Gaps in the Care of Subjects with Familial Hypercholesterolemia: Insights from the Thai Familial Hypercholesterolemia Registry

AIMS

Familial hypercholesterolemia (FH) is currently underdiagnosed and undertreated. The establishment of a FH registry could facilitate a deeper understanding of this disease. We described the clinical characteristics of subjects with FH from the Thai FH Registry, compared our data with the regional and global data, and identified gaps in the care of these subjects.

METHODS

A multicenter, nationwide prospective FH registry was established in Thailand. Our data were compared with those of the European Atherosclerosis Society-FH Studies Collaboration. Multiple logistic regression analyses were performed for variables associated with lipid-lowering medication (LLM) use and the attainment of low-density lipoprotein-cholesterol (LDL-C) goal.

RESULTS

The study includes 472 subjects with FH (mean age at FH diagnosis: 46±12 years, 61.4% women). A history of premature coronary artery disease was found in 12%. The percentage of LLM use in subjects with a Dutch Lipid Clinic Network score of ≥ 6 (probable or definite FH) in our registry (64%) was slightly lower than the regional data but higher than the global data. Among those who received statins, 25.2% and 6.4% achieved LDL-C levels of ＜100 mg/dL and ＜70 mg/dL, respectively. Women with FH were less likely to achieve LDL-C ＜70 mg/dL (adjusted odds ratio: 0.22, 95% confidence interval: 0.06-0.71, p=0.012).

CONCLUSIONS

FH in Thailand was diagnosed late, and treatment was inadequate for the majority of subjects. Women with FH were less likely to achieve LDL-C goals. Our insights could potentially help raise awareness and narrow the gap in patient care.

ODP561 Unilateral Vestibular Schwannoma as the Presentation and Aggravation to be Severe Primary Hyperparathyroidism

Background

A rare benign and slow-growing tumor as vestibular schwannoma (acoustic neuroma) usually presents with asymptomatic/unilateral hearing loss or tinnitus and loss of balance between the ages of 49 to 60 years. 90% of vestibular schwannoma are unilateral and not specifically grown in patients with neurofibromatosis type2 (NF2) (1). The association of schwannoma and parathyroid adenoma has been published not much but consistently until now. However, those were not mention to the relationship between pre- and post-treatment of schwannoma with parathyroid hormone level. Clinical case: A 65-year-old woman, previously healthy, presented with progressive fatigue and loss of balance for 1 month. She developed hearing loss, dysarthria and facial palsy within 1 week. At her first visited, she looked drowsiness and had slow verbal and motor response with right facial palsy, lower motor neuron type. She lost only her right facial sensation by pinprick and hyperreflexia without significant other neurological deficits and abnormal skin lesions. She denied family history of NF2. Severe hypercalcemia (17.66 mg/dL) with markedly elevated parathyroid hormone (PTH 1,115.1 pg/mL; 15-68.3) levels and mild elevation of serum creatine (Cr 1.32 mg/dL) was revealed. MRI brain showed an extra-axial enhancing mass at right CPA-IAC region size 3.7×4.2×2.9 cm possible vestibular schwannoma, this mass causing pressure effect to right sided of pons, medulla, cerebellar hemisphere and fourth ventricle. After treatment with saline hydration, her serum creatinine was recovered to normal range with slightly high normal serum calcium (11.85 mg/dL) but not being well. She came back to hospital again with fatigue and polyuria for 3 days. Her serum calcium rose up to 21.3 mg/dL with very high PTH level; 1,643 pg/mL and elevation of serum creatine (Cr 1.71 mg/dL). Again, she was treated with saline hydration for 3 days before receiving zoledronate 4 mg intravenously. After that her serum calcium and creatinine returned to normal level (Ca 10.32 mg/dL, Cr 1. 08 mg/dL) with being better. She was undergone surgery for removal right vestibular tumor and proved to be schwannoma in pathology. During further investigation of hyperparathyroidism, she had normocalcemia and her PTH level dropped to about 400 pg/mL.

Conclusion

Our patient showed the contribution of vestibular schwannoma to rise up the level of PTH as same level as parathyroid carcinoma. There could be some relationships of mechanism between there two diseases that should be explored further. Reference: 1. Carlson ML, Link MJ. Vestibular Schwannomas. Review article. N Engl J Med 384;14,Apr 8, 2021.

