PE Poster Presentation-Endocrine (1-21

PE-01

COCURRENT GRAVES’ DISEASE AND BILATERAL CAROTID ARTERY STENOSES (MOYAMOYA DISEASE): A CASE REPORT

1SHIH-CHE HUA, 2PO-YEN YEH

1Division of Endocrinology and Metabolism, Department of Internal Medicine, St. Martin De Porres Hospital, Chiayi, Taiwan; 2Division of Neurology, Department of Internal Medicine, St. Martin De Porres Hospital, Chiayi, Taiwan

Background:

Moyamoya disease is a cerebrovascular disorder characterized by bilateral stenoses or occlusion of the terminal portions of the internal carotid arteries accompanied by typical netlike collateral vessels at the base of the brain. Although higher incidence in Asians, it is very rare to report patients suffering Moyamoya disease and Graves’ disease simultaneously. We present a young lady with the diagnosis of concurrent Moyamoya disease and Graves’ disease.

Case report:

A 28-year-old lady with past history of Graves’ disease visited our hospital complaining of bilateral frontal headache followed by progressive weakness of his left arm, which had been getting worse for 3 days. An emergent head computed tomography showed one small acute infarction in the right parietal lobe; old infarction in the right frontal lobe, right corona radiata and left parietal lobe. reference: 84.6-201.8) and T4 (14.3 ng/ dl, reference: 4.6-12.0), abnormal AMIA: 1:6400(+). He was admitted to Neurology ward. A brain magnetic resonance imaging (MRI) scan showed acute infarct over right middle cerebral artery (MCA) territory. Computed tomography angiography (CTA) and magnetic resonance angiogram (MRA) all revealed bilateral carotid stenosis and the presence of collaterals. Laboratory screening tests for young stroke including protein C, protein S, and Rheumatologic exams all showed negative. As to treatment, antiplatelet therapy (Aspirin 300mg/day) and antithyroid therapy (methimazole 20mg/day combined with propranolol) were performed. After her neurological symptoms/signs improved, she was discharged and followed up at the clinic with the above mentioned drugs.

Discussions:

Although it has previously been reported, coexistence of Moyamoya disease and Graves’ disease is very rare. Moyamoya disease and Graves’ disease are with implicated genetic factors because one gene locus of Moyamoya disease (chromosome 8q23, MYMY3) is very close to that of autoimmune thyroid disease (8q23-24). There has not been available for optimal treatment yet. It has been suggested to use antiplatelet, antithyroid therapy, or revascularization surgery in some literatures.

PE-02

ALTERNATIVE UPTAKE (FLIP-FLOP) OF METAIODOBENZYLGUANIDINE (MIBG) AND FLUORODEOXYGLUCOSE (FDG) IN DETECTING CATECHOLAMINE PRODUCING TUMOR: DEMONSTRATE 3 CASES

1YU-PEI LIN, 2SHAUH-DER YEH, 3YEU-LIN LIU, 4CHING-HUEI KUNG, 5SEY-EN LIN, 6CHEN-LING HUANG, 1,6CHUNG-HUEI HSU

1 Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan; 2 Department of Urology, Taipei Medical University Hospital, Taipei, Taiwan 3 Department of Pediatrics, Taipei Medical University Hospital, Taipei, Taiwan; 4 Department of Radiology, Taipei Medical University Hospital, Taipei, Taiwan; 5 Department of Pathology, Taipei Medical University Hospital, Taipei, Taiwan; 6 Department of Nuclear Medicine, Taipei Medical University Hospital, Taipei, Taiwan

Introduction: Radioiodine labeled MIBG (MetaiodoBenzylGuanidine) incorporated into noradrenalin storage granules is a functioning imaging for localizing and evaluating catecholamine producing tumors arising from adrenal gland or extraadrenal origin. We present three cases, malignant pheochromocytoma, paraganglioma and neuroblastoma, respectively, using 123I-MIBG (MyoMIBG-I 123, FUJIFILM RI Pharma Co., LTD, Tokyo, Japan) scan for this rare disease.

Case1: urinary catecholamine levels and MRI showing a tumor in right adrenal gland received right adrenectomy for pheochromocytoma 12 years previously. Recurrence of the disease was suspected on account of reappearance of the symptoms. Urinary biochemical levels were normal. MRI revealed an irregular lesion at medial aspect of right suprarenal region. The lesion was MIBG avid. After surgery, metastatic paraspinal lymph node and invasion of surrounding soft tissue was proved. Recurrent MRI images recently, while FDG-PET was negative.

Case2: 60-yr-old male who had symptoms and markedly elevated urinary biochemical markers to suggest catecholamine producing tumor. CT scan revealed a huge retroperitoneal tumor in upper paraaortic region. The tumor appeared devoid of MIBG uptake (cold), while FDG-PET revealed intense uptake into the tumor. Paraganglioma was diagnosed after operation-pathological

Case 3: 24-yr-old male who harbored left adrenal gland neuroblastoma with lymph nodes metastases since 12 years of age (2003) had received operation, stem-cell transplantation and radio/ chemotherapy. Recurrence of the disease was noted in 2009, 2012, 2014 and 2015, respectively. Recent CT scan showed soft tissue mass at left para-vertebral region of posterior lower mediastinum. FDG-PET/CT revealed increased tumor glucose metabolism while MIBG scan showed faint

visualization of the mass. Metastatic neuroblastoma involving soft tissue and lymph nodes was proven by surgery. The tumor tissue showed strong positive Anaplastic Lymphoma Kinase (ALK) protein expression.

