Texas Diabetes & Endocrinology

Disclosure: M.H. Shafiq: None. S. Haider: None. S. Sheikh: None. S.R. Panja: None.Background: Incidental pituitary lesions are frequently discovered on neuroimaging performed for unrelated symptoms. While often benign, these findings can signify hormonally active adenomas requiring prompt evaluation. This case illustrates how an incidental finding in a patient with nonspecific symptoms led to the diagnosis of Cushing’s disease. Case Presentation: A 34-year-old female with no significant past medical history presented to her primary care provider with persistent sinus headaches. CT imaging incidentally revealed a pituitary lesion measuring 6 × 9.5 × 10 mm, with a solid component measuring 7 × 6 × 3 mm in the right adenohypophysis, suggestive of a microadenoma. She was referred to outpatient endocrinology for further assessment.Upon evaluation, the patient endorsed weight gain, fatigue, elevated blood glucose, and persistent headaches but denied visual disturbances. Endocrine workup revealed an abnormal low-dose dexamethasone suppression test, followed by elevated 24-hour urinary cortisol levels, confirming hypercortisolism. The patient was diagnosed with Cushing’s disease and referred to a tertiary center, where she underwent successful transsphenoidal resection at MD Anderson Cancer Center.At present the patient is on 15mg of hydrocortisone per day. After surgery, her weight decreased from 227lb to 150lb. Discussion: This case highlights the clinical importance of thoroughly evaluating incidental pituitary lesions, especially in the presence of subtle or common symptoms such as fatigue and weight gain. Failure to investigate hormonal activity may delay the diagnosis of conditions like Cushing’s disease, which can carry significant morbidity if untreated. Conclusion: Incidental pituitary lesions require careful endocrine evaluation. Simply evaluating prolactin is insufficient. This case reinforces the need for a high index of suspicion and a structured diagnostic approach to prevent missed diagnoses of functional pituitary adenomas.Presentation: Monday, July 14, 2025

In the thyroid, abnormal growth can be the result of either benign thyroid nodules (BTNs) or differentiated thyroid cancers (DTCs). If the growth is confirmed to be a DTC, surgical intervention, either a partial or total thyroidectomy, is recommended. Although a majority of BTNs do not require treatment, intervention becomes necessary when nodules cause symptoms, enlargement, or a rare suspicion of malignancy. Clinical presentations of symptoms include psychological and aesthetic ones, such as a large lump on the neck, difficulty swallowing, pressure on the neck, and/or voice changes. The most common form of intervention for minimizing the volume of the BTN is surgery. However, due to several drawbacks to surgery and patient ineligibility, minimally invasive techniques such as radiofrequency ablation (RFA) have been recommended. Radiofrequency ablation serves as a minimally invasive non-surgical procedure that has been recognized to decrease the volume of BTNs. In the following case, we present a 50-year-old female patient with a growing multinodular goiter (MNG). A thyroid fine needle aspiration (FNA) biopsy and genetic testing confirmed the diagnosis of thyroid disease with possible malignancies. The nodule was increasing in size, causing discomfort, and possible malignancies were indicated by the FNA results. In order to avoid surgical intervention, the patient chose to undergo RFA, effectively decreasing the size of the BTN and dissipating the symptoms. This case highlights the effectiveness of RFA as a non-surgical alternative for treating benign MNG. Additionally, this case study provides insight into the unique treatment plans available for patients who opt out of surgery.

Abstract Disclosure: J. Chippior: None. L. Ghalib: None. A 44 year-old female with a PMH of primary hypothyroidism, and a pituitary macroadenoma that was lost to follow up, presented to the ED with a chief complaint of an acute headache and decreased visual acuity involving the right eye over the past year. Patient was found to have a large, homogenous suprasellar mass with the largest dimension measuring 6.3 cm in size, and causing displacement of the optic chiasm. Initial hormonal workup was most notable for elevated prolactin at 128 ng/ml (3.3-26.7 ng/ml), which was slightly lower than when it was previously measured 10 years ago. The patient was taken to the OR for transsphenoidal endoscopic partial resection, but within 24 hours of post-op, she developed hypernatremia at 153 mmol/dL (135-145 mmol/dL) that was suspected to be secondary to diabetes insipidus (DI). In addition, she also suffered several small strokes involving her right midbrain and basal ganglia. She required multiple doses of DDAVP throughout her stay and this was ultimately continued upon discharge. Unfortunately, as follow up MRI had shown residual tumor within the third ventricle, she returned for a 2nd resection but once again suffered additional post-operative complications. The patient experienced additional strokes involving the right frontal and parietal lobes, and her DI became more labile than before, with her serum sodium peaking at 172 mmol/dL. Despite such a high degree of hypernatremia, she did not demonstrate any signs of thirst or any desire to access free water, even after her post-stroke encephalopathy had largely resolved. With less than 100 severe cases documented over the past four decades, it was suspected that the patient had a rare form of DI known as “adipsic DI”. Osmoreceptors within the hypothalamus can trigger the release of ADH or stimulate thirst, with the former requiring a smaller change in serum osmolality to generate such a response. Pituitary surgery involves manipulation of the infundibulum and any inadvertent severing can prevent ADH’s ability to travel from the hypothalamus to the posterior pituitary, subsequently leading to DI. The majority of patients with post-op DI increase their free water intake and subsequently do not develop hypernatremia. Those with adipsic DI lack this compensatory mechanism which leads to the electrolyte disturbance, and carries a higher risk of morbidity and mortality than those with typical DI. Following her second surgery, our patient was discharged with DDAVP once again but this time with a higher dose and frequency. She’s had numerous hospital readmissions since then for altered mental status in the setting of hypernatremia as she still struggles to meet her free water intake and continuously relies on her family for reminders. Though her case is certainly not typical, it highlights the added complexity of managing adipsic DI as it relies not only on DDAVP replacement, but replicating what is supposed to be an innate behavior. Presentation: 6/3/2024

