Abstract Disclosure: S. Bulchandani: None. N. Janicic-Kahric: None. Introduction: Thyroiditis is an inflammatory disease of the thyroid; the cause can be autoimmune, infectious or drug induced. Patients can have an initial phase of hyperthyroidism (thyrotoxicosis) attributed to the release of preformed thyroid hormone from damaged thyroid cells. This can be followed by hypothyroidism, when the thyroid stores are depleted, and then eventual restoration of normal thyroid function. Some patients may develop permanent hypothyroidism.1 We report a case of thyroiditis caused by cabozantinib. CASE REPORT: 39-year-old female presented with abdominal pain, vomiting and palpitations. Past medical history was significant for metastatic clear cell renal carcinoma. Eight weeks before the presentation, she had started on cabozantinib 60 mg daily as part of therapy for her renal carcinoma. On presentation, the patient’s temperature was 36.6 Celsius, heart rate was 118 beats/minute, blood pressure was 114/84 mm Hg and oxygen saturation was 100% on room air. Laboratory evaluation was notable for white blood cell count of 12.3 k/uL, Hemoglobin of 16.5g/dl, Platelet count of 573 k/uL bicarbonate level of 13 mmol/L, anion gap 24 mmol/L, Total bilirubin of 0.6 mg/dl, Aspartate aminotransferase of 36 units/L, Alanine aminotransferase of 30 units/L, Alkaline phosphatase of 121 units/L. Thyroid function tests revealed thyroid stimulating hormone (TSH) which was low at 0.045 uIU/ml and free thyroxine level (Free T4) which was elevated at 4.29 ng/dl. Thyroid function tests performed eight weeks prior to presentation showed TSH of 6.9 uIU/ml, attributed to immunotherapy that the patient received 1 month prior. She was admitted and received intravenous fluids. Prednisone at 40 mg orally daily was initiated. Labs demonstrated a decrease in Free T4 level. She was discharged on a tapering course of prednisone. Free T4 one week later was normal at 1.35ng/dl. Repeat laboratory evaluation three weeks later revealed that the patient had developed hypothyroidism with TSH level of 8.7 uIU/ml and she was started on 50 micrograms of levothyroxine. Cabozantinib was discontinued. Discussion: Tyrosine Kinase inhibitor therapy can result in clinically significant thyroid dysfunction. Cabozantinib treatment can result in thyroid dysfunction varying from subclinical hypothyroidism to symptomatic thyrotoxicosis. Early detection and close follow-up are essential to provide adequate management2 Presentation Date: Saturday, June 17, 2023
INTRODUCTION: Despite substantial progress for women in medicine, women remain underrepresented in many aspects of the scholarly publication process. Appointment to an editorial board conveys a degree of prestige that may influence hiring, tenure, or promotion decisions and provides opportunities for intellectual growth and networking that can improve the quality of a research program. Women face multiple challenges in representation in medicine and our aim was to look at the representation of women in the scholarly publication process. The purpose of this study was to analyze the proportion of female representation in editorial boards of the major gastroenterology journals. METHODS: We examined the four major gastroenterology journals, American Journal of Gastroenterology, Gastroenterology, Gastrointestinal Endoscopy, and Hepatology. The editorial boards of each journal from 2020 were included. The gender of each person, and the total number of individuals as editors and on the editorial board were abstracted. The number of females on the editorial boards were compared to the total number of individuals. RESULTS: There were a total of 511 individuals across the four major journals included as editors, associate, or deputy editors and on the editorial boards of the journals. The total number of women included as associate or deputy editors varied but remained significantly below that of men. (See Figure 1). None of the editors in chiefs of the major gastroenterology journals were females. Similarly, the representation of women on editorial boards was extremely low and significantly below that of men. (See Figure 2). CONCLUSION: There were significant disparities in female representation in editorial boards across the major gastroenterology journals. Addressing these disparities may promote academic advancement for female gastroenterologists and promote greater equality of participation in the scholarly peer-review process.Figure 1
