detect-
for	 further	 evaluation.	 An	 esophagogastroduodenoscopy	           able	tracer	uptake	in	the	thyroid	gland	and	findings	con-
showed	mild	gastritis	which	did	not	explain	the	patient’s	           sistent	 with	 thyroiditis.	 The	 patient	 was	 diagnosed	 with	
complaints.	 Thyroid	 function	 tests	 were	 obtained;	 TSH	         AIT	type	II	and	was	started	on	metoprolol	and	high	dose	
was	 <	 0.01	 mIU/L	 (normal,	 0.35-4.5)	 and	 Free	 T4	 was	        prednisone.	The	dose	of	prednisone	was	increased	in	two	
77	pmol/L	(normal,	9-19).	A	technitium99	scan	showed	a	              weeks	due	to	lack	of	response.	In	four	weeks	an	empiric	
homogenous	increased	uptake	in	both	thyroid	lobes	with	              trial	of	methimazole	was	used	because	of	further	increases	
a	significantly	increased	uptake	at	17	%	(normal,	2-4	%).	           in	free	T4	and	T3.	Due	to	complaints	of	anxiety,	insom-
The	diagnosis	of	Graves’	disease	was	made	and	she	was	               nia	 and	 agitation	 the	 dose	 of	 prednisone	 was	 reduced.	
started	on	Methimazole	10	mg	twice	daily	and	Propranolol	            After	 8	 weeks	 from	 initial	 diagnosis	 the	 patient	 had	 to	
40	mg	twice	daily.	Her	condition	significantly	improved;	            be	readmitted	to	the	hospital	due	to	severe	weakness	and	
vomiting	 resolved	 and	 she	 was	 discharged	 after	 staying	       altered	mental	status.	His	labs	showed	TSH	<	0.01	µIU/
in	the	hospital	for	7	days.	After	6	weeks,	she	reported	no	          mL,	free	T4	5.2	ng/dL	and	T3	444	ng/dL.	Iodine	123	thy-
complaints	and	had	gained	10	kilograms.	TSH	was	<	0.01	              roid	scan	showed	absence	of	tracer	uptake	in	the	thyroid	
and	Free	T4	was	17.4.                                                consistent	 with	 Amiodarone	 induced	 thyroiditis.	 A	 trial	
      Discussion:	 The	 diagnosis	 of	 thyrotoxicosis	 is	 gen-      of	plasma	exchange	was	decided	up	on	due	to	persistent	
erally	 suspected	 on	 clinical	 grounds.	 Typical	 symp-            thyrotoxicosis	 with	 exacerbation	 of	 his	 comorbidities.	
toms	 of	 sympathetic	 overactivity	 are	 usually	 observed.	        His	 labs	 after	 the	 first	 plasma	 exchange	 showed	 free	T4	
Gastrointestinal	 manifestations	 of	 thyrotoxicosis,	 which	        3.8	ng/dL	and	T3	282	ng/dL.	He	received	a	total	of	three	
are	not	commonly	reported,	have	included	increased	fre-              plasma	exchanges	over	the	course	of	the	next	two	weeks.	
quency	of	stools	and	weight	loss	due	to	increased	calorie	           His	mental	status	improved	and	his	free	T4	at	the	time	of	
requirement	or	malabsorption.	The	patient	we	are	report-             discharge	was	2.2	ng/dL	and	T3	179	ng/dL	and	were	stable	
ing	had	an	unusual	presentation,	as	she	presented	with	per-          and	not	increasing.
sistent	vomiting.	The	diagnosis	was	delayed	until	thyroid	           	     Discussion:	 AIT	 type	 II	 is	 a	 type	 of	 destructive	
function	tests	were	obtained.                                        inflammatory	 thyroiditis.	 It	 can	 occur	 any	 time	 during	
	     Conclusion:	 Thyrotoxicosis	 should	 be	 suspected	 in	        amiodarone	 therapy	 or	 even	 long	 after	 discontinuation.	
patients	who	present	with	prolonged	and	unexplained	gas-             Glucocorticoids	 have	 been	 considered	 to	 be	 the	 drug	
trointestinal	symptoms	such	as	vomiting.	This	will	assure	           of	 choice.	 Individual	 case	 reports	 have	 shown	 plasma	
timely	diagnosis	and	treatment.                                      exchange	as	a	therapeutic	option	for	rapid	control	of	thy-
                                                                     rotoxicosis	due	to	other	causes.	This	case	demonstrates	its	
Abstract #1020                                                       potential	utility	for	acute	treatment	of	AIT	type	II.
                                                                     	     Conclusion:	 Plasma	 exchange	 can	 be	 a	 therapeutic	
THERAPEUTIC UTILITY OF PLASMA                                        option	 in	AIT	 type	 II	 not	 responding	 to	 glucocorticoids	
EXCHANGE IN AMIODARONE INDUCED                                       and	may	achieve	more	rapid	control.
THYROTOXICOSIS TYPE II
                                                                     Abstract #1021
Harsha Karanchi, MD, Christopher Leveque, MD,
Dale J. Hamilton, MD, FACP, FACE                                     MALIGNANT STRUMA OVARII

    Objective:	 To	 describe	 improvement	 of	 amiodarone	           Tricia Diane Hislop-Chesnut, MD, Mary Beth Hodge, MD
induced	thyrotoxicosis	(AIT)	type	II	after	use	of	plasma	
exchange.                                                            	    Objective:	 Struma	 Ovarii	 (SO)	 is	 the	 presence	 of	
	   Case Presentation:	 The	 patient	 is	 a	 seventy-seven	          thyroid	tissue	as	a	major	cellular	component	in	an	ovar-
year	old	Caucasian	man	with	history	of	Parkinson’s	dis-              ian	tumor.	It	is	nearly	always	present	in	a	teratoma.	It	is	
ease	 and	 atrial	 fibrillation.	 He	 had	 been	 on	 amiodarone	     found	most	commonly	between	the	ages	of	40	and	60	and	


                                                               – 155 –
                                              ABSTRACTS – Thyroid Disease

patients	 typically	 present	 with	 a	 pelvic	 mass,	 hyperthy-        Abstract #1022
roidism	or	ascites.	Malignancy	in	the	setting	of	SO	is	rare	
and	 the	 incidence	 is	 thought	 to	 be	 0.1%	 to	 0.5%	 of	 all	     THYROID STIMULATING HORMONE: A
ovarian	tumors.	We	present	a	case	report	of	a	middle	aged	             USEFUL MARKER FOR THYROID CANCER?
female	with	a	history	of	a	toxic	multinodular	goiter	who	
presented	with	recurrent	abdominal	pain	and	was	found	to	              Michael Pakdaman, MD, Jacques How, MB, ChB,
have	malignant	SO	at	the	time	of	laparotomy.                           MRCP, MD, Rania Ywakim, MD,
	     Case Presentation:	A	57-year-old	female	with	a	his-              Richard J. Payne, MD, FRCS(C)
tory	 of	 a	 right	 thyroid	 lobectomy	 24	 years	 ago	 for	 ade-
nomatous	goiter	and	treatment	with	radioactive	iodine	5	               	    Objective:	 Thyrotropin	 (TSH)	 is	 a	 known	 thyroid	
years	ago	for	a	toxic	left	nodule	presented	with	abdominal	            growth	factor.	We	aim	(1)	to	compare	preoperative	serum	
pain.	She	had	noted	postprandial	pain	for	the	last	several	            TSH	 among	 patients	 with	 documented	 well	 differenti-
months	and	she	underwent	a	cholecystectomy	for	chole-                  ated	 thyroid	 carcinoma	 versus	 patients	 with	 benign	 thy-
lithiasis.	 Because	 of	 persistent	 abdominal	 pain,	 she	 had	       roid	 disease	 and	 (2)	 to	 search	 for	 a	 specific	 relationship	
a	CT	scan	of	her	abdomen	and	pelvis.	It	was	remarkable	                between	TSH	levels	and	papillary	microcarcinoma	(PMC)	
for	 a	 non-obstructing	 internal	 hernia	 and	 a	 1.9	 cm	 right	     incidence.
adnexal	mass	consistent	with	a	benign	dermoid	tumor.	She	              	    Methods:	 We	 reviewed	 1047	 patients	 who	 under-
underwent	 exploratory	 laparotomy,	 lysis	 of	 adhesions,	            went	 total	 thyroidectomy	 at	 our	 university	 teaching	
repair	of	internal	hernia	and	right	oophorectomy.	                     hospital	 between	 2002	 and	 2008.	 Patients	 without	 pre-
      Results:	 The	 pathology	 revealed	 a	 cystic	 teratoma	         operative	TSH	 values	 or	 those	 outside	 the	 normal	 range	
with	struma	ovarii.	Within	the	teratoma,	there	was	a	5	mm	             were	 excluded,	 as	 well	 as	 cases	 of	 poorly	 differentiated	
focal	 neoplastic	 thyroid	 tissue	 consistent	 with	 follicular	      carcinoma	(n=576).	Values	were	compared	using	the	chi-
variant	 of	 papillary	 carcinoma.	 Her	 thyroid	 stimulating	         squared	test.
hormone	(TSH)	5	months	prior	was	3.4	uIU/ml	(0.3-4.5).	                	    Results:	 Our	 results	 yielded	 223	 benign	 cases,	 346	
She	 then	 underwent	 a	 completion	 thyroidectomy	 which	             cases	 of	 papillary	 carcinoma,	 4	 follicular	 carcinomas,	
was	consistent	with	an	adenomatous	goiter.	A	thyroglobu-               and	 3	 Hürthle	 cell	 carcinomas.	 The	 incidence	 of	 malig-
lin	level	drawn	1	month	after	thyroidectomy	was	0.2	ng/                nancy	was	43.8%	in	patients	with	serum	0.4	≤	TSH	<	0.8	
ml	 (<33.1ng/ml)	 with	 negative	 antithyroglobulin	 anti-             mIU/l	(p	<	.001)	versus	56.8%	for	those	with	0.8	≤	TSH	
body.	A	 CT	 scan	 of	 her	 abdomen	 and	 pelvis	 repeated	 6	         <	1.4	mIU/l	(p	=	0.124)	and	71.3%	for	those	with	1.4	≤	
months	after	her	laparotomy	did	not	show	any	evidence	of	              TSH	 <	 4.0	 mIU/l	 (p	 <	 .001).	 No	 statistically	 significant	
metastatic	disease.                                                    differences	 in	 the	 mean	 serum	 free	T4	 and	 free	T3	 con-
	     Conclusion:	 This	 is	 a	 case	 of	 a	 patient	 with	 a	 his-    centrations	were	found	between	the	malignant	v/s	benign	
tory	 of	 a	 toxic	 multinodular	 goiter	 status	 post	 radioac-       groups.	 Tumor	 size	 was	 not	 found	 to	 increase	 in	 paral-
tive	iodine	therapy,	which	was	incidentally	found	to	have	             lel	with	TSH	concentrations	and	there	was	no	association	
malignant	change	of	struma	ovarii.	Her	follow	up	has	been	             between	the	serum	TSH	values	and	the	frequency	of	extra-
reassuring	for	surgical	cure.	Earlier	studies	suggested	that	          thyroidal	extension.
small	areas	of	nuclear	changes	without	evidence	of	inva-               	    Discussion:	This	study	demonstrates	that	the	risk	of	
sion	and/or	metastases	were	not	diagnostic	of	malignancy.	             malignancy	in	thyroid	nodules	increases	in	parallel	with	
However,	 recent	 studies	 have	 suggested	 that	 malignant	           higher	serum	TSH	concentrations	within	the	normal	range.	
SO	should	be	monitored	for	at	least	20	years,	as	there	is	             Further	studies	are	necessary	to	assess	the	predictive	value	
potential	for	metastases.	Patients	should	be	followed	with	            of	this	association	and	its	potential	clinical	application.
periodic	imaging	studies	and	thyroglobulin	levels	for	any	             	    Conclusion:	Preoperative	serum	TSH	concentrations	
evidence	of	recurrent	disease.	Treatment	and	follow	up	of	             may	serve	as	a	predictor	for	thyroid	malignancy.
these	patients	has	been	variable	due	to	the	few	cases	iden-
tified	in	the	literature.




