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Background Liver transplantation is an established treatment for patients with end-stage liver disease. In 2021 more than 8,400 liver transplants were performed in the United States. Although successful transplantation can reverse many complications of end organ failure, disturbance of bone and mineral metabolism may persist, which can contribute substantially to morbidity and mortality. It is important to assess whether liver transplant patients are getting bone density screening and treatment. Objective Our goal is to assess current practice in bone density screening in patients who have undergone liver transplant at our medical center, to identify if these patients are being screened for metabolic bone disease before and after transplant, and to improve management of such patients by initiating a provider work flow that is based on available data and evidence. Study Design: The first phase was a survey of the liver transplant team to assess the current protocol for screening. The second phase involved retrospective chart review of patients at our institution who had a liver transplant between October 2008 and April 2021. The findings will be used to create an institutional protocol for osteoporosis screening and management. Results Survey results: 62.5% of liver transplant providers knew that guidelines or a protocol are being used to screen liver transplant recipients for osteoporosis. 75% said that dual-energy x-ray absorptiometry (DXA) scans are always obtained before liver transplantation, while 25% said they are sometimes obtained. There were mixed results regarding monitoring post transplant. All respondents agreed that creating a protocol for osteoporosis screening would improve outcomes of bone health in transplant patients. Chart review results: We reviewed 243 liver transplant recipients between October 2008 and April 2021. After excluding duplicate transplants and those less than 18 years old, 234 patients were included in analysis. 59% of patients were men with a median age of 63.5. The most common etiologies of pre-transplant liver disease were Hepatocellular Carcinoma (29%), Hepatitis C (17%), alcoholic cirrhosis (16%) and NASH (5%). 72% of transplant patients had a DXA before transplant and 28% did not. Of those with a pre-transplant DXA, 28% had normal bone density, 50% had osteopenia, and 20% had osteoporosis. The remainder did not have data available. Among those with a diagnosis of osteoporosis pre-transplant, 41% received treatment while 56% did not receive any bone-specific therapy. Discussion The majority of providers in our liver transplant team are aware of the need for bone health screening and treatment in liver transplant candidates. Most patients received a DXA prior to transplant however less than half of the patients with osteoporosis were started on treatment. Our study shows the need for developing an institutional work flow to optimize bone health in patients undergoing liver transplant. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m., Saturday, June 11, 2022 1:06 p.m. - 1:11 p.m.

Introduction Multiple primary tumors are defined as the presence of two primary tumors of different histologies in the same individual, which can be diagnosed at the same time or at different times. We present a rare case of papillary thyroid cancer (PTC) with pulmonary metastasis and lung adenocarcinoma diagnosed simultaneously and highlight the importance of identifying multiple primary cancers to guide management and improve patient outcomes. Clinical Case A 57-year-old female with no prior history of malignancy was found to have a 12 mm left upper lobe lung nodule on CT chest as a part of evaluation of worsening cough. A fluorodeoxyglucose PET scan showed increased uptake in the left upper lobe nodule as well as a hypermetabolic thyroid nodule in the right thyroid lobe. She underwent a thoracoscopy, wedge resection, and left lung lobectomy with lymph node dissection, and pathology revealed adenocarcinoma of the lung as well as incidentally found PTC. Subsequently, thyroid ultrasound was obtained which showed a right upper mid-pole thyroid nodule measuring 1.7 cm. She underwent a total thyroidectomy, and pathology showed PTC, tall cell variant in the right lobe, with largest tumor dimension 1.5 cm with no extrathyroidal extension, no lymphatic, and no vascular invasion. A nuclear uptake scan post thyroidectomy showed focal uptake in the thyroid corresponding to residual thyroid tissue, without evidence of metastatic disease. She subsequently received 152.6 mCi of radioactive iodine (RAI). A post-therapy scan obtained one week later showed no new uptake. After RAI, her thyroglobulin antibody remained negative and thyroglobulin became undetectable. She remains on levothyroxine therapy with her TSH at target of 0.1-0.4 U/L. However, she unfortunately had recurrent disease of her lung adenocarcinoma and is continuing to undergo treatment with chemotherapy Conclusion PTC is the most common type of differentiated thyroid cancer and generally has a better prognosis than other types of thyroid cancer given its indolent course. Histologic subtype, presence of extra thyroidal extension, lymph node involvement, and distant metastasis play a role in prognosis, and PTC metastasizes to the lungs in about 5% of cases. Clinicians should be aware of the possibility of multiple primary tumors, and the use of diagnostic modalities like FDG-PET and tissue biopsy can help differentiate a second primary tumor from metastatic disease. Radioactive iodine therapy (RAI) for management of differentiated thyroid carcinoma has been linked to predisposition to other primary malignancies such as leukemia and lymphoma, however our patient was found to have both malignancies simultaneously prior to receiving RAI. This suggests the possibility of genetic susceptibility or alterations in the immune constituency. Further studies are needed to analyze the genetic and environmental factors that lead to development of two primary tumors in certain individuals. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Introduction Pituitary abscesses are rare, representing less than 1% of pituitary lesions. Patients may present with pituitary hypofunction, headache, and/or vision changes, often without systemic or biochemical signs of infection, with diagnosis only made intraoperatively. Cases A 74-year-old man with history of diabetes and coronary artery disease presented with headache and left-eye ptosis. MRI revealed a 1.8 cm hypoenhancing cystic, hemorrhagic sellar mass extending into the left cavernous sinus. Pre-operative labs showed AM cortisol 1.1 ug/dL, testosterone 43 ng/dL (reference range 250-1100), FSH 15.3 mIU/mL, LH 4.5 mIU/mL consistent with adrenal insufficiency and hypogonadism. He underwent transsphenoidal pituitary resection (TSR) during which frank pus was demonstrated after incision into the dura overlying the pituitary. Surgical pathology showed necrosis and granulation-type reaction with acute inflammatory cell infiltrates. Gram stain and methenamine silver stains did not reveal definite micro-organisms while tissue bacterial cultures showed normal skin flora. He remained hemodynamically stable without fevers throughout the hospitalization and was discharged on empiric antibiotics and hydrocortisone. A 74-year-old female with history of a pituitary macroadenoma was admitted for worsening headaches. Labs were consistent with her known history of secondary adrenal insufficiency and hypogonadotropic hypogonadism. Repeat MRI showed characteristics suggestive of hemorrhage within a 1.8 cm intrasellar mass with inhomogeneous and peripheral enhancement after contrast. She underwent TSR and intraoperatively frank pus was encountered. Surgical pathology showed sinonasal mucosa with chronic inflammation. There was no growth in aerobic, fungal, or AFB cultures; anaerobic cultures grew rare commensal bacteria. She was discharged with a course of antibiotics and remains on hydrocortisone. A 42-year-old male presented with headache and was found to have a 2.5 cm sellar mass with rim enhancement elevating and compressing the optic chiasm on MRI. Labs were significant for AM cortisol 4.9 ug/dL and testosterone 8 ng/dL, FSH 0.4 mIU/mL, LH <0.2 mIU/mL consistent with adrenal insufficiency and hypogonadism. He underwent TSR and was found to have purulent debris in the sella. Pathology showed epithelial tissue fragments insufficient for diagnosis, and cultures grew few skin and oropharyngeal contaminants. He was discharged on hydrocortisone with a course of antibiotics. Conclusion We describe three patient cases presenting with headache and varying degrees of hypopituitarism, found to have purulent material emanating from the sella during transsphenoidal resection. None presented with clinical or biochemical systemic signs of infection. MRI imaging was variable, ranging from cystic, hemorrhagic features to peripheral enhancement. Surgical pathology and cultures were unrevealing for a definitive infectious source or other cystic lesion such as Rathke's cleft cyst. This case series demonstrates the potential nonspecific presentation of pituitary abscesses including negative cultures and pathology. It is important to keep this rare diagnosis in the differential for patients presenting with pituitary disease. Presentation: Sunday, June 12, 2022 12:30 p.m. - 12:35 p.m., Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

Introduction: Thyrotoxic periodic paralysis (TPP) is an uncommon disorder characterized by simultaneous thyrotoxicosis, hypokalemia, and paralysis. It is a rare complication of hyperthyroidism with a prevalence of 1 in 100,000. It has a higher prevalence in young Asian males, with much fewer cases reported in Hispanic patients. The majority of cases are seen in hyperthyroidism due to Grave’s disease, however other causes of thyrotoxicosis have been associated with TPP. Hypokalemia occurs when thyroid hormone stimulates the sodium-potassium-ATP pump by binding to the thyroid response elements upstream of the genes for this pump, increasing its activity and thereby causing a transcellular shift of potassium into the intracellular fluid. Attacks usually begin with proximal muscle weakness of the lower extremities and may progress to tetraplegia, with the degree of muscle weakness corresponding to serum potassium levels. Interestingly, no correlations with serum T3 or T4 levels have been found. Clinical Case: A 38-year-old Hispanic man with a history of GERD presented to the emergency department with an inability to move his extremities. Initial labs were significant for profound hypokalemia to 2.0 mEq/L (3.5-5) and hyperthyroidism, with TSH<0.05 uU/mL (0.3-4.2) and free T4 2.4 ng/dL (0.6-1.5). Additional workup revealed a positive thyroid stimulating immunoglobulin and a positive thyrotropin binding inhibitor, and thyroid ultrasound demonstrated a hyperemic thyroid with numerous subcentimeter hypoechoic nodules, all of which was suggestive of Grave’s disease. His symptoms resolved with potassium repletion, suggesting thyrotoxic periodic paralysis secondary to hyperthyroidism. Upon further evaluation, the patient endorsed several months of hyperthyroid symptoms such as tremors, heat intolerance, and weight loss. He also endorsed alcohol use, a high carbohydrate diet, and recent life stressors, a combination of which likely precipitated his thyrotoxic periodic paralysis. He was discharged on methimazole 10 mg daily and propranolol 40 mg BID, with a decrease in his free T4 and improvement in his symptoms. He has been educated to avoid alcohol consumption and high-carbohydrate meals to avoid precipitating another episode of periodic paralysis, and once his hyperthyroidism is under better control he plans to undergo radioactive iodine ablation (RAI) for definitive management. Conclusions: Thyrotoxic periodic paralysis is a rare but dangerous complication of hyperthyroidism, and should be considered in the differential diagnosis when young individuals present with otherwise unexplained hypokalemia and paralysis. Acute management is potassium repletion, long term management involves treatment of thyrotoxicosis and avoiding precipitating factors, and definitive therapy is RAI or thyroidectomy.