Case based learning (W3)

Question 1

Addisons Disease Clinical Signs, Testing

Answer 1

d/t AuIm. or TB

Unintentional Loss of weight - gaunt appearance
Diarrhoea
Depression & lack of energy
Hyperpigmentation: mucosal, skin, scar areas
Postural HypoT

ACTH stimulation: SYCANTHEN
SYNACTHEN TEST + BASAL ACTH: basline cortisol and ACT > synthetic ACTH (tetracosactrin) > measure over time,
= 450nmol+ over normal
= 1º adrenal insufficiency = no response
= 2º adrenal insufficiency = no CRH thus trophic diminished = stunted cortisol production

Na, K, Glucose

Question 2

DDx of Addisons

Answer 2

Viral Infection
Anorexia nervosa
Thyroid disease
Diabetes type 1
2o hypoadrenalism
Long term steroid use

Question 3

Addisons Tx

Answer 3

Hydrocortisone 15-30mg daily
+steroid adjustment for STRESS

Follow up:
Diagnostic autoimmune screen in future (80% of cases are due to autoimmunity)
ACTH levels to be stored and checked- 1o & 2o Differentiated with ACTH level
Steroid Education
Yearly check up
Carry a steroid card in case of emergency.
Inform GP & patient about the need to increase hydrocortisone if unwell
Inform patient about use of IM hydrocortisone when needed (i.e when vomiting stops the use of oral hydrocortisone)

Question 4

Addisonian Crisis

Answer 4

HypoGlc & HypoT.

> Hydrocortisone sodium succinate 100mg IV stat & 6 hourly, IV saline 0,9% 3-4 litres initially at 1l/hour till BP improves and watching for fluid overload, Monitor blood glucose very carefully
* check cortisol and ACTH

Question 5

2º Hypoadrenalism

Answer 5

long term steroid use should be informed of the risk secondary hypoadrenalism due to suppression of the pituitary-adrenal axis. This only becomes apparent on the stopping of steroids so proper patient education should occur in conjunction with their GP.

Question 6

Acromegaly Clinical Signs, Testing

Answer 6

XS GH secr. d/t functional tumour

• soft tissue overgrowth, wide feet, coarse facial features, thick lips tongue
• carpal tunnel syndrome
• syndrome
• CHIASMAL COMPRESSION complication

- screening: igf-1 ELEVATED?
\+Glc, Ca, PO4
\+ vis field
- OGT: glucose load suppressed
- pituitary MRI

Question 7

Acromegaly Tx

Answer 7

1) Tumour Removal Sx

2) monthly IM Sandostatin - somatostatin analogues (acromeg.): can induce tumor shrinkage
•monthyl injections
•sfx: nausea etc., therefore slow release preparations

3) Pegvisomant - GH receptor antagonist (acromegaly)

Followup:
Yearly IGF1, Visual field examination
Warn patient of possible diabetes mellitus
Vascular examination (mortality often due to vascular complications)
Other tests to consider:
Colonoscopy
Echocardiography

Question 8

DDx for Acromegaly

Answer 8

Pregnancy, Osteoarthritis, Hypothyroidism

Question 9

27 year old woman presents at your regular GP clinic with the complaint that her periods have stopped, and her breasts have been sore. She has also put on weight.

She took a pregnancy test and it was negative.

What hormone imbalance could cause these issues?

Answer 9

Hyperprolactinaemia

often caused by Tumours arising in pituitary (prolactin secreting adenoma)

alternatively via

• dopamine suppressing meds
• large pit tumour disrupting = DISCONNECTION HYPERPROLACTINAEMIA
• hypothyroidism
• chronic renal failure,
• POLYCYSTIC OVARY SYNDROME

Question 10

Other symptoms of Hyperprolactinaemia

Answer 10

Galactorrhoea

Question 11

What level on a blood test would indicate hyperprolactinaemia?

Answer 11

Basal plasma prolactin >550mu/l

Question 12

What further investigations should be undertaken to decide the cause of the hyperprolactinaemia?

Answer 12

Prolactin stimulation test (Metoclopramide)
MRI scanning of the pituitary gland
Testing of the thyroid & kidneys
Test for polycystic ovarian syndrome

Question 13

The goal of treatment is to return prolactin secretion to normal, reduce tumour size, correct any visual abnormalities, and restore normal pituitary function

What are the treatments available?

Answer 13

1st line — Dopamine agonists (Bromocriptine, Cabergoline)

Surgery — for prolactinoma (rarely used, often only in cases where there is contraindications)

Question 14

Significance of planned pregnancy and hyperprolactinaemia

Answer 14

tumour may grow during pregnancy

macroadenomas signs and symptoms:
report sudden/unusual headaches or visual concerns

= IMAGING AND BROMORIPTINE (dopamine agonist)

Question 15

Visual disturbance associated with hyperprolactinaemia

Answer 15

bitemporal hemianopia

Question 16

Other complications with hyperprolactinaemia

Answer 16

pregnancy considerations

osteoporosis risk d/t reduced oestrogen/testosterone
>exercise and calcium intake through diet or supplementation, and by avoiding smoking

Question 17

Mr D., age 40, presents to your clinic complaining of weight increase & impaired sexual function. He has noticed stretch marks appearing on his body, and while playing with his children he says he bruises easily.

What endocrine disorder do these symptoms show and how?

Answer 17

Cushing’s Syndrome d/t

• LT steroid use (glucocorticoid)
• pit tumour (cushings disease)
• ectopic ACTH-prod. tumour
• adrenal tumour = adrenal hyperplasia!

Question 18

What physical abnormalities would you expect if you were to examine Mr D? (cushings)

Answer 18

Easy bruising
BUFFALO HUMP
Facial plethora
Proximal myopathy (or proximal muscle weakness)
Striae (especially if reddish purple and > 1 cm wide)
Unexplained osteoporosis

In children, weight gain with decreasing growth velocity

Question 19

What are the differential diagnosis of Cushing’s Syndrome?

Answer 19

Obesity
Depression
Alcoholism
Eating Disorders

Question 20

How is Cushing syndrome diagnosed?

Answer 20

1. hx and exam

2.
• urinary cortisol 24hr
An increased level of cortisol shows Cushing’s

• overnight low dose dexamethasone suppression test
Low Dose Dexamethasone suppression test — Cortisol measurement taken. Dexamethasone 1mg is given at 11pm and cortisol is measured again @ 8am. Serum cortisol >50nmol/l indicates Cushing’s.

+ HIGH DOSE DEX TEST: exerts neg feedback on ACTH but will not exert if ectopic ACTH prod. or adrenal adenoma therefore LOCALISES
= if sensitive to high dose then indicates cushings disease as pituitary still retains feedback

3. MRI confirms pituitary adenoma

Question 21

Mr D. is not cured with this operation (pit. tumour) and is unwilling for further pituitary surgery. He therefore has a bilateral adrenalectomy. What should be done as part of his follow-up?

Answer 21

As the adrenal glands have been removed Mr D. should begin immediate steroid replacement therapy.