Developing and Evaluating the DiabetesXcel Mobile Application for Adult Patients With Type 2 Diabetes

The authors trialed a mobile application, DiabetesXcel, which included type 2 diabetes-focused educational videos and modules, in 50 adults of Bronx, NY, a region with a high prevalence of diabetes and diabetes complications. From baseline to 4 months and from baseline to 6 months, there was significantly improved quality of life, self-management, knowledge, self-efficacy, depression, A1C, and LDL cholesterol among those who used DiabetesXcel. There was also a significant decrease in diabetes-related emergency department visits and hospital admissions from baseline to 6 months. This study demonstrates that DiabetesXcel could be beneficial for type 2 diabetes management.

PMON109 A Case of Non-functioning Pituitary Adenoma With Unexpectedly High Prolactin Level

Introduction

Lactotroph or prolactin (PRL)-secreting adenomas account for approximately 45% of all pituitary adenomas. They are classified by size as microprolactinomas (<10 mm) and macroprolactinomas (≥10 mm). A giant prolactinoma is arbitrarily defined as an adenoma > 4 cm. PRL levels are often proportional to the size of tumor ranging from <200 ng/mL in adenomas smaller than 1 cm, 200 ng/mL to 1000 ng/mL in 1 cm to 2 cm adenomas and more than 1000 ng/ml in tumors larger than 2 cm. Nonfunctioning pituitary adenomas (NFPA) can cause mild increases in PRL levels due to pituitary stalk compression, however, levels more than 6 times the upper limit of normal have not been reported. We present a rare case of NFPA with significantly elevated prolactin levels Case: 42 yo female presented with headache and left eye blurry vision worsening over 2 years. MRI revealed a pituitary macroadenoma measuring 4.1×4.7×3cm with supra-sellar extension, mass effect including severe compression and displacement of the optic apparatus, and potential cavernous sinus invasion. Initial biochemical profile: TSH 1.01 (0.30–4.20 uU/mL), FT4 0.9 (0.6–1.5 ng/dL), AM ACTH of 20 (7.2-20 pg/ml), peak cortisol 18.8 mg/dl after cosyntropin stimulation, FSH 14.6 mIU/mL, LH 2.4 mIU/mL, IGF-1 71 (52-328 ng/mL) and prolactin 452 (<25.0 ng/mL), confirmed by dilution. PRL levels were concerning for prolactinoma but did not correlate with tumor size making giant prolactinoma an unlikely diagnosis. Yet, levels were higher than those expected from stalk compression. An interdisciplinary decision was made to proceed with operative management. The patient underwent trans-sphenoidal pituitary resection (TSPR). Tumor pathology showed sparsely granulated gonadotroph adenoma with weak LH expression and negative PRL staining, confirming NFPA. PRL level one-month post op was 33.2 ng/mL and vision is improved.

Conclusion

Medical treatment with dopamine agonists is first line treatment for any size prolactinoma with a high remission rate of 90% and prescribed before TSPR even in those with vision disturbance or neurologic symptoms. Giant NFPAs with compressive symptoms are best surgically managed.To our knowledge, this is the first report of significant PRL elevation due to stalk compression. Not only was the PRL higher than that previously associated with stalk compression, but also well above 250 ng/mL, which is typically diagnostic of prolactinoma. This case also highlights the importance of assessing the relationship between PRL level and tumor size to determine the correct course of management.

Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

PSAT282 A Case of Papillary Thyroid Cancer in a Thyroglossal Duct Cyst

Background

Thyroglossal duct cysts (TGDC) are common congenital neck anomalies. They persist through adulthood in 7% of the general population. Associated malignancy is rare, occurring in <1% of cases. Over 90% of such malignancies are papillary thyroid carcinoma (PTC). Twenty to 60% of patients with TGDC malignancies are found to have concomitant cancer in the thyroid. The rarity of TGDC malignancy make its management particularly challenging, given limited long term outcome data. We describe a case of a 4cm TGDC PTC.