                                                                 – 156 –
                                            ABSTRACTS – Thyroid Disease

Abstract #1023                                                      Abstract #1024

TOTAL THYROIDECTOMY SECTIONING AND                                  ECTOPIC SITES OF NODAL METASTASIS IN
YIELD OF INCIDENTAL DISEASE                                         PAPILLARY THYROID CARCINOMA:
                                                                    A REVIEW OF 10 CASES
Michael Pakdaman, MD, Louise Rochon, MD,
Richard J. Payne, MD                                                Michael Pakdaman, MD, Dipti Kamani, MD,
                                                                    Gregory W. Randolph, MD, FACS
	    Objective:	The	thickness	of	pathologic	sectioning	of	
the	 surgical	 thyroidectomy	 specimen	 is	 variable	 among	              Objective: Papillary	thyroid	carcinoma	is	commonly	
different	 institutions.	 Additionally,	 many	 institutions	        known	to	metastasize	to	regional	nodes	in	the	neck,	with	
choose	only	to	analyze	“representative	sample”	-	sections	          subsequently	 good	 prognostic	 outcomes.	 Metastases	 to	
within	the	portion	of	the	thyroid	with	gross	disease.	This	         ectopic	sites	such	as	the	parapharyngeal	space	and	axilla	
study	 investigates	 our	 previously	 reported	 highest	 inci-      are	rare	and	uncommonly	reported.	We	aim	to	present	the	
dence	of	papillary	microcarcinoma	(PMC)	by	(1)	compar-              rate	 and	 behavior	 of	 papillary	 carcinomas	 with	 ectopic	
ing	yield	of	disease	when	serial	sections	are	submitted	in-         metastases	at	our	institution.
toto	versus	representative	samples	and	(2)	assessing	for	a	               Methods: We	reviewed	all	consecutive	cases	of	neck	
relationship	between	the	number	of	sections-per-gram	of	            thyroidectomy	 and	 neck	 dissection	 performed	 under	
thyroid	tissue	and	rates	of	PMC.                                    one	surgeon	from	2004	to	June	2009	(1030	cases	in	911	
	    Methods:	 Pathology	 results	 were	 reviewed	 for	 all	        patients).	Neck	dissections	were	planned	using	a	standard-
consecutive	total	thyroidectomies	between	2002	and	2008	            ized	algorithm	based	on	preoperative	CT	scan.	All	cases	
(n=1045).	All	specimens	were	serially	sectioned	at	3mm.	            of	papillary	thyroid	carcinoma	(PTC)	in	the	thyroid	bed,	
Specimen	 data	 recorded	 included	 sample	 weight,	 num-           soft	 tissue,	 or	 lymph	 nodes	 were	 recorded	 (512	 cases	 in	
ber	 of	 sections,	 and	 whether	 all	 sections	 were	 assessed	    434	 patients).	 Cases	 of	 ectopic	 nodal	 metastases	 were	
“in-toto”	or	as	a	“representative	sample”	based	on	gross	           identified.
inspection.	 Statistical	 significance	 was	 calculated	 using	           Results:	Of	368	cases	with	PTC	in	the	thyroid	bed,	
chi-squared	analysis.                                               124	 had	 concomitant	 nodal	 disease	 (33.7%).	 10	 surgical	
	    Results:	Among	 the	 790	 thyroids	 submitted	 in-toto,	       cases	 identified	 ectopic	 lymph	 nodes	 (3.8%	 of	 all	 cases	
PMC	incidence	was	53%,	compared	to	39%	in	cases	where	              with	 positive	 nodal	 disease).	 Ectopic	 sites	 included	 the	
representative	samples	were	submitted	(p	<	0.01).	In	cases	         floor	 of	 mouth,	 retropharynx,	 parapharyngeal	 space,	 lat-
where	<=0.6	sections-per-gram	were	submitted,	the	inci-             eral	chest	wall,	axilla,	and	parotid	gland.
dence	of	PMC	was	43%	versus	56%	when	>0.6	sections-                       Discussion: While	rare,	ectopic	sites	of	nodal	metas-
per-gram	were	submitted	(p	<0.001).	The	total	incidence	            tasis	 do	 occur	 in	 patients	 with	 papillary	 carcinoma	 of	
of	PMC	at	our	institution	was	52.0%.	By	extrapolation,	if	          the	 thyroid,	 warranting	 discussion	 on	 the	 importance	 of	
only	representative	samples	were	viewed	at	our	institution	         patients	with	thyroid	cancer	undergoing	preoperative	CT	
and	all	were	sliced	at	5mm	sections,	the	incidence	of	PMC	          from	the	skull	base	to	the	mediastinum.
is	estimated	at	28.6%.                                                    Conclusion: We	 report	 the	 largest	 series	 of	 ectopic	
	    Discussion:	This	indicates	that	thick	sectioning	may	          nodal	metastases	from	papillary	thyroid	carcinoma.
decrease	 the	 yield	 of	 PMC,	 as	 can	 limiting	 pathologic	
analysis	 to	 sections	 involving	 the	 representative	 sample.	    Abstract #1025
These	findings	may	explain	our	previously	reported	high-
est	incidence	of	PMC.                                               POST-PARATHYROIDECTOMY THYROIDITIS
	    Conclusion:	This	study	found	a	higher	yield	of	dis-
ease	when	increased	portions	of	thyroid	tissue	were	ana-            Daniel Rubin, MD, Alan Farwell, MD,
lyzed.	Extrapolation	to	conform	to	conventional	method-             Stephanie Lee, MD, PhD
ology	yields	results	similar	to	previous	literature.
                                                                    	    Objective:	To	describe	a	case	of	post-parathyroidec-
                                                                    tomy	thyroiditis.
                                                                    	    Case Presentation:	 A	 60	 year-old	 female	 with	 no	
                                                                    history	 of	 thyroid	 disease	 presented	 with	 tachycardia,	
                                                                    hypertension,	and	palpitations	11	days	after	undergoing	a	
                                                                    difficult	resection	of	a	340	mg	right	parathyroid	adenoma	




                                                              – 157 –
                                             ABSTRACTS – Thyroid Disease

for	primary	hyperparathyroidism.	Physical	exam	revealed	              disease.	 In	 all	 three	 patients,	 the	 thyroid	 was	 diffusely	
a	palpable	but	non-tender	thyroid	of	normal	size,	a	mild	             swollen	 and	 tender	 on	 examination.	 They	 all	 had	 ele-
tremor	and	no	Graves’	ophthalmopathy.	The	healing	neck	               vated	thyroxine	levels	and	suppressed	thyrotropin	levels.	
scar	had	no	signs	of	inflammation.	Preoperative	TSH	was	              Painful,	subacute	thyroiditis	was	suspected.	Thyroid	scin-
1.90	uIU/mL	(NL	0.35-5.50).	On	postoperative	day	(POD)	               tigraphy	 was	 homogeneous	 with	 elevated	uptake	 indica-
11,	 testing	 showed:	 TSH	 <0.01	 uIU/mL,	 T3	 269	 ng/mL	           tive	of	Graves’	disease	in	all	3	patients.	Two	patients	had	
(NL	60-181),	T4	9.6	mcg/dL	(NL	4.5-10.9),	and	FTI	4.1	                positive	serum	thyrotropin	receptor	antibodies	and	inflam-
(NL	1.0-4.0).	TPO	antibodies	were	negative.	Nuclear	thy-              matory	markers	were	absent.	These	were	not	obtained	in	
roid	 scan	 on	 POD	 15	 showed	 a	 1.8%	 4-hr	 I-123	 uptake	        the	third	patient	as	it	was	felt	that	the	results	of	her	scin-
(NL	5-15%)	with	reduced	visualization	of	the	right	lobe,	             tigraphy	and	thyroid	function	tests	were	sufficient	to	make	
ipsilateral	to	the	surgery.	The	patient	was	treated	only	with	        the	diagnosis.	Two	patients	were	successfully	treated	with	
a	 beta	 blocker	 and	 symptoms	 resolved	 within	 days.	 On	         radioactive	iodine	therapy,	resulting	in	resolution	of	their	
POD	21,	thyroid	tests	were:	TSH	0.02,	T3	169,	and	FT4	                hyperthyroidism	 and	 goiter,	 while	 the	 third	 elected	 to	
1.11	(NL	0.89-1.80).	By	postop	week	9,	the	thyroid	tests	             undergo	thyroidectomy.
normalized	to:	TSH	1.55	and	FT4	1.05.                                 	    Discussion:	 Graves	 disease	 with	 hyperthyroidism	
	     Discussion:	 Post-parathyroidectomy	 thyroiditis	 was	          typically	 presents	 with	 a	 minimally	 or	 non-tender	 dif-
first	reported	in	1992.	Patients	present	within	2	weeks	after	        fusely	 enlarged	 thyroid	 gland.	 It	 is	 less	 common	 for	
surgery	 with	 thyrotoxicosis	 and	 low	 radioactive	 iodine	         patients	with	Graves	to	present	with	marked	thyroid	ten-
thyroid	 uptake.	 Anti-thyroid	 medications	 are	 not	 indi-          derness,	 and	 few	 cases	 have	 been	 reported.	 In	 contrast,	
cated	as	the	low	uptake	suggests	that	the	thyroid	hormone	            patient’s	with	subacute	thyroiditis	classically	present	with	
excess	is	not	from	production	but	of	release	resulting	from	          a	painful	thyroid.
thyroid	 manipulation	 during	 surgery.	 Thyroid	 function	           	    Conclusion:	A	painful	thyroid	can	be	a	less	common	
tends	to	normalize	in	weeks	to	months.	Symptomatic	thy-               way	for	Graves’	disease	to	present.	In	patients	clinically	
rotoxicosis	has	been	reported	in	15-35%	of	parathyroidec-             presenting	 with	 the	 signs	 and	 symptoms	 of	 thyroiditis,	
tomy	patients	followed	prospectively.	Predictors	of	post-             including	 thyroid	 tenderness,	 it	 is	 important	 to	 rule	 out	
parathyroidectomy	 thyroiditis	 are	 having	 the	 procedure	          Graves’	 hyperthyroidism	 by	 performing	 thyroid	 uptake	
done	 in	 a	 community	 vs.	 an	 academic	 setting,	 bilateral	       with	radioactive	iodine.
vs.	unilateral	exploration,	lithium	use,	and	the	absence	of	
a	concurrent	thyroid	lobectomy.	Similar	cases	have	been	              Abstract #1027
reported	 in	 the	 setting	 of	 surgery	 for	 secondary	 and	 ter-
tiary	hyperparathyroidism.	The	present	case	is	notable	for	           NOT ALL THAT LIES IN THE TRACHEA IS
a	nuclear	thyroid	scan	that	localizes	very	low	uptake	to	the	         INVASIVE THYROID CANCER
operative	site.
	     Conclusion:	 Post-parathyroidectomy	 thyroiditis	 is	 a	        Eran Alon, MD, Mark Urken, MD
rare	 but	 possibly	 under-recognized	 cause	 of	 low	 uptake	
thyrotoxicosis.	 Endocrinologists	 should	 be	 aware	 of	 the	        	    Objective:	To	report	on	5	patients	with	suspected	pri-
risk	 of	 thyrotoxicosis	 after	 difficult	 parathyroid	 dissec-      mary	thyroid	neoplasms	with	tracheal	invasion	that	ulti-
tions.	 In	 patients	 at	 risk	 for	 complications	 of	 thyrotoxi-    mately	proved	not	to	be	invasive	thyroid	cancer,	and	in	so	
cosis,	 postoperative	 monitoring	 of	 thyroid	 function	 and	        doing	to	make	clinicians	aware	of	other	tracheal	patholo-
prophylactic	beta	blocker	therapy	should	be	considered.               gies	that	may	mimic	invasive	thyroid	carcinoma.
                                                                      	    Case Presentation:	We	present	a	retrospective	review	
Abstract #1026                                                        of	 5	 cases	 presenting	 with	 suspected	 thyroid	 malignan-
                                                                      cies	with	tracheal	invasion.	3	patients	were	found	to	have	
GRAVES’ HYPERTHYROIDISM PRESENTING AS                                 benign	 pathologies	 (benign	 tracheal	 scarring,	 recurrent	
A TENDER THYROID                                                      laryngeal	nerve	schwanoma,	and	benign	intratracheal	thy-
                                                                      roid	rest),	the	fourth	patient	was	diagnosed	with	a	chon-
Lyndell Cheston Horine, MD, Krishna Bhaghayath, MD,                   drosarcoma	 of	 the	 trachea,	 and	 the	 fifth	 patient	 suffered	
Fred Faas, MD, Antoine Makdissi, MD                                   from	 a	 collision	 tumor	 with	 papillary	 thyroid	 carcinoma	
                                                                      and	squamous	cell	carcinoma	of	the	larynx.
	    Objective:	To	describe	3	patients	who	presented	with	            	    Discussion:	 The	 incidence	 of	 tracheal	 invasion	 in	
a	painful	thyroid	gland	and	hyperthyroidism	secondary	to	             thyroid	carcinoma	is	reported	to	be	between	1%	to	13%	
Graves	disease.                                                       and	 is	 a	 major	 cause	 of	 death.	 Imaging	 studies	 play	 an	
	    Case Presentation:	 Three	 patients	 are	 described	             important	 role	 in	 diagnosis,	 staging,	 treatment	 and	 sur-
who	presented	with	painful	thyroid	goiters	due	to	Graves	             veillance	 of	 thyroid	 neoplasms.	 Ultrasonography,	 MRI	


