RF06 | PSAT153 Osteoporosis Screening of Liver Transplant Patients in a Tertiary Urban Medical Center

Background

Liver transplantation is an established treatment for patients with end-stage liver disease. In 2021 more than 8,400 liver transplants were performed in the United States. Although successful transplantation can reverse many complications of end organ failure, disturbance of bone and mineral metabolism may persist, which can contribute substantially to morbidity and mortality. It is important to assess whether liver transplant patients are getting bone density screening and treatment.

Objective

Our goal is to assess current practice in bone density screening in patients who have undergone liver transplant at our medical center, to identify if these patients are being screened for metabolic bone disease before and after transplant, and to improve management of such patients by initiating a provider work flow that is based on available data and evidence.

Study Design: The first phase was a survey of the liver transplant team to assess the current protocol for screening. The second phase involved retrospective chart review of patients at our institution who had a liver transplant between October 2008 and April 2021. The findings will be used to create an institutional protocol for osteoporosis screening and management.

Results

Survey results: 62.5% of liver transplant providers knew that guidelines or a protocol are being used to screen liver transplant recipients for osteoporosis. 75% said that dual-energy x-ray absorptiometry (DXA) scans are always obtained before liver transplantation, while 25% said they are sometimes obtained. There were mixed results regarding monitoring post transplant. All respondents agreed that creating a protocol for osteoporosis screening would improve outcomes of bone health in transplant patients.

Chart review results: We reviewed 243 liver transplant recipients between October 2008 and April 2021. After excluding duplicate transplants and those less than 18 years old, 234 patients were included in analysis. 59% of patients were men with a median age of 63.5. The most common etiologies of pre-transplant liver disease were Hepatocellular Carcinoma (29%), Hepatitis C (17%), alcoholic cirrhosis (16%) and NASH (5%). 72% of transplant patients had a DXA before transplant and 28% did not. Of those with a pre-transplant DXA, 28% had normal bone density, 50% had osteopenia, and 20% had osteoporosis. The remainder did not have data available. Among those with a diagnosis of osteoporosis pre-transplant, 41% received treatment while 56% did not receive any bone-specific therapy.

Discussion

The majority of providers in our liver transplant team are aware of the need for bone health screening and treatment in liver transplant candidates. Most patients received a DXA prior to transplant however less than half of the patients with osteoporosis were started on treatment. Our study shows the need for developing an institutional work flow to optimize bone health in patients undergoing liver transplant.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m., Saturday, June 11, 2022 1:06 p.m. - 1:11 p.m.

ODP512 Renal Cell Carcinoma Metastatic to Thyroid: A Case Report

Introduction

The thyroid gland is an uncommon site (0.7%) among all distant metastasis from renal cell carcinoma (RCC). Here we report a case of metastasis from RCC to the thyroid gland, diagnosed 15 years after treatment.

Clinical Case

A 63-year-old female, was referred to endocrine for evaluation of neck mass of several months’ duration. Thyroid function test revealed mildly low TSH and normal free T4. Recent thyroid ultrasound showed multinodular thyroid, the largest nodule was in mid to upper left thyroid lobe and measured 6cm in max diameter. Biopsy of 4 thyroid nodules was performed. Three nodules were benign (Bethesda 2), but the left mid to upper 6cm thyroid nodule showed Atypia of Undetermined Significance (Bethesda 3). Due to concern of large size, potential for further growth and gradual development of local compressive symptoms, total thyroidectomy was recommended. Patient was initially hesitant, however, within several months, she developed dysphagia and progressive neck swelling, and eventually had total thyroidectomy. Surgical pathology revealed metastatic RCC involved left thyroid lobe (8.4cm in greatest dimension) and right thyroid lobe (0.3cm in greatest dimension). Immunohistochemical stain were positive for CA9, CD10, PAX8, while negative for CKIT, CK7, TFT-1, thyroglobulin, synaptophysin, chromogranin, calcitonin, and PTH. Patient reported a history of right nephrectomy in 2005 and did not require adjuvant therapy at that time. Post-operative workup including CT neck/chest/abdomen/pelvis revealed a 2.4cm left superior mediastinum mass suspicious for metastasis. Patient was evaluated by genitourinary oncology and the decision was to continue surveillance with CT every three months. A new gallbladder lesion was detected after six months, laparoscopic cholecystectomy was performed, and pathology showed metastatic RCC.

Conclusion

This is an unusual case of metastatic RCC to thyroid gland, diagnosed 15 years after initial presentation with RCC that required only a nephrectomy. The cytology – pathology discrepancy in our case highlights the limitation of FNA in diagnosing rare thyroid masses of extra-thyroidal origin. A study has showed thyroid cytology was only diagnostic in 29.4% of population with RCC metastatsis(1). Especially when rapid growth is seen, surgery needs to be considered regardless of FNA results. Reference: 1. Khaddour K, Marernych N, Ward WL, Liu J, Pappa T. Characteristics of clear cell renal cell carcinoma metastases to the thyroid gland: A systematic review. World J Clin Cases. 2019 Nov 6;7(21): 3474-3485. doi: 10.12998/wjcc. v7. i21.3474. PMID: 31750330; PMCID: PMC6854394.

Presentation: No date and time listed

Severe Osteomalacia and Fractures Secondary to Vitamin D Deficiency

Background: Vitamin D deficiency is a common entity among the elderly. Low vitamin D levels can lead to poor bone mineralization, in addition to elevations in PTH levels with resultant increases in bone turnover. However, severe Vitamin D deficiency causing osteomalacia has become uncommon in the United States due to increased screening and treatment. Vitamin D supplementation is a mainstay of therapy for osteoporosis, yet its effect on bone density is generally thought to be modest. We present here an extreme case of vitamin D deficiency leading to severe secondary hyperparathyroidism and bone demineralization, with excellent response to supplementation.

