Adrenocortical carcinoma (ACC) is reported to be present in 3-10% of the population with most tumors presenting as benign tumors. Most cases of ACC are a sporadic accumulation of mutations over time. However, studies show a predisposition to various genetic mutations may contribute. Research over the last couple of decades has elucidated causes of ACC to be driven by several molecular changes that include inactivation of tumor suppressor genes and activation of a myriad of different oncogenes, DNA mutations, and epigenetic changes. The widely adopted staging of ACC is by European Network of Study of Adrenal Tumors (ENSAT) due to its correlations with clinical outcomes. At the time of presentation, a detailed history taking with attention to the history of symptoms of hormonal excess and family history of possible hereditary influence is the first step of evaluation. It is followed by a thorough physical examination for evaluation of ACC. Management of ACC poses a unique challenge as it involves oncologic and endocrine issues. Except for one trial, treatment guidelines are based on retrospective studies and non-randomized trials, and therefore the level of evidence is grade II to grade IV. Personalized therapy including identifying the actionable target in each patient is the future of ACC management. The knowledge base of ACC is evolving based on the basic science and clinical trials conducted by worldwide groups such as COMITE of France, ENSAT of Europe, TCGA project and American Australian Asian Adrenal Alliance (A5). Future studies should aim at clear molecular and clinical standardization. Recommended therapeutic strategies should be prospectively recorded.

Objective We aimed to review of literature on the clinical presentation, management and outcomes of pituitary apoplexy following gonadotrophic release hormone (GnRH) agonist administration for the treatment of prostate cancer. Methods We used PRISMA guidelines for our systematic review and included all English language original articles on pituitary apoplexy following GnRH agonist administration among prostate cancer patients from Jan 1, 1995 to Dec 31, 2020. Data on patient demographics, prostate cancer type, Gleason score at diagnosis, history of pituitary adenoma, clinical presentation, GnRH agonist, interval to pituitary apoplexy, laboratory evaluation at admission, radiologic findings, treatment of pituitary apoplexy, time to surgery if performed, pathology findings, and clinical/hormonal outcomes were collected and analyzed. Results Twenty-one patients with pituitary apoplexy met our inclusion criteria. The mean age of patients was 70 (60–83) years. Leuprolide was the most common used GnRH agonist, used in 61.9% of patients. Median duration to symptom onset was 5 h (few minutes to 6 months). Headache was reported by all patients followed by ophthalmoplegia (85.7%) and nausea/vomiting (71.4%). Three patients had blindness at presentation. Only 8 cases reported complete anterior pituitary hormone evaluation on presentation and the most common endocrine abnormality was FSH elevation. Tumor size was described only in 15 cases and the mean tumor size was 26.26 mm (18–48 mm). Suprasellar extension was the most common imaging finding seen in 7 patients. 71.4% of patients underwent pituitary surgery, while 23.8% were managed conservatively. Interval between symptoms onset to pituitary surgery was 7 days (1–90 days). Gonadotroph adenoma was most common histopathologic finding. Clinical resolution was comparable, while endocrine outcomes were variable among patients with conservative vs surgical management. Conclusion Although the use of GnRH agonists is relatively safe, it can rarely lead to pituitary apoplexy especially in patients with pre-existing pituitary adenoma. Physicians should be aware of this complication as it can be life threatening. A multidisciplinary team approach is recommended in treating individuals with pituitary apoplexy.

Herpes simplex virus (HSV) encephalitis is the most common cause of nonendemic sporadic encephalitis in the USA. Decreased mortality with early treatment with acyclovir has been documented. Although common complications include cortical petechial hemorrhages, frank intracerebral hematomas are considered very rare. Only few cases have been reported in the literature. We report a case of HSV encephalitis complicated by intracerebral hemorrhage 12 days after initiation of acyclovir therapy.

