2017 Bridging the World of Endocrinology 19-22 October 2017 Regnum Carya Hotel, Antalya - Turkey

SELECTED CASES www.endobridge.org 2017 SCIENTIFIC PROGRAM

Friday, 20 October 2017

08.40 - 09.00 Welcome and Introduction to EndoBridge 2017

MAIN HALL Chairs: Ahmet Sadi Gündoğdu, Sevim Güllü 09.00 - 09.30 The pituitary hepatic pancreatic axis - AJ van der Lely 09.30 - 10.00 Aggressive pituitary tumors - Gerald Raverot 10.00 - 10.30 Medical management in Cushing’s disease - Lynnette Nieman 10.30 - 11.00 Hyponatremia - When and how should be treated? - Chris J. Thompson

11.00-11.20 COFFEE BREAK

11.20 - 12.50 Interactive Case Discussion Sessions HALL A Pituitary - AJ van der Lely, Gerald Raverot HALL B Bone / Calcium - Carola Zillikens, Dilek Gogas Yavuz HALL C Neuroendocrine Tumors - Camilla Schalin-Jäntti, Corin Badiu HALL D Male Reproductive Endocrinology - Dimitrios Goulis, Güzin Fidan Yaylalı

12.50-14.00 LUNCH

14.00 - 15.30 Interactive Case Discussion Sessions HALL A Pituitary - Lynnette Nieman, Chris J. Thompson HALL B Bone / Calcium - Misa Pfeifer, Aliya Khan HALL C Neuroendocrine Tumors - Andreas Kjaer, Camilla Schalin-Jäntti HALL D Female Reproductive Endocrinology - George Mastorakos, Djuro Macut

15.30-15.50 COFFEE BREAK

MAIN HALL Chairs: Füsun Saygılı, Kürşad Ünlühızarcı 15.50 - 16.20 Evaluation and management of pheochromocytoma - Felix Beuschlein 16.20 - 16.50 The role of nuclear medicine in management of neuroendocrine tumors - Andreas Kjaer 16.50 - 17.20 Secondary amenorrhea: From hypothalamus to ovary - George Mastorakos 17.20 - 17.50 Increasing complexity and challenges in male hypogonadism - Dimitrios Goulis

2 19 - 22 October, 2017 Antalya - Turkey 2017 SCIENTIFIC PROGRAM

Saturday, 21 October 2017

MAIN HALL Chairs: İlhan Yetkin, Ayşe Kubat Üzüm 09.00 - 09.30 Diabetes Technology-Continuous subcutaneous insulin infusion therapy and continuous glucose monitoring in adults- Anthony L. McCall 09.30 - 10.00 Cardiovascular outcomes of antidiabetic medications - Leszek Czupryniak 10.00 - 10.30 Management of hyperglycemia in the hospitalized patient - Priyathama Vellanki 10.30 - 11.00 New insulin and GLP-1 combinations in diabetes - Sten Madsbad

11.00-11.20 COFFEE BREAK

11.20 - 12.50 Interactive Case Discussion Sessions HALL A Diabetes - Anthony L. McCall, Priyathama Vellanki HALL B Adrenal - Guillaume Assie, Melek Eda Ertörer HALL C Thyroid - Marco Medici, İnan Anaforoğlu HALL D Obesity / Lipids - Karl Neff, Halil Önder Ersöz

12.50-14.00 LUNCH

14.00 - 15.30 Interactive Case Discussion Sessions HALL A Diabetes - Leszek Czupryniak, Stavroula A. Paschou HALL B Adrenal - Felix Beuschlein, Guillaume Assie HALL C Thyroid - Tomasz Bednarczuk, Murat Faik Erdoğan HALL D Obesity / Lipids - Francois Mach, Neslihan Başçıl Tütüncü

15.30-15.50 COFFEE BREAK

MAIN HALL Chairs: Oğuzhan Deyneli, Alev Altınova 15.50 - 16.20 Management of new fractures during antiresorptive treatment - Carola Zillikens 16.20 - 16.50 Difficult cases in primary hyperparathyroidism - Aliya Khan 16.50 - 17.20 Monogenic bone diseases as models for osteoporosis treatment - Jens Bollerslev 17.20 - 17.50 What is new in osteoporosis treatment? - Misa Pfeifer

3 19 - 22 October, 2017 Antalya - Turkey 2017 SCIENTIFIC PROGRAM

Sunday, 22 October 2017

MAIN HALL Chairs: M. Sait Gönen, Oya Topaloğlu 09.00 - 09.30 Update of thyroid disorders in pregnancy - Marco Medici 09.30 - 10.00 What is new in the diagnosis and management of Graves’ hyperthyroidism?- Tomasz Bednarczuk 10.00 - 10.30 New terminology in thyroid cancer - Isabel Amendoeira 10.30 -11.00 Response and toxicity of tyrosine kinase inhibitors - Katerina Saltiki

11.00-11.20 COFFEE BREAK

MAIN HALL Chairs: Fahri Bayram, Seda Sancak 11.20 - 11.50 Microbiota and metabolic disorders - Okan Bülent Yıldız 11.50 - 12.20 Reversal of Type 2 diabetes through lifestyle, pharmacotherapy and bariatric surgery - Barbara McGowan 12.20 - 12.50 Endocrine and metabolic complications in post-bariatric surgery patients - Karl Neff 12.50 - 13.20 Update on cholesterol management: PCSK9 Inhibitors - Francois Mach 13.20 - 13.30 Closing comments and adjourn

4 19 - 22 October, 2017 Antalya - Turkey 2017 SELECTED CASES

DATE TIME HALL SESSION TITLE

O - 01 / Detection of {AIP} Mutation (R304Q) in a Young Invasive and Drug Intolerant Macroprolactinoma Lacking MEN1 Components up to 18 Years

O - 02 / MGMT Immunoexpression May Predict Response 20.10 11.20-12.50 A Pituitary to Temozolomide In Invasive Prolactinomas

O - 03 / Granulomatosis with Polyangiitis as an Uncommon Cause of Panhypopituitarism: A Case Report

O - 04 / A Case of Granulomatous Hypophysitis

O - 06 / Maxillary Brown Tumor in a Patient with Secondary Hyperparathyroidism

O - 07 / Teriparatide Treatment Due to Persistent Hypoparathyroidism in a Beta-Thalassemia Major Patient 20.10 11.20-12.50 B Bone/Calcium O - 08 / A Parathyroid Carcinoma with Rapidly Progressive Proximal Muscle Weakness

O - 09 / Systemic Mastocytosis as a Cause Of Osteoporosis in a Man

O - 10 / Long-acting Somatostatin Analogue Octreotide in the Treatment of Hereditary Paraganglioma Located in Neuroendocrine the Posterior Mediastinum 20.10 11.20-12.50 C tumors O - 12 / Successful Treatment of Tumor Induced Hypoglycemia

O - 13 / Androgen Insensitivity Syndrome – Not Always a Sentence Male reproductive 20.10 11.20-12.50 D endocrinology O - 15 / Testicular Adrenal Rest Tumor (TART) in Congenital Adrenal Hyperplasia

O - 16 / ACTH Secreting Pituitary Carcinoma with Liver Metastasis: A Case Report

O - 17 / Acromegaly with Negative Immunostaining for Growth Hormone on the Contrary to Silent Somatotroph Tumor

O - 18 / Pseudo-Cushing’s Syndrome Due to Night Shift 20.10 14.00-15.30 A Pituitary Work

O - 19 / Glucocorticoid Excess Severely Affects Bone Tissue, Leading to Fragility Fractures by Several Mechanisms, Which Can Present the Disease Many Years Before Other Physical Charateristics

O - 20 / Differential Diagnosis of Diabetes Insipidus in a Patient With Hypercalcemia

5 19 - 22 October, 2017 Antalya - Turkey 2017

DATE TIME HALL SESSION TITLE

O - 21 / Parathyroid Carcinoma with Brown Tumors

O - 22 / Teriparatide Induced Severe Hypercalcemia in an 20.10 14.00-15.30 B Bone/Calcium Osteoporosis Patient

O - 23 / Tenofovir-Related Fanconi Syndrome and Chronic Renal Failure in Diabetic Patient

O - 24 / Malignant Paraganglioma Syndrome Type 1 - A Complex Clinical Case Neuroendocrine 20.10 14.00-15.30 C tumors O - 25 / A Rare Cause of Hypoglycemia: Insulin Autoimmune Syndrome (Hirata Disease)

O - 27 / An Overlooked Cause of Secondary Diabetes; Hereditary Hemochromatosis

21.10 11.20-12.50 A Diabetes O - 28 / Euglycemic Diabetic Ketoacidosis After Sleeve Gastrectomy Following Dapagliflozin Therapy

O - 29 / Severe Insulin Resistance in a Male Patient

O - 30 / How Can Diabetic Ketoacidosis Save Your Life? An Unusual First Presentation of An Adrenal Tumour

O - 31 / 17 α-Hydroxylase, 17-20 Lyase Deficiency, A Rare 21.10 11.20-12.50 B Adrenal Case with Infertility

O - 32 / Abdominal Pain and Testicular Masses in a Male Patient with Untimely Recognized Congenital Adrenal Hyperplasia

O - 33 / Macro-TSH Existence in a Patient Treated with Tyrosine Kinase Inhibitor

O - 34 / False Positive Post RAI Scan in a Subject with Papillary Thyroid Cancer Secondary to Urine Contamination 21.10 11.20-12.50 C Thyroid O - 35 / Myoedema and Increased Serum Creatinine in a Child Caused by Hypothyroidism

O - 36 / A Rare Cause of Excess Leucocytosis: Anaplastic Thyroid Carcinoma

O - 37 / The Tough Journey to the Cause of Weakness 21.10 11.20-12.50 D Lipids/Obesity O - 38 / Continuation of Evolution: Headliner Glargine U300

O - 39 / A Rare Cause of a Newly Diagnosed Diabetic Case with Diabetic Ketoacidosis: Pancreatic Fistula 21.10 14.00-15.30 A Diabetes O - 41 / Mauriac’s Syndrome Caused by Munchausen Syndrome-Associated Insulin Abuse in Type 1 Diabetes Mellitus

6 19 - 22 October, 2017 Antalya - Turkey 2017

DATE TIME HALL SESSION TITLE

O - 42 / Oncocytic Neoplasm: A Rare Type of Adrenocortical Tumor

O - 43 / Differential Diagnosis of Cushing’s Syndrome: Is 21.10 14.00-15.30 B Adrenal basal serum ACTH enough?

O - 44 / Systemic Burkitt’s Lymphoma Mimicking Adrenal Carcinoma

O - 46 / Two Subacute Thyroiditis Patients Presenting as Fever of Unknown Origin (FUO) and Diagnosed After F-18 Fluorodeoxyglucose (FDG) Positron Emission Tomography 21.10 14.00-15.30 C Thyroid (PET) Findings

O - 47 / Papillary Thyroid Carcinoma Lymph Node and Lung Metastases Without Primary Tumor

O - 48 / A Case Report: Dumping Syndrome After Sleeve Gastrectomy 21.10 14.00-15.30 D Lipids/Obesity O - 49 / A success Story in Weight Loss: You Can Do It Without Bariatric Surgery or Medication!

7 19 - 22 October, 2017 Antalya - Turkey 2017

ORAL PRESENTATIONS

8 19 - 22 October, 2017 Antalya - Turkey 2017

O - 01 Pituitary DETECTION OF AIP MUTATION (R304Q) IN A YOUNG INVASIVE AND DRUG INTOLERANT MACROPROLACTINOMA LACKING MEN1 COMPONENTS UP TO 18 YEARS FEYZA NUR TUNCER1, SEMA ÇIFTÇI2, FATMA YELIZ EKICI1, SEMA YARMAN2 1 DEPARTMENT OF GENETICS, ISTANBUL UNIVERSITY AZIZ SANCAR INSTITUTE OF EXPERIMENTAL MEDICINE, ISTANBUL, TURKEY 2 DIVISION OF ENDOCRINOLOGY AND METABOLIC DISEASES, DEPARTMENT OF INTERNAL MEDICINE, ISTANBUL UNIVERSITY, ISTANBUL MEDICAL FACULTY, ISTANBUL, TURKEY

Introduction: Given their rarity, young-onset pituitary adenomas Patient’s genomic DNA were isolated from peripheral blood and are more likely to be associated with a variety of genetic syndromes, AIP genetic screen was performed on all exons, exon-intron bound- the commonest being multiple endocrine neoplasia type 1 (MEN1). aries and UTR regions of the gene. Sequence analyses revealed a More recently, germline inactivating mutations in aryl hydrocar- germline heterozygous c.911G>A (p.R304Q; rs104894190) clinical bon receptor-interacting protein (AIP) gene have been found in a variant in AIP (Figure 1). significant percentage of young patients presenting with pituitary Result: This mutation in AIP gene may also be involved in predis- macroadenoma without any apparent family history. The aim of this position to dopamine agonist intolerance in young patients, as a study is to investigate AIP mutation(s) in a young woman with in- cause in pathogenesis of aggressive macroprolactinoma. If this vasive macroprolactinoma and dopamine agonists (Bromocriptine result is supported by other cases, patients with drug intolerance (BRC), Cabergoline (CAB)) intolerance, who is negative for MEN1 may be able to help determine the permanent treatment regimen components. in a shorter time. Case: On admission, a 21-year-old woman presented secondary This work was supported by Scientific Research Project Coordina- amenorrhea and bitemporal hemianopsia. The patient first noticed tion Unit of Istanbul University Project Number: 54222. amenorrhea and galactorrhea beginning at the age of 15. For the first time, her mother took the patient to the gynecologist, when Keywords: young patient, macroprolactinoma, MEN1, AIP, R304Q, she was 16 years old. According to the interviews with the patient, rs104894190 the PRL value was found to be high and BRC treatment was initi- ated, but due to nausea, dizziness and hypotension, the drug was used at low dose and irregularly. When she applied to our pituitary outpatient clinic after 6 years, she still didn’t have menstruation. Her family history was negative for pituitary, parathyroid, pancreat- Figure 1 ic, and gastrointestinal tumor and for recurrent kidney stones and hypercalcemia. Laboratory evaluation showed a highly elevated se- rum PRL level (>389 ng/dl) with both central hypothyroidism and hypogonadism, however basal cortisol was found in normal range. Pituitary MRI showed an invasive macroadenoma, with compres- sion of the optic chiasm and extended to bilateral cavernous sinus. A visual field examination showed bitemporal hemianopsia con- sistent with chiasmal optic nerve compression. Low dose (0.5mg weekly) of CAB could not be tolerated and symptomatic hypoten- sion occurred. Surgical debulking was performed, which resulted Chromatogram of the clinical variant c.911G>A (p.R304Q; in complete decompression of the optic chiasm and hypothyroid- rs104894190) detected in patient’s AIP gene sequence analysis is ism. PRL level was reduced, but remained elevated at 4 weeks after shown. surgery (70ng/dl). BRC could be increased up to 10 mg/day without side effects. Two years later, empty sella, permanent hypothyroid- ism and hypogonadism developed.

9 19 - 22 October, 2017 Antalya - Turkey 2017

O-02 Pituitary MGMT IMMUNOEXPRESSION MAY PREDICT RESPONSE TO TEMOZOLOMIDE IN INVASIVE PROLACTINOMAS SAYID ZUHUR1, GÜLŞAH ELBÜKEN1, EMRAH BARIŞAN2, TARKAN YETIŞYIĞIT3 1 DEPARTMENT OF ENDOCRINOLOGY AND METABOLISM, NAMIK KEMAL UNIVERSITY FACULTY OF MEDICINE, TEKIRDAG, TURKEY 2 DEPARTMENT OF INTERNAL MEDICINE, NAMIK KEMAL UNIVERSITY FACULTY OF MEDICINE, TEKIRDAG, TURKEY 3 DEPARTMENT OF MEDICAL ONCNCOLOGY, NAMIK KEMAL UNIVERSITY FACULTY OF MEDICINE, TEKIRDAG, TURKEY

Background: Prolactinomas are common tumors of the anterior pi- initiation of temozolomide showed a significant decrease in tumor size tuitary gland. While dopamine agonists are usually effective in con- (17x15 mm). Serum prolactin continued to decrease, after which time trolling tumor growth, some patients develop treatment-resistant tu- it stabilized at <150 ng/ml. mors. Temozolomide, an alkylating agent, has been successfully used Conclusion: Temozolomide is an effective and well-tolerated drug in the management of invasive and conventional treatment resistant for the treatment of patients with invasive prolactinomas unre- pituitary adenomas. The response to TMZ is suggested to be inversely sponsive to conventional therapy. Our case suggests MGMT im- correlated with tumoral expression of O-6 meghylguanine DNA meth- munoexpression status can predict response to temozolomide in yl transferase (MGMT). In this report, we present a case of an invasive invasive pituitary adenomas. prolactinoma with negative MGMT immunoexpression, that respond- ed dramatically to the administration of temozolomide. Keywords: Invasive prolactinoma, MGMT, Temozolomide

Case Presentation: A 34 year old male patient was admitted to our Figure 1 A outpatient clinic in 2013 for erectile dysfunction and headache. Lab- oratory findings revealed hypopituitarism and a hyperprolactinemia (> 470 ng/mL). A 48 x 36 mm pituitary mass, compressing the optic chiasm, was found on MRI (Figure 1). A complet right side visual loss was found on visual field examination. The patient underwent trans- sphenoidal surgery. Due to incomplete resection and high prolactin level, treatment with cabergoline 1 mg twice per week was started. After an initial reduction in both the serum prolactin and the size of the tumor, the prolactin level again began to increase, and the MRI revealed growth of the tumor into the bilateral cavernous sinuses. The dose of cabergoline was increased gradually to 8 mg per week T1-weighted pituitary MRI showing a 48 x 36 mm pituitary mass at but there was no resulting decrease in prolactin concentration and presentation. tumor size. In early 2015, the patient lost to follow-up. In late 2015 Figure 1 B he returned to outpatient clinic because of gradual loss of vision and severe headache. Imaging revealed growth of the tumor beyond the left cavernous sinus and invasion of the left temporal lobe and com- pression of the optic chiasm (Figure 1). The patient underwent tran- scranial surgery. Immunohistochemichemical analysis of the tumor was positive for prolactin, negative for MGMT, and Ki-67 LI was 20% (Figure 2). A CT scan of the head, chest, abdomen, and pelvis revealed no evidence of cranial or extra cranial metastasis. Due to continued tumor growth and hyperprolactinemia,the patient received 40 Gy in 40 fractions delivered to the mid-plane of the sella turcica and the pa- tient started temozolomide 300 mg (150 mg/m2) by mouth daily for 5 days out of each 28-day cycle. Three months later, an MRI revealed a substantial decrease in the size of the tumor. He tolerated the medi- T1-weighted pituitary MRI showing a 57 x 65 mm pituitary mass cation well, without adverse events. Follow-up MRI one year after the before starting temozolomide. 10 19 - 22 October, 2017 Antalya - Turkey 2017

Figure 1 C Figure 2 B

T1-weighted pituitary MRI showing a 25 x 17 mm pituitary mass 3 months after treatment with temozolomide.

Immunohistochemistry shows High Ki-67 Li of 20% (x100).

Figure 2 C

Figure 1 D

T1-weighted pituitary MRI showing a 17x 15 mm pituitary mass one year after treatment with temozolomide.

Pituitary adenoma cells positively stained for prolactin (x 100). Figure 2 A Figure 3

Negative MGMT immunoexpression, white arrows show some pro- lactinoma cells positively stained for MGMT and black arrows show positive internal controls, (x100). Serum Prolactin levels after treatment with temozolomide.

11 19 - 22 October, 2017 Antalya - Turkey 2017

O-03 Pituitary GRANULOMATOSIS WITH POLYANGIITIS AS AN UNCOMMON CAUSE OF PANHYPOPITUITARISM: A CASE REPORT ÖZLEM ÇELIK1, MELIKE KALFA2, ALI RIZA CENK ÇELEBI3, SAVAŞ CEYLAN4 1DIVISION OF ENDOCRINOLOGY AND METABOLISM, DEPARTMENT OF INTERNAL MEDICINE, ACIBADEM UNIVERSITY SCHOOL OF MEDICINE, ISTANBUL, TURKEY 2DIVISION OF RHEUMATOLOGY, DEPARTMENT OF INTERNAL MEDICINE, ACIBADEM UNIVERSITY SCHOOL OF MEDICINE, ISTANBUL, TURKEY 3DEPARTMENT OF OPHTALMOLOGY, ACIBADEM UNIVERSITY SCHOOL OF MEDICINE, ISTANBUL, TURKEY 4DEPARTMENT OF NEUROSURGERY, KOCAELI UNIVERSITY SCHOOL OF MEDICINE, PITUITARY RESEARCH CENTRE, KOCAELI, TURKEY Introduction: Granulomatosis with polyangiitis (GPA), previously Conclusion: Pituitary dysfunction should be carefully considered known as Wegener’s granulomatosis is characterized by necrotiz- in patients with sellar mass and GPA. The available data about the ing small-vessel vasculitis, which mainly affects the upper respi- treatment and outcome of PD in patients with GPA is limited. It ratory tract, lungs and kidneys. Pituitary gland involvement in GPA appears to respond well to remission induction therapy for severe is rare. Since the first case was described in 1953 by Ahlstrom et GPA, like cyclophosphamide or rituximab-based regimen. al, only three case series and 34 cases have been published de- Keywords: Granulomatosis with polyangiitis, panhypopituitarism, scribing GPA-related pituitary dysfunction (PD) in English medical hypophysitis literatüre. Pituitary MRI Clinical Case: A 65-year old woman was referred to endocrinolo- gy outpatient clinic for evaluation of weakness, fatigue symptoms and thyroid dysfunction on her laboratory results. GPA had been diagnosed 10 years earlier due to recurren upper respiratory tract and lung infections. Panhypopituitarism with mild hyperprolactin- emia were found. Pituitary MRI revealed enlargement of the pitu- itary gland and thickened stalk with optic chiasma compression. Ophtalmological examination showed bitemporal hemianopsia. Trans-sphenoidal endoscopic surgery was performed for treat- ment outcome and the diagnosis of pituitary involvement. Histo- pathological examination showed granulomas with multinuclear giant cells and mixt inflammatory infiltration. Visual field defect improved after surgery. One mg/kg prednisolon and rituximab treatment was started.

Enlargement of the pituitary gland and thickened stalk with optic chiasma compression was shown.

12 19 - 22 October, 2017 Antalya - Turkey 2017

O-04 Pituitary A CASE OF GRANULOMATOUS HYPOPHYSITIS NILÜFER ÖZDEMIR KUTBAY1, MUSTAFA BERKER2, GÖZDE ELIF TAŞAR3, FIGEN SÖYLEMEZOĞLU3, HATICE ÖZIŞIK4, BANU SARER YÜREKLI4 1 UNIVERSITY OF HEALTH SCIENCES GAZI YASARGIL EDUCATION AND TRAINING HOSPITAL, ENDOCRINOLOGY DEPARTMENT, DIYARBAKIR, TURKEY 2 ACIBADEM HOSPITAL, ANKARA, TURKEY 3 HACETTEPE UNIVERSITY, FACULTY OF MEDICINE, PATHOLOGY DEPARTMENT, ANKARA, TURKEY 4 EGE UNIVERSITY, FACULTY OF MEDICINE, ENDOCRINOLOGY DEPARTMENT, IZMIR, TURKEY

Introduction: Hypophysitis is a rare disease of pituitary gland Keywords: granulomatous hypophysitis, pituitary tumor, surgical caused by either an infection or autoimmune related issues. Its in- treatment cidence is 1/9.000.000. Less than 1% requires surgical treatment. Hypophysis MRI The first diagnosis is usually secretory pituitary tumor. Etiology refers to primary or secondary cases of hypophysitis, which deter- mines the treatment protocol. In our report, rarely seen granulo- matous hypophysitis is studied.

Case: A 34-year-old male applied to the endocrine clinic with the complaints of headache, fatigue and loss of libido. The re- sults of his hormone tests were as follows: TSH:1.27µIU/ml, fT4:0.582ng/dl, fT3:1.88pg/ml, ACTH:14.8 pg/ml, cortisol:9.05 ug/ dl, LH:0,81mIU/ml, FSH:0.97mIU/ml, total testosterone: 0,091ng/ ml, prolactin:22.23ng/ml, GH:0.086ng/ml IGF-1:98 (115-307)ng/ml. His urine density was 1013. After the detection of hypopituitarism, a pituitary MR was requested. The MRI showed a macroadenoma located in adenohypophysis. The tumor, 15x9x10mm, pushed nor- mal parenchyma towards inferior making it tape-like, and infundib- ulum slightly towards superior (Figure 1).The patient first received steroid treatment followed by thyroid hormone replacement treat- ment and was referred to neurosurgery department. A total adeno- ma excision was performed by endoscopic endonasal TS technique. The pathology test result revealed lymphoplasmacytic cell infiltra- tion destructing adenohypophysis gland widely and non-necro- tizing granuloma containing Langhans-type multinucleated giant cells. GMS, PAS and ARB specific organisms weren’t observed. The pathological diagnosis was indicated as granulomatous hypoph- ysitis. The patient is on hydrocortisone 20mg/day and levothyrox- ine 75mcg/day and he receives testosterone replacement every 3 weeks.

Discussion: The prevalence of hypophysitis has increased today in line with the increase of immunosuppressive therapies. Hypoph- ysitis patients, just like our case, might be pre-diagnosed with hypophysis adenoma and be given misleading treatments. So, id- iopathic granulomatoushypophysitis should be considered for de- finitive diagnosis.

13 19 - 22 October, 2017 Antalya - Turkey 2017

O-05 Pituitary CYCLICAL CUSHING PRESENTED AS PCOS IN 37 YEARS OLD LADY BAYAR AHMED QASIM DEPARTMENT OF MEDICINE, COLLEGE OF MEDICINE, UNIVERSITY OF DUHOK, DUHOK, IRAQ

Background: PCOS is the most frequent endocrine disorder in sion test was normal too. These tests repeated after 4 weeks and women of reproductive age but its diagnosis remains one of the were normal again. After another 6 weeks, patient continues to most challenging issues in endocrinology, gynecology, and repro- complain of more weight gain and appearance of few striae, here ductive medicine. Cyclic Cushing’s syndrome (CS) is a rare disor- the tests repeated and both 24-hour urinary free cortisol and over- der, characterized by repeated episodes of cortisol excess followed night dexamethasone suppression tests were positive (repeated by periods of normal cortisol secretion. The cycles of hypercorti- twice) also midnight salivary cortisol level were increased. 48 hr solism can occur regularly or irregularly with phases of normal low dose dexamethasone suppression test (DST) showed failure cortisol secretion ranging from days to years. of cortisol suppression. High dose DST suppressed cortisol to 49 nmol/l confirming ACTH dependent Cushing Syndrome. Pituitary History: 37 years old lady presented with weight gain for 2 years MRI demonstrated a 12×10 mm adenoma. Transphenoidal pituitary duration. She has noticed that her weight and hirsutism fluctuated surgery was performed, however patient continue to have hyper- significantly in cycles despite strict dieting and regular exercises, cortisolism after surgery, then she underwent radiotherapy and for which she visited many clinics for almost 2 years. She finally she received also ketoconazole for controlling her cortisol level, diagnosed as a case PCOS. Upon more history taking her weight which continue to show fluctuations. increased by 20 kilograms mainly trunkal. There was no associated proximal myopathy. She was also complaining from amenorrhoea. Conclusion: Cyclical Cushing Syndrome is a rare entity and often There was no easy bruising, or striae. misdiagnosed. Cyclical manifestation of hypercortisolism symp- toms and signs are suggestive of the diagnosis and endocrine Diagnosis and Treatment: On presentation BMI was 50 kg/m2 testing during symptoms will help to reach the diagnosis. Mean- witht marked truncal obesity. Blood pressure was 160/80 mmHg while PCOS is much more than just oligomenorrhea, amenorrhea, and there were no other clinical stigmata of hypercortisolism. or infertility and may point to serious underlying cause such as The diagnosis of PCOS was revised and possibility of Cushing’s Cushing’s syndrome, especially it shares common symptoms with syndrome kept in mind especially in setting high blood pressure CS like hyperandrogenism and weight gain and is often over diag- and progressive weight-gain. 17-OHP and serum testosterone was nosed. A high index of suspicion is crucial for diagnosis. normal. 24-hour urinary free cortisol excretion was normal at 280 (normal<200 nmol/24 h) and overnight dexamethasone suppres- Keywords: Cushing’s Syndrome, Cyclical Cushing, PCOS

14 19 - 22 October, 2017 Antalya - Turkey 2017

O-06 Bone/Calcium MAXILLARY BROWN TUMOR IN A PATIENT WITH SECONDARY HYPERPARATHYROIDISM ÖMERCAN TOPALOĞLU, İBRAHIM ŞAHIN, BAHRI EVREN DEPARTMENT OF ENDOCRINOLOGY, INONU UNIVERSITY MEDICAL FACULTY, MALATYA, TURKEY

Introduction: Brown tumor is one of the benign osseous lesions, mg/dL, PTH 62.4 pg/mL, 25(OH)D₃ 71.17 ng/mL. The patient was and most commonly resulted by primary hyperparathyroidism. followed up with medical treatment, and no surgical explorations These tumors are generally located in the articular ends of the long or excisions were needed. bones, and mostly around the knee. We present an interesting case DISCUSSION: We showed that secondary hyperparathyroidism due with a maxillary brown tumor led by secondary hyperparathyroid- to vitamin D deficiency could lead to maxillary brown tumor. Al- ism, arising from severe deficiency of vitamin D. though rare, maxillary brown tumors should be suspected in pa- Case: 18 year-old female patient was referred to our clinics with tients with gingival symptoms, and secondary hyperparathyroidism a complaint of purplish discoloration and pain in her gingiva. She should be kept in mind as etiologic factor. had no history of chonic illnesses or did not use any drugs regu- Keywords: maxillary brown tumor, secondary hyperparathyroid- larly. On physical examination, vital signs were in normal limits, ism, vitamin D deficiency and examinations of cardiovascular, pulmonary and gastrointes- tinal systems were unremarkable. Tenderness was detected on the right part of the maxilla. External auditory canal and pharynx were normal. After dental and periodontal examination, incision- al biopsy was performed from the right upper part of the gingiva. Figure 1 The biopsy revealed that brown irregular tissue of 1.7x0.8 cm in size was diagnosed as giant cell granuloma. Complete blood count and biochemical tests were as followings: leukocyte 6960x10⁶/L, Hb 14.4 g/dL, platelet 379.000x10⁶/L, creatinine 0.65 mg/dL, ALT 11 U/L, Na 137 mmol/L, K 4.09 mmol/L, Ca 8.3 mg/dL, P 3.5 mg/ dL, ALP 118 U/L. To reveal if any hyperparathyroidism was pres- ent, we measured PTH and 25(OH)D₃ levels, and detected that PTH was 208.4 pg/mL (10-65), 25(OH)D₃ 0.90 ng/mL. We thought that maxillary brown tumor of the patient could be resulted from severe vitamin D deficiency. Plain radiographs detected no other brown tumor in long bones and cranium. Bone mineral densitometry re- vealed osteopenia in femur neck and lumbar vertebra. In the right part of the maxilla, lytic lesion of 1.5 cm in size, having irregular borders, was found in maxillofacial computed tomography (Figure 1). Magnetic resonance imaging showed us relatively well-defined lesion of approximately 19x15 mm in size in the right anterior part of the maxilla, which destructed the bony cortex and medulla and therefore leading to expansion. To correct this severe deficiency of vitamin D, 150.000 units of 25(OH)D₃ preparation was given as oral loading dose. Biochemical and hormonal tests 1 month after ther- apy were as followings: creatinine 0.71 mg/dL, Ca 9.7 mg/dL, P 5.6 Arrow points to brown tumor destructing the maxilla.