Clinical Case: Patient was a 73-year-old woman with hypertension who presented to the ER with acute on chronic back and lower extremity pain. She had these pains for about a year, but they had worsened over the last 4 days. She had been homebound for the past 1–2 years due to severe pain while ambulating, reported a five-inch loss of height and 50 pounds weight loss, and maintained a vegan diet. She had not had medical care in 15 years. Imaging studies demonstrated a displaced left femoral neck fracture, a nondisplaced right femoral neck fracture, multilevel thoracolumbar compression fractures, and a nondisplaced right scapular fracture. Blood tests revealed normal renal function, calcium 8.6mg/dL (nl 8.5–10.5), phosphorus 2.6mg/dL (nl 2.5–4.5), and alkaline phosphatase 2,821U/L (nl 45–164). Secondary osteoporosis workup was negative for hypercalciuria or multiple myeloma, but was notable for a PTH level of 2,190 pg/mL (nl 10–65) and 25-OH Vitamin D level of <5ng/mL (nl >30). C-telopeptide was measured at 3,346 pg/mL (nl <1000) and osteocalcin >300ng/mL (nl 8–32). DEXA scan showed T-scores of -4.2 at the lumbar spine and -6.8 at the distal forearm. She was started on high-dose vitamin D supplementation, with serum Vitamin D level rising to 42.1ng/mL after 6 months of treatment. This corresponded to a decrease in PTH to 141.1pg/mL and alkaline phosphatase to 375U/L. Repeat DEXA two years later showed 52.8% increase in bone mineral density at the lumbar spine, and 27.1% increase at the forearm. The patient’s body pains have significantly improved and she is now ambulatory again.

Conclusions: Vitamin D deficiency is an uncommon cause of severe bone demineralization in the United States. However, in certain high-risk populations, it can present with debilitating osteomalacia and numerous pathologic fractures. Even in cases of osteoporosis with severe PTH elevation, Vitamin D deficiency must be ruled out as a potential secondary etiology, as it can be easily treated with potentially dramatic response.

Successful Multimodal Treatment of a TSH-Secreting Pituitary Adenoma (TSH-oma)

Background: TSH-omas are rare tumors accounting for 0.5-2% of all pituitary adenomas. Due to their indolent nature, most TSH-omas are diagnosed at the stage of invasive macroadenomas. Over the past several decades, the management of TSH-omas has evolved substantially. While surgery remains first-line therapy, somatostatin analogs have emerged as important therapeutic agents as a result of their effectiveness in normalizing thyroid hormone levels in ~95% of patients with severe hyperthyroidism and reducing TSH-oma size in ~50% of patients.

Clinical Case: A 52-year-old woman with a history of multinodular goiter was incidentally found to have a 2.2 x 1.8 x 2.1 cm pituitary macroadenoma with suprasellar extension, mass effect on the optic chiasm, and left cavernous sinus involvement when she presented with chest pain, palpitations, headache, and left-sided numbness and weakness. Laboratory results showed high FT4/T4/T3 with inappropriately high TSH, elevated α-subunit, and low cortisol with low-normal ACTH highly suggestive of TSH-oma with concurrent secondary adrenal insufficiency. An ophthalmology exam revealed a left superior temporal defect. The patient was treated with atenolol, prednisone, and octreotide two weeks before surgery with symptomatic improvement and near-normalization of FT4. Following an uncomplicated transsphenoidal resection, FT4 normalized within one week. At her one-month follow-up, both TSH and FT4 were normal, and her secondary adrenal insufficiency had resolved. Her visual field defect also recovered.

Laboratory Results: TSH 5.35 (normal range 0.40-4.60 μU/mL), FT4 3.0 (0.8-1.7 ng/dL), T4 18.1 (5.0-12.0 μg/dL), T3 235 (80-200 ng/dL), ACTH 10 (6-50 pg/mL), cortisol 4.5 (5.0-25.0 μg/dL), α-subunit 8.0 (0.1-1.5 ng/mL); after 2 weeks on SQ octreotide 50mg q12h: TSH 1.93 (0.30-4.20 μU/mL), FT4 1.7 (0.6-1.5 ng/dL); 1 month post-op: TSH 1.53 (0.30-4.20 μU/mL), FT4 0.8 (0.6-1.5 ng/dL), ACTH 12 (7.2-63 pg/mL), cortisol 6.9 (4.0-20.0 μg/dL)

Conclusion: Since the first reported case of TSH-oma in 1960, the diagnostic and therapeutic management of these rare pituitary adenomas have evolved due to the emergence of ultrasensitive TSH assays, advanced imaging and surgical techniques, and somatostatin analogs. However, to this day, most TSH-omas are still diagnosed at the stage of invasive macroadenomas, when successful surgical resection becomes more difficult. Hence, up to two-thirds of patients may require adjuvant therapy with medication or radiation. As evidenced in our patient, who achieved a near-euthyroid state within just two weeks of starting low dose octreotide, somatostatin analogs are highly effective in controlling hyperthyroidism and have solidified their place in the therapeutic management of TSH-omas. This case highlights the success of a multimodal approach to the treatment of TSH-omas.

The Effect of Vitamin D Supplementation on Severe COVID-19 Outcomes in Patients With Vitamin D Insufficiency

Introduction: Coronavirus Disease 2019 (COVID-19) deaths have surpassed one million worldwide with limited treatment modalities, and physicians are relying on alternative methods, such as Vitamin D supplementation, to prevent or halt disease progression without direct evidence. Research has proven that vitamin D supplementation can prevent inflammation based on its role in innate immune response; however, there have been limited studies regarding vitamin D supplementation in COVID-19. We aimed to determine whether vitamin D supplementation in vitamin D insufficient patients was associated with fewer severe COVID-19 outcomes, defined as mechanical ventilation or death. Methods: Retrospective study that analyzed data from all adult patients admitted to our tertiary care center between March 2020 and July 2020 with a positive RT-PCR for SARS CoV-2 and a serum 25-hydroxyvitamin D (25[OH]D) level measured within 90 days prior to the index admission. Patients with 25(OH)D <30 ng/mL were considered vitamin D insufficient and patients ordered for least one weekly dose of ≥1,000 units of ergocalciferol or cholecalciferol were considered supplemented. Supplemented vitamin D insufficient patients were compared to non-supplemented vitamin D insufficient patients in terms of severe COVID-19 disease as defined by mechanical ventilation or death. Results: 129 COVID-19 patients with a vitamin D level <30 ng/mL were identified, with a median vitamin D level of 21.4 ng/mL. A total of 43 patients (33.3%) had severe COVID-19 outcomes. 65 (50.4%) patients with vitamin D insufficiency were supplemented and 64 (49.6%) were not supplemented. Vitamin D supplementation with ≥1,000 units (OR 0.6, 95% CI 0.28 - 1.40; p=0.25), ≥5,000 units (OR 0.5, 95% CI 0.26 - 1.23; p=0.15), or ≥50,000 units (OR 1.0, 95% CI 0.42–2.20, p=0.92) weekly had no statistically significant effect on severe COVID-19 outcomes. The odds of severe COVID-19 outcomes in supplemented patients were non-significantly reduced at lower cutoff values for vitamin D insufficiency (<20 ng/mL and <12 ng/mL) for all supplementation amounts. Conclusion: Vitamin D supplementation in patients with vitamin D insufficiency did not significantly reduce severe COVID-19 outcomes; however, vitamin D supplementation was associated with non-statistically significant reduced odds of severe COVID-19 outcomes at lower cutoff values of vitamin D level. These results demonstrate that Vitamin D supplementation may have a protective effect against severe COVID-19 outcomes in patients with lower baseline levels of vitamin D.