Introduction Granuloma annulare (GA) is a benign self-limiting dermatosis, typically characterized by an annular arrangement of erythematous or flesh-colored papules, affecting patients of all ages. An association between GA and autoimmune diseases (including autoimmune thyroiditis) has been reported in the literature thus suggesting that GA belongs to the spectrum of autoimmune diseases. However, only a few case reports described the unusual association of localized GA with hyperthyroidism. The definitive correlation between thyroid disease and GA hasn't been established. It was suggested that there is a common immunogenic predisposition or that both diseases share a common pathway. We present a rare case of generalized granuloma annulare in a patient with Graves’ disease. Case report A 52-year-old African American female with a past medical history of Graves’ disease with mild Graves’ ophthalmopathy was referred to the endocrinology clinic. She was diagnosed with Graves’ disease seven years ago and was medically managed ever since. Initially, she was treated with a high dose of methimazole however, for the past six years, she was on a stable dose of methimazole 5 mg daily. Two years following diagnosis of Graves’ disease, she developed serpiginous non-pruritic erythematous skin papules and patches in the right upper arm which slowly progressed over the course of years to involve bilateral inner thighs and under the breasts. She was evaluated by dermatology at that time and was empirically treated with a topical antifungal agent without any significant improvements. After establishing care with us, there was suspicion of methimazole-induced ANCA vasculitis or other autoimmune diseases. Extensive rheumatological workup including ANCA level was performed with negative results. Since her thyroid function tests (TSH and free T4) were normal on a low dose of methimazole for an extended period, we discontinued methimazole, however, skin rash didn't improve. The patient was then evaluated by dermatology and was diagnosed with GA based on clinical judgment. She was subsequently treated with an extended course of triple antibiotics therapy using rifampin, ofloxacin, and minocycline for 5 months with significant improvement of the skin rash. Currently, the patient has been off methimazole for 12 months and off triple antibiotic for 4 months with no recurrence of symptoms. Conclusion Although rare, generalized granuloma annulare can be seen in patients with autoimmune thyroid disease including Graves’ disease. Hence, endocrinologists should be aware of the different skin manifestations which can be seen in patients with autoimmune thyroid disease. Further studies are necessary to clarify the association of GA with autoimmune thyroid disease. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Fournier's gangrene is an extremely rare infection that can occur in immunocompromised patients, especially those with diabetes. Given the severity of this infection and the new associated link to sodium-glucose cotransporter-2 inhibitors, the US FDA recently issued a warning in August 2018. Few cases of Fournier's gangrene have been reported in the literature in diabetic patients taking these oral medications. We report a case of Fournier's gangrene presenting 10 days after a patient with type 2 diabetes started empagliflozin therapy.

Abstract Management of gender-affirming hormone therapy (HT) in transgender women includes surveillance of testosterone (T) levels. Failure of T to suppress, despite adherence to therapy, warrants additional investigations for unexpected sources of T or factors stimulating T secretion. Possible causes include T or gonadotropin production by an occult neoplasm. Testicular cancer is the most common malignancy affecting biological men aged between 15 and 35 years. Patients may be asymptomatic until tumor burden is high and/or metastatic. Hormone-producing tumors have rarely been reported in treated transgender women. Routine screening tests are recommended in a gender-incongruent person as per the 2017 Endocrine Society guidelines with measurement of T levels every 3 months initially to reach a goal of less than 50 ng/dL. Expectations should be discussed in detail with the transgender person since anticipated physical changes may not be notable for 6 to 18 months. We herein describe a case of a transgender woman who underwent standard HT including gonadotropin suppression with a gonadotropin-releasing hormone agonist, whose total T level failed to suppress. Testing revealed an elevated serum level of the beta subunit of human chorionic gonadotropin (β-hCG), diagnostic of an hCG-secreting testicular seminoma, as the underlying cause of unexpected T production. This case illustrates how easily a testicular cancer can remain unnoticed because it can be asymptomatic and the necessity to be alert to, and act on, anomalous laboratory results during treatment of a transgender person.

Angiotensin-converting enzyme (ACE) inhibitors are among the most common medications used to treat patients with concomitant diabetes and hypertension. They are considered the first line of treatment for hypertension in this population. Several case studies have reported that ACE inhibitors can induce hypoglycemia in patients with diabetes. To our knowledge, however, ACE inhibitors have not been found to induce hypoglycemia in patients without diabetes. This report describes a patient without diabetes experiencing recurrent severe hypoglycemia induced by the ACE inhibitor lisinopril.

Tyrosine kinase inhibitors (TKIs) have been used in the treatment of multiple types of cancer. Pazopanib is one of the TKIs and is considered a first-line treatment for adult patients with metastatic renal cell carcinoma. Many endocrine-related adverse effects have been noted with the use of TKIs including hypothyroidism, vitamin D deficiency, altered bone density, secondary hyperparathyroidism, abnormal glucose metabolism, gynecomastia, and hypogonadism. Subclinical glucocorticoid deficiency and adrenal insufficiency have been reported with the use of TKIs in only a few cases so far; thus, its true prevalence and clinical significance have yet to be fully elucidated. The mechanism is still not fully understood; however, adrenal toxicity with hemorrhage and/or necrosis of the adrenal glands has been observed in studies. In this article, we describe the first reported case of pazopanib inducing primary adrenal insufficiency in a patient with metastatic renal cell carcinoma diagnosed after the exclusion of all other causes of primary adrenal insufficiency.