15 19 - 22 October, 2017 Antalya - Turkey 2017

O-07 Bone/Calcium TERIPARATIDE TREATMENT DUE TO PERSISTENT HYPOPARATHYROIDISM IN A BETA-THALASSEMIA MAJOR PATIENT NARIN NASIROĞLU İMGA, ÖZDEN ÖZDEMIR BAŞER, DILEK BERKER DEPARTMENT OF ENDOCRINOLOGY, ANKARA NUMUNE EDUCATION AND RESEARCH HOSPITAL, ANKARA, TURKEY

Introduction: Iron overload secondary to chronic blood transfusion dL (reference range 8.5-1.0.5), phosphorus: 10.1 mg/dL (reference is the main cause of endocrine complications of β-thalassemia range 2.5-4.5), PTH: 4.4 pg/mL (reference range 12-88), 25(OH)D: major (β-TM). Most of adult β-TM patients have endocrine prob- 30.6 ng/mL. Initially calcium acetate treatment was given. Two days lems such as hypogonadism, hypothyroidism, hypoparathyroidism, later due to persistently high serum phosphate, he was started on diabetes and reduced growth. Hypoparathyroidism due to low or phosphate binder aluminum hydroxide and after that sevelamer inappropriate secretion of parathormone (PTH) has been reported therapy. But one week later he continued to have hypocalcemia and to affect 3–20% of patients with β-TM and the mechanism is mul- hyperphosphatemia. Because of he did not respond to phosphate tifactorial. Hypoparathyroidism is diagnosed in the presence of low binders, teriparatide treatment was started. After that both clinical serum calcium, increased serum phosphate, and PTH levels, even- and laboratory improvement was observed. tually in most of patients. Normocalcemia is achieved with vitamin Conclusion: Hypoparathyroidism is not an uncommonly observed D analogues and calcium supplements, while hyperphosphatemia complication in thalassemic patients and seems to be accompanied usually treated with phosphate binders. Rarely, some patients are by other endocrinopathies. Parathyroid function should be tested resistant to classical treatments because these therapies do not periodically, because early management of hypoparathyroidism is replace the deficient hormone. We present a case of β-TM who had an important issue for the prevention of complications. Teriparati- persistent hypoparathyroidism and unresponsive to classic thera- de is an alternative treatment for adults with hypoparathyroidism py, following responded successfully to teriparatide treatment. especially when the classic therapies are neither feasible nor ef- Clinical Case: A 26 year-old male patient of β-TM who required fective. Although there are limited data on long-term usage, in se- treatment for his permanent hypoparathyroidism with severe hy- lected cases, teriparatide treatment might be considered. perphosphatemia and hypocalcemia was admitted to our clinic. Keywords: Hypoparathyroidism, β-thalassemia major, teriparatide Also he had partial hypopituitarism and growth retardation. Results of laboratory tests were as follows; corrected calcium: 6.16 mg/

16 19 - 22 October, 2017 Antalya - Turkey 2017

O-08 Bone/Calcium A PARATHYROID CARCINOMA WITH RAPIDLY PROGRESSIVE PROXIMAL MUSCLE WEAKNESS SILA ÇETİK, SEDA OĞUZ, ÖMER ALPER GÜRLEK DEPARTMENT OF INTERNAL MEDICINE, HACETTEPE UNIVERSITY, ANKARA, TURKEY

Introduction: Parathyroid carcinoma is a rare type of endocrine on calcitonin 3x200 IU. A spinal MRI examination was performed cancer and cause of hypercalcemia,with an estimated incidence to eliminate other causes of paraparesis.Parathyroid ultrasound of 2 cases per 10,000,000 people/year.Although this entity is rarely confirmed the presence of a 16x18x35mm hypoechoic,heteroge- seen,it is still important to acknowledge its existence due to the neous nodule located in posterior right lobe of thyroid gland.Me- significantly high morbidity and mortality rates as a consequence tastasis was not observed as shown by a thoraco-abdominal CT.The of this disease.For this reason, we would like to share our experi- patient was then referred to the Department of Surgery where a ence on a newly diagnosed parathyroid carcinoma case. right hemi-thyroidectomy and inferior parathyroidectomy was per- formed.Following surgery, the parathormone level was reduced to Clinical Case: A 36-year-old male was admitted to our neurology 6 pg/ml and control Tc-MIBI scintigraphy was performed which did department due to cramps and muscle weakness in both of his legs not show any residual parathyroid tissue.Histopathological exam- and left arm,which developed 8 months ago and worsened gradu- ination revealed parathyroid carcinoma with positive surgical mar- ally and urge type incontinence for the last 3 months.An EMG ex- gin.Afterwards, the patient was consulted to Department of Sur- amination revealed an acute/subacute motor neuron disease in left gery for a second surgery in order to reach the negative surgical upper and lower extremities.At the time of admission;his serum margin.Patient was discharged from hospital with normal calcium calcium level was 13,6 mg/dl,phosphorus 1,6 mg/dL,albumin 4,34 and phosphorus levels, waiting for his surgery date to come. g/dl,ALP 2376 U/L,other biochemical and CBC values were within normal range.His physical examination revealed that the patient Conclusion: Parathyroid carcinomas are one of the rarest tumors had 4/5 muscle strength in bilateral lower extremities and left arm. of endocrine system;extremely high parathyroid hormone levels, Serum parathormone level was found to be 2691,5 pg/ml,which was resistant hypercalcemia, significant bone loss and rapidly pro- thought to be extremely high for an adenoma.To eliminate the pos- gressive proximal myopathy are important clues for clinicians in sibility of vitamin D toxicity, 25-OH Vitamin D levels were examined, order to make the diagnosis. Surgical removal is the only curable which was 5,77 µg/L.The 24-hour calcium excretion was 827 mg/ option,however,many patients require life-long medical treatment day and calcitonin level was 4,02 pg/ml.Hydration and i.v diuretic with calcium sensing receptor agonists. treatment was started. However, because this treatment regime Keywords: Parathyroid carcinoma, hypercalcemia, parathyroidec- wasn’t enough to control hypercalcemia, the patient was also ad- tomy, muscle weakness ministered a single dose of 4 mg zoledronic acid, followed by salm-

17 19 - 22 October, 2017 Antalya - Turkey 2017

O-09 Bone/Calcium SYSTEMIC MASTOCYTOSIS AS A CAUSE OF OSTEOPOROSIS IN A MAN SÜLEYMAN NAHIT ŞENDUR1, RAHIME DURAN2, MIYASE BAYRAKTAR1 1 DEPARTMENT OF ENDOCRINOLOGY AND METABOLISM, HACETTEPE UNIVERSITY, ANKARA, TURKEY 2 DEPARTMENT OF INTERNAL MEDICINE, HACETTEPE UNIVERSITY, ANKARA, TURKEY

Osteoporosis in men is less common than in women and, in 50% day. Cortisol was suppressed after 1 mg overnight dexametha- of cases, is associated with an underlying secondary cause. There- sone suppresion test [0.85 μg/dL]. He had no symptoms to sug- fore, a detailed evaluation for secondary causes should be fulfilled. gest hypogonadism and gonadal axis was intact (FSH: 6.8 mIU/mL [n:1.2-19.2], LH: 5.6 mIU/mL [n: 1.8-8.6], prolactin: 7.1 ng/mL [n: A 47-year-old male patient was admitted to neurosurgery clinic 2.6-13.3] and testosteron: 304 ng/dL [n: 181-772]).Thyroid function due to severe back pain that occurred after carrying a heavy ob- tests were normal(TSH:2.04μIU/mL[n:0.38-5.33],fT4:10.76pmol/ ject. Lumbar CT elicited compression fractures at L3-4-5 vertebra. L[n:7.8-14.4]). Bone survey demonstrated a lytic lesion at the right The patient was observed without surgical intervention since there humerus. were no signs of nerve compression and was consulted to endocri- nology for advanced assessment. No monoclonal gammopathy was detected on protein electropho- resis and immunofixation. Peripheral blood smear showed mild Past medical history revealed PLEVA (Ptriyasis Licheniodes et Va- eosinophilia (9%) and serum tryptase level was high [28.9 μg/L n: rioliformis Acuta) and two previous lumbar fractures after forced 0-20]. Bone marrow aspiration and biopsy showed atypical mast exercise three and fifteen years ago respectively. He reported a cell aggregates suggestive of systemic mastocytosis. He was com- 30-pack-year history of smoking and he quit 6 years ago. There menced on denosumab therapy along with calcium and vitamin D was no history of alcohol consumption. The patient did not report supplementation. The patient was consulted with hematology and any medication use except tetracycline for a year for PLEVA. His his treatment schedule was planned as weekly IFN –alpha. BMD family history revealed that his mother had a history of osteoporo- improvement was noted on denosumab treatment. sis and his brother died of acute myelogenous leukaemia at his 36. On physical examination, he had multiple hyperpigmented macular Detailed investigations should be performed in young men with os- lesions on the chest, arms and back. teoporosis to rule out secondary causes of osteoporosis. System- ic mastocytosis, although rare, should be considered as a cause Bone mineral density(BMD) was measured and showed a lumbar in patients with idiopathic osteoporosis. A RANK ligand inhibitor spine Z score of -3.2. Further studies were performed to determine denosumab is a useful treatment option in systemic mastocytosis possible causes of secondary osteoporosis. Laboratory examina- related osteoporosis. tion showed normal serum corrected calcium: 9.5 mg/dL [n:8.8- 10.6], phosphorus: 3.4 mg/dL [n: 2.5-4.5], ALP:59U/L [n: 30-120] Keywords: Secondary osteoporosis, systemic mastocytosis, deno- and PTH: 19 pg/mL [n:12-88] levels. 25 OH vitamin D level was low sumab (6.7 µg/L, [n:25-80]) and 24 hours urinary Ca excretion was 235mg/

18 19 - 22 October, 2017 Antalya - Turkey 2017

O-10 Neuroendocrine Tumors LONG-ACTING SOMATOSTATIN ANALOGUE OCTREOTIDE IN THE TREATMENT OF HEREDITARY PARAGANGLIOMA LOCATED IN THE POSTERIOR MEDIASTINUM LIANA KHATSIMOVA1, ULIANA TSOY1, LIUBOV IANEVSKAIA2, ELENA GRINEVA1, ANNA DALMATOVA1, EKATERINA ORLOVA1, GLEB BERKOVICH1, ANNA KOSTAREVA1, DARIA RYZHKOVA1 1 ALMAZOV NATIONAL MEDICAL RESEARCH CENTRE, SAINT-PETERSBURG, RUSSIA 2 PAVLOV FIRST SAINT PETERSBURG STATE MEDICAL UNIVERSITY, SAINT-PETERSBURG, RUSSIA

Background: Pheochromocytoma and paraganglioma (PPGLs) are lesion showed an increased uptake.No signs of metastasis were rare chromaffin cell neuroendocrine tumors. 15%-20% of these tu- found. Paraganglioma of posterior mediastinum was diagnosed. mors arise from the ganglia of the sympathetic chain in thorax, ab- Genetic testing was carried out and SDHB mutation was confirmed. domen and pelvis. 30% of PPGLs are genetically determinated. Or- After the discussion by the multidisciplinary team the surgery was dinarily surgery is first-line treatment for PPGLs.However in some refused because of the high risk of fatal hemorrhage during the cases of PPGLs surgical intervention is not possible because of sig- operation. The therapy with the long-acting somatostatin analogue nificant intraoperative risk. There are some data that somatostatin octreotide 30 mg every 28 days was initiated.Control examination analogues can be successfully applied for the control of excessive was performed after 12 months.BP control improved,the frequency catecholamine secretion in PPGLs patients. Diagnostic evalua- of paroxysmal BP elevations reduced to 2-3 times in a month,max- tion:female patient 37 years old with the long history of resistant imal BP was 170/90 mmHg, the dose of alpha-adrenergic receptor arterial hypertension was admitted for diagnosis and treatment. blockers reduced from 8 to 4 mg in a day, 24-hour urinary excre- It was known from the anamnesis that in 2011 due to suspected tion of metanephrines were normal.But chromogranin-A level re- pheochromocytoma the right adrenalectomy was done, but accord- mained elevated:337 ng/ml(0-100).CT scan and scintigraphy were ing to pathology examination the diagnosis was not confirmed.After done, no signs of local progression or metastasis were found. the operation high hypertension was persisted.At the time of hospi- Continuation of octreotide therapy was prescribed. Also consider talization maximal blood pressure (BP) level was 220/120 mmHg in positive results of 123I-MIBG scan, high chromogranin-A level, and spite of the treatment with combination of alpha-and beta-adren- absence of PPGLs reduction, 131I-MIBG therapy was recommend- ergic receptor blockers, frequency of paroxysmal BP elevation was ed to this patient. 3-4\week.24-hour urinary excretion of metanephrines was elevat- Conclusion: Long-acting octreotide therapy may be effective for ed:346 mcg/24-hours(74-297). Also serum chromogranin-A level clinical and biochemical control in inoperable hereditary PPGLs. was 8.51 nmol/l(0-3).Thorax CT scan revealed a high vascularized But low anti-proliferative effect of this therapy requires the use of 4.8x4.3x4.3 cm solid mass without signs of malignancy in the pos- other radical methods of treatment. terior mediastinum, which was closely associated with pericardium and right pulmonary artery and expanded behind the left atrium Keywords: Pheochromocytoma, paraganglioma, Long-acting so- from the tracheal bifurcation, the lesion was heterogeneous due to matostatin analogue octreotide a single calcification. By the scintigraphy with 123I-MIBG data this

19 19 - 22 October, 2017 Antalya - Turkey 2017

O-12 Neuroendocrine Tumors SUCCESSFUL TREATMENT OF TUMOR INDUCED HYPOGLYCEMIA MEHMET MUHITTIN YALÇIN1, ETHEM TURGAY CERIT1, NILGÜN YILDIRIM2 1 GAZIANTEP DR.ERSIN ARSLAN TRAINING AND RESEARCH HOSPITAL DEPARTMENT OF ENDOCRINOLOGY AND METABOLISM 2 GAZIANTEP DR.ERSIN ARSLAN TRAINING AND RESEARCH HOSPITAL DEPARTMENT OF MEDICAL ONCOLOGY

Introduction: Treatment of underlying (primary) tumor is the main One month later, he was hospitalized for hypoglycemic coma. Af- therapy of tumor induced hypoglycemia. Until the effect of the on- ter dextrose infusion he recovered as well. He was suffering from cological therapy emerges, the first step is dietary modifications to hypoglycemic episodes despite eating meals every two hours. His overcome hypoglycemia. However, some of these patients don’t re- biopsy result was spindle cell carcinoma and oncology department spond well with dietary modifications and require additional ther- planned to give imatinib for his tumor. Thus, we started dexam- apies. etasone 0.5 mg two times a day in order to prevent hypoglycemia. There was no hypoglycemia after the glucocorticoid treatment was Clinical Case: 62 y/o male was admitted to our clinic with frequent started. hypoglycemic episodes started two months ago. He had admitted to emergency room for several times with loss of consciousness. Three months after treatment he is fine with dexamethasone with- He was recovered after dextrose infusion. out ER admissions, without hypoglycemic symptoms. He did not require to have meal at midnight. His blood glucose levels were He was not using any medication. Multiple intra-abdominal masses between 96-175 mg/ dL. He is taking İmatinib 400 mg/day. were found on CT scan performed for epigastric pain one week ago. A tru-cut bipsy was planned for these masses. Conclusion: Glucocorticoids can be a treatment option for dietary resistant tumor induced hypoglycemia patients. In laboratory analysis fasting Glucose was 61 mg/ dL, İnsulin level was 0.2 and C-peptide level was:, cortisol level was 12.3 ng/dL. Re- Keywords: hypoglycemia, tumor induced, dexamethasone nal and hepatic function tests were normal. He was diagnosed as tumor induced hypoglycemia and we recommend frequent meals and primary treatment of tumor.

20 19 - 22 October, 2017 Antalya - Turkey 2017

O-13 Male Reproductive Endocrinology ANDROGEN INSENSITIVITY SYNDROME – NOT ALWAYS A SENTENCE ELENA MORNEALO1, VICTOR MUNTEAN2, DIANA AL FARAJ3 1 DEPARTMENT OF INTERNAL MEDICINE, ENDOCRINOLOGY, MEDPARK INTERNATIONAL HOSPITAL, CHISINAU, MOLDOVA 2 DEPARTMENT OF SURGERY, UROLOGY, MEDPARK INTERNATIONAL HOSPITAL, CHISINAU, MOLDOVA 3 DEPARTMENT OF REPRODUCTIVE MEDICINE, MEDPARK INTERNATIONAL HOSPITAL, CHISINAU, MOLDOVA

Introduction: Androgen insensitivity syndrome (AIS) represents a both children to be healthy, even no carries of defective gene. spectrum of defects in androgen action, caused by a mutation of Conclusion: Treatment with high doses of androgens in some in- gene encoding androgen receptor AR, determining resistance of dividuals with PAIS can overcome the functional deficit of AR and the target tissues to androgens. As the result 46,XY individuals do improve patients’ condition, ameliorate prognosis and even restore not virilize normally despite the presence of bilateral testes and the fertility. This approach should be systematically assessed, to serum testosterone concentrations within or above the normal describe more extensively dosage, duration of treatment, benefits, male range. The severity of the disorder varies widely. Infertility as well as adverse effects and recommended follow-up. is invariable characteristic for all forms of AIS; it is presented as non-restorable in the majority of publications. We present a case Keywords: androgen insensitivity syndrome, fertility, hormone of the patient with Partial AIS, predominantly male phenotype, treatment but having genitalia with both male and female characteristics. Our patient has been treated with high doses of testosterone for 12 months, resulting in improved masculinization, successful tes- ticular sperm extraction, performing the ICSI and obtaining twin pregnancy in his wife. External genitalia appearance

Case Presentation: A 33-year-old male presented with complaints of infertility and reduced libido. His personal history is remarkable for hypospadias and gynecomastia. Family history is noticeable – brother and cousin have had hypospadias and gynecomastia. Phys- ical exam revealed high-pitched voice, sparse pubic and axillary hear and absent facial hair, micropenis, testes located in the scro- tum, but small in size, blind rudimentary vagina. Lab test results in December 2015: karyotype 46XY; azoospermia; double increased testosterone; double increased LH. The diagnosis of PAIS was sup- posed. Being inspired and guided by some published professional data we decided to try high doses of androgens, primarily in order to improve male secondary sex characteristics. In March 2016 the administration of testosterone undecanoate 1000mg/4 weeks (X3 usual doses) was initiated. After 12 months of treatment patient re- marked refined libido, development of facial hair, improved quality of life. Lab test revealed normalization of LH level, but persistent azoospermia. Excited by the results patient requested fertility treatment. In March 2017 mobile spermatozoa were obtained by TESA method and frozen to be used for IVF. In May 2017 successful ICSI procedure has been done, resulting in twin pregnancy in his wife. Now, in August 2017, she is in the second trimester of preg- nancy, both fetuses normally developing, both having male gender. Image have been taken during the TESA procedure. Micropenis, hy- As AIS is an X-linked recessive genetic disease, we are waiting for pospadias, rudimentary vagina. 21 19 - 22 October, 2017 Antalya - Turkey 2017

O-15 Male Reproductive Endocrinology TESTICULAR ADRENAL REST TUMOR (TART) IN CONGENITAL ADRENAL HYPERPLASIA HATICE ÖZIŞIK1, BANU ŞARER YÜREKLI1, ILGIN YILDIRIM ŞIMSIR1, İLKER ALTUN1, UTKU SOYALTIN1, EZGI GÜLER2, HÜSEYIN ONAY3, BANU SARSIK4, FÜSUN SAYGILI1 1 EGE UNIVERSITY FACULTY OF MEDICINE, DEPARTMENT OF ENDOCRINOLOGY 2 EGE UNIVERSITY FACULTY OF MEDICINE, DEPARTMENT OF RADIOLOGY 3 EGE UNIVERSITY FACULTY OF MEDICINE,DEPARTMENT OF MEDICAL GENETICS 4 EGE UNIVERSITY FACULTY OF MEDICINE, DEPARTMENT OF PATHOLOGY

Congenital adrenal hyperplasia is one of the most common autoso- adrenal insufficiency for 35 years. He underwent right orchiecto- mal recessive genetic disorders. Testicular adrenal tumors are sig- my operation due to the testicular mass in 2010 and the patholog- nificant complications of congenital adrenal hyperplasia. We would ical examination revealed Leydig cell tumor. In scrotal ultrasound, like to present two patients of testicular adrenal rest tumors. Pa- small multifocal lesions were detected on the left testis and re- tient 1 24 year-old male, he was diagnosed with congenital adrenal section was done. It was reported as testicular adrenal rest tumor. hyperplasia at the age of 8 due to precocious puberty. He received He is being followed-up with glucocorticoid treatment according to hydro-cortisone treatment until the age of 18. Testicular mass had androgen and adrenocorticotropic hormone levels. Early diagnosis been detected and right radical orchiectomy had been applied 6 of testicular adrenal rest tumor is significant in preventing irre- months ago and reported as testicular adrenal rest tumor. In scro- versible testicular damage and infertility. In the differential diagno- tal ultrasound, a mixed type mass lesion (6x4x3 cm) covering a sis, we should keep in mind that testicular adrenal rest tumor can large part of left testis was observed. The imaging findings were mimic other testicular tumors such as primary germ cell tumors. consistent with adrenal rest tumor. The patient took adrenocorti- Keywords: Congenital adrenal hyperplasia, testicular adrenal rest cotropic hormone supressive therapy with dexamethasone 0.75 mg tumor once a day. Patient 2, 38 year-old male, he had been followed-up as

22 19 - 22 October, 2017 Antalya - Turkey 2017

O-16 Pituitary ACTH SECRETING PITUITARY CARSINOMA WITH LIVER METASTASIS: A CASE REPORT MELIHA MELIN UYGUR1, OĞUZHAN DEYNELI2, DILEK GOGAS YAVUZ2 1 SIRNAK STATE HOSPITAL, ENDOCRINOLOGY AND METABOLISM DISEASE DEPARTMENT, SIRNAK,TURKEY 2 MARMARA UNIVERSITY SCHOOL OF MEDICINE,ENDOCRINOLOGY AND METABOLISM DISEASE DEPARTMENT, ISTANBUL, TURKEY

Background: Pituitary carsinoma is a rare disorder that usually a PET CT scan which showed hyper-metabolic lesions at hypoph- secretes ACTH or prolactin. The presence of distant metastases is ysis and liver parenchyma. An ultrasound guided liver biopsy was required for diagnosis. The difficulties in diagnosis is responsible performed and the previous surgical specimen was consulted to for poor outcomes. our pathology clinic for the histological analysis. It was reported as an ACTH secreting pituitary carcinoma with 16% Kİ index and Case: A 62 year old woman with a history of an ACTH producing 10% p53 expression as the same findings was seen at liver biopsy. pituitary adenoma presented for endocrine evaluation. A null cell The patient was consulted to oncology clinic. The renal, hepatic and adenoma was diagnosed 4 years earlier, in 2012 which was mani- bone marrow functions were normal so chemotherapy carboplatin/ fested with headache and ptosis. Without any endocrine evaluation etoposide was started. On the third day blood chemistry tests were she underwent gamma knife radio surgery which healed her symp- normal and she was discharged from the hospital. She was hospi- toms. In 2013, after the symptoms of Cushing’s disease became talized on day 7 due to fever and neutropenia. Granulocyte colony obvious, endocrine evaluation showed marked elevation of plasma stimulating factors and broad spectrum antibiotics were admin- ACTH and cortisol levels which were not suppressed by low or high istered. However, the condition of the patient deteriorated rapidly dose dexamethasone administration. After inferior petrosal si- and she was moved to intensive care unit. She succumbed on the nus sampling confirmed ACTH secreting pituitary adenoma, trans second day despite of active rescue. sphenoidal surgery was performed at an another neurosurgery clinic. The pathological findings were associated ACTH secreting Conclusion: An ACTH-producing pituitary adenoma with high pro- pituitary adenoma with 3-4% Kİ 67 index. Ketoconazole treatment liferation marker levels should be followed for recurrence and/or started after second gamma knife radio surgery in 2014 because metastatic spread biochemical remission was not achieved. Pasireotide treatment Keywords: pituitary carsinoma, corticotroph carsinoma, cusing’s was started instead of ketoconazole in 2015 because it was no more disease available in Turkey. Serum ACTH levels and 24 hour urine cortisol levels stayed elevated despite stable pituitary MRI, that prompted

23 19 - 22 October, 2017 Antalya - Turkey 2017

O-17 Pituitary ACROMEGALY WITH NEGATIVE IMMUNOSTAINING FOR GROWTH HORMONE ON THE CONTRARY TO SILENT SOMATOTROPH TUMOR BANU SARER YÜREKLI1, HATICE ÖZIŞIK1, NILÜFER ÖZDEMIR KUTBAY1, İLKER ALTUN1, YEŞIM ERTAN2, FÜSUN SAYGILI1 1 EGE UNIVERSITY FACULTY OF MEDICINE, DEPARTMENT OF ENDOCRINOLOGY, IZMIR, TURKEY 2 EGE UNIVERSITY FACULTY OF MEDICINE, DEPARTMENT OF PATHOLOGY, IZMIR, TURKEY

Introduction: Silent somatotropinomas are not rare. On the con- mianl CT was performed and a lesion with a 3 cm in diameter on trary to that, the absence of GH immunostaining in acromegaly has the right adrenal gland was observed. Urinary metanephrin and not been well defined. So, we would like to to draw the clinician’s normetanephrin was normal. GHRH level was 5 pg/mL (5-18). Ec- attention to such an entity through a case of acromegaly with neg- topic acromegaly was rulled out. ative GH staining. Discussion: Pituitary tumors are classified according to specific Case: Fifty-four year old male patient applied for the complaints immunohistochemical staining patterns. When the clinical features of acral enlargement, headache and excessive sweating. Acro- are absent in context of positive immunostaining for somatotroph, megaloid appearance was remarkable. The gap between teeth corticotroph, thyrotroph, gonadotroph, those adenomas are de- was increased. On his laboratory examination; the level of Growth fined as silent adenomas. The opposite condition in which there is Hormone (GH) and IGF-1 level were 19.7 ng/mL and 965 ng/mL negative staining for GH in patients with clinical acromegaly diag- (71-284), respectively. There was a lesion with 10x10x13 mm in di- nosed biochemically is more rare. To our knowledge in the litera- ameters located on left pituitary gland showing pituitary adenoma. ture there is one case report and five case series of negative GH Trans-sphenoidal operation was performed and the pathology was immunostaining in acromegalic patients. We would like to discuss consistent with pituitary adenoma with positive immunostaining for the possible explanations for a case of acromegaly with negative follicule stimulating hormone (FSH) and focal thyroid stimulating immunostaining. hormone (TSH). After diagnosis of acromegaly, as immunostainig Conclusion: If we suspect the diagnosis of acromegaly, further test for GH was negative, evaluation of pathological slides were repeat- should be done even if the GH immunostaining is negative. There ed but the result was the same indicating negative GH immunos- is a need for further studies to decide whether this situation has a taining. In the postoperative period, GH and IGF-1 levels were 4 ng/ prognostic significance. mL and 800 ng/mL, respectively. Somatostatin analog treatment was started postoperatively to provide biochemical and clinical Keywords: acromegaly, negative immunostaining, GHRH control of the disease. According to those results, thoracoabdo-

24 19 - 22 October, 2017 Antalya - Turkey 2017

O-18 Pituitary PSEUDO-CUSHING’S SYNDROME DUE TO NIGHT SHIFT WORK SÜLEYMAN NAHIT ŞENDUR, MIYASE BAYRAKTAR DEPARTMENT OF ENDOCRINOLOGY AND METABOLISM, HACETTEPE UNIVERSITY, ANKARA, TURKEY

Pseudo-Cushing’s syndrome constitutes several physiological con- The alteration of the diurnal rhythm of cortisol secretion by night ditions and disorders that lead to increased cortisol production. shift work may cause pseudo-Cushing’s syndrome. Clinical find- Typical clinical and biochemical features of Cushing syndrome ings quickly disappear by restoring of the normal sleep-wake cycle. could be seen in pseudo-Cushing’s syndrome. Here we present a Keywords: Pseudo-Cushing’s syndrome, night shift work, desmo- pseudo-Cushing’s case due to night shift work. pressin stimulation test, osteoporosis, depression, insulin resis- A 26 year old male patient was referred to endocrinology clinic be- tance cause of weight gain. He was a chronic night shift worker, works as Physical examination findings of patient a security guard for 5 years. On review of medical history, insulin resistance and depression were noted. He was using metformin and paroxetine. Physical examination showed cushingoid signs with accumulation of fat in the face, marked central obesity, thin extremities, mild facial plethora and dorsocervical fat pad (Figure 1). The patient did not report any kind of glucocorticoid use and fur- ther tests were performed to exclude Cushing’s syndrome. Morning cortisol and ACTH levels were 4.47 µg/d L and 10.1 pg/mL respec- tively. 24-hour urinary cortisol was measured two times and the re- sults were in normal limits. 24-hour serum cortisol profile was as- sessed in real-life conditions (Figure 2). Then he was hospitalised to rule out Cushing’s syndrome. After normal sleep-wake cycle was 24-hour serum cortisol profile restored, on 5th hospitalisation day, 24-hour serum cortisol profile was reassessed. Reversal of cortisol rhyhtm to physiologic state was noted (Figure 2). Serum cortisol was suppressed after 1 mg overnight dexamethasone suppression test. Desmopressin stimu- lation test was performed and it revealed blunted ACTH response. 24-hour serum cortisol profile, before hospital admission( orange The patient was diagnosed with pseudo-Cushing’s syndrome. To line), on hospital admission after normal sleep-wake cycle re- detect the effect of cortisol excess, bone mineral density was mea- stored (blue line) sured and showed a lumbar spine Z score of -3.1. The patient lost five kilograms during one-week hospitalisation and metformin was stopped. The shift change was suggested.

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O-19 Pituitary GLUCOCORTICOID EXCESS SEVERELY AFFECTS BONE TISSUE, LEADING TO FRAGILITY FRACTURES BY SEVERAL MECHANISMS, WHICH CAN PRESENT THE DISEASE MANY YEARS BEFORE OTHER PHYSICAL CHARATERISTICS VINCENZO CIMINO1, MARIO PEROTTI2, FRANCESCA GALBIATI2, ALESSANDRA SIRONI3, ILARIA BESTETTI3, DAMIANO CALELLA1, SILVIA GALLIANI1, PALMA FINELLI3, ANGELA IDA PINCELLI2 1 SCHOOL OF ENDOCRINOLOGY UNIVERSITY OF INSUBRIA, VARESE, ITALY 2 ENDOCRINOLOGY SERVICE SAN GERARDO HOSPITAL, MONZA, ITALY 3 LABORATORY OF MEDICAL CYTOGENETICS AND MOLECULAR GENETICS, IRCCS ISTITUTO AUXOLOGICO ITALIANO, MILAN, ITALY

Histomorphometric studies have shown that hypercortisolism low-up, physical examination showed cushingoid features, such as causes abnormalities of bone turnover through the inhibition of abdominal obesity and easy bruising on legs, raising the suspicion osteoblasts function and consequent increase of bone resorption. of endogen hypercortisolism. This was confirmed by high values Moreover, glucocorticoid-induced protein breakdown is supposed of free urinary cortisol excretion and non-suppression of serum to decrease bone collagen content. This would lead to an impair- cortisol level with a low-dose dexamethasone administration. High ment of bone strength with a mechanism which is similar to the levels of ACTH and characteristic response to CRH and vasopressin one of dermal changes occurring in Cushing’s syndrome and char- provocative tests were considered diagnostic of a pituitary-depen- acterized by loss of dermal collagen with the result of thin, fragile dent disease. MRI examination of pituitary sella showed a single and more susceptible to bruises skin. low-density mass in the left lobe of the pituitary gland measuring 4mm. The patient was diagnosed for Cushing’s disease caused by We report a 55-year-old woman who presented more than 40 ribs an ACTH-secreting pituitary adenoma. During trans-sphenoidal stress fractures, mostly at the metatarsal level, in the last ten surgery, bilateral lesions were found. Immunohistochemical study years. She did not exhibit any other clinical manifestations of hy- confirmed the hypothesis of double ACTH –expressing adenoma. percortisolism. She had a history of central hypothyroidism with a questionable pituitary MRI. Relevant exams: normal calcium-phos- This case describes a rare case of endogen hypercortisolism with porus metabolism, vertebral and femoral osteoporosis, asymptom- the clinical presentation of brittle bones and collagen synthesis atic vertebral compression fractures ruled, molecular sequencing impairment in the absence of other typical features of Cushing’s studies on most of genes involved in collagen synthesis did not con- syndrome. In addition, at the moment, ubiquitibn-specific protease firm the hypothesis of osteogenesis imperfecta, ALP gene analysis 8 (USP8) gene analysis is ongoing in order to find if could exist a ruled out the hypothesis of Hypophosphatasia. Discrepancy be- somatic mutation as the molecular background of the double corti- tween unfavorable clinical evolution and laboratory data induced cotroph adenoma described in our patient. us to additional investigations. Histological and ultrastructural Keywords: Cushing’s syndrome, fragility fractures, UPS8, collagen analysis of bone and skin biopsy suggested a quantitative deficit of synthesis impairment type 1 collagen synthesis. Teriparatide therapy lead to a partial im- provement of clinical course, however, while receiving this therapy, the patient experienced new metatarsal fractures. During the fol-

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O-20 Pituitary DIFFERENTIAL DIAGNOSIS OF DIABETES INSIPIDUS IN A PATIENT WITH HYPERCALCEMIA GÖKNUR YORULMAZ1, BENGÜR TAŞKIRAN2, AYSEN AKALIN1, NURETTIN ERBEN3, SUZAN ŞAYLISOY4, HÜSEYIN YILDIRIM5 1 DEPARTMENT OF ENDOCRINOLOGY AND METABOLIC DISORDERS, OSMANGAZI UNIVERSITY, ESKISEHIR, TURKEY 2 DEPARTMENT OF ENDOCRINOLOGY, YUNUS EMRE STATE HOSPITAL, ESKISEHIR, TURKEY 3 DEPARTMENT OF INFECTIOUS DISEASES, OSMANGAZI UNIVERSITY, ESKISEHIR, TURKEY 4 DEPARTMENT OF RADIOLOGY, OSMANGAZI UNIVERSITY, ESKISEHIR, TURKEY 5 DEPARTMENT OF PULMONARY AND CHEST DISEASES, OSMANGAZI UNIVERSITY, ESKISEHIR, TURKEY

Introduction: Vitamin D intoxication and granulomatous diseases berculosis drugs were commenced. After taperment and cessation are rare causes of severe hypercalcemia. Hypercalcemia associ- of dexamethasone therapy for tuberculosis menengitis and cereb- ated with other endocrine disorders may be a sign of an extensive ritis, steroid replacement was continued with methyl prednisolone disease involving multiple tissues. therapy. Levothyroxine was added afterwards. She continued des- mopressin therapy. The findings on cerebral images regressed sig- Case: A 40 year old female was hospitalized due to severe hyper- nificantly. The diameter of pituitary stalk regressed to 3.6 mm. calcemia and complaints of polydipsia, polyuria, and clouded con- sciousness. She denied any chronic illness despite recently diag- Conclusion: As a granulomatous disease, tuberculosis may mani- nosed DM. She was not menstruating for 1 year. The medication fest with a variety of endocrine disorders in a single patient. history included oral antidiabetic drugs and 600 000 U Vitamin D3 Keywords: hypercalcemia, diabetes insipidus, tuberculosis, hypo- which were prescribed 2 months ago due to low vitamin D level pituitarism without baseline calcium measurement. She was maneged with saline and furosemide. Parathyroid hormone was suppressed and Figure we excluded primary hyperparathyroidism. Vitamin D level was not as high as expected in case of severe hypercalcemia suggesting intoxication. During follow-up calcium level normalized only after zoledronate and calcitonin therapy. Therefore in order to evaluate possible underlying malignancy bone scintigraphy, mammogra- phy, abdominal ultrasound, and upper gastrointestinal endoscopy were performed. There were nonsignificant findings. Dexametha- sone 32 mg/d was commenced after multiple discrete masses and vasogenic edema were detected on cerebral MRI images. Thorax CT also revealed multiple pulmonary nodules. Agitation developed while electrolytes were normal and was managed with haloperi- dol. Although she was normoglycemic and not using furosemide, hypernatremia and polyuria developed 3 days after onset of steroid therapy. Central diabetes insipidus (DI) was diagnosed and des- mopressin was commenced. Steroid was withdrawn and referred to Osmangazi University. Bronchoscopy was performed. Cytologic examination of bronchoalveolar lavage and endobronchial US guid- ed biopsy was nonsignificant. In order to obviate the cause of DI, cerebral imaging including hypophysis MRI was done. There was a lot of high intensity signal lesions compatible with menengitis and cerebritis. Pituitary stalk and hypothalamus demonstrated signifi- Abnormal contrast enhancement in pituitary gland, brain paran- cant contrast enhancement. The stalk diameter was increased (5.6 chyma, intraventricular space, and sulci on sagitttal plane MRI mm). Hormones of anterior pituitary were studied and panhypo- pituitarism accompanied by hyperprolactinemia were detected. Meanwhile microbiological report was obtained and the specimen was positive for ARB using Ziehl Neelson stain. Therefore antitu- 27 19 - 22 October, 2017 Antalya - Turkey 2017

Table 1

19 Apr 26 May 2 June 6 June 9 June 10 June 11 June 19 June 20 June 28 June

Glucose (mg/dl) 241 139 127 150 196 186 152

HgbA1c (%) 9.5 6.7

Creatinine (mg/dl) 0.75 1.22 0.73 0.70 0.71 0.71 0.78 0.70

ALT (U/l) 18 10 11 10 6

Calcium (mg/dl) 16.4 12.6 9.27 8.12 8.41 9.95

Ionized calcium 1.24 (mmol/L)

Phosphorus (mg/dl) 4.6 2.6 2.1 2.7 3.1 4.5

Sodium (meq/l) 146 137 154 160 130 131 141 138 142

Potassium (meq/l) 3.9 3.8 3.6 3.72 4.11 3.9 3.74 3.79 4.35

Chloride (mmol/l) 106 124 97.6 99 103

Albumin (g/dl) 4.4 3.5 3.8 3.4 3.9

ALP (U/l) 55 47 62 55 90

LDH (U/l) 175 146

Uric acid (mg/dl) 10.8 4.15

ESR (mm/hr) 36 38

Leukocytes (/mm3) 9870 13020 15350

Neutrophils (/mm3) 5260 11760 12450

Lymphocytes (/mm3) 3050 930 1750

Hemoglobin (g/dl) 15.0 13.8 12.0

Urine density 1014 1003 1003

Urine osm. (mmol/kg) 62

Serum osm. (mmol/kg) 284

HCO3 (mmol/l) 27.7

Magnesium (mg/dl) 0.87

24 hr urine Calcium >488 (mg/d)

C-peptide (ng/ml) 0.81

Anti GAD (IU/ml) 5>

Anti-TPO (IU/ml) 1.8 Laboratory data

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Table 2

Baseline values before Admission Normal range Follow-up values therapy values

TSH (mIU/l) 0.27-4.20 1.03 0.66 2.28

Free T4 (ng/dl) 0.93-1.70 0.90 0.7

Free T3 (pg/ml) 2.3-4.5 2.53 2.06

ACTH (pg/ml) 7.2-63.3 7.55

Cortisol (mcg/dl) 12-18 1.8

LH (mIU/l) 1.0-11.4 0.1>

FSH (mIU/l) 1.7-7.7 5.32

E2 (pg/ml) 22.3-341 5>

Prolactin (ng/ml) 6-29 125.8

Growth hormone (ng/ml) 0.126-9.880 0.489

IGF-1 (ng/ml) 97-263 50

Parathyroid hormone (pg/ml) 15-65 9.4 14.48

25-OH vitamin D3 (ng/ml) >20 75.4

1,25-OH vitamin D3 (pg/ml) 26.1-95.0 106 Hormone profile at admission and during work-up

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O-21 Bone/Calcium PARATHYROID CARCINOMA WITH BROWN TUMORS EREN İMRE, DILEK GOGAS YAVUZ DEPARTMENT OF ENDOCRINOLOGY, MARMARA UNIVERSITY FACULTY OF MEDICINE, ISTANBUL, TURKEY

Case: We reported a 28 years old woman complained of a swelling partially excised for insizyonel biopsy. Hypocalcemia occured on on the right upper jaw bone consisted and grew during two years. the first postoperative day. Patient complained of tingling sensa- The patient was suffering hypertension and chronic renal failure tion, Chvostek’s and Trousseau’s signs were observed on physical after left nephroctomy due to pyelonephritis till 1999 and getting examination. Serum Calcium, Phosphorus, and PTH were 5,5 mg/ hemodialysis treatment three times a week till 2011. A needle bi- dL, 3,7 mg/dL, and 21 pg/mL, respectively and the clinical situation opsy is performed and pathologic investigation demonstrated a gi- was suggestive of hungry bone syndrome. She was started on i.v. ant cell granuloma. The biochemistry workup pointed out tertiary and oral calcium and calcitriol replacement. Symptoms resolved hyperparathyroidism with parathormon level 1609 pg/mL (15 - 65), and laboratory values normalized with the treatment. Intravenous calcium 10,8 mg/ dL (8.8-10.2), phosporus 6 mg/dl (2.5- 6). So the treatments were switched to maintenance therapy with oral sup- patient was referred to outpatient clinic of endocrinology. A neck plements. She was discharged with prescriptions for calcitriol, ultrasound was performed because of the suspicion of a possible calcium and vitamin D. Parathyroid carcinoma and a brown tumor parathyroid adenoma and revealed multipl hypoechoic nodules were reported in the pathological examination. After this result, in on the posterior neighbourhood of middle part of the right thyroid june 2017 total thyroidectomy and central lymph node dissection lob, in the middle part of the left posterior thyroid lobe and on the was performed. neighbourhood of the left inferior pole. Then 99mTc-MIBI scintig- Conclusion: Parathyroid carcinoma is rare in patients at such raphy(15.02.2017) was performed and depicted an uptake which young age with chronic kidney disease and short-term dialysis is a 12 mm lesion at the posterior of the left thyroid lobe. It also treatment. The development of brown tumor and hungry bone syn- showed elevated Tc-99m MIBI uptake of expansile lesions on the drome in such a patient is probably associated with the elevated left parietal bone, on the right side of maxilla and on the right nasal bone turnover due to aggressive parathyroid carcinoma. wing which are thought to be brown tumors. In April 2017 para- thyroidectomy and the expansile lesion on the right maxilla was Keywords: Parathyroid, Carcinoma, Brown, Tumor, Hungry, Bone

