Decatur Memorial Hospital

Disclosure: L. Mitchell: None. S. Gundlapally: None. S. Patel: None. A. Smoleva: None. B. Wright: None. M. Antony: None.Introduction: Studies have reported an association between Primary Hyperparathyroidism [PHPT] and thyroid cancer. However, the overall association is rare with most of the cases being papillary thyroid carcinoma followed by follicular thyroid carcinoma. Tumor characteristics also show that patients usually have a small-sized tumor measuring up to 1 cm with fewer cases of extra-thyroidal invasion. Case Description: A 37-year-old Caucasian female with past medical history of obesity, nephrolithiasis, sleep gastrectomy and primary hypothyroidism presented with complaints of polyuria and polydipsia. Lab evaluation revealed elevated corrected serum calcium 11.2 mg/dl [8.0-10.0 mg/dl], elevated PTH 100 pg/ml [15-65 pg/ml], normal creatinine 0.69 mg/dl [0.5-0.9 mg/dl], EGFR> 60 ml/min/1.73m2 milligram. Sestamibi parathyroid scan was non-localizing. 4D parathyroid CT scan revealed candidate bilateral parathyroid adenomas versus low-density exophytic posterior thyroid nodules. Patient underwent surgery and final pathology revealed 0.7 mm intrathyroidal hypercellular parathyroid gland with multifocal bilateral classic subtype PTC with greatest tumor size of 2.4 cm with 3 out of 12 positive lymph nodes with 0.6 cm largest size of the metastatic deposit. Postoperative neck ultrasound revealed multiple bilateral suspicious lymph nodes and subsequent FNA of right level 6 lymph node reported to be metastatic PTC. Patient underwent modified radical neck dissection and final pathology revealed 7 out of 31 positive lymph nodes with size of largest metastatic deposit 2.6 cm and presence of extra nodal extension. Patient received 156 mci I-131 as remnant radioactive iodine treatment using thyroid hormone withdrawal thyroid. Posttherapy whole-body scan revealed no significant uptake in the neck. Follow-up neck ultrasound revealed bilateral morphologically benign-appearing lymph nodes and labs revealed thyroglobulin 0.1 ng/ml [1.5-38.5 ng/ml], thyroglobulin antibody<1.0 IU/mL [0.0-0.9 IU/mL], TSH 0.039 uIU/mL [0.30-4.0 uIU/mL]. Conclusion: PHPT and thyroid cancer can co-exist in a patient. Neck ultrasound should be considered as the initial choice of imaging during evaluation of PHPT due to the following reasons. It helps in early detection of thyroid cancer before the thyroid tumor can grow or spread outside the thyroid gland. It also helps to decide the extent of the initial neck surgery and avoid future additional surgery as well as all the surgical complications associated with repeat surgery.Presentation: Monday, July 14, 2025

BACKGROUND Viral infections can cause a spectrum of muscle involvement, from mild myalgia to severe conditions like rhabdomyolysis. While benign muscle pain is common, viral myositis complicated by rhabdomyolysis and acute kidney injury is an uncommon but serious occurrence. If not promptly recognized and treated, these complications can result in significant morbidity and even mortality. Timely diagnosis and intervention are crucial to mitigating the risks. CASE REPORT We present the case of a 47-year-old man with a history of recent flu-like symptoms, who developed generalized muscle pain and weakness. Upon further evaluation, he was diagnosed with acute viral myositis. His condition was complicated by severe rhabdomyolysis, as evidenced by a markedly elevated creatine phosphokinase (CPK) level of 880 300 U/L, which subsequently led to acute kidney injury. Despite immediate intervention with aggressive intravenous fluid resuscitation, he required emergency hemodialysis secondary to electrolyte imbalances. Over the course of several weeks, he required ongoing dialysis, but with continued treatment his renal function gradually improved, and dialysis was discontinued after 1 month. CONCLUSIONS This case highlights the importance of early recognition and treatment of viral myositis complicated by rhabdomyolysis and acute renal failure. Aggressive management, including fluid resuscitation and hemodialysis, is crucial in preventing life-threatening complications.