                                                                – 158 –
                                             ABSTRACTS – Thyroid Disease

or	 Computed	 Tomography	 can	 be	 used	 to	 diagnose	 and	          Abstract #1029
evaluate	the	extent	of	tracheal	involvement.	Mapping	the	
extent	of	loco-regional	disease	is	vital	to	optimal	patient	         THYROTOXIC PERIODIC PARALYSIS-TPP–
consultation	and	surgical	planning.	Tracheal	involvement	            AN UNUSUAL CAUSE OF ACUTE
will	alter	surgical	planning	and	may	require	shave	resec-            QUADRIPLEGIA IN A YOUNG PATIENT
tion,	window	resection	or	circumferential	tracheal	resec-
tion	with	reconstruction.	However,	the	clinician	must	bare	          Saima O. Farghani, MD, Jay A. Sher, MD
in	 mind	 that	 other	 pathologies	 both	 benign	 and	 malig-
nant	 may	 mimic	 invasive	 thyroid	 carcinoma	 and	 falsely	        	     Objective:	 To	 describe	 an	 alarming	 complication	 of	
upstage	the	disease.                                                 hyperthyroidism	characterized	by	sudden	onset	of	muscle	
	    Conclusion:	 Thyroid	 carcinoma	 with	 tracheal	 inva-          paralysis	in	apparently	young	healthy	patients.
sion	 is	 a	 major	 cause	 of	 death	 in	 thyroid	 malignancies.	    	     Case Presentation:	 A	 29-year-old	 healthy	 Asian	
However,	 the	 clinicians,	 radiologists	 and	 pathologists	         woman	presented	with	sudden	onset	weakness	of	her	legs	
should	 keep	 in	 mind	 other	 pathologies	 that	 may	 mimic	        bilaterally.	 Within	 the	 next	 12	 hours	 the	 weakness	 had	
tracheal	invasion.                                                   progressed	upwards	to	involve	her	upper	extremities.	Her	
                                                                     serum	 Potassium	 was	 1.4	 with	 urinary	 potassium	 of	 90	
Abstract #1028                                                       meq/ml.	She	denied	any	history	of	laxative	abuse	or	lico-
                                                                     rice	 intake.	 Detailed	 history	 did	 not	 reveal	 any	 features	
EFFECTS OF SELENIUM SUPPLEMENTATION                                  related	to	hyperfunctioning	of	the	thyroid	gland.	On	phys-
ON TPOAB IN ACTIVE AUTOIMMUNE                                        ical	examination	no	goiter	was	appreciated.	TSH	was	sup-
THYROIDITIS                                                          pressed	at	0.04	and	free	T4	was	2.71.	Patient’s	potassium	
                                                                     was	replaced	intravenously	as	well	as	she	was	started	on	
Slavica	Ciric,	MD                                                    Propylthoiuracil	(PTU)	100	mg	q6hours	and	Propranolol	
                                                                     20	 mg	 q8	 hours.	 Within	 the	 next	 12	 hours	 she	 made	 a	
      Objective:	 In	 several	 prospective	 randomized	 tri-         remarkable	recovery	with	total	improvement	of	her	weak-
als	 it	 has	 been	 shown	 that	 selenium	 supplementation	 in	      ness	in	all	four	limbs.	She	was	discharged	on	potassium	
patients	 with	 autoimmune	 thyroiditis	 (AIT)	 significantly	       supplements	 and	 PTU	 three	 days	 later.	 Repeat	 thyroid	
reduces	serum	thyroid	peroxidase	antibody	(TPOAb)	con-               function	tests	6	weeks	later	were	normal.
centrations	 after	 3	 and	 6	 months	 treatment.The	 effect	 of	    	     Discussion:	 Thyrotoxic	 Periodic	 Paralysis	 (TPP)	
selenium	(Se)	 supplementation	was	 more	 pronounced	 in	            is	 a	 potentially	 lethal	 complication	 of	 hyperthyroidism	
patients	 with	 higher	 TPOAb	 concentrations	 (>1200	 U/            characterized	 by	 muscle	 paralysis	 and	 hypokalemia.	 It	
ml).The	aim	of	our	study	was	to	investigate	the	effects	of	          is	a	well-known	complication	of	thyrotoxicosis	in	20-40	
Se	tretmant	on	patient	with	newly	developed	or	active	AIT	           year	old	Asian	men.	The	attack	is	characterized	by	recur-
and	high	TPOAb	titers.                                               rent,	 episodes	 of	 muscle	 weakness	 that	 range	 from	 mild	
	     Methods:	 Forty	 AIT	 female	 petients(aged	 23	 –	 56	        weakness	 to	 complete	 flaccid	 paralysis.	 Seldom	 cases	
years)	with	elevated	plasma	TPOAb	above1200	U/ml	and	                of	 total	 paralysis	 of	 respiratory,	 bulbar	 and	 ocular	 mus-
basal	TSH	within	the	normal	range	were	included	in	the	              cles	 have	 been	 reported.	 Patients	 usually	 experience	 the	
present	study.All	patients	received	200	µg	sodium	selenite	          attack	after	a	heavy	carbohydrate	rich	meal	as	they	have	
per	day	orally	over	a	period	of	3	months.TPOAb,TSH,and	              an	exaggerated	insulin	response	during	oral	glucose	chal-
free	 thyroid	 hormones	 were	 determined	 by	 commercial	           lenge.	 Our	 patient	 had	 the	 episode	 after	 her	 carb-	 rich	
assays.All	 patients	 underwent	 ultrasonographical	 his-            breakfast.	Serum	potassium	level	is	usually	<	3.0	mmol/
togram	 analyses	 under	 standardized	 conditions.Mean	              liter.	Hypokalemia	is	the	consequence	of	a	massive	shift	
densities	 of	 the	 thyroid	 tissues	 were	 determined	 in	 grey	    of	potassium	from	the	extracellular	into	the	intracellular	
scales(GWE).                                                         compartment.	This	 is	 related	 to	 increased	 sodium-potas-
	     Results:	No	significant	difference	in	the	TPOAb	lev-           sium-adenosine	 triphosphatase	 pump	 activity	 in	 patient	
els	 was	 found	 after	 Se	 administration	 (1972	 ±	 1055	 vs.	     with	TPP.	The	enhanced	ß-adrenergic	response	in	thyro-
1953	 ±	 1054	 U/ml;	 p=0.055).Also,	 we	 found	 no	 differ-         toxicosis	further	enhances	this	pump’s	activity.
ences	of	thyroid	echo	levels	(17.04	±	2.07	GWE	vs.	17.01	                  Conclusion:	TPP	 is	 a	 rare	 condition	 in	 non-Asians,	
±	2.05	GWE;	p=0.166)                                                 and	the	diagnosis	at	presentation	is	often	delayed	because	
	     Conclusion:	We	 demonstrate	 that	 Se	 administration	         of	the	subtleness	of	the	clinical	features	of	thyrotoxicosis	
in	 our	 AIT	 patients	 with	 high	 disease	 activity	 does	 not	    and	the	similarities	of	the	paralysis	with	other	more	com-
induce	 significant	 changes	 of	 TPOAb	 levels	 and	 sono-          mon	conditions.	It	is	now	being	seen	more	frequently	in	
graphic	echogenicity	of	the	thyroid	gland.                           the	Western	world	with	the	admixture	of	different	ethnic	
                                                                     populations.	Early	diagnosis	is	crucial	to	prevent	serious	


                                                               – 159 –
                                             ABSTRACTS – Thyroid Disease

complications.	 TPP	 is	 a	 curable	 disorder	 that	 resolves	        	     Case Presentation:	A	60-year-old	female	with	a	his-
when	euthyroid	status	is	achieved.                                    tory	of	depression	and	GERD	was	referred	for	the	evalu-
                                                                      ation	of	an	abnormally	high	thyroglobulin	(TG)	of	1040	
Abstract #1030                                                        ng/mL	 that	 was	 discovered	 serendipitously	 by	 her	 PCP	
                                                                      at	the	time	of	ordering	a	thyroid	panel.	Her	TG	antibod-
THYROID FUNCTION AND VOLUME                                           ies	 were	 undetectable.	 She	 had	 a	 normal	TSH	 (2.4	 uIU/
DISORDERS CORRELATES WITH IQ IN                                       mL),	free	T4	(1.1	mg/dL)	and	free	T3	(282	pg/dL).	The	
MENTALLY RETARDED CHILDREN                                            patient	 had	 multiple	 symptoms	 such	 as	 fatigue,	 head-
                                                                      ache,	nausea	and	lower	extremity	pain	present	for	several	
Hamid Reza Bazrafshan, MD, S. Vahedi, Gh. Jafari,                     months.	She	denied	abdominal	or	pelvic	pain.	A	thyroid	
N. Bahnampour                                                         ultrasound	showed	a	normally	appearing	thyroid	with	no	
                                                                      focal	 abnormalities.	 A	 whole	 body	 I-123	 scan	 revealed	
      Objective:	Goiter	is	still	an	endemic	health	problem	in	        a	 normal	 24	 hr	 uptake	 of	 14.5	 %	 that	 was	 entirely	 con-
Gorgan	after	a	decade	of	universal	salt	iodization	in	Iran.	          centrated	in	the	thyroid	with	no	extrathyroidal	uptake.	A	
Hypothyroidism	has	more	complications	in	children	than	               pelvic	 ultrasound	 showed	 a	 4.8	 cm	 right	 adnexal	 mass	
adults.	 Developmental	 disorders	 of	 CNS	 are	 so	 impor-           containing	 cystic	 and	 solid	 components.	 A	 laproscopic	
tant.	This	study	proposed	to	determine	that	prevalence	of	            right	 salpingo-oophorectomy	 was	 performed.	 Histology	
thyroid	function	and	volume	disorders	and	its	correlation	            revealed	 a	 benign	 struma	 ovarii	 accompanying	 an	 ovar-
with	the	IQ	of	mentally	retarded	(MR)	children.                       ian	teratoma.	Immunochemistry	staining	for	thyroglobulin	
	     Methods:	This	cross-sectional	study	was	carried	out	            was	positive.	One	month	following	surgery,	her	TG	was	
on	 120	 mentally	 retarded	 students	 at	 two	 rehabilitation	       down	to	48.7	ng/mL	(normal	range:	1-55	ng/mL)	and	she	
centers	 in	 Gorgan,	 north	 of	 Iran.	 We	 excluded	 cerebral	       reported	resolution	of	all	her	presenting	symptoms.
palsy	and	major	metabolic	disease	suffering	patients	from	            	     Discussion:	 The	 typical	 presentation	 of	 a	 struma	
this	 study.	 Thyroid	 volume	 was	 measured	 by	 an	 ultra-          ovarii	is	that	of	abdominal	pain	or	a	palpable	abdominal/
sonography	(US)	specialist.	IQ	was	evaluated	by	a	stan-               pelvic	mass	that	leads	to	imaging	and	eventually	surgery.	
dard	questionnaire.                                                   A	 whole	 body	 I-123	 may	 not	 reveal	 the	 diagnosis	 pre-
	     Results:	The	mean	age	of	the	children	was	11.7	years.	          operatively,	as	in	the	above	patient,	due	to	concentration	
Goiter	 prevalence	 in	 physical	 examination	 was	 42%	 but	         of	I-123	by	the	thyroid	gland.	Other	vague	symptoms	as	
it	was	84%	in	the	US	evaluation.	Mean	concentration	of	               reported	 by	 the	 patient	 have	 been	 documented,	 but	 it	 is	
TSH	and	T4	in	all	cases	was	3.9	and	5.7	respectively.	TSH	            unclear	 whether	 they	 are	 secondary	 to	 the	 high	TG	 lev-
had	a	reverse	linear	correlation	with	IQ	but	T4	was	oppo-             els.	 Uncommon	 presentations	 include	 vaginal	 bleeding,	
site	of	this	(P<0.05).	34	cases	(28.3%)	had	a	higher	level	           ascites	 and	 pleural	 effusion	 (pseudo-Meig’s	 syndrome).	
of	 TSH,	 45	 cases	 had	 low	 IQ	 scores,	 42	 had	 moderate	        Hyperthyroidism	 from	 a	 functional	 struma	 ovarii	 occurs	
scores	and	33	had	high	IQ	scores.                                     only	in	about	5-15%	of	the	cases.	Malignant	transforma-
	    Conclusion:	We	 found	 that	 serum	TSH	 and	 thyroid	            tion	 is	 reported	 in	 0.3-	 5	 %	 of	 cases	 with	 papillary	 car-
volume	have	had	a	reverse	correlation	with	IQ	in	MR	chil-             cinoma	 being	 the	 most	 common.	 Metastatic	 malignant	
dren.	 Thyroid	 enlargement	 and	 hypothyroidism	 is	 more	           struma	ovarii	have	also	been	reported.
prevalent	in	mentally	retarded	children	than	others.	So	a	            	     Conclusion:	 Struma	 ovarii	 are	 difficult	 to	 diagnose	
decision	should	be	made	to	screen	and	cure	thyroid	disor-             pre-operatively.	 Challenging	case	 reports	 include	 struma	
ders	in	this	high	risk	population.	We	should	also	consider	           ovarii	 coexisting	 with	 Graves’	 disease,	 non-toxic	 multi-
evaluating	the	iodine	intake	status,	thyroid	autoimmunity	            nodular	goiter,	Hashimoto’s	thyroiditis,	and	primary	thy-
and	 other	 causes	 of	 goiter	 in	 this	 population	 for	 future	    roid	cancer.	Benign	struma	ovarii	may	present	with	ascites	
investigation.                                                        and	elevated	CA-125	levels	mimicking	a	malignant	ovar-
                                                                      ian	neoplasm.	Surgical	resection	for	benign	struma	ovarii	
Abstract #1031                                                        is	 recommended	 but	 there	 is	 no	 consensus	 on	 the	 treat-
                                                                      ment	of	malignant	disease:	chemotherapy,	surgical	resec-
THE ENIGMA OF STRUMA OVARII                                           tion,	radiation	and	radioiodine	ablation	following	thyroid-
                                                                      ectomy	have	been	described.
Kishore M. Lakshman, MD, MPH,
Beatrice M. DeMoranville, MD,
Lewis E. Braverman, MD, FACE