Discussion: 123I-MIBG whole body scan is a useful tool to detect and evaluate catecholamine producing tumor. Concomitant utilization of FDG-PET can assess malignant potential of the disease.

PE-03

THE OCCULT ECTOPIC ACTH SYNDROME TREATED WITH METYRAPONE - A CASE REPORT

1KAI-PI CHENG, 1HAO-CHANG HUNG, 1HORNG-YIH OU

1Division of Endocrinology and Metabolism, Department of Internal Medicine, National Cheng Kung University Hospital

Endogenous Cushing’s syndrome is a disease with diverse manifestations due to prolonged exposure to excess glucocorticoids. It can be further divided into adrenocorticotropic hormone (ACTH) dependent and ACTH independent forms. Although the vast majority of patients with ACTH dependent Cushing’s syndrome are caused by the pituitary corticotroph adenoma, some are due to ectopic (extrapituitary) tumors that secrete ACTH. Around 6.7%-18.9% patients with ectopic ACTH a case with occult ectopic ACTH syndrome treated successfully with metyrapone.

A 62-year-old man was admitted to our hospital because of progressive limbs edema and unintentional body weight gain for one year. On examination, Cushingoid appearance including moon face, facial plethora, buffalo hump and central obesity was found. The am and pm cortisol and 78.8 pg/ml, respectively. The cortisol levels were not suppressible by overnight and low dose dexamethasone suppression tests. In spite of more than 50 percent decrease of cortisol level under high dose dexamethasone suppression test, no pituitary gland lesion was detected by magnetic resonance imaging. In addition, there was hypokalemic metabolic alkalosis. Therefore, ectopic Cushing’s syndrome was impressed. However, chest, abdominal, and pelvic computed tomography did not FDG uptake in the ascending colon, biopsy through the colonoscopy showed colitis only. Moreover, other tests, including urinary 5-HIAA, 24 hours urinary catecholamines and VMA, serum calcitonin glucocorticoids, after well discussing with the patient, we gave metyrapone to inhibit steroidogenesis. The serum cortisol level decreased then. We will continue to evaluate the patient’s condition closely and provide necessary examinations to discover the occult source of ACTH secretion.

PE-04

TUMORAL CALCINOSIS IN CHRONIC HEMODIALYSIS WITH HYPERPHOSPHATEMIA - A CASE REPORT

YI-HSIN LIN

Division of Endocrinology and Metabolism, Department of Internal Medicine, Taiwan Adventist Hospital

Tumoral calcinosis is an uncommon disorder in which calcium salt deposition is found in solitary or multiple, peri-articular soft tissue. The accumulations are often outside of the large joint capsule, such as hip, elbow, shoulder, ankle, and wrist. They cause progressive swelling around joints, but less pain and rare restriction of movement, secondary to compression of normal surrounding structures. They have potential to extrude and ulcerate the overlying skin. There are two types of tumoral calcinosis. The primary type is an inborn abnormality of phosphorus metabolism, known as hyperphosphatemic familial tumoral calcinosis, caused by increased renal absorption of phosphate due to loss-of-function mutations in the FGF23 or GALNT3 gene. (Less frequently normophosphatemia may also be noted). The secondary tumoral calcinosis is often associated with hyperphosphatemia in chronic renal failure with long term dialysis. We presented a 37-year-old female foreigner (Palau), end stage renal disease under hemodialysis since 2007, referred from international medical service for progressive, painful, and swelling over her right shoulder and scheduled percutaneous transluminal

PE-05

A CASE REPORT OF VON HIPPEL-LINDAU DISEASE

1YU YI LIN, 2KUANG KUO WANG

Division of Endocrinology and Metabolism, Department of Internal Medicine, Cheng Hsin General Hospital, Taiwan, R.O.C

Background. Von Hippel-Lindau disease (VHL) is a rare autosomal dominantly inherited neoplastic syndrome and is characterized by highly vascular tumors of the retina, brain, and spinal cord, as well as benign and malignant tumors and/or cysts of the kidneys, adrenal medulla and sympathetic paraganglia, endolymphatic sac, epididymis, and broad ligament. VHL disease is caused by germ-line mutations of the VHL tumor suppressor gene, located on the short arm of chromosome 3 (3p25-26), regulating hypoxia-inducible factor ( HIF) for upregulation of vascular endothelial growth and erythropoietin substances. Since the discovery of the VHL gene in 1993, genetic testing for VHL is widely available and will detect a disease-causing mutation in rate 95% to 100% of individuals who have a clinical diagnosis of VHL.

Method. We report a case of VHL disease presenting with multiple pancreatic cysts, renal cysts and craniospinal hemangioblastomas.