Background: Gestational diabetes (GDM) is glucose intolerance detected for the first time during pregnancy. Women with a history of GDM have a 7-fold higher lifetime risk of developing type 2 diabetes (DMII) compared to women without a history of GDM. Women with a history of GDM should be screened for DMII 6 to 12 weeks postpartum with a 2-hour 75-g oral glucose tolerance test (OGTT) and then again one year after delivery. The long-term goal of this project is to improve screening for DMII in women with a history of GDM. This report establishes the prevalence of GDM, determines the postpartum screening rate, and assesses for barriers to screening at an urban safety-net hospital. This information will be used to design interventions to improve postpartum screening. Methods: We conducted a retrospective chart review of women who had a delivery at Truman Medical Center between January 1, 2017 to December 31, 2019 and had a diagnosis of GDM. Charts were reviewed for demographic data, management of GDM, postpartum appointments, and screening for DMII. Results: There were 9569 deliveries during the three-year period. Of the total deliveries, 537 (5.6%) had a diagnosis of GDM. Of the patients with GDM, 426 (79%) had a postpartum visit scheduled, 354 (66%) attended a 6-week postpartum appointment, 219 (41%) had the recommended test ordered, and 49 (9%) completed the test. The data revealed a significant association with ethnicity, language, insurance type, and site of prenatal care with attending the postpartum appointment (p<0.05) as well as with insurance status on completing the screening test (p<0.05). Conclusion: There is gap in the number of women with GDM and those who are screened for DMII in the postpartum period. There appears to be a disconnect in the ordering of the recommended 2-hour OGTT and the completion of the test. The baseline data supports a multi-prong approach including patient education, system changes, and advocacy for extended insurance benefits to cover screening. Disclosure V. Rakhra: None. M. Riley: None. S. Jordan: None. S. Bulchandani: None. J. Allsworth: None. B. Drees: None.
INTRODUCTION: Pembrolizumab, a monoclonal antibody against programmed death receptor 1 (PD-1), is a form of immunotherapy used in multiple malignancies. PD-1 inhibitors have been associated with numerous “immune-related adverse events” (irAEs) affecting most organs in the body. IrAEs in the lower gastrointestinal tract have been widely reported, with only few in the upper GI tract. We present a case of acute, grade 3 esophagitis in a patient on pembrolizumab. CASE DESCRIPTION/METHODS: Case report and literature review. We searched the words “esophagitis” “immune checkpoint inhibitors” “pembrolizumab” on PubMed. A 70-year-old male was admitted to the hospital with a 1-month history of progressive dysphagia and odynophagia. Medical history was notable for metastatic lung adenocarcinoma (stage T1cN3M1c) with a tumor proportion score of 95% positive PDL-1. Patient received 31 cycles of pembrolizumab 200mg IV prior to symptom onset. Physical exam demonstrated buccal mucosa swelling and oral candidiasis upon admission. With candida esophagitis as the primary differential, patient was started on IV fluconazole 200mg q24 hours with a 400mg loading dose. After 48 hours of IV fluconazole, symptoms did not improve; Gastroenterology was consulted. An esophagogastroduodenoscopy was performed which demonstrated linear furrows and esophagitis throughout the whole esophagus and no signs of candidal infection. Biopsy showed acute esophagitis with ulceration, reactive epithelial changes, and granulation tissue. Patient was started on IV methylprednisolone 60 mg for ICI-associated esophagitis. Dysphagia improved after two days of IV steroids. Oral prednisone was continued and pembrolizumab was held. Steroid dose was gradually tapered. Tumor progression was not observed four months after discontinuation of pembrolizumab and it was not reinitiated. DISCUSSION: Immune checkpoint inhibitor therapies are associated with a wide range of adverse events that can include the upper gastrointestinal system. Management includes initiation of corticosteroids and cessation of chemotherapy in severe cases. Early recognition and timely initiation of appropriate therapy are the keys to optimal outcomes. With the growing use of pembrolizumab in oncology, physicians must be aware of all potential irAEs. This case is one of the first to highlight acute esophagitis as one of its irAE. We conclude that close monitoring for manifestations of esophagitis is crucial when prescribing PD-1 inhibitors.Figure 1.: Linear furrows and esophagitis in the mid-esophagus.