	    Objective:	 To	 report	 a	 case	 of	 struma	 ovarii	 and	
review	its	pathophysiology.


                                                                – 160 –
                                             ABSTRACTS – Thyroid Disease

Abstract #1032                                                       a	second	neoplasm	may	suggest	a	genetic	background	but	
                                                                     an	incidental	finding	may	also	be	involved.
NEUROENDOCRINE TUMORS AND                                                 Conclusion:	 There	 are	 several	 dysfunctions	 of	 the	
THYROID NODULES                                                      genes	that	control	the	cell	cycle	reported	in	the	pancreatic	
                                                                     as	well	as	thyroid	neoplasia.	Whether	the	thyroid	would	be	
Catalina I. Poiana, MD, PhD, FACE,                                   systematically	checked	once	a	patient	with	NET	came	to	
Mara Carsote, MD, Corina Chirita, MD,                                the	attention	of	an	endocrinologist	is	a	challenging	matter	
Andrei Goldstein, MD, Adina Croitoru, MD,                            to	prove	for	the	future.
Dan Peretianu, MD, PhD, Dana Terzea MD,
Simona Fica, MD, PhD, FACE                                           Abstract #1033

	     Objective:	 We	 report	 a	 series	 of	 three	 cases	 with	     DETECTION OF THYROID CANCER IN
patients	 already	 known	 with	 different	 neuroendocrine	           TWO PATIENTS WITH HYPERTHYROIDISM
tumors	where	accidentally	thyroid	nodules	were	found.
	     Case Presentation: A 59-year-old	female	has	a	one	             Arinola Ipadeola, MBBS, Temilola Akande, MBBS,
year	history	of	a	pancreatectomy	for	a	9	cm	solid	tumor	             Willliams Balogun, MBBS, Jokotade Adeleye, MBBS
of	the	body	and	the	tail.	The	pathological	report	pointed	
rare	mitosis	(2-3/10	HPF).	Positive	immuno-staining	is	for	          	    Objective:	To	report	two	patients	with	hyperthyroid-
chromogranin,	 synaptophysin,	 neuronal	 specific	 enolase.	         ism	who	were	also	discovered	to	have	thyroid	cancer.
The	 diagnosis	 is	 well	 differentiated	 pancreatic	 neuroen-       	    Case Presentation: A	68-year-old	lady	with	a	back-
docrine	 carcinoma.	 Increased	 serotonin	 (twice	 normal)	          ground	history	of	hypertension,	presented	with	a	three	week	
is	 normalized	 3	 months	 after	 therapy	 with	 octreotidum	        history	 of	 recurrent	 vomiting	 and	 diarrhea.	 Examination	
LAR	 20	 mg/month.	Also	 a	 left	 thyroid	 node	 of	 3	 cm	 is	      findings	were	in	keeping	with	congestive	cardiac	failure	
discovered	 with	 normal	 thyroid	 function	 and	 calcitonin.	       and	atrial	fibrillation.	During	the	course	of	her	admission,	
Total	thyroidectomy	is	performed.	The	pathological	exam	             she	 was	 noted	 to	 have	 an	 enlarged	 asymmetric	 thyroid	
revealed	 a	 micro-follicular	 and	 trabecular	 embryo-fetal	        gland,	periorbital	puffiness,	tachycardia	and	fine	tremors	
adenoma.	A	51-year-old	male	had	4	years	ago	a	right	hemi-            of	the	hands.	Thyroid	function	test	result	was	in	keeping	
colectomy	with	L-T	ileotransverse	anastomosis	for	a	poly-            with	a	diagnosis	of	hyperthyroidism.	Thyroid	ultrasound	
ploidy	tumor	of	4	cm,	at	the	level	of	ileocecal	valve,	with	         scan	showed	a	diffusely	enlarged	gland.	Fine	needle	aspi-
local	 invasion	 into	 the	 wall	 and	 local	 lymph	 nodes.	The	     ration	cytology	(FNAC)	was	reported	as	consistent	with	
immunohistochemistry	 was	 positive	 for	 chromogranin,	             papillary	carcinoma.	A	42-year-old	lady	presented	with	a	
NK1.	The	PCNA	proliferation	marker	was	increased	(50-                day’s	 history	 of	 fever	 and	 joint	 pain.	There	 was	 a	 back-
60%).	In	the	present,	the	clinical	exam	discovered	a	left	           ground	history	of	an	anterior	neck	swelling	and	increased	
thyroid	 node	 of	 1	 cm.	The	 fine	 needle	 aspiration	 biopsy	     protrusion	of	both	eyes	of	eighteen	months’	duration	for	
suggested	 papillary	 carcinoma.	 The	 pathological	 exam	           which	she	had	being	receiving	treatment	at	another	health	
after	 total	 thyroidectomy	 confirmed	 it.	Thyroid	 suppres-        care	facility.	She	had	lost	weight	(4kg)	had	heat	intoler-
sion	therapy	was	started.	Also	100	mCi	of	131I	was	added.	           ance	 as	 well	 as	 hyperdefaecation.	 Clinical	 examination	
A	 70-year-old	 female	 had	 2	 years	 ago	 total	 gastrectomy	      revealed	an	asymmetric	thyromegaly,	tachycardia,	a	dis-
for	 gastric	 cancer	 with	 local	 lymph	 nodes	 invasion.	The	      placed	apex	beat,	periorbital	puffiness	and	tremors	of	the	
histological	exam	revealed	a	tumor	of	5	cm	with	features	            outstretched	 hands.	 An	 impression	 of	 Hyperthyroidism	
of	poor	differentiated	carcinoma.	At	age	of	70,	a	large	goi-         was	 made.	 Thyroid	 ultrasound	 scan	 showed	 a	 diffusely	
ter	was	accidentally	discovered.	Thyroidectomy	was	per-              enlarged	gland	while	the	FNAC	showed	features	thought	
formed	and	metastasis	from	a	neuroendocrine	tumor	was	               to	be	suspicious	of	a	malignant	neoplasm.	Both	patients	
diagnosed.	The	immuno-hystological	profile	was	positive	             were	 placed	 on	 anti-thyroid	 medications	 and	 have	 been	
for	synaptophysin,	chromogranin	A	and	negative	for	calci-            referred	to	the	Consultant	General	Surgeon	for	total	thy-
tonin	and	thyreoglobulin.	The	same	phenotype	was	retro-              roidectomy	in	view	of	the	FNAC	reports.
spectively	analyzed	in	the	gastric	tumor.	The	value	of	ki67	         	    Discussion:	The	coexistence	of	hyperthyroidism	and	
was	25%.	Therapy	with	octreotidum	LAR	20	mg	monthly	                 thyroid	 cancer	 had	 previously	 been	 considered	 an	 infre-
was	started.                                                         quent	 event,	 but	 recent	 literature	 suggests	 the	 incidence	
	     Discussion:	In	patients	with	neuroendocrine	tumors,	           is	increasing.	FNAC	in	both	cases	was	done	routinely	as	
the	 thyroid	 involvement	 is	 atypical,	 unless	 metastasis	 is	    part	 of	 investigations	 in	 evaluating	 persons	 who	 present	
presented	(except	for	the	cases	diagnosed	from	the	begin-            with	goitres.	This	case	report	draws	attention	to	the	asso-
ning	with	the	medullar	thyroid	carcinoma).	The	finding	of	           ciation	between	hyperthyroidism	and	thyroid	cancer.	The	



                                                               – 161 –
                                           ABSTRACTS – Thyroid Disease

coexistence	of	thyroid	cancer	in	the	hyperthyroid	patient	        FT4	1.70,	FT3	2.53	and	thyroglobulin	195.	Thyroglobulin	
will	certainly	significantly	influence	the	treatment	options	     AB	and	Anti	TPO	AB	were	negative.	Thyroid	stimulating	
and	management	plan	as	in	the	two	cases	presented.                AB	412	(0-129)	and	thyrotropin	recptor	AB	2.80	(0-1.75).	
	     Conclusion:	Fine	needle	aspiration	cytology	is	a	sim-       Graves’	disease	causing	hyperthyroidism	was	diagnosed.	
ple	and	essential	tool,	especially	when	ultrasound	guided	        	    Conclusion:	 Endogenous	 hyperthyroidism	 can	
and	should	be	done	in	all	patients	presenting	with	a	goi-         develop	 in	 patients	 with	 long	 standing	 hypothyroidism	
ter	 and	 hyperthyroidism.	 Nuclear	 scintigraphy	 may	 also	     due	 to	 various	 etiologies.	 Non-suppressed	 thyroglobulin	
be	helpful	in	the	investigation	of	hyperthyroid	patients,	as	     can	differentiate	endogenous	hyperthyroidism	from	exog-
the	presence	of	“cold”	nodules	may	suggest	malignancy	&	          enous	hyperthyroidism	due	to	over	dose	of	levothyroxine.	
guide	FNAC.	The	association	needs	to	be	further	explored	         Non	 functional	 thyroid	 nodules	 may	 become	 functional	
amongst	Nigerians	with	regards	to	defining	the	risk	fac-          over	 time	 and	 cause	 endogenous	 hyperthyroidism	 espe-
tors,	clinicopathologic	features	and	outcomes.                    cially	in	setting	of	Iodine	loading	.In	autoimmune	thyroid	
                                                                  disease	 lymphocytes	 can	 switch	 from	 producing	 thyroid	
Abstract #1034                                                    receptor	blocking	to	stimulating	antibodies	over	time	and	
                                                                  can	cause	endogenous	hyperthyroidism	after	long	stand-
ETIOLOGY OF ENDOGENOUS                                            ing	hypothyroidism.
HYPERTHYROIDISM IN TWO PATIENTS WITH
LONG STANDING HYPOTHYROIDISM                                      Abstract #1035