Results. A 27-year-old female presented with poor glycemic control, intermittent nausea, vomiting and occipital headache for about 2 months. Physical examination revealed a thin girl with revealed multiple cysts in the pancreas and two small cysts in the right kidney. To further identify the cause of those lesions, abdominal CT was performed. Because of worsening of headache combined with severe vomiting, brain CT was arranged to make sure whether there was intra-cranial lesion or not. Brain CT showed a cystic mass in left cerebellum, compressing fourth ventricle. Her symptoms persisted and aggrevated despite symptomatic treatments. Brain MRI with contrast also revealed a cystic mass in left cerebellum. Esophagogastroduodenoscopy revealed GERD, Grade A and external compression at antrum. Her family pedigree showed autosomanl dorminant heritage of multiple tumors involving pancreas, kidneys and retina. Taken together, she was clinically diagnosed as VHL disease. Left occipital craniotomy and removal of brain tumor under microscope was performed. The pathological report revealed a hemangioblastoma with extensive vascular network and neoplastic stromal cells; which is compatible with VHL disease. Twenty five days later, she was admitted again due to progressive low back pain with radiation to bilateral thighs.MRI of spine revealed intramedullary soft tissue mass located between T11 and 12. Laminectomy was performed and months of operation showed complete resolution of intracranial lesions.

Conclusion. VHL disease is often difficult to diagnose due to the wide range of clinical symptoms. Patients diagnosed with hemangioblastoma should be tested for VHL gene mutations. If mutations are present, the patient’s relatives should be offered a genetic consultation. VHL patients may develop further lesions many years after the initial diagnosis, despite complete excision of initial neoplasm. Continuous close and long-term follow-up in patients with VHL disease is necessary.

PE-06

THE STRATEGY OF CUSHING’S DISEASE WITHOUT INITIAL MANIFESTATION OF PITUITARY ADENOMA IN MRI EXAMINATION: A CASE REPORT

1WEI-FU HUANG, 1CHWEN-YI YANG, 1KAI-JEN TIEN, 1NAI-CHENG YEH, 1SHANG-GYU LEE

1.Division of Endocrinology and Metabolism, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan

Background

The goal of our study was to the evaluate next step of Cushing’s disease with initial negative pituitary magnetic resonance imaging(MRI)

Material and Methods

Cushing’s disease was diagnosed in a 30 year old female on the basis of clinical and biochemical was 21.35ug/dl) with ACTH elevation (73.63 pg/ml) and it appeared no changeability of circadian rhythm.

Results

Due to the lack of indication for transsphenoidal surgery (TSS) with hesitating in inferior petrosal sinus sampling(IPSS) study, cabergoline monotherapy was prescribed. A 8-month course of treatment resulted in no amelioration of hypercortisolism. Re-arrangement of brain pituitary resonance imaging appeared a poorly-enhanced nodular lesion(7x5mm), favoring pituitary microadenoma. Transferred to neurosurgery for transsphednoidal surgery. Postoperatively the patient’s hypercortisolism and hyperprolactinaemia improved right away.

Conclusion

Pituitary ACTH tumor grows very slowly. The biochemical evidence usually preceded the disease and closely following up with medication treatment. Besides, we extremely suggest repeating pituitary MRI examination at least 6 months later if hypercortisolism still existed.

PE-07

CASE REPORT: A CASE OF UNCONTROLLED GRAVES’ DISEASE PRESENTING WITH MITRAL VALVE CHORDAE RUPTURE WITH SEVERE MITRAL REGURGITATION

YU-LING LIN

Feng yuan hospital, ministry of health and wealfare

Heart failure due to metabolic derangements is uncommon in clinical practice. Hyperthyroidism is associated with some serious complications involved the heart. When the precipitating factor is recognized and treatment is initiated in a timely fashion, These complications generally are reversible with appropriate treatment.

We report a 44 year-old female, a case of 1. arrthymia 2. hyperthyroidism lost F/U for yeart. This time, she suffered from short of breath and DOE, with palpitation for 3 weeks. She came to CV OPD at 0713, PE revealed no obvious rales. EKG showed Af with RVR. X ray sowed bilateral pleural admission, concor 1.25mg 1#BID with methimazole 2#TID were prescribed, ATD side effect education is done. Followed lab revealed TSH:0.02, free T4:4.66. We also arranged cardiac echo to follow cardiac function: mitral valve chordae rupture with severe MS were found(cardiac echo: Heart echo: RA/RV/LA enlarged. Af. LVEF 68%. Mod TR, peak systolic pressure gradient = 82mmHg, suggesting and family. Thyroid function must be controlled, and then surgery will be arranged as soon as possible.

After well preoperative preparation, MVR + tricuspid repair were performed on 1050929. Postoperative course was smooth and warfarin was prescribed. She was discharged when INR reached the target level. Now postoperation course smooth, pt was under ATD therapy at meta opd.

Early recognition and prompt management of hyperthyroidism and associated cardiac complication can result in an imminent improvement of cardiac function.