Plasmapheresis as First Line Therapy for Thyrotoxicosis in a Critically Ill Patient

Introduction: The role of plasmapheresis (TPE) in thyrotoxicosis management is not well established. Its use may be determined on an individualized basis (1). We report a case of a critically ill patient where TPE was utilized as first-line therapy for refractory thyrotoxicosis. Clinical Case: A 33-year-old woman with Graves’ disease complicated by medication non-adherence presented with rapidly ascending paralysis and bulbar weakness. Primary work up was consistent with acute inflammatory demyelinating polyneuropathy (AIDP) based on EMG findings of motor fiber polyneuropathy with demyelinating features. Laboratory evaluation revealed uncontrolled hyperthyroidism (TSH <0.05 uU/mL, N 0.3-4.2 uU/mL; fT4 3.9 ng/dL, N 0.6-1.5 ng/dL; tT3 318, N 60-160 ng/dL). Initially, there was low concern for thyrotoxicosis based on a Burch-Wartofsky score of 15 (2). Standard dose methimazole and aggressive beta-blockade were initiated. Hospital course was complicated by hypoxic respiratory failure due to progressive paralysis requiring intubation and septic shock from Klebsiella pneumonia requiring initiation of pressors and broad-spectrum antibiotics. Biochemical evaluation showed increasing fT4 (3.8 ng/dL) and tT3 (419 ng/dL) levels. Burch-Wartofsky score increased to 55, consistent with a thyrotoxic crisis. Due to the patient’s critical condition, TPE was rapidly initiated along with standard therapy for thyrotoxic crisis (high dose methimazole, esmolol drip, stress dose corticosteroids, cholestyramine, and potassium iodide) as a bridge to definitive management with thyroidectomy. Rapid clinical improvement with a decline in fT4 levels (3.8 to 2.1 ng/dL) was noted after initiation of TPE with normalization in fT4 (1.5 ng/dL) and tT3 (54 ng/dL) after three sessions. Thyroidectomy was pursued after clinical stabilization. Surgical pathology showed diffuse papillary hyperplasia consistent with Graves’ disease. Due to persistent respiratory failure, the patient underwent tracheostomy placement. Repeat EMG revealed severe myopathic dysfunction without demyelinating features favoring a diagnosis of acute thyrotoxic myopathy over AIDP. Patient was ultimately discharged to a long term acute care facility due to slow neurological recovery. Conclusion: TPE should be considered as first line management in conjunction with conventional medical therapy in critically ill patients with thyrotoxicosis as a bridge to thyroidectomy due to rapid time to effect and patient stabilization. References: (1) Padmanabhan A, et al. J Clin Apher. 2019 Jun;34(3):171-354. (2) Bahn Chair RS, et al. Thyroid. 2011 Jun;21(6):593-646.

Thyroid Dysfunction in Lung Cancer Patients Treated with Immune Checkpoint Inhibitors (ICIs): Outcomes in a Multiethnic Urban Cohort

Simple Summary

Which factors predispose individuals to developing immune-related adverse events (irAEs) remains unclear. In addition, the relationship between irAEs and survival outcomes warrants further investigation. We sought to investigate the association between immunotherapy-related thyroid dysfunction and demographic and clinical characteristics in a diverse urban cohort of patients with lung cancer receiving immune checkpoint inhibitors (ICIs). This study was conducted with the aim of helping to identify patients at a higher risk of experiencing irAEs and clarify whether irAEs portend a survival advantage.

Abstract

We sought to characterize thyroid dysfunction and its association with baseline clinical and demographic characteristics, as well as progression-free survival (PFS), in a multiethnic cohort of lung cancer patients treated with ICIs. A retrospective chart review of lung cancer patients receiving an anti-PD1 or PD-L1 agent was performed. Multivariate Cox proportional hazards were fitted to compare time to thyroid dysfunction among race subgroups controlling for age, gender, treatment type, and duration. Thyroid dysfunction was based on laboratory testing; clinical symptoms were not required. PFS at a 24-week landmark analysis point among patients with and without thyroid dysfunction was compared using a log-rank test. We identified 205 subjects that received ICIs, including 76 (37.1%) who developed thyroid dysfunction. Rates of thyroid dysfunction by one year occurred at similar frequencies among all races (p = 0.92). Gender and concurrent chemotherapy showed no significant association with thyroid dysfunction (p = 0.81 and p = 0.67, respectively). Thyrotoxicosis occurred at higher rates in Black (25, 31.6%) subjects than in White (7, 16.7%) and Hispanic (8, 12.7%) subjects when employing the log-rank test (p = 0.016) and multivariate Cox regression (HR 0.48, p = 0.09 for White and HR 0.36, p = 0.01 for Hispanic compared to Black subjects). PFS was similar among subjects with and without thyroid dysfunction when applying the log-rank test (p = 0.353). Gender, concurrent treatment with chemotherapy, and PFS were not associated with thyroid dysfunction in patients receiving ICIs; however, Black race was a risk factor for thyrotoxicosis. The mechanisms underlying the role of race in the development of irAEs warrant further study.

Are we responding effectively to bone mineral density loss and fracture risks in people with epilepsy?