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O-22 Bone/Calcium TERIPARATIDE INDUCED SEVERE HYPERCALCEMIA IN AN OSTEOPOROSIS PATIENT SAVAŞ KARATAŞ1, AYSUN IŞIKLAR2 1 DEPARTMENT OF ENDOCRINOLOGY PROF. DR. ILHAN VARANK RESEARCH AND EDUCATION HOSPITAL 2 DEPARMENT OF INTERNAL MEDICINE, PROF. DR. ILHAN VARANK RESEARCH AND EDUCATION HOSPITAL

Osteoporosis is a major worldwide health problem which causes had no any chronic disease except osteoporosis and bilateral salp- fractures,disabilities and seen in millions of people, and has been ingophoroctomy at age 33. She had osteoporosis diagnosis since 8 a great health budget problem in the world.Traditionally, the man- years,used bisphosphonats for 5 years intermittantly, She had L3- agement of osteoporosis in men and women has included the use L4 fracture 5 months ago, and left wrist fracture 4 months ago. of antiresorptive agents in combination with calcium and vitamin D Teriparatide was started 15 days ago, and her teriparatide start supplementation. In 2002 levels were: Ca:9,3 mg/dl, P:3 3 mg/dl Albumin:3.5 g/dl PTH 18,9 pg/ml,TSH:1.2 uıu/ml,ALP:77 u/L, 25 (OH) Vitamin D: 30.3 mg/ Teriparatide, a recombinant PTH, an anabolic treatment for osteo- dl,Mg:1.9mg/dl; HB:15 g/dl, WBC: 8000 ESR:16 mm/h. She was porosis that increases bone density had been approved by FDA. The admitted to hospital and was given %0.9 i.v. isotonic 3000/d, intro- mechanism of action of teriparatide is unique in that it possesses venous furosemide 2x1 for 5 days. Teriparatide was stopped. Her anabolic properties and therefore builds bone. Because of its use- calciım levels began to decrease.When she was externalised her ful results teriparatide had taken an important place in osteopo- Ca: 9.2 mg/d, phosphorus:3 mg/dl.Her serum electrophorosis and rosis therapy in short time. It had been seen as a miracle for this bone scan was normal. 25(OH) Vitamin D:25.6 mg/dl, 1,25 (OH) vi- disease. But it has a few side effects.The most commonly reported tamin D:21.9 mg /dl. side effects are nausea, leg cramps and dizziness. Asymptomatic hypercalcemia has been reported in 5% of patients. Hypercalcemia Her Calcium levels returned to normal without treatment after 5 is seen after 4-6 hours of its subcutaneous (SC) injection, and re- days. solves usually within 16 hours of drug administration. Persistent Discussion: There has no been found a side effect like prolonged hypercalcemia, although not observed in clinical trials, is rarely re- hypercalcemia in managing osteoporosis with teriparatide in phase ported. We present here a case with osteoporosis and had raised 3 trials. The maximum postdose (4–6 hours after dosing) serum Ca levels (18.9 mg/dl )after teriparatide treatment. calcium in the phase-3 trial was about 11 mg/dL.In our case after Case Presentation: A 55 year old woman presented to our clinic teriparatide use serum calcium has reached 18.9 mg/dl toxic leves, with headache, nausea, vomiting complaints. Her blood tests were: after hydration, diuretic and teriparatide discontinuitaion serum Ca:18.9 mg/dl, P:3 mg/dl Albumin:3.5 g/dl PTH<3 pg/ml,TSH:1.2 calicum level has returned to normal range within few days. uıu/ml,ALP:77 u/L, 25 (OH) Vitamin D: 33.7 mg/dl,Mg:1.8 mg/dl; Keywords: osteoporosis, hypercalcemia, teriparatide HB:15.1 g/dl, WBC: 10400 ESR:8 mm/h Her medical past history

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O-23 Bone/Calcium TENOFOVIR-RELATED FANCONI SYNDROME AND CHRONIC RENAL FAILURE IN DIABETIC PATIENT HÜLYA HACIŞAHINOĞULLARI, SAKIN TEKIN, AYŞE KUBAT ÜZÜM, FERIHAN ARAL, REFIK TANAKOL DEPARTMENT OF ENDOCRINOLOGY AND METABOLISM, ISTANBUL UNIVERSITY,ISTANBUL MEDICAL FACULTY, ISTANBUL,TURKEY

Introduction: Tenofovir disoproxil fumarate (TDF) is a nucleotide which were compatible with Fanconi syndrome. L1-L4 T score on reverse transcriptase inhibitor used to treat hepatitis B infection. DEXA was -3.4 and bone scan showed increased uptake in multiple Herein, we report a case of tenofovir induced Fanconi syndrome fracture lines. Renal biopsy which was performed to identify the who was misdiagnosed as Paget ‘s disease. etiology of chronic renal failure showed granular degeneration of tubulus and was not associated with diabetes mellitus. Diagnosis Case: A 56-year old male who was under TDF treatment for HBV of tenofovir induced osteomalacia due to Fanconi syndrome and infection had a fragility femur fracture in 2014 and had been treated phosphate wasting was made. with IV zolendronate 5 mg. A few months after that, he was admit- ted to another clinic with diffuse bone pain, weakness especially TDF was switched to entecavir 5 mg/d. Oral phosphate supplemen- at lower extremities, difficulty in ambulation. Because of hypo- tation (sodium phosphate 1500 mg/d) and calcitriol (0.25 mg thrice phosphatemia, elevated alkaline phosphatase (ALP) and increased a day) were initiated. Phosphate level increased to 2.7 mg/dl in 3 osteoblastic activity on bone scintigram, Paget’ s disease was the weeks and his symptoms improved, he can walk with walker, but diagnosis and he was referred to our Endocrinology clinic for eval- creatinine level did not change. uation of hypophosphatemia and osteoporosis. He had a history of Conclusion: Despite being a rare adverse event, Fanconi syndrome diabetes from year 2006. secondary to TDF can occur and glomerular and tubular function Serum phosphorus:1.1 mg/dL (N:2.7-4.5 mg/dL), bone ALP: 71 µ/L should be monitored closely. This case also highlights the impor- (4-22 µ/L), calcium:9 mg/dL (N: 8,5-10.5 mg/dL), creatinine 1,6 mg/ tance of monitoring for bone disease and clinical aspects of hypo- dL(N: 0.7-1.4 mg/dL), uric acid 1.5 mg/dl (N:2,5-7,5 mg/dl), TMP/ phosphatemia in these patients. GFR was calculated as 0,008 mmol/L. Metabolic acidosis with nor- Keywords: diabetes mellitus, fanconi syndrome hypophosphate- mal anion gap, aminoaciduria, hypophosphatemia with increased mia, tenofovir, fractional excretion of phosphate, glycosuria, hypouricemia all of

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O-24 Neuroendocrine Tumors MALIGNANT PARAGANGLIOMA SYNDROME TYPE 1 - A COMPLEX CLINICAL CASE SARA DONATO1, DANIEL MACEDO2, HELDER SIMÕES1, VALERIANO LEITE1 1 ENDOCRINOLOGY DEPARTMENT, INSTITUTO PORTUGUÊS DE ONCOLOGIA DE LISBOA FRANCISCO GENTIL, LISBON, PORTUGAL 2 ENDOCRINOLOGY SECTION - INTERNAL MEDICINE II DEPARTMENT, CENTRO HOSPITALAR DO ALGARVE, FARO, PORTUGAL

Background: Paragangliomas (PGLs) are rare neuroendocrine tu- Four months after surgery, due to increasing urinary metaneph- mors derived from sympathetic or parasympathetic tissue. They rines (3.5 mg/24h), blood pressure rising and progression con- can be sporadic or familial. firmed on 68Ga-DOTANOC PET (more hepatic and bone metas- tases), PRRT was started. He completed three cycles with a total PGL syndrome type 1 is characterized by an autosomal dominant, activity of 200 mCi. Progression after PRRT was again observed and paternally inherited germinal mutation in SDHD subunit. Patients this therapy was stopped. with this syndrome have frequently multifocal PGLs, but low ma- lignancy rate. Nine months later he was submitted to chemoembolization of hy- pervascular liver lesions. After fourteen months of PRRT he devel- We present a rare case of a malignant PGL syndrome type 1. oped exophthalmos and amaurosis of left eye due to a large bone Clinical Case: Dutch male aged 38 presented with chronic abdomi- metastasis located on the orbital vertice. Then he was then sub- nal pain and resistant hypertension. He had a past history of a right mitted to decompressive surgery and radiotherapy, with significant cervical PGL removal seven years before and a relevant family his- functional improvement. Due to evident disease progression (uri- tory. His father had two cervical PGLs and his sister is a known nary metanephrines of 22.3 mg/24h, widespread bone metastases SDHD mutation carrier. and left carotid body PGL enlargement documented in 18F-FDG PET), it was decided to initiate CVD chemotherapy, while maintain- A CT scan showed a right retroperitoneal mass with 67x59x51mm ing bisphosphonate therapy. Four chemotherapy cycles were com- and two hepatic nodules. Initial body staging revealed a left carotid pleted, with no observed improvement, but he is now waiting for body PGL with 59x34mm, a mediastinic PGL and multiple bone me- 18F-FDG PET reevaluation. tastases. MIBG scan only showed uptake on the abdominal mass. Biochemical analysis revealed urinary metanephrines of 9 mg/24h Conclusion: This case is a rare combination of multiple, secretory, (normal < 1 mg/24h) and vanilmandelic acid of 50 mg/24h (normal sympathetic and parasympathetic PGLs with malignant behavior. It < 14 mg/24h). A germinal mutation in exon 3 of the SDHD gene was illustrates how challenging managing advanced/metastatic PGLs found. can be. Bone metastases are particularly frequent and treatment resistant. 18F-FDG PET is a useful tool identifying distant metas- After four months he developed a vertebral pathological fracture tases. Systemic therapy with 177Lu-DOTATATE PRRT proved to be with local acute pain, treated with radiotherapy and bisphospho- inefficient. SDHD founder mutations have been described in the nates. Then he was then submitted to abdominal PGL and hepatic Netherlands. metastases removal. After surgery, urinary metanephrines de- creased (1.5 mg/24h) and there was a transient but significant im- Keywords: Paraganglioma; Paragangliomas, Familial, 1; Succinate provement of blood pressure. Dehydrogenase/genetics

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O-25 Neuroendocrine Tumors A RARE CAUSE OF HYPOGLYCEMIA: INSULIN AUTOIMMUNE SYNDROME (HIRATA DISEASE) ZEYNEL ABIDIN SAYINER, ERSIN AKARSU, SUZAN TABUR, MUSTAFA ARAZ DEPARTMENT OF ENDOCRINOLOGY AND METABOLISM, GAZIANTEP UNIVERSITY, GAZIANTEP, TURKEY

Insulin autoimmune syndrome (IAS) is a rare condition character- lightheadedness, blurry vision symptoms. At that time his plasma ized by hyperinsulinemic hypoglycemia associated with high titers glucose level was 48 mg/dl. The markedly increased insulin lev- of antibody to endogenous insulin. Absence of pathological abnor- el and the non suppressed connecting peptide (C-peptide) result malities of the pancreatic islets and prior exposure to exogenous were seen in the blood tests. Computed tomography (CT) of the insulin are needed for diagnosis. The syndrome was first described pancreas did not identify any masses. Ga-68 dotate CT was done by Hirata in 1970. Since then approximately 400 patients have been for an endocrine tumor suspicion. There were no positive finding. described which are mostly from japan. IAS is known as the third Selective arterial calcium stimulation was performed to differenti- common cause of spontaneous hypoglycemia. ate between insulinoma and diffuse hypertrophy. Regardless of the region, all areas had similarly raised insulin and C-peptide levels. A 65-year-old man was referred to the endocrinology clinic with a IAS was considered and anti insulin antibodies and proinsulin tests 3 month history of recurrent symptoms of sweating, headache and revealed high titers of anti insulin antibodies and proinsulin. The confusion occurring regardless of meal time. The fingerstick blood patient was advised for low glycemic index diet with frequent small sugar readings during these symptoms were 48mg/dL, 56 mg/dL. meals. The patient has not been experienced any hypoglycemic ep- His symptoms were improved after eating or drinking a beverage. isodes. We did not need to use acarbose or corticosteroids. He has no history of illness and he has never used a drug for any reason. There was no history of diabetes mellitus in the patient IAS should be considered in differential diagnosis of endogenous or his family. He did not smoke, drink alcohol, or use recreational hyperinsulinemic hypoglycaemia. Very high serum insulin levels drugs. His physical examination was unremarkable. Patient was (100–10 000 mU/ml) are frequently seen in IAS. A clinical suspicion internated to endocrinology clinic. Laboratory investigations re- of IAS can avoid expensive imaging and unnecessary surgery in af- vealed normal renal, thyroid and liver function.There was no sign of fected patients. any blood disorder. Hemoglobin A1c was 5.2 %. Synacthen (ACTH) Keywords: Hypoglycemia, Insulin autoimmun syndrome, Hirata stimulation test indicated that there was no adrenal insufficiency. disease When patient on prolonged fasting test patient developed fatigue,

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O-27 Diabetes AN OVERLOOKED CAUSE OF SECONDARY DIABETES; HEREDITARY HEMOCHROMATOSIS EMINE KOCA DEPARTMENT OF INTERNAL MEDICINE, MUGLA SITKI KOCMAN UNIVERSITY, MUGLA, TURKEY

Background: Hereditary hemochromatosis (HH) is a genetic dis- glucose level of 640 mg/dl, urinary ketone positive, urea 131 mg/ order of iron metabolism which leads to irregular iron absorption dl, creatinin 1.1 mg/dl, sodium 116 mg/dl, HbA1C 14.7 %, adreno- from the intestine and iron overload in patients diagnosed with the corticotropin releasing hormone 33.46 mIU/mL, cortisol 17.75 mIU disease. Diabetes mellitus occurs in 20–50% of patients with HH / mL. His full blood count was in normal range (Hb: 16.4 Htc: 46.7). and results chiefly from loss of insulin secretory capacity due to Abdominal ultrasound showed coarsened echo texture of the liver pancreatic haemosiderosis but may be mistaken for type 2 diabe- parenchyma consistent with chronic liver disease. Based on skin tes. In this study, we report a case of hereditary hemochromatosis bronzing, diabetes mellitus, chronic liver disease and suspicious which presents with diabetes mellitus. family story, hereditary hemochromatosis was suspected in the pa- tient. Iron studies confirmed iron overload with serum iron levels Case: 56 year old male patient admitted to our clinic with complaints of 64 ug/dl, iron binding capacity 218 μg/dl, transferrin saturation of weakness and dyspnea. He had a general hyperpigmentation all 29.35% and ferritin 757.2 ng/ml. Liver biopsy showed mild hepa- over the body. He had a history of bronchial asthma, pulmonary tocellular injury and hemosiderosis. Genotyping confirmed a het- hypertension, congestive heart failure and type 2 diabetes mellitus erozygous H63D mutation of HFE gene. Regular phlebotomy was for six years. He had no history of blood transfusions, smoking or started for the treatment of the patient. alcohol use. In his family story, he reported a sudden cardiac death in his cousin at 56 years-old and he did not have a relative with Conclusion: Hereditary hemochromatosis is the most common in- hyperpigmentation. He was using insulin aspart 3x30 units, insulin herited disorder in Caucasians. The classic clinical triad includes detemir 1x20 units, diltiazem, spironolactone and furosemid. In his cirrhosis, diabetes and hyperpigmentation. Early recognition and physical examination, his body mass index was 26 kg/m². Respira- treatment can reduce long term complications and mortality. tory system examination revealed crepitant rales at the bilateral Keywords: Secondary diabetes, hemochromatosis, iron storage lower zones. In neuromuscular examination, he had a 3/5 strength diseases loss on both upper extremities. Laboratory tests showed plasma

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O-28 Diabetes EUGLYCEMIC DIABETIC KETOACIDOSIS AFTER SLEEVE GASTRECTOMY FOLLOWING DAPAGLIFLOZIN THERAPHY ÜMIT ÇAVDAR, BAŞAK ÖZGEN SAYDAM, MEHMET YIĞIT, GÜNKUT ARSLAN, BARIŞ AKINCI DEPARTMENT OF ENDOCRINOLOGY, DOKUZ EYLUL UNIVERSITY, İZMIR, TURKEY

Although several factors trigger diabetic ketoacidosis (DKA); bar- Keywords: dapagliflozin, euglycemic diabetic ketoacidosis, meta- iatric surgery itself may cause this life threatening complication. bolic surgery The FDA has recently issued a warning about an increased risk of euglycemic diabetic ketoacidosis associated with the use of SGLT-2 inhibitors. We herein present a case of diabetic ketoacidosis after sleeve gastrectomy following dapagliflozin treatment.

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O-29 Diabetes SEVERE INSULIN RESISTANCE IN A MALE PATIENT RAMAZAN ÇAKMAK, HÜLYA HACIŞAHINOĞULLARI, SAKIN TEKIN, SEHER TANRIKULU, MEHMET SAIT KOÇ, ÖZLEM SOYLUK SELÇUKBIRICIK, NURDAN GÜL, AYŞE KUBAT ÜZÜM, KUBILAY KARŞIDAĞ, NEVIN DINÇÇAĞ, MEHMET TEMEL YILMAZ, ILHAN SATMAN DEPARTMENT OF ENDOCRINOLOGY, İSTANBUL MEDICAL FACULTY, İSTANBUL, TURKEY

Introduction: Severe insulin resistance is a rare clinical condition In the meanwhile, genetic testings for MODY and insulin receptor and should be suspected if a patient requires more than 2 iu/kg/ gene were normal. Underlying medical conditions such as excess day of insulin. Herein, we represent a case who had uncontrolled of counter-regulatory hormones, endocrine disorders, malignities, diabetes despite high doses of insulin. history of medication causing hyperglycemia were excluded. An- ti-GAD,islet cell antibody and insulin receptor antibodies were neg- Case: A 54 year old male patient who had diabetes for 22 years was ative. However,anti-insulin antibody titre was elevated at 4.8 U/mL referred to our clinic due to insufficiently controlled glucose levels. (N: < 0.4 U/ml). The patient was discharged due to personal rea- In his past medical history, he had moderately controlled diabetes sons with insulin pump, metformin 2x1000 mg, dapagliflozin 10 mg with metformin and sulfonylurea. Four years ago, he had under- and pioglitazone 30 mg. He re-admitted six months later, HbA1C went transurethral resection for benign prostat hyperplasia, after was 16 %. Because antiinsulin antibody was elevated 10 folds up- than insulin requirement increased rapidly. Basal-bolus (insulin per limit of normal, we started methylprednisolone pulse therapy glargine and aspart) plus metformin regimen had started in a local and continued with 32 mg orally, and tapered 4 mg per week. We health center. Then exenatide had been tried, but not tolerated. obtained partial response with steroid and insulin requirement de- On his admission, no remarkable physical finding was noted in- creased by 50 %. Unfortunately, after two months insulin require- cluding achantosis nigricans. Weight: 77 kg, BMI:25.4 kg/m2. Labo- ment increased steadily. Glucose levels were >400 mg/dL under ratory evaluations were as follows:Triglycerides:1212 mg/dL, HDL- current treatment with 450 iü/day insulin glargine U-300, 150 iü Chol:22 mg/dL, LDL:196 mg/dL, creatinine:0.8 mg/dL, AST:14 IU/L, insulin aspart, metformin 2000 mg, dapagliflozin 10 mg, gliclazide ALT:20 IU/L, HbA1C:10%, C-peptid: 1.1 ng/mL MR 60 mg, sitagliptin 100 mg and pioglitazon 30 mg.

He was under metformin 2x1000 mg, NPH insulin 3x34 iu, aspart Conclusion: Despite aggressive treatment models, we achieved insulin 3x32 iu, pioglitazon 30 mg, perindopril 10 mg, essitalopram insufficiently control on glycemia and decided to try Rituximab, 10 mg. We increased insulin doses up to 300 iu, then we tried insulin and obtained a special permission from the council in Ministry of pump. No response was noted despite 5 iü/h insulin. We thought he Health to use this agent. might have subcutaneous insulin resistance, therefore we adminis- So what do you suggest else? tered insulin by intramuscular way, but no response was achieved. Intravenous insulin infusion was given for four weeks and the dose Keywords: diabetes, severe insulin resistance, anti insulin anti- was increased up to 20 iu/h, however the response was insufficient. body, rituximab

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O-30 Adrenal HOW CAN DIABETIC KETOACIDOSIS SAVE YOUR LIFE? AN UNUSUAL FIRST PRESENTATION OF AN ADRENAL TUMOUR LIA ANGUELOVA1, ARCHANA DHERE1, MIKE TADMAN1, BAHRAM JAFAR MOHAMMADI1, GARRY D TAN1,2 1 OXFORD CENTRE FOR DIABETES, ENDOCRINOLOGY & METABOLISM, OXFORD UNIVERSITY HOSPITALS NHS FOUNDATION TRUST, OXFORD OX3 7LE, UK 2 NIHR BIOMEDICAL RESEARCH CENTRE, OXFORD, UK

Introduction: Mild to moderate impaired glycaemia is common prandial insulin and remained on a low dose of basal insulin. At with pheochromocytoma and is seen in 20-40% cases. Pheochro- presentation, his fasting low C-peptide (89 pmol/L) with a glucose mocytomas causing acute metabolic decompensation in the form of 7.2mmol/L supported a diagnosis of type 1 diabetes mellitus. of diabetic ketoacidosis (DKA) is uncommon and we present a case However arguing against a diagnosis of type 1 diabetes, his an- here. ti-GAD, anti-IA2 and anti-islet cell antibodies were all negative and his HbA1c was high (11%). Case: A 36-year-old gentleman presented with severe headache, vomiting, polyuria, polydipsia and weight loss over two months. Four months after the removal of his phaeochromocytoma he de- He was dehydrated, tachycardic (100 beats/min) and hypertensive veloped hypoglycaemia and his subcutaneous insulin injections (220/110 mmHg). Biochemical investigations showed raised glu- were stopped. His HbA1c is now in the nondiabetic range (5.7%) cose (23mmol/L), raised ketones (3.3 mmol/L), and mild acidosis and his C-peptide is normal (863pmol/L), suggesting that the initial (pH 7.32). A diagnosis of DKA was made and treatment with intra- DKA was as a result of excess catecholamines. venous insulin and fluids was started in line with local guidelines. Conclusion: Diabetic ketoacidosis as first presentation of a phaeo- He reported headaches, profound episodic sweating especially on chromocytoma is extremely rare. In our case, it led to early identi- exertion, and gradual weight loss. He had no palpitations, anxiety, fication of a tumour with malignant propensity. dizziness, flushing or pallor. He had no diarrhoea or abdominal pain. He had a family history of Type 2 diabetes mellitus but no Keywords: Pheochromocytoma,paraganglioma,DKA,SDHB other history of endocrinopathy. He had no signs of Cushing’s or Acromegaly. Picture 1

At this point, investigations for secondary hypertension demon- strated elevated urinary and plasma Normetanephrine 4786 pmol/L (120-1180).He had a normal response to overnight dexa- methasone suppression test. A diagnosis of a phaeochromocytoma was biochemically suspected and a CT- abdomen showed a 6cm left retro-peritoneal necrotic lesion (Picture 1). NM-MIBG (123) scan was consistent with a MIBG-avid left adrenal phaeochromo- cytoma (Picture 2).

A laparoscopic left adrenalectomy was performed without compli- cations. Histopathology demonstrated a pheochromocytoma with a PASS score of 11/20. It was positive for chromogranin and syn- aptophysin, and negative for inhibin and melan-A. Genetic testing confirmed an SDHB mutation and counselling is planned as he has two children (6y old son, 9y old daughter). Picture 1 – Left retro-peritoneal necrotic lesion From a diabetes perspective, following recovery from DKA, he was started on a basal-bolus subcutaneous insulin regime. Interest- ingly, when he was started on alpha and beta blockade for phae- ochromocytoma, his glycaemic control improved: he stopped his 38 19 - 22 October, 2017 Antalya - Turkey 2017

Picture 2

Picture 2 - MIBG-avid left adrenal phaeochromocytoma

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O-31 Adrenal 17 Α-HYDROXYLASE, 17-20 LYASE DEFICIENCY, A RARE CASE WITH INFERTILITY GÜLAY ŞIMŞEK BAĞIR1, FILIZ EKŞI HAYDARDEDEOĞLU1, BÜLENT HAYDARDEDEOĞLU2, EMRE BOZKIRLI1, OKAN BAKINER1, MELEK EDA ERTÖRER1 1 DEPARTMENT OF ENDOCRINOLOGY, BASKENT UNIVERSITY, ADANA,TURKEY 2DEPARTMENT OF OBSTETRICS AND GYNECOLOGY, BASKENT UNIVERSITY, ADANA, TURKEY

Introduction: 17 alpha hydroxylase, 17-20 lyase (17-OH/17-20- was normal. Her laboratory results were: FSH: 29.9 mIU/ml (1.37- lyase) deficiency is a rare type of congenital adrenal hyperplasia 9.9), LH: 15.2 mIU/ml (1.68-15), Estradiol (E2): 11.8 pg/ml (30-119), (CAH). It is due to a mutation in CYP17A1 gene and characterized Progesterone: 7.4 (0.15-1.4), details in Table 1. No uterovaginal with adrenal and gonadal sex steroid deficiency, delayed puberty, anomalies was detected at abdominal and pelvic imaging. Karyo- hypergonadotrophic hypogonadism and infertility. This mutation, type analysis was 46, XX. Her low serum cortisol, DHEA-S, an- disrupts steroidogenesis both in adrenals and gonads and causes drostenedione and high progesterone levels were consistent with decreased production of glucocorticoids and sex steroids. Accom- 17-OH/17-20-lyase deficiency. Treatment with dexamethasone was panying high mineralocorticoid precursors may result in varying started to control adrenal progesterone production. The progester- degrees of hypokalemia and hypertension. Depending on the se- one levels were suppressed with glucocorticoid therapy at the end verity of the mutation, affected 46, XY individuals may exhibit am- of the first month of therapy (Progesterone: 0.0 (0.15-1.4). She is biguous genitalia or female phenotype, where as 46, XX patients now being treated for infertility at our institution. Her genetic anal- present without secondary sexual characteristics and/or regular ysis for CAH is pending. menses and with low-renin hypertension and hypokalemia. Serum Conclusion: 17-OH/17-20-lyase deficiency is a rare form of CAH steroid profile of the patients typically demonstrate low androgen, caused by mutations in the CYP17A1 gene. Low serum cortisol, estrogen levels with high gonadotrophins and adrenocorticotropic DHEA-S, 17-OH progesterone and high progesterone are charac- hormone (ACTH). Herein, we present an infertile woman with pri- teristics of 17-OH/17-20-lyase deficiency. It should be considered mary amenorrhea, hypertension and hypokalemia whose clinical in any female patient with primary amenorrhea and deficient sec- and laboratory findings are compatible with 17-OH/17-20-lyase ondary sex characteristics, especially accompanied with hyperten- deficiency. sion and hypokalemia. Clinical Case: A 29-year-old woman was admitted with the com- Keywords: 17 alpha hydroxylase, 17-20 lyase, hypertension, infer- plaint of infertility. She had the history of primary amenorrhea tility and hypertension. On physical examination; her weight was 70 kg, height was 171 cm and blood pressure was 120/70 mmHg. Her breast development was at Tanner stage 3-4 and external genitalia

Table 1. Laboratory findings of the patient

Glucose: 82 mg/dL (74-106) Total testosterone:0.17ng/ml(0.14-0.76) serum creatinine:0.5 mg/dL (0.7-1.3) 17 OH progesterone: 0.35 ng/mL (0.3-1) K: 3.1 (3.5-5.5 mEq/L) DHEA-S <15 (35-430 ug/dL) ACTH: 6.38 pg/mL (0-46) Androstenedione: 2.78 ng/dL (33-134) Cortisol: 1.04 mcg/dL (4.3-22.4) TSH<2.1 uıU/mL (0.4-4.67) PRA<0.15 ng/mL/hour (0.7-3.3) free T4:15.2 pmol/L (11.5-22.7) Aldosterone: 4.1 ng/dL (2.7-27) AMH: 0.85 ng/mL (0-10.3) Blood gases pH: 7.42 (7.35-7.45) Prolactin: 7.4 ng/mL (2.8-29.2) HCO3: 28.2 mmol/L (21-26) PRA: Plasma renin activity AMH: Anti mullerian hormon

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O-32 Adrenal ABDOMINAL PAIN AND TESTICULAR MASSES IN A MALE PATIENT WITH UNTIMELY RECOGNIZED CONGENITAL ADRENAL HYPERPLASIA KARIN ZIBAR TOMŠIĆ1, MIRSALA SOLAK2, DARKO KAŠTELAN3 1 DEPARTMENT OF ENDOCRINOLOGY, DIABETOLOGY AND METABOLISM, VUK VRHOVAC CLINIC, MERKUR UNIVERSITY HOSPITAL, DUGI DOL 4A, ZAGREB, CROATIA 2 DEPARTMENT OF ENDOCRINOLOGY, UNIVERSITY HOSPITAL CENTRE ZAGREB, KIŠPATIĆEVA 12, 10000 ZAGREB, CROATIA 3 DEPARTMENT OF ENDOCRINOLOGY, UNIVERSITY HOSPITAL CENTRE ZAGREB, KIŠPATIĆEVA 12, 10000 ZAGREB, CROATIA; SCHOOL OF MEDICINE, UNIVERSITY OF ZAGREB, ŠALATA 3, 10000 ZAGREB, CROATIA

Introduction: Testicular adrenal rest tumors (TARTs) and enlarge- progesterone (836 nmol/L) and ACTH (23.1 pmol/L). The diagnosis ment of the adrenal glands are both seen in long-standing and of CAH with TARTs was made and dexamethasone treatment initi- poorly controlled congenital adrenal hyperplasia (CAH). ated. After five months of the treatment, ACTH, progesterone, 17- hydroxyprogesterone and testosterone were suppressed but adre- Clinical Case: We report a male patient, aged 49 years, who pre- nal masses only slightly reduced in size. To date, the patient has sented with a few months history of abdominal and left testicular been treated for few years with dexamethasone and testosterone pain. Physical examination revealed enlarged and stiff left tes- undecanoate. The adrenal masses are being treated conservatively. tis, palpable mass besides right testis, while laboratory results showed normal concentrations of testosterone (19.4 nmol/L), LDH Conclusion: This case report highlights unrecognized CAH in pa- (127 U/L) and AFP (1.9 mcg/L). Beta HCG was negative. Left orchi- tient with consequently developed giant adrenal glands tumors and ectomy was performed. Histopathology analysis found infiltrated TARTs. There is a regular lifetime need for endocrinological and testis with brown, soft tumor. Immunohistochemical staining was radiological follow-up and there is still open question what to do positive for vimentin, melan-A, inhibin and synaptophysin. Reinke’s with giant adrenal glands tumors in future. crystals were absent. Abdominal MSCT revealed giant tumor in left Keywords: abdominal pain, testicular masses, adrenal glands en- retroperitoneal area (22 x 15 x 18 x 12 cm) and right adrenal gland largement, congenital adrenal hyperplasia, testicular adrenal rest (5 x 9 cm) with negative attenuation values. Additional hormonal tumor evaluation showed high progesterone (171 nmol/L), 17- hydroxy-

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O-33 Thyroid MACRO-TSH EXISTENCE IN A PATIENT TREATED WITH TYROSINE KINASE INHIBITOR SÜLEYMAN NAHIT ŞENDUR1, ÖZGE AYBI2, MIYASE BAYRAKTAR1 1 DEPARTMENT OF ENDOCRINOLOGY AND METABOLISM, HACETTEPE UNIVERSITY, ANKARA, TURKEY 2 DEPARTMENT OF INTERNAL MEDICINE, HACETTEPE UNIVERSITY, ANKARA, TURKEY

Recently, targeted drugs like tyrosine kinase inhibitors (TKIs) are In the endocrinology clinic, TFTs were rechecked: TSH: 100.3uIU/ commonly used for the treatment of various malignant tumours mL, fT4: 5.4 pmol/L, fT3: 2.6pmol/L. Anti-thyroglobulin antibody with a marked prolongation of survival. Many endocrinologic side was 43 IU/mL (0-4 IU/ml), anti-TPO antibody was 0.4 IU/mL (0-9 effects have been reported with these new drugs but thyroid dys- IU/ml). The thyroid gland was atrophic on thyroid ultrasonography. function is clearly the most common. Diverse mechanisms with re- On the basis of weird TFTs results, TSH measurement interference spect to this adverse effect of tyrosine kinase inhibitors have been was suspected. The measurements were repeated on different an- proposed. Here we report falsely and inappropriately elevated TSH alytical platforms. Results were similar. Heterophile antibody stud- level due to macro-TSH presence in a patient treated with axitinib. ies were negative. Dilution study of patient’s plasma was nonlinear. A 56-year-old female patient was diagnosed with renal cell carci- A 21% recovery was detected by PEG precipitation. Results showed noma five years ago. She was commenced on axitinib for last two that high TSH levels were due to its complex formation with high years due to metastatic disease. Pretreatment TFTs were normal. molecular weight substrate, called macro-TSH. L-thyroxine was On the 18th month of treatment, TFTs were repeated. Test results initiated at a dose of 75 mcg. We decided to titrate dose of L-thy- were suggestive of primary hypothyroidism and 50 mcg of L-thy- roxine on fT3, fT4 levels and clinical findings. roxine was started. After three months of replacement therapy, This is the first report regarding macro-TSH presence in a patient TSH level was higher and the dose of L-thyroxine was increased treated with tyrosine kinase inhibitor. Measurement interference to 100 mcg. After dose increase control TSH level was suppressed. should be kept in mind in patients have discordant thyroid func- L-thyroxine was stopped and the patient was consulted to endocri- tion test results. TSH level should not be used to titrate L-thyroxine nology department because of weird thyroid function tests (TFTs) dose in the patients who use tyrosine kinase inhibitors. results on L-thyroxine treatment. The summary of TFTs were shown in table 1. Keywords: Tyrosine kinase inhibitors, macro-TSH, measurement interference

Thyroid function tests results 18th month of On L-thyroxine After dose increase After L-thyroxine is Pretreatment axitinib 50 μg 100 μg stopped

TSH 0.85 47.9 308.3 0.061 100.3 (0.27-4.2 uIU/mL)

fT4 13.34 9.82 4.20 . 5.4 (12-22 pmol/L)

fT3 3.87 4.39 2.97 . 2.6 (3.1-6.7 pmol/L) Thyroid function tests results of the patient

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O-34 Thyroid FALSE POSITIVE POST RAI SCAN IN A SUBJECT WITH PAPILLARY THYROID CANCER SECONDARY TO URINE CONTAMINATION UMUT MOUSA1, ŞEBNEM AYDIN2, HASAN SAV1, NAFIYE DIREKTOR3, OSMAN KÖSEOĞLULARI1 1 DEPARTMENT OF ENDOCRINOLOGY AND METABOLISM, B NALBANTOGLU HOSPITAL, LEFKOSA, CYPRUS 2 DEPARTMENT OF NUCLEAR MEDICINE, B NALBANTOGLU HOSPITAL, LEFKOSA, CYPRUS 3 DEPARTMENT OF INTERNAL MEDICINE, B NALBANTOGLU HOSPITAL, LEFKOSA, CYPRUS

Introduction: Radioactive iodine (RAI) for remnant ablation and Discussion: Post RAI scanning is a very important technique for post RAI scanning are very frequently employed modalities in dif- determining metastases in subjects with DTC. Contamination with ferentiated thyroid cancers (DTC). Radioactive iodine is secreted body fluids can cause false metastatic findings in which other ra- into physiological secretions such as tears and urine. In this case diological methods and personal history can aid the physicians in report we present a case who received RAI for DTC with a surpris- making a decision. ing post RAI scan compatible with multiple metastases. Keywords: thyroid cancer, iodine scan, false Case Report: A 53 year old male subject underwent total thyroid- Figure 1 ectomy and ipsilateral lymph node dissection after being diagnosed as papillary thyroid cancer (PTC) via fine needle aspiration cytolo- gy (FNAC). He received 150mCI of RAI due to lymph node metas- tases. His stimulated thyroglobulin level (Tg) was 33.3 ng/ml and was positive for anti thyroglobulin antibodies. In the post RAI scan we visualized suspicious metastases in the thyroidal area together with the mid abdominal, proximal right femoral, mid left femoral and distal left tibia areas. The metastatic findings were untypical and were localized anteriorly. Also the patients’ general situation was fine so we planned a bone scan and PET CT to confirm these findings. Both bone scans and FDG PET was negative for metasta- ses. The subjects’ socioeconomic status and personal hygiene was very low thus we suspected these findings were secondary to urine contamination. Six months later he underwent a whole body scan which was negative for metastases. His stimulated Tg was 1.16ng/ ml and anti Tg was positive during the scan. Areas of high uptake suspicious for metastasis are viewed