Case

A 49-year-old female with a history of autoimmune thyroid disease presented for evaluation of a goiter. She reported 6 months of painful midline neck swelling. No family history of thyroid cancer and she had no history of radiation to her head or neck. She denied swallowing, dyspnea, or hoarseness. Physical exam was notable for a mildly tender, firm 2.5 cm submental midline neck mass overlying the hyoid. TSH was normal and thyroid peroxidase antibody was >1000 (n: <5 IU/mL). Neck ultrasound showed a 3.7×2.5×1.6 cm mixed solid/cystic midline neck mass and a mildly enlarged, heterogeneous, and vascular thyroid without discrete intrathyroidal nodules. A neck CT with contrast indicated that the midline mass was heterogeneously enhancing with tiny internal cystic spaces. The differential diagnosis included an infected thyroglossal duct cyst versus malignant transformation. Fine needle aspiration of the mass was suggestive of PTC. The patient underwent the Sistrunk procedure, with excision of the thyroglossal duct cyst, the middle of the hyoid bone, and the tissue surrounding the thyroglossal tract. Final pathology was consistent with a 4 cm PTC, classical type, without lymphatic, vascular or perineural invasion. Surgical margins were negative for malignancy. Two months postoperatively, TSH remained normal, and the thyroglobulin (TG) level was 78 with negative TG antibodies. She declined a thyroidectomy.

Conclusion

To date, there is no consensus guideline regarding optimal management for malignancy involving TGDC. Studies suggest that surgical decision making be based on patient risk stratification. High risk factors include age older than 45 years, tumor >4 cm in size, extension of tumor to adjacent soft tissue, and/or the presence of nodal or distant metastases. In high-risk patients, treatment with Sistrunk procedure combined with thyroidectomy, neck dissection and radioactive iodine therapy have shown excellent results. In younger than 45 years with tumor size <1.5 cm, without extension beyond cyst wall and normal thyroid ultrasound Sistrunk procedure alone might be sufficient. Despite low risk factors patients should still be advised to have thyroidectomy as there could be a 20% risk of coexisting thyroid cancer. Additional longitudinal studies are needed to confirm that this approach leads to optimal long-term outcomes for patients with TGDC-associated malignancy.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

PSAT285 A Rare Case of Co-Existing Papillary Thyroid Cancer with Lung Metastasis and Lung Adenocarcinoma

Introduction

Multiple primary tumors are defined as the presence of two primary tumors of different histologies in the same individual, which can be diagnosed at the same time or at different times. We present a rare case of papillary thyroid cancer (PTC) with pulmonary metastasis and lung adenocarcinoma diagnosed simultaneously and highlight the importance of identifying multiple primary cancers to guide management and improve patient outcomes.

Clinical Case

A 57-year-old female with no prior history of malignancy was found to have a 12 mm left upper lobe lung nodule on CT chest as a part of evaluation of worsening cough. A fluorodeoxyglucose PET scan showed increased uptake in the left upper lobe nodule as well as a hypermetabolic thyroid nodule in the right thyroid lobe. She underwent a thoracoscopy, wedge resection, and left lung lobectomy with lymph node dissection, and pathology revealed adenocarcinoma of the lung as well as incidentally found PTC. Subsequently, thyroid ultrasound was obtained which showed a right upper mid-pole thyroid nodule measuring 1.7 cm. She underwent a total thyroidectomy, and pathology showed PTC, tall cell variant in the right lobe, with largest tumor dimension 1.5 cm with no extrathyroidal extension, no lymphatic, and no vascular invasion.

A nuclear uptake scan post thyroidectomy showed focal uptake in the thyroid corresponding to residual thyroid tissue, without evidence of metastatic disease. She subsequently received 152.6 mCi of radioactive iodine (RAI). A post-therapy scan obtained one week later showed no new uptake. After RAI, her thyroglobulin antibody remained negative and thyroglobulin became undetectable. She remains on levothyroxine therapy with her TSH at target of 0.1-0.4 U/L. However, she unfortunately had recurrent disease of her lung adenocarcinoma and is continuing to undergo treatment with chemotherapy