Saba Faiz, MD, Tipu Saleem, MD, MS, FACE,                         GRAVES’ DISEASE PRESENTING AS
Abid Yaqub, MD, FACP, Parsana Santhanam, MD                       TAKOTSUBO CARDIOMYOPATHY IN A
                                                                  YOUNG ADULT WOMAN
	     Objective:	To	describe	etiology	and	diagnostic	work	
up	 of	 endogenous	 hyperthyroidism	 in	 two	 patients	 who	      Theresa Adadzewa Fynn, MD, Wolali Odonkor, MD,
have	long	standing	hypothyroidism.                                Gail Nunlee-Bland, MD, Vijaya Ganta MD, Suliman
	     Case Presentation:	 A	 48-year-old	 lady	 admitted	 to	     Abdelwahab, MD
psychiatry	 ward	 with	 suicidal	 ideation.	 She	 has	 hypo-
thyroidism	 for	 20	 years.	 She	 was	 taking	 synthroid	 250	         Objective:	 To	 describe	 thyrotoxicosis	 as	 a	 cause	 of	
mcg/day	for	many	years	with	normal	TFTs	one	year	ago.	            myocardial	stunning	in	a	case	of	Graves’	disease.
She	has	a	recent	contrast	enhanced	CT	scan	of	spine	for	          	    Case Presentation:	A	forty	year-old	African	American	
surveillance	 of	 spinal	 cord	 tumor.	 Physical	 examination	    woman	 bus	 attendant,	 with	 past	 medical	 history	 signifi-
revealed	pulse	101,	temp	98.1,	blood	pressure	116/76	and	         cant	 for	 eczema,	 sinusitis	 and	 bronchitis	 was	 admitted	
non-tender	enlarged	goiter	with	a	nodule	on	left	side.	TFTs	      to	the	intensive	care	unit	for	acute	onset	chest	pain.	Pain	
showed	 TSH	 0.015	 (0.3-4.4)	 and	 FT4	 5.38	 (0.75-2.0).	       was	located	in	the	central	chest,	8/10	in	intensity,	sharp,	
Synthroid	 was	 stopped,	 repeat	 TFTs	 in	 a	 week	 showed	      radiating	to	both	shoulders	with	associated	dyspnea.	She	
TSH<0.004,	FT4	1.44	and	FT3	2.28	(1.8-4.2).	TFTs	in	2	            admitted	to	palpitations	and	recurrent	leg	swelling	in	the	
months	showed	TSH	0.016,	FT4	1.95	and	thyroglobulin	              past	few	months	but	denied	orthopnea,	weight	loss	or	heat	
13.	Anti	TPO	AB,	anti	thyroglobulin	AB,	thyroid	stimu-            intolerance.	She	was	found	to	have	unexplained	increase	
lating	AB	and	thyrotropin	receptor	AB	were	negative.	She	         in	 Troponins-	 (32ng/ml)	 and	 normal	 exercise	 tolerance,	
had	low	I-123	uptake	of	2.3	%	at	24	hours	while	24	hour	          with	 no	 coronary	 artery	 disease	 risk	 factors	 and	 nega-
urine	 iodine	 786	 ug/spec	 (100-460)	 was	 high	 .Neck	 US	     tive	drug	screen.	The	EKG	showed	ST-	T	wave	changes	
showed	multinodular	goiter.	Toxicity	of	multinodular	goi-         but	was	inconsistent	with	acute	ST	elevation	myocardial	
ter	was	attributed	to	recent	iodine	loading	in	form	of	con-       infarction	(MI).	Unable	to	adequately	explain	the	elevated	
trast	material	used	in	recent	CT	scan.	FNAC	of	left	sided	        troponins,	a	cardiac	catheterization	was	performed	which	
3	cm	nodule	was	categorized	as	atypical	cells	and	pt	had	         showed	clean	coronaries	with	apical	hypokinesis.	A	thy-
total	thyroidectomy.	Histopathology	showed	benign	nodu-           roid	panel	revealed	TSH-0.02	mu/ml,	T3-367	ng/dl,	total	
lar	 hyperplasia.	A	 86-year-old	 lady	 presented	 with	 CHF	     T4-20.19	 mc/dl,	 T3UP	 43.5%	 and	 TSI	 140%	 consistent	
and	atrial	fibrillation.	She	had	long	standing	hypothyroid-       with	Graves’	disease.	She	was	managed	with	methimazole	
ism.	She	was	on	a	stable	dose	of	synthroid	50	mcg/day.	           and	did	well.
She	denied	any	symptoms	of	hypothyroidism	or	hyperthy-                  Discussion:	 First	 described	 in	 1991,	 Takotsubo	 is	
roidism.	She	had	temp	97.9,	HR	90,	BP	120/60	and	pal-             generally	 characterized	 by	 transient	 systolic	 dysfunction	
pable	thyroid	gland	without	any	discrete	nodule	or	bruit.	        of	 the	 apical	 and/or	 mid	 segments	 of	 the	 left	 ventricle	
TFT’s	 showed	 TSH	 .025	 and	 FT4	 2.02.	 Synthroid	 was	        that	 mimics	 MI,	 but	 in	 the	 absence	 of	 significant	 coro-
stopped	for	a	week	and	repeat	testing	showed	TSH	0.067,	          nary	artery	disease.	The	following	are	the	proposed	Mayo	


                                                            – 162 –
                                             ABSTRACTS – Thyroid Disease

Clinic	diagnostic	criteria,	all	four	of	which	are	required	for	       dL).	 Thyrotoxicosis	 was	 slightly	 improved	 (TT3=250	
the	diagnosis:	Transient	hypokinesis,	akinesis	or	dyskine-            ng/dL,	TT4=14.3	µg/dL).	Methimazole	was	stopped	and	
sis	 of	 the	 left	 ventricular	 mid	 segments	 with	 or	 without	    lithium	 carbonate	 450	 to	 600	 mg/day	 was	 started,	 with	
apical	involvement.	The	regional	wall	motion	abnormali-               successful	control	of	thyroid	hormones	levels	(TT3=183	
ties	typically	extend	beyond	a	single	epicardial	coronary	            ng/dL,	 TT4=12	 µg/dL)	 and	 without	 side	 effects	 (lithae-
distribution.	 Absence	 of	 obstructive	 coronary	 disease	           mia=	 0.38;	 0.37	 mEq/L).	 Intravenous	 corticotherapy	
or	 angiographic	 evidence	 of	 acute	 plaque	 rupture.	 New	         (Methylprednisolone	 125	 mg/day,	 3	 days)	 followed	 by	
electrocardiographic	 abnormalities	 (either	 ST-segment	             oral	 corticosteroids	 (Prednison	 1	 mg/kgc/day,	 gradually	
elevation	 and/or	 T-wave	 inversion)	 or	 modest	 elevation	         decreasing	the	dose)	and	folic	acid	5	mg/day	successfully	
in	 cardiac	 tropinins.	 Absence	 of	 pheochromocytoma	 or	           controlled	hemolytic	anemia:	hemoglobin	increased	from	
myocarditis.	 Conservative	 treatment	 with	 hydration	 and	          13	 g/dL	 to	 14	 g/dL;	 there	 was	 a	 gradual	 decrease	 up	 to	
resolution	of	the	stressor,	usually	results	in	rapid	resolu-          normalization	of	both	total	bilirubin	(3.62;	1.59;	1.07	mg/
tion	of	symptoms	and	EKG	changes.	The	patient	met	the	                dL)	and	unconjugated	bilirubin	(2.82;	0.96;	0.75	mg/dL).	
above	criteria	and	her	symptoms	resolved	after	conserva-              Total	thyroidectomy	was	safely	performed	and	the	patient	
tive	treatment	with	hydration	and	treatment	of	the	thyro-             had	an	uneventful	recovery.
toxicosis	with	methimazole.                                                 Discussion:	TSH	was	measured	by	immunoradiomet-
      Conclusion:	 Reversible	 left	 ventricular	 dysfunction	        ric	 assay,	TT3,	 FT4,	TT4	 by	 chemiluminescence,	TRAb	
precipitated	 by	 thyrotoxicosis	 has	 been	 reported	 and	 the	      by	MEIA.	Hematological	side	effects	of	antihyroid	drugs	
mechanism	 can	 be	 explained	 by	 exaggerated	 sympa-                such	as	agranulocytosis,	aplastic	anemia	and	thrombocy-
thetic	 dysfunction.	 In	 conclusion	 all	 patients	 presenting	      topenia	are	well	known,	but	hemolytic	anemia	was	very	
with	 Takotsubo	 cardiomyopathy	 must	 be	 evaluated	 for	            seldom	 reported.	 Acquired	 immune	 hemolytic	 anemia	
hyperthyroidism.                                                      due	 to	 methimazole-dependent	 red	 blood	 cell	 antibodies	
                                                                      (as	already	been	reported	for	carbimazole)	which	reacted	
Abstract #1036                                                        with	all	erythrocytes	or	concomitant	autoimmune	hemo-
                                                                      lytic	anemia	revealed	by	methimazole	could	be	involved	
HEMOLYTIC ANEMIA ASSOCIATED WITH                                      in	pathogenesis.
METHIMAZOLE TREATMENT IN A PATIENT                                          Conclusion:	 This	 is	 the	 first	 case	 report	 of	 hemo-
WITH GRAVES’ DISEASE                                                  lytic	anemia	associated	with	Methimazole	in	Romania.	It	
                                                                      should	be	kept	in	mind	that	hemolytic	anemia	may	be	a	
Raluca-Alexandra Trifanescu, MD,                                      rare	complication	associated	with	methimazole	therapy.
Madalina Vasilica, MD, Serban Radian, MD,
Catalina Poiana, MD, FACE                                             Abstract #1037

     Objective:	 To	 present	 a	 case	 of	 hemolytic	 anemia	         PLASMAPHERESIS AND CHOLESTYRAMINE IN
associated	with	Methimazole	treatment	in	a	patient	with	              THE TREATMENT OF THYROID STORM
Graves’	disease.
     Case Presentation:	N.L,	male,	51	years,	initially	pre-           Gregory D. Cook, MD, Diane Biskobing, MD
sented	 with	 severe	 Graves’	 disease	 (TSH<	 0.03	 mIU/L,	
FT4>100	 pmol/L,	 TT3>500	 ng/dL,	 TRAb=7.62	 IU/L)	                  	    Objective:	To	describe	a	case	where	cholestyramine	
without	 significant	 ophthalmopathy.	 Hemoglobin	 was	               and	 plasmapheresis	 were	 used	 with	 conventional	 treat-
14.7	 g/dL	 and	 alkaline	 phosphatase	 slightly	 increased	          ment	to	rapidly	lower	thyroid	hormone	levels.
(149	IU/L).	Antithyroid	drugs	were	started	(Methimazole	              	    Case Presentation:	 A	 25-year-old	 woman	 with	
30	 mg/day).	 After	 2	 weeks	 Methimazole	 treatment,	 the	          Graves’	disease	presented	for	treatment	of	hyperthyroid-
patient	 presented	 with	 pruritus,	 artrhalgia	 and	 urticaria,	     ism.	 Prior	 treatment	 with	 PTU	 had	 been	 stopped	 due	 to	
unresponsive	 to	 the	 replacement	 of	 Methimazole	 with	            financial	difficulties.	She	was	admitted	to	the	hospital	after	
Carbimazole.	 Clinical	 exam	 revealed	 scleral	 jaundice,	           jaundice	 developed	 within	 weeks	 of	 resuming	 PTU.	 On	
macular	 rash,	 liver	 enlargement	 without	 splenomegaly.	           initial	exam:	BP	156/72,	HR	148,	T	102.	Pertinent	findings	
Biochemical	data	showed	hemolytic	anemia:	hemoglobin	                 included	marked	jaundice,	diffusely	enlarged	goiter	with	
decreased	 from	 14.7	 to	 13	 g/dL,	 increased	 reticulocytes	       bruit,	tachycardia,	and	a	hyper-pigmented	papular	rash	on	
(3.1%),	increased	total	bilirubin	3.62	mg/dL	with	increased	          abdomen.	Lab	data:	TSH	<0.01,	total	T4	24.4	(4.5-12.5),	
unconjugated	 bilirubin	 2.82	 mg/dL.	 Both	 transaminases	           free	 T4	 5.1	 (0.8-1.8),	 total	 T3	 653	 (60-181),	 albumin	
were	normal.	Thrombocytes	were	normal	(165,000/mm3),	                 3.4,	alk.	phos.	260,	total	bilirubin	27,	conj.	bilirubin	20,	
coagulation	 tests	 (INR,	 APTT)	 were	 normal,	 exclud-              AST	 102,	ALT	 45.	 Initial	 treatment	 with	 hydrocortisone	
ing	 Evans’	 syndrome.	 Sideremia	 was	 normal	 (85.1	 µg/            and	 propranolol	 resulted	 in	 temporary	 improvement.	 On	