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O-35 Thyroid MYOEDEMA AND INCREASED SERUM CREATININE IN A CHILD CAUSED BY HYPOTHYROIDISM MARIA PAPAGIANNI1, KONSTANTINOS KOLLIOS2, KYRIAKI TSIROUKIDOU1, KONSTANTINA KOSTA1, ZOI EFSTATHIADOU3, IOANNIS TSANAKAS1 1 Endocrine Unit, 3rd Pediatric Department, Aristotle University of Thessaloniki, Hippokrateion Hospital of Thessaloniki, Thessaloniki, Greece 2 Nephrology Unit, 3rd Pediatric Department, Aristotle University of Thessaloniki, Hippokrateion Hospital of Thessaloniki, Thessaloniki, Greece 3 Department of Endocrinology, Hippokrateion Hospital of Thessaloniki, Thessaloniki, Greece

Background: Hypothyroidism is at the origin various disorders. ingly no characteristic symptoms or signs of hypothyroidism such Myoedema occurs in approximately one third of patients with hypo- as fatigue, constipation or bradycardia with regard to the low fT4 thyroidism. However, it is a rare complication in childhood. concentrations she presented. Moreover, she reported at least one hour of daily physical activity. Clinical Case: A 9.5-year-old girl presented with mild eyelid ede- ma for approximately 2 weeks, skin dryness and progressive mus- During follow-up under treatment, investigation tests showed cle “hypertrophy”, especially in back muscles, noticed during the gradual reduction of the elevated creatinine, enzymes, cholesterol last 2 months. and TSH concentrations with all being normal within one month ex- cept TSH that normalized in 1.5 month. Moreover, fT4 was gradually Her past history was clear. Regarding her family history, her mater- increased to normal levels in 2 weeks’ time. Regarding myoedema, nal grandmother suffered sarcoidosis, type 2 diabetes mellitus and slight improvement was noticed two months after the treatment’s hypertension while her paternal grandmother ankylosing spondy- initiation. loarthritis. Conclusion: Hypothyroidism should be considered in the differen- Her weight was between 25th-50th centile, her height between tial diagnosis of myoedema even in the absence of characteristic 10th-25th centile and she was prepubertal. Physical examination symptoms or signs of this entity. Thyroxine replacement treatment revealed facial swelling and periorbital puffiness, skin dryness and should be initiated as soon as the diagnosis is made leading to myoedema. Neurological examination and the rest of the physical complete improvement in children. examination showed nothing but normal findings. Keywords: hypothyroidism, myoedema, child Her initial investigation tests revealed elevated creatinine (1,26mg/ dl, NR:0,5-0,9), CPK (2450 IU/L, NR<150), LDH (477 IU/L, NR:100- 250), transaminases (AST:144 IU/L, ALT:136 IU/L), cholesterol (530mg/dl) and LDL (420mg/dl) concentrations. Thyroid function tests showed extremely elevated TSH (>500 mIU/L) and very low fT4 (<0.30 ng/dl, NR: 0.84-1.76) concentrations, and high titer of anti-TPO (>600 IU/ml, NR<34) and anti-TG (>4000 IU/mL, NR<135) antibodies. Her myoglobulin levels were also elevated (117μg/L, NR:3-76). Thyroid ultrasound findings were characteristic for Hashimoto’s thyroiditis (diffuse hypo/hyper-echogenicity, micro- nodular thyroid pattern). Electrocardiogram findings were consis- tent with minor ST-T repolarization abnormalities in left precor- dial leads while echocardiogram study was normal. The child was diagnosed with hypothyroidism due to autoimmune thyroiditis and Myoedema was put on thyroxine treatment. Clinically, the patient had surpris-

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O-36 Thyroid A RARE CAUSE OF EXCESS LEUCOCYTOSIS: ANAPLASTIC THYROID CARCINOMA SEDA BAYKAL OĞUZ, UĞUR ÜNLÜTÜRK, MIYASE BAYRAKTAR DEPARTMENT OF INTERNAL MEDICINE, DIVISION OF ENDOCRINOLOGY AND METABOLISM, HACETTEPE UNIVERSITY, ANKARA, TURKEY

Introduction: Anaplastic thyroid carcinoma is a rare but very ag- cm in size with retrosternal extension, invading the right jugular gressive malignancy which accounts for 1–2% of all thyroid can- vein. Multiple metastatic lesions were observed by thorax CT. After cers. Here we report a patient diagnosed as anaplastic thyroid car- normalisation of INR, the patient underwent tracheostomy in order cinoma, presenting with excess leucocytosis. to maintain upper airway patency. During the operation, excision- al thyroid biopsy was performed. Pathology report came back as Case: A 65-year old female was admitted to the emergency depart- high grade epithelial carcinoma, consistent with anaplastic thyroid ment with complaints of rapidly growing cervical mass, difficulty in carcinoma. Bone marrow aspiration was hypercellular, showing in- swallowing, shortness of breath and progressive fatigue. The pa- creased myeloid:eritroid ratio. These bone marrow findings were tient have noticed the cervical mass 2 months ago, which has been interpreted as related to the primary malignancy. Oral hydroxy- rapidly growing since. Past medical history revealed hypertension, urea therapy was initiated. Surgical site infection occurred which coronary artery bypass graft surgery and atrial fibrillation. She required referral to intensive care unit, and the patient died due to also described a recent acute ischaemic stroke which occurred 6 septic shock one month after admission. months ago. While being examined for underlying etiologic factors for stroke, incidental thyroid nodule in the right lobe measuring 2 Conclusion: Median survival in anaplastic thyroid carcinoma pa- cm were found, but diagnostic biopsy was not performed since the tients is 5-6 months. Conventional therapies does not prolong the patient was under anticoagulant and antiagregant therapy. survival of these patients. Patients with leucocytosis have been re- ported to have even shorter survival than patients without leucocy- On admission, the patient appeared to be unwell. A cervical mass tosis. Increased serum G-CSF values and positive immunostaining measuring 10x10 cm was visible which was very hard and fixated with G-CSF had been detected in patients with associated parane- on palpation. Significant trachea deviation was present. Laboratory oplastic leucocytosis. examination revealed mild anaemia, extreme leucocytosis (48200/ uL) and high INR value (>10) due to warfarin overdose. Thyroid func- Keywords: Anaplastic thyroid carcinoma, paraneoplastic leucocy- tion tests and serum calcitonin were in normal range. Nasophar- tosis, short survival ynx MRI detected intrathyroidal mass lesion measuring 10x8x12

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O-37 Lipids/Obesity THE TOUGH JOURNEY TO THE CAUSE OF WEAKNESS OLGU ERKIN ÇINAR, SÜLEYMAN NAHIT ŞENDUR, UĞUR ÜNLÜTÜRK HACETTEPE UNIVERSITY FACULTY OF MEDICINE, ANKARA, TURKEY

Introduction: Lipid storage diseases are a group of inherited met- The patient has been referred to our hospital because of treatment abolic disorders in which harmful amounts of lipids accumulate in failure about ten months ago. The neurological examination had some parts of the body; especially in central and peripheral nervous shown no objective muscle weakness and EMG was normal. The system, muscles, liver, spleen and bone marrow. The causes are patient has been considered depressive and consulted to Psychia- absence or dysfunction of an enzyme involved in lipid metabolism. try. No improvement was achieved with antidepressant treatment Therefore related enzymatic problem can cause many subtypes of in 3 months. Neurological evaluation was repeated, mild proximal lipidosis’ according to the affected pathway. Lipid storage diseases muscle weakness was detected and the patient has been consult- are often diagnosed in childhood but rarely there are forms that ed to Rheumatology and Endocrinology departments. Previous progress slowly and diagnosed in adulthood. muscle biopsy sample obtained and its pathological evaluation renewed. Findings were suggestive of polymyositis but clinicians Clinical Case: A 35-year-old woman presented with general body didn’t agree with the pathologists. The patient was hospitalized for pain with movement and weakness which began 2 years ago and close follow-up and diagnostic uncertainty. Muscle biopsy of quad- worsened gradually. She has been followed at a third step hospi- riceps muscle was performed and compatible with lipid storage tal for about six months. Creatine kinase and LDH elevations were disease, no subtype could be specified. Carnitine and coenzyme-Q detected in laboratory tests and rheumatic antibody screening supplements are prescribed. The patient is still being followed out- was negative for ANA and ENA. Gastrocnemius muscle biopsy had patiently. shown obscure and nonspecific findings of necrosis, lymphocytic infiltration and muscle fiber abnormalities. Patient has been diag- Conclusion: Slow-progressing forms of lipid storage diseases can nosed with ‘seronegative’ polymyositis, then treatment was start- be a cause for musculoskeletal, neurologic complaints, organo- ed with 60 mg/day methylprednisolone but after one week, steroid megaly or non-specific but severe constitutional problems in adult- treatment was stopped due to generalized rash. By the way, hy- hood. After frequent causes excluded from differential diagnosis, poglycemic values of at least 46 mg/dl were detected in glycemic lipid storage diseases must be considered in patients undiagnosed follow-up. The genetic test for McArdle and enzyme activity test for or when expected improvement could not be achieved. Pompe disease (alpha 1-4 glucosidase) were found normal. EMG Keywords: lipid storage disease, weakness, polymyositis, glycogen study was normal. Patient has been diagnosed with an unspecified storage disease subtype of glycogen storage disease and starch treatment started, but no significant improvement has been achieved.

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O-38 Lipids/Obesity CONTINUATION OF EVOLUTION: HEADLINER GLARGINE U300 UTKU ERDEM SOYALTIN, ILGIN YILDIRIM ŞIMŞIR, ŞEVKI ÇETINKALP, BANU PINAR ŞARER YÜREKLI DEPARTMENT OF INTERNAL MEDICINE, DIVISION OF ENDOCRINOLOGY AND METABOLISM, FACULTY OF MEDICINE, EGE UNIVERSITY, TURKEY

When the glargine U300 molecule was first developed, the target to pancreatitis, the patient was responded to the insulin infusion was the patients, who treated with high insulin dosage, due to its therapy without apheresis treatment. Based on this clue, to extent three times concentrated composition and gradual release com- the aphaeresis intervals by activating LPL for longer time and in- pared to U100 formulation. The following studies have also showed crease its stability, the U100 treatment was stopped and U300 was that, with the use of U300 formulation compared to the use of U100 initiated. Following the U300 use, the frequency of aphaeresis was formulation, there were fewer nocturnal episodes of severe hypo- initially observed to be 4 weeks and then which became to 6 weeks glycemia, lower weight gain (-0.5 kg) and smaller difference be- (Table 1). The patient has still been followed in our clinic. tween maximum and minimum glucose levels within the 24 hour Result and Discussion: In primary hypertriglyceridemia with pre- period, which means less glucose variability. The U300, which has served LPL activity, due to the advantages such as slow absorption a prolonged efficiency (48-72 h), was also ideal to use as single and prolonged effect, U300 can be used in primary treatment or dose a day. Moreover, no difference is observed in glycemic vari- to prolong apheresis intervals. It will be appropriate to investigate ability based on day or night use. Due to its advantages over U100 this hypothesis with large patient series by measuring LPL activity formulation, the U300 molecule has become an ideal basal insulin and duration. molecule in patients who has type 1 or type 2 Diabetes mellitus (DM) by evolving from its first development purpose. Keywords: Glargine U300, Hypertriglyceridemia, Lipoprotein lipase

Treatment is difficult in primary hypertriglyceridemia (HTG) group. Table 1 Despite the use of lifestyle modification, fibrates, nicotinic acid, Weeks and Apheresis Times TG level (mg/dl) omega-3 fatty acids, insulin and heparin in combination, plasma- With U100 post apheresis 352 pheresis is the only option in patients who has 1000 mg/dl or higher After 1 week after apheresis with U100, 1600 triglyceride (TG) levels. Apo-C3 antisense inhibitors, gene therapy than initiate U300 with alipogene tiparvovec, and clinical use of DGAT1 inhibitors will 1 327 provide new agents for the treatment of this group of patients. 2 564 While we are waiting for these new treatment agents to be ap- 3 782 proved for use in our country, we would like to share our experience 4 916 in a patient who was treated with weekly plasmapheresis. We tried 5, apheresis 1214 to extend lipoprotein lipase (LPL) activity and to make more stable 1 336 with U300 molecule to extent apheresis intervals. 2 544 Case: 53 year-old female had type-5 hyperlipidemia, chronic pan- 3 656 creatitis due to HTG, and DM secondary to chronic pancreatitis. 4 812 HbA1c levels were 6.9% while she was treated with metformin (2 g/ 5 896 day) and glargine U100 (12U/day). While treatment with gemfibrozil 6 956 (2x600 mg), nicotinic acid (2 g/day) and omega-3 fatty acid (4 g/ 7, apheresis 1154 day) for HTG, she was treated with weekly plasmaphaeresis due to Comparison of TG concentrations under treatment with glargine TG levels higher than 1000 mg/dl. In previous hospitalization due U100 and glargine U300

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O-39 Diabetes A RARE CAUSE OF A NEWLY DIAGNOSED DIABETIC CASE WITH DIABETIC KETOACIDOSIS: PANCREATIC FISTULA ADNAN BATMAN, EMRE SEDAR SAYGILI, SEZIN DOĞAN ÇAKIR, SEDA EREN BASMAZ, FEYZA YENER ÖZTÜRK, ESRA ÇIL ŞEN, RUMEYSA SELVINAZ EROL, MUHAMMED MASUM CANAT, YÜKSEL ALTUNTAŞ CLINIC OF ENDOCRINOLOGY AND METABOLISM,UNIVERSITY OF HEALTH SCIENCE,SISLI ETFAL TRAINING AND RESEARCH HOSPITAL,ISTANBUL,TURKEY

Introduction: Diabetic ketoacidosis (DKA) is also a life-threatening 4.9 mEq/l.(Table-1)Abdominal computer tomography was performed condition in which severe insulin deficiency leads to uncontrolled due to abcess history and abdominal tenderness. There was observed hyperglycemia, metabolic acidosis, hyperosmolality,dehydration, an abscess 5x8x12 cm sizes in subdiafragmatic area and pancreatic and electrolyte imbalances.We present a case of a newly diagnoctic multiple calcifications.The patient was admitted to the our clinic with a diabetic case with diabetic ketoacidosis due to pancreatic fistüla. diagnosis of diabetic ketoacidosis and abdominal abcess. Intravenous fluids, insulin and potassium replacement was started. The abscess Case: A 41 years old female patient was presented emergency depart- drainage was done and empirical antibiotic treatment. On the follow ment with polydipsia, polyuria and abdominal pain.Her medical histo- up patient,there was no decrease in the liquid from the drain and no ry included operation because of renal cist and splenectopmy because reproduction in cultures taken.Amylase and lipase assays were done of complication during the operation two years ago.After the operation on the liquid from the drain. Pancreatic fistula was diagnosed upon her abdominal pain complain was occasionally repeated and treated detection of amylase: 39679 U/L, lipase 99400 U/L. After 14 days of with the diagnosis of intraabdominal abscess few times.On examina- antibiotherapy therapy, antibiotics were discontinued due to no repro- tion, her temperature was 36 ˚C, blood pressure was 110/70 mmHg, duction in cultures and followed by drainage.After the bloof sugar was pulse was 106, and respirations were 22. Her head and neck examwas regulated,the treatment was planned for follow-up with a 6 week drain normal. Her lung sounds were clear without wheezes or rhonchi. Her to improve the fistula tract. heart sounds were normal. The abdominal exam revealed tenderness to deep palpation in the left upper quadrant and epigastric area but no Conclusion: There are so many causes of secondary diabetes such rebound tenderness or guarding. Extremities were well perfused with ac pancreatectomy, pancreatic cancer, hemochromatosis, polycys- symmetric pulses.Laboratory results were remarkable for a room air tic ovary syndrome, cushing, chronic pancreatitis...etc. Pancreatic arterial blood gas with pH of 7.27, bicarbonate of 17 mEq/l. Urinaly- fistula, that is a rare cause of chronic recurrent pancreatitis, may sis revealed 4+ glucose and 3+ ketones. Chemistry panel revealed a result in a loss of β cell function caused secondary diabetes. glucose of 301 mg/dl, BUN of 20 mg/dl, creatinine of 0,49 mg/dl, CRP Keywords: pancreatic fistula,diabetes mellitus,diabetic ketoacidosis of 128 mg/L,HbA1c of 16,9 %,sodium of 135 mEq/l and potassium of Table-1

Test results of the patient 48 19 - 22 October, 2017 Antalya - Turkey 2017

O-41 Diabetes MAURIAC’S SYNDROME CAUSED BY MUNCHAUSEN SYNDROME-ASSOCIATED INSULIN ABUSE IN TYPE 1 DIABETES MELLITUS SÜLEYMAN ŞENDUR, EZGI ÇALIŞKAN, SELÇUK DAĞDELEN, UĞUR ÜNLÜTÜRK, TOMRIS ERBAŞ, MIYASE BAYRAKTAR DEPARMENT OF ENDOCRINOLOGY,HACETTEPE UNIVERSTY,ANKARA,TURKEY

Introduction: Mauriac syndrome is a rare but preventable com- and revealed megamitochondrias with extensive macrovesicular plication of poorly controlled type 1 diabetes mellitus which was steatosis. Intranuclear glycogen inclusions in hepatocytes were firstly described by Pierre Mauriac in 1930 as the triad of dwarf- seen. Despite strict dietary precautions and intensive insulin regi- ism, hepatomegaly and cushingoid like obesity in children with di- men, blood glucose control was not achieved and frequent hypogly- abetes.It manifests as hepatomegaly due to hepatic glycogenosis, cemia attacks were noted. At one ward visit, incidentally, an insulin elevated liver enzymes, serum lipids, varying degrees of dwarfism injector was found on patient’s bed. The patient was consulted to due to puberty and growth delay, cushingoid features like abdomi- psychiatry. Munchausen syndrome was diagnosed and the patient nal obesity,abdominal protuberance, proximal muscle wasting and was transferred to the psychiatry clinic. Detailed psychiatric ques- moon face. We hereby report a case of Mauriac’s syndrome which tioning revealed past history of sexual abuse by step grand-father was triggered by insulin abuse. and domestic violence. Glucose control was succeeded with psy- chiatric support. With appropriate management of good glycemic Clinical Case: A 19-year-old female, refferred to our hospital in control, the patient showed improvement in liver size, at liver func- case of liver transplant requirement with a history of abdominal tions. The fasting blood sugar and triglycerides showed a reduction. protuberance, poor glucose regulation and newly diagnosed hep- atomegaly with elevated liver enyzmes. She was diagnosed to have Discussion: Hereby we report a type 1 diabetic patient emerged T1DM at 9 years old. Since then she had been on intensive insulin with Munchausen syndrome by self-manipulating insülin regimens treatment. During the last two years, she complains abdominal and then complicated with Mauriac’s syndrome. Inappropriate in- distension which was gradually increasing and abdominal discom- sulinization like in our case, may cause excessive hepatic glyco- fort on right upper quadrant. Her height was 148 cm (<3%) and gen storage and so on Mauriac’s Syndrome which is also known her weight was 46 kg (3-10%). On physical examination, a large as pseudo-Von Gierke disease. This rare clinical entity should be non-tender liver was palpated below subcostal margin with regu- considered in differential diagnosis of delayed puberty and pseu- lar contours, no ascites were detected. Secondary sexual charac- do-Cushing’s syndrome as well. So the physician should always ters were arrested at Tanner stage 3. There were signs of Cushing’s keep this syndrome in mind while treating patients with diabetes. syndrome. Transamimases were elevated, and her HbA1c level was Keywords: Type 1 Diabetes Mellitus, Mauriac’s Syndrome, Mun- 9.9%. Abdominal USG showed hepatomegaly ( long axis: 21 cm), chausen Syndrome hepatosteatosis and a hemangioma. Liver biopsy was performed

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O-42 Adrenal ONCOCYTIC NEOPLASM: A RARE TYPE OF ADRENOCORTICAL TUMOR HANDE PEYNIRCI1, BENGÜR TAŞKIRAN2, ÖZLEM SARAYDAROĞLU3, ERDINÇ ERTÜRK4 1 DEPARTMENT OF ENDOCRINOLOGY, KASTAMONU STATE HOSPITAL, KASTAMONU, TURKEY 2 DEPARTMENT OF ENDOCRINOLOGY, YUNUS EMRE STATE HOSPITAL, ESKIŞEHIR, TURKEY 3 DEPARTMENT OF PATHOLOGY, ULUDAĞ UNIVERSITY, BURSA, TURKEY 4 DEPARTMENT OF ENDOCRINOLOGY AND METABOLIC DISORDERS, ULUDAĞ UNIVERSITY, BURSA, TURKEY

Introduction: Oncocytomas are neoplasms consisting of cells with was not suppressed below 1.8 mcg/dl, 2 day dexamethasone sup- abundant eosinophilic granular cytoplasm, swollen mitochondria, pression test was run. Cortisol level was not suppressed again (29 and plenty of oncocytes. Adrenal gland is a rare site of occurrence. mcg/dl). Plasma renin activity was 2 ng/mL/hour and aldosterone Until recently about 160 cases have been reported. Adrenal oncocy- level was 103 ng/dL. We excluded Conn syndrome. Catecholamines tomas (AO) are classified into three histological categories; benign, and derivatives were also measured in 24 hour collected urine. undetermined malignant potential, and carcinoma according to They were within normal range. While diagnostic work up was un- Lin-Weiss-Bisceglia criteria. They are usually incidentally detect- derway, she got pregnant. DM was out of control and oral single ed, nonfunctional, and benign. AOs are management in a similar antidiabetic therapy was switched to intensive insulin treatment. manner to adrenal adenomas, namely function and suspicion of Hypertension ensued and raised up to 200/100 mmHg. A council malignancy are key considerations. consisting of endocrinologists,obstetricians, and pediatricians dis- cussed the case and surgery in the second trimester was planned. Case: A 32 year old female patient was admitted to the endocrinol- She underwent left side adrenalectomy ar 22nd week of gestation. ogy unit due to weight gain, increased hair, and irregular menstrual Unfortunately the neonate did not survive. Histopathological diag- bleeding in 2011. She had diabetes mellitus and was managed on nosis was benign oncocytoma measuring 32x32x27 mm. metformin therapy. On physical examination she had moon face,buf- falo hump, and abdominal violet striae. Our preliminary diagnosis Conclusion: In the literature 17% of AOs are functional. Functional was Cushing syndrome. Therefore we studied ACTH and basal cor- AOs may secrete aldosterone, androgens, interleukin-6, or cortisol tisol (1 pg/ml and 27 mcg/dl). ACTH level supported adrenal origin. in excess. There are 6 case reports of cortisol producing AOs in the Adrenal CT was performed. An ovoid mass, measuring 30x25 mm literature. There is only one case in the literature regarding cortisol in size with smooth margin, homogenous on contrast enhanced im- secreting AO in pregnancy. ages was noted. Low dose dexamethasone suppression test was Keywords: adrenal oncocytoma, Cushing syndrome, pregnancy performed and cortisol level was 17.6 mcg/dl. Since cortisol level

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O-43 Adrenal DIFFERENTIAL DIAGNOSIS OF CUSHING’S SYNDROME: IS BASAL SERUM ACTH ENOUGH? BÜŞRA FIRLATAN1, SEDA OĞUZ BAYKAL2, MIYASE BAYRAKTAR2 1 DEPARTMENT OF INTERNAL MEDICINE,HACETTEPE UNIVERSITY SCHOOL OF MEDICINE,ANKARA,TURKEY 2 DEPARTMENT OF INTERNAL MEDICINE,DIVISION OF ENDOCRINOLOGY AND METABOLISM,HACETTEPE UNIVERSITY SCHOOL OF MEDICINE,ANKARA,TURKEY

Introduction: Cushing’s syndrome consists a group of signs and nary free cortisol.There was no suppression of cortisol by low dose symptoms that reflect prolonged and high exposure to glucocor- Liddle test. Dynamic pituitary MRI detected a lesion in the junc- ticoids.The clinical picture is significantly variable. Occasionally,- tion of adenohypophysis and neurohypophysis measuring 1 mm, Cushing’s syndrome accompanies pregnancies and could be misdi- with no contrast enhancement. Inferior petrosal sinus sampling agnosed as preeclampsia/HELLP or gestational diabetes. Here we was performed.Since peak central to peripheral plasma ACTH ra- present a case of Cushing’s syndrome with many misleading and tio was less than 3, the patient was further examined for ectopic confounding features. sources of ACTH secretion. Thorax CT did not discover any mass lesion, while an adrenal mass measuring 45x32 mm was noticed by Case Presentation: A 35-year-old primiparous woman was ad- abdominopelvic CT, which was consistent with adrenal adenoma. mitted to obstetrics and gynecology department due to high blood 24-hour urine metanephrine and normetanephrine levels were in pressure, muscle weakness and edema at the 21st week of ges- normal range. Because of the size of the adenoma, unilateral left tation. On admission,her blood pressure was 200/110 mmHg.Hy- adrenalectomy was performed. Histopathologic examination con- pertension was diagnosed during pregnancy, and she was being firmed a benign adrenocortical adenoma. Signs and symptoms of treated with alpha metildopa since 8th week of gestation. Labo- hypercortisolism disappeared after surgery and the patient’s blood ratory studies revealed Hb:13.1 gr/dL, Platelet:136 x10³/µL,ALT:53 pressure was 120/75 mmHg without medication. U/L(<35),AST: 35 U/L( <35),GGT: 152 U/L(<38),ALP:31 U/L(30-120). Serum electrolytes were in normal range except mild hypokalemia. Discussion: Early recognition of Cushing’s syndrome in pregnancy Proteinuria of 4708 mg/day was detected. The patient was diag- is important for maternal and fetal outcome. The differential di- nosed as HELLP syndrome and the pregnancy was terminated.She agnosis of Cushing’s syndrome can be challenging in most cases. was referred to nephrology clinic due to hypertension, proteinuria Contrary to what is believed, a normal ACTH does not rule out ad- and edema two weeks after delivery. Mean blood pressure was renal Cushing’s syndrome, as seen in our patient.Positive pituitary measured as 152/106 mmHg by 24-hour ambulatory blood pres- imaging is not adequate to diagnose Cushing’s disease, since inci- sure monitoring. Spot urine albumin to creatinine ratio was 1292 dental pituitary adenomas are frequent findings which can easily mg/g creatinine.Because of her cushingoid appearance, the pa- mislead clinicians. tient was referred to endocrinology. Basal cortisol and ACTH levels Keywords: Cushing’s syndrome, pregnancy, adrenal adenoma, uni- were 27,06 µg/dL (N: 6.7-22.6) and 26 pg/mL (N:0-46), respectively. lateral adrenalectomy A 24 hour urine collection revealed 3.5 fold increased level of uri-

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O-44 Adrenal SYSTEMIC BURKITT’S LYMPHOMA MIMICKING ADRENAL CARCINOMA İBRAHIM DEMIRCI1, ORHAN DEMIR1, CEM HAYMANA1, SEMRA İNCE2, AYDOĞAN AYDOĞDU1, ALPER SÖNMEZ1, ÖMER AZAL1 1 DEPARTMENT OF ENDOCRINOLOGY AND METABOLISM, GULHANE TRAINING AND RESEARCH HOSPITAL, ANKARA, TURKEY 2 DEPARTMENT OF NUCLEAR MEDICINE, GULHANE TRAINING AND RESEARCH HOSPITAL, ANKARA, TURKEY

Background: Burkitt’s lymphoma is a distinct pathologic entity char- McGrath A and B protocol was started immediately following the acterized by a diffuse undifferentiated malignant lymphoma of B cell Burkitt’s Lymphoma Diagnosis. Biochemical and radiological re- origin. While primary adrenal lymphoma is a very rare, adrenal me- mission was achieved after third cycle of chemotherapy. An Autol- tastases occur late in the course of disseminated cancers. Cure rate ogous Bone Marrow transplantation following high dose chemo- is 70-80% when effective therapy is initiated precisely. Salvage therapy therapy is planned. has been generally ineffective in patients failing the initial treatment, Conclusion: Although it’s rare, lymphoma should be considered in emphasizing the importance of the initial treatment approach. Here the presence of adrenal mass as treatment approaches are com- we report a case of a 36 yrs. old male with right adrenal mass diag- pletely different. Fine needle aspiration cytology can be very effec- nosed as Burkitt’s lymphoma on metastatic lymph node biopsy. tive for detection of such rare presentations which will help in initi- Case: A 36-year-old male patient with persistent headache di- ation of early therapeutic intervention. rected to our hospital after a 5-day pulse steroid therapy, which Keywords: Adrenal, Burkitt’s Lymphoma, Carcinoma, Meningitis is given at previous clinic by considering a demyelinating disease. His headache was very severe and ongoing for about one month Figure - 1 despite analgesics, and didn’t relieve by the pulse steroid therapy.

When he admitted to our hospital there were no specific finding in his physical examination. Lymph nodes were not palpable. There was no motor deficit in neurologic examination, and cranial MRI was normal. There wasn’t any pathologic value observed in his initial biochemistry investigations and investigations for HCV, HIV 1 and 2, HBV were neg- ative. Because of high fever (>38 Celsius) and persistent headache, a cerebro-spinal fluid (CSF) sampling was performed to exclude men- ingitis. Some atypical lymphocytes were reported in the cytological evaluation of CSF. In the next step, bone marrow examination and a thoracoabdominal CT scan planned. CT imaging showed a 42*40*50 mm heterogeneous right adrenal mass, with Haunsfield Unit 64 and A. Maximum intensity projection (MIP) image of FDG PET study in a absolute washout 36%. In dynamic MRI the signal index of lesion was 6-year-old male patient with lymphoma shows multiple malignant le- 9. The functionality tests of adrenal mass were not suspicious for ste- sions with increased FDG uptake. B. Axial fusion and C. Axial CT imag- roid or catecholamine synthesis. A council was gathered consisting es show increased FDG uptake of a left surrenal mass (SUVmax:23.2) of related clinics and a consensus of performing a PET/CT scan and (short thin arrow). D. Axial fusion image shows focal increased FDG biopsy of most suspicious and suitable lymph node was made. uptake of a subcutaneous nodule in anterior cervical region (SUV- max:6) (long thick arrow). E. Sagittal fusion image shows linearly A suspicious cervical lymph node was detected in the PET/CT scan increased FDG uptake in spinal cord between T12-S1 considered as (Picture 1) and a biopsy was performed. The immunochemistry re- neural invasion (long thin arrow) (SUVmax:13.4). F. Axial fusion image sult was consistent with “B cell acute lymphoblastic leukemia/lym- shows focal increased FDG uptake of a subcutaneous nodule next to phoma”; the neoplastic cells were positive for Pax-5, Bcl-2, Bcl-6, right masseter muscle (SUVmax:6.7) (short thick arrow). G. Maximum CD10, CD19 (weak), CD99, TdT, c-Myc and Ki-67 proliferation index intensity projection (MIP) image of FDG PET study after chemotherapy was almost 100%. There was no infiltration reported in bone mar- shows no pathologic FDG uptake in whole body. This finding was con- row examination. sidered as metabolic complete response to therapy. 52 19 - 22 October, 2017 Antalya - Turkey 2017

O-45 Thyroid DOES THE ACR TI-RADS SCORING ALLOW US TO SAFELY AVOID UNNECESSARY THYROID BIOPSY? SINGLE CENTER ANALYSIS IN A LARGE TURKISH COHORT FATOŞ DILAN KÖSEOĞLU1, BARIŞ AKINCI2, BAŞAK ÖZGEN SAYDAM2, NIHAT ALI ERARSLAN3, AYŞE GÜLDEN DINIZ ÜNLÜ4, HAMIYET YILMAZ YAŞAR5 1 DEPARTMENT OF INTERNAL MEDICINE, TEPECIK TRAINING AND RESEARCH HOSPITAL, IZMIR, TURKEY 2 DEPARTMENT OF ENDOCRINOLOGY AND METABOLISM, DOKUZ EYLUL UNIVERSITY FACULTY OF MEDICINE, IZMIR, TURKEY 3 DEPARTMENT OF RADIOLOGY, TEPECIK TRAINING AND RESEARCH HOSPITAL, IZMIR, TURKEY 4 DEPARTMENT OF PATHOLOGY, TEPECIK TRAINING AND RESEARCH HOSPITAL, IZMIR, TURKEY 5 DEPARTMENT OF ENDOCRINOLOGY AND METABOLISM,TEPECIK TRAINING AND RESEARCH HOSPITAL, IZMIR, TURKEY

Introduction: Thyroid nodules are a common clinical problem and nosed with papillary microcarcinoma that was detected on thyroid- thyroid ultrasonography (US), in conjunction with fine needle as- ectomy specimens despite benign FNAB results. Thyroid cancer piration biopsy (FNAB), plays an important role in evaluation of a rates were 7/273 (2.6 %) in patients with TR3; ≥ 25 mm category, patient with thyroid nodule. The American College of Radiology’s 68/896 (7.6 %) in patients with TR4 category, and 19/63 (30.2 %) in (ACR) recently implemented guideline endorses a clinical approach patients with TR5 category. The clinical usefulness of ACR TI-RADS for management of patients with thyroid nodules according to US scoring to avoid unnecessary FNAB was also assessed by specifici- findings to decide whether a FNAB is required. This approach may ty analysis, which showed that the scoring was 98.1 % (95 % CI: 97.2 avoid unnecessary biopsies. However, it is possible that some ma- to 98.7) specific for identification of a benign nodule. The specificity lignant nodules may be overlooked. To address this question, we was calculated as 98.8 % (95 % CI: 98 to 99.3) when patients with retrospectively analyzed our FNAB data primarily by focusing on papillary microcarcinoma who had presurgery FNAB Bethesda II nodules for which no biopsy is recommended based on the ACR results were excluded. Thyroid Imaging, Reporting and Data System (TI-RADS) guideline. Discussion: We were able to detect very few patients with thyroid Materials and Methods: The data were collected in 2847 patients cancer within TR2 and TR3; <25 mm categories. These patients all with thyroid nodules who underwent FNAB in Izmir Tepecik Train- had differentiated thyroid cancers with favorable prognosis, except ing Hospital between 2010 and 2014. Routine FNAB was performed two patients with medullary carcinoma. Our analysis suggested in accordance with 2009 American Thyroid Association guideline. that ACR TI-RADS scoring was highly specific for identification of The nodules were then re-classified according to the ACR TI-RADS a benign nodule. As most thyroid nodules are benign, and even guideline as benign (TR1), not suspicious (TR2), mildly suspicious malignant nodules, particularly nodules smaller than 1 cm, fre- (TR3), moderately suspicious (TR4) and highly suspicious (TR5). quently exhibit indolent or nonaggressive behavior, it is important The TR3 category was stratified into two subgroups regarding to to develop strategies that avoid unnecessary biopsies. Our findings nodule size (TR3; < 25 mm and TR3; ≥ 25 mm). suggest that ACR TI-RADS scoring is a rational, applicable and po- tentially cost-effective approach to determine thyroid nodules to be Results:Among patients classified in the TR2 and TR3; <25 mm biopsied. category, thyroid malignancy was detected in 27 of 1382 patients (2 %). FNAB was able to determine thyroid cancer in 17 of these Keywords: thyroid nodules, fine needle aspiration biopsy, thyroid patients (1.2 %); however, the rest of them (10 patients) were diag- cancer, thyroid ultrasound

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O-46 Thyroid TWO SUBACUTE THYROIDITIS PATIENTS PRESENTING AS FEVER OF UNKNOWN ORIGIN (FUO) AND DIAGNOSED AFTER F-18 FLUORODEOXYGLUCOSE (FDG) POSITRON EMISSION TOMOGRAPHY (PET) FINDINGS NURDAN GÜL1, HÜLYA HACIŞAHINOĞULLARI1, EBRU YILMAZ2, HALUK ERAKSOY3, FERIHAN ARAL1, REFIK TANAKOL1 1 DEPARTMENT OF INTERNAL MEDICINE, DIVISION OF ENDOCRINOLOGY AND METABOLISM, ISTANBUL UNIVERSITY, ISTANBUL FACULTY OF MEDICINE, ISTANBUL, TURKEY 2 DEPARTMENT OF NUCLEAR MEDICINE, ISTANBUL UNIVERSITY, ISTANBUL FACULTY OF MEDICINE, ISTANBUL, TURKEY 3 DEPARTMENT OF INFECTIOUS DISEASES, ISTANBUL UNIVERSITY, ISTANBUL FACULTY OF MEDICINE, ISTANBUL, TURKEY

Introduction: 18F-FDG PET in the diagnostic work-up of FUO is Clinical Case-2: A 37-year-old male patient complained of fe- gaining importance. We herein describe two subacute thyroiditis ver, weight loss and sweating. His complaints persisted despite a patients diagnosed after PET-CT imaging. course of antibiotics. Since his fever continued for three weeks, he was admitted to the infectious diseases department. During the Clinical Case-1: A 47-year-old male patient was admitted to out- investigations, a PET-CT imaging revealed a heterogeneous fo- patient clinic with fever, neck pain and sweating. He was investi- cal FDG uptake (SUDmax=5.5-7.1) in the thyroid gland. Although gated one month ago for neck pain and fever. At that time, thyroid the patient didn’t have neck pain, he was considered to have sub- function tests were normal; neck ultrasound revealed a 16x10 mm acute thyroiditis as his acute phase reactants were high, his TSH hypoechoic region with irregular margins without a halo in the left was 0.008 mIU/mL, free T3 was 6.65 pmol/L and free T4 was 28.8 thyroid lobe. The fine needle aspiration biopsy of the lesion was pmol/L. During physical examinations, his thyroid gland was grade reported as benign. He was later admitted to our infectious dis- IB; his right lobe was hard, not tender and a nodule was not pal- eases department with the diagnosis of fever of unknown origin. pated. No uptake was found in the thyroid scintigraphy, but he had His ESR was 111 mm/h, and his C-reactive protein (CRP) was 55 a CT imaging with contrast before. Thyroid ultrasound revealed two mg/L. His investigations for malignancy, infectious and rheumatic isoechoic nodules (16.6x11.7 and 8.8x 7 mm) with irregular mar- diseases were negative. PET-CT revealed a diffuse FDG uptake in gins in the right lobe. During the follow up, his fever, ESR and CRP the thyroid gland (SUDmax=10). The findings were thought to be normalized without treatment. Because heart rate was normal, he compatible with subacute thyroiditis. Since CT imaging had been was not given beta-blockers for thyrotoxicosis. His TSH later rose performed with contrast during investigations, thyroid scintigra- up to 4.7 mIU/mL while free T3 and free T4 were in normal ranges. phy could not be done. During the follow-up, we observed that his TSH levels were suppressed and that free T4 and free T3 levels had Conclusion: Subacute thyroiditis can be easily diagnosed due to increased; he later became hypothyroid. After diclofenac and pro- symptoms such as neck pain, fever and accompanying laboratory pranolol treatment he gradually recovered, and his ESR and CRP findings such as an increase in acute phase reactants and thyroid normalized in a month. dysfunction. However, in patients with normal thyroid function tests on disease onset or with rare patients without typical neck pain, di- agnosis can be challenging, and a PET-CT imaging may be helpful.