PE-08

THYROID STORM: CASE REPORT

YU-LING LIN

Division of Endocrinology and Metabolism, Department of Internal Medicine, Feng yuan hospital, ministry of health and wealfare

Thyroid storm is an endocrine emergency, remains a diagnostic and therapeutic challenge. The incidence of thyroid storm in the emergency department is low, with a mortality rate of 20%-30%; thus, it should not be overlooked. We present a 42 y/o female, a case of HBV carrier, denied thyroid disease in the past. In 105/08/15, she was sent to our ER due to shortness of breath, bilateral lower limbs pitting edema and decreased urine amount for several days. In our ER, acute pulmonary edema and cardiomegaly were noted, r/o CAD, she was admitted to ICU for intensive care. Under concerned of young age and without other vital organ dysfunction, we had checked thyroid function and primary hyperthyroidism(Free T4: 5, TSH: 0.02). Meta specialist was consulted and thyroid storm was impressed (Burch-wartofsky score: Temp:5 + CNS:0 + GI:20 + HR:20 + Heartfailure:15 + precipitant; 0 = 60). We added methimazole, lugol solution, hydrocortisone and propranolol for controlling. With monitoring her clinical performance, we kept shifting her medication dosage frequently. Diuretic agents was for fluid balance. With adjusting fluid suplement and medication dosage, we also tried weaning protocol. Her condition improved by closely monitored therapy guided by team consisting of Cardiologists and Endocrinologists. Endotracheal tube and ventilator were successfully weaning on 105/08/23. With relatively improving respiratory pattern, we transferred to ordinary ward for further care at 1050819. Now pt was under ATD therapy smoothly at meta opd.

Many cases of thyroid storm occur after a precipitating event. Early diagnosis and appropriate treatment may reduce mortality and morbidity rates. In the emergency departments, thyroid storm must be put on the list of differential diagnoses in 30-50 y/o patients, esp. female, if the patient is presenting with suspicious symptoms/signs.

PE-09

A CASE REPORT: THYROID VOLUME IN A PATIENT WITH HASIMOTO THYROIDITIS IS PROGRESSIVELY REDUCED AS A SEQUELA OF CHEMOTHERAPY FOR LYMPHOMA

1HUAN-WEN CHEN, 2JIE-YU YOU, 3CHU-TEH CHEN, 1HSIAO-LIEN CHEN

1Division of Endocrinology and Metabolism, Department of Internal Medicine, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yi-Lan, Taiwan, R.O.C; 2Division of Oncology and Hematology, Department of Internal Medicine, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yi-Lan, Taiwan, R.O.C; 3Division of Pathology, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yi-Lan, Taiwan, R.O.C

Hashimoto’s thyroiditis is a chronic lymphocytic thyroiditis, and it is an autoimmune disease. The thyroid gland is gradually destroyed. The thyroid may enlarge in early stage.

We report a 70 year-old female with large thyroid gland for years. Hypothyroidism was noted in Sep 2009. The level of Thyroid-stimulating hormone (TSH) was 22.6 uIU/ml. The level of Microsomal Ab (AMIA) was 1:100 (+). After eltroxin replacement, she was often under euthyroidism. But the thyroid volume was not reduced much. She ever received partial thyroidectomy to exclude thyroid lymphoma, but the pathology reported compatible with Hasimoto thyroiditis.

She sometimes had enlarged lymph nodes at neck. Diffuse large B-cell lymphoma was diagnosed after excision of lymph node at other hospital in May 2011. She received chemotherapty since that time. The thyroid volume was progressively reduced.

Hashimoto thyroiditis is a known risk factor for the development of primary thyroid lymphoma. Chemotherapy can decrease the thyroid volume in primary thyroid lymphoma. But primary thyroid lymphoma was excluded after partial thyroidectomy in our patient. Our patient’s thyroid became atrophy after chemotherapy. So we suggested to check thyroid function and AMIA or anti-thyroid peroxidase antibody (anti-TPO ab) to exclude Hasimoto thyroiditis before the patient receiving chemotherapy for lymphoma. If the patient had Hasimoto thyroiditis, we suggested to check thyroid function frequently after the patient receiving chemotherapy for lymphoma. Adequate eltroxin replacement therapy is important when early detect thyroid atrophy and hypothyroidism.

PE-10

PARATHYROID CARCINOMA MIMICKING ANAPLASTIC THYROID CARCINOMA

1YIN-HUEI CHEN, 1CHING-CHUNG CHANG, 1CHING-CHU CHEN, 1YI-CHIH HUNG, 2YEN-NIEN LIN, 1CHWEN-TZUEI CHANG

1Division of Endocrinology and Metabolism, Department of Internal Medicine, China Medical Universiry Hospital, Taichung, Taiwan, R.O.C.; 2Division of Cardiovascular medicine, Department of Internal Medicine, China Medical Universiry Hospital, Taichung, Taiwan, R.O.C.

Parathyroid carcinoma is very rare endocrine malignancy, it accounts for 0.5~5% all cases of primary hyperparathyroidism. We report a case of parathyroid carcinoma with brief literature review. A 48-year-old previously healthy female presented with hypercalcemic crisis and PTH dependent hyperparathyroidism. Thyroid ultrasound revealed a 3.5x2.4x3.9 cm lobulated heterogenous high tissue PTH level. Sestamibi scan displayed increased radionucleotide uptake in same left inferior thyroid. The patient underwent left thyroidectomy parathyroidectomy and left group VI lymph node dissection. Upon surgical exploration, the parathyroid mass was found to be grossly fibrotic and irregular in comparison to adjacent tissue. Histopathological examination revealed parathyroid carcinoma with contained capsular invasion while thyroid and lymph node specimens were negative for malignancy.

