Introduction

This month I tapped into some of our upcoming virtual Metabolic & Endocrine Disease Summit 2023 (MEDS) faculty to find out about their most recent interesting cases. In this field, some cases more than others can really be a challenge to address for various reasons—here are three that these faculty share for your benefit.
In last month’s issue, thought leaders weighed in on the most challenging thing(s) to treat, the team approach to multifaceted care, and the challenge to keep current on new advances, research and literature—and what they do to stay up to date across multiple clinical spectrums.

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Save the Date! You can register for these online separately or save by purchasing as a bundle:

MEDS Summer 2023 Virtual—Join us online July 13-15, 2023 …

• The latest advances in metabolic and endocrine diseases, from diabetes and thyroid and adrenal disorders to obesity…
• MEDS will get you current via panel discussions, Q&A, and case studies!
• All online—attend from your home or office! 
• Click here to register!

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MEDS Fall 2023—Join us on in person October 12-14, 2023 in Orlando, Florida…

• The best resource for the most up-to-date, clinically relevant information on treatment of diabetes, obesity, Cushing’s Syndrome, PCOS, osteoporosis, hypercalcemia, and thyroid disease, it’s a one-stop shop to get you up to speed with CME!
• Take home the cutting-edge knowledge and clinical breakthroughs that can make a lasting difference in your patients’ lives. 
• Click here to register and get info! https://events.medscapelive.org/website/35587/home/

Thank you to these thought leaders featured in this issue for their continuing efforts to educate. Please contact me at colleen@cmhadvisors.com with comments or suggestions. Thanks for reading MEDS eNews!—Colleen Hutchinson

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Interesting Cases… MEDS 2023 Faculty 

Faculty and participant affiliations can be found by clicking here.

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What was one of your most interesting cases over the last year or so? 

Christine Kessler: My most intriguing recent case was a consultation for a nurse practitioner who reached out to me after hearing me speak at a national conference. She was seeking answers and treatment options to address sudden and dramatic change in her thyroid function.

The patient had been successfully treated with levothyroxine for symptomatic Hashimoto’s thyroiditis for at least 2 years prior to, and during, an uncomplicated pregnancy. Following the pregnancy, her thyroid labs and symptoms remained controlled and at target levels. The patient had refused to take the COVID vaccine during her pregnancy, choosing to delay it until after she finished breastfeeding her child. She eventually took the vaccination 6 months post-partum. Four weeks after being fully vaccinated, the patient suddenly developed severe hyperthyroid symptoms and was quickly taken off her TRH. However, symptoms persisted, with reflected hyperthyroid changes in her thyroid labs, which included elevated thyroglobulin AND TRabs. Currently, she is being successfully treated with anti-thyroid medication (methimazole) and low dose beta-blocker. Her thyroid function is being closely monitored.

Transient thyroiditis, presenting with mild to moderate hyperthyroid symptoms (without TRabs) has been observed within 5 to 8 weeks (or longer) following COVID infections AND/OR vaccinations. This thyroiditis will either abate or lead to hypothyroidism. Indeed, hyperthyroidism preceding hypothyroidism is far more common regardless of COVID or VAX. This case is very unusual in that hypothyroidism long preceded hyperthyroidism. It also demonstrated how vaccination-related proliferation of T-cell lymphocytes may exacerbate, or precipitate, autoimmune disease, in this case dual Hashimoto’s and Graves’ disease.

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Ashlyn Smith: An interesting case recently was a consultation for a 65-year-old male recently diagnosed with a pituitary adenoma and abnormal cortisol. The actual consult specified adrenal insufficiency, but I soon found it was much more complicated. He had a hx of T2DM, HTN, osteopenia, and COPD with intermittent PO steroid tx for exacerbations over the last 16 years.