Corn wet milling (CWM) and corn starch flash drying processing conditions reduce undesirable microorganisms, such as Salmonella. Finished products are historically safe, with intrinsic properties such as low water activity inhibiting microbial growth. Corn processors could use quantified levels of reduction in this study of Salmonella surrogate Enterococcus faecium (E. faecium) to update their food safety plans. Industry-relevant conditions for CWM processes were recreated at pilot or lab scale for 3 unit operations: (1) steeping treatment in sulfur dioxide (SO2) with low (750ppm SO2, 20h, 43.3°C), medium (1,500ppm SO2, 30h, 48.9°C), and high (2,200ppm SO2, 40h, 53.3°C) treatment conditions; (2) hydrogen peroxide (H2O2) treatment tested on bench scale with a factorial design (pH 3.5, 4.0, and 4.5), H2O2 concentrations (0.05%, 0.10%, 0.15% (w/w)), and temperatures (32, 38, and 46°C) for 3 and 6h; (3) flash drying treatment at 4 different temperatures (149, 177, 204, and 232°C) with 2 different inoculation methods. E. faecium was reduced during each of these unit operations. By the end of each steeping treatment, E. faecium was consistently below the limit of quantitation (LOQ), meaning >6.5 log CFU/mL reduction in steep water, and >3.7 log CFU/g reduction in ground corn. The peroxide step had a reduction range from 0.03 log CFU/mL in the control group (0% H2O2 added) to >6 log CFU/mL observed in the high-intensity treatment of corn starch slurry. Flash drying had a reduction range from 1.7 to 2.7 log CFU/g. There was also no biologically meaningful change (<1 log CFU/g reduction) of E. faecium counts during an 8-week survival study of the dried final product. This hurdle approach study shows that existing CWM conditions are effective for Salmonella surrogate reduction through processing into finished starch and provides quantified E. faecium reductions for use in food safety plans.

Background: In patients with end-stage heart failure, durable Left Ventricular Assist Devices (LVADs) can be used as a bridge to transplant or destination therapy. LVADs have been shown to improve survival for patients with heart failure (HF). HF is associated with electrolyte abnormalities and the development of sustained arrhythmias. However, data on the influence of arrhythmias and electrolyte imbalances on inpatient outcomes in LVAD patients are lacking. Furthermore, previous works assessing inpatient outcomes focused mainly on the role of chronic comorbidities in those outcomes. Methods: In this cross-sectional study, we used discharge data from the National Inpatient Sample from 2019 to 2020 to assess the influence of acute arrhythmias on inpatient mortality in patients with LVADs. We also investigated the relationship between acute medical conditions and mortality. Results: There were 9418 (not survey-adjusted) hospitalizations with LVAD, among which 2539 (27%) died during the hospitalization. Univariate analysis of arrhythmias showed that ventricular arrhythmias (VAs)-ventricular fibrillation/flutter and ventricular tachycardia-as well as complete heart block were associated with significantly higher odds of mortality. Follow-up multivariable logistic analysis showed that these arrhythmias retain their increased association with death. Hyperkalemia and acidosis had increased adjusted odds of death (1.54 (95% confidence interval: 1.28-1.85) (p < 0.001) and 2.44 (CI: 2.14-2.77) (p < 0.001), respectively). Conclusions: VAs, complete heart block, hyperkalemia, and acidosis were associated with increased odds of all-cause mortality. Females had higher odds of inpatient mortality. These findings suggest that electrolyte management, maintenance of optimal acid-base balance, and interventions to treat sustained ventricular arrhythmias may be suitable therapeutic targets to reduce mortality in hospitalized patients with LVADs.