PE-11

TRANSIENT THYROID SWELLING FOLLOWING FINE NEEDLE ASPIRATION: A RARE COMPLICATION OF THYROID FINE NEEDLE ASPIRATION

1SHIH-CHANG LO, 1EDY KORNELIUS, 1CHIEN-NING HUANG, 1YI-SUN YANG

1Division of Endocrinology and Metabolism, Department of Internal Medicine, Chung Shan Medical University Hospital

We report a case of acute transient thyroid swelling following fine-needle aspiration, a rare complication and still unknown pathophysiology. A 43-year-old woman visited the clinic because of right thyroid goiter. The ultrasonographic pattern was an eccentric nodule with partial cyst and measured 24.3 x 18.2 x 14.2 mm. Fine needle aspiration of the right nodule was performed with a 19-gauge needle. Less than 5 minutes after the aspiration, the patient felt bilateral neck acute pain, especially during swallowing. Ultrasound showed rapid swelling of bilateral lobe: the right thyroid volume increased from 8.54 ml to 18.93 ml and left volume also increased from 7.06 ml to 14.84 ml. No evidence of bleeding on ultrasound and physical examination. The thyroid swelling returned to baseline after 3 days and painful sensation recovered about 1 week. Cytology was colloid, colloidophages, and scant follicular cells.

PE-12

RARE ORGAN METASTASES IN A RARE SKIN NEUROENDOCRINE TUMOR

1LO-CHIAO HUNG, 1MING-FONG TSAI, 1PEI-HUA HSU, 1YUIN-JU KUO, 1,2CHIEN-CHIN HSU

1 Chiayi Chang Gung Memorial Hospital 2 Kaohsiung Chang Gung Memorial Hospital

We described the case of a rare cutaneous neuroendocrine tumor with multiple organ involvement in a ninety-three years old woman who underwent right facial skin tumor excision biopsy. The immunohistochemical pathology report showed that the tumor cells were positively stained for CK-20, diagnosis of Merkel cell carcinoma (MCC).

F18-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) was performed and showed multiple organ metastases, involving the thyroid glands, bilateral adrenal glands, small bowel, peritoneum, bone, and left subscapular soft tissue.

MCC is an uncommon neoplasm involving the skin, while very rare, subsequently metastasize to lymph nodes and other organs. These tumors are believed to arise from neuroendocrine-derived mechanoreceptor, Merkel cells, located at basal layer of the epidermis, that form synapse-like contacts with enlarged nerve terminals. The main risk factor is sunlight exposure, especially the ultraviolet light. The incidence of MCC has been rising steadily in Caucasian population, but few cases have been reported in Asian patients. We present here the 18F-FDG PET/CT images of a Merckel cell skin tumor manifested with rare multiple organ metastasis.

PE-13

A CASE OF HYPOPITUITARISM PRESENTING WITH GALACTORRHEA

1YIN-HUEI CHEN,

1CHING-CHU CHEN, 1CHING-CHUNG CHANG, 1YI-CHIH HUNG, 2YEN-NIEN LIN, 1ZI-YUAN WANG

Division of Cardiovascular medicine, Department of Internal Medicine, China Medical Universiry Hospital, Taichung, Taiwan, R.O.C.

Pituitary stalk interruption syndrome (PSIS) is a rare abnormality of the pituitary. It was first reported by Fujisawa et al in 1987. It is characterized by a classic triad of interrupted pituitary stalk on MRI, absent or ectopic posterior pituitary and anterior pituitary hypoplasia or aplasia. PSIS variable degree and timing of onset. In addition, clinical presentation also varies according to age. In adults, it presents as short stature and anterior pituitary deficiency. Perinatal events and genetic mutations may cause PSIS but the exact pathophysiology has not been illuminated yet. Without early diagnosis and treatment, mortality and morbidity in these patients is high. Here in, we want to describe a 28 year old female with pituitary stalk interruption syndrome who presented with short body stature and galactorrhea.

PE-14

A CROSS-SECTIONAL RETROSPECTIVE STUDY TO IDENTIFY INDICATORS FOR INITIATING THYROID HORMONE REPLACEMENT THERAPY IN PATIENTS WITH SUBCLINICAL HYPOTHYROIDISM

1PEI-CHI CHEN, 2CHIH-YUAN WANG

1 2

Subclinical hypothyroidism (SCH) is defined by elevated serum thyroid stimulating hormone (TSH) levels and normal levels of total or free thyroxin. SCH is associated with increased risk of cardiovascular morbidity and mortality, but convenient risk indicators are lacking. We aimed to identify reliable indicators of cardiovascular risk for determining initiation of thyroid hormone replacement therapy in SCH patients. This is a cross-sectional ret rospective study. Medical records of 412 consecutive healthy subjects with SCH who underwent routine health check-ups at National Taiwan University Hospital between January 1, 2009 and December 31, 2009 were reviewed. Demographic, physical and clinical data were collected, including waist circumference, body mass index, thyroid function tests, fasting blood glucose, glycohemoglobin (HbA1c), and lipid profiles. Cholesterol Education Program Adult Treatment Panel III (NCEP ATPIII) risk assessment was used P < 0.001), postprandial glucose (P < 0.001), triglycerides (P < 0.001) and lower HDL-C (P = 0.039) than groups 1 and 2. HbA1c levels > 5.7% are associated with cardiovascular risk in SCH patients. HbA1c is an objective, convenient parameter for determining initiation of thyroid hormone replacement therapy in SCH patients with higher cardiovascular risk. Further studies are needed to demonstrate HbA1c capability for predicting cardiovascular risk in SCH patients and whether T4 treatment can improve outcomes.