Conclusion

PTC is the most common type of differentiated thyroid cancer and generally has a better prognosis than other types of thyroid cancer given its indolent course. Histologic subtype, presence of extra thyroidal extension, lymph node involvement, and distant metastasis play a role in prognosis, and PTC metastasizes to the lungs in about 5% of cases. Clinicians should be aware of the possibility of multiple primary tumors, and the use of diagnostic modalities like FDG-PET and tissue biopsy can help differentiate a second primary tumor from metastatic disease. Radioactive iodine therapy (RAI) for management of differentiated thyroid carcinoma has been linked to predisposition to other primary malignancies such as leukemia and lymphoma, however our patient was found to have both malignancies simultaneously prior to receiving RAI. This suggests the possibility of genetic susceptibility or alterations in the immune constituency. Further studies are needed to analyze the genetic and environmental factors that lead to development of two primary tumors in certain individuals.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Targeting Technology in Underserved Adults With Type 1 Diabetes: Effect of Diabetes Practice Transformations on Improving Equity in CGM Prescribing Behaviors

OBJECTIVE

Continuous glucose monitoring (CGM) is associated with improved outcomes in type 1 diabetes, but racial-ethnic disparities exist in use. We were interested in examining whether addressing structural health care barriers would change provider prescribing behaviors to make CGM access more equitable.

RESEARCH DESIGN AND METHODS

From January 2019 to December 2021, we used multilevel stakeholder input to develop and implement several non-grant-funded practice transformations targeted toward equity, which included 1) developing a type 1 diabetes clinic, 2) conducting social needs assessments and management, 3) training support staff to place trial CGMs at the point of care, 4) optimizing prescription workflows, and 5) educating providers on CGM. Transformations were prioritized based on feasibility, acceptability, and sustainability. To examine effect on prescribing behaviors, we collected monthly aggregate data from the electronic medical record and performed multiple linear regression to examine and compare change in CGM prescriptions over the 3 years of transformation.

RESULTS

In total, we included 1,357 adults with type 1 diabetes in the analysis (mean ± SD age 38 ± 18 years; 30% Black [n = 406], 45% Hispanic [n = 612], 12% White [n = 164]; and 74% publicly insured [n = 1,004]). During the period of transformation, CGM prescription rates increased overall from 15% to 69% (P < 0.001). Improvements were seen equally among Black (12% to 72%), Hispanic (15% to 74%), and White adults (20% to 48%) (between-group P = 0.053).

CONCLUSIONS

Diabetes practice transformations that target equity, offload provider burdens, and focus on feasible sustainable stakeholder-driven solutions can have powerful effects on provider prescribing behaviors to reduce root causes of inequity in CGM among underserved adults with type 1 diabetes. Continued focus is needed on upstream determinants of downstream CGM use.

Silent Corticotroph and Somatotroph Double Pituitary Adenoma: A Case Report and Review of Literature

Clinically silent double pituitary adenomas consisting of corticotroph and somatotroph cells are an exceedingly rare clinical finding. In this report, we present the case of a 28-year-old man with a 1-year history of recurrent headaches. Imaging revealed a 2.1 (anterior-posterior) × 2.2 (transverse) × 1.3 (craniocaudal) cm pituitary adenoma invading into the left cavernous sinus and encasing the left internal carotid artery. Endoscopic transnasal resection was performed without complications. Immunohistochemical staining revealed a double adenoma consisting of distinct sparsely granulated somatotroph and densely granulated corticotroph cells that were positive for growth hormone and adrenocorticotropic hormone, respectively. K _i -67 index labeling revealed a level of 6% within the corticotroph adenoma. No increase in serum growth hormone or adrenocorticotropic hormone was found, indicating a clinically silent double adenoma. While transsphenoidal surgery remains a first-line approach for silent adenomas presenting with mass effects, increased rates of proliferative markers, such as the K _i -67 index, provide useful insight into the clinical course of such tumors. Determining the K _i -67 index of silent pituitary adenomas could be valuable in predicting recurrence after initial surgical resection and identifying tumors that are at an increased risk of needing additional therapeutic interventions or more frequent surveillance imaging.

