Incidental Solitary Adrenal Metastasis as the Initial Manifestation of a Solid Variant of Papillary Thyroid Carcinoma, With Emphasis on Pathologic Diagnosis and Clinical Management.

Objective: Distant metastases from papillary thyroid carcinoma (PTC) are relatively rare and may be associated with a poor prognosis. The adrenal gland is a highly unusual site of metastasis in the natural course of PTC. Herein, we describe a case of an incidentally detected metastatic solid variant of PTC in the adrenal gland of an asymptomatic patient as the initial presentation. Case Report: A 67-year-old male patient was evaluated for a 4.7-cm adrenal incidentaloma discovered during a workup for nephrolithiasis. Biochemical evaluation revealed a nonfunctioning adrenal mass. The patient underwent adrenalectomy, which revealed metastatic PTC. A subsequent thyroid ultrasound revealed an isthmic nodule. Fine needle aspiration of the nodule was cytologically suspicious for a follicular neoplasm, and gene expression analysis revealed an HRAS c.182A>G sequence variation. The patient subsequently underwent total thyroidectomy, which revealed a 1.2-cm solid variant of PTC in the thyroid isthmus. Postoperatively, the patient underwent radioactive iodine ablation. Discussion: Our case illustrates an exceedingly rare and challenging situation-a metastatic solid variant of PTC in the adrenal gland of a patient with no prior history of PTC. When confronted with a PTC in the adrenal gland in the absence of a previously identified primary tumor, our experience suggests that the next step in management should be total thyroidectomy followed by radioactive iodine ablation. Conclusion: A solid variant of PTC is a rare cause of an incidentally detected adrenal lesion. Multidisciplinary care team coordination is essential for accurate diagnosis and treatment plan formulation.

Expression of humoral autoimmunity is related to androgen receptor CAG repeat length in men with systemic lupus erythematosus.

We sought to explore whether inherited differences in androgen sensitivity conferred by variation in the length of a CAG repeat in exon 1 of the androgen receptor gene could be correlated with differing manifestations of humoral autoimmunity in men with lupus. In a sample of 15 men with lupus, AR CAG repeat length was linearly correlated with levels of antibodies against extractable nuclear antigens and with the number of diagnostic criteria for lupus. Protein microarrays were used to assess levels of 86 different IgG and IgM autoantibodies in the sera of these patients. IgG autoantibodies were more frequently observed in male lupus patients with longer AR CAG repeat length (>23), while IgM autoantibodies were more prevalent in subjects with shorter CAG repeat length (≤23). These data support a potential role for androgen signaling in the modulation of immunoglobulin class switching processes, with consequent impact on the autoimmune phenotype in men with lupus.

A Case of Hypophysitis Following Immunization With the mRNA-1273 SARS-CoV-2 Vaccine.

The emergence of a novel coronavirus and global pandemic raised the need for the rapid development of new vaccines to reduce the morbidity and mortality associated with Covid-19. Common side effects of these vaccines such as myalgia, arthralgia, nausea, fatigue, and injection site reaction are usually self-resolving. Recognition of other potential adverse effects of these novel vaccines is important due to their rapid and widespread distribution. We report a case of a 51-year-old man admitted to Parkland Memorial Hospital with headache, nausea, vomiting, malaise, and diffuse arthralgias 3 days after he received his second mRNA-1273 SARS-CoV-2 vaccination. He was found to have hyponatremia and a low serum cortisol level. Further workup revealed hypopituitarism with central hypothyroidism, hypogonadism, and a subnormal response to cosyntropin. Magnetic resonance imaging revealed a diffusely enlarged pituitary gland consistent with acute hypophysitis. The patient responded well to glucocorticoid and thyroid hormone supplementation and was discharged after 2 days in the hospital. This is the first reported case of hypopituitarism potentially associated with Covid-19 immunization.

Improving Diabetic Retinopathy Screening Among Patients With Diabetes Mellitus Using the Define, Measure, Analyze, Improve, and Control Process Improvement Methodology.

ABSTRACT: Diabetic retinopathy, a complication of diabetes mellitus (DM), is the leading cause of blindness in the United States. Early detection and appropriate timely treatment would result in 50-70% reduction in blindness due to DM, with a positive economic impact on patients and the healthcare system. The purpose of our project is to improve screening rates for retinopathy among patients with DM seen in a large endocrinology clinic applying the Lean Six Sigma Define, Measure, Analyze, Improve, and Control project framework and clinical decision support tools embedded in the electronic health record (EHR). Retinopathy screening rates improved from 49% to 72% by the end of the project. Interventions included identifying care gaps using a population registry, patient outreach through the electronic medical record patient portal, placing referrals to ophthalmology, improving documentation in health maintenance, and tracking improvement for sustainability. Our results demonstrate that process improvement methodologies and EHR tools can be successfully applied to improve care and clinical outcomes in patients with DM.

The changing face of Sheehan's syndrome.

Postpartum necrosis of the anterior pituitary gland is known as Sheehan's syndrome in honor of Harold Leeming Sheehan who characterized the syndrome as the consequence of ischemia after severe puerperal hemorrhage. With advancements of obstetrical care, Sheehan's syndrome has become uncommon except in developing countries. In many affected women, anterior pituitary dysfunction is not diagnosed for many years after the inciting delivery. This review emphasizes the long period of time that may elapse between the puerperal hemorrhage and the eventual diagnosis of hypopituitarism. The pathophysiology, epidemiology, clinical features and treatment of this disorder are discussed.