PE-15

A CASE REPORT: ACUTE SUPPURATIVE THYROIDITIS WITH GAS FORMATION ORIGINATING FROM URINARY TRACT INFECTION

1HUAN-WEN CHEN, 2YUAN-YUN TAM, 3I-HUNG SHAO, 1HSIAO-LIEN CHEN

1Division of Endocrinology and Metabolism, Department of Internal Medicine, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yi-Lan, Taiwan, R.O.C; 2 Department of Otorhinolaryngology - Head and Neck Surgery, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yi-Lan, Taiwan, R.O.C; 3 Division of Urology, Department of Surgery, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yi-Lan, Taiwan, R.O.C

Introduction: Because of a relatively high amount of iodine in the tissue, high vascularity and lymphatic drainage to the region, the thyroid is resistant to bacterial infection. So acute suppurative thyroiditis (AST) is rare. AST often involves the left lobe of the thyroid because it is often associated with the persistence of a pyriform sinus from the pharynx to the thyroid capsule. Therefore, AST is usually in children and young adults. It is often caused by oral bacteria including Staphylococcus aureus, Streptococcus hemolyticus, and pneumococcus. Other aerobic or anaerobic bacteria may also be involved. Acute emphysematous thyroiditis is AST with gas formation. It is a severe pyogenic infection of the thyroid gland characterized by the production of gas. It is a rarer type of AST.

Case report: We present the clinical course of 78 year-old female patient with urosepsis and a large neck mass. She was a known diabetic for years on irregular oral hypoglycaemic agents. She was admitted to receive antibiotics for urinary tract infection (UTI) in early July 2015. One large (CT). But she refused further study or treatment for goiter. After completing the course of antibiotics, she was discharged. She fell down and she suffered from neck contusion about 4 days before this admission in late July 2015. She complained of more and more neck tightness. She was taken to the emergent room on July 27, 2015 when she had consciousness disturbance. On examination, she had erythaema or edema. Pyuria, leukocytosis, and large neck mass were found. CT revealed a large mass, about 6.6x5.4x6.7 cm, with marked hetergeneous gas collection in right lobe of thyroid gland and the trachea was compressed on July 27, 2015. Subclinical hyperthyrodism was noted. She was diagnosed as having urosepsis and thyroid abscess, and hence she received emergency surgical exploration and abundant neutrophils and a few erythrocytes and a few histiocytes and few lymphocytes were seen. Intraoperative neck sonography was done to screen out other focus of pus or hematoma. The patient was treated with antibiotic therapy followed by emergency surgical exploration and fine needle aspiration. Right lobe of thyroid became smaller initially, and then it enlarged again. Neck CT revealed a focal large air-trapping lesion in right lobe of thyroid gland with tracheal compression. So she

some pus were drained. Escherichia coli (E. coli) was the causative micro-organism cultured from the pus, urine and blood specimen. So we suspected that E. coli in the patient’s AST resulted from hematogenous spread. We changed antibiotics according to infection specialist’s suggestion. Her thyroid function became normal after 10 days. No antithyroid drug was prescribed.

Conclusion: AST is rare in old age people. Acute emphysematous thyroiditis is AST with gas formation. It is a rarer type of AST. Fine needle aspiration or surgical exploration and drainage to remove the pus is very important. We also need to search the infection source and give adequate antibiotics when the old age people suffer from AST.

PE-16

HYPERCALCEMIA FROM SUSPECTED MATASTATIC GASTROINTESTINAL STROMAL TUMOR (GIST) TO THE LUNG: A CASE REPORT

1WEI CHE CHEN, 2CHEN WANG CHANG, 3PEI JAN CHEN, 1CHUN CYUAN LI

1Division of Endocrinology and Metabolism, Department of Internal Medicine, Mackay Memorial Hospita, Taiwan, R.O.C.; 2Division of Gastroenterology, Department of Internal Medicine, Mackay Memorial Hospita, Taiwan, R.O.C.; 3Division of Chest Medicine, Department of Internal Medicine, Mackay Memorial Hospita, Taiwan, R.O.C.;

Hypercalcemia is a paraneplastic syndrome and is common in advanced lung cnacer, breast cancer and multiple myeloma. The invasion of bone from the malignancy could cause it. It also might be from the production of parathyroid hormone-related protein (PTHrP), parathyroid hormone or 1,25-dihydroxylvitamin D. Hypercalcemia of malignancy often means a poor prognosis.

We present a case report of hypercalcemia in a 84 years-old female. We found a lung tumor in the right apical lung from the computed tomography. Biopsy from broncoscopy was done and the pathological report present gastroinstetinal stromal tumor (GIST), most likely metastatic.