Direct oral anticoagulants (DOACs), such as apixaban, are used for the prevention and management of thromboembolic diseases. Here, we presenta case of a 72-year-old African American woman who presented to the hospital with shortness of breath and precordial chest pain for three days. The patient was diagnosed with volume overload associated with the progression of chronic kidney disease (CKD) and subsequently admitted to the hospital. Since the patient failed to adequately respond to diuretics, hemodialysis was initiated. During the hospital stay, she developed paroxysmal atrial fibrillation. Along with amiodarone, apixaban was started for primary stroke prophylaxis. Within 72 hours, the patient developed worsening chest pain. An echocardiogram revealed a large pericardial effusion with cardiac tamponade.She was taken for an emergent open pericardial window placement to relieve cardiac tamponade, where 600 mL of blood was drained. Considering the timeline of the development of a large bloody pericardial effusion following initiation of apixaban, spontaneous hemorrhagic cardiac tamponade attributed to the use of apixaban was diagnosed. The patient was eventually taken off all anticoagulants. In considering potential mechanisms, impaired hepatic and renal metabolism of apixaban could be factored in this case. In addition, CKD can increase bleeding risk, due to platelet dysfunction and impaired interaction of von Willebrand factor with GPIIb-IIIa. Moreover, renal secretion of apixaban is mediated by p-glycoprotein and amiodarone is an inhibitor of this protein. Although extremely rare, spontaneous hemorrhagic cardiac tamponade can occur with the use of DOACs, such as apixaban. Prompt recognition and urgent treatment remain keys to avoiding adverse patient outcomes.

In this report, we present the case of a 71-year-old African-American woman experiencing 2 months of intermittent headaches and episodes of blurred vision. Despite a comprehensive medical history that revealed chronic conditions and previous unrelated surgeries, the initial evaluation appeared to be unremarkable. Following the discovery of a mass on an imaging and a subsequent biopsy, the diagnosis of craniopharyngioma (WHO grade I) was confirmed. However, a brain mass was identified after additional ophthalmologic examination and MRI. This case explores the significance of recognizing atypical presentations of a brain injury that required a specific approach for diagnosis, surgical intervention and treatment, and postoperative care. This case contributes to the constantly evolving understanding of atypical manifestations of tumor characteristics and their complexities, along with the need to develop appropriate patient management strategies and provide optimal outcomes.

Abstract Disclosure: M. Antony: None. S. Gundlapally: None. M. Joglekar: None. B. Fritz: None. S. Patel: None. V. Verma: None. R. Kant: None. INTRODUCTION: Elevated TSI antibody and/or diffuse uptake on radioactive Iodine-123 scan is diagnostic of Graves’ disease. Thyromegaly with increased blood flow on color doppler seen on thyroid USG can also aid in the diagnosis. Rare presence of positive TSI antibody without hyperthyroidism has been reported1. Rare co-existence of both Graves’ disease and Hashimoto’s thyroiditis in a patient causing a challenging clinical course has been reported2. Presence of a neutralizing or blocking antibody against the TSH receptor1 or a false positive TSI have been implicated in such rare cases. CLINICAL CASE: A 37-year-old Caucasian Female was seen at our endocrinology clinic for further evaluation of thyroid disorder. Patient initially experienced goiter during 1st pregnancy at age 18, followed by hypothyroidism during last pregnancy needing levothyroxine treatment. Due to goiter history, patient underwent work-up by her primary physician in 2021. Thyroid ultrasound (usg) showed bilateral hyperemia, heterogeneous echotexture, and 0.2 cm cystic nodule in the right upper lobe. Labs showed normal TSH 1.33 uIU/ml (0.3-4.0 uIU/ml), normal Free T4 0.99 ng/dl (0.8-1.8 ng/dl), normal total T3 140 ng/dl (71-180 ng/dl). Patient underwent further work-up by endocrinology in 2022. Thyroid ultrasound again revealed bilateral hyperemia with other similar findings. Labs showed normal TSH 2.02uUI/ml, normal free T4 0.93 ng/dl, normal total T3 138 ng/dl. Interestingly, TSI antibody and TPO antibody were significantly elevated at 66.70 IU/L (0.0-0.55 IU/L) and 517 IU/ml (0-34 IU/ml), respectively. Repeat labs in April 2022, again showed normal TSH 1.77 uIU/ml, normal free T4 0.90 ng/dl and normal free T3 2.94 (2.0-4.40 pg/ml). Thyroid uptake scan was not performed due to persistently normal TSH values. Patient denied the use of biotin supplementation. Patient continues to remain clinically and biochemically euthyroid without treatment. CONCLUSION: Our case supports the rare presence of TSI antibody without hyperthyroidism. Close monitoring is warranted due to possibility of future progression to overt hyperthyroidism. REFERENCE: 1. Alvin Mathew A, Papaly R, Maliakal A, et al.(November 10, 2021)Elevated Graves’ Disease-Specific Thyroid-Stimulating Immunoglobulin and Thyroid Stimulating Hormone Receptor Antibody in a Patient With Subacute Thyroiditis. Cureus 13(11): e19448. doi:10.7759/cureus.194482. Vipin Verma, MD, Mc Anto Antony, MD, PSAT346 Persistent Fluctuation Between Hypothyroidism and Hyperthyroidism in a Patient with Both Hashimoto's Thyroiditis and Graves’ Disease: Challenges in Diagnosis and Treatment Approach, Journal of the Endocrine Society, Volume 6, Issue Supplement_1, November-December 2022, Page A833, https://doi.org/10.1210/jendso/bvac150.1723 Presentation Date: Saturday, June 17, 2023