A 28 year old female with AIDS on retroviral treatment came with Crohn's disease. She had Crohn's disease for more than 2 years and was getting worse. Labs and endoscopy confirmed her to have moderate to severe Crohn's disease. Patient had been on mesalamine products; however continues to have symptoms; however given her advanced HIV the treatment options remain complicated. A systematic review was performed of treatment options in patients with HIV and severe Crohn's. A search was made of PubMed using search terms “HIV and Crohns,” “HIV and IBD,” “AIDS and Crohns.” We only found a few case reports exploring the treatment of Crohn's disease with anti-TNF agents in patients with HIV. In one case report, 1 patient developed sepsis and died after was started in anti-TNF agents. There were a couple of case reports which showed successful treatment of Crohn’s disease with infliximab with 1 patient being on a retroviral and the other not being on a retroviral. In one case report, 1 patient developed pulmonary and nodal tuberculosis when started on infliximab. Management of severe Crohn’s disease in people with HIV infection can be very difficult, looking for the balance between immune suppression and infectious complications and the role on anti TNF agents needs to be clarified.
Abstract Background New-onset diabetes after transplantation (NODAT) is a serious complication after a solid organ transplant. NODAT occurs in 2% to 53% of all solid organ transplant recipients.1 Tacrolimus is an immunosuppressive agent associated with diabetogenic potential which predominantly is a result of suppression of insulin secretion from pancreatic beta cells. Diabetic ketoacidosis as the first presentation of new onset tacrolimus induced diabetes is rare. We report a case of diabetic ketoacidosis (DKA) in a patient without prior history of diabetes mellitus and receiving tacrolimus as part of immunosuppressive regime post-renal transplant. Clinical Case A 62-year-old female with past medical history of autosomal polycystic kidney disease status-post deceased donor renal transplant and hypertension presented with weakness and fatigue. She had undergone transplant 8 months prior to this presentation and her immunosuppressive regime consisted of mycophenolate mofetil and tacrolimus. The patient was encephalopathic on arrival with normal vitals. Laboratory evaluation was significant for blood glucose of 673, bicarbonate of <10, anion gap of 24, Beta-hydroxybutyrate >8 and a pH of 7.19 on arterial blood gas analysis thus confirming diagnosis of diabetic ketoacidosis (DKA). Tacrolimus level was elevated at 35.7. Intravenous fluids and insulin were initiated with resolution of symptoms and DKA. She was transitioned to a basal-bolus insulin regimen. Further labs revealed Hemoglobin A1C of 11.6% (no previous value), negative insulin antibodies and glutamic acid decarboxylase antibody, and a low C-peptide level at 0.47 (when blood glucose was 150mg/dl). Her tacrolimus dose was adjusted, and she was discharged on a basal-bolus insulin regimen. On follow up, the patient had lower insulin requirements with improvement in C-peptide level to 1.8, thus, indicating beta cell dysfunction in setting of supratherapeutic tacrolimus levels. Conclusion Tacrolimus remains the preferred immunosuppressive agent after kidney transplantation given lower incidence of acute rejections and better tolerance. However, due to its toxic effects on pancreatic beta cells it is imperative blood sugar levels should be routinely monitored in patients on tacrolimus. Appropriate monitoring can lead to timely diagnosis and successful outcomes. Further studies are required to investigate risks factors associated with tacrolimus induced DKA. References 1. Pham PT, Pham PM, Pham SV, Pham PT, Pham P. New onset diabetes after transplantation (NODAT): an overview. Diabetes Metab Syndr Obes. 2011;4: 175-186, https://doi.org/10.2147/DMSO.S19027 Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