Presentation: No date and time listed

Long-term persistence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike protein-specific and neutralizing antibodies in recovered COVID-19 patients

Understanding antibody responses after natural severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can guide the coronavirus disease 2019 (COVID-19) vaccine schedule, especially in resource-limited settings. This study aimed to assess the dynamics of SARS-CoV-2 antibodies, including anti-spike protein 1 (S1) immunoglobulin (Ig)G, anti-receptor-binding domain (RBD) total Ig, anti-S1 IgA, and neutralizing antibody against wild-type SARS-CoV-2 over time in a cohort of patients who were previously infected with the wild-type SARS-CoV-2. Between March and May 2020, 531 individuals with virologically confirmed cases of wild-type SARS-CoV-2 infection were enrolled in our immunological study. Blood samples were collected at 3-, 6-, 9-, and 12-months post symptom onset or detection of SARS-CoV-2 by RT-PCR (in asymptomatic individuals). The neutralizing titers against SARS-CoV-2 were detected in 95.2%, 86.7%, 85.0%, and 85.4% of recovered COVID-19 patients at 3, 6, 9, and 12 months after symptom onset, respectively. The seropositivity rate of anti-S1 IgG, anti-RBD total Ig, anti-S1 IgA, and neutralizing titers remained at 68.6%, 89.6%, 77.1%, and 85.4%, respectively, at 12 months after symptom onset. We observed a high level of correlation between neutralizing and SARS-CoV-2 spike protein-specific antibody titers. The half-life of neutralizing titers was estimated at 100.7 days (95% confidence interval = 44.5–327.4 days, R² = 0.106). These results support that the decline in serum antibody levels over time in both participants with severe disease and mild disease were depended on the symptom severity, and the individuals with high IgG antibody titers experienced a significantly longer persistence of SARS-CoV-2-specific antibody responses than those with lower titers.

Long-term specific IgG response to SARS-CoV-2 nucleocapsid protein in recovered COVID-19 patients

This study monitored the long-term immune response to severe acute respiratory syndrome coronavirus (SARS-CoV)-2 infection in patients who had recovered from coronavirus disease (COVID)-19. Anti-nucleocapsid immunoglobulin G (anti-N IgG) titer in serum samples collected at a single (N = 302) or multiple time points (N = 229) 3–12 months after COVID-19 symptom onset or SARS-CoV-2 detection in respiratory specimens was measured by semiquantitative chemiluminescent microparticle immunoassay. The 531 patients (966 specimens) were classified according to the presence or absence of pneumonia symptoms. Anti N IgG was detected in 87.5% of patients (328/375) at 3 months, 38.6% (93/241) at 6 months, 23.7% (49/207) at 9 months, and 26.6% (38/143) at 12 months. The anti-N IgG seropositivity rate was significantly lower at 6, 9, and 12 months than at 3 months (P < 0.01) and was higher in the pneumonia group than in the non-pneumonia/asymptomatic group at 6 months (P < 0.01), 9 months (P = 0.04), and 12 months (P = 0.04). The rate started to decline 6–12 months after symptom onset. Anti-N IgG sample/cutoff index was positively correlated with age (r = 0.192, P < 0.01) but negatively correlated with interval between symptom onset and blood sampling (r =  − 0.567, P < 0.01). These findings can guide vaccine strategies in recovered COVID-19 patients.

SARS-CoV-2 RNA shedding in recovered COVID-19 cases and the presence of antibodies against SARS-CoV-2 in recovered COVID-19 cases and close contacts, Thailand, April-June 2020

Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although Thailand has been fairly effective at controlling the spread of COVID-19, continued disease surveillance and information on antibody response in recovered patients and their close contacts remain necessary in the absence of approved vaccines and antivirals. Here, we examined 217 recovered COVID-19 patients to assess their viral RNA shedding and residual antibodies against SARS-CoV-2. We also evaluated antibodies in blood samples from 308 close contacts of recovered COVID-19 patients. We found that viral RNA remained detectable in 6.6% of recovered COVID-19 cases and up to 105 days. IgM, IgG, and IgA antibodies against SARS-CoV-2 were detected in 13.8%, 88.5%, and 83.4% of the recovered cases 4-12 weeks after disease onset, respectively. Higher levels of antibodies detected were associated with severe illness patients experienced while hospitalized. Fifteen of the 308 contacts (4.9%) of COVID-19 cases tested positive for IgG antibodies, suggesting probable exposure. Viral clearance and the pattern of antibody responses in infected individuals are both crucial for effectively combating SARS-CoV-2. Our study provides additional information on the natural history of this newly emerging disease related to both natural host defenses and antibody duration.

Uncommon presentation of primary hyperaldosteronism with severe hypomagnesemia: a Gitelman syndrome mimic

Primary hyperaldosteronism (PA) usually presents with moderate to severe hypertension with or without hypokalemia in adults. However, PA is not commonly associated with severe hypomagnesemia. By contrast, Gitelman syndrome usually presents with clinical manifestations of hypokalemia and hypocalcemia due to hypomagnesemia. Here, we present the case of a 44-year-old woman who first presented with peripheral paresthesia. Her laboratory tests revealed severe hypokalemia, metabolic alkalosis, severe hypomagnesemia, hypocalcemia and secondary hyperparathyroidism. The patient took high dose KCL tablets and Mg tablets to maintain normal values. She took only low-dose hydralazine to maintain normal blood pressure. Further investigations revealed PA with a left adrenal tumor. After left adrenalectomy, she remained in a normotensive, normokalemic and normomagnesemic state without any medical supplements. Thus, PA should be considered in patients with severe hypomagnesemia without moderate to severe hypertension.

SAT-324 An Unusual Association between Pheochromocytoma and Hyperparathyroidism in a Patient with Neurofibromatosis Type 1: A Possible Co-Occurrence of Two Hereditary Endocrine Tumor Syndromes

Background: Patients with neurofibromatosis type 1 (NF1) have increased risk of developing various types of endocrine tumors including pheochromocytoma; however, an association with hyperparathyroidism is a rare entity. We present an unusual combination of pheochromocytoma and hyperparathyroidism in a NF-1 patient; a double mutation or digenic inheritance in hereditary endocrine syndromes is proposed. Clinical case: A 66-year-old woman with clinical features of NF1 presented with alteration of consciousness. Physical examination was unremarkable except a large lower abdominal mass and normotension. Severe hypercalcemia (15.02 mg/dL) with markedly elevated parathyroid hormone (PTH 1,550.6 pg/mL; 15-68.3) levels was revealed. A neck ultrasonography showed a 1.6-cm well-defined heterogeneous hypoechoic lesion at postero-inferior aspect of right thyroid lobe corresponding to the result from Tc99m MIBI parathyroid scintigraphy suggestive of parathyroid adenoma. CT whole abdomen revealed a huge uterine myoma and an accidental finding of a 2.5-cm well-defined enhancing nodule at right adrenal gland. Pheochromocytoma was diagnosed by an elevated of 24-h urine metanephrine (771.1 ug; < 276.1) with a normal level of 24 h-urine normetanephrine (273.7 ug; < 668.7). Genetic study showed a heterogeneous mutation at Gly681Ser in exon 11 of RET gene. The co-existence of NF1 and multiple endocrine neoplasia type 2A (MEN2A) was proposed. Laparoscopic right adrenalectomy was performed and its pathological findings confirmed the diagnosis of pheochromocytoma. Subsequently, total parathyroidectomy with thyroidectomy was done with its pathological study showing a parathyroid adenoma, multinodular goiter without the evidence of medullary thyroid carcinoma. The patient refused to perform the treatment for her myoma uteri. During the follow-up period, she has remained asymptomatic with calcium/vitamin D and thyroid hormone replacement without an evidence of pheochromocytoma or hyperparathyroidism recurrence. Conclusion: Our patient has the distinctive features of pheochromocytoma and primary hyperparathyroidism in the patient carrying the double mutations in NF1 and RET gene. This gene-gene interaction may explain the phenotype variability among the affected patients with the hereditary endocrine tumor syndromes.