                                                                – 163 –
                                             ABSTRACTS – Thyroid Disease

day	3	her	condition	rapidly	deteriorated	and	efforts	were	            noted	to	have	mildly	enlarged	and	palpable	thyroid	with-
made	to	prepare	her	for	urgent	thyroidectomy.	Treatment	              out	 nodules	 and	 negative	 exophtalmos.	 Further	 work-up	
included	 methimazole	 30mg	 daily,	 SSKI	 250mg	 Q	 8H,	             demonstrated	low	TSH,	elevated	free	T4,	elevated	thyro-
hydrocortisone	 100mg	 IV	 Q8h,	 esmolol	 infusion,	 cho-             globulin	and	decreased	24-hour	uptake.	In	light	of	the	long	
lestyramine	4	g	Q	6h,	and	plasmapheresis.	Prior	to	plas-              treatment	with	lithium,	the	diagnosis	of	lithium	associated	
mapheresis	on	day	4,	free	T4	was	3.3.	After	one	plasma-               thyroiditis	was	suggested.	Lithium	was	discontinued	and	
pheresis	session,	free	T4	decreased	to	2.4.	Subsequently,	            patient	 was	 switched	 to	 Valproic	 acid.	 Thyroid	 function	
free	T4	decreased	to	1.3	on	day	6	and	to	0.6	on	day	8.	In	            and	iodine	uptake	at	24	hours	done	2	months	later	were	
spite	of	efforts	to	control	her	hyperthyroidism,	she	did	not	         normal.
survive.	 Hospital	 course	 was	 complicated	 by	 pulmonary	          	    Discussion:	 This	 case	 enhances	 the	 importance	 of	
hemorrhage,	fungemia,	renal	and	liver	failure.                        a	 complete	 history	 and	 detailed	 physical	 exam	 in	 the	
	    Discussion:	 Thyroid	 storm	 can	 be	 life-threatening,	         primary	 care	 setting.	 This	 case	 also	 illustrates	 that	 for	
with	 a	 mortality	 rate	 of	 20-30%.	 Traditional	 therapy	          patients	under	lithium	treatment,	thyroid	hormonal	follow	
includes	thionamides,	inorganic	iodine,	beta-blockers,	and	           up	is	essential.	The	main	lesson,	however,	is	the	recogni-
steroids.	Some	clinical	situations	require	rapid	lowering	of	         tion	of	the	variety	of	thyroid	pathologies	associated	with	
thyroid	hormone	levels.	In	hyperthyroidism	the	enterohe-              lithium	ranging	from	hypothyroidism	to	hyperthyroidism.
patic	circulation	of	thyroid	hormone	is	increased.	In	this	
setting	 cholestyramine,	 a	 bile	 acid	 sequestrant,	 has	 been	     Abstract #1039
shown	to	rapidly	lower	thyroid	hormones	by	binding	and	
removing	thyroid	hormone	from	the	enterohepatic	circu-                “GREYHOUND THYROTOXICOSIS”:
lation.	Thyroid	hormone	is	over	99%	protein	bound	and	                COINCIDENTAL SUBACUTE THYROIDITIS IN
plasmapheresis	lowers	thyroid	hormone	levels	by	remov-                THE SETTING OF UNDIAGNOSED
ing	protein	bound	hormone.	Additionally,	as	the	plasma	is	            GRAVES’ DISEASE
exchanged	with	fresh	frozen	plasma	or	albumin	solutions,	
new	 binding	 sites	 are	 available,	 thereby	 decreasing	 free	      Brittany Bohinc, MD, John Parker, MD, FACE, ECNU
hormone	levels.	With	the	addition	of	plasmapheresis	and	
cholestyramine	 therapy	 in	 our	 patient,	 thyroid	 hormone	         	    Objective:	 To	 present	 a	 case	 of	 thyrotoxicosis	 (TS)	
levels	were	rapidly	decreased	to	normal	levels	in	2-3	days.           and	 goiter	 discovered	 after	 neck	 trauma	 and	 outline	 the	
	    Conclusion:	 Cholestyramine	 and/or	 plasmapheresis	             course	of	subsequent	autoimmune-mediated	hypothyroid-
can	be	added	to	the	treatment	of	severe	hyperthyroidism	to	           ism	(HT).
facilitate	more	rapid	lowering	of	thyroid	hormone	levels.             	    Case Presentation:	A	59-year-old	white	female	devel-
                                                                      oped	cervical	swelling	and	right-sided	tenderness	after	her	
Abstract #1038                                                        pet	greyhound	stepped	on	her	neck.	Ultrasonography	(US)	
                                                                      demonstrated	 a	 3.6-cm	 irregular	 mass	 on	 the	 right	 with	
HYPERTHYROIDISM AND BIPOLAR DISORDER.                                 normal	 L.	 lobe.	 Laboratory	 testing:	 TSH	 0.009	 µIU/mL	
WHAT IS THE LINK?                                                     (0.35-5.5),	 total	 T4	 18.7	 µg/dL	 (4.7-13.3),	 total	 T3-391	
                                                                      ng/dL	 (85-205).	 Within	 21	 days,	 the	 tenderness	 abated,	
Juan Pablo Brito, MD, Andrea Sosa, MD                                 but	she	developed	fullness	on	the	L.	side	and	US	revealed	
                                                                      an	 inhomogenous	 appearance	 (no	 absent	 vascularity	 by	
     Objective:	 Lithium	 has	 been	 used	 in	 the	 treat-            power	 Doppler	 (PD)	 examination),	 with	 reduction	 in	
ment	 of	 manic	 and	 hypomanic	 depressive	 disorders.	              R.	 lobe	 volume	 (no	 nodularity)	 and	 increase	 in	 L.	 lobe	
Approximately,	 5	 to	 35%	 of	 patients	 receiving	 lithium	         volume.	TS	 persisted	 [TSH	 <0	 .01.	 free	T4-2	 .38	 ng/dL	
develop	biochemical	hypothyroidism.	The	etiology	of	this	             (0.89-1.76),	 free	 T3-6.5	 pg/mL	 (2.3-4.2)],	 with	 support	
condition	can	be	explained	by	the	inhibitory	effect	of	this	          for	 Graves’	 disease	 (GD)	 [thyroid	 peroxidase	Ab	 (TPO)	
drug	 on	 thyroid	 hormonal	 release,	 thyroglobulin	 iodida-         Ab	243	IU/mL	(0-34),	TSH	receptor	Ab	(TRAb)	26	IU/L	
tion	 and	 coupling	 reaction.	On	 the	 other	 hand,	 only	 few	      (0-1.75].	She	was	placed	on	methimazole	at	5	mg	daily,	
cases	 of	 hyperthyroidism	 related	 to	 lithium	 have	 been	         but	within	6	weeks	time,	she	developed	HT	[TSH	130.79,	
reported	 in	 the	 literature	 and	 the	 etiology	 has	 not	 been	    free	 T4	 0.29,	 free	 T3	 0.9,	 TPO	 Ab	 306,	 TRAb	 37.18,	
explained	adequately.                                                 thyroglobulin	 (Tg)	 <0	 .5	 ng/mL	 (0.5-55),	 Tg	Ab	 66	 IU/
	    Case Presentation:	 A	 63-year-old	 male	 with	 prior	           mL	 (0-40),	 thyroid-stimulating	 immunoglobulin	 (TSI)	
history	of	bipolar	disorder	under	medical	treatment	pres-             130%	 (0-139)].	 She	 was	 started	 on	 levothyroxine	 at	 25	
ents	to	his	Primary	Care	Doctor	complaining	of	increasing	            mcg	 daily,	 as	 HT	 persisted.	After	 4	 weeks	 of	 treatment:	
episodes	 of	 severe	 anxiety	 all	 day	 long	 for	 two	 months	      TSH	152.52.	Free	T4	0.19,	TRAb	36.24,	TSI	84%	and	US	
beyond	his	baseline	levels.	During	physical	exam	he	was	              showed	 decrease	 in	 thyroid	 volume,	 with	 no	 substantial	


                                                                – 164 –
                                             ABSTRACTS – Thyroid Disease

internal	 vascularity.	 Euthyroidism	 was	 achieved	 on	 88	         evaluation	 of	 post	 thyroidectomy	 cases	 of	 differentiated	
mcg	daily	(TSH	1.06,	free	T4	1.6,	TRAb	>40,	TSI	73%).                thyroid	 carcinoma.	 The	 presence	 of	 the	 unique	 sodium	
	     Discussion:	It	is	coincidental	that	she	has	had	clear	         iodide	symporter	(NIS)	in	the	basolateral	surface	of	thy-
evidence	of	GD	but	experienced	thyroiditis	(as	evidenced	            roid	follicular	cells	resulting	in	sodium-dependant	active	
by	 absence	 of	 intense	 vascularity	 within	 the	 thyroid	 by	     transport	 of	 iodine,	 its	 organification	 and	 retention	 has	
PD),	possibly	from	the	pressure	on	her	neck	by	the	grey-             been	 successfully	 exploited	 in	 investigation	 as	 well	 as	
hound.	 While	 profound	 HT	 developed	 rapidly	 on	 low-            targeted	treatment	of	various	thyroid	disorders	with	 131I.	
dosage	 of	 thyrostatic	 drug	 therapy	 (TDT),	 it	 is	 unlikely	    The	 thyroid	 and	 the	 thymus	 are	 embryologically-related	
that	such	a	short	duration	of	therapy	could	have	induced	            organs	and	thymic	ectopy	in	the	thyroid	has	been	reported	
this	 remission.	 Subsequent	 testing	 indicated	 persistence	       in	 mice	 as	 well	 as	 adult	 humans	 with	 and	 without	 thy-
of	 TRAb,	 but	 without	 overwhelming	 TSI	 activity.	 It	 is	       roid	 disease.	While	 ectopic	 thyroid	 tissue	 in	 the	 thymus	
posited	 that	 conversion	 from	 TSH	 receptor	 stimulatory	         could	explain	the	131I	uptake	in	the	mediastinum,	the	exact	
antibodies	to	TSH	receptor	blocking	antibodies	occurred,	            explanation	for	thymic	131I	uptake	remains	unknown.
leading	to	HT.                                                       	    Conclusion:	 Whole	 body	 131I	 scans	 can	 have	 false	
	     Conclusion:	The	exact	etiology	for	TS	is	often	easily	         positive	 uptake	 due	 to	 thymus	 even	 at	 extremes	 of	 age.	
discerned	 but	 in	 our	 case,	 the	 coexistence	 of	 supportive	    While	 131I	 uptake	 has	 been	 described	 in	 young	 patients	
tests	for	GD	with	US	evidence	to	the	contrary	portrayed	a	           with	 thymic	 hyperplasia,	 we	 present	 here	 2	 cases	 of	
mixed	picture.	The	timeframe	for	the	subsequent	HT	was	              elderly	patients	with	false	positive	uptake	in	thymus.	With	
neither	typical	for	subacute	thyroiditis	or	remission	of	GD	         aging	population	and	increasing	incidence	of	thyroid	car-
on	 TDT.	 Simultaneous	 measurement	 of	 TRAb	 and	 TSI	             cinoma,	physicians	need	to	be	aware	of	this	entity	to	avoid	
proved	beneficial	in	clarifying	the	diagnosis.                       over-treatment.

