Myxedema coma is a rare diagnosis but if not early recognized, this medical emergency possesses a high mortality rate. Over the years, it has been described predominantly in elderly women with history of hypothyroidism and as a precipitant factor that converges to evolve in a full presentation. We report a case of myxedema coma in a young male without risks for this disease. A 38 y/o Latin-American male with medical history ofhepatitis C virus and intravenous drug abuser that was brought to the emergency department after being found in the streets. The patient was agitated, oriented only to person, had slurred speech and reports last dose of heroin was two days ago. Denied other condition or medications. Vital signs BP 103/90mmHg, pulse: 41 bpm, T: 35.8°C RR: 19 rpm, SPO2: 99% at room air and BMI: 23.9. kg/m 2 . Physical examination pertinent for a disheveled male with anasarca, diffused dry skin with piloerection without surgery scars, non-palpable nor tender thyroid gland, bilateral exophthalmos, decreased bowel sound, positive fluid wave and abdomen diffusely tender to palpation with bilateral lower extremities infected ulcers. Blood workup showed impaired renal function, severe azotemia, hyponatremia, hypoglycemia and normocytic anemia. TSH 147uIU/mL. Imaging studies remarkable for bilateral pleural effusions, intestinal ileus, and negative brain CT scan. Patient was admitted with diagnosis of uremic encephalopathy, drug withdrawal and soft skin tissue infection. Patient was treated with emergent hemodialysis, drug withdrawal measures and IV antibiotics. Despite treatment, patient's clinical condition began to decline. He was found obtunded requiring endotracheal intubation. TSH was persistently elevated in 55.7uIU/mL with suppressed free T4 <0.42ng/dL. Patient noted with persistent sinus bradycardia, hypothermia, ileus, ascites, bilateral pleural effusions, and hypotension. Patient was consulted to endocrinology department who evaluated the overall clinical presentation and myxedema coma was diagnosed. He was treated with levothyroxine 100mg IV for two days, but eventually developed multiorgan failure and unfortunately died. Myxedema coma is a complication of severe hypothyroidism that slows down the functions of multiple organs and directly affects their function. It is an endocrinologic emergency that leads to decline of the clinical presentation of patients. The epidemiology favors this presentation in patients with history of hypothyroidism, more specifically elderly women. Multiple conditions may present with similar signs and symptoms. Physicians must be aware that myxedema coma must be suspected in a patient with altered mental status, hypothermia, hypoglycemia, hypotension, anasarca among others even in the presence of more common conditions and in rare populations like our patient. Opioid Induced Endocrinopathies still remain a complication that is underdiagnosed. The aim of this case is to createmedical awareness on the importanceto consider myxedema coma in patients with Opioid abuse and withdrawal. Presentation: No date and time listed

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Papillary thyroid Carcinoma (PTC) with apparent distant metastasis but lacking a primary thyroid cancer on pre-operative ultrasonographic examination, is referred by some as occult PTC. In most cases, primary carcinomas are identified after careful pathologic examination of the specimen but in some rare cases the primary tumors were not detected. Hereby, we describe the rare case of a patient with metastatic PTC without initial visualization on imaging of primary tumor location along with inconsistent pathology results between fine needle aspiration (FNA) biopsy and gross specimen pathology results. A 60-year-old female with past medical history of Diabetes Mellitus type 2 and Hypothyroidism presenting for follow-up visit after being found with neck nodules on head and neck CT scan. Thyroid and neck Ultrasound (US) were performed finding three right irregularly shaped hypoechoic lymph nodes (LN's) measuring > 1 cm, concerning for metastatic disease, but no thyroid nodules were noted. Patient denies family history of thyroid cancer, and no head and neck radiation exposure. Physical examination did not reveal goiter or palpable nodules. Laboratory results: TSH: 2.95 and Total T4: 9.32, both within normal range. Cervical LN's FNA biopsy was performed, yielding results consistent with PTC tall cell variant. Chest CT scan showed suspicious lesions for pulmonary micrometastasis. Total thyroidectomy was performed and gross pathology findings showed an infiltrating, follicular variant PTC with multifocal tiny primary tumors of the thyroid, with lesions measuring up to 0.2 cm, dimension which explains why nodules could not be identified on imaging studies. LN's FNA biopsy results and thyroid pathology did not correlate. Thyroid gross pathology was clearly PTC with follicular variant, infiltrating a small area away from greatest dimension tumor, with cells with apparent dedifferentiation to tall cell cytologic features. Due to high risk of recurrence, radioactive iodine therapy was recommended as adjunctive therapy for metastatic disease and eradication of residual neck disease to be started with levels of TSH>30 mU/ml. Postopertative Thyroglobulin level (Tg) was adequate < 0. 01 ng/ml but unreliable based on above normal range antithyroglobulin antibody > 1000 IU/ml, which increases risk of recurrence. Whole body scan also done showing bilateral lung metastasis and small neck metastatic disease. Repeated postoperative thyroid US also demonstrated a suspicious cystic lymph node in right central neck for which FNA with saline washout of aspirate for Tg measurement was ordered. Metastatic thyroid carcinoma without primary tumor after extensive thyroid sampling is a rare but existent phenomenon that can be encountered in daily practice. Genotyping or immunostaining mestastatic lesions could help direct the Pathologist to the source of the metastasis. Patients with a higher risk of recurrence are monitored more aggressively as it is believed that early detection of recurrent disease offers the best opportunity for effective treatment. Presentation: No date and time listed