Role of Octreotide in Sulfonylurea-Induced Hypoglycemia

Introduction: The most common adverse effect associated with sulfonylurea ingestion is hypoglycemia. Sulfonylureas have very narrow therapeutic indices with a prolonged half-life in End-Stage renal Disease (ESRD). As per literature review, insulin and oral sulfonylureas are responsible for 13.9% and 10.7% of emergency hospitalizations respectively. It is, however, not surprising that intentional or unintentional overdose with these agents can lead to prolonged hypoglycemia which can prove to be fatal.

Case Report:76-year-old female presented to the Emergency Department (ED) with complaints of generalized weakness since the past three days. Her past medical history was significant for ESRD, Hypertension and Non-Insulin Dependent Diabetes Mellitus type II (home regimen of glipizide 10 mg daily). On physical exam, she was tachypneic and appeared lethargic. Her neurological exam was intact, and she was oriented to time, place and person. Her labs were significant for BUN of 77 mg/dL (5–20 mg/dL), Creatinine of 9.94 mg/dL (<1.3mg/dL) and blood glucose of 89 mg/dL (70-140mg/dL). Liver and thyroid function tests were normal. Computed Tomography scan of the head was unremarkable. In the ED, she received 5 mg of glipizide after which she became more confused and lethargic. Her blood glucose level was 21mg/dL thus she received seven pushes of intravenous (IV) dextrose (25g each), two doses of intramuscular glucagon (1mg each) and was started on a continuous infusion of dextrose (D10) at 75cc/hour. Her blood glucose levels continued to remain low with a repeat value of 34 mg/dL and her mental status continued to worsen. Labs checked at that time were significant for a C-Peptide level of 22.13ng/ml (1.00–4.00ng/ml) and an insulin level of 43.7uU/ml (<20uU/ml) suggesting it to be sulfonylurea toxicity. Sulfonylurea level could not be checked due to laboratory limitations. She was started on subcutaneous octreotide 30 mcgs every 6 hours as per endocrinology recommendations. Her blood glucose started to improve, and her mental status returned to baseline. Per oral food intake was resumed, she remained euglycemic and octreotide was discontinued.

Conclusion: Octreotide is a synthetic octapeptide analogue of somatostatin which can effectively suppress insulin secretion. Glucose, on the other hand, would stimulate insulin release and cause rebound hypoglycemia. Boyle et al, showed that octreotide was superior to diazoxide and glucose in preventing sulfonylurea-induced hypoglycemia. Therefore, we as clinicians should be able to quickly recognize sulfonylurea toxicity as the cause of hypoglycemia and attempt to administer octreotide as soon as possible. This in turn would help decrease length of hospital stay and avoid the detrimental effects of hypoglycemia like seizures, coma and death especially in older individuals.

A Case of Non-Islet Cell Tumor Hypoglycemia in Metastatic Solitary Fibrous Tumor

Introduction: Insulin like growth factor (IGF-2) mediated hypoglycemia secondary to solitary fibrous tumor (SFT), also known as Doege-Potter syndrome is a rare paraneoplastic syndrome. The tumor cells produce large amounts of high molecular weight IGF 2 precursor protein called “big IGF-2” which binds to insulin and IGF receptors in liver, muscle and other peripheral tissues. This causes reduced gluconeogenesis and increased uptake of glucose by the muscle and other tissues leading to hypoglycemia. Big IGF-2 also exerts central negative feedback of growth hormone causing reduction of IGF-I production. Most SFTs are benign and localized (approximately 78-88%). As a result, tumor excision alone would often lead to resolution of the hypoglycemia. We present a case of metastatic SFT with multiple metastasis managed with oral prednisone.