Keywords: Subacute thyroiditis, PET-CT, fever of unknown origin

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O-47 Thyroid PAPILLARY THYROID CARCINOMA LYMPH NODE AND LUNG METASTASES WITHOUT PRIMARY TUMOR RADAN DZODIC1, NADA SANTRAC2 1 DEPARTMENT OF SURGERY, MEDICAL SCHOOL, UNIVERSITY OF BELGRADE, DR SUBOTICA 8, BELGRADE, SERBIA 2 SURGICAL ONCOLOGY CLINIC, INSTITUTE FOR ONCOLOGY AND RADIOLOGY OF SERBIA, PASTEROVA 14, BELGRADE, SERBIA

Introduction: A 25-years old female was admitted to our institu- Postoperative course was uneventful. Multidisciplinary team decided tion after extirpation of middle neck line tumor in regional hospital, for adjuvant radioiodine I-131 therapy. Whole body post-iodine therapy with pathohistological (PH) diagnosis of lymph node (LN) metasta- scan showed no fixation in the neck, but presence of micro nodular sis of papillary thyroid carcinoma (PTC, follicular type). There was changes in lungs were recorded. Suppressive levothyroxine dose was no evidence of LN tissue in the metastasis. started. In the follow-up, chest computed tomography and whole body scintigraphy will be done to assess status of lung metastases. Clinical Case: In preparation for re-do surgery, physical and ultra- sound examination were showed pathological LNs in both jugular Conclusion: Based on initial presentation of the disease and defi- regions, no tumors in thyroid gland, nor signs of thyroglossal duct nite PH findings LN metastases in central and jugular regions, remnant. Chest X ray was clear for metastases. Other findings of without PTC in the lobes, the most probable explanation is that py- laryngoscopy, abdominal ultrasound, biochemical analyses, thyroid ramidal lobe PTC was removed during initial surgery, later to be and parathyroid status were within normal range. After multidisci- mistaken for pre-cricoid LN metastases on PH analysis. There are plinary team decision, based on protocols for thyroid malignancy, only several cases of pyramidal lobe PTCs described in literature. patient was reoperated. To complete surgical treatment, we per- Other possibility is that the removed structure in the middle neck formed total thyroidectomy, bilateral central neck dissection and line was actually metastatic pre-cricoid (Delphian) LN (or LNs), and bilateral lateral neck dissections (regions III and IV on the left, re- that complete involution of primary PTC in the lobes occurred, or it gions III, IV and V on the right side), along with excision of pre-cri- was lost on PH analysis due to small diameter. coid LNs and scar after previous operation. Whatever the genesis of PH findings and current disease extent is, Definite PH showed no PTC in thyroid gland. However, LN me- adequate preoperative diagnostic algorithm would have prevented tastases were found in 3/9 central LNs, 1/8 left jugular LNs and two-step surgery in this young female patient. It is mandatory that 2/24 right jugular LNs. Additionally, malignant PTC infiltration of thyroid or head and neck surgery is performed in specialized, high pre-cricoid tissue and scar was found, which suggested inadequate volume surgical centers, with well-defined and established diag- resection during initial surgery. nostic and treatment protocols.

Keywords: papillary thyroid carcinoma, pyramidal lobe, primary carcinoma involution

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O-48 Lipids/Obesity A CASE REPORT: DUMPING SYNDROME AFTER SLEEVE GASTRECTOMY EREN ERDOĞAN, EREN İMRE, GÜLAY ARDALI, ÖZLEM ÜSTAY TARÇIN, OĞUZHAN DEĞNELI, DILEK GOGAS YAVUZ DEPARMENT OF ENDOCRINOLOGY,MARMARA UNIVERSITY,ISTANBUL,TURKEY

Case: A 33 year old female patient, known to have had diabetes around 50 mg/dL accompanied by sweating, weakness, and diz- mellitus and hypertension controlled by metformin and ACE- inhib- ziness which decreased when she ate. She also mentioned that itor treatment for 10 years, underwent sleeve gastrectomy in July these complaints happened 1 hour after the each meal during the 2016 since her BMI was 45.09 kg/m2. Six months after the surgery, day time. The patient was referred to the endocrinology outpatient the patient was observed with 37 kg weight loss. Three months af- clinic and we hospitalized the patient. Because of the postprandial ter the operation, the patient attended to the outpatient clinic of hypoglycaemia, we performed a mixed meal tolerance test (MMTT) general surgery department with the complaints of fatigue, nau- and 75gr oral glucose tolerance test (OGTT). C-Peptide could not sea and vomiting. She was describing that her nausea was starting be measured for technical reasons. We excluded insulinoma since right after the each meal. The Patient was consulted to the sur- the MMTT and OGTT showed decrease in insulin levels correlated gery with the complaint of right upper quadrant pain radiating to with decrease in glucose levels (Table 1). Her clinical features were the back and with the gall stones in her gallbladder detected by thought to be compatible with dumping syndrome. Acarbose was the ultrasonography. Therefore cholecystectomy was performed in initiated by suggesting high fiber, complex carbohydrate, and pro- January 2017 due to the cholelithiasis. In April 2017, hypoglycaemic tein rich foods in her diet. Regression of hypoglycaemic complaints attacks were also added to clinical picture. But the patient’s dia- was detected under the current treatment. betes spontaneously regressed after the operation and was under Conclusion: Dumping syndrome is an important complication after follow-up without medication. Gastroscopic examination in April the bariatric surgery. It should not be overlooked, although it’s rare 2017 was found to be consistent with antral gastritis and gastric after Sleeve gastrectomy. In the treatment of dumping syndrome, emptying scintigraphy showed the acceleration of emptying. She first of all, dietary regulation should be recommended and acar- was not able to adapt to lifestyle changes such as smoking ces- bose may be useful in case of insufficient life style modifications. sation, diet and sports. The frequency of hypoglycaemia increased and hypoglycaemic attacks occurring at night were added to the Keywords: Dumping Syndrome, Sleeve Gastrectomy, Hypoglycaemia clinical picture. She described that her blood sugar levels fell to

Tests 75 gr Oral Glucose 75 gr Oral Glucose Mixed Meal Tolerance Test Mixed Meal Tolerance Test Tolerance Test Tolerance Test

Minute Glucose(mg/dL) Insulin (IU/mL) Glucose(mg/dL) Insulin (IU/mL)

0. 79 3.13 174 31.98

30. 104 12.36

60. 73 2.7 170 -

90. 74 6.07

120. 75 2.05 56 9.8

180. 78 2.3 43 9.6 Table for Mixed Meal Tolerance Test and 75 gr Oral Glucose Tolerance Test

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O-49 Lipids/Obesity A SUCCESS STORY IN WEIGHT LOSS: YOU CAN DO IT WITHOUT BARIATRIC SURGERY OR MEDICATION! FERAY AKBAŞ, HANIFE USTA ATMACA, FETTAH SAMETOĞLU, GÖKALP AVLAĞI, MUSTAFA BOZ ISTANBUL TRAINING AND RESEARCH HOSPITAL, INTERNAL MEDICINE CLINIC, ISTANBUL, TURKEY

Purpose: Obesity treatment includes diet, exercise, medication has been a loyal patient attending his sessions for 4 years. And at and bariatric surgery. Medical treatment options are limited. Bar- the end of 4 years, he lost totally 40 kg (BMI is now 32 kg/m2) with iatric surgery is still not common because of postsurgical compli- only life style changes. He no longer had sleep apnea syndrome, cations and difficulties. Thus; life style changes are still the core of his metabolic state [FBG (mg/dl): 112-99, Fasting insulin (uU/ml): obesity treatment. Here, we present a patient who achieved to lose 43.5-5.8, HOMA-IR:12-1.4] and exercise capacity improved dramat- 40 kg with only lifestyle changes to inspire other patients who think ically and psychologically, he claimed to be better than ever. During such success is impossible without an intervention. his follow-up period he didn’t gain any weight and than he missed his controls for a year. After a year, he gained 5 kg and started his Case Report: 46 year-old, male patient applied to obesity outpa- follow-up sessions again. His new metabolic test results are: [FBG tient clinic in 2011. He had hypertension, sleep-apnea syndrome (mg/dl): 88, Fasting insulin (uU/ml): 12.6, HOMA-IR:2.7] He is on and chronic hepatitis-B. He was put on Orlistat and Sibutramin LMWH for phlebitis and there are no other accompanying diseas- before, lost some weight but regained more in time. His BMI was es. He is showing full compliance again understanding the conse- 44 kg/m2 ( height:182 cm, weight:147 kg). He was put on a Med- quences of missing follow up sessions and has already started to iterranean style diet, calories calculated according to his weight lose weight. and designed considering accompanying diseases. 30 minutes of daily walking was recommended and an education was given about Conclusion: Weight loss is a hard, tricky path for every patient. It nutrition and exercise. He was seen at different intervals and af- needs strength, motivation, support, consistency, time and so much ter weight loss had started, his diet and exercise were modified. effort. It is not easy to have all these components for every patient Intensity, duration and kind of exercise were increased gradually, but when possible, adding the same effort and time from a health- but kept simple and doable. New food and recipes were introduced. care team consisting a specialist doctor, dietitian, physical thera- Most important of all, in every session, enough time was given by pist and psychiatrist, success is possible for most of the patients. the doctor and the patient was intensely motivated. The patient Keywords: obesity, weight loss, life-style changes showed perfect compliance with the instructions he was given and

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POSTER PRESENTATIONS

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P-01 Adrenal A RARE CASE OF PHEOCHROMOCYTOMA WITH RECURRENT HYPOTENSIVE ATTACKS MERVE LEHIMCIOĞLU1, MERVE GENÇ1, RIDVAN ERGIN1, AŞKIN GÜNGÜNEŞ2, ŞENAY ARIKAN DURMAZ2 1 KIRIKKALE UNIVERSITY, FACULTY OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE, KIRIKKALE/TURKEY 2 KIRIKKALE UNIVERSITY, FACULTY OF MEDICINE, DEPARTMENT OF ENDOCRINOLOGY, KIRIKKALE/TURKEY

Introduction: Although most of the pheochromocytomas are pre- 34x35 mm with a santral hypodense area (necrosis?) with a periph- sented with hypertension, sometimes hypotension could be seen. eral region that was isodense. Its absolute washout was % 26.5 Because intraoperative mortality of pheochromocytomas is high, and relative washout was % 12.5, pre-contrast density was below preoperative preparation with alfa- and beta blockers is required. 10 HU. Plasma aldosteron, DHEAS, total testosteron levels were in But there is not enough knowledge about preoperative preparation normal range. Serum cortisol level was 0.576 ug/dl (supressed) af- of pheochromocytomas with hypotension. We aim to mention about ter 1 mg dexametason supression test. Chromagranin A level was preoperative preparation of a case of pheochromocytoma with hy- higher than normal (189.2 ng/ml). Preoperatively midodrin was potension. stopped, 3 g oral salt and 1000 cc % 0.9 NaCl were given and she continued to take flecainide. Doxazosin (4 mg/day) was given daily Case Presentation: Sixty-one years-old woman first referred to for 14 days under close follow up of her blood pressure. The beta the cardiology outpatient clinic 4 years ago. She was diagnosed ar- blocker or phentolamine weren’t required during operation. rhythmia so prescribed midodrine 2.5 mg and flecainide 100 mg/ day. We became suspicious of pheochromocytoma because of her Conclusion: Preoperative preparation of pheochromocytoma with complaints of flushing and hypotension. Her blood pressure was hypotension is different from hypertensive patients. 70/40 mm/Hg. Pulse was 85/min. High metanephrine level was Keywords: adrenal, Preoperative preparation, pheochromocytoma, detected as 1889.54 ug/24 hours urine. Then, abdominal comput- hypotension ed tomography was performed. There was an adrenal tumor sized

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P-02 Adrenal AN AUTOIMMUNE POLYGLANDULAR SYNDROME TYPE 1 WITH ECTODERMAL DYSTROPHY IN HER NAIL MERVE GENÇ1, NURCIHAN ZEYNEP ALTUNDAĞ DERIN1, AYŞE ÖNAL1, AŞKIN GÜNGÜNEŞ2, ŞENAY ARIKAN DURMAZ2 1 KIRIKKALE UNIVERSITY, FACULTY OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE, KIRIKKALE/TURKEY 2 KIRIKKALE UNIVERSITY, FACULTY OF MEDICINE, DEPARTMENT OF ENDOCRINOLOGY, KIRIKKALE/TURKEY

Introduction: Autoimmune polyglandular syndrome type 1 (OPS- her mouth, absence of axillary and pubic hair and ectodermal dys- 1), also been called autoimmune polyendocrinopathy-candidia- trophy in her second finger’s nail. Serum PTH:7.86 pg/ml (15-65), sis-ectodermal dystrophy, has three major components including Ca:7.01 mg/dl (8.6-10) P:4.73 mg/dl (2.5-4.5), Cortisol:1.09 ug/dl mucocutaneous candidiasis, hypoparatiroidism and Addison’s dis- (6.2-19.4), ACTH:262 pg/ml (7.2-63) plasma aldosteron:<20 pg/ml ease. It is an autosomal recessive disorder caused by mutations (29.4-161),Plasma renin activity: 4.18 ng/ml (0.5-1.90). There was in the AIRE gene found on chromosome 21. We aim to indicate a asplenism at her abdominal ultrasonographic examination. Since young woman with autoimmune polyglandular syndrome type 1 all of the three major components of OPS-1 were existing, diagno- presented with ectodermal dystrophy in her nail. sis of OPS-1 was certain.

Case Presentation: A 21 years-old woman who diagnosed with Ad- Conclusion: Autoimmune polyglandular syndrome type 1 can be dison’s Disease came to our outpatient clinic for routine control. presented with ectodermal dystrophy and attention must be paid to She first applied to a hospital at the age of 6 with complaints of ectodermal dystrophy during diagnostic evaluation. fatigue and hyperpigmentation and diagnosed Addison’s disease. Keywords: OPS-1, Addison Disease, ectodermal dystrophy After 6 months, primary hypoparathyroidism has been found. At physical examination there were mucacutaneous candidiasis at

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P-03 Adrenal GA-68 DOTATATE PET/CT IMAGING IN BILATERAL PHEOCHROMOCYTOMA GÜVEN BARIŞ CANSU1, GÖKNUR YORULMAZ2, MAHMUT KEBAPÇI3, MEDINE NUR KEBAPÇI2, BENGÜR TAŞKIRAN1, HASAN ÖNNER4, EVRIM YILMAZ5 1 DEPARTMENT OF ENDOCRINOLOGY, YUNUS EMRE STATE HOSPITAL, ESKISEHIR, TURKEY 2 DEPARTMENT OF ENDOCRINOLOGY AND METABOLIC DISORDERS, OSMANGAZI UNIVERSITY, ESKISEHIR, TURKEY 3 DEPARTMENT OF RADIOLOGY, OSMANGAZI UNIVERSITY, ESKISEHIR, TURKEY 4 DEPARTMENT OF NUCLEAR MEDICINE, OSMANGAZI UNIVERSITY, ESKISEHIR, TURKEY 5 DEPARTMENT OF PATHOLOGY, OSMANGAZI UNIVERSITY, ESKISEHIR, TURKEY

Introduction: Pheochromocytomas are discovered incidentally in 10% 3. Besides, coexpression of SSTR-2A and 3 in pheochromocytomas and bilateral in 25% of cases. MIBG scintigraphy has 53-94% sensi- may lead to heterodimerization and form a novel receptor. This nov- tivity, 82-92% specificity, and a false negative rate of 10% especially el receptor may completely abolish SSTR-3 function. SSTR-2 and 3 in case of extensive necrosis. Ga-68 DOTATATE PET/CT has sensitivity may also show subcellular distribution in addition to membrane of 81-90% and specificity of 82-90%. It is superior to MIBG due to less associated immunoreactivity. In our case, two different activities duration of testing procedure, more accurate spatial localization, less in Ga-68 DOTATATE PET/CT study of bilateral pheochormocytomas exposure to irradiation. Venous sampling and arteriography are rarely may arise from different SSTR subtypes or acitivities. In conclu- performed in case of extra-adrenal pheochromocytomas. sion, results of scintigraphies should be considered in context of SSTR subtype, distribution, number, and heterodimerization. Case: A 52 year old male patient attended endocrinology unit due to vague abdominal discomfort and bilateral adrenal masses detected on Keywords: dotatate gallium ga-68, pheochromocytoma, hypertension CT. He denied any chronic disease except hypertension. Unenhanced Figure images showed 3 masses: right adrenal mass 60x55 mm, and two left adrenal masses 22x18 and 10x10 mm with densities of 30 HU, 25, and 20 HU, respectively. We did low dose dexamethasone suppression test and excluded Cushing syndrome (Table). Catecholamine derivatives in 24 hr collected urine were high and compatible with pheochromocy- toma. Detecting the accurate site of secretion was important to avoid unnecessary and burdensome bilateral adrenalectomy. Alternate di- agnosis were bilateral pheochromocytoma and metastatic pheochro- mocytoma. MIBG might yield false negative results, therefore Ga-68 DOTATATE PET/CT was done and revealed background activity in right adrenal (58.6x47.4 mm, SUVmax 2.52) and increased uptake in left ad- renal (29x16 mm, SUVmax 15.31). He underwent bilateral adrenalec- tomy. Histopathological diagnosis was bilateral pheochromocytoma, PASS score was 8, immunohistochemical staining was positive for MART-1; Ki 67 proliferation index was 4-5%. He was discharged un- eventfully on steroid replacement therapy.

Discussion: Somatostatin receptors (SSTR) are expressed both in adrenal cortex and medulla. Although adrenal glands express all SSTR subtypes, SSTR-2 are concentrated in adrenal medulla. While many pheochromocytomas express SSTR-2, the other receptors are variably expressed. Ga-68 DOTATATE PET/CT may provide addi- tional information regarding lateralization and functionality in case of multiple pheochromocytomas. However if adrenal tumors do not express SSTR or SSTR expression is downregulated, scintigraphy Background activity in right adrenal using Ga-68 DOTA peptides may yield negative results. Among 3 and increased activity in left adrenal Ga-68 DOTA peptides, only DOTA-NOC bears good affinity for SSTR- pheochromocytoma.

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Table 1 Preoperative Postoperative Normal range Glucose (mg/dl) 131 80 70-110 BUN (mg/dl) 13 13 6-20 Creatinine (mg/dl) 0.83 0.93 0.7-1.2 Sodium (mmol/l) 143 139 135-148 Potassium (mmol/l) 4.44 4.56 3.5-5.5 ALT (U/l) 26 20 0-41 AST (U/l) 21 22 0-40 Calcium (mg/dl) 9.24 9.35 8.6-10.2 Albumin (g/dl) 4.6 4.2 3.5-5.2 LDL (mg/dl) 152 164 89-197 25 OH vitamin D3 (ng/ml) 12.3 >20 ACTH (pg/ml) 52.85 7.2-63 Basal cortisol (mcg/dl) 21.43 18< Aldosterone (ng/dl) 8.7 10> Renin (IU/l) 28.6 4.2-59 Urinary cortisol (mcg/day) 137.3 36-137 LDDST: ACTH (pg/ml) 8.12 LDDST: cortisol (mcg/dl) 5.54/1.53 1.8> TSH (mIU/l) 2.90 2.32 0.27-4.20 FreeT4 (ng/dl) 1.23 1.44 0.93-1.70 Free T3 (pg/ml) 3.61 3.95 2.70-4.30 Serotonin (mcg/day) - 108 27-183 5-HIAA (mg/day) - 4.06 2.0-8.0 Metanephrin (mcg/day) 8363.6 3.68 52-341 Normetanephrin (mcg/day) 1490.8 182 484>; 88-444 Adrenalin (mcg/day) - 4> 4-20 Noradrenalin (mcg/day) - 54.7 23-105 Dopamine(mcg/day) - 327.2 62-446 VMA (mg/day) 20.6 4.5 8>; 1.6-7.3

Preoperative and postoperative serum biochemical values, serum hormone levels, and catecholamine and its derivatives in 24 urine collection are shown

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P-04 Adrenal A CHALLENGING CASE OF ADRENOCORTICAL CARCINOMA ORHAN KALAYCI1, GÜVEN BARIŞ CANSU2, BENGÜR TAŞKIRAN2, ÖZLEM EREN3, EYLEM BAHADIR4 1 DEPARTMENT OF SURGICAL ONCOLOGY, YUNUS EMRE STATE HOSPITAL, ESKISEHIR, TURKEY 2 DEPARTMENT OF ENDOCRINOLOGY, YUNUS EMRE STATE HOSPITAL, ESKISEHIR, TURKEY 3 DEPARTMENT OF PATHOLOGY, YUNUS EMRE STATE HOSPITAL, ESKISEHIR, TURKEY 4 DEPARTMENT OF RADIOLOGY, YUNUS EMRE STATE HOSPITAL, ESKISEHIR, TURKEY

Introduction: Adrenocortical carcinoma (ACC) has a prevalence of 3% Conclusion: Low Ki-67 and mitotic index does not necessarily over age 50. About 40% are nonsecretory. Recurrence rate varies be- indicate a benign course. Metastasis and recurrences may occur tween 40-95% according to the stage. Stage I and II ACCs are confined soon after initial surgery even in Stage I ACC. Patients with Stage I to the adrenal glands. Stage IV is characterized with distant metasta- ACC may be a good candidate for novel therapies to avoid repetitive sis. Five year survival rate at stage I is 65%, while it drops to 10% at surgeries, radiotherapy sessions, and established chemotherapies stage IV. CASE: A 62 year old female patient was diagnosed with right along with mitotane. Prolonged survival may not be associated with sided nonsecretory ACC (20x15x9 mm) in 2001. She was followed up disease free survival. ACC may metastasize to spleen quite rarely. without adjuvant therapy until 2005. She underwent partial resection Keywords: adrenocortical carcinoma, splenic neoplasms, adrenal for recurrent mass at contrlateral adrenal gland and 4 sessions of ra- insufficiency diotherapy. Fludrocortisone was started along with deflazacort.

In 2009 ACC recurred at the left sided residual adrenal tissue and me- tastasized to the lower lobe of left lung. In addition a suspicious lymph Figure 1 at left renal pelvis and many calcified and non calcified millimetric nod- ules scattered within all pulmonary tissue were observed. She received 4 sessions of chemotherapy along with mitotane for 10 months after surgical removal of the masses. Ten sessions of radiotherapy were given after cessation of mitotane therapy due to progression of lesions (24x18 mm solid lesion at left renal hilus, 14x3 mm lesion at left adrenal lodge). Meanwhile she received 6 sessions of capecitabine because of progression in imaging studies (18 mm mass in right uppler lobe of right lung, 17 mm supradiaphragmatic mass in the left lung, multiple mass- es measuring 42 mm maximally in close proximity to the left kidney). Therefore mitotane was started and escalated up to 4 g a day in 2014.

In October 2015 combination therapy with mitotane and capecit- abine was discontinued. A new hypodense nodular lesion in superi- or-anterior part of the spleen was discovered until November 2016. She refused combination therapy involving capecitabine, cisplatin, and mitotane. In January 2017 imaging studies revealed multiple mediastinal masses maximum 23*14 mm in size, multiple scat- tered pulmonary nodules maximum 8 mm in size, 60*43 mm mass at splenic hilum, and conglomerated masses extending from left psoas muscle to the lateral contour of left kidney. She underwent debulking surgery including splenectomy. Histopathological eval- left side mass in close proximity to spleen uation revealed capsule and peritumoral adipose tissue invasion and necrosis. Spleen was metastasized. Ki-67 was %3-5 and mitot- ic count was 3-4/ 50 BBA. She did well after surgery and referred to oncology for further radiotherapy and chemotherapy.

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Table 1

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Sodium (meq/L) 144 141 125 145 138 137 139 139 139 137 Potassium (meq/L) 6.7 4.46 6.72 5.36 5.11 4.96 5.52 4.77 5.87 5.0 Chloride (mmol/L) 104 95 111 103 Glucose (mg/dL) 90 97 80 79 80 98 85 87 87 87 BUN (mg/dL) 25 24 48 28.1 23 22 17 23 21 21 Creatinine (mg/dL) 1.00 0.85 0.99 0.80 0.76 0.81 0.86 1.05 0.87 0.79 Calcium (mg/dL) 10.4 9.72 10.39 9.70 9.40 10.1 8.90 9.26 8.90 Phosphorus (mg/dL) 4.83 3.70 3.40 Total protein (g/dL) 8.10 6.94 7.42 7.06 7.50 6.1 Albumin (g/dL) 4.80 4.12 3.80 4.10 4.10 3.28 4.00 3.00 Uric acid (mg/dL) 3.31 3.8 2.5 HDL (mg/dL) 63 70 52 46 Triglyceride (mg/dL) 177 143 230 191 LDL (mg/dL) 136 175 145 172 TSH (mIU/L) 2.31 4.04 Free T4 (ng/dL) 0.829 0.73 Free T3 (pg/mL) 2.60 2.84 Hemoglobin (g/dL) 13.7 11.9 13.1 12.5 11.2 11.2 11.9 10.7 12.1 10.6 Leukocytes 7400 6610 7690 9400 7920 7190 5880 5290 5800 8700 Platelets 293 419 481 335 675 366 380 296 346 667 Hemoglobin A1c (%) 5.49 5.63 AST (U/L) 24 55 49 23 22 16 15 19 16 ALT (U/L) 31 59 23 23 28 13 15 18 18 Vitamin B12 (pg/mL) 130 130 Ferritin (ng/mL) 342 343 ALP (U/L) 164 59 115 88 72 64 128 104 LDH (U/L) 540 143 196 227 181 310 152 Amylase (U/L) 106 52 DHEASO4 (mcg/dL) 7.34

Laboratory data are shown.

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P-05 Bone/Calcium AN INTERESTING CASE WITH RECURRENT TERTIARY HYPERPARATHYROIDISM DEVELOPED FROM AUTOTRANSPLANTED PARATHYROID GLAND AYŞE ÖNAL1, RIDVAN ERDIN1, AŞKIN GÜNGÜNEŞ2, ŞENAY ARIKAN DURMAZ2, ÜMIT ÖZTEKIN3 1 DEPARTMENT OF INTERNAL MEDICINE, KIRIKKALE UNIVERSITY, FACULTY OF MEDICINE, KIRIKKALE, TURKEY 2 DEPARTMENT OF ENDOCRINOLOGY, KIRIKKALE UNIVERSITY, FACULTY OF MEDICINE, KIRIKKALE, TURKEY 3 DEPARTMENT OF NUCLEAR MEDICINE, KIRIKKALE YÜKSEK IHTISAS HOSPITAL, KIRIKKALE, TURKEY

Total parathyroidectomy with autotransplantation of parathyroid Parathyroid hormone: >5000 pg/dl, total calcium: 9.5 mg/dl, phos- gland in the forearm is generally accepted as the treatment choice phorus: 8.55 mg/dl, 25-hydroxy vitamin D: 26.54 ng/ml, albu- for multiglandular disease, however there is contraversion about min:3.39 g/dl, urea:112 mg/dl, creatinine: 5.15 mg/dl levels were optimal surgical procedure. Autotransplantation of parathyroid measured. Surface tissue ultrasound was performed on the left tissue in the forearm is a favorable method for reducing morbid- forearm which revealed suspicious hyperechoic cystic formation ity risk due to the re-exploration of neck. We aim to present an of 27x9 mm dimension. Tc 99m-SestaMIBI parathyroid sintigraphy interesting case with recurrent tertiary hyperparathyroidism from showed findings compatible with a hyperfunctional parathyroid tis- autotransplanted parathyroid gland. sue. An operation was planned for these lesion.

A sixty-seven year old female patient with a twenty-five year old In conclusion, patients undergoing hemodialysis with a history of history of chronic renal failure undergoing hemodialysis who ap- total parathyroidectomy and parathyroid autotransplantation may plied to outpatient clinic with complaint of itching. In 2001, total develop recurrent tertiary hyperparathyroidism. The risk of the de- parathyroidectomy and autotransplantation of the parathyroid velopment of hypoparathyroidism postoperatively is high therefore, gland were performed due to tertiary hyperparathyroidism. close follow-up of patients is necessary.

Keywords: hyperparathyroidism, recurrent, autotransplant, tertiary

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P-06 Bone/Calcium A HYPOPHOSPHATASIA PATIENT WITH MULTIPLE STRESS FRACTURES KORCAN EMRE GÜLTEKIN1, MERVE GENÇ1, AYŞE ÖNAL1, AŞKIN GÜNGÜNEŞ2, ŞENAY ARIKAN DURMAZ2, PINAR ATASOY3 1 KIRIKKALE UNIVERSITY, FACULTY OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE, KIRIKKALE/TURKEY 2 KIRIKKALE UNIVERSITY, FACULTY OF MEDICINE, DEPARTMENT OF ENDOCRINOLOGY, KIRIKKALE/TURKEY 3 KIRIKKALE UNIVERSITY, FACULTY OF MEDICINE, DEPARTMENT OF PATHOLOGY, KIRIKKALE/TURKEY

Introduction: Hypophosphatasia is a rare, genetic disease, char- analysis and organic acid analysis are performed in terms of hy- acterized by mutations in the tissue non-specific alkaline phospha- pophosphatasia, osteogenesis imperfecta and organic aciduria due tase (TNSALP) gene, leading to a diminished activity of the TNSALP to isolated low ALP levels determined in the patient’s routine bio- enzyme in target tissues and accumulation of TNSALP substrates, chemistry and osteopenia detected in the bone mineral densitom- including inorganic pyrophosphate, an inhibitor of mineralization. eter. COL1A1 gene mutation was not observed. On the other hand Clinical features include low levels of alkaline phosphatase in se- organic aciduria was not detected. When ALP gene was amplified, rum and bone and the development of osteomalacia and periodon- heterozygous p.V459M class 2 and heterozygous p.R335K class 3 tal disease. In this case we aim to introduce a patient who suffers mutations were detected. from this very rare disease. In conclusion, the diagnosis of hypophosphatasia in patient with Case Presentation: A forty years-old woman applied to the ortho- multiple stress fractures and low plasma ALP level should be con- pedic outpatient clinic with gait disturbance and tibial pain. She clusive and necessary genetic analyzes should be performed. was operated on because of multiple stress fractures and was di- Keywords: bone, hypophosphatasia, fracture rected to the endocrinology department in terms of etiology. Gene

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P-07 Bone/Calcium A RARE CASE WITH PRIMARY HYPERPARATHYROIDISM DUE TO AN ECTOPIC PARATHYROID ADENOMA IN SUPERIOR MEDIASTINUM NURCIHAN ZEYNEP ALTUNDAĞ DERIN1, BERKAND ÖZPOLAT3, MERVE LEHIMCIOĞLU1, KORCAN GÜLTEKIN1, AŞKIN GÜNGÜNEŞ2, ŞENAY ARIKAN DURMAZ2 1 KIRIKKALE UNIVERSITY, FACULTY OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE, KIRIKKALE/TURKEY 2 KIRIKKALE UNIVERSITY, FACULTY OF MEDICINE, DEPARTMENT OF ENDOCRINOLOGY, KIRIKKALE/TURKEY 3 KIRIKKALE UNIVERSITY, FACULTY OF MEDICINE, DEPARTMENT OF THORACIC SURGERY, KIRIKKALE/TURKEY

Introduction: Primary hyperparathyroidism is the most common neck region was not seen by neck ultrasonograpy. Mediastinel nod- cause of hypercalcemia. The 80-85% of primary hyperparathyroid- ular appearance was detected with thorax computed tomography. ism causes parathyroid adenomas and 15-20% due to parathyroid Ectopic parathyroid adenoma was localized in superior mediasti- hyperplasia. One of the rare causes is parathyroid cancer (%1). num by T 99m-SestaMIBI scintigraphy. Then mediastinel parathy- Most of these adenomas are located near thyroid lobes, but ec- roid adenoma was surgically removed. topic localizations rarely have also been reported. We reported an Conclusion: When the ectopic parathyroid adenoma is in medias- interesting case that has ectopic parathyroid adenoma in superior tenium, preoperative localization of adenoma might be difficultly mediastinum. diagnosed. Case Presentation: We report a case of mediastinel parathyroid Keywords: hypercalcemia, ectopic parathyroid adenoma,medias- adenoma. A 63-year-old female patient was found to have elevated tenium calcium and parathyroid hormone levels. Parathyroid adenoma in

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P-08 Bone/Calcium A RARE PRESENTATION OF PRIMARY HYPERPARATHYROIDISM: GENERALIZED BROWN TUMORS ZEYNEP ÇETIN1, DILEK ŞENSÖZ BERKER2 1 SABUNCUOGLU SEREFEDDIN EDUCATIONAL AND RESEARCH HOSPITAL ENDOCRINOLOGY AND METABOLISM DEPARTMENT, AMASYA UNIVERSITY, AMASYA, TURKEY 2 ANKARA NUMUNE EDUCATIONAL AND RESEARCH HOSPITAL ENDOCRINOLOGY AND METABOLISM DEPARTMENT,UNIVERSITY OF HEALTH SCIENCES, ANKARA, TURKEY

Primary Hyperparathyroidism is a common and easily diagnosed fully with minimally invasive parathyroidectomy. The Brown tumors disease at the present time. Fortunately its presentation like brown retracted after surgery. We understand that, primary hyperparathy- tumor is uncommon. Hereinafter, we reported a case with primary roidism still presents with common bone involvement and can be im- hyperparathyroidism who applied with fragility fracture and in whom proved clinically and radiologically with appropriate treatment. detected common asymmetrically located Brown tumors. The para- Keywords: primary hyperparathyroidism, brown tumor, fracture, thyroid adenoma was located radiologically then operated success- adenoma

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P-09 Bone/Calcium A PRIMARY HYPERPARATHYROIDISM PATIENT WITH ACUTE CHOLECYSTITIS İFFET DAĞDELEN DURAN1, NEŞE ERSÖZ GÜLÇELIK2 1 KIRIKKALE YÜKSEK IHTISAS HOSPITAL, DEPARTMENT OF ENDOCRINOLOGY AND METABOLIC DISEASES 2 ANKARA GÜLHANE EDUCATION AND RESEARCH HOSPITAL, DEPARTMENT OF ENDOCRINOLOGY AND METABOLIC DISEASES

Introduction: Primary hyperparathyroidism(PHPT) and acute/ demonstrated diffuse toxic goiter while parathyroid scintigraphy chronic pancreatitis accompaniment is well-known while PHPT and reported hyperactivity in the inferolateral margin of left lobe. After acute cholelithiasis (AC) do not frequently co-occur. We reported a antibiotherapy and fasting, hepatobiliary inflammation regressed. patient with nausea, weight loss and fatique, who was diagnosed as Dual-energy x-ray absorptiometry (DEXA) scan documented osteo- PHPT and AC managed by parathyroid surgery and thyroidectomy. penia while renal ultrasonography revealed normal findings. Fine needle aspiration biopsy to selected thyroid nodules revealed be- Case: A 75 year old female attended our clinic with 15 kg weight nign results. The patient underwent total thyroidectomy with mini- loss, fever about 38.3 C, vomiting and muscle weakness. She had mal invasive parathyroid surgery. Surgical specimen’s histopathol- no history of disease, no smoking/alcohol habit or drug consump- ogy manifested parathyroid adenoma with benign thyroid disease. tion. Her blood pressure was 140/80 mmHg, pulse rate:102/min, The surgical intervention achieved Ca decrease to 8.4 mg/dl, while body temperature: 38.4. In physical exam she had only mild ten- PTH became 9.47 pg/ml and by time it allowed weight gain to pa- derness in abdomen. Her laboratory evaluation revealed that: cal- tient after disappearance of nausea. One month after surgery, her cium(ca):13.6 mg/dl, albumin:3.2 mg/dl, parathormon(pth): 339 pg/ Ca was 8.3 mg/dl, p: 2.4 mg/dl under 2000 mg calcium carbonate, ml, 25-OH-vitaminD3: 9.5 ng/dl, phosphorus(P): 2.1 mg/dl, mag- giving permission to relieve any symptoms. nesium:1.1 mg/dl, thyrotropin(TSH):0.15, free thyroxine(fT4): 1.27, free triiodothyronine (fT3):2.0, sodium:139, potassium: 4.3,Alanine Conclusion: PHPT and AC, when both established in same individ- aminotransferase (ALT): 20 U/L, Gamma glutamyltransferase ual, would derive the clinician to a dilemma, which to communicate (GGT): 63 U/L, C-reactive protein (CRP):10.93 mg/dl, erythrocyte priorly, especially when dyspeptic symptoms are prevailing, those of sedimentation rate(ESR): 62 mm/h,white blood cell (WBC):10.73 K/ what would be devoted to both diseases and also when the Ca levels µL. She was treated with saline hydration but calcium levels did are so high that they have to be manage promptly. After controlling not decrease, so zolendronate was administered. Abdominal ultra- infection and hypercalcemic state, merely parathyroidectomy would sonography (USG) showed gallstones with dilated bile ducts sup- be an option to cure the patient without cholecystectomy. Total thy- porting AC. Antibiotic therapy was initiated. Thyroid USG showed roidectomy would have played role in assessment of recovery. multinodular goiter with the largest nodule, 12x16x20 mm in the Keywords: primary hyperparathyroidism, acute cholecystitis, nau- right lobe and parathyroid USG assessed 16x22x30 mm hypoechoic sea lesion in the inferolateral border of left lobe. Tyroid scintigraphy

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P-10 Bone/Calcium A CASE OF HYPERCALCEMIA DUE TO SARCOIDOSIS AYŞA HACIOĞLU, ASLI SEZGIN ÇAĞLAR, KÜRŞAD ÜNLÜHIZARCI, ZÜLEYHA CIHAN ÖZDAMAR KARACA, FATIH TANRIVERDI, FAHRETTIN KELEŞTEMUR DEPARTMENT OF ENDOCRINOLOGY AND METABOLISM, ERCIYES UNIVERSITY MEDICAL SCHOOL, KAYSERI, TURKEY

INTRODUCTION: We aim to present the diagnostic approach to a patient with hypercalcemia who only had constitutional symptoms.