Abstract #1040                                                       Abstract #1041

THYMIC UPTAKE OF IODINE-131 IN                                       PAPILLARY THYROID MICROCARCINOMA
ANTERIOR MEDIASTINUM                                                 ASSOCIATED WITH BENIGN THYROID TISSUE
                                                                     IN THE DELPHIAN LYMPH NODE
Sunil Asnani, MD, FACE, Anupam Ohri, MD
                                                                     Emad Naem, MD, Mae Sheikh-Ali, MD,
      Objective:	 To	 describe	 2	 cases	 of	 131I	 uptake	 by	      Abdul-Razzak Alamir, MD
thymus.
      Case Presentation:	 An	 82-year-old	 man	 with	 fol-                 Objective:	To	report	a	case	of	benign	thyroid	tissue	in	
licular	carcinoma	of	thyroid	gland	was	treated	with	total	           the	Delphian	lymph	node	of	a	patient	with	papillary	thy-
thyroidectomy,	 remnant	 ablation	 and	 TSH	 suppression.	           roid	microcarcinoma.
Follow	up	thyroid	sonogram	was	negative	for	any	resid-                     Methods:	We	 present	 a	 case	 report,	 including	 clini-
ual/recurrent	disease	in	the	neck.	Stimulated	thyroglobu-            cal	and	laboratory	data	as	well	as	surgical	histopathology	
lin	 (Tg)	 level	 1	 year	 later	 was	 <0.5	 ng/ml.	 Concurrent	     in	 a	 women	 with	 papillary	 thyroid	 microcarcinoma	 and	
whole	body	131I	scan	(WBS)	revealed	a	focus	of	minimal	              concomitant	benign	thyroid	tissue	in	the	Delphian	lymph	
to	mildly	increased	tracer	uptake	anteriorly	at	the	level	of	        node.
superior	mediastinum.	Chest	X	ray	and	CT	chest	did	not	                    Results:	A	41-year-old	female	with	family	history	of	
reveal	any	abnormality.	A	78-year-old	woman	with	papil-              thyroid	 cancer	 presented	 with	 thyroid	 nodules.	 Thyroid	
lary	 thyroid	 carcinoma	 was	 treated	 with	 total	 thyroidec-      US	 showed	 multiple	 small	 hypoechoic	 nodules	 in	 both	
tomy,	remnant	ablation	and	TSH	suppression.	Serial	thy-              thyroid	 lobes.	 Her	 thyroid	 function	 tests	 were	 normal.	
roid	 sonograms	 were	 negative	 for	 any	 residual/recurrent	       Patient	 underwent	 total	 thyroidectomy	 and	 prelaryngeal	
disease	 in	 the	 neck.	 Stimulated	 thyroglobulin	 (Tg)	 level	     lymph	node	dissection.	Surgical	pathology	showed	papil-
1	 year	 later	 was	 0.2	 ng/ml.	 Concurrent	WBS	 revealed	 a	       lary	microcarcinoma	(0.3	cm)	located	in	the	left	lobe	of	
focus	of	minimally	increased	activity	at	superior	mediasti-          thyroid.	 The	 Delphian	 node	 pathology	 revealed	 lymph	
num.	CXR	or	CT	chest	did	not	reveal	any	lymphadenopa-                tissue	with	two	microscopic	foci	of	cytologically	benign	
thy.	PET	scan	did	not	show	any	abnormal	activity.                    appearing	 thyroid	 inclusions.	 The	 inclusions	 immunos-
No	further	intervention	was	done.	Both	patients	are	being	           taining	 with	 Thyroglobulin	 and	 TTF-1	 was	 positive	 and	
monitored	with	serial	sonogram	and	Tg	levels;	they	con-              consistent	with	thyroid	origin.	No	thyroid	cancer	metas-
tinue	to	be	in	remission.                                            tasis	 was	 found	 in	 the	 other	 2	 lymph	 nodes	 that	 were	
      Discussion:	 WBS	 is	 a	 highly	 accurate	 procedure	          removed.
that	plays	a	pivotal	role	in	clinical	decision	making	in	the	


                                                               – 165 –
                                           ABSTRACTS – Thyroid Disease

      Discussion:	 Papillary	 thyroid	 microcarcinomas	                 Methods:	 Systematic	 review	 and	 meta-analysis	 of	
                                  l
(PTMC)	generally	have	an	excel	ent	prognosis	(Mazzaferri          relevant	randomized,	placebo-control,	blinded	trials.
et al).	Lobectomy	without	131I	thyroid	remnant	ablation	          	     Results:	Patients	with	HT	assigned	to	Se	supplemen-
                    m
is	reasonable	treat	 ent	for	the	low-risk	group	with	unifo-       tation	for	 three	months	 demonstrated	significantly	lower	
cal	PTMC	smaller	than	1	cm.	The	ATA	recommends	131I	              thyroid	 peroxidase	 autoantibodies	 (TPOab)	 titers	 (four	
remnant	ablation	for	all	patients	with	TNM	stage	III	and	         studies,	random	effects	WMD:	-271.09,	95%	CI:	-421.98	
IV	cancer	and	for	all	patients	with	stage	II	cancer	who	are	      to	 -120.19,	 p	 <	 10-4)	 and	 a	 significantly	 higher	 chance	
younger	 than	 45	 years.	The	ATA	 also	 recommends	 131I	        of	reporting	an	improvement	in	well-being	and/or	mood	
remnant	ablation	for	most	patients	45	years	or	older	with	        (three	studies,	random	effects	RR:	2.79,	95%	CI:	1.21	to	
stage	II	cancer	and	selected	patients	with	stage	I	cancer,	       6.47,	p	=	0.016)	as	compared	to	controls.	Natural	course	
especially	those	with	multifocal	disease,	nodal	metastases,	      of	HT,	demands	in	levothyroxine	(LT4)	replacement	ther-
extrathyroidal	 or	 vascular	 invasion,	 and/or	 more	 aggres-    apy	and	ultrasonographic	thyroid	morphology	were	found	
sive	histologies.	The	patient	presented	above	is	considered	      either	unaltered	or	underreported.
stage	one	by	TNM	classification.	She	had	a	total	thyroid-         	     Discussion:	Based	on	the	best	available	evidence,	Se	
ectomy	 which	 seems	 an	 appropriate	 operation	 for	 her.	      supplementation	is	associated	with	a	significant	decrease	
Aggressive	therapy	with	131I	remnant	ablation	would	not	          in	 TPOab	 levels	 at	 3-months	 and	 with	 improvement	 in	
be	 recommended	 by	 the	ATA	 criteria.	 However,	 she	 has	      mood	and/or	general	well-being.	Evidence	suggests	a	dif-
ectopic	benign	thyroid	tissue	in	the	Delphian	lymph	node.	        ferent	 pattern	 of	 response	 to	 Se	 supplementation	 in	 HT	
The	prevalence	of	the	incidental	finding	of	thyroid	inclu-        relative	to	baseline	TPOab	levels	that,	if	confirmed,	could	
sions	in	neck	dissections	ranged	from	the	0.6%	estimated	         be	 used	 to	 identify	 which	 patients	 would	 benefit	 most	
by	Gerard-Marchant10	and	the	1.0%	determined	by	Clark	            from	treatment.
et	al.	It	does	not	necessarily	indicate	the	need	for	aggres-      	     Conclusion:	An	improvement	in	thyroid	function	and	
sive	therapy	(Leo´n	et	al).	Development	of	primary	pap-           morphology	 should	 be	 demonstrated	 before	 Se	 routine	
illary	 thyroid	 carcinoma	 from	 malignant	 transformation	      supplementation	could	be	recommended	in	HT.
of	benign	intranodal	thyroid	inclusions	has	been	reported	
(Wang	et	al).	The	risk	of	malignant	transformation	seems	         Abstract #1043
to	be	higher	in	this	patient	since	she	did	have	PTMC	as	
well	as	a	family	history	of	thyroid	cancer.	Based	on	that,	       ATROPHIC THYROIDITIS ASSOCIATED WITH
131I	thyroid	remnant	ablation	was	recommended	to	this	            SPURIOUS CHRONIC KIDNEY DISEASE
patient.
      Conclusion:	Ectopic	thyroid	tissue	in	the	lymph	node	       Sandra Omozehio Iwuala, MBBS,
is	a	rare	entity.	The	need	for	aggressive	therapy	is	not	nec-     Ibilola A. Sanusi, MBBS,
essarily	indicated.	However,	in	high	risk	patients,	malig-        Olufemi A. Fasanmade, MBBS, FWACP
nant	 transformation	 may	 occur	 and	 aggressive	 therapy	
should	be	considered.                                             	    Objective:	To	present	a	case	of	hypothyroidism	com-
                                                                  plicated	by	low	creatinine	clearance	and	diagnosed	with	
Abstract #1042                                                    chronic	kidney	disease.
                                                                  	    Case Presentation:	A	38-year-old	woman	presented	
SELENIUM SUPPLEMENTATION IN THE                                   with	 history	 of	 heavy	 menstrual	 losses	 of	 eight	 months	
TREATMENT OF HASHIMOTO’S THYROIDITIS                              associated	with	facial	swelling	and	cold	intolerance	both	
                                                                  of	six	months	duration.	A	detailed	history	was	obtained,	
Konstantinos A. Toulis, MD, MSC,                                  followed	 by	 a	 full	 physical	 examination.	 Laboratory	
Athanasios D. Anastasilakis, MD, PhD,                             assessment	included	lipid	profile,	full	blood	count,	elec-
Thrasivoulos G. Tzellos, MD, MSc,                                 trolyte,	urea	and	creatinine	and	thyroid	function	tests.	The	
Dimitrios G. Goulis, MD, PhD,                                     history	 also	 revealed	 easy	 fatigability,	 reduced	 energy	
Dimitrios Kouvelas MD, PhD                                        drive,	slowed	mental	activity,	cold	intolerance	and	perior-
                                                                  bital	swelling.	There	were	no	urinary	symptoms.	Physical	
	    Objective:	Evidence	suggests	that	selenium	(Se)	sup-         Examination	 revealed	 a	 woman,	 who	 looked	 older	 than	
plementation	could	be	useful	as	an	adjunctive	therapy	to	         her	stated	age	with	periorbital	fullness	and	palor.	She	had	
levothyroxine	 (LT4)	 in	 the	 treatment	 of	 Hashimoto	 thy-     no	pedal	edema	or	goiter.	Her	BMI	was	28kg/m2	and	her	
roiditis	(HT).	However,	the	benefit	from	this	supplementa-        waist	 hip	 ratio	 0.72.	 Her	 TSH	 was	 76.22miu/l,	 free	 T3	
tion	in	terms	of	clinical	practice	remains	unclear	and	thus,	     1.5pmol/l	 and	 free	 T4<1.9pmol/l.	 Lipid	 profile	 revealed	
no	evidence-based	recommendation	regarding	Se	supple-             increased	 total	 cholesterol	 and	 LDL	 cholesterol	 while	
mentation	in	the	treatment	of	HT	is	available	yet.                HDL	 cholesterol	 and	 triglycerides	 were	 within	 normal	