PE-17

A CYCLIN-DEPENDENT KINASE INHIBITOR, DINACICLIB IN PRECLINICAL TREATMENT MODELS OF THYROID CANCER

1SHU-FU LIN, 1JEN-DER LIN, 2CHUEN HSUEH, 3TING-CHAO CHOU, 4RICHARD WONG

1Department of Internal Medicine, 2Department of Pathology, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan; 3Laboratory of Preclinical Pharmacology Core, Memorial Sloan-Kettering Cancer Center, New York, NY, USA; 4Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA

Background: We explored the therapeutic effects of dinaciclib, a cyclin-dependent kinase (CDK) inhibitor, in the treatment of thyroid cancer.

Materials and methods: Seven cell lines originating from three pathologic types of thyroid cancer (papillary, follicular and anaplastic) were studied. The cytotoxicity of dinaciclib was measured using a lactate dehydrogenase assay. The expression of proteins associated with cell cycle and apoptosis was (ATC) were treated with intraperitoneal injections of dinaciclib.

Results: Dinaciclib inhibited thyroid cancer cell proliferation in a dose-dependent manner. cancer cell lines. Dinaciclib decreased CDK1, cyclin B1, and Aurora A expression, induced cell cycle arrest in the G2/M phase, and induced accumulation of prophase mitotic cells. Dinaciclib decreased Mcl-1, Bcl-xL and survivin expression, activated caspase-3 and induced apoptosis. In vivo, the growth of ATC xenograft tumors was retarded in a dose-dependent fashion with daily dinaciclib treatment. lower-dose dinaciclib (40 mg/kg) treatment.

Conclusions: Dinaciclib inhibited thyroid cancer proliferation both in vitro and in vivo. These patients with refractory thyroid cancer.

PE-18

RATHKE’S CLEFT CYST INDUCED PANHYPOPITUITARISM PRESENTED WITH RECURRENT HYPONATREMIA

1CHIH-KANG WAN, 1CHUNG-MO CHANG, 2CHING-LING LIN

1 Department of Internal Medicine Cathay General Hospital Taipei; 2 Division of Endocrinology and Metabolism Cathay General Hospital Taipei

Case report:

A 59-year-old Asian male complained of persistent dizziness, nausea and vomiting for one week, which prompted him to our ER. On arrival his vital sign showed BP:170/79 mmHg, PR:68/min, RR:20/ min. BT:37 . Lab data showed Hb:11.1, Na+ :113, K:3.8, Cr: 0.87, Osm: 235, CRP: 1.933, Urine Na: 113, Urine Osm: 436, FENa:2.3%. Brain CT showed no evidence of intracranial hemorrhage but widening of pituitary fossa was noted. Under the impression of hyponatremia and mild ileus, he was admitted for further evaluation. He denied fever, cough, rhinorrhea, chest tightness, dysuria, pitting edema, sore throat, palpitation, dyspnea, and tarry stool. He also denied decreased libido, LOBW and no loss of pubic or axillar hair. History review showed that hyponatremia had been found some 1.5 yr ago in another medical center while he suffered from the same S/S however no further evaluation had been conducted due to he recovered promptly. Diagnostic work-up for hyponatremia revealed TSH = 3.09, FT4 = 0.33, ACTH (8AM) = 14.9pg/ml, Cortisol (8AM) = 6.6, Testosterone = 2.0 ng/mL , GH = 0.05ng/ml, IGF-1 = 54.4ng/ml, LH = 0.40mIU/ml, FSH = 1.98mIU/ml, Prolactin = 20.2ng/ml with normal liver, cardiac and renal function. Panhypopituitism was impressed. An enhanced MRI of pituitary revealed a 1.4 x 1.6 x 1.3 cm sellar lesion with hyperintensity both on T1W and T2W images. and the patient underwent endoscopic endonasal transsphenoidal hypophysectomy. Prior to surgery his hyponatremia responded poorly to 3% saline infusion but normalized promptly after replacement of cleft cyst without evidence of malignancy. After surgery his serum sodium remained normal without further requirement of thyroxin and cortisone acetate therapy during OPD follow up.

Discussion:

Rathke’s cleft cysts (RCC) are non-neoplastic remnants of Rathke’s pouch. They usually remain asymptomatic with a prevalence of 13% to 22% in autopsies series and treatment is rarely required. However, symptoms could develop if adjacent structures are compressed. Presentation of symptomatic Also hypopituitarism can be caused by compression of adjacent pituitary tissue or pituitary stalk. In characteristic imaging finding to facilitate the diagnosis of Ratheke’s cleft cysts from other sellar

lesions. Delayed diagnosis therafore is not uncommon in clinical setting. Surgery is not a routine solution for asymptomatic, incidentally found pituitary lesions but sometimes it is the only solution Rathke’s cleft cysts also require pathological evidence since the variable radiographic features of Rathke’s cleft cyst sometimes made it indistinguishable from other sellar lesions. Our case highlights nd to panhypopituitarism and physicians should be vigilant in such clinical scenario to unearth the disease underneath which include Rathke’s cleft cyst.