Objective

A 2007 study performed at Montefiore Medical Center (Bronx, NY) identified high prevalence of reduced bone density in an urban population of patients with epilepsy and suggested that bone mineralization screenings should be regularly performed for these patients. We conducted a long-term follow-up study to determine whether bone mineral density (BMD) loss, osteoporosis, and fractures have been successfully treated or prevented.

Methods

In the current study, patients from the 2007 study who had two dual-energy absorptiometry (DXA) scans performed at least 5 years apart were analyzed. The World Health Organization (WHO) criteria to diagnose patients with osteopenia or osteoporosis were used, and each patient's probability of developing fractures was calculated with the Fracture Risk Assessment Tool (FRAX).

Results

The median time between the first and second DXA scans for the 81 patients analyzed was 9.4 years (range 5-14.7). The median age at the first DXA scan was 41 years (range 22-77). Based on WHO criteria, 79.0% of patients did not have worsening of bone density, while 21.0% had new osteopenia or osteoporosis; many patients were prescribed treatment for bone loss. Older age, increased duration of anti-epileptic drug (AED) usage, and low body mass index (BMI) were risk factors for abnormal BMDs. Based on the first DXA scan, the FRAX calculator estimated that none of the patients in this study had a 10-year risk of more than 20% for developing major osteoporotic fracture (hip, spine, wrist, or humeral fracture). However, in this population, 11 patients (13.6%) sustained a major osteoporotic fracture after their first DXA scan.

Significance

Despite being routinely screened and frequently treated for bone mineral density loss and fracture prevention, many patients with epilepsy suffered new major osteoporotic fractures. This observation is especially important as persons with epilepsy are at high risk for falls and traumas.

Thyroid dysfunction in lung cancer patients treated with immune checkpoint inhibitors (ICI): Role of race, gender, and concurrent chemotherapy in a multiethnic urban cohort

e21622

Background: Immune-related adverse events (irAE) associated with ICI have been reported, but remain poorly understood. We sought to characterize patterns of thyroid dysfunction—one of the most common irAE—in a large cohort of ethnically-diverse lung cancer patients treated with ICI. Methods: A retrospective chart review of lung cancer patients receiving an anti-PD1 or PD-L1 agent from January 2016 to July 2019 was performed. Subjects included had normal baseline thyroid function. Thyrotoxicosis and hypothyroidism was defined as thyroid-stimulating hormone level less than 0.4 and greater than 4.6, respectively. Time to event analysis with inverted Kaplan Meier curves and log-rank tests were used to compare thyroid dysfunction among race, gender, and treatment subgroups. Results: We identified 256 subjects: 206 had normal baseline thyroid function and 76 went on to develop thyroid dysfunction. Rates of thyroid dysfunction by one year occurred at similar frequencies among all races. Thyrotoxicosis occurred at significantly higher rates in Black (25, 31.7%) than in White (8, 12.9%) and Hispanic (7, 16.7%) subjects. In contrast, hypothyroidism occurred more often in White (13, 21.0%) and Hispanic (18, 42.9%) than in Black (12, 15.2%) subjects. Gender and concurrent chemotherapy showed no significant association with thyroid dysfunction. Of subjects with thyrotoxicosis (N = 42), hypothyroidism followed in 33.3% (N = 14) with 1 subject receiving methimazole and 13 levothyroxine. In those subjects, median time to thyrotoxicosis and hypothyroidism was 4.0 and 7.2 weeks, respectively. Conclusions: Despite the higher prevalence of non-ICI-related thyroid disease among females and the anticipated immunosuppressive effect of chemotherapy, neither gender nor chemotherapy correlated with thyroid dysfunction; however, race did. Black subjects exhibited significantly higher rates of thyrotoxicosis. Our findings are consistent with prior research showing that thyrotoxicosis, including Graves’ disease, occurs more often in Blacks. While the pathogenesis of ICI-related thyroid dysfunction is unclear, the early onset of thyrotoxicosis demonstrated by our study calls for careful monitoring, especially for particular races. [Table: see text]

MON-240 Histologically Proven Lymphocytic Hypophysitis with Marked Improvement on Glucocorticoid Therapy

Background: Lymphocytic hypophysitis (LH) is a rare autoimmune disorder characterized by lymphocytic infiltration of the pituitary gland. The disease predominantly affects women, with >50% of cases presenting during pregnancy or postpartum.¹ LH is often associated with other autoimmune conditions, primarily thyroiditis, and adrenalitis.²

Clinical case: A 27-year-old female presented with secondary amenorrhea for eight months. Workup revealed hyperprolactinemia (PRL 65 ng/mL) and a heterogenous pituitary mass measuring 3.3 cm in the largest dimension. Cabergoline was initiated for a presumed prolactinoma. Laboratory evaluation was significant for hypogonadotropic hypogonadism (estradiol <50 pg/mL, progesterone <1 ng/mL, FSH 2.9 mIU/mL, LH 0.45 mIU/mL) despite normalization in prolactin. She was also found to have Hashimoto’s thyroiditis (FT4 0.7 ng/dL, TSH 8.2 uU/mL with positive TPO antibodies) and was started on levothyroxine.

Repeat imaging demonstrated a 2.4 cm heterogenous expanding sellar mass with soft tissue extension to the dorsum sella concerning for a meningioma. Visual field testing was intact without evidence of chiasmal compression. She underwent trans-sphenoidal pituitary decompression surgery which was terminated prematurely due to the presence of extensive fibrous tissue in the sella. Pathology was consistent with LH. Immunohistochemical staining was positive for lymphocytic markers CD3 and CD20, confirming marked infiltration of inflammatory B-cells and T-cells. Her postoperative course was notable for panhypopituitarism. In view of the pathological findings of LH, she was started on a high dose of 40mg of prednisone daily. Within two months, sellar magnetic resonance imaging revealed a homogenous normal-appearing pituitary with a reduction in soft tissue mass in the sellar and suprasellar region. Oral contraceptive therapy was initiated for sex hormone replacement with the resumption of menses. Prednisone was gradually tapered to 5mg/day, and she was subsequently transitioned to maintenance hydrocortisone for central adrenal insufficiency.