                                                            – 166 –
                                             ABSTRACTS – Thyroid Disease

limits.	 ECG	 showed	 bradycardia	 and	 low	 voltages	 and	           euthyroid	on	Synthroid	150	mcg	daily	postoperatively.	In	
her	PCV	was	28%.	Anti	thyroid	anti	bodies	were	strongly	              March	of	2008,	the	patient	delivered	a	healthy	term	infant.	
positive.	Creatinine	clearance	was	36.2ml/min.	Other	lab	             In	April	of	2008,	after	she	had	stopped	breastfeeding,	the	
results	were	within	normal	limits.	A	diagnosis	of	atrophic	           patient	was	admitted	for	inpatient	I-131	ablation.
thyroiditis	 with	 chronic	 kidney	 disease	 was	 made.	 She	         	     Discussion: Although	 this	 patient	 was	 not	 pregnant	
was	 placed	 on	 L-thyroxine,	 and	 after	 3	 months	 became	         at	 the	 time	 of	 diagnosis,	 it	 is	 recommended	 that	 thyroid	
euthyroid	and	her	creatinine	clearance	became	normal.                 nodules	discovered	during	pregnancy	be	evaluated	in	the	
     Discussion:	 The	 causes	 of	 hypothyroidism	 in	                same	 manner	 as	 in	 non-pregnant	 women.	 FNAB	 can	 be	
Nigerian	adult	practice	are	mainly	post	surgery,	Sheehans	            performed	for	evaluation	dominant	nodule(s)	discovered	
syndrome	 and	 post	 radiotherapy.	 Spontaneous	 hypothy-             during	 pregnancy	 (scintiscan/radioactive	 isotopes,	 how-
roidism	 appears	 to	 be	 rare	 in	 our	 setting.	 Thyroid	 hor-      ever,	 must	 be	 avoided).	 Well	 differentiated	 thyroid	 can-
mones	can	have	clinically	relevant	effects	on	the	glomeru-            cers	 affect	 approximately	 1	 in	 1000	 pregnant	 women.	
lar	filtration	rate	as	reflected	in	the	serum	creatinine	and	         Evidence	 suggests	 that	 the	 prognosis	 of	 differentiated	
creatinine	clearance.	Hypothyroidism	has	also	been	found	             thyroid	 cancer	 in	 pregnancy	 is	 similar	 to	 that	 occurring	
to	 be	 associated	 with	 acute	 renal	 failure.	 The	 marked	        in	 non-pregnant	 women	 of	 similar	 age.	 Optimal	 timing	
variation	in	serum	creatinine	and	thus	creatinine	clearance	          for	thyroidectomy	in	a	pregnant	woman	is	controversial.	
observed	in	the	index	case	with	her	thyroid	status	has	been	          Some	 authors	 advocate	 surgery	 during	 pregnancy	 (due	
documented	in	literature	but	may	not	be	widely	known.                 to	 concerns	 that	 human	 chorionic	 gonadotropin	 release	
	    Conclusion:	 Hypothyroidism	 with	 elevated	 serum	              during	 pregnancy	 can	 accelerate	 growth	 of	 thyroid	 car-
creatinine	may	not	be	due	to	kidney	disease.                          cinomas).	Others	advocate	postponing	surgery	until	after	
                                                                      delivery	(citing	prognosis	similar	to	that	in	non-pregnant	
Abstract #1044                                                        women	 and	 concerns	 of	 potential	 maternal/fetal	 compli-
                                                                      cations).	Thyroidectomy	can	safely	be	performed	during	
INITIATION OF TREATMENT OF WELL-                                      the	second	trimester	of	pregnancy	(thus	avoiding	potential	
DIFFERENTIATED THYROID CANCER                                         teratogenic	 effects	 of	 surgery	 performed	 during	 the	 first	
DURING PREGNANCY: A CASE REPORT                                       trimester	and	risk	of	preterm	labor	associated	with	surgi-
                                                                      cal	procedures	performed	in	the	third	trimester).
Jennifer R. Pedersen-White, DO, FACE                                        Conclusion:	 Treatment	 options	 for	 well-differenti-
                                                                      ated	 thyroid	 cancer	 in	 pregnancy	 include	 surgical	 resec-
	    Objective:	To	report	a	case	of	well	differentiated	thy-          tion	during	the	second	trimester	or	delay	of	surgery	until	
roid	cancer	in	a	23-year-old	pregnant	female	and	to	review	           after	delivery.	Radioiodine	scans	and	treatment	should	be	
the	treatment	she	received	during	and	after	her	pregnancy.            delayed	until	after	delivery	and	cessation	of	breastfeeding.
	    Case Presentation:	 A	 23-year-old	 female	 was	
referred	 to	 the	 endocrinology	 clinic	 for	 evaluation	 of	 an	    Abstract #1045
incidentally	 discovered	 thyroid	 nodule	 (discovered	 in	
March	 of	 2007	 when	 a	 CT	 of	 the	 head	 was	 performed	          CALCITONIN-NEGATIVE NEUROENDOCRINE
after	a	motor	vehicle	accident).	The	nodule	was	reported	             TUMOR OF THE THYROID (CNNETT):
to	be	a	hypodense,	3.3	cm	x	3.2	cm	x	3.0	cm	mass	which	               A DISTINCT CLINCAL ENTITY
compressed	and	deviated	the	trachea	to	the	right.	Thyroid	
US	performed	4/17/07	revealed	a	3.0	cm	x	2.3	cm	x	2.9	                Saima O. Farghani, MD, Tomer Davidov, MD,
cm	 heterogeneous	 nodule	 with	 a	 hypoechoic	 rim	 which	           Ly Ma, MD, Nicola J. Bernard, MD, S. Trooskin, MD,
deformed	and	expanded	the	contour	of	the	thyroid.	Fine	               L.F. Amorosa, MD
needle	 aspiration	 biopsy	 (FNAB)	 of	 left	 thyroid	 nodule	
on	 4/25/09	 revealed	 papillary	 thyroid	 cancer.	There	 was	        	    Objective:	Medullary	thyroid	carcinoma	(MTC)	is	a	
no	history	of	radiation	exposure	and	no	family	history	of	            neuroendocrine	tumor	arising	from	the	parafollicular	cells	
thyroid	cancer.	The	patient	was	scheduled	to	undergo	total	           (C-cells)	of	the	thyroid	gland.	Calcitonin	is	secreted	from	
thryoidectomy	in	May	of	2007,	but	was	postponed	by	the	               C-cells	and	therefore	serves	as	a	tumor	marker	for	medul-
patient	until	July	of	2007.	In	mid-June	of	2007,	the	patient	         lary	thyroid	cancer.	Here	we	present	a	case	of	a	calcitonin-
became	 pregnant.	 Despite	 this,	 she	 verbalized	 a	 strong	        negative	neuroendocrine	tumor	of	the	thyroid	(CNNETT),	
desire	to	undergo	thyroidectomy	during	her	pregnancy;	at	             arising	 from	 thyroid	 follicular	 cells.	 The	 differentiation	
14	weeks	gestation	this	was	performed.	Surgical	pathology	            between	MTC	and	CNNETT	is	important	as	the	manage-
revealed	a	3.3	cm	papillary	thyroid	cancer,	follicular	vari-          ment	may	differ.
ant	with	no	nodal	involvement	but	with	evidence	of	vas-               	    Case Presentation:	 A	 healthy	 40-year-old	 woman	
cular	invasion.	The	patient	was	maintained	biochemically	             presented	 with	 an	 incidental	 right	 thyroid	 nodule	 on	


                                                                – 167 –
                                              ABSTRACTS – Thyroid Disease

MRI	 of	 the	 cervical	 spine.	 Ultrasound	 revealed	 a	 soli-         in	VA	Network	2	(upstate	New	York).	We	compared	the	
tary	hypoechoic	2.0	cm	right	thyroid	nodule.	Fine	needle	              frequency	of	diagnosis	of	thyroid	cancer,	nodules,	hypo-
aspiration	 showed	 findings	 suspicious	 for	 a	 poorly	 dif-         thyroidism	 and	 Graves’	 disease	 in	 Veterans	 classified	 as	
ferentiated	 carcinoma	 with	 neuroendocrine	 differentia-             exposed	 (n=19,709)	 or	 not	 exposed	 (n=50,913)	 to	 AO.	
tion.	Staining	for	calcitonin	was	negative,	arguing	against	           Between	groups,	differences	in	race,	smoking	history,	and	
MTC.	Stains	were	positive	for	CK8,	CK18,	thyroglobulin,	               diabetes	mellitus	(DM)	were	first	assessed	with	chi-square	
synaptophysin	and	pankeratin,	suggesting	that	the	tumor	               tests	and	t	tests,	and	then	with	multivariate	logistic	regres-
was	arising	from	follicular	cells.	The	serum	calcitonin	and	           sion.	The	odds	ratios	(OR),	corresponding	95%	confidence	
the	patient’s	RET-oncogene	mutation	assay	were	negative.	              intervals	(CI),	and	p-values	(with/without	Bonferroni	cor-
Calcium	level	was	normal	at	9.8,	and	her	parathyroid	hor-              rection)	were	determined	for	each	condition.
mone	level	was	normal	at	35.	Urine	VMA	and	metaneph-                   	     Results:	All	the	Graves’	patients	were	male	(annual	
rines	were	negative.	The	patient	had	no	family	history	of	             incidence	of	Graves’	disease	in	men	has	been	estimated	at	
any	endocrine	disorder.	A	CT	of	the	head,	chest,	abdomen,	             ~5-8/100,000).	Graves’	prevalence	in	Veterans	exposed	to	
and	 pelvis	 showed	 no	 suspicious	 lesions.	 There	 was	 no	         AO	was	three	times	that	in	the	unexposed	group.	(18/19709	
evidence	of	lymphadenopathy	based	on	examination	and	                  vs.	 15/50913	 in	 the	 unexposed	 group;	 OR=3.1023,	 95%	
neck	 MRI.	 PET	 scan	 was	 negative.	 She	 underwent	 total	          CI=1.563-6.159,	 p=0.00128).	 Interestingly,	 if	 the	 more	
thyroidectomy.	Final	pathology	showed	a	well	differenti-               conservative	 Bonferroni	 correction	 was	 not	 used,	 hypo-
ated	1.5cm	neuroendocrine	tumor	confined	to	the	thyroid	               thyroidism	appeared	to	be	decreased	in	those	exposed	to	
gland.	No	mitotic	activity	or	vascular	invasion	was	identi-            AO	(597/19709	vs.	1733/50913	in	the	unexposed	group;	
fied.	 Calcitonin	 staining	 was	 negative	 but	 thyroglobulin	        OR=0.344,	 95%	 CI=0.806-0.97,	 p=0.013).	 The	 preva-
and	 synaptophysin	 were	 positive.	 She	 did	 not	 receive	           lence	of	thyroid	cancer	or	nodules	between	the	two	groups	
iodine-131	or	any	adjuvant	treatment	and	is	disease	free	              was	 not	 statistically	 different.	 In	 a	 multivariate	 logistic	
on	6	month	follow-up.                                                  regression	 model,	AO	 exposure	 was	 the	 most	 important	
	    Discussion:	 Neuroendocrine	 tumors	 (NET)	 arise	                predictor	 of	 Graves’	 disease,	 OR=3.23,	 95%	 CI=2.88-
from	the	embryonic	neural	crest	and	are	present	in	many	               3.58,	 p<0.001.	Age,	 smoking	 and	 DM	 were	 not	 signifi-
organs,	especially	the	midline	organs	including	the	esoph-             cantly	 associated,	 although	 smoking	 history	 was	 almost	
agus,	 stomach,	 pancreas,	 intestine,	 and	 lung.	 Less	 com-         universal.
mon	sites	of	NET	are	the	pituitary,	adrenal,	skin	and	thy-             	     Discussion:	 2,3,7,8-	 tetrachlorodibenzo-	 p-	 dioxin	
roid	(MTC).	Neural	crest	tissue	form	calcitonin-producing	             (TCDD),	 a	 contaminant	 in	Agent	 Orange,	 binds	 to	AhR	
C-cells	that	migrate	and	fuse	with	the	primordial	thyroid	             (aryl	hydrocarbon	receptor)	extremely	tightly,	and	causes	
gland.	These	are	the	cells	that	rise	to	medullary	carcinoma.	          prolonged	 activation	 of	 genomic	 and	 non-genomic	
In	our	case,	the	NET	of	the	thyroid	was	calcitonin-nega-               pathways	 involved	 in	 development,	 oncogenesis	 and	
tive	 and	 positive	 for	 markers	 of	 follicular	 thyroid	 cells,	    metabolic	 disorders.	 In	 mice,	AhR	 can	 regulate	 the	 dif-
arguing	for	a	NES	arising	from	the	diffuse	neuroendocrine	             ferentiation	of	regulatory	T	cells	and	of	T	cells	that	pro-
system	of	the	thyroid	rather	than	from	C-	cells.	This	dis-             duce	 interleukin-17,	 and	 AhR	 ligands	 like	 TCDD	 can	
tinction	between	MTC	and	CNNETT	is	important	as	the	                   modulate	 autoimmunity	 (Nature	 453:65-71,	 2008;	 J.	
treatment	and	prognosis	may	differ.                                    Immunol.182:6576-6586,	2009).
                                                                       	     Conclusion:	 Despite	 the	 limitations	 associated	 with	
Abstract #1046                                                         retrospective	 chart	 reviews	 and	 studying	 an	 uncommon	
                                                                       disease,	in	view	of	known	immune	modulating	effects	of	
ARE VETERANS EXPOSED TO AGENT ORANGE                                   TCDD,	the	prevalence	of	Graves’	disease	in	AO	exposure	
MORE LIKELY TO GET GRAVES’ DISEASE?                                    warrants	further	investigation.

Ajay Varanasi, MD, Toufic Abdo, MD, David Kasinski,                    Abstract #1047
Amy O’Donnell, MD, Stephen Spaulding, MD
                                                                       CASE REPORT - THYROIDITIS AFTER
	    Objective:	 Environmental	 factors	 can	 increase	 the	           NECK SURGERY
prevalence	of	autoimmune	diseases.	
	    Methodology: Most	Vietnam	era	Veterans	have	been	                 Radha Andukuri, MD, Laura Armas, MD,
assessed	for	possible	Agent	Orange	(AO)	exposure.	In	the	              Andjela Drincic, MD, Shalini Bichala, MD
summer	of	2008	we	reviewed	the	prevalence	of	major	thy-
roid	diagnoses	in	the	Veterans	Administration	(VA)	elec-               	    Objective:	 To	 discuss	 the	 possibility	 of	 thyroiditis	
tronic	medical	record	database	beginning	in	1996	for	vet-              after	neck	surgery.	Traumatic	thyroiditis	was	reported	after	
erans	born	between	1925	and	1950	who	received	treatment	               seat	belt	injuries	and	also	after	vigorous	thyroid	palpation.	


                                                                 – 168 –
                                            ABSTRACTS – Thyroid Disease

Post-operative	thyroiditis	was	reported	after	neck	explora-         patients	 (55.1%)	 received	 30	 mg	 of	 antithyroid	 drug.	
tion	for	parathyroidectomy	and	thyroidectomy.	However,	             Treatment	was	changed	to	lithium	carbonate	in	30.4%	of	
it	was	not	reported	after	other	kinds	of	neck	surgery.              patients,