PE-19

HYPERALDOSTERONISM RELATED HYPOKALEMIA IN ANOREXIA NERVOSA, A CASE REPORT

1CHIA-WEI LAI, 1HE-JIUN JIANG, 1WEI-WEN HUNG, 1SHYI-JANG SHIN, 1PI-JUNG HSIAO

Division of Endocrinology and Metabolism, Kaohsiung Medical University Hospital

medical morbidities. The overall standard mortality rates were 6 folds in female and 5.0 folds in male patients with anorexia nervosa than in general population. Anorexia nervosa occurs in adolescents and adults worldwide. The estimated lifetime prevalence in adult is 0.6 ~ 4.2 % in Caucasian and it is reported to increase in a trend in Asia, including Taiwan.

Here, we reported a 37-year-old female admitted with main manifestation of general weakness, severe hypokalemia and emaciation. She looked extremely thin (BW 18 kg, BH: 162 cm, BMI < 7 kg/m2) and was bedridden for a long time. Her biochemistry demonstrated severe microcytic anemia, hyponatremia, hypokalemia and metabolic alkalosis. Secondary hyperaldosteronism was caused by her repeated, and long-time self-inducing vomiting and laxative misuse since she was 18 years old. Extreme status of anorexia nervosa was diagnosed based on her BMI < 15 kg/m2, hypogonadotropic hypogonadism, hypercortisolism, non-thyroidal illness syndrome, severe osteoporosis (T-score of BMD -5) and multiple bony fractures. and total parenteral nutrition supplement. However, acute refeeding syndrome occurred with features of progressive short of breath, cardiomegaly and bilateral pleural effusion one week later. These symptoms were improved by intravenous infusion with albumin and loop diuretics. Then, she was discharged and sustained with home parenteral nutrition therapy. Her body weight was raised up to 30 kg in 6 months and was regularly followed at outpatient clinic until now.

All causes of the mortality rate among patients with anorexia nervosa were reported up to 5.9%. Sudden cardiac death and suicide mainly account for 60% of the death. The exact mechanism of sudden cardiac death remains unknown but maybe relevant to left ventricular atrophy, myocardial fibrosis, alteration in cardiac conduction, high-grade atrioventricular block, QTc-prolongation in background of profound hypokalemia. Therefore, patients manifested with hypokalemia, metabolic alkalosis and extreme emaciation should be hospitalized and treated soon.

PE-20

DEDUCED MECHANISM OF EPIMEDIUM INDUCED MYOTUBE HYPERTROPHY IN C2C12 CELLS

1YI-AN LIN, 2MEI-CHICH HSU, 3SZU-TAH CHEN

1 National Taiwan Sport University, 2Kaohsiung Medical University, 3Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital, Linko

BACKGROUD: Both insulin-like growth factor 1 (IGF-1) and androgen are known to be associated with muscle hypertrophy through the activation of PI3K/Akt/mTOR signaling pathway; which is also important for myogenesis and therefore, attenuation of muscle atrophy. Recently, Epimedium and its constitutional flavonoids have been found to mediate PI3K/Akt/mTOR signaling cascades in myocytes and adipocytes; however, the mechanisms remain unclear.

PURPOSE: To study the difference between Epimedium and IGF-1 or androgen induced PI3K/Akt/ mTOR cascades.

METHODS: Epimedium extracts (EE) was applied to differentiated C2C12 myotubes in this study. (MyHC). The expression levels of IGF-1R, Akt, p70S6K, ERK 1/2, and MyHC proteins as well as MYH2, MYH4, MYH7, MRF4, myogenin, MAFbx, and MuRF1 mRNAs were assessed by western blot and RT-PCT, respectively.

RESULTS: EE enhanced C2C12 myotube hypertrophy through PI3K/Akt/mTOR activation and MyHC isoform overexpreession like IGF-1 and testosterone did. All these treatment alo promoted ERK 1/2 phosphorylation. Different from testosterone treatment, the activated ERK 1/2 induced by EE and IGF-1 could be abolished by LY294002 and rapamycin. Consequently, EE up-regulated MRF4 and MYH2 (MyHC 2A) gene expression could be reduced byPI3K/Akt/mTOR inhibition.

CONCLUSION: Our data suggested that EE stimulated myotube hypertrophy was more likely through IGF-1 related signaling pathways.

PE-21

INFUNDIBULO-NEUROHYPOPHYSITIS WITH DIABETES INSIPIDUS: A CASE REPORT

1TSE CHEN, 1PEI-CHI CHEN

1Division of Endocrinology and Metabolism, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taiwan, R.O.C.

Backgournd. Hypophysitis is heterogenous in underlying etiologies and histopathological types. hypophysitis. However, the incidence seemed to increase in these years.

Methods. We reported a case of infundibulo-neurohypohpysitis presenting as diabetes insipidus and review the literatures.

Results. A 51 y/o male who suffered from polydipsia, polyuria, and nocturia for three months. It was noted that the patient had abnormally diluted urine and could be fully corrected with DDAVP. Central diabetes insipidus was diagnosed, and infundibulo-neurohypohpysitis was considered to be the cause after sella MRI. There was no compression symptoms and signs of pituitary. Considering of the risks of surgery, radiation therapy, or steroid use, the patient only received DDAVP replacement therapy. The pituitary image improved after a year, though, the deficiency of ADH seemed to be permanent.

Conclusions. Diabetes insipidus is a rare disease. The manifestations might be vague, and it was sometimes neglected at the first place. Therefore, we should keep this diagnosis in mind when the patients complain of polyuria and polydipsia.