Discussion: LH is a rare chronic inflammatory disease that should be considered in the differential diagnosis of a non-secreting pituitary mass, especially if occurring in young women presenting during pregnancy or postpartum. The condition is associated with preferential destruction of corticotroph and thyrotroph cells.³ Appropriate management remains controversial. High dose glucocorticoid therapy, to which our patient responded to dramatically, has been shown to be beneficial in reducing mass effect. Optimal treatment involves surgical resection of the pituitary mass to decompress surrounding structures.³

References:

1. JCEM, Volume 100, Issue 10, October 2015, Pages 3841-3849

2. JCEM, Volume 80, Issue 8, August 1995, Pages 2302-2311

3. Horm Res, 2007;68 Supplement 5:145-50

MON-341 New Diagnosis of Hypophosphatasia in a 79-Year-Old Woman with Low Bone Density

Introduction: Hypophosphatasia is a rare metabolic bone disease caused by one of several mutations in the ALPL gene which encodes tissue nonspecific alkaline phosphatase (ALP). It is usually diagnosed in childhood and can have a heterogenous clinical presentation depending on the extent of enzyme deficiency. Here we report the oldest known patient with hypophosphatasia.

Clinical Case: A 79-year-old woman with a history of medullary thyroid cancer (MTC) in remission, was referred to our metabolic bone disease clinic for the evaluation and treatment of osteopenia. She had suffered from numerous musculoskeletal complaints for several years and had received a diagnosis of polymyalgia rheumatica. However, her symptoms persisted despite a six month trial of prednisone. Although she had developed dental caries at a young age, she denied premature tooth loss. Her family history was significant for arthralgias and vertebral disc disorders in multiple family members, including both her children. Her mother carried a diagnosis of rheumatoid arthritis and osteoporosis. The only pertinent physical exam finding was short stature (Height -4’6”). A DEXA scan was performed using a Hologic unit and revealed a T Score of -1.0 at the L-spine and -1.9 at the femoral neck. A FRAX score predicted a 14% risk of major osteoporotic fracture and 4% risk of hip fracture.

Laboratory data revealed: Serum Calcium 9.3 (8.5-10.5 mg/dL), Albumin 4.3 (3.5-5.0 g/dL), ALP 21 (<130 U/L), Vitamin D 25OH 46.2 (>30 ng/ml), Intact PTH 28.3 (15.0-65.0 pg/ml), Vitamin B6 87.7 (2-21 ng/ml).

On review of her medical record, low ALP levels ranging between 20-30 U/L were noted to be present for the last twenty years. Given her history of musculoskeletal complaints, short stature, elevated Vitamin B6 and low ALP, genetic testing for hypophosphatasia was performed. Her results confirmed a known pathogenic mutation in the ALPL gene.

Conclusion: This case highlights the importance of reviewing ALP levels and relevant patient history to rule out hypophosphatasia prior to initiating therapy for osteoporosis. This condition is often unrecognized. Bisphosphonates, which are often the first line of treatment in osteoporosis, are contraindicated in hypophosphatasia as they can increase the risk of atypical fractures.¹ Teriparatide may improve bone density depending on the extent of ALP deficiency. Asfotase alfa is a new agent that is currently available for the management of certain cases of hypophosphatasia.

References:

1.”Atypical femoral fractures”during bisphosphonate exposure in adult hypophosphatasia; Sutton,RA; Mumm,S;Coburn SP; Ericson,KL; Whyte, MP; Journal of Bone and Mineral Research 2012 May;27(5):987-94.

SAT-279 Crooke’s Cell Adenoma- an Aggressive Form of Cushing’s Disease

Introduction: Cushing’s disease is a condition of cortisol overproduction caused by an ACTH-producing tumor. Corticotroph cells surrounding an ACTH-producing tumor usually undergo Crooke’s hyaline change, where cytokeratin filaments accumulate in the cytoplasm in response to glucocorticoid excess. These changes are thought to be a mechanism of feedback inhibition and thus facilitate a suppression of ACTH. However, in a subtype of ACTH-secreting tumors known as Crooke’s cell adenomas (CCA), the ACTH-producing cells also undergo these hyaline changes. This would be expected to suppress hormone secretion but these cells are still able to release significant amounts of ACTH.

Case presentation: A 32-year-old woman presented to the hospital after an episode of syncope. On head MRI, she was found to have a 2 cm sellar mass with optic chiasm compression. Labs showed low TSH, free FT4, T3, FSH, and LH. She was also pre-diabetic with an HgbA1c of 6.2%. Her baseline cortisol of 20.6 µg/dL did not suppress after 1 mg of dexamethasone. After receiving 4 mg of dexamethasone, her cortisol suppressed to 5.2 µg/dL. She was diagnosed with hypopituitarism except for cortisol and a likely ACTH-producing pituitary macroadenoma. She completed a transsphenoidal pituitary resection and pathology revealed Crooke’s hyaline changes with immunohistochemical stains positive for ACTH. The immunostain for the proliferation marker Ki67 showed a relatively low proliferation index. Her course was complicated by diabetes insipidus. She was ultimately discharged on 20 mg hydrocortisone each morning, 10 mg hydrocortisone each afternoon, desmopressin 0.05 µg daily, and levothyroxine 125 µg daily. Two weeks later, the patient was sent to the emergency room by her endocrinologist for hyperglycemia up to 288 mg/dL. She was also found to be newly diabetic with an HgbA1c of 6.5%. A fasting morning cortisol was collected during her admission and showed a cortisol level of &lt;1.0 µg/dL, proving she was cured of Cushing’s disease. However, she will need close endocrinology follow up and MRI imaging of her pituitary for this aggressive type of pituitary adenoma.

Discussion: We have come across an interesting case of a young woman who presented for syncope and was found to have a pituitary macroadenoma with pathology consistent with CCA. This type of ACTH-producing tumor is known for aggressive patterns including high rates of recurrence with rates of up to 60% reported in literature, persistent disease after surgery, malignant transformation, and metastases. Despite presentation and symptoms similar to those of other ACTH-producing adenomas, the dangerous pattern of Crooke’s cell adenomas necessitate long-term follow-up in affected patients.

