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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

Introduction: Isolated adrenocorticotropic hormone (ACTH) deficiency is a rare pituitary hormone deficiency defined by secondary adrenal insufficiency and normal secretion of all other pituitary hormones. Patients present with fatigue, weakness, weight loss, anorexia, nausea, low cortisol levels and low ACTH levels. Isolated ACTH deficiency is more common in males and usually presents in the fifth decade of life. Main mechanisms involved in the pathogenesis are genetics and autoimmune causes, traumatic brain injury and infarction of the pituitary postpartum, known as Sheehan’s syndrome. Sheehan’s syndrome is characterized by postpartum hemorrhage, failure to lactate and menstrual irregularities and it can occur from immediate postpartum period to years after delivery. The most common hormone deficiencies are prolactin and growth hormone. Empty sella is the most common finding on brain MRI. We are reporting a case of a woman in her third decade with isolated ACTH deficiency due to Sheehan’s syndrome two years postpartum, able to lactate, with normal menses and normal brain MRI. Clinical Case: A 33-year-old woman G3P3A0 with hypothyroidism who was referred to Endocrinology clinics due to tiredness, fatigue and weakness. She reported postpartum hemorrhage requiring 4 PRBC transfusions and IV steroids after last pregnancy 5 years ago. Patient was able to lactate after pregnancy and continued in her usual state of health until 3 years ago when she referred loss of consciousness with traumatic head injury due to hypoglycemia. At Endocrinology office physical examination and vital signs were unremarkable, including no blood pressure or heart rate variations with positional changes. Despite hypothyroidism being adequately controlled, she continued with extreme fatigue and weakness affecting her quality of life, for which cortisol and ACTH levels were ordered. Laboratories showed normal electrolytes, negative autoantibodies, cortisol 0.20 μg/dL (5-25 μg/dL) and ACTH 22 pg/mL (10-60 pg/mL) suggesting partial isolated ACTH deficiency. ACTH stimulation test was done and noted with suboptimal response. Evaluation of other anterior pituitary hormones was normal. Brain MRI showed normal pituitary gland. She was started on hydrocortisone in AM and PM and symptoms resolved. Conclusion: Immediate recognition of isolated ACTH deficiency due to Sheehan’s syndrome is necessary due to the availability of effective treatment and morbidity and mortality associated with this serious condition. To our knowledge isolated ACTH deficiency due to Sheehan’s syndrome in which the patient was able to lactate and normal findings on brain MRI has not previously been reported.References: Shivaprasad C. Sheehan’s Syndrome: Newer advances. Indian J Endocrinol Metab. 2011 Sep; 15(3): S203-207. DOI:10.4103/2230-8210.84869.

Latent autoimmune diabetes in adults (LADA), is a recognized form of Diabetes Mellitus (DM), that initially presents in middle-aged adults and sometimes it is misdiagnosed as type 1 or 2 DM. However, patients often have autoantibodies directed against pancreatic islet-cells, and the progression to insulin dependence is much faster. Studies indicate that 10% of patients who present with Type 2 Diabetes Mellitus (T2DM) have a positive serum glutamic acid decarboxylase (GAD) antibody titer. The subsequent case report will demonstrate the progression of Gestational Diabetes, complicated with Diabetic Ketoacidosis (DKA) and later diagnosed with LADA due to positive GAD antibodies in a patient without history of autoimmune predisposition. It is important to address that DKA is an extremely rare complication of women with Gestational Diabetes, occurring in only about 0.5 -3.0 %. DKA usually is associated with T1DM but also it can occur in T2DM under extreme conditions, unwantedly on pregnancy could lead to a fetal mortality up to 35% and risks of preterm birth. The following case presents a 27 year old female G2P2A0 on week 25 of pregnancy that came to our institution after a high blood glucose level detected before performing routine 75g OGTT screening for Gestational Diabetes. Patient had a previous history of Gestational Diabetes four years ago and referred that after vaginal delivery blood glucose levels were within normal limits, but denied routine outpatient screening for DM after delivery. Patient referred that 1 week before arrival to the hospital developed a generalize weakness associated with anorexia, nausea, vomits, polydipsia and polyuria. Besides previous Gestational Diabetes, patient denied any other medical conditions and denied family history of autoimmune conditions as well. At physical examination pertinent findings were a BMI of 18.3, dry oral mucosa, fruity breath odor, drowsiness, and evidence of vaginosis at pelvic examination. At hospital arrival patient had ABGs with a pH of 7.2, with serum HCO3 in 7, serum glucose in 605, and large ketones fulfilling criteria for DKA. Patient was admitted to ICU for DKA management with success and subsequently discharged on tight subcutaneous insulin regimen. This case reveals the importance of screening for postpartum DM after a Gestational Diabetes, and when the diagnosis does not fit, further investigation should be made. Taking in consideration the previous case report, a focused family history, risk factors, and demographics an autoimmune workup should be ordered for patients who do not have the classic presentation of T2DM. This case made a statement in which early identification makes the difference, recertifying what studies have shown that identifying LADA early and initiating insulin therapy helps preserve beta cell function, improve quality of life and may prevent a potentially life threatening condition such as DKA.