PurposeAnti-PD-1 therapy provides clinical benefit in 40–50% of patients with relapsed and/or metastatic head and neck squamous cell carcinoma (RM-HNSCC). Selection of anti- PD-1 therapy is typically based on patient PD-L1 immunohistochemistry (IHC) which has low specificity for predicting disease control. Therefore, there is a critical need for a clinical biomarker that will predict clinical benefit to anti-PD-1 treatment with high specificity.MethodsClinical treatment and outcomes data for 103 RM-HNSCC patients were paired with RNA-sequencing data from formalin-fixed patient samples. Using logistic regression methods, we developed a novel biomarker classifier based on expression patterns in the tumor immune microenvironment to predict disease control with monotherapy PD-1 inhibitors (pembrolizumab and nivolumab). The performance of the biomarker was internally validated using out-of-bag methods.ResultsThe biomarker significantly predicted disease control (65% in predicted non-progressors vs. 17% in predicted progressors, p < 0.001) and was significantly correlated with overall survival (OS; p = 0.004). In addition, the biomarker outperformed PD-L1 IHC across numerous metrics including sensitivity (0.79 vs 0.64, respectively; p = 0.005) and specificity (0.70 vs 0.61, respectively; p = 0.009).ConclusionThis novel assay uses tumor immune microenvironment expression data to predict disease control and OS with high sensitivity and specificity in patients with RM-HNSCC treated with anti-PD-1 monotherapy.

The National Surgical Adjuvant Breast and Bowel Project B-42 trial evaluated extended letrozole therapy (ELT) in postmenopausal breast cancer patients who were disease free after 5 years of aromatase inhibitor (AI)-based therapy. Seven-year results demonstrated a nonstatistically significant trend in disease-free survival (DFS) in favor of ELT. We present 10-year outcome results. In this double-blind, phase III trial, patients with stage I-IIIA hormone receptor-positive breast cancer, disease free after 5 years of an AI or tamoxifen followed by an AI, were randomly assigned to 5 years of letrozole or placebo. Primary endpoint was DFS, defined as time from random assignment to breast cancer recurrence, second primary malignancy, or death. All statistical tests are 2-sided. Between September 2006 and January 2010, 3966 patients were randomly assigned (letrozole: 1983; placebo: 1983). Median follow-up time for 3923 patients included in efficacy analyses was 10.3 years. There was statistically significant improvement in DFS in favor of letrozole compared with placebo (hazard ratio [HR] = 0.85, 95% confidence interval [CI] = 0.74 to 0.96; P = .01; 10-year DFS: placebo = 72.6%, letrozole = 75.9%, absolute difference = 3.3%). There was no difference in the effect of letrozole on overall survival (HR = 0.97, 95% CI = 0.82 to 1.15; P = .74). Letrozole statistically significantly reduced breast cancer-free interval events (HR = 0.75, 95% CI = 0.62 to 0.91; P = .003; absolute difference in cumulative incidence = 2.7%) and distant recurrences (HR = 0.72, 95% CI = 0.55 to 0.92; P = .01; absolute difference = 1.8%). The rates of osteoporotic fractures and arterial thrombotic events did not differ between treatment groups. The beneficial effect of ELT on DFS persisted at 10 years. Letrozole also improved breast cancer-free interval and distant recurrences without improving overall survival. Careful assessment of potential risks and benefits is necessary for selecting appropriate candidates for ELT.