Changes in bone mineral density during 5 years of adjuvant treatment in premenopausal breast cancer patients

PURPOSE

Adjuvant treatment for breast cancer in postmenopausal women is a risk factor for bone loss. However, the association between bone mineral density (BMD) changes in premenopausal breast cancer patients and various adjuvant treatment regimens is not well characterized. In this study, we evaluated the changes in BMD according to adjuvant treatment in premenopausal women with breast cancer.

METHODS

Between 2006 and 2010, BMD data of 910 premenopausal women with breast cancer before operation and 1, 2, 3.5, and 5 years post-operation were retrospectively analyzed. The patients were divided according to the type of treatment: observation (O), tamoxifen (T), chemotherapy (C), C followed by T (C → T), and gonadotropin-releasing hormone (GnRH) agonist with T (G + T).

RESULTS

After 5 years of follow-up, BMD changes were similar between the T and O groups (all p > 0.05). Within 1 year of treatment, the C group showed the most significant BMD loss. The C → T and G + T groups showed more significant BMD loss in the lumbar spine and femur than the O and T groups (both p < 0.001, both). After 1 year of treatment, BMD loss in the lumbar spine was significantly greater in the C → T and G + T groups than in the T group; this tendency was maintained for 5 years of treatment (all p < 0.005).

CONCLUSION

Premenopausal women who received adjuvant treatment which induced menopause showed significant bone loss which lasted for 5 years. Although no significant difference was observed between the O and T groups, tamoxifen treatment during chemotherapy or GnRH agonist treatment might prevent bone loss.

SAT-323 Thoracic Paraganglioma Presenting with Recurrent Cerebrovascular Events

Background: Thoracic spine paraganglioma precipitating acute stroke is extremely rare. We report a case of a patient with thoracic paraganglioma at high risk for spinal cord compression with recurrent cerebrovascular events. Clinical Case: A 59 year old male was admitted for transient right hemiplegia after recent admission for right lacunar CVA. The patient was noted to have episodes of labile hypertension, sinus tachycardia and paroxysmal diaphoresis. Five days after admission, he developed ataxia with right pronator drift and was treated with intravenous thrombolytics for suspected acute CVA. Incidentally, an 8 cm thoracic paraspinal necrotic mass invading T10 and T11 vertebral bodies with impending cord compression was found on imaging. CT-guided needle biopsy of the mass was performed. Pathology showed an oval and spindle cell neoplasm staining positive for synaptophysin and chromogranin, favoring paraganglioma. Chromogranin A was elevated 472 ng/mL (25 - 140 ng/mL). Plasma free metanephrines were 32 g/mL (n < 57 pg/mL) and plasma free normetanephrines were 7690 pg/mL (n < 148 pg/mL). MIBG scan showed focus of increased uptake at T10 and T11 as well as in the left posterior eighth rib and peri-aortic region. Subsequently, the patient developed acute right leg weakness and dysmetria; MRI brain confirmed acute infarct in the posterior limb of the left internal capsule. Alpha blockade followed by beta blockade was initiated. After approximately 2.5 weeks of alpha blockade, the patient underwent spinal angiogram with tumor embolization followed by successful en bloc tumor resection by neurosurgery and cardiothoracic surgery. Final pathology showed a 7.5 cm paraganglioma which demonstrated some aggressive pathologic features including Ki67 index>20% and 10% focal necrosis. Post-operative plasma free normetanephrines decreased to 568 pg/mL and metanephrines were undetectable. Genetic testing utilizing Ambry Genetics PGLnext panel was negative. Conclusion: A differential diagnosis of paraganglioma should be considered in any patient presenting with recurrent stroke and paraspinal mass. Biopsy should be avoided. Timing of surgical resection to decrease risk of further cerebrovascular compromise is challenging and requires a multidisciplinary approach (1). Locally invasive paragangliomas are rare and are often associated with SDHB mutations; however, a full genetic analysis did not identify any known genetic mutations. Reference: (1) Oak, S., Javid, M., Callender, G., Carling, T., Gibson, C. Management of pheochromocytoma in the setting of acute stroke. AACE Clinical Case Reports 2018 4:3, e245-e248.

MON-490 Iatrogenic Hypophosphatemia Presenting as Low Bone Mass

Introduction: The incidence of osteomalacia is 1 in every 1000 individuals and the most common cause is vitamin D deficiency. Hypophosphatemia is a less recognized but important etiology of osteomalacia. Here we describe a case who was referred to Endocrinology for osteoporosis but was found to have medication induced hypophosphatemic osteomalacia. Case: A 68 years old woman from Thailand with known past medical history of chronic hepatitis B infection, Sjogren’s syndrome, lung cancer s/p lobectomy had screening DEXA scan which showed T score of -2.9SD at Forearm. She was referred to Endocrinology for osteoporosis work up. She reported at least 8-month long history of myalgia and noticed pain in the chest wall exacerbated by motion such as rolling in bed for the last few months. Blood work showed normal calcium, robust vitamin D and high bone specific alkaline phosphatase levels. Phosphorus levels were noted to be in the range of 1.4 to 2.1 mg/dl for 2 years before the presentation and fractional excretion of phosphorous was 71%. Bone scan showed foci of increased radiotracer uptake in multiple ribs which correlated to the site of prior thoracotomy. Patient was taking adefovir 10 mg daily for 4 years for hepatitis B infection which is known to cause increased renal phosphate loss similar to Fanconi’s syndrome. The medication was changed and phosphate repletion was started which alleviated the symptoms promptly. Discussion: This case emphasizes on the importance of considering osteomalacia as a potential cause of low bone mass. Adefovir is commonly used for hepatitis B treatment and is known to cause renal phosphate loss at higher doses like 20-40 mg a day. This case illustrates that it can cause similar phosphoturic effect even at lower doses if used over a long period of time as a result of the cumulative dose effect of this drug. It is important to be cognizant of this side effect of Adefovir as it is a widely used medication and monitor patients for hypophosphatemia while undergoing therapy.