Case: Fourty-six-year-old woman presented with weakness, de- lymphadenopathy and the bone scan was normal. She already had creased apetite, weight loss and lower back pain. Prior to admis- thorax and abdominal CT scans before admission to our hospital sion to our clinic some tests had been performed and she was which revealed mediastinal lymphadenopathy and nephrolithiasis. diagnosed as Hashimoto thyroiditis and cholelithiasis and she un- Bronchoscopy was performed and the transbronchial lymph node derwent a cholecystectomy at a different center. Her complaints biopsy was non-diagnostic. Thereafter, mediastinoscopically lymph did not improve even after cholecystectomy. She appeared weak, node excision was performed. The pathology was consistent with pale and had a low-grade fever, but her physical examination was granulomatous disease that pointed to sarcoidosis. The patient was otherwise normal. The laboratory data revealed a leucocyte count consultated with the Chest Diseases department and the tubercu- of 7400/μL, with 71% granulocytes, hemoglobin of 9.5 g/dL (MCV: losis was ruled out with appropriate investigations. Serum ACE lev- 78 fL) and platelets of 316.000/μL. The sedimentation rate was 54 el was also high. The patient was started on glucocorticoid therapy mm/h, ferritin 104 ng/ml and vitamin B12 382 pg/ml (197-771). Her and within three days hypercalcemia had resolved and there was a creatinine was 1.1 mg/dL (glomerular filtration rate 59 ml/min), significant clinical improvement. calcium 13 mg/dL (8.8-10.2), phosphorus 4 mg/dL (2.5-4.5), total Conclusion: Once hyperparathyroidism is ruled out, hypercalcemia protein 5.8 g/dL (6.4-8.3), albumin 2.9 g/dL (3.5-5.2), 25-OH vita- of malignancy seems to be the most likely diagnosis especially if min D 17 μg/L (30<), parathyroid hormone (PTH) 7 pg/mL (15-65) severe constitutional symptoms accompany. Here we aimed to re- and alkaline phosphatase 65 U/L (35-105). The patient was thought mind sarcoidosis as a possible diagnosis even if patient presents to have PTH independent hypercalcemia. The rheumatologic tests with malignancy like symptoms. were negative, the protein electrophoresis and thyroid hormones were within normal range. The chest X-ray revealed bilateral hilar Keywords: Hypercalcemia, sarcoidosis, lymphadenopathy

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P-11 Bone/Calcium HEARING LOSS IN REGRESSED PAGET DISEASE EREN İMRE, DILEK GOGAS YAVUZ DEPARTMENT OF ENDOCRINOLOGY AND METABOLISM, MARMARA UNIVERSITY FACULTY OF MEDICINE, ISTANBUL, TURKEY

Case: We reported a 68 year old woman who attended to ortho- gressed despite treatment and regression of the disease. İt seems pedia outpatient clinic complaining of pain on her right arm. The rational to repeat audiometric assesments during the routine fol- X-ray showed extensive lytic and sclerotic lesions on the right or- low up of the Paget disease if there is disease activation in calvari- thopedics. Because of the suspect of a malignancy, a biopsy was um even in regression. performed and depicted Paget Disease. So the patient was re- Keywords: Paget, Hearing, Loss, zolendronic, acid ferred to outpatient clinics of endocrinology. Total body bone scan was performed and revealed intense uptake of the radionuclide Humerus AP graphy in the calvarium, especially more marked in left parietal, and in right humerus that is generally diffuse but heterogenous in left hemipelvis which are consistent with elevated osteoblastic activ- ity of paget disease. In Laboratory investigations serum calcium, phosphorus, urea, creatinine, liver enzyme levels, serum alkaline phosphatase (ALP) activity and parathyroid hormone (PTH) levels were normal. Serum vitamin D level was deficient. In October 2015 a single 5 mg dose iv zolendronate was given for the treatment of her Paget’s disease after vitamin D deficiency had been correct- ed. The complainings of pain and the pysical findings of pain after pressure on right humerus and warmth of right humerus felt by palpation regressed three months following this treatment and the patient had no sense of hearing loss. Biochemical tests revealed normal calcium, phosporus, parathormon and insufficient vitamin D levels. In January 2017 the patient attended endocrinology out- patient clinics because of began recent problems in hearing. Total body bone scan was repeated and revealed obvious regretion when compared to the bone scan in 2014. But there was still diffuse mild to moderate osteoblastic hyperactivity observed in cranium which decreased according to the previous bone scan after the therapy. The audiometric reassesment showed sensorineural hearing loss. Since there is still uptake on calvarium and hearing loss 5 mg dose iv zolendronic acid was performed again. The follow up of the pa- tient is still continuing with vitamin D replacement.

Conclusion: Hearing loss due to Paget’s disease may not be re- versible but early diagnosis and treatment may prevent further progression of hearing loss. At this patient the loss of hearing pro-

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P-12 Diabetes AN OVERLOOKED RHEUMATOLOGIC MANIFESTATION OF DIABETES: DIABETIC CHEIROARTHROPATHY NESLIHAN GÖKÇEN1, SEHER ÇETINKAYA ALTUNTAŞ2, İLKE COŞKUN BENLIDAYI3, MURAT SERT2, ERSIN NAZLICAN4, TUNAY SARPEL3 1 DEPARTMENT OF PHYSICAL MEDICINE AND REHABILITATION, DIVISION OF RHEUMATOLOGY, CUKUROVA UNIVERSITY MEDICAL SCHOOL, ADANA, TURKEY 2 INTERNAL MEDICINE, DIVISION OF ENDOCRINOLOGY, CUKUROVA UNIVERSITY MEDICAL SCHOOL, ADANA, TURKEY 3 DEPARTMENT OF PHYSICAL MEDICINE AND REHABILITATION, CUKUROVA UNIVERSITY MEDICAL SCHOOL, ADANA, TURKEY 4 DEPARTMENT OF PUBLIC HEALTH, CUKUROVA UNIVERSITY MEDICAL SCHOOL, ADANA, TURKEY

Background/Purpose: Diabetic Cheiroarthropathy (DCA) is de- Results: Two hundred thirty-nine patients (160 female, 79 male) scribed by limitation of the joints in the hand without pain. Patients with diabetes were stratified into three groups: a) Type 1 diabetes with contractures, however, have been shown to manifest of pain mellitus (n=59), b) Type 2 diabetes mellitus (n=89) c) Pre-diabetes and stiffness caused by decreased hand function. DCA as known (n=91). Mean age of patients was 47.8±15.3 years. DCA was deter- an endocrine arthropathy resembles a number of rheumatologic mined in 35.1% of the patients. There were no differences between disorders such as acute arthritis and systemic sclerosis. The aim sex (p=0.097). The percentages of DCA in patients with Type 1 DM, of the current study was to evaluate the frequency of DCA as well Type 2 DM and pre-diabetes were found as 28.8%, 27.0% and 47.3%, as investigate the relationship between the clinical parameters and respectively (p=0.009). The association between DCA and diabetic type of diabetes particularly pre-diabetic states including fasting nephropathy as well as diabetic retinopathy was not established hyperglycemia and impaired glucose tolerance test. (p=0.128, 0.363; respectively). In contrast, DCA was found in a rela- tionship with polyneuropathy (p=0.005). Pre-diabetic DASH scores Methods: The study was designed as a cross-sectional study. 239 were found to be significantly higher compared to type 1 and type 2 patients with diabetes mellitus (DM) who were admitted to Depart- diabetic DASH scores (F=9.326, p<0.001). ment of Internal Medicine, Division of Endocrinology and Metabo- lism at Cukurova University School of Medicine between January Conclusion: DCA was significantly found in patients with pre-dia- 2016 to March 2017 were included in the study. Patients with neu- betes when compared the groups. This result may show that mus- rological and rheumatologic disorders, diabetic ulcers on hands culoskeletal manifestations emerge as an early sign of diabetes in as well as amputation of fingers were excluded. DCA was defined pre-diabetes patients. with regard to physical examination. The patients who had positive Keywords: Diabetes, diabetic cheiroarthropathy, hand, pre-diabe- table top sign and/or positive prayer sign were accepted as DCA. tes, rheumatologic manifestation A self-administered questionnaire (Disabilities of Arm, Shoulder and Hand-DASH) was used to assess the functional disability of patients with DCA.

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P-13 Diabetes IMPROVING DIABETIC FOOT SCREENING (DFS) AND DIABETIC RETINAL PHOTOGRAPHY (DRP) SCREENING RATES AMONG EMPANELLED PATIENTS IN A LOCAL POLYCLINIC IN SINGAPORE TRICIA CHANG NATIONAL HEALTHCARE GROUP POLYCLINICS, ANG MO KIO POLYCLINIC, SINGAPORE

Background: The prevalence of Diabetes Mellitus in Singapore is Results: Patients found materials useful and easy to understand 11.3% based on a National Health survey in 2010 and is increasing and were more willing to undergo screening tests to avoid com- year on year. People with diabetes mellitus may be at risk of de- plications. Doctors and care managers developed a better under- veloping foot problems. They should go for annual screening for standing of the entire screening process and waiting time. After the monitoring and identification of any changes in the patient’s 6 months, the DFS and DRP rates increased to 50 and 53% re- foot risk-status. Diabetic retinopathy is the commonest cause of spectively. This also boosted the clinic’s overall screening rates to blindness in the working age population of developed countries be one of the highest among all the other polyclinics in the same including Singapore. However, it is preventable. About 60% of pa- healthcare cluster. Screening rates ccontinued to increase even tients with diabetes for 15 years of more will have some blood ves- after the project has ended. This translates to early detection of sel damage in their eyes, some of whom are at risk of developing complications and timely referrals where needed. blindness. Keywords: Diabetic foot screening, Diabetic Retinal Photography, Aim/Objective: To achieve 80% DFS and DRP screening rates for Complications, Diabetes Mellitus empanelled patients in Ang Mo Kio Polyclinic Teamlet A within Results 6 months (by end Q3 2016) from the current (as of end Q4 2015) screening rates of 48% for DFS and 34% for DRP, respectively.

Implementation: Visual cues like patient education materials with photographs were utilised to explain to patients regarding poten- tial complications. Efforts were also made to engage patient’s next- of-kin to encourage compliance. The Care coordinator of the team actively checked if DFS/DRP were done at other centres and high- lighted to the Doctors and Care managers if patients were resis- tant to screening. Teamlet staff personally went through the DFS/ DRP process to better empathise with patients. Timely referrals to the financial counsellor, arrangements to pair with other services when making appointments and same-day transfer of suitable pa- tients were also implemented. Using a multi-disciplinary approach helped to increase awareness of the importance of regular screen- ing. After 6 months, the DFS and DRP rates increased to 50 and 53% respectively. The rates continued to improve even after the project had ended.

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P-15 Diabetes THE RELATIONSHIP BETWEEN MICROVASCULAR COMPLICATIONS IN TYPE 2 DIABETES WITH MEAN PLATELET VOLUME (MPV), RED BLOOD CELL DISTRIBUTION WIDTH (RDW), NEUTROPHILE LYMPHOCYTE RATIO (NLO) ZEYNEL ABIDIN SAYINER1, SALMAN ATAKUR2, AYTEN ERAYDIN1, MESUT ÖZKAYA1 1 DEPARTMENT OF ENDOCRINOLOGY AND METABOLISM, GAZIANTEP UNIVERSITY, GAZIANTEP, TURKEY 2 DEPARTMENT OF INTERNAL MEDICINE, GAZIANTEP UNIVERSITY, GAZIANTEP, TURKEY

Introduction: Diabetes Mellitus (DM) is a complex syndrome Results: In this study, we evaluate relationship between microvas- caused by lack of insulin secretion and/or insulin resistance and cular complications with RDW, MPV, NLO. There was statistically emerges with high blood glucose levels, along with multiorgan in- significant difference between nephropaty with RDW, MPV, and NLO volvement and characterized by micro/macro complications. Treat- (respectively p: 0.008, p: 0.014 and p: 0.017). There was statistical- ment process and complications of the disease are huge financial ly significant difference between retinopathy with RDW and MPV and moral problems for society as well as individuals. (respectively p: 0.036 and p: 0.019), no statistically difference with NLO (p: 0.129). Within neuropathy, there was statistically significant Objective: Our aim in this study is to determine relationship be- difference between neuropathy with RDW and NLO (respectively p: tween regulation of blood glucose leves with red cell distribution 0.001 and p: 0.045), no relationship with MPV (p: 0.157). width (RDW), platelet count, neutrophil / lymphocyte ratio (NLO) and mean platelet volume (MPV), also to find theese as useful Conclusion: We evaluated relationship between microvascular markes that predict microvascular compliations or not. We think complications with RDW, MPV, NLO; that we can simply determine early precautions in colmpications will contribute patients survival by hemogram from patients admitted to hospital. These parame- and life quality. ters are benefical and cost-efective markers that we established. However, it will be beneficial to examine whether RDW, MPV and Materials-Methods: In this study, MPV, RDW, glycosylated hemo- NLO have a role or not in more clinical trials and with more DM globin (HbA1c), neutrophil and lymphocyte counts, microvascular patients complications (neuropathy, retinopathy and nepropathy) of 60 pa- tiens diagnosed as diabetes and 60 healty individuals have been Keywords: Diabetes mellitus, MPV, RDW, NLO, Daibetic complica- evaluated retrospectively. Patients with diabetes have been evalu- tions ated according to their HbA1c levels.

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P-16 Diabetes A CASE OF TYPE 1 DIABETES MELLITUS FOLLOWING SLEEVE GASTRECTOMY TAMER TETIKER, GAMZE AKKUŞ, MEHTAP EVRAN, MURAT SERT CUKUROVA UNIVERSTY ENDOCRINOLOGY DEPARTMENT

Bariatric surgery is more effective process in achieving weight loss el, autoantibody seropositivity and recurrent diabetic ketoasidosis and in the treatment obesity associated with comorbid disease history were noticed and suitable intensive insulin treatment was than medical therapy. In this report, we would like to mention a prescribed. We hypothesized that developing autoimmune diabetes young male patient who developed autoimmun diabetes mellitus mellitus is closely related with the changes in immune system af- and underwent bariatric surgery. He was consultated to have his ter the bariatric surgery. blood glucose regulated before necrotising fasciitis surgery. At Keywords: type 1 diabetes mellitus, obesity, autoimmunity, bariat- initial evaluation; high blood glucose, undetectable C-peptit lev- ric surgery

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P-18 Diabetes THE RELATIONSHIP BETWEEN HEMATOLOGICAL INDICES AND INFLAMMATION IN DIABETIC PATIENTS ABDULHALIM ŞENYIĞIT1, BÜLENT YAPRAK2, YILDIZ OKUTURLAR2, BAHAR ÖZDEMIR2, TIMUR ORHANOĞLU1 1 BIRUNI UNIVERSITY, INTERNAL DISEASES CLINIC 2 BAKIRKÖY DR.SADI KONUK TRAINING AND RESEARCH HOSPITAL, INTERNAL DISEASES CLINIC

Aim: Platelets play an important role in the development of vascu- mass indices were calculated. Cases’ hemoglobin A1c (HbA1c) lev- lar complications in diabetic patients. els were investigated. MPV, NLR and PRL were compared between the diabetic and healthy control groups. Large platelets are more active than small ones, and the mean platelet volume (MPV) is a marker used to indicate platelet activ- Findings: 162 patients with type 2 diabetes and 70 healthy control ity. White blood cell (WBC) count, MPV, platelet distribution width subjects were enrolled in the study. Mean MPV was 10.01±0.72 in (PDW), platelcrit (PCT) platelet number, platelet-tolymphocyte the patient group and 9.92±0.70 in the control group. A significant ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) have been difference was determined between the two groups in terms of identified as predictors of endothelial dysfunction and inflamma- MPV (p=0.03), but not in terms of NLR, PLR, UA, fibrinogen, CRP or tion in recent years. The purpose of this study was to investigate homocysteine. When the entire patient group was analyzed, MOPV the association between MPV, NLR and PLR and waist circumfer- was significantly positively correlated with BMI (r=0.138; p=0.04), ence, insulin resistance and body mass index in patients with type waist circumference (r= 0.140; p=0.03), FBS (r=0.151; p=0.02), 2 diabetes mellitus. HbA1c (r=0.130; p=0.04) and HOMA (r=0.141; p=0.03).

Materials-Methods: 162 patients with type 2 diabetes mellitus Conclusion: Our study is compatible with the previous literature. under monitoring at the internal diseases clinic and 70 healthy Inflammation, tendency to clot and thrombosis can be predicted us- subjects were included in the study. Complete blood count, c-reac- ing easily available and inexpensive hematological indices. Large- tive protein (CRP), homocysteine, fibrinogen, uric acid (UA), fasting scale studies are needed to assess their practicality and efficiency. blood sugar (FBS), insulin and insulin resistance were investigat- Keywords: Diabetes, Mpv, Inflammation ed in all patients. Waist circumferences were measured and body

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P-19 Diabetes INSULINOMATOUS AND NONINSULINOMATOUS: TWO HYPOGLYCEMIC CASES İFFET DAĞDELEN DURAN KIRIKKALE YÜKSEK IHTISAS HOSPITAL, DEPARTMENT OF ENDOCRINOLOGY AND METABOLIC DISEASES

Hypoglycemia would result from various reasons in nondiabeto- had no alcohol or drug habitual history. But she was a heavy smok- genics:ranging from drugs, inanition, chronic illnesses to hyper- er, 15 pack year. Her laboratory examination was: FPG:54.9 mg/ insulinemia.The investigation and management is critical since dl, creatinin: 0.55 mg/dl, ALT: 10 U/l, GGT:9 U/l,TSH: 1.08 µIU/ml, hypoglycemia develops troublesome consequences even death. We sodium:138 mmol/l, plasma cortisol: 14.3 mcg/dl. She was recom- reported two seemingly-well hypoglycemic patients: mended to start 72 hour fasting after admission to hospital. First four hours of the test passed when FPG level decreased to 37 mg/ Case1: 26 year old female arrived at our clinic with symptoms for dl. Insulin: <0.2 IU/ml, c-peptit: 0.12 ng/ml were assassed. Abdom- eight years, of shivering, palpitation and loss of consciousness inal ultrasonography and chest X-ray were normal, to exclude criti- which arise before or after meals, sometimes deriving her to emer- cal illnesses. Mammography and colonoscopy were ordered. It was gency department. Plasma glucose was 25-55 mg/dl when medical realized despite the nicotine’s effect increasing insulin resistance, intervention was performed. Her grandmother and dad were type there were studies advocating hypoglycemia frequency increases 2 diabetic. She had no drug consumption. She was hospitalized in smoking individuals but usually in those with diabetes. For our for fasting test’s initialization. Her Fasting Plasma glucose (FPG) patient, smoking was apparently found more suspected for hypo- was 63mg/dl, creatinine(cre):0.6mg/dl, alanine aminotransferase glycemia and she was advised to quit smoking. Dietary modification (ALT): 9 U/l, Gamma Glutamyltransferase (GGT): 7 U/l, sodium: 140 with small frequent meals was also interpreted. Breast and bowel mmol/l,Thyrotropin (TSH): 2.41 µIU/ml. At 2nd hour of test, insulin: investigations are waited. 12.85 ıu/ml, c-peptit: 3.34ng/ml were detected while FPG dropped to 43mg/dl. After glucagon administration FPG level increased to Conclusion: Hypoglycemia would be produced by several entities 99 mg/dl in 10 min. Anti-insulin antibody was negative. İnsulinoma in nondiabetogenic patients. When there is no alternative expla- diagnosis was suggested and radiological investigation revealed a nation, one reason is insulinoma and is diagnosed usually by hy- 9X15 mm hypervascular lesion in inferior of pancreatic uncinate poglycemia stimulated during the first day of fasting test. Smoking process by abdominal computed tomography (CT). Endoscopic ul- although is reported to provoke hypoglycemia in diabetic patients it trasonography was offered for adequate localization. would yet be a possible factor in nondiabetic patients with hypogly- cemic episodes after exclusion of other reasons. Case2: A 27 year old lady was referred to our clinic with hypogly- cemic episodes for one year eliciting tremor and pre-syncope. She Keywords: hypoglycemia,nondiabetogenic, insulinoma, smoking

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P-20 Diabetes EFFICACY OF LIRAGLUTIDE WITH CHANGE OF LIFESTYLE IN TYPE 2 DIABETES MELLITUS FERUZA ABRAROVNA TAKHIROVA, NODIRA MIRSHAVKATOVNA ALIKHANOVA, ZAIRKHODJA SABIROVICH AKBAROV, KHILOLA RUSTAMOVNA GULYAMOVA CENTRE FOR THE SCIENTIFIC AND CLINICAL STUDY FOR ENDOCRINOLOGY

Background: It is important to achieve glycemic goals in type 2 di- Treatment: Liraglutide was added to his metformin, his treat- abetes mellitus patients. It is well known that weight loss in type 2 ment schedule was planned as weekly increasing doses of 0.6, 1.2 diabetes patients is priority, because it stipulates efficacy of treat- and 1.8 mg of liraglutide. He complained on nausea, but when he ment and is the cause of decrease of cardiovascular risk. achieved the highest dose (1.8 mg of liraglutide per day) he didn’t feel nauseaous anymore. To addition to treatment he was teached Clinical Case to principles of a healthy lifestyle. Diagnostic Evaluation: We are presenting the case of thirty-seven years old male patient with a-7 year history type 2 diabetes. He was Follow-up: We followed-up patient with 3 months intervals, after referred to the diabetic clinic for help in managing his diabetes. first 3 months fasting blood glucose decreased to 8.0, HbAIc to When he was diagnosed with diabetes, he had BMI=45.3 kg/m², but 8.6%. The patient was satisfied with treatment. he refused bariatric surgery and was started on metformin (2,000 Another 3 months he was on Mediterranean diet and was engaged mg), he initially responded to this treatment, but he didn’t change in walking. his lifestyle. His laboratory results were as follows: fasting blood glucose - 4.0 At the time of referral physical exam revealed normal vital signs umol/L, HbAIc - 4.4%, AST - 27 U/L, ALT - 35 U/L, total cholesterol - and no retinopathy or other signs of diabetic complications. He 3.5 umol/L, triglyceride - 0.8 umol/L, HDL-cholesterol - 0.8 umol/L, had hypertension and fatty liver disease. His height of 1.76 meter, LDL-cholesterol - 2.3 umol/L, serum creatinine - 80 umol/L and weight of 123 kg, BMI=39.8 kg/m², blood pressure of 140/90 mmHg, microalbumin in spot urine - 25.5 mg/L. and a regular pulse of 84 beats/min. He didn`t receive any treatment for dyslipidemia. In the end of fol- His laboratory results were as follows: fasting blood glucose - 10.9 low-up he lost 13 kg of the weight, his BMI was 35.5 kg/m². umol/L, HbAIc - 11.4%, AST - 31 U/L, ALT - 43 U/L, total choles- terol - 4.9umol/L, triglyceride - 1.9 umol/L, HDL-cholesterol - 0.8 Conclusion: Injections of liraglutide additionally to metformin and umol/L, LDL-cholesterol - 3.25 umol/L, serum creatinine - 80 lifestyle changes with Mediterranean diet and active mobility can umol/L and microalbumin in spot urine - 26.5 mg/L. help to achieve glycemic goals and decrease cardiovascular risk in type 2 diabetes mellitus patients.

Keywords: Type 2 diabetes mellitus, liraglutide, glycemic goals

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P-21 Male Reproductive Endocrinology GENDER IDENTITY DISORDERS – NEEDS FOR ACKNOWLEDGMENT AND IMPROVING THE CARE ELENA MORNEALO1, DANIELA IVANOV2, MAXIM CALARAS3 1 DEPARTMENT OF INTERNAL MEDICINE, ENDOCRINOLOGY, MEDPARK INTERNATIONAL HOSPITAL, CHISINAU, MOLDOVA 2 DEPARTMENT OF CARDIOLOGY, MEDPARK INTERNATIONAL HOSPITAL, CHISINAU, MOLDOVA 3 DEPARTMENT OBSTETRICS AND GYNECOLOGY, MEDPARK INTERNATIONAL HOSPITAL, CHISINAU, MOLDOVA

Introduction: Transgender persons. A lot of challenges they face lar visits he decided to give more details regarding past personal are left in the shadow; both patients and physicians avoid speaking history: 6 years ago has been started testosterone administration about it, former because of constraint, latter because of ignorance for virilization as a part of gender reassignment process. Amen- and lack of accurate information. At the same time, hormonal ther- orrhea appeared after first injection; a male phenotype developed apy followed by transgender persons needs proper regular moni- over the next months. After 6 months mastectomy has been done. toring. We describe a case of a transgender man who had been out He continued to take androgen medicine, but couldn’t maintain an of medical evidence for 2 years; continued taking the androgens efficient relation with his endocrinologist, hadn’t made any medical without checking any lab tests. As the result developed cardiovas- visits, no lab tests for 30 months until spring 2017, when was evalu- cular and hematologic complications. It was by pure chance that ated for hypertension and diagnosed with erythemia. He was taken the trusted young cardiologist, told his personal history and could over by our young medical team: cardiologist, endocrinologist and fix all wrong things. gynecologist; hormone treatment was adjusted and the next stage of surgery – gonadectomy- had been done. The erythrocytes and Case Presentation: A 36-year-old male presented to the cardi- hematocrit levels stay in normal ranges with no any phlebotomy. ologist office with complaints of headache, dizziness, episodically The BP values have been normalized, it was possible to stop anti increased BP, anxiety. The patient stated he had no significant past hypertensive medication. Conclusion. Transgenderism concept is medical history. He was diagnosed with hypertension 10 months not explored in traditional medical training, the management of ago. He was taking regularly medication with no proper cardiolo- transgender persons is confusing for many physicians. There is a gist follow-up, having periodically increased BP values to 180/100 need to greater acknowledgment, to inform the medical aspects mmHg. His general blood count performed few weeks ago re- of care, enabling more doctors to be involved in care of transgen- vealed increased erythrocytes, hemoglobin, hematocrit. He visit- der persons. Also, we would like to emphasize that developing a ed hematologist; was diagnosed with erythemia; got indication for trustworthy doctor-patient relationship is a keystone of care for any phlebotomy. Patient underwent 7 phlebotomies through the next patient; for the transgender person it is of greatest importance. month and was waiting for bone marrow biopsy. At the time of each phlebotomy procedure he was supervised by our young cardiologist Keywords: transgender, hormone treatment monitoring, doc- who has excellent communication abilities and could develop con- tor-patient relationship fident and trust relations with the patient. During one of the regu-

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P-22 Neuroendocrine Tumors THE CASE OF THE NON-ISLET CELL TUMOUR- INDUCED HYPOGLYCEMIA RIFKI ÜÇLER1, GÜLÇIN MIYASE SÖNMEZ2, SALIHA YILDIZ1, MURAT ALAY1 1 DEPARTMENT OF ENDOCRINOLOGY AND METABOLISM, MEDICAL SCHOOL, YUZUNCU YIL UNIVERSITY, VAN, TURKEY 2 DEPARTMENT OF INTERNAL MEDICINE, MEDICAL SCHOOL, YUZUNCU YIL UNIVERSITY, VAN, TURKEY

Introduction: Non-islet cell tumour hypoglycaemia (NICTH) is in our case, we think that the gastric cancer liver metastasis that defined as hypoglycemia resulting from an insulin-independent make large and diffuse infiltration in the liver is closely related to pathway that may be caused by hepatocellular carcinoma, mesen- the development of hypoglycaemia. As a summary, the treatment chymal or other extrapancreatic tumors. Studies have shown the of a rare NITCH case with steroids, in which the gastric cancer with relationship between NICTH and high molecular weight IGF-II lev- recurrence of liver metastasis was suspected of having high-mo- els. In cases where the high-molecular-weight IGF-II level cannot lecular-weight IGF-II secretion, has been reported. be studied the NICTH diagnosis is based on the detection of the Keywords: Non-islet cell tumour, hypoglycaemia, steroid treatment presence of extra pancreatic tumour and the exclusion of other dis- eases that may be caused by hypoglycaemia. Primary tumour re- Laboratory results of the case. section is the first-line treatment for NICTH. When curative resec- tion is difficult, chemotherapy, steroids or growth hormone therapy (Reference range) Glucose (mg/dL) 10 is recommended to reduce the size of the tumour. 70-105 Cre (mg/dL) 0,34 0.7–1.3 Case: Upon an 80-year old male patient’s loss of consciousness AST (U/L) 56 0 - 37 complaint on 16.10.2016, the necessary examinations were applied ALT (U/L) 28 0–41 and he was diagnosed with hypoglycaemia. In his story, it has been ALP (U/L) 206 40-140 seen that on 08.10.2015 he was diagnosed with low differential ade- nocarcinoma after total gastrectomy due to gastrointestinal bleed- GGT (U/L) 82 8 – 61 ing. The patient had no complaints about 1 year before and after Albumin (g/dL) 2,5 3.5–5.2 the operation and at his first visit to hospital he has been diagnosed T.bilirubine (mg/dl) 0,92 0,2-1,2 with hypoglycaemia and hypokalemia resistant to treatment with D.bilirubine (mg/dl) 0,47 0 -0,5 high concentration glucose-containing fluids. Serum insulin was Ammoniac (umol/L) 23,5 16-60 determined as 0.3 μU / ml (normal range 2.7-10.4 μU / ml) and WBC (103/μL) 10.5 4–11 C-peptide 0.0 ng / ml (normal range 0.78-5.19 ng / ml) in the patient Hgb (g/dL) 11.2 11–18 suspected of having syncope. Other causes of hypoglycemia were PLT (103/μL) 207 150–400 excluded. An approximately 15 cm bulk was detected in the liver INR 1.1 0.8 – 1.1 after imaging methods and the biopsy presented the low-differen- Cortisol (ug/dL) 21.7 3.7–19.4 tial adenocarcinoma. Diagnosed with NICTH steroid treatment was given to the patient and in the follow-up it has been observed that fT3 (pg/mL) 1.69 1.71–3.71 the hypoglycaemic attacks were over. fT4 (ng/dL) 1.03 0.7–1.48 TSH (μIU/mL) 0,53 0.35–4.94 Conclusion: In this article a rare NITCH case of hypoglycaemia at- Insulin (uU/mL) 0.3 2.7 – 10.4 tacks treated with steroids will be reported; a patient diagnosed C-peptid ( ng/ mL) 0.0 0.78 – 5.19 with gastric cancer who had hypoglycaemia, that was resistant to GH ( ng/ mL) 1.31 0-3 high concentration glucose-containing fluids treatment, was de- tected to have liver metastasis in the recent examination and hy- IGF-I (ng/ mL) 36.4 55-177 poglycaemia attacks were treated with steroids. In addition to this

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P-23 Pituitary A THYROTROPIC HYPERPLASIA CASE MIMICKING MACROPROLACTINOMA RIFKI ÜÇLER1, SALIHA YILDIZ1, MURAT ALAY1, İSMAIL GÜLŞEN2 1 DEPARTMENT OF ENDOCRINOLOGY AND METABOLISM, MEDICAL SCHOOL, YUZUNCU YIL UNIVERSITY, VAN, TURKEY 2 DEPARTMENT OF NEUROSURGERY, MEDICAL SCHOOL, YUZUNCU YIL UNIVERSITY, VAN, TURKEY

Introduction: Increased hypothalamic TRH release in response to Hypophyseal MR imaging before levothyroxine replacement reduced levels of circulating triiodothyronine (T3) and thyroxine (T4) in primary hypothyroidism leads to an increase in the secretion of pituitary TSH and prolactin (PRL). In such a case, a hypophyseal en- largement that mimics the hypophyseal macrogenome is a rare oc- currence. Although thyrotropic hyperplasia is a condition resolved by levothyroxine replacement, some cases of this condition may inadvertently be misdiagnosed as a hypophyseal adenoma and are subject to diagnostic delay or unnecessary surgical intervention.

Case: A 19-year-old female patient was admitted to our outpatient clinic with amenorrhea for 9 months. The patient had no known illnesses or drug use history. She was examined with the same complaint at another clinic about 6 months before the application to our polyclinic and PRL: 71.69 ng / mL (2.27-26.7) and a pitu- itary MR examination revealed a macroadenoma of 19x18x12 mm in size, and cabergoline 2x5 mg / week was initiated. The patient was found to have amenorrhea, fatigue, constipation, weight gain, Hypophyseal MR imaging after levothyroxine replacement voice thickening and myalgia complaints. However, galactorrhea never occurred. Patients who had a marked elevation of TSH (TSH> 100 μIU / ml), low fT3 and fT4 and whose other anterior pituitary hormones were detected at normal limits; primary hypothyroidism was diagnosed and levothioxine was administered at a dose of 100 μg / day and cabergoline treatment was discontinued. The control pituitary MRI examination, which was performed 6 months after the onset of levothyroxine therapy, revealed normal pituitary find- ings and disappearance of macroadenomic image.