Prior to the consultation with me, the patient had recently been dx with pituitary macroadenoma without with compressive features and was started on prednisone 20mg three tabs daily for 10 days by an outside provider to "stimulate the pituitary" reportedly. It is still unclear why this medication was given. Five days into this treatment, random cortisol was undetectable, and ACTH was 11. Based on this blood test, the patient was diagnosed with adrenal insufficiency, was prescribed hydrocortisone 20mg AM and 10mg PM, and was sent for repeat adrenal testing. Interestingly, the patient elected NOT to start hydrocortisone until he completed the additional testing about 40 days later, which showed AM ACTH midrange and cortisol high at 41.3. The patient then started hydrocortisone. 

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At the time of his initial consultation with me, BP was well controlled, and patient was complaining of weight gain predominantly in the abdomen and weakness in arms and legs. His physical exam supported these findings. Prior to hydrocortisone and prednisone, patient was asymptomatic for adrenal insufficiency or excess. 

I gave the patient the dx of abnormal cortisol (both suppressed and elevated) with pituitary macroadenoma. As the current hydrocortisone dose was supraphysiologic for his body surface area, We titrated down hydrocortisone over 2 weeks, then off hydrocortisone for 2 weeks, then assessed fasting ACTH and cortisol.

Follow-up evaluation off hydrocortisone showed continued normal BP, AM cortisol and ACTH both midrange, and patient was asymptomatic. His final dx was pituitary macroadenoma with normalized cortisol. This case highlights the importance of context when ordering and interpreting adrenal function testing. The initial previous secondary adrenal insufficiency was likely due to exogeneous hydrocortisone use, with subsequent possible physiological variation given comorbidities, subsequent normalization. The clinical picture supports normal adrenal function as well. Exogeneous steroid tx would have worsened this patient's glycemic control, bone density, and blood pressure. Out of an abundance of caution and due to the discrepancy in previous testing, the plan is for surveillance for 6 months then reassess.

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Scott Urquhart: One day ago, I had a new consultation with a 48-year-old female (Casie) who was referred by her PCP for an abnormal 2hr-OGTT 3 months ago (fasting 96 mg/dL and 2hr value 264 mg/dL). Her A1c was 5.2% at the time. She had gestational diabetes mellitus (GDM) 18 years ago requiring insulin treatment throughout her third trimester. She did not develop T2D or even Pre-DM over the years. In the past 2 years, Casie was able to successfully lose 25 pounds with dietary changes and light exercise.

See saw her PCP for routine annual P.E. and since she had a H/O GDM in the past, a fasting glucose and A1C were ordered. It is still unclear why a 2hr- OGTT was ordered with a normal A1c and fasting glucose < 100 mg/dL in an asymptomatic patient. As a result, her PCP ordered another 2hr-OGTT 27 days later (fasting -- 95 mg/dL and 2hr value 211 mg/dL). Her PCP put her on metformin ER 500mg one each AM and referred her to our endocrine practice for uncertainly of diagnosis and how to proceed. 

Casie has been checking fasting glucose values a few times a week with values in the 75- 94 mg/dL range. She feels great and wonders if she has T2D. We discussed Pre-DM and T2D diagnosis and treatments. Our discussion specific to exercise revealed that she is unable to exercise as she is in need of bilateral knee replacements. Since she is considered too young for the procedure she had received bilateral intra-articular steroid injections the morning of her first 2hr-OGTT. This led to deeper discussions about the accuracy and interpretation of the OGTT results and the contribution of increased glucose from the corticosteroids. Since the second 2hr-OGTT showed only an 11 mg/dL value >200 and the recent A1c was 5.2%, it was questioned if Casie has Impaired Glucose Tolerance vs. early T2D. 

Casie’s options were to continue vs. discontinue her metformin and then obtain and fasting glucose and A1c in 3months with her PCP. Since the steroid injections did not provide any pain benefit I suggested no more steroid injections and discuss hyaluronic acid knee injections with her orthopedist or reconsideration for knee replacements. She was happy and agreeable with our discussion and plan. She will need routine followup and adherence to her dietary plan, as well as tolerable physical activity.

This case demonstrates the importance of obtaining a detailed past medical history and any current treatments the patient may be receiving outside of your expertise of medical care. It also shows the importance that some medications can affect laboratory values potentially leading to an inaccurate final diagnosis.

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