SAT-597 Diagnostic and Therapeutic Challenges of Riedel's Thyroiditis

Background: Riedel’s thyroiditis is an extremely rare condition characterized by an overgrowth of inflammatory fibrosis that destroys the thyroid follicular architecture. The presentation can mimic malignancy, and due to its rarity, the diagnosis can be delayed. Experience with treatment of this condition is limited, but glucocorticoids and tamoxifen have both been shown in case reports to be effective. Clinical Case: A 68 year old woman presented with dyspnea and weakness. Her exam showed a diffusely enlarged thyroid with a hard texture. Labs showed hypothyroidism for which she was started on levothyroxine, and imaging revealed a goiter with a dominant 3.1cm left thyroid nodule causing tracheal narrowing. Laryngoscopy showed R vocal fold paralysis. FNA of this nodule was non-diagnostic; therefore a core biopsy was attempted which showed no thyroid tissue but skeletal muscle and sclerotic fibro-connective tissue infiltrated by chronic inflammatory cells. Neck CT done 1 month after initial presentation showed a diffusely enlarged and heterogeneous thyroid gland encasing the R carotid artery, infiltrating the peri-thyroidal fat, and causing tracheal narrowing. Given ongoing concern for malignancy, she had open incisional thyroid biopsy showing dense fibrous tissue with chronic inflammation and entrapped skeletal muscle, but again no thyroid tissue was identified. Pathology was believed to be consistent with Riedel’s thyroiditis. She was started on prednisone 60mg daily with improvement in her symptoms, and the steroids were gradually tapered off after 9 months of treatment given stable imaging.&nbsp;&nbsp; The patient remained off steroids and without new symptoms for 1.5 years.&nbsp; She was then admitted for syncope and had further evidence of disease progression on CT scan, with continued growth of the mediastinal component as well as encasement of the bilateral internal carotid arteries, right brachiocephalic trunk, trachea, and upper esophagus. Repeat biopsy again showed dense fibrous tissue with scattered small lymphocytes and plasma cells. She was started back on prednisone 60 mg daily, and imaging done after 3 months of treatment showed shrinkage of the size of the neck and mediastinal mass. However, the patient was noted to have Cushingoid features, including moon facies and weight gain. Therefore, tamoxifen 10mg twice a day was started, and the glucocorticoids were successfully tapered off. To date, she remains asymptomatic without evidence of disease progression while on tamoxifen 10mg twice a day. Conclusion: Riedel’s thyroiditis is a rare chronic inflammatory disease characterized by an invasive fibrotic process that can mimic malignancy. Treatment with glucocorticoids and/or tamoxifen can result in improvement in symptoms and reduction of the size of the mass.

Thyroid Storm Presenting as Psychosis

Thyroid storm is a life-threatening endocrine emergency with an incidence rate of 1% to 2%. It is a systemic condition of excessive thyroid hormone production and release leading to thermoregulatory, adrenergic, neuropsychiatric, cardiovascular, and abdominal manifestations. Although it is a rare condition, it carries a significant mortality rate. Hence, knowing the common and uncommon presentations of thyroid storm is important for its prompt diagnosis and treatment. In this article, we present an unusual case of a young woman who presented with psychosis as the manifesting symptom of thyroid storm. She did not respond adequately to conventional medical treatment, requiring plasmapheresis and a definitive thyroidectomy, which ultimately led to the return of patient’s baseline mental status and a dramatic recovery.

Medical optimization of lumbar fusion in the osteoporotic patient

PURPOSE

In patients undergoing lumbar fusion, osteoporosis has been shown to lead to poorer outcomes and greater incidence of fusion-related complications. Given the undesirable effect of osteoporosis on lumbar fusion surgery, a number of medications have been proposed for use in the peri- and postoperative period to mitigate risks and enhance outcomes. The purpose of this review was to summarize and synthesize the current literature regarding medical management of osteoporosis in the context of lumbar fusion surgery.

METHODS

A literature search of PubMed, Embase, and Web of Science was conducted in October 2016, using permutations of various search terms related to osteoporosis, medications, and lumbar fusion.

RESULTS

Teriparatide injections may lead to faster, more successful fusion, and may reduce fusion-related complications. Bisphosphonate therapy likely does not hinder fusion outcomes and may be useful in reducing certain complications of fusion in osteoporotic patients. Calcitonin and selective estrogen receptor modulator therapy show mixed results, but more research is necessary to make a recommendation. Vitamin D deficiency is associated with poor fusion outcomes, but evidence for supplementation in patients with normal serum levels is weak.

CONCLUSIONS

Overall, the current body of research appears to support the use of teriparatide therapy to enhance lumbar fusion outcomes in the osteoporotic patient, although the extent of research on this topic is limited. Additionally, very little evidence exists to cease any of the mentioned osteoporosis treatments prior to lumbar fusion.

Testosterone Treatment and Sexual Function in Older Men With Low Testosterone Levels

CONTEXT

The Testosterone Trials are a coordinated set of seven trials to determine the efficacy of T in symptomatic men ≥65 years old with unequivocally low T levels. Initial results of the Sexual Function Trial showed that T improved sexual activity, sexual desire, and erectile function.

OBJECTIVE

To assess the responsiveness of specific sexual activities to T treatment; to relate hormone changes to changes in sexual function; and to determine predictive baseline characteristics and T threshold for sexual outcomes.

DESIGN

A placebo-controlled trial.

SETTING

Twelve academic medical centers in the United States.

PARTICIPANTS

A total of 470 men ≥65 years of age with low libido, average T <275 ng/dL, and a partner willing to have sexual intercourse at least twice a month.

METHODS

Men were assigned to take T gel or placebo for 1 year. Sexual function was assessed by three questionnaires every 3 months: the Psychosexual Daily Questionnaire, the Derogatis Interview for Sexual Function, and the International Index of Erectile Function.

RESULTS

Compared with placebo, T administration significantly improved 10 of 12 measures of sexual activity. Incremental increases in total and free T and estradiol levels were associated with improvements in sexual activity and desire, but not erectile function. No threshold T level was observed for any outcome, and none of the 27 baseline characteristics predicted responsiveness to T.

CONCLUSIONS

In older men with low libido and low T levels, improvements in sexual desire and activity in response to T treatment were related to the magnitude of increases in T and estradiol levels, but there was no clear evidence of a threshold effect.

Recruitment and Screening for the Testosterone Trials

BACKGROUND

We describe the recruitment of men for The Testosterone (T) Trials, which were designed to determine the efficacy of T treatment.

