Background: Tumor-generated ectopic intact PTH is difficult to diagnose and should be suspected in patients with apparent primary hyperparathyroidism but with normal parathyroid glands. Clinical Case: A 72-year-old man presented with symptoms of hypercalcemia including generalized weakness, polyuria, and polydipsia. Initial labs were consistent with primary hyperparathyroidism: calcium 12.1 mg/dL (n 8.6–10.3 mg/dL, albumin-corrected 12.5 mg/dL), intact PTH (iPTH) 115.6 pg/mL (n 10–65 pg/mL), low normal 25-OH vitamin D (25 ng/mL, n 25–100 ng/mL), and relatively high normal 1,25 dihydroxyvitamin D (52 pg/mL, n 18–78 pg/mL). 24-hour urine calcium was 381 mg/day (n 100–300 mg/day) and PTHrP was 1.6 pmol/L (n <4.2 pmol/L). Neck ultrasound demonstrated a 0.5 x 1 cm hypoechoic mass near right thyroid inferior pole, though sestamibi SPECT/CT scan did not reveal scintographic evidence of a parathyroid adenoma. He underwent subtotal parathyroidectomy with largest excised gland weighing 0.262 grams. The left inferior parathyroid gland appeared normal intraoperatively, thus was clipped and left in place. PTH decreased from 194 pg/mL to 98 pg/mL postoperatively. Pathological examination revealed three normocellular parathyroid glands with enlargement of only the right superior gland. Venous sampling of the parathyroid vasculature failed to identify the source of autonomous iPTH post operatively. Due to refractory hypercalcemia, cinacalcet was initiated. However, hypercalcemia as high as 12.6 mg/dl and hyperparathyroidism to 672 pg/mL persisted despite dose escalation. He eventually received pamidronate with subsequent transition to denosumab due to declining renal function. A  68Ga DOTATATE scan was performed to locate occult ectopic parathyroid, which reported multiple foci of presumed somatostatin receptor expression involving the liver and intra-abdominal lymph nodes without significant uptake in the neck concerning for metastatic disease. Liver lesion biopsy was consistent with pancreato-biliary adenocarcinoma. Surprisingly, the biopsy was negative for iPTH and neuroendocrine tumor markers on staining/immunohistochemistry. Given his poor prognosis and multiple comorbidities, the patient opted not to pursue any further workup or therapy for his malignancy. Conclusion: Occult malignancy should be suspected for a patient with persistent hyperparathyroidism after parathyroidectomy. Treatment of the malignancy may lead to an improvement in hypercalcemia and iPTH levels. Employment of iPTH mRNA testing or intra-abdominal venous sampling to prove ectopic iPTH secretion would be ideal, as iPTH staining could be falsely negative. Further testing was not completed as the patient declined further evaluation.

Compared to multiple daily insulin injections (MDI), continuous subcutaneous insulin infusion (CSII) has proven to reach target HbA1c level with less frequent hypoglycemia, be more cost-effective, and improve quality of life. However, data on the effectiveness of CSII therapy in the African American population remain limited. The primary objective of our study was to compare the effectiveness of CSII therapy in lowering HbA1c levels in patients with type 1 diabetes (T1D) and type 2 diabetes (T2D) in a predominantly African American population. The secondary objective was to identify factors that affect the effectiveness of CSII. Participants were selected randomly from a list of patients currently receiving CSII at our institution’s diabetic clinic. Each patient’s consent was obtained over the phone or during a visit to the clinic. Primary data were collected with a questionnaire, whereas additional data, including HbA1c levels before and after starting CSII, were collected from medical records. A total of 57 participants were enrolled in the study. African Americans represented 79% of the participants; 43% of the participants were unemployed, and 56% had an annual income of less than 20,000 USD. Since commencing CSII therapy, all participants achieved a decrease in mean HbA1c level from 9.7% to 8.0% (P = 0.001), and that of African American participants decreased from 9.8% to 8.2%. Increase number of individuals at home was associated with less reduction in HbA1c levels after starting CSII therapy (P = 0.02). Overall, satisfaction with CSII therapy was high, and 63% of participants reported being very satisfied with the treatment. The mean BMI among participants while using MDI was 32.6 kg/m2 but significantly increased to 33.9 kg/m2 (P = 0.01) while using CSII. The increase in mean BMI after starting CSII therapy was significantly higher in participants with T2D than in ones with T1D (P = 0.001). While receiving MDI, female participants had a significantly higher mean BMI than their male counterparts (P = 0.02); however, that difference became nonsignificant after they began CSII therapy (P = 0.06). The level of physical activity after starting CSII therapy did not alter the risk of increased BMI. The results of our interim analysis indicate the significant effect of CSII in lowering HbA1c levels in all diabetic patients regardless of sex, race, BMI, type of diabetes, marital status, employment status, level of education, adherence to diabetic diet, physical activity, duration on CSII, and use of other antidiabetic medications. The significant increase in BMI once CSII therapy commenced may reflect the increase in insulin dose among patients who were not adherent to insulin while receiving MDI. Patients need to be aware of that side effect, and additional interventions for weight management may be considered for overweight and obese patients planning to start treatment with CSII.