Abstract Disclosure: C. Kelly: None. L. Ghalib: None. Hypophysitis is rare; accounting for 0.24-0.39% of all pituitary diseases. Hypophysitis can be primary or secondary in nature. Granulomatous disease rarely causes pituitary enlargement, but Sarcoidosis and Granulomatosis with Polyangiitis have been documented to cause granulomatous infiltration of the pituitary. This case regards a man with granulomatous infiltration of the pituitary not consistent with either of the aforementioned disease processes. A 40 year old male presented to Urgent Care with headaches and blurry vision. Headaches were unresponsive to analgesics. The patient then presented to his PCP with the same complaints. MRI was then performed which showed a heterogeneously enhancing sellar and suprasellar mass. He was evaluated by Neurosurgery who recommended he undergo endoscopic resection of the pituitary lesion. Preoperative evaluation of pituitary axes were concerning for central hypothyroidism with a TSH of 1.046 uIU/mL (0.550-4.780) and free T4 of 0.76 ng/dL (0.89-1.76),as well as central hypogonadism with a FSH of 0.4 mIU/mL (<18.1), LH of 0.18 mIU/mL (1.5-9.3),and testosterone of 17 ng/dL (87-814). All other axes normal. Resection of the pituitary mass occurred approximately one week later at which time he was evaluated by Endocrinology for the first time. Prior to discharge, the patient was started on levothyroxine, but gonadal replacement was deferred to outpatient setting. Grossly the pituitary mass was concerning for lymphocytic hypophysitis (LH), and thus the patient was discharged on prednisone for empiric therapy. At the time of his endocrinology follow up, his headaches and visual changes had improved, but he was experiencing polydipsia, polyuria, and nocturia. Labs were consistent with Diabetes Insipidus (DI), and he was started on desmopressin. Surgical pathology had returned “acute and chronically inflamed granulation-like tissue associated with necrosis” confirming LH. CT chest was performed to evaluate for secondary causes of granulomatous disease which showed mediastinal lymphadenopathy without parenchymal lung disease. Serologic evaluation was positive for ANA, myeloperoxidase antibody, and SS-B antibody. While attempting to wean his prednisone the patient experienced recurrence of his headaches, which resolved when he returned to higher doses. The patient was evaluated by Pulmonology given the mediastinally mphadenopathy, who recommended bronchoscopy. When specimens from the mediastinal lymph nodes were evaluated by pathology, it was again significant for necrotizing granulomatous disease, but ACE and IL-2 were negative which argued against a diagnosis of sarcoidosis. He was evaluated by Rheumatology who recommended further infectious work upas well as consideration of initiation of a steroid-sparing agent for granulomatous disease. Workup of secondary etiologies for LH is ongoing given the systemic involvement. Presentation: Friday, June 16, 2023

A composite metric for the quality of glycemia from continuous glucose monitor (CGM) tracings could be useful for assisting with basic clinical interpretation of CGM data. We assembled a data set of 14-day CGM tracings from 225 insulin-treated adults with diabetes. Using a balanced incomplete block design, 330 clinicians who were highly experienced with CGM analysis and interpretation ranked the CGM tracings from best to worst quality of glycemia. We used principal component analysis and multiple regressions to develop a model to predict the clinician ranking based on seven standard metrics in an Ambulatory Glucose Profile: very low-glucose and low-glucose hypoglycemia; very high-glucose and high-glucose hyperglycemia; time in range; mean glucose; and coefficient of variation. The analysis showed that clinician rankings depend on two components, one related to hypoglycemia that gives more weight to very low-glucose than to low-glucose and the other related to hyperglycemia that likewise gives greater weight to very high-glucose than to high-glucose. These two components should be calculated and displayed separately, but they can also be combined into a single Glycemia Risk Index (GRI) that corresponds closely to the clinician rankings of the overall quality of glycemia (r = 0.95). The GRI can be displayed graphically on a GRI Grid with the hypoglycemia component on the horizontal axis and the hyperglycemia component on the vertical axis. Diagonal lines divide the graph into five zones (quintiles) corresponding to the best (0th to 20th percentile) to worst (81st to 100th percentile) overall quality of glycemia. The GRI Grid enables users to track sequential changes within an individual over time and compare groups of individuals. The GRI is a single-number summary of the quality of glycemia. Its hypoglycemia and hyperglycemia components provide actionable scores and a graphical display (the GRI Grid) that can be used by clinicians and researchers to determine the glycemic effects of prescribed and investigational treatments.