METHODS

Men were eligible if they were ≥65 years, had an average of two morning total T values <275 ng/dL with neither value >300 ng/mL, and had symptoms and objective evidence of mobility limitation, sexual dysfunction, and/or low vitality. Men had to be eligible for and enroll in at least one of these three main trials (physical function, sexual function, vitality).

RESULTS

Men were recruited primarily through mass mailings in 12 U.S. communities: 82% of men who contacted the sites did so in response to mailings. Men who responded were screened by telephone to ascertain eligibility. Of 51,085 telephone screens, 53.5% were eligible for further screening. Of 23,889 initial screening visits (SV1), 2,781 (11.6%) men were eligible for the second screening visit (SV2), which 2,261 (81.3%) completed. At SV2, 931 (41.2%) men met the criteria for one or more trials, the T level criterion and had no other exclusions. Of these, 790 (84.6%) were randomized; 99 (12.5%) in all three trials and 348 (44%) in two trials. Their mean age was 72 years and mean body mass index (BMI) was 31.0 kg/m(2). Mean (standard deviation) total T (ng/dL) was 212.0 (40.0).

CONCLUSION

Despite the telephone screening to enrollment ratio of 65 to 1, we met the recruitment goals for each trial. Recruitment of symptomatic older men with low testosterone levels is difficult but feasible.

Association of sex hormones with sexual function, vitality, and physical function of symptomatic older men with low testosterone levels at baseline in the testosterone trials

CONTEXT

The prevalence of sexual dysfunction, low vitality, and poor physical function increases with aging, as does the prevalence of low total and free testosterone (TT and FT) levels. However, the relationship between sex hormones and age-related alterations in older men is not clear.

OBJECTIVE

To test the hypotheses that baseline serum TT, FT, estradiol (E2), and sex hormone-binding globulin (SHBG) levels are independently associated with sexual function, vitality, and physical function in older symptomatic men with low testosterone levels participating in the Testosterone Trials (TTrials).

DESIGN

Cross-sectional study of baseline measures in the TTrials.

SETTING

The study was conducted at 12 sites in the United States.

PARTICIPANTS

The 788 TTrials participants were ≥ 65 years and had evidence of sexual dysfunction, diminished vitality, and/or mobility disability, and an average of two TT < 275 ng/dL.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Question 4 of Psychosocial Daily Questionnaire (PDQ-Q4), the FACIT-Fatigue Scale, and the 6-minute walk test.

RESULTS

Baseline serum TT and FT, but not E2 or SHBG levels had small, but statistically significant associations with validated measures of sexual desire, erectile function, and sexual activity. None of these hormones was significantly associated within or across trials with FACIT-Fatigue, PHQ-9 Depression or Physical Function-10 scores, or gait speed.

CONCLUSIONS

FT and TT levels were consistently, independently, and positively associated, albeit to a small degree, with measures of sexual desire, erectile function, and sexual activity, but not with measures of vitality or physical function in symptomatic older men with low T who qualified for the TTrials.

The aging thyroid

PURPOSE OF REVIEW

As life expectancy increases and population age advances, diagnosis and treatment of diseases common in the geriatric population assume an increasingly important role in modern medicine. In the last few years, the emergence of age-specific reference ranges for thyroid-stimulating hormone (TSH) has added to the complexity of diagnosis of thyroid dysfunction in this age group, especially in the 'subclinical' category.

RECENT FINDINGS

The recent studies confirm an increase in population TSH distribution with age, both in cross-sectional and longitudinal studies. Conclusive evidence about adverse cardiovascular, metabolic, and cognitive consequences of subclinical hypothyroidism in the elderly remains elusive. The transient nature of subtle degrees of thyroid dysfunction in a significant proportion of elderly patients has also been reproduced in the recent publications.

SUMMARY

A growing body of literature in the last few years, reviewed here, highlights the importance of employing additional caution before assigning diagnoses of hypothyroidism or hyperthyroidism to elderly patients and initiation of treatment modalities that can have long-lasting effects.

Post-challenge hyperglycemia in older adults is associated with increased cardiovascular risk profile

CONTEXT

Post-challenge hyperglycemia (PCH) is common in older adults and is associated with increased cardiovascular disease (CVD) risk and total mortality. However, PCH is rarely recognized in clinical settings, and the glycemic exposure and CVD risk profile of elderly individuals with PCH has not been defined.

OBJECTIVE

The aim of the study was to characterize metabolic and CVD risk profile of elderly subjects with PCH and to determine the effect of acute postprandial metabolic changes on vascular biomarkers.

DESIGN

We conducted a cross-sectional study with a standard meal challenge protocol.

PARTICIPANTS

Older adults with normal glucose tolerance (n = 30) or PCH (fasting glucose <126 mg/dl and 2-h glucose >or=170 mg/dl; n = 28) participated in the study.

MAIN OUTCOME MEASURES

We assessed fasting and postprandial levels of glucose, insulin, lipids, high sensitivity C-reactive protein, plasminogen activator inhibitor-1, and adiponectin and endothelial function using reactive hyperemia peripheral arterial tonometry.

RESULTS

Normal glucose tolerance and PCH subjects were matched for age, sex, body mass index, and ethnicity. Fasting glucose (102 +/- 3 vs. 93 +/- 2 mg/dl; P < 0.001) and glycosylated hemoglobin (5.7 vs. 5.4%; P = 0.01) were modestly higher in the PCH group, which was also more insulin resistant (homeostasis model assessment for insulin resistance, 7.0 +/- 1.3 vs. 4.1 +/- 0.6; P = 0.03). Fasting high sensitivity C-reactive protein was higher (2.6 +/- 0.5 vs. 1.3 +/- 0.2 mg/dl; P = 0.05), and adiponectin was lower (11.6 +/- 1.6 vs. 14.0 +/- 1.3 microg/ml; P = 0.03) in subjects with PCH. Peak and 6-h postprandial area under the curve glucose, insulin, and lipids were higher in PCH subjects, who also had higher fasting and postprandial levels of plasminogen activator inhibitor-1. Reactive hyperemia peripheral arterial tonometry declined postprandially only in PCH.

CONCLUSIONS

Older adults with PCH experience significant fasting and postprandial metabolic dysregulation, which is accompanied by a proatherosclerotic and prothrombotic vascular profile.