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.

Lingual thyroid gland is an unusual embryological abnormality that occurs when the thyroid gland fails to migrate from the foramen cecum to the pretracheal position. It manifests in 1: 100,000 - 1: 300,000 subjects of the general population, making this diagnosis extremely rare. The typical presentation is asymptomatic, but when symptoms develop the most commonly seen are odynophagia, dysphagia, dyspnea and dysphonia. Due to the rarity of this condition it is often overlooked, resulting in complications later in life. We present a case of lingual thyroid gland in a Hispanic female patient complaining of voice changes. A 41-year-old female patient with no past medical history presented to the Otolaryngology - Head and Neck Surgery clinics with a three week history of dysphonia and odynophagia. The patient denied any constitutional symptoms or associated symptoms of thyroid dysfunction. Fiber optic flexible indirect laryngoscopy was used to examine patient’s airway, and a mass highly suspicious for an ectopic thyroid gland was identified at the base of tongue. A Neck CT scan and a thyroid ultrasound were performed, demonstrating the absence of thyroid tissue in its normal anatomic position without lymphadenopathy. Thyroid scan revealed the presence of a lingual thyroid gland. This structure was causing mass effect on esophagus and vocal cords, resulting in dysphagia and dysphonia. The patient was referred to the Endocrine service where she was found to have a TSH of 6.3 mIU/L, Total T4: 6.89 mIU/L, and a negative anti TPO antibody, which is remarkable for Subclinical Hypothyroidism not requiring medical management. However, on a close follow up visit, her TSH increased to 9.60 mIU/L and Free T4 was found at 0.9 mIU/L, leading us to a diagnosis of overt Hypothyroidism requiring medical management. Lingual Thyroid Gland is an extremely rare anatomical variation that might be often overlooked. Literature demonstrates that in 70% of the cases reported, the lingual thyroid appeared to be the only functioning thyroid tissue. It is most often diagnosed during puberty, pregnancy, or menopause when the increase in thyroid hormone requirement and subsequent increase in TSH causes thyroid tissue hypertrophy and therefore obstructive symptoms. Levothyroxine treatment has caused marked reduction in the size of the lingual thyroid potentially avoiding the need of a surgical intervention or the need to exclude malignancy. A recent systematic review found 28 cases of Lingual Thyroid Carcinoma (LTC). There are no distinguishing clinical findings to differentiate benign lingual thyroid from LTC. However, in the setting of a well-defined, smooth, benign-appearing mass and neck CT scan without evidence of mass extension or lymphadenopathy, a conservative approach could be pursued with follow up evaluation of the mass after hormone replacement therapy.

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