Clinical Case: A 44-year-old man with metastatic SFT presented with bilateral humeral fractures. He has known metastatic disease to the brain, lung, liver, bony lytic lesions over a course of eleven years. It has progressed despite multiple chemotherapy and radiation therapies. Prior to admission, he had multiple syncopal episodes associated with fasting hypoglycemia. He reported capillary blood glucose values ranging between 30-50 mg/dl during these episodes which would improve after drinking juice or eating candy. There was no history of diabetes mellitus or use of oral hypoglycemic agents or insulin. On admission, he had a capillary blood glucose value of less than 20 mg/dl, which was confirmed by a serum glucose value of 18 mg/dl on basic metabolic panel. His renal, liver and thyroid function tests were normal. Significant labs include: serum glucose 17 mg/dl, C-peptide &lt;0.10 ng/ml (n: 1-4 ng/ml), serum insulin &lt;1.6 Uu/ml (n: &lt;20 Uu/ml), beta-hydroxybutyrate &lt;0.2 mmol/L (n: &lt;0.3), cortisol 10.8 ug/dl(n: 5-15 ug/dl) glucagon 6 pg/ml(ref 8-57 pg/ml), insulin-like growth factor-1 (IGF 1) 20 ng/ml (n: 52-328), and IGF-2 level 380 ng/ml (267-616 ng/ml), improvement in blood glucose from 46 to 111 mg/dl after 1-gram glucagon administration. The IGF-2/IGF-1 ratio of 19 confirmed our clinical suspicion of non-islet cell tumor hypoglycemia (NICTH). He was started on prednisone 20 mg twice daily with marked improvement in hypoglycemia.

Conclusion: NICTH is a rare cause of hypoglycemia and should be considered in the differential while evaluating hypoglycemia in malignancy. For diagnosing NICTH, assays for big IGF-II are not commercially available. However, the IGF-II:IGF-I ratio is considered to be a surrogate marker of big IGFII concentration. The normal ratio is 3 and ratio &gt;10 is diagnostic of NICTH. In cases like ours where tumor resection is not possible, glucocorticoids are most effective in management of hypoglycemia by inhibiting big IGF2 production and stimulating gluconeogenesis.

A Case of Thyrotoxic Periodic Paralysis

Introduction: Thyrotoxic periodic paralysis (TPP) is an uncommon disorder characterized by simultaneous thyrotoxicosis, hypokalemia, and paralysis. It is a rare complication of hyperthyroidism with a prevalence of 1 in 100,000. It has a higher prevalence in young Asian males, with much fewer cases reported in Hispanic patients. The majority of cases are seen in hyperthyroidism due to Grave’s disease, however other causes of thyrotoxicosis have been associated with TPP. Hypokalemia occurs when thyroid hormone stimulates the sodium-potassium-ATP pump by binding to the thyroid response elements upstream of the genes for this pump, increasing its activity and thereby causing a transcellular shift of potassium into the intracellular fluid. Attacks usually begin with proximal muscle weakness of the lower extremities and may progress to tetraplegia, with the degree of muscle weakness corresponding to serum potassium levels. Interestingly, no correlations with serum T3 or T4 levels have been found.

Clinical Case: A 38-year-old Hispanic man with a history of GERD presented to the emergency department with an inability to move his extremities. Initial labs were significant for profound hypokalemia to 2.0 mEq/L (3.5-5) and hyperthyroidism, with TSH<0.05 uU/mL (0.3-4.2) and free T4 2.4 ng/dL (0.6-1.5). Additional workup revealed a positive thyroid stimulating immunoglobulin and a positive thyrotropin binding inhibitor, and thyroid ultrasound demonstrated a hyperemic thyroid with numerous subcentimeter hypoechoic nodules, all of which was suggestive of Grave’s disease. His symptoms resolved with potassium repletion, suggesting thyrotoxic periodic paralysis secondary to hyperthyroidism. Upon further evaluation, the patient endorsed several months of hyperthyroid symptoms such as tremors, heat intolerance, and weight loss. He also endorsed alcohol use, a high carbohydrate diet, and recent life stressors, a combination of which likely precipitated his thyrotoxic periodic paralysis. He was discharged on methimazole 10 mg daily and propranolol 40 mg BID, with a decrease in his free T4 and improvement in his symptoms. He has been educated to avoid alcohol consumption and high-carbohydrate meals to avoid precipitating another episode of periodic paralysis, and once his hyperthyroidism is under better control he plans to undergo radioactive iodine ablation (RAI) for definitive management.

Conclusions: Thyrotoxic periodic paralysis is a rare but dangerous complication of hyperthyroidism, and should be considered in the differential diagnosis when young individuals present with otherwise unexplained hypokalemia and paralysis. Acute management is potassium repletion, long term management involves treatment of thyrotoxicosis and avoiding precipitating factors, and definitive therapy is RAI or thyroidectomy.