SUN-501 Grave’s Disease Concealing the Diagnosis of Pancreatic Carcinoma

Background: Hyperthyroidism is a disease that presents with various nonspecific symptoms. Unintentional weight loss can often be the presenting complaint. We present a patient with unexplained weight loss that was attributed to Grave’s hyperthyroidism, but was later discovered to be secondary to pancreatic carcinoma. Case Description: A 58-year-old man with no significant medical history, was referred to the endocrine clinic for weight loss, low energy, and abnormal TFT’s. He reported 45 lb. weight loss over the past one year. Past Medical history was notable for opioid use, and is enrolled in the Methadone program for the past 10 years. Family history is significant for type 2 diabetes. He smokes ½ a pack of cigarettes, denies alcohol or drug use. On exam, heart rate was 84 bpm with fine tremors on outstretched upper extremities, no proptosis, lid lag, thyromegaly, or pretibial edema, normal reflexes. His labs were TSH=0.01; (n=0.270 - 4.20 uIU/mL), FT4=2.1; (n= 0.55 - 1.60 ng/dL), FT3=283;(n=2.52 - 4.34 pg/mL) Thyroglobulin Ab 4 IU/ml, Thyroid peroxidase Ab > 900 IU/ml, TSI 358(n=<140%). He was diagnosed with Grave’s disease and was started with Methimazole and Propranolol, which were titrated to an optimal range over the next few months. However, the patient was lost to follow up, and presented one year later to the ED with complaints of abdominal pain, jaundice for one-week, greasy diarrhea for 6 months, also reporting noncompliance with thyroid medications during this time. On examination, he was icteric and jaundiced with hepatomegaly, trace pedal edema. Although LFT’s were previously normal, the labs now showed alkaline phosphatase=533, (n=40-129 IU/L); AST=107 units (n= 0-32 IU/L), ALT=213units (n= 0-40 IU/L), total bilirubin 11.4 (n= 0-1.0 mg/dl), TSH=0.01, FT4=0.6, FT3=3.2. Ultrasound showed gallbladder sludge, CT abdomen-dilatation of the pancreatic duct in neck and body of pancreas, MRCP- marked pancreatic ductal dilatation and soft tissue fullness within the pancreatic head. CA 19-9= 64.8, he underwent ERCP, and was later diagnosed with adenocarcinoma of the Pancreatic head. He was discharged with referrals to GI and Oncology for further treatment. Discussion:Although weight loss and diarrhea are nonspecific, and can often result from hyperthyroidism, this case highlights the importance of further investigation for other causes and avoiding attribution to a single diagnosis. Other diagnoses were only looked into when the patient presented with painless jaundice and hepatomegaly several months later. The effects of autoimmune hyperthyroidism on the pancreas function remain unclear. However, patients with Grave’s hyperthyroidism have a higher number of islet cell antibodies, as compared to controls. Further studies are required in this regard. We also emphasize the importance of patient education and compliance which can lead to earlier diagnosis, and overall better outcomes.