Introduction: Tuberculosis (TB) involving the thyroid gland is rare and typically results in hypothyroidism. Here we report a case of thyroid TB that presented with hyperthyroidism. Clinical Case: A 54-year-old woman with a history of hyperthyroidism due to toxic multinodular goiter presented to the emergency department with fever of unknown origin associated with sore throat, non-productive cough, night sweats, diarrhea, and right anterior neck pain that worsened with coughing. Her fevers were intermittent, ranging from 38 to 39 degrees Celsius, and would subside with acetaminophen. She reported that her symptoms had started after getting a thyroid [Tc-99m] pertechnetate scan and 24 hour [I-131] sodium iodide uptake study a month prior. The scan at the time revealed hyperfunctioning thyroid nodules in the lower lobes bilaterally. The 24-hour uptake was 20.2% which is within the normal range of 7 to 30%. TSH on presentation was 0.01 mIU/L (Normal range 0.3-5.50 mIU/L), free T4 was 2.05 ng/dL (Normal range 0.76 -1.7 ng/dL), and free T3 was 5 pg/mL (Normal range 1.9-3.9 pg/mL). Exam revealed a multinodular goiter, which was firm with mild tenderness, and no cervical lymphadenopathy. Infectious workup was unremarkable other than a positive interferon-gamma release assay. As for TB risk factors, the patient immigrated to the United States from Albania about 13 years prior. The patient denied any known TB exposure, neither had she been treated for TB. Radiograph and computed tomography (CT) of the thorax were unremarkable other than re-demonstration of the multinodular goiter. Fluorodeoxyglucose-18 positron emission tomography (FDG-PET), which was performed to identify any focus of active TB, had revealed intense, infiltrative, heterogeneous FDG uptake of the nodular thyroid gland with reactive level 3 and 4 cervical lymph nodes. Also, the scan revealed hyper-metabolic hilar, pre-tracheal, and sub-carinal lymph nodes which could represent latent TB. Further workup for any other foci of active TB including broncho-alveolar lavage, sputum cultures, lumbar puncture, and bone marrow biopsy were unremarkable. Thyroid ultrasound revealed 2 right sided and 3 left sided thyroid nodules, mostly solid and hypoechoic. Fine needle aspiration of nodules revealed benign follicular nodules bilaterally, however the left aspirate contained loose aggregates of histiocytes consistent with non-necrotizing granulomas. Acid-fast bacilli stain of the aspirate was negative. The patient was started on therapy for active TB with isoniazid, rifampin, pyrazinamide, and ethambutol. Six weeks after treatment her fevers had resolved. Conclusion: Thyroid TB should be considered when the severity of symptoms cannot be explained by the degree of hyperthyroidism alone in patients with increased risk of TB. Additionally, TB in the thyroid can be challenging to identify in a patient with known underlying thyroid disease.