Introduction: Cocaine is a drug that is abused by 5 million Americans and most of the cocaine that comes to the United States has been tainted with Levamisole, a veterinary anti-helmintic, which recently has been linked to ANCA Associated Vasculitis (AAV) [1]. AAV is an unusual necrotizing vasculitis that attacks small vessels more often, and can have an ominous prognosis if left untreated [2].

INTRODUCTION Amphetamine and amphetamine-analogues, such as synthetic cathinones, popularly known as “bath salts”, should induce hyperglycemia, due to their increased dopaminergic activity. However, a handful of case reports have described paradoxical hypoglycemia with the use of synthetic cathinones. CLINICAL CASE A 39-year-old man with no known prior medical history was admitted to the Medical ICU after being found agitated and combative; he was intubated at the scene. In the ED fingerstick glucose monitoring was 57mg/dL and later confirmed by venous blood chemistry. The rest of his chemistry was remarkable for a creatinine of 2.14mg/dL (0.7-1.20mg/dL), a mild elevation of AST-SGOT at 85 units/L (0-40 units/L), and a creatinine kinase of 1937 units/L (20-200 units/L). His CBC revealed a WBC count of 22.39 x 10 9 /L (3.50-10.50 x 10 9 /L), with normal differential. A comprehensive urine drug screen was positive for amphetamine and methamphetamine and a screen for hypoglycemic agents was negative. He remained hypoglycemic for the initial 48h of his hospital admission, despite continuous supplementation with D10W and frequent administration of D50% boluses. Patient was weaned off the ventilator and admitted to the ingestion of “bath salts” prior to his hospitalization. His physical examination was essentially unremarkable, except for noted tachycardia and intermittent episodes of confusion and disorganized speech; with these findings improving within 48 hours of admission. His hospital course was complicated and prolonged due to concomitant sepsis secondary to MRSA and Klebsiella pneumoniae bacteremia, with acute liver and kidney failure. Euglycemia was achieved once oral intake was initiated; remaining this way for the rest of his hospital stay and continuous dextrose infusion was weaned off in 4 days. Our patient’s hypoglycemia was suspected to be derived from the use of synthetic cathinones, and to a lesser degree from the combination of early starvation and impaired gluconeogenesis in the setting of acute liver and kidney failure. CONCLUSIONS Although amphetamine derivatives, including synthetic cathinones, have been shown to produce hypoglycemia in a few animal studies (1), this remains to be confirmed in humans. The suspicion or confirmation of the use of illicit stimulants, including “bath salts” in the setting of prolonged hypoglycemia, should prompt the clinician to include this as a major contributing factor to disruptions in glucose metabolism. REFERENCES Soto-Montenegro, Marisa & Vaquero, Juan Jose & Arango, C & Ricaurte, G & García-Barreno, P & Desco, Manuel. (2007). Effects of MDMA on blood glucose levels and brain glucose metabolism. European journal of nuclear medicine and molecular imaging. 34. 916-25. 10.1007/s00259-006-0262-8.

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Case 1, a 62-year-old female with recurrent invasive ductal carcinoma metastatic to lung and bone, was referred to Endocrinology for management of hyperglycemia. Case 2, a 47-year-old female with history of major depressive disorder, generalized anxiety disorder, and recurrent metastatic breast cancer, was referred to Endocrinology for management of alpelisib-induced diabetes. Case 3, a 59-year-old female with metastatic invasive ductal carcinoma, gastroesophageal reflux disease, and chronic low back pain, was diagnosed with alpelisib-induced diabetes.

INTRODUCTION The incidence of thyroid cancer has risen steadily over the last decades, in part due to increasing diagnosis of apparently low-risk well-differentiated cancers. The outcomes of well-differentiated thyroid cancers, including follicular variant papillary thyroid carcinoma (PTC), are believed to be quite favorable, with a largely indolent benign course. We examine an encapsulated follicular-variant of micropapillary carcinoma presenting with distant bony metastasis. CASE 55-year-old lady presented to clinic after biopsy of iliac crest (IC) mass revealed thyroid tissue. One year prior she started having dull pain at right hip, attributed to increased physical activity. She noticed a tender “lump” on her right hip. CT revealed destructive right iliac 8 cm mass with extraosseous soft tissue component, central necrosis, and eccentric calcifications; and right ovarian cyst. Right IC biopsy was consistent with thyroid tissue with positive Thyroglobulin and TTF-1 immunostains. Physical exam was normal, except for mild tachycardia, hypertension, right flank large rounded mass fixed to IC, tender to palpation without erythema or warmth on overlying skin. Thyroid ultrasound showed normal thyroid gland except 5.58 x 6.22 x 7.76 mm left lobe nodule without increased vascularity but with coarse peripheral calcification. FNA was unsatisfactory. Thyroid function tests revealed undetectable TSH, elevated FT4, FT3, and markedly elevated thyroglobulin and TSI. PET/CT scan showed focal area of mild FDG avidity, corresponding to the right iliac crest mass, without additional areas of FDG avidity suggestive of metastatic disease or primary neoplastic process. Three weeks after presentation, patient began having symptoms of hyperthyroidism. As FT4 and FT3 continued to rise, she was started on propranolol and methimazole. Due to inadequate response, methimazole was switched to high dose propylthiouracil with mild improvement. Thyroid uptake and scan and SPECT-CT revealed increased thyroid uptake and thyromegaly consistent with Graves’ disease and redemonstrated large right IC lesion with increased uptake in the periphery and central photopenia, suggesting metastatic thyroid malignancy. Pathology from total thyroidectomy reported encapsulated follicular variant of PTC, confined to the left lobe of the thyroid, without extrathyroidal extension, greatest tumor dimension 0.6cm. As metastasis to the IC were unlikely to have originated from this small encapsulated thyroid cancer, it was recommended to proceed with right oophorectomy for suspected malignant struma ovarii and IC lesion debulking. Surgical pathology revealed right ovary and fallopian tube without pathologic changes or features of teratoma and tissue from right iliac mass consistent with PTC. Patient is off all antithyroid medications and remains biochemically euthyroid, awaiting radioactive iodine therapy.