Discussion: In this article, we would like to emphasize the impor- tance of hypophyseal hyperplasia cases that can be mistakenly considered hypophyseal adenomas. We also emphasize the need to consider all pituitary hormones together when evaluating pitu- itary pathologies.

Keywords: Thyrotropic Hyperplasia, Hypothyroidism, Prolactinoma

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P-24 Pituitary THERAPY OPTIONS IN AGGRESIVE TSH SECRETING PITUITARY ADENOMA ADNAN YAY, LEVENT ÖZSARI, EYLEM ÇAĞILTAY, FERRAT DENIZ, ARIF YÖNEM DEPARTMENT OF ENDOCRINOLOGY AND METABOLISM, MINISTRY OF HEALTH, MEDICAL SCIENCES UNIVERSITY, SULTAN ABDULHAMID HAN EDUCATION AND RESEARCH HOSPITAL,ISTANBUL, TURKEY

Background: Pituitary adenomas which secrete thyrotropin (TSH) noma was detected by control pituitary MRI. She underwent to sur- are a very rare cause of hyperthyroidism.They typically present with gery second time. The result of the histological examination was signs and symptoms of hyperthyroidism and rarely can be asymp- the presence of TSH producing cells of the tumor. The post-oper- tomatic. Nevertheless however a diffuse goiter, visual field defects, ation MRI was reported as secondary changes related to the oper- menstrual disturbances, and headache may be seen in patients. ation. Generally the definitive therapy for patients with TSH-secreting pi- Six months later, in October 2016, control pituitary MRI was re- tuitary adenomas (TSHomas) is the transsphenoidal resection of ported as 22x16x16 mm recurrent pituitary macroadenoma. She the tumor. On the other hand approximately half of patients with underwent to surgery third time. The result of the histological ex- macroadenomas will require additional therapy for residual dis- amination was the presence of TSH producing cells of the tumor. ease. After surgery, we prefer to treat with somatostatin analogs in The post-operation MRI was reported as 14x15x24 mm residual short term control of the disease and than pituitary irradiation for pituitary macroadenom with mild compression optic chiasm. Her long term treatment. visual field examination is normal but she has severe headhache. Case Presentation: A 42 year old woman presented with head- The serum levels of thyroid hormon and TSH were high. ache, menstrual disturbances in 2007. She had no medical history. We started long acting octreotide 10 mg once monthly and caber- Her laboratory tests displayed high free circulating thyroid hor- golin 0.5 mg once weekly. After a month, she was no headheache mones and high TSH concentrations. Thyroid ultrasound showed a and the serum levels of thyroid hormon were betten than before. thyroid gland of normal size with heterogeneous echogenicity. The measurement of sex hormone binding globulin was normal range Discussion-Conclusion: The use of somatostatin analogs has but T3 supression test was not supressed. Pituitary magnetic res- been approved for the treatment of TSH secreting pituitary ade- onance imaging (MRI) revealed 20 mm in diameter a pituatiry mac- nomas pre and postoperatively. In our case, she had been operat- roadenoma with mild compression to optic chiasm. Other anterior ed three times by transsphenoidal surgery for recurrent TSHoma. pituitary hormones levels were in normal range. The tumor was Nevertheless, last MRI was reported; recurrent pituitary macroad- removed by transsphenoidal surgery. Histological examination and enom with mild compression optic chiasm. After the long acting immunostaining confirmed the presence of TSH producing cells of octreotide therapy her symptoms were declined dramatically and the tumor. laboratuary tests were normalized.

After surgery, in January 2016, 18x17x24 mm pituitary macroade- Keywords: Aggresive, TSH secreting adenomas,Medical treatment

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P-25 Pituitary ACROMEGALY CASE WHICH CANNOT BE TREATED VIA SURGICAL METHOD, FOLLOWED WITH DOSE OPTIMISATION IN MEDICAL TREATMENT ÖZGE POLAT KORKMAZ, PINAR KADIOĞLU ISTANBUL UNIVERSITY CERRAHPASA MEDICAL FACULTY, DIVISION OF ENDOCRINOLOGY, METABOLISM AND DIABETES,ISTANBUL, TURKEY

Introduction: Transsphenoidal surgery is the first treatment option Figure 1 (Before medical traetment pituitary MR /may 2009) and medical treatment is not recommended as a primary treat- ment in Acromegaly. But, medical treatment is to be started as a primary treatment in case of high sugical risk and for the patients refusing surgery. These patients should be followed up closely and optimization of treatment dose should be provided.

Clinical Case (Diagnostic Evaluation, Treatment, Follow-Up): 58 years old female patient has the complaints of enlargement in her hands-feet and increased spacing between her lower teeth for a year. She has also HT (severe hypertension for a year), Type 2 DM, Sleep Apnea Syndrome (for a year). In May 2009, patient is directed from an external clinic with the preliminary diagnosis of Acromeg- aly. Patient on admission laboratory results was IGF-1: 922 ng/ml (Normal Range:75-225), GH:14,3 ng/ml and all of GH levels follow- ing OGTT test were <1 ng/ml. Hypophysis MR is considering partial empty cella sydrome and there was a microadenoma (3-4 mm) on the left hemisphere of the prominently atrophied pituitary gland. The patient did not accept transsphenoidal surgery. Patient is being followed up in remission with octreotide LAR 20 mgr/mth treat- figure 2 (after medical treatment pituitary MR / january 2017) ment between 2009-2012. Patient’s need for CPAP is decreased and also has controlled blood pressure, blood glucose levels. Af- ter the treatment, Sella MR work-up revealed that the microade- noma looks regressed. Approximately 3 years after the beginning of the medical treatment IGF-1 and GH levels are increased and than cabergoline 3,5 mg/week was added. But disease was not in remisson with this combination therapy and octreotide dose was made maximal. After Octreotide-LAR 40 mg/mth + Cabergoline 3,5 mg/week treatment 12 th month (January 2017); clinical findings of acromegaly were degraded compared to the first admission and biochemical normalization was provided.

Conclusion: Close follow-up of patient and dose optimisation of medical treatment are very important for acromegaly patients to whom surgical treatment cannot be applied as a primary treatment during the period of remission.

Keywords: acromegaly, medical treatment, dose optimisation

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P-26 Pituitary MANAGEMENT OF A CHALLENGING CASE WITH ECTOPIC ACTH SYNDROME GÜLŞAH YENIDÜNYA YALIN1, SEMA ÇIFTÇI DOĞANŞEN2, SEHER TANRIKULU3, REFIK TANAKOL4, SEMA YARMAN4 1 BASKENT UNIVERSITY, ISTANBUL HOSPITAL, DEPARTMENT OF INTERNAL MEDICINE, DIVISION OF ENDOCRINOLOGY AND METABOLIC DISEASES, ISTANBUL, TURKEY 2 UNIVERSITY OF HEALTH SCIENCES BAKIRKOY DR. SADI KONUK TRAINING AND RESEARCH HOSPITAL, DEPARTMENT OF INTERNAL MEDICINE, DIVISION OF ENDOCRINOLOGY AND METABOLIC DISEASES, ISTANBUL, TURKEY. 3 UNIVERSITY OF HEALTH SCIENCES HAYDARPASA NUMUNE TRAINING AND RESEARCH HOSPITAL, DEPARTMENT OF INTERNAL MEDICINE, DIVISION OF ENDOCRINOLOGY AND METABOLIC DISEASES, ISTANBUL, TURKEY. 4 ISTANBUL UNIVERSITY, ISTANBUL FACULTY OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE, DIVISION OF ENDOCRINOLOGY AND METABOLIC DISEASES, CAPA ISTANBUL, TURKEY.

Introduction: Prevelance of Cushing’s syndrome (CS) due to ec- on the lung nodule which was previously interpreted as nonspecific topic ACTH secretion is 10-15%. Secretion from neuroendocrine nodule in radiology consultation. Patient was referred for thoracal tumor (NET) is not inhibited by dexamethasone,however in some surgery. Histopathological evaluation showed carcinoid tumor with cases,cortisol can be suppressed with high dose dexamethasone. a size of 0.8 cm, chromogranin(+), synaptophysin(+), ACTH(+), TTF- In these cases IPSS is required in differential diagnosis. If IPSS 1(+),P53(-), Ki67<1% with no invasion. Postoperative cortisol was points to NET but radiology is not helpful,111In-Octreotide scintig- <2 mcg/dl, corticosteroid replacement was initiated and lasted 16 raphy(OCT) is the main method in clarifying ectopic ACTH source. months. We hereby report a case with ectopic ACTH syndrome and the chal- Conclusion: When the diagnostic tests and imaging methods are lenges during the investigation of underlying disorder. not indicative of an ectopic lesion, short-term treatment with ke- Case: A 47 year-old-female patient was referred with diagnosis toconazole may be beneficial by reducing the circulating cortisol of CS. She had a diagnosis of hypertension (140/85mmHg) and levels in cases without life-threatening disease, and providing bet- diabetes mellitus (161 mg/dl;HbA1C: 6.5%) for 4 months. Central ter results with nuclear receptor imaging modalities. Furthermore, obesity, acne, muscle weakness and hirsutism was also present. ketoconazole may even prevent bilateral adrenalectomy and life- Plasma ACTH level was 45.2 (0-46 pg/l). Plasma cortisol were non- long replacement therapy in such cases. supressible with low dose dexametasone supression test (LDST), Keywords: Cushing’s syndrome, Ectopic ACTH secretion, In-Oct- but it was supressible with high dose DST. Inferior petrosal sinus reotide scintigraphy sampling (IPSS) was compatible with ectopic CS.Pancreas was normal in abdominal MRI, plasma chromogranin A and NSE lev- els were normal. 24-h urinary 5-HIAA level was 13.23 (2-9 mg/ day). Thorax HRCT revealed 8 mm nodular lesion on the upper lobe of left lung. Lesion did not show high uptake in the OCT-scin- Figure-1. 111 Indium-octreotide scintigraphy. tigraphy. Interestingly, there was high uptake on the right side of mandibula-maxillary junction. Cranium MRI showed presence of a maxillary retension cyst on the same location. Because there was no other uptake on the OCT, cystectomy was performed for the maxillary retension cyst. ACTH staining was negative in eval- uation of the resected maxillary cyst. Basal plasma cortisol level was same after cystectomy. Because the clinical picture was not severe, and hypertension and hyperglycemia was well controlled, Ketoconazole 200 mg was initiated and the dose was titrated up to 400mg/day. Cortisol level was 8.7 mcg/dl one week after of Ke- toconazole treatment. After two months of treatment, nodule was stable on thorax HRCT. PET-CT was negative for the localisation of Isolated uptake on the right maxillary location (arrow). ectopic CS. Interestingly, repetitive OCT scan revealed high uptake

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P-27 Pituitary DELAYED REMISSION OF CUSHING’S DISEASE AFTER TRANSSPHENOIDAL SURGERY İBRAHIM DEMIRCI, COŞKUN MERIÇ, NAZLI KIRNAP, CEM HAYMANA, ORHAN DEMIR, AYDOĞAN AYDOĞDU, ALPER SÖNMEZ, ÖMER AZAL DEPARTMENT OF ENDOCRINOLOGY AND METABOLISM, GULHANE TRAINING AND RESEARCH HOSPITAL, ANKARA, TURKEY

Introduction: Although surgery is the choice of therapy for Cush- to vascular anatomic conditions specific to this patient. Another ing’s disease when a microadenoma is identified preoperatively, treatment option, stereotactic radiotherapy, was not thought to be medical therapy is often required when surgery is delayed, con- a suitable option because of it’s late onset effect. Eventually, pasi- traindicated, or unsuccessful. Here we report a patient with severe reotide, a multireceptor ligand somatostatin analog is started at Cushing’s disease treated with pasireotide and ketakonazole, fol- 0.6 mg twice daily on post operatively 8th day. At post-op. 22nd day lowing transsphenoidal surgery. still there was not any significant clinical or laboratory improve- ment despite pasireotide. 24h UFC was 2102 mg/day, and he was Case: 31-year old male patient was admitted to hospital with weight still using 120 mEq/day IV potassium, oral potassium tablets and gaining, new onset diabetes and hypertension. He had dorsal fat 100 mg spironolactone to compensate his potassium loss. Keto- pad, round face, depression, central obesity, acne and proximal conazole 2x200 mg added and insulin and potassium requirement muscle weakness. He had been using levothyroxine sodium, potas- dramatically decreased day by day. After two months, many of his sium, metformin and verapamil-trandolapril for the last 2 months. drugs were stopped and he was able to walk 10 meters by walkers. His serum bazal cortisol level was 48.9 mcg/dL. Following 1 mg His 24h UFC was 262 nmol/day after three months from surgery. Dexamethasone Suppression Test (DST) serum basal cortisol was The patient is still in follow-up as an outpatient and can walk with- 43,69 mcg/dL (not suppressed). ACTH and 24h urine free cortisol out any support, he is taking only levothyroxine and testosterone (UFC) levels were also high (185 pg/ml and >1575 ug/days, respec- replacement. tively). Following 8 mg DST, serum cortisol levels were not sup- Conclusion: The choice of treatment after failed transsphenoidal pressed (38 mcg/dL) however 24h UFC levels were suppressed surgery should be individualized for each patient. Before putting (780 ug/day). Pituitary MRI showed a hyperintense, 3x1,5mm le- the patient into “failed surgery” category, if it’s possible, patients sion located posterolaterally. Consistent with the lesion, inferior should be followed under medical treatment for a while to avoid petrosal sinus sampling also lateralized to right side (Table 1). The irreversible approaches such as surgery and radiotherapy. Some- patient underwent to trans sphenoidal surgery. Following oper- times, as seen in our case, by unknown mechanism, the effect of ation his clinic worsened, insulin and potassium need increased surgery may be revealed later than expected. and he became more depressed. Because of severe muscle weak- ness he wasn’t able to walk or feed himself. Re-operation was not Keywords: Cushing, Pasireotide, Ketaconazole, Trans-sphenoidal recommended by surgeons because of high morbidity risk related surgery

Table - 1 Time ACTH (pg/ml) ACTH (pg/ml) ACTH (pg/ml) IPS ratio** C/P ratio* (minutes) Right petrosal Left petrosal Peripheral (lateralization) 0. 466 182 161 2.89 2.56 3. 274 271 176 1.56 1.01 5. >1250 302 243 5.14 4.14 10. >1250 351 265 4.72 3.56 15. >1250 373 336 3.72 3.35 Inferior Petrosal Sinüs Sampling results (stimulated by CRH) showing lateralization to right pituitary site * Central to Peripheral ACTH ratio (≥2 (non-stimulated) or ≥3 (stimulated) supports Cushing’s disease ** Lateralization ratio (if >1.4 it lateralized to greater side)

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P-28 Pituitary IGF-1 RECEPTOR EXPRESSION AS A RESULT OF THE ASSOCIATION BETWEEN ACROMEGALY AND RENAL CELL CANCER GAMZE AKKUŞ1, TAMER TETIKER1, ŞEYDA ERDOĞAN2, MEHTAP EVRAN1, MURAT SERT1, KIVILCIM ERDOĞAN2 1 CUKUROVA UNIVERSITY ENDOCRINOLOGY DEPARTMENT 2 CUKUROVA UNIVERSITY PATHOLOGY DEPARTMENT

Acromegaly occurs as a result of growth hormone secretion and it’s Legend of Figure clinical features. Plasma IGF-1 levels have shown to be correlated with disease-related cancer mortality has been indicated in previ- ous studies. Renal cell carcinoma (RCC) that has been diagnosed in adults as a malignant disease incidence is % 2-3 and takes the fifth of cancer ranking. First acromegaly patient had a renal mass whereof length was 10 cm extended to the right renal hilum and in- cluded multilocule and cystic components via abdominal MRI. The second acromegaly patient had a solid exophytic mass whereof di- ameter was 25 mm, extended to anterior renal hilum was revealed in the middle part of the right kidney. Both of two patients renal mass were renal cell carcinoma. We showed two acromegaly pa- tients with RCC that was stained with IGF-1 receptor antibody.

Keywords: Acromegaly, Renal Cancer, IGF1 receptor

Hormon Status of Patients

GH: 33,6 ng/mL (0-10) FPG: 95 mg/dl IGF-1: 550ng/mL (115-307) Cortisol: 2,36 mcg/dL (6,7-22,6) BUN: 7 mg/dl WBC: 5,25 10^3/µL (4,5-10,3) Prolactin: 38,67 ng/mL ACTH:: 27,2 pg/mL (10-50) Cr: 0,49 mg/dl Hb: 11,7 g/dL (13,6-17,2) Patient 1 (3,34-26,72) Htc: 35,3 % FSH:2,26 mIU/ml (3,85-8,78) Na: 137 mmol/L PLT: 242 10^3/µL fT4:: 0,42 ng/dL (0,61-1,12) LH:1,56 mIU/ml (2,12-10,89) K: 4,3 mmol/L TSH: 2,63 mIU/L (0,34-5,60) FPG: 142 mg/dl GH: 22,8 ng/mL Cortisol: 5.71 mcg/dL HbA1C: 7.5 % IGF-1: 1507 ng/mL ACTH: 22 pg/mL WBC: 6.44 10^3/µL BUN:25 mg/dl Patient 2 Hb: 12.8 g/dL Prolactin: 75 ng/mL FSH:7.86 mIU/ml Cr: 3.27 mg/dl Htc: 38.2 % fT4: 0.56 ng/dL LH: 2.15 mIU/ml eGFR: 30 ml/dk/m2 TSH: 0.14 mIU/L T.Testosterone: 0.65 ng/mL Na:135 mmol/L K: 4.1 mmol/L

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P-29 Pituitary SOTOS SYNDROME SHAIMAA SAMIR AMIN MASHAL LECTURER OF INTERNAL MEDICINE DEPARTMENT,ENDOCRINOLOGY AND DIABETES, FACULTY OF MEDICINE, TANTA UNIVERSITY

Personal History: Male patient, named Ahmed M.S,20years,single,- like growth factor-1(49.6) ug/l Abdominal ultrasonography normal ex- from El Mahalla,not working,has no special habits cept for mild hepatosplenomegaly. ECHO mild mitral incompetence. X ray on the hand shows partially closed epiphysis. C/O:The patient came to outpatient endocrinology and diabetes clinic at Tanta University Hospital with his parents. The complaint Clinically this is Sotos Syndrome (Cerebral Gigantism) character- was given by the parents: Enlarged hands and feet, progressive in- ized by:a large (macrocephaly) dolichocephalic head,prominent crease in body height, difficulty in breathing. forehead and jaw, hypertelorism, antimongoloid slant of the pal- pebral fissures, high-arched palate, large hands&feet with thick- History of the Present Illness:The condition has been noticed by ened subcutaneous tissue. Growth hormone (GH), IGF-1, and other parents since early childhood, they noticed abnormal facies, pro- endocrine studies are usually normal no distinctive laboratory or gressive enlargement of their kid’s hand&feet, that seemed differ- radiologic marker for the syndrome.Most cases of Sotos syndrome ent from his brothers and other children of the same age,but unfor- are caused by mutations in the NSD1 (nuclear receptor SET do- tunately did not seek medical advice at this age. The child failed to main-containing protein 1) gene. Unfortunately Genetic testing for continue in ordinary school as it was difficult to him to learn as his NSD1 was not available in our city and was not done. colleagues,so they withdraw their son from the school. The patient suffered from dyspnea grade II which increased by extra effort and Keywords: Cerebral Gigantism, Tall stature, NSD1 gene, Sotos relived by inhalation of bronchodilators,not associated with ortho- syndrome, growth hormone pnea or PND There were no specific investigations regarding the Abdominal Ultrasonography progressive increase in tall and enlarged hands and feet.

Past History: No Drugs taken by the mother during pregnancy.Nor- mal vaginal delivery of full term baby.No history of incubation-No history of head trauma or operations.No Diabetes or hypertension. No history of drug intake.

Family History: No consanguinity.No history of the same condition in the family.

On examination, the patient is tall with acromegaloid facial features,- mentally unstable.his height is 195 cm.Span 193 cm. macrocephaly, wide interpupillary distance, high arched palate-elongated face-long slender enlarged hands&feet.A.B.p 100/60 mmhg pulse 75 beat/min- ute R.B.G 84 mg% Neck diffuse thyroid swelling Chest bilateral diffuse sibilant rhonchi Abdomen mild hepatomegally, L.L enlarged feet, no oedema. Investigations show: FPG 83 mg% cholesterol 110 mg% TSH 2.68 ulU/ml free T4 1.53 ng/dl serum prolactin 13.2 ng/ml LH 5.56 ulU/ ml free testosterone 7.40 pg/ml Growth hormone suppression test with glucose (Basal) 0.258 ng/ml GH after 30 min 0.164 ng/ml after 60 min 0.134 ng/ml after 90 min 0.683 ng/ml,after 120 min 0.212 ng/ ml GH after 150 min 0.444 ng/ml GH after 180 min 0.322 ng/ml Insulin Normal findings except for mild hepatosplenomegaly

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Bone age enlarged foot normal levels of insulin like growth factor -1 and growth hormone level

partially closed epiphysis of the joints of the hand and wrist

enlarged sized elongated foot

fundus examination Characteristic facies of Sotos Syndrome

normal IGF-1 normal growth hormone level and normal growth hormone suppression test using glucose

tall stature

Characteristic facies of Sotos Syndrome Normal fundi examination elongated hand with slender fingers

high arched palate

specific facial characters for Sotos syndrom

TSH and serum prolactin

high arched palate, elongated face, thin enlarged elongated hand with slender fin- normal TSH and serum prolactin chin, protruded jaw gers in comparison to a hand of the same age and sex 89 19 - 22 October, 2017 Antalya - Turkey 2017

P-30 Thyroid ALOPECIA UNIVERSALIS CASE SPONTANEOUS HEALING AFTER THYROIDECTOMY ASSOCIATED WITH GRAVES’ DISEASE RIFKI ÜÇLER1, GÜLÇIN MIYASE SÖNMEZ2, SALIHA YILDIZ1, MURAT ALAY1 1 DEPARTMENT OF ENDOCRINOLOGY AND METABOLISM, MEDICAL SCHOOL, YUZUNCU YIL UNIVERSITY, VAN, TURKEY 2 DEPARTMENT OF INTERNAL MEDICINE, MEDICAL SCHOOL, YUZUNCU YIL UNIVERSITY, VAN, TURKEY

Introduction: Graves’ disease is an autoimmune disease charac- sion of the alopecia universalis is seen despite the absence of any terized by the presence of antibodies that cause hyperthyroidism immunosuppressive treatment after thyroidectomy. As a result, we and goitre and bind to and stimulate the TSH receptor. Alopecia think that thyroidectomy must be considered in similar cases that universalis is an autoimmune disease in which hair follicles have do not respond to medical treatment. an abnormal T cell response to their antigen. Alopecia universalis Keywords: Graves’ disease, Alopecia universalis, Thyroidectomy is generally characterized by loss of hairless scalp throughout the body. Alopecia universalis associated with graves disease has been Alopecia universalis case before thyroidectomy reported in several cases in the literature. In this article, a case report of alopecia universalis with graves disease and spontaneous remission of alopecia after total thyroidectomy was made. This is the first case in the literature that shows a significant improvement in alopecia after total thyroidectomy.

Case: In a 27-year-old male patient who was referred to our clin- ic for hyperthyroidism on March 2016, he had alopesia areata for 6 years and an alopecia universalis for the last 6 months (figure 1). The patient was diagnosed with graves disease as a result of laboratory and imaging studies. Systemic corticosteroid therapy from 1 mg / kg for alopecia and PTU 3x100 mg for hyperthyroid- ism was initiated. A few weeks later, the patient had severe aller- gic skin reactions due to anti-thyroidal therapy and the antithyroid therapy was discontinued. Subsequently, thyroidectomy operation was performed after establishin euthyroidism with cholestyramine and potassium iodide. During this period, no improvement was ob- served despite systemic corticosteroid treatment in skin findings Image of the patient after thyroidectomy and all treatments after surgery were discontinued and only thy- roid hormone replacement therapy was continued. In the following months, it was observed that terminal hair regeneration resumed in all body lesions (figure 2).

Conclusion: Alopecia universalis and Graves’ disease are two auto- immune diseases that affect hair follicle and thyroid gland, respec- tively. There are only 3 cases in the literature with graves disease and alopecia universalis association. It has been reported that in all 3 cases, the alopecia universalis disease does not respond to the local and systemic treatments used. Thyroidectomy was not performed in the first and second cases. In the third case, alopesia universalis developed after 10 years of thyroidectomy. The differ- ence of our case from previous cases is that spontaneous remis-

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P-31 Thyroid COMBINATION OF NEWLY DIAGNOSED HODGKIN LYMPHOMA AND MYXEDEMA COMA: A RARE CASE RIFKI ÜÇLER1, NUR DÜZEN OFLAS2, MEHMET ASLAN2 1 DEPARTMENT OF ENDOCRINOLOGY AND METABOLISM, MEDICAL SCHOOL, YUZUNCU YIL UNIVERSITY, VAN, TURKEY 2 DEPARTMENT OF INTERNAL MEDICINE, MEDICAL SCHOOL, YUZUNCU YIL UNIVERSITY, VAN, TURKEY

Introduction: Hypothyroidism develops in thyroid hormone de- Conclusion: The myxedema coma is essentially a hypometabolism. ficiency and myxedema coma is a rare complication of prolonged Infection is a condition that can develop in the presence of precipi- hypothyroidism. The myxedema coma is an endocrinological emer- tating factors such as trauma and can be fatal if delayed. This case gency and mortality can be high. Differences in mental status, is interesting because the precipitating factor is a rare association. lethargy, decreased cognitive function, hypothermia, hypotension, As a result, all causes that can precipitate in cases with myxedema bradycardia, hyponatremia and hypoventilation are clinical condi- coma should be carefully investigated and pay particular attention tions that can be seen in myxedema clinic. In this article, the case to the physical examination findings. of Hodgkin’s lymphoma, which is the cause of myxoma coma, is Keywords: Hypothyroidism, Myxedema coma, Hodgkin lymphoma presented. Laboratory results of the case. Case: A 33-year-old male patient was brought to the emergency room with complaints of widespread swelling, slowing in speech Reference range and movements and general impairment. The patient had been op- WBC (103/μL) 6.0 4–11 erated on due to multinodular goiter about 3 months ago and did Hgb (g/dL) 10.6 11–18 not receive any medication.The patient had no known disease and PLT (103/μL) 162 150–400 no history in his descent. On physical examination, the patient was fT3 (pg/mL) 1.2 1.71–3.71 conscious the general situation was moody, sleepiness was pres- fT4 (ng/dL) <0.4 0.7–1.48 ent, and there was a slowness in movement. The patient had swell- TSH (μIU/mL) 28 0.35–4.94 ing on his hands and ++ pretibial odema on his legs. In addition, kreatinin (mg/dl) 0.77 0.6-1.1 bilateral axillary and inguinal regions showed the lymph nodes of Na (mEq/L) 130 136-147 about 1 cm. The patient was evaluated as a myxedema coma after laboratory findings (table) and was followed up with levothyroxine K (mEq/L) 4.6 3.5-5.1 replacement. After the myxedema coma has healed, excisional bi- Cl (mEq/L) 102 98-108 opsy was performed on the patient’s lymph nodes and the patholo- ALT (u/L) 36 0-34 gy results were reported as Hodgkin lymphoma. CRP (mg/dl) 141 0-5

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P-32 Thyroid THE RELATIONSHIP BETWEEN DISEASE PERCEPTION, ANXIETY, DEPRESSION AND LIFE QUALITY IN THYROID CANCER PATIENTS UMUT ELBOĞA, GÜZIDE AKYILDIZ, Y. ZEKI CELEN DEPARTMENT OF NUCLEAR MEDICINE, GAZIANTEP UNIVERSITY,GAZIANTEP,TURKEY

Introduction: We evaluated disease susceptibility, anxiety, depres- 48 percent of them said it was related to the disease. The symp- sion and quality of life in well differentiated thyroid cancer patients tom of pain remained at 40%, the result is that the symptoms of who had received radioactive iodine 131 treatment after total thy- pain in the cases of differentiated thyroid cancer are not a defin- roidectomy. ing symptom of the disease. The symptoms of weight loss were last symptoms associated with the disease, the actual complaint of Methods: We researched whether patients, who were in the pro- most women was weight gain. cess of new diagnosis and treatment, and whose treatment was completed had triggered symptoms of anxiety and depression and Conclusion: There was a noticeable decrease in the patient’s abili- adversely affected quality of life. Sickness Perception Scale (SFI), ty to understand the disease. The scores on the quality of life scale SF-36 Quality of Life Scale, Beck Depression Scale, Beck Anxiety were slightly lower. However, significantly higher fatigue and power Scale and socio-demographic form prepared by the researcher anxiety, lower quality of life, emotional role strength and physical were applied when all diseases were evaluated. RESULTS: The role weakness were found in our cases. mean age of the participants was 40.62 ± 10,28 years. There were Keywords: Disease Perception, Anxiety, Depression, Life Quality, 84 (84.0%) female and 16 (16.0%) male cases. 72 reported that they Thyroid Cancer had lost power, and 60% of them attributed this symptom to the disease. 60 patients stated that they had difficulty in breathing, and

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P-33 Thyroid ECTOPIC LINGUAL THYROID PRESENTING WITH HEMATEMESIS IŞILAY TAŞKALDIRAN1, GÖNÜL KOÇ1, SEVIM ASLAN FELEK2, MEHMET AKIF SALTABAŞ3, TÜLAY OMMA1, CAVIT CULHA1 1 DEPARTMENT OF ENDOCRINOLOGY AND METABOLIZM, ANKARA RESERCH AND EDUCATION HOSPITAL, ANKARA, TURKEY 2 DEPARTMENT OF OTORHINOLARYNGOLOGY HEAD AND NECK SURGERY, ANKARA RESERCH AND EDUCATION HOSPITAL, ANKARA, TURKEY 3 DEPARTMENT OF INTERNAL MEDICINE, ANKARA RESERCH AND EDUCATION HOSPITAL, ANKARA, TURKEY

Ectopic lingual thyroid is a rare developmental anomaly caused tests showed elevated thyroid-stimulating hormone (TSH) 39 IU/ by embryological anomaly during the migration of thyroid gland. ml concentrations. He was diagnosed as a case of lingual thyroid Most patients are asymptomatic. However there are cases where with hypothyroidism. Substitutive hormone therapy was start- the mass can be enlarged and cause dysphagia, dyspnoea, up- ed and during the follow-up, the patient showed improvement in per airway obstruction, dysphonia, hypothyroidism or bleeding. A symptom and no hemoptysis episodes were observed again. The 33-year-old man was referred to emergency department of our management of treatment of a lingual thyroid depends on the size, hospital complaining of hematemesis. Upper gastrointestinal en- symptoms, and the presence of complications. Thyroid hormone doscopy exam¬ination revealed fresh blood in the stomach, with- substitution therapy should be started as a initial therapeutic strat- out any evidence of mucosal ab¬normalities in the esophagus and egy. Using levothyroxine to suppress TSH, it was aimed to correct stomach. On physical examination oral and nasal mucosae were hypothyroidism and to reduce gland size and local symptoms. İn normal. On laryngoscopic examination, the mass had a smooth and cases with severe hematemesis; after excluded common causes of reddish surface with vessels located at the base of the tongue, lar- acute gastrointestinal bleeding by gastroendoscopic examination, ynx that was considered ectopic lingual thyroid. bleeding ectopic lingual thyroid could be considered. And if we can not see thyroid gland in normal location, ectopic thyroid should be His blood hemoglobin level was 7 g/dL. Thyroid ultrasonography considered and should be investigated. revealed absence of the thyroid gland. Thyroid scintigraphy showed an ectopic uptake in the tongue base consistent with lingual thy- Keywords: ectopic, lingual, thyroid, hematemesis roid and no uptake in the normal thyroid location. Thyroid hormone

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P-34 Thyroid NEWLY DIAGNOSED MEN 2B SYNDROME IN A PATIENT WITH HISTORY OF HYPOGONADISM MUHAMMET ÖZER, ÜMIT ÇAVDAR, BAŞAK ÖZGEN SAYDAM, TEVFIK DEMIR, BARIŞ AKINCI DIVISION OF ENDOCRINOLOGY AND METABOLISM, DEPARTMENT OF INTERNAL MEDICINE, DOKUZ EYLUL UNIVERSITY, IZMIR, TURKEY

Multiple endocrine neoplasia type 2 (MEN2) is an autosomal dom- Here we describe a case newly diagnosed MEN2B Syndrome in our inant disorder. MEN2 is subclassified into two distinct syndromes: inpatient clinic. Twenty seven years old male patient who has already types 2A (MEN2A) and 2B (MEN2B). The genetic defect in these dis- been diagnosed with secondary hypogonadism was admitted to our orders involves the RET proto-oncogene on chromosome 10. hospital with a complaint of hoarseness and feeling discomfort during swallowing. On physical examination, he has Marfanoid habitus, joint Multiple endocrine neoplasia type 2B (MEN2B) is an autosomal laxity, papillomatous lesions on his tongue. On thyroid examination, we dominant disorder characterized by Medullary Thyroid Cancer detected bilateral thyroid nodules and on a laboratory evaluation blood (MTC) and Pheochromocytoma but not Hyperparathyroidism. The calcitonin level was high. Thus, we suspected of MTC and possibility of prevalence of MEN 2B is estimated as between 1 in 600,000 to 1 MEN2B Syndrome and we initiate tests for further evaluation. We de- in 4 million, but no figures exist. The annual incidence has been tected nodular lesion on right adrenal gland which has the suspected estimated is to be at 4 per 100 million per year. MTC occurs in al- apperance of pheochromocytoma on Abdominal MRI. The biopsy from most all patients. Pheochromocytoma occurs in approximately 50 the lesions on his tongue revealed ganglioneuromas. At the end the percent of patients with MEN2B. The tumor develops at an earlier genetic mutation analysis showed that RET M918T was positive. age and is more aggressive than in MEN2A. Surgery is often not curative. Thus, early diagnosis and prevention are crucial. MEN2B Syndrome should be suspected in any patient with MTC or pheochromocytoma, particularly when the tumors occur at a young The syndrome of MEN2B also includes mucosal neuromas, typi- age (<35 years), are multicentric, or when more than one family cally involving the lips and tongue, and intestinal ganglioneuromas. member is affected. The diagnosis of MEN2B is based upon the Patients with MEN2B also have development abnormalities, a de- presence of the classical clinical features, family history, and ge- creased upper/lower body ratio, skeletal deformations (kyphosco- netic testing. In the absence of an autosomal dominant familial in- liosis or lordosis), joint laxity, Marfanoid habitus, and myelinated heritance pattern or RET mutation, the majority of classical clinical corneal nerves. Disturbances of colonic function are common, in- features of MEN2B are required to make a clinical diagnosis. MEN cluding chronic constipation and megacolon. Unlike patients with 2B remains a relatively rare condition and can be easily missed if Marfan syndrome, MEN2B patients do not have ectopia lentis or the diagnosis has not been considered. aortic abnormalities. Keywords: Men2b, Hypogonadism, Pheochromocytoma, Medullary Thyroid Cancer, Ganglioneuroma, Ret Mutatio

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P-35 Thyroid A CASE OF PAINFUL HASHIMOTO’S THYROIDITIS EMA LUMI1, ENTELA PUCA2, BLERTINA DYRMISHI3, RAJMONDA TARE4, THANAS FURERAJ5, AGRON YLLI6 1 REGIONAL HOSPITAL “TENI KONOMI”, KORCE, ALBANIA. 2 “AMERICAN HOSPITAL”, TIRANE, ALBANIA. 3 “HYGEIA HOSPITAL”, TIRANE, ALBANIA. 4 REGIONAL HOSPITAL, ELBASAN, ALBANIA 5 UNIVERSITY MEDICAL CENTER “MOTHER TERESA”,TIRANA, ALBANIA 6 HEAD OF ENDOCRINE DEPARTMENT, UNIVERSITY MEDICAL CENTER “MOTHER TERESA”,TIRANE, ALBANIA.