Bin/amphiphysin/Rvs (BAR) domains are positively charged crescent-shaped modules that mediate curvature of negatively charged lipid membranes during remodeling processes. The BAR domain proteins PICK1, ICA69, and the arfaptins have recently been demonstrated to coordinate the budding and formation of immature secretory granules (ISGs) at the trans-Golgi network. Here, we identify 4 coding variants in the PICK1 gene from a whole-exome screening of Danish patients with diabetes that each involve a change in positively charged residues in the PICK1 BAR domain. All 4 coding variants failed to rescue insulin content in INS-1E cells upon knock down of endogenous PICK1. Moreover, 2 variants showed dominant-negative properties. In vitro assays addressing BAR domain function suggested that the coding variants compromised BAR domain function but increased the capacity to cause fission of liposomes. Live confocal microscopy and super-resolution microscopy further revealed that PICK1 resides transiently on ISGs before egress via vesicular budding events. Interestingly, this egress of PICK1 was accelerated in the coding variants. We propose that PICK1 assists in or complements the removal of excess membrane and generic membrane trafficking proteins, and possibly also insulin, from ISGs during the maturation process; and that the coding variants may cause premature budding, possibly explaining their dominant-negative function.

BackgroundWe previously found that a 6-month multidimensional diabetes program, TIME (Telehealth-Supported, Integrated Community Health Workers, Medication-Access) resulted in improved clinical outcomes.ObjectiveTo follow TIME participant clinical outcomes for 24 monthsParticipantsLow-income Latino(a)s with type 2 diabetesDesign and InterventionWe collected post-intervention clinical data for five cohorts (n = 101, mean n = 20/cohort) who participated in TIME programs from 2018 to 2020 in Houston, Texas.Main MeasuresWe gathered HbA1c (primary outcome), weight, body mass index (BMI), and blood pressure data at baseline, 6 months (intervention end), and semiannually thereafter until 24 months after baseline to assess sustainability. We also evaluated participant loss to follow-up until 24 months.Key ResultsParticipants decreased HbA1c levels during the intervention (p < 0.0001) and maintained these improvements at each timepoint from baseline to 24 months (p range: < 0.0001 to 0.015). Participants reduced blood pressure levels during TIME and maintained these changes at each timepoint from baseline until 18 months (systolic p range < 0.0001 to 0.0005, diastolic p range: < 0.0001 to 0.008) but not at 24 months (systolic: p = 0.065; diastolic: p = 0.85). There were no significant weight changes during TIME or post-intervention: weight (p range = 0.07 to 0.77), BMI (p range = 0.11 to 0.71). Attrition rates (loss to follow-up during the post-intervention period) were 5.9% (6 months), 24.8% (12 months), 35.6% (18 months), and 41.8% (24 months).ConclusionsIt is possible for vulnerable populations to maintain long-term glycemic and blood pressure improvements using a multiple dimensional intervention. Attrition rates rose over time but show promise given the majority of post-intervention timepoints occurred during the COVID-19 pandemic when low-income populations were most susceptible to suboptimal healthcare access. Future studies are needed to evaluate longitudinal outcomes of diabetes interventions conducted by local clinics rather than research teams.

The SUSTAIN clinical trials demonstrated the efficacy and safety of once-weekly subcutaneous semaglutide, a glucagon-like peptide 1 analog for the treatment of type 2 diabetes (T2D). SUSTAIN 9 investigated semaglutide 1.0 mg vs placebo as add-on to a stable dose of sodium–glucose co transporter-2 inhibitor (SGLT-2i) therapy, with or without metformin or a sulfonylurea. The primary and secondary endpoints were, respectively, change from baseline in HbA1c and body weight at week 30. In this post hoc analysis, SUSTAIN 9 data were analyzed by background SGLT-2i (empagliflozin, canagliflozin, dapagliflozin or other [ipragliflozin, luseogliflozin and tofogliflozin; drugs available only in Japan]). In total, 302 subjects were randomized to semaglutide or placebo. Reductions in HbA1c and body weight were greater with semaglutide vs placebo. There was no significant interaction between background SGLT-2i and treatment effect (interaction p-value > 0.05 for both endpoints), with a smaller observed weight reduction in the ‘Other’ group. No safety concerns were identified when adding semaglutide to SGLT-2i therapy. No diabetic ketoacidosis or lower limb amputation events occurred. In conclusion, in subjects with T2 D already receiving an SGLT-2i, semaglutide generally resulted in superior HbA1c and body weight reductions vs placebo, regardless of background SGLT-2i therapy.