Glucagon-like peptide-1 (GLP-1) receptor agonists improve glycemic control in patients with type 2 diabetes mellitus, have cardioprotective and renoprotective effects, and do not cause weight gain or signifi cant hypoglycemia. In fact, they have been found to be effective for weight loss in patients with obesity with and without diabetes. They are now the preferred drugs to add to the regimen when oral metformin by itself is not enough to meet the patient's hemoglobin A1c goal.
Background: Thyroid ultrasound is usually used to risk-stratify incidental thyroid nodules. Nodules with high risk sonographic features for malignancy are evaluated by fine-needle aspiration. The role of core needle biopsy for thyroid nodules is limited to cases where the fine needle aspiration is inconclusive. Case presentation: We describe a rare case of mesenchymal chondrosarcoma of the thyroid gland with uncertain primary origin. Thyroid ultrasound showed right sided large, solid, hypoechoic nodule with calcifications and peripheral vascularity and unremarkable isthmus and left thyroid lobe. Fine needle aspiration of the right nodule suggested lymphocytic thyroiditis. The sonographic findings contradicted the typical bilateral clinical and sonographic picture of lymphocytic thyroiditis. A core needle biopsy showed mesenchymal chondrosarcoma. Conclusion: This case highlights the importance of correlating pathologic diagnosis with sonographic findings, the appropriate utilization of fine needle aspiration and core needle biopsy to evaluate thyroid nodules and the rare incidence of mesenchymal chondrosarcoma involving the thyroid.
Background: PTHrP-secreting pancreatic neuroendocrine tumors (PNET) are a recognized cause of malignancy associated hypercalcemia. Herein, we report a case of severe hypercalcemia due to an extreme elevation of PTHrP from a PNET, where after treatment of the hypercalcemia, symptomatic hypocalcemia occurred. Clinical Case: A 59 year-old-woman with a recurrent PNET with liver metastases undergoing an evaluation for multi-visceral transplant presented with acute confusion, nausea and vomiting. Diagnostic testing identified an extreme elevation of total calcium (Ca) [>20.1 mg/dL (8.5 - 10.2)] from two different samples [serum albumin 4.1 g/dL (3.9 - 4.9)]. The total Ca level one month earlier was 8.3 mg/dL with a serum albumin of 3.1 g/dL. Total Ca measurements were performed with the Ca Gen.2 assay on a cobas c702 chemistry analyzer (Roche Diagnostics). Results greater than the analytical measurement range (0.8 – 20.1 mg/dL) were diluted with saline and confirmed (22.6 mg/dL). A Radiometer ABL 800 Flex blood gas analyzer was used to determine the ionized Ca concentration [2.94 mmol/L (1.08 - 1.30)]. Upon presentation the serum creatinine (Cr) was 2.07 mg/dL (0.58 - 0.96); eGFR utilizing the MDRD equation 24 mL/min/1.73m2; baseline serum Cr 0.78 mg/dL. Her serum 25-OH vitamin D was 31 ng/mL (31.0 - 80.0), PTH 12 pg/mL (15 - 65), phosphate 4.3 mg/dL (2.7 - 4.8) and 1, 25-OH vitamin D 39.1 (15.0 - 60.0). PTHrP measurements were performed by ARUP Laboratories via liquid chromatography tandem mass spectrometry (LC-MS/MS) and resulted in a reported value of >2500 pmol/L (0.0 - 3.4). Her symptoms resolved and the corrected Ca gradually decreased to 8 mg/dL after treatment with IV fluids, calcitonin 200 units sc every 12 hours for 48 hours, 60 mg IV pamidronate, and five sessions of hemodialysis. Within thirteen days of receiving pamidronate, her corrected Ca slowly increased to 12mg/dL; thus, she received a single dose of 120 mg sc denosumab. Nine days later, the patient developed symptomatic hypocalcemia (7.3 mg/dL) manifested by paresthesia in the hands and feet and perioral numbness. She then received multiple doses of oral and intravenous Ca along with 50,000 units of oral ergocalciferol twice weekly. The corrected Ca normalized (8.1 mg/dL) and symptoms resolved. The patient was discharged with plans for future treatment of her underlying malignancy. Conclusion: This is the first report of a PNET producing an extreme elevation of PTHrP of higher than 2500 pmol/L, resulting in a concordant extreme elevation of total calcium within a month of documented normocalcemia. Treatment of hypercalcemia with denosumab may result in the development of hypocalcemia requiring treatment.