Introduction: Hashimoto’s thyroiditis (HT) is the most common larged inhomogeneous goiter, a slight compression of the trachea cause of hypothyroidism in iodine-sufficient areas of the world. HT and reactive lateral cervical lymph nodes. 99mTc pertechnetate is characterized clinically by gradual thyroid failure, with or with- uptake in both thyroid lobes was normal. Fine needle aspiration out goiter formation,due to autoimmune-mediated destruction of biopsy revealed reactive and polymorphous lymphoid cells. Oral the thyroid gland. Although the thyroid enlargement that can oc- Ibuprofene 800mg/d and Levothyroxine 50mcg,qd as the starting cur is usually asymptomatic, rare patients have thyroid pain and dose were prescribed. Her clinical signs and symptoms improved. tenderness,particularly if there is rapid thyroid swelling. We report NSAIDs were tapered and stopped in 1 month, while Levothyroxine a case of painful HT in a 53-years old woman,who presented with was increased to 75 then 100mcg,qd. On her follow-up visit in 2 pain, and tenderness in a hard goiter. Her thyroid functional tests weeks,she ameliorated. Physical examination revealed moderate suggested overt hypothyroidism of autoimmune origin. Her clinical tenderness of the thyroid. There months later her serum TSH level symptoms showed a response to NonSteroidal Anti-inflammatory was decreased to 6mIU/ml. Thyroid dimensions were decreased in Drugs (NSAIDs). She is now on Levothyroxine therapy. ultrasound. Six months later she has no pain,no difficulty in swell- ing.TSH level was 0.5mIU / ml. She is now on maintenance therapy Case: A 53-years old woman,with no history of thyroid disorders, with Levothyroxine (75mcg/daily). presented with pain on the anterior neck and tenderness. Her symp- toms had been apparent for 2 weeks. On physical examination she Conclusions: HT is common and usually presents as a diffuse had both thyroid lobes enlarged with a very hard consistency with painless goiter. However it has been reported that HT can present marked tenderness. She was afebrile.Her thyroid function tests very rarely as pain and tenderness on a preexisting goiter.In our revealed overt hypothyroidism: serum TSH level was 21.9mIU/ml, case we described a painful Hashimoto’s thyroiditis in a patient that (normal range, 0.27-4.2mIU/ml), serum FT4 level=10pg/ml (normal didn’t report a chronic goiter. However we can’t prove this fact,as ranges,12-22pg/ml), serum FT3 level=2.8pg/ml (normal ranges, the patient has no previous examinations. Our patient responded to 3.1-6.8pg/ml). The anti-TPO level>600 IU/ml (normal range, <34IU/ NSAIDs treatment. To our knowledge in the literature few cases of ml). Tests for inflammatory markers were: ESR=35mm/h(normal painful HT were reported. Most of them were resolved with steroid range, 3-20mm/h); C-reactive protein=5.15mg/dl (normal range, therapy or surgery. 0.00-5mg/dl). Complete blood count was in normal range. Thyroid Keywords: Hashimoto’s Thyroiditis, NSAIDs, Levothyroxine. ultrasonography revealed an inhomogeneous enlarged thyroid gland with hypoechoic changes. Her neck CT scan revealed en-

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P-36 Thyroid PRETIBIAL MYXEDEMA AS AN ELEPHANTIASIC PRESENTATION FOLLOWING THYROIDECTOMY FOR GRAVES’ DISEASE SALIM MARZOOG AL IBRAHIMI, ISRAA NIHAD AHMED FAREED DIABETIC AND THYROID CLINIC, AL MANATHIRA GENERAL HOSPITAL / IRAQ

Objective: We report the case of 65 year old woman diagnosed with plaque, nodular and elephantiasis form. Elephantiasis PTM is a sev- GRAVES’ disease was treated with thyroidectomy because of failure of er manifestation of GD, and refractory to treatment. We report a rare medical therapy and after 10 years she developed pretibial myxedema case of elephantiasis PTM. Pathogenesis of the disorder is unclear which is usually a late manifestation of Graves’ and are relatively rare. and there is no effective treatment available at present. Management for elephantiasis PTM remains a therapeutic challenge Case: A 65 year old woman diagnosed as GD when she was 45 years old. She was treated with thyroidectomy because of failure of medical Keywords: GD Graves’ disease, PTM pretibial myedema, GO Grav`s therapy. Subsequent thyroxine replacement with L - thyroxine sodium ophthalmopathy.DM diabetes mellitus. 75 mg daily was given for treating thyroidectomy induced hypothyroid- Fig 1 ism. She developed clinically mild inactive GO of 10 years duration post thyroidectomy in the form of grittiness, redness, protrusion of eyes with periorbital edema without diplopia or diminution of vision. She also developed non pruritic multiple firm nodules ( cobblestone - like appearance deforming the skin ) increased gradually in size surround- ed by deep fissures, particularly around the ankles and dorsae of feet. The swelling has started with swelling of the dorsum of her feet and with progressive involvement of the front of legs. She had history of type II DM for 8 years and was using insulin and metformin. On exam- ination, she had mild exophthalmus, redness of eyes and periorbital edema (fig 1) and had old thyroidectomy scar (fig 2). She had multiple firm, nodules cobblestone like appearance (fig3). Laboratory evalua- tion revealed TSH 3ml/L and FT4 15pmol/L(7.72-22.5). An antibody to Face showing features of Graves’ ophthalmopathy in the form of ex- TSH receptor was elevated ≥30u/L(≤9). Both thyroid peroxidase and ophthalmos, redness and protrusion of eyes with periorbital edema thyroglobulin antibodies were negative. Biochemistry studies and complete blood counts were within normal. No evidence of chronic Fig 2 venous insufficiency at duplex ultrasonography was seen. Skin biopsy from the pretibial skin was performed to confirm the diagnosis. He- matoxylin and eosin stain of the skin biopsy specimen showed thick- ening of the dermis with myxoid connective tissue in the dermis most likely due to mucopolysacchride deposition, there are focal lymphocyt- ic infiltration with normal appearing epidermis (fig 4). She was treated with thyroxine 75 mg/day, the lesions of dermopathy were not treated as they were a sympotomatic.

Conclusion: Dermopathy of GD (PTM) is uncommon autoimmune ex- trathyroidal manifestation of GD, seen in 0.5-4.3% of patients with GD. It is almost always associated with Graves’ dermopathy. PTM is as- sociated with accumulation of glycosaminoglycans. Dermopathy as- sociated with GD is classified into the four forms: non pitting edema, neck showing scar of an old thyroidectomy

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Fig 3 Fig 4

photo micrograph of skin biopsy specimen ( H and E, x 40) from pretibial region showing thickening of the dermis with myxiod con- nective tissue in the dermis (most likely due to mucopolysacchride deposition)

dermopathy of GRAVES’ disease, with multiple nodules cobble- stone like appearance over both ankles and dorsae of feet.

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P-37 Thyroid INTERFERON-ALPHA INDUCED GRAVES’ DISEASE IN CHRONIC VIRAL HEPATITIS B: A CASE REPORT HAVVA SEZER1, DILEK YAZICI1, BÜLENT BARAN2, FARUK ALAGÖL1 1 DIVISION OF ENDOCRINOLOGY AND METABOLISM, KOÇ UNIVERSITY SCHOOL OF MEDICINE, ISTANBUL, TURKEY 2 DIVISION OF GASTROENTEROLOGY AND HEPATOLOGY, KOÇ UNIVERSITY SCHOOL OF MEDICINE, ISTANBUL, TURKEY

Introduction: In contrast to chronic or subacute thyroiditis, Graves’ Keywords: Interferon-alpha,graves, thyroid disease rarely complicates interferon-alpha (IFN-alpha) therapy Fig. 1. for chronic viral hepatitis. We report here a case of Graves’ disease during IFN-alpha treatment.

Case: A 44-year-old female patient was referred with hyperthyroid- ism, complaning of symptoms including fatigue, weakness, loss of weight, nervousness, insomnia, tremor, palpitation, heat intolerance and sweating. Her pulse rate was 102 beats/min. She had mild tremor, and mild diffuse goiter. She had been followed with the diagnosis of chronic hepatitis B infection for 20 years. She had started IFN treat- ment 20 weeks prior to these symptoms. Before IFN treatment, thy- roid function tests were normal, thyroid USG was normal and thyroid antibody titers were unknown. She had no history of thyroid disease. She had elevated serum fT4, fT3 and suppressed thyrotropin levels (table 1) and high antibody titers. TRAb level was 2.6 IU/L, anti TPO lev- el was 534 IU/mL, and anti Tg level was 723 IU/mL. Thyroid scintigrapy showed increased symmetric diffuse and homogeneous uptake, along with the pyramidal lobe (figure 1). Thyroid USG showed an increased thyroid volume, a diffuse hypoechoic thyroid gland structure (figure 2) Thyroid scintigrapy showed increased symmetric diffuse and ho- and Doppler evaluation of thyroid showed a diffusely enhanced thyroid mogeneous uptake along with the pyramidal lobe blood flow. In our patient, the cause of thyrotoxicosis was Graves’ dis- ease. IFN treatment was stopped and entecavir was started for chron- Fig. 2. ic hepatitis. Therapy with 10 mg/day methimazole (MM) and low dose propranolol were administered. The MM therapy was gradually de- creased and stopped after six months. After at the end of therapy, she gained 4 kg of weight. The patient was free of symptoms with normal thyroid hormone levels. TRAb level was 0.7 IU/L (negative). Thyroid ul- trasound showed a normal thyroid volume and Doppler evaluation of thyroid showed a normal thyroid blood flow.

In conclusion, it is important to identify the mechanism of INF-al- pha-induced thyroid dysfunction. Thyroid antibodies, more special- ly TSH receptor antibodies and radionuclide uptake scans are help- ful in making this distinction. We report here a case of new onset of Graves’ disease emerging during IFN-alpha treatment with chronic hepatitis B. We suggest measuring TSH and thyroid autoantibody Thyroid USG showed severe thyroiditis gland structure, twenty levels before treatment and at regular intervals during IFN treat- weeks after starting IFN therapy ment.

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Table 1. Before IFN- March 2016 (After 20 September January April 2016 June 2016 July 2016 May 2017 alpha therapy weeks of therapy) 2016 2017 TSH (µIU/mL) 3.3 0.01 ↓ 0.01 ↓ 0.35 ↓ 1.01 1.0 2.0 1.95 FT4 (ng/dL) 0.82 3.71↑ 0.94 0.77 0.94 1.29 1.25 1.2 FT3 (pg/mL) - 14.4 ↑ 2.8 2.7 2.8 3.1 3.0 3.0 Methimazol - 2x1 2x1 1x1 1x1/2 stopped - - 5 mg Thyroid hormone function tests before and during therapy

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P-38 Thyroid TRASTUZUMAB-ASSOCIATED DESTRUCTIVE THYROIDITIS IN A PATIENT WITH BREAST CANCER HAVVA SEZER1, DILEK YAZICI1, NIL MOLINAS MANDEL2, FARUK ALAGÖL1 1 DIVISION OF ENDOCRINOLOGY AND METABOLISM, KOÇ UNIVERSITY SCHOOL OF MEDICINE, ISTANBUL, TURKEY 2 DIVISION OF MEDICAL ONCOLOGY, KOÇ UNIVERSITY SCHOOL OF MEDICINE, ISTANBUL, TURKEY

Introduction: The cell surface extracellular domain of human epi- on overexpression of HER-2. Trastuzumab treatment was started. Af- dermal growth factor receptor 2 (HER-2) expression is associat- ter two months of starting trastuzumab therapy, the patient developed ed with tumor aggressiveness in breast cancer. Trastuzumab is a clinical features of hyperthyroidism, elevated serum fT4, suppressed monoclonal antibody directed against HER-2. It is a standart treat- thyrotropin level. TRAb level was 0.3 IU/L ( negative), anti TPO level ment for breast cancer patients whose tumors overexpress HER- was 9.6 IU/mL, and anti Tg level was 23.2 IU/mL. On physical exam- 2. Trastuzumab is generally well tolerated, a small number of pa- ination, she was afebrile and tachycardic. Thyroid USG showed an tients develop mild adverse reactions. Autoimmune thyroiditis is a increased thyroid volume with many nodules. Doppler evaluation of rare adverse event associated with trastuzumab. To date, five cases thyroid showed a diffusely enhanced thyroid blood flow. Thyroid scin- of trastuzumab- associated autoimmune thyroid disease have been tigrapy showed very low uptake (0.02 %). Propronolone therapy was reported in breast cancer patient studies. There is no reported case started. The complaints disappeared. Propronolone therapy was then of trastuzumab-associated destructive thyroiditis in a breast can- stopped. After four months, hypothyroidism developed. Levothyroxine cer patient in the literature. Here we report a case of trastuzum- 50 µcg/d was started. In the follow up, levothyroxine dose was gradu- ab-associated destructive thyroiditis that developed 2 months after ally decreased and the medication was stopped eventually. The patient the trastuzumab therapy in a breast cancer patient. is in euthyroid status now.

Case: A 43-year-old female patient was referred due to nervousness. In conclusion, trastuzumab can cause thyroid dysfunction, espe- The patient has several episodes of decreased TSH levels between cially in the early period of the therapy. The underlying mechanism 1994 and 2005 but was never given any therapy. In 2011, TSH was de- of trastuzumab therapy-associated thyroiditis is unknown. It may creased again, along with positive anti TPO and anti Tg antibody levels. be recommended that clinicians be aware of the possibility of de- She was given a short period of methimazole therapy. We do not have veloping thyroiditis in breast cancer patients treated with trastu- the report of thyroid scintigraphy that was performed then. The pa- zumab therapy. Thyroid function may be checked regularly before tient had undergone modified radical bilateral mastectomy followed and after starting therapy. by chemotherapy. Examination of the surgical breast tissue revealed Keywords: Trastuzumab, breast cancer, thyroiditis Table 1 01.08.16 21.12.16 20.01.17 10.02.17 29.03.17 16.06.17 04.07.17 25.07.17 TSH (µIU/mL) 0.98 0.005 ↓ 0.14 ↓ 22 ↑ 3.9 2.7 1.08 1.4 FT4 (ng/dL) 2.33 4.24 ↑ 0.85 0.46 ↓ 1.07 1.25 - - FT3 (pg/mL) 1.0 - - - - 2.24 - - T3 (ng/dL) - 224 ↑ 59 ↓ - - - - - After 2 LT4 50 µcg 5/7 Medication - months of - LT4 50 µcg/d LT4 50 µcg/d LT4 25 µcg/d LT4 stopped LT4 75 µcg 2/7 Trastuzu-mab Thyroid function tests

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P-39 Thyroid A PATIENT WITH UNILATERAL GRAVES’ DISEASE İFFET DAĞDELEN DURAN KIRIKKALE YÜKSEK IHTISAS HOSPITAL, DEPARTMENT OF ENDOCRINOLOGY AND METABOLIC DISEASES

Introduction: Graves’ disease (GD) is an autoimmune disorder of antithyroperoxidase and antithyroglobulin antibodies were within the thyroid which is characterized by hyperthyroidism and diffuse normal ranges while leucocyte count was again normal. On thyroid goiter. Thyroid scan usually reveals diffuse bilateral increased up- ultrasonography, echogenity of the thyroid parenchyma was mod- take of radioisotopes while unilateral involvement is a rare entity. erately heterogeneous with no nodular formation. Tc-99m scintig- Here we present a case of GD who had unilateral involvement of raphy of the thyroid gland revealed increased uptake in the left lobe the thyroid gland. whereas there was an accompanying suppression in the right lobe. Low dose diltiazem was started. For the condition of TSH decrease, Case: A 47-year-old man admitted to the endocrinology clinic with antipsychotic drugs may be thought to be responsible however TSH a few months history of palpitation. On physical examination his level’s such a decrease to even undetectable levels in the past and blood pressure was normal while pulse rate was 102 beats/min,- unilateral increased uptake in thyroid gland which is not awaited fine tremor was present and there was no tenderness on thyroid from physiology of a normal thyroid, drives us to suggestion of uni- gland. He was on antipsychotic drugs for five years and since he lateral GD as the most rational option for differential diagnosis. was cared in social service institution,his family history could not be delivered. On laboratory examination tests were as follows; Conclusion: Diffuse and unilateral uptake on thyroid scan is a rare TSH: 0.128 mIU/mL fT4: 1.54 (0.93-1.7) ng/dl, fT3:3.7 (2.0-4.4) pg/ entity in patients with GD. Congenital or acquired functional or ml, creatinine: 0.79 mg/dl and alanine aminotransferase (ALT): 17 structural differences between the two lobes may lead to this rare U/l. Thyroid function test measures belonged to before two year presentation. were: TSH: 0.00 mIU/mL with normal fT4 and fT3 values. Levels of Keywords: graves’ disease, unilateral, antipsychotics

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P-40 Thyroid GRAVES’ DISEASE PRESENTED AS MYASTHENIA GRAVIS IN 14 YEARS OLD GIRL BAYAR AHMED QASIM DEPARTMENT OF MEDICINE, COLLEGE OF MEDICINE, DUHOK UNIVERSITY, DUHOK, IRAQ

Introduction: Myasthenia Gravis (MG) is an autoimmune disorder bilateral ptosis. Bilateral weakness of both median and abducent which affects the neuromuscular junction which has a predilection nerves were demonstrated on examination. Diagnosis of myasthe- for muscles innervated by the cranial nerves. Autoimmune Thyroid nia gravis (MG) was established depending on history, examination Disease (AITD) namely Graves’ disease is a similar autoimmune and positive response to pyridostigmine stimulation test. Thyroid disorder due to stimulating thyroid auto-antibodies. The coexis- function test shows TSH<0.05 µIU/ml, Free T4: 28 Pmol/L(NR 9-20) tence of Graves’ disease and ocular Myasthenia Gravis has been and Free T3: 9 Pmol/L (NR 3-7). TRAB level was 4.55 IU/L (normally reported occasionally although it is rare. As far as clinical features Anti TSH Receptor Abs is up to 1.75). Thorax CT demonstrated a of these conditions could easily be overlooked, the aim is to empha- 52×30 mm fainting enhancing soft tissue density in upper medi- size on the importance of high index of suspicion in similar cases. astinum (thymoma). Treatment of thyrotoxicosis was started with carbimazole 30mg/day in divided doses with gradual tapering to History: 14 years old girl presented with diplopia and drooping of achieve euthyroid status. While pyridostigmine used for Myasthe- eyelids on both sides for 1 month duration. She has noticed that nia Graves’ treatment. her diplopia is worsened by the end of the day, which was mainly on looking to right side. Upon more history taking she gave history of Conclusion: In summary, this case emphasizes the need of high recent weight loss, however there was no associated heat intoler- index of suspicion of coexisting Myasthenia Gravis and Graves’ dis- ance, palpitation, tremor, or diarrhoea. Her past medical and past ease. As a rule diagnosing MG at an early stage is essential as it surgical history were negative while she has positive family history may have prognostic significance. It should be remembered that of thyroid disease. presence of ptosis is not an expected feature in thyroid eye disease.

Diagnosis and Treatment: On examination Blood pressure was Keywords: Autoimmune Thyroid Disease (AITD), Myasthenia Gravis 130/70 mmHg, Pulse: 130 beats/min, and respiratory rate of 18 cy- (MG), Graves’ disease cles/min. Examination also revealed that she was lethargic and had

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P-41 Thyroid A CASE OF POSSIBLE FETAL HYPERTHYROIDISM IN A 35-YEAR OLD WOMEN I.C. VAN NIEUWPOORT, R. T. DE JONGH, M. DEN HEIJER DEPARTMENT OF INTERNAL MEDICINE, SECTION ENDOCRINOLOGY, VU UNIVERSITY MEDICAL CENTER, AMSTERDAM, THE NETHERLANDS

Introduction: We will discuss a clinical case of a 35-year old wom- decided to opt out of cordocentesis because of complication risk en with possible fetal hyperthyroidism. We will present the clinical and to perform weekly ultrasounds and/or CTG measurements. course, additional research that was performed and the patient’s Treatment: At AD 29 weeks, propylthiouracil (PTU) was start- treatment. ed at a dosage of 100 mg three times a day because fetal heart rate was persistently elevated for AD (165-170 bpm), ultrasound Clinical Case: Diagnostic evaluation: A 35-year old pregnant wom- showed no other abnormalities. Levothyroxine dosage was in- en was referred to our out-patient clinic when she was 22 weeks creased, TSH and FT4 levels remained within treatment targets. pregnant. She had a medical history of Crohn’s disease, Wolff Par- Follow-up: At first, fetal heart rate showed a downward trend kinson White syndrome and a hypothyroidism for which she was but later on slightly increased again despite treatment with PTU treated with levothyroxine by her general practitioner (GP) until she at maximal dose. At AD 38w4d a baby boy was born after labor was pregnant. At the beginning of the pregnancy, her GP measured induction. He was in good clinical condition, showed no signs of TSH-receptor antibodies. The dose of levothyroxine was adjust- neonatal hyperthyroidism (heart rate 145 bpm, no abnormalities ed and her TSH and FT4 levels were within reference values for on electrocardiogram, birth weight 3760 grams), but laboratory re- pregnant women. She had no complaints other than feeling a bit sults showed hypothyroidism (TSH 150 mU/L and FT4 8.5 pmol/L). tired. She was referred to us because of a persistent fetal tachy- TSH and FT4 spontaneously improved. After 4 days he was released cardia, possibly due to fetal hyperthyroidism since TSH-receptor from the hospital. Shortly thereafter, he was treated with levothy- antibodies were elevated. Clinical examination revealed no ab- roxine for a very short period until he was euthyroid without medi- normalities. TSH levels were between 0.24-0.65 mU/L and FT4 cation. Three months later, he had no health problems. between 16-25 pmol/L with repeated measures. Measurement of TSH-receptor antibodies was repeated and they were proven Conclusion: A 35-year old pregnant women diagnosed with possi- to be stimulatory with highly elevated levels (34.6-38.9 IU/L, nor- ble fetal hyperthyroidism, treated with PTU during pregnancy, de- mal < 0,55 IU/L). At AD 22 weeks fetal ultrasound showed a heart livered a baby boy, without signs of neonatal hyperthyroidism but a rate around 170 bpm, acceptable for AD, no fetal goiter, structur- temporary hypothyroidism. al abnormalities or secondary signs of fetal hyperthyroidism (e.g. Keywords: thyroid, hyperthyroidism, fetal IUGR, decompensated heart failure, increased fetal movement, advanced bone maturity). In multidisciplinary consultation it was

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P-42 Bone/Calcium A 60 YEAR OLD WOMEN WITH BONE PAIN I.C. VAN NIEUWPOORT, R. T. DE JONGH, M. DEN HEIJER DEPARTMENT OF INTERNAL MEDICINE, SECTION ENDOCRINOLOGY, VU UNIVERSITY MEDICAL CENTER, AMSTERDAM, THE NETHERLANDS

Introduction: We will discuss a clinical case of a 60-year old wom- volume and a thin cortex, compatible with hypophosphatemic os- en with bone pain. We will present the clinical course, additional teomalacia. research that was performed and the patients treatment. Treatment: Treatment with oral liquid phosphate, calcium and Clinical Case: Diagnostic evaluation: A 60-year old women was re- alfacalcidol was started and the levels of phosphate and alkaline ferred to our out-patient clinic because of bone pain. She had no phosphatase normalized. relevant medical history. She complained of walking difficulty and Follow-Up: After the start of this treatment, patient’s complaints pain in her feet and later also in her ribs. She had no previous frac- disappeared and the past years she was able to live a pain free tures, had always been physically active in- and outdoors and had active life again. BMD as measured by DXA-scan improved with a an adequate calcium intake. Bone pain was progressive over time T-score of -2.7 at lumbar spine and -1.2 at hip region in 2008 to a and later on she also developed muscle weakness. Her length had T-score of -0.7 and -1.0 respectively in 2009. Further investigations decreased in the past years, although it was not known how much. revealed an elevated FGF23 concentration (299 RU/mL). No mu- Her menarche was at the age of 18 years and menopause at 47 tation in the PHEX- or FGF23-gene were detected. Both PET with or 48 years of age. Laboratory investigations showed a decreased low dose CT-scan and octreotide-SPECT-scan did not show any ab- phosphate level (0.44 mmol/L) and an increased level of alkaline normalities. Despite extensive research as mentioned above, we phosphatase (320 U/L) and PTH (8.8 pmol/L). Levels of calcium, were not able to find a cause for the elevated FGF23 concentration albumin, creatinine and 25-OH-vitamin D were normal. Concentra- and repeated measurement in the past years showed a downward tion of 1,25 dihydroxyvitamin D was 20 pmol/L (decreased). Urine trend. Therefore no further investigations were performed and analysis showed a slightly elevated hydroxyproline creatinine ratio treatment was continued. (28 mmol/mol) and phosphate wasting (decreased renal phosphate threshold of 0.3 mmol/L). A bone scan showed several hotspots Conclusion: A 60-year old women with bone pain due to hypophos- (ribs, lumbar spine, pelvis and feet). Subtle impression fractures at phatemic osteomalacia due to an increased FGF23 of unknown ori- L2 and L5 and bilateral insufficiency fractures of the sacrum were gin, treated with oral medication with a very good clinical response seen on MRI scan. Mammography and CT-scan of the neck, thorax was reported. and abdomen showed no abnormalities. A bone biopsy was per- formed which showed widened osteoid seams, increased osteoid Keywords: Bone pain, hypophosphatemic, osteomalacia

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A C DZODIC, RADAN 55 ABRAROVNA TAKHIROVA, FERUZA 79 CALARAS, MAXIM 80 AKALIN, AYSEN 27 CALELLA, DAMIANO 26 E AKARSU, ERSIN 34 CANAT, MUHAMMED MASUM 48 EFSTATHIADOU, ZOI 44 AKBAŞ, FERAY 57 CANSU, GÜVEN BARIŞ 61, 63 EKICI, FATMA YELIZ 9 AKINCI, BARIŞ 36, 53, 94 CELEN, Y. ZEKI 92 EKŞI HAYDARDEDEOĞLU, FILIZ 40 AKKUŞ, GAMZE 76, 87 CERIT, ETHEM TURGAY 20 ELBOĞA, UMUT 92 AKYILDIZ, GÜZIDE 92 CEYLAN, SAVAŞ 12 ELBÜKEN, GÜLŞAH 10 ALAGÖL, FARUK 98, 100 CHANG, TRICIA 74 ERAKSOY, HALUK 54 ALAY, MURAT 81, 82, 90 CIMINO, VINCENZO 26 ERARSLAN, NIHAT ALI 53 AL FARAJ, DIANA 21 COŞKUN BENLIDAYI, İLKE 73 ERAYDIN, AYTEN 75 AL IBRAHIMI, SALIM MARZOOG 96 CULHA, CAVIT 93 ERBAŞ, TOMRIS 49 ALTUNDAĞ DERIN, NURCIHAN ERBEN, NURETTIN 27 ZEYNEP 60, 67 Ç ERDIN, RIDVAN 65 ALTUN, İLKER 22, 24 ÇAĞILTAY, EYLEM 83 ERDOĞAN, EREN 56 ALTUNTAŞ, YÜKSEL 48 ÇAKMAK, RAMAZAN 37 ERDOĞAN, KIVILCIM 87 ANGUELOVA, LIA 38 ÇALIŞKAN, EZGI 49 ERDOĞAN, ŞEYDA 87 ARAL, FERIHAN 32, 54 ÇAVDAR, ÜMIT 36, 94 EREN BASMAZ, SEDA 48 ARAZ, MUSTAFA 34 ÇELEBI, ALI RIZA CENK 12 EREN, ÖZLEM 63 ARDALI, GÜLAY 56 ÇELIK, ÖZLEM 12 ERGIN, RIDVAN 59 ARIKAN DURMAZ, ŞENAY 59, 60, 65, ÇETIK, SILA 17 ERKIN ÇINAR, OLGU 46 66, 67 ÇETINKALP, ŞEVKI 47 EROL, RUMEYSA SELVINAZ 48 ARSLAN, GÜNKUT 36 ÇETINKAYA ALTUNTAŞ, SEHER 73 ERSÖZ GÜLÇELIK, NEŞE 69 ASLAN FELEK, SEVIM 93 ÇETIN, ZEYNEP 68 ERTAN, YEŞIM 24 ASLAN, MEHMET 91 ÇIFTÇI DOĞANŞEN, SEMA 85 ERTÖRER, MELEK EDA 40 ATAKUR, SALMAN 75 ÇIFTÇI, SEMA 9 ERTÜRK, ERDINÇ 50 ATASOY, PINAR 66 ÇIL ŞEN, ESRA 48 EVRAN, MEHTAP 76, 87 AVLAĞI, GÖKALP 57 EVREN, BAHRI 15 AYBI, ÖZGE 42 D F AYDIN, ŞEBNEM 43 DAĞDELEN DURAN, İFFET 69, 78, 101 FAREED, ISRAA NIHAD AHMED 96 AYDOĞDU, AYDOĞAN 52, 86 DAĞDELEN, SELÇUK 49 FIRLATAN, BÜŞRA 51 AZAL, ÖMER 52, 86 DALMATOVA, ANNA 19 DEĞNELI, OĞUZHAN 56 FINELLI, PALMA 26 B DE JONGH, R. T. 103, 104 FURERAJ, THANAS 95 BAHADIR, EYLEM 63 DEMIRCI, İBRAHIM 52, 86 G BAKINER, OKAN 40 DEMIR, ORHAN 52, 86 GALBIATI, FRANCESCA 26 BARAN, BÜLENT 98 DEMIR, TEVFIK 94 GALLIANI, SILVIA 26 BARIŞAN, EMRAH 10 DENIZ, FERRAT 83 GENÇ, MERVE 59, 60, 66 BATMAN, ADNAN 48 DEYNELI, OĞUZHAN 23 GOGAS YAVUZ, DILEK 23, 30, 56, 71 BAYRAKTAR, MIYASE 18, 25, 42, 45, 49, DHERE, ARCHANA 38 GÖKÇEN, NESLIHAN 73 51 DINÇÇAĞ, NEVIN 37 GRINEVA, ELENA 19 BERKER, MUSTAFA 13 DINIZ ÜNLÜ, AYŞE GÜLDEN 53 GÜLER, EZGI 22 BERKOVICH, GLEB 19 DIREKTOR, NAFIYE 43 GÜL, NURDAN 37, 54 BESTETTI, ILARIA 26 DOĞAN ÇAKIR, SEZIN 48 GÜLŞEN, İSMAIL 82 BOZKIRLI, EMRE 40 DONATO, SARA 33 GÜLTEKIN, KORCAN EMRE 66, 67 BOZ, MUSTAFA 57 DURAN, RAHIME 18 DÜZEN OFLAS, NUR 91 GÜNGÜNEŞ, AŞKIN 59, 60, 65, 66, 67 DYRMISHI, BLERTINA 95 GÜRLEK, ÖMER ALPER 17

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H MIRSHAVKATOVNA ALIKHANOVA, R HACIOĞLU, AYŞA 70 NODIRA 79 RUSTAMOVNA GULYAMOVA, KHILOLA HACIŞAHINOĞULLARI, HÜLYA 32, 37, MOHAMMADI, BAHRAM JAFAR 38 79 54 MOLINAS MANDEL, NIL 100 RYZHKOVA, DARIA 19 HAYDARDEDEOĞLU, BÜLENT 40 MORNEALO, ELENA 21, 80 HAYMANA, CEM 52, 86 MOUSA, UMUT 43 S HEIJER, M. DEN 103, 104 MUNTEAN, VICTOR 21 SABIROVICH AKBAROV, ZAIRKHODJA 79 I N SALTABAŞ, MEHMET AKIF 93 IANEVSKAIA, LIUBOV 19 NASIROĞLU İMGA, NARIN 16 SAMETOĞLU, FETTAH 57 IŞIKLAR, AYSUN 31 NAZLICAN, ERSIN 73 SANTRAC, NADA 55 IVANOV, DANIELA 80 SARAYDAROĞLU, ÖZLEM 50 O SARPEL, TUNAY 73 İ OĞUZ BAYKAL, SEDA 51 SARSIK, BANU 22 İMRE, EREN 30, 56, 71 OĞUZ, SEDA 17 SATMAN, ILHAN 37 İNCE, SEMRA 52 OĞUZ, SEDA BAYKAL 45 SAV, HASAN 43 OKUTURLAR, YILDIZ 77 SAYGILI, EMRE SEDAR 48 K OMMA, TÜLAY 93 SAYGILI, FÜSUN 22, 24 KADIOĞLU, PINAR 84 ONAY, HÜSEYIN 22 SAYINER, ZEYNEL ABIDIN 34, 75 KALAYCI, ORHAN 63 ORHANOĞLU, TIMUR 77 SERT, MURAT 73, 76, 87 KALFA, MELIKE 12 ORLOVA, EKATERINA 19 SEZER, HAVVA 98, 100 KARATAŞ, SAVAŞ 31 SEZGIN ÇAĞLAR, ASLI 70 Ö KARŞIDAĞ, KUBILAY 37 SIMÕES, HELDER 33 ÖNAL, AYŞE 60, 65, 66 KAŠTELAN, DARKO 41 SIRONI, ALESSANDRA 26 ÖNNER, HASAN 61 KEBAPÇI, MAHMUT 61 SOLAK, MIRSALA 41 ÖZDAMAR KARACA, ZÜLEYHA CIHAN KEBAPÇI, MEDINE NUR 61 SOYALTIN, UTKU 22 70 KELEŞTEMUR, FAHRETTIN 70 SOYALTIN, UTKU ERDEM 47 ÖZDEMIR, BAHAR 77 KHATSIMOVA, LIANA 19 SOYLUK SELÇUKBIRICIK, ÖZLEM 37 ÖZDEMIR BAŞER, ÖZDEN 16 KIRNAP, NAZLI 86 SÖNMEZ, ALPER 52, 86 ÖZDEMIR KUTBAY, NILÜFER 13, 24 KOCA, EMINE 35 SÖNMEZ, GÜLÇIN MIYASE 81, 90 ÖZER, MUHAMMET 94 KOÇ, GÖNÜL 93 SÖYLEMEZOĞLU, FIGEN 13 KOÇ, MEHMET SAIT 37 ÖZGEN SAYDAM, BAŞAK 36, 53, 94 KOLLIOS, KONSTANTINOS 44 ÖZIŞIK, HATICE 13, 22, 24 Ş KOSTA, KONSTANTINA 44 ÖZKAYA, MESUT 75 ŞAHIN, İBRAHIM 15 KOSTAREVA, ANNA 19 ÖZPOLAT, BERKAND 67 ŞARER YÜREKLI, BANU PINAR 13, 22, KÖSEOĞLU, FATOŞ DILAN 53 ÖZSARI, LEVENT 83 24, 47 KÖSEOĞLULAR, OSMAN 43 ÖZTEKIN, ÜMIT 65 ŞAYLISOY, SUZAN 27 KUBAT ÜZÜM, AYŞE 32, 37 ŞENDUR, SÜLEYMAN NAHIT 18, 25, P 42, 46, 49 PAPAGIANNI, MARIA 44 L ŞENSÖZ BERKER, DILEK 16, 68 PEROTTI, MARIO 26 LEHIMCIOĞLU, MERVE 59, 67 ŞENYIĞIT, ABDULHALIM 77 PEYNIRCI, HANDE 50 LEITE, VALERIANO 33 ŞIMŞEK BAĞIR, GÜLAY 40 LUMI, EMA 95 PINCELLI, ANGELA IDA 26 POLAT KORKMAZ, ÖZGE 84 T M PUCA, ENTELA 95 TABUR, SUZAN 34 MACEDO, DANIEL 33 TADMAN, MIKE 38 Q MASHAL, SHAIMAA SAMIR AMIN 88 TANAKOL, REFIK 32, 54, 85 QASIM, BAYAR AHMED 14, 102 MERIÇ, COŞKUN 86 TAN, GARRY D 38

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TANRIKULU, SEHER 37, 85 Ü YETIŞYIĞIT, TARKAN 10 TANRIVERDI, FATIH 70 ÜÇLER, RIFKI 81, 82, 90, 91 YILDIRIM, HÜSEYIN 27 TARE, RAJMONDA 95 ÜNLÜHIZARCI, KÜRŞAD 70 YILDIRIM, NILGÜN 20 TAŞAR, GÖZDE ELIF 13 ÜNLÜTÜRK, UĞUR 45, 46, 49 YILDIRIM ŞIMŞIR, ILGIN 22, 47 TAŞKALDIRAN, IŞILAY 93 ÜSTAY TARÇIN, ÖZLEM 56 YILDIZ, SALIHA 81, 82, 90 TAŞKIRAN, BENGÜR 27, 50, 61, 63 YILMAZ, EBRU 54 TEKIN, SAKIN 32, 37 V YILMAZ, EVRIM 61 TETIKER, TAMER 76, 87 VAN NIEUWPOORT, I. C. 103, 104 YILMAZ, MEHMET TEMEL 37 TOMŠIĆ, KARIN ZIBAR 41 YIĞIT, MEHMET 36 TOPALOĞLU, ÖMERCAN 15 Y YLLI, AGRON 95 TSANAKAS, IOANNIS 44 YALÇIN, MEHMET MUHITTIN 20 YORULMAZ, GÖKNUR 27, 61 TSIROUKIDOU, KYRIAKI 44 YAPRAK, BÜLENT 77 YÖNEM, ARIF 83 TSOY, ULIANA 19 YARMAN, SEMA 9, 85 TUNCER, FEYZA NUR 9 YAŞAR, HAMIYET YILMAZ 53 Z YAY, ADNAN 83 ZUHUR, SAYID 10 U YAZICI, DILEK 98, 100 USTA ATMACA, HANIFE 57 YENER ÖZTÜRK, FEYZA 48 UYGUR, MELIHA MELIN 23 YENIDÜNYA YALIN, GÜLŞAH 85

107 19 - 22 October, 2017 Antalya - Turkey Bridging the World of Endocrinology

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