Background A head and neck paraganglioma is a rare diagnosis with most cases found incidentally or diagnosed due to mass effect symptoms. Only 3.5% of them are found to secrete catecholamines leading to episodic symptoms. Herein, we present a rare case of a functioning neck paraganglioma with head movement induced hyperadrenergic paroxysms. Clinical Case A 79-year-old Caucasian man, with previous left neck mass found incidentally on imaging after a motor vehicle accident, presented to the ER with syncope. While the mass had been growing for 10 years, he sought medical attention when he could no longer turn his head to the left due to worsening symptoms. He reported recurrent brief syncopal attacks along with intermittent episodes characterized by profuse sweating, headaches, palpitations, and flushed skin. Upon evaluation, he was afebrile, tachycardic and had labile blood pressure readings (high of 340/150 mmHg and a low of 70/40 mmHg). He was oriented to time and place but appeared lethargic and underweight. A solid non-tender neck mass, with an audible bruit, was apparent at the Level II of the left neck. A CT scan of the neck showed a 7.7cm left glomus vagale tumor with partial encasement of the left internal and external carotid artery. He was admitted to the intensive care unit for close blood pressure monitoring via an intra-arterial line. Due to high suspicion for a catecholamine driven process, he was started on Doxazosin 1 mg every 12 hours which stabilized his blood pressure and improved his symptoms. CT scan of the abdomen and pelvis showed a 1.1 cm left adrenal nodule with an intensity of 4 Hounsfield units. A trial of Hyoscyamine was done to help with hypotension and symptoms of dizziness and bradycardia. Labs showed plasma catecholamines that were significantly elevated to ten times the upper limit of normal. An MIBG scan showed uptake in the left carotid mass. He was a poor surgical candidate because of the proximity of the mass to the neuro-vascular bundle and was treated with radiation during hospitalization. The patient was discharged home on Doxazosin with improvement in his blood pressure. Genetic testing was negative for a pathogenic variant but detected a variant of uncertain significance (VUS) in CDKN2A, c.373G>C (p.Asp125His). Unfortunately, three months later the patient was admitted with an intracranial hemorrhage secondary to a fall and was transitioned to hospice care. There was no change in the tumor size noticed during that admission. Conclusion To our knowledge, this is the first case to describe hypertension paroxysms triggered by movements of the neck in the setting of a functional neck paraganglioma. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
Background Acquired hypoparathyroidism is known to be transient when caused by surgical trauma but unlikely in idiopathic etiology. Herein we describe a unique presentation of idiopathic hypoparathyroidism that was diagnosed in early adolescence and remitted in adulthood. Clinical Case A male patient was diagnosed with idiopathic hypoparathyroidism at 13 years old after presenting with severe hypocalcemia resulting in generalized convulsive seizure. At diagnosis, his corrected calcium (cCa) was 6.7 (8.5-10.2 mg/dL) and PTH was 8.5 (15-65 pg/mL). Patient was noted to have oral candidiasis raising concerns for autoimmune regulator mutations associated with autoimmune polyendocrinopathy. Adrenal function was normal. Genetic testing was not done due to cost. Calcium citrate of 500 mg twice daily and calcitriol, gradually increased to 1.5 mcg daily, were initiated with normalization of calcium level. At age 24, he presented with altered mental status and was admitted with hypercalcemia and subarachnoid hemorrhage. He had cCa of 12.6 compared with previous calcium levels ∼ 7 (8.5-10.2 mg/dL), ionized calcium of 1.57 mmol/L, magnesium of 1.8 (1.7-2.3mg/dL), hypophosphatemia of 0.4 (2.7-4.8 mg/dL) and undetectable PTH. Further testing showed AKI with creatinine of 2.1, from baseline of 0.8 (0.7-1.22 mg/dL). Vitamin D 25 OH and 1,25 dihydroxy vitamin D, ACE level and PTHrP were all unremarkable. Workup for multiple myeloma was negative. Adrenal and thyroid function tests were normal. CT brain showed diffuse subarachnoid blood with CTA showing an elongated saccular aneurysm measuring 2.57×1.72×1.85 mm.Hypercalcemia and AKI resolved with hydration. Interestingly, corrected calcium remained in the low-normal range between 8.6 - 8.8 (8.5-10.2 mg/dL), throughout 10 days of hospitalization despite holding all calcium citrate and calcitriol supplements, which were also held on discharge. PTH level prior to discharge was 7 (15-65 pg/mL) with cCa of 9.1 and magnesium of 1.7. At one week follow up, a reduced dose of calcium citrate of 250 mg twice a day and calcitriol 0.5 mcg daily were resumed which resulted in recurrent hypercalcemia and AKI with normalization by holding treatment. Repeated testing after one month showed cCa of 8.6, creatinine of 1.3, PTH of 17, magnesium of 1.7, and 25 OH vitamin D of 27.2 (31-80 ng/mL). Calcium citrate of 250 mg daily along with weekly ergocalciferol of 50,000 units and Magnesium Oxide 400 mg TID were initiated. Testing 8 months after the hospitalization revealed cCa of 8.6, creatinine of 1.2, magnesium of 1.6, and a low-normal PTH of 18 which was the highest value ever recorded for this patient. Conclusion To our knowledge, this is the second reported case of spontaneous remission of idiopathic hypoparathyroidism in adulthood. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.
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