Case based learning (W3) Flashcards
Addisons Disease Clinical Signs, Testing
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
DDx of Addisons
Viral Infection Anorexia nervosa Thyroid disease Diabetes type 1 2o hypoadrenalism Long term steroid use
Addisons Tx
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)
Addisonian Crisis
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
2º Hypoadrenalism
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.
Acromegaly Clinical Signs, Testing
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
Acromegaly Tx
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
DDx for Acromegaly
Pregnancy, Osteoarthritis, Hypothyroidism
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?
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
Other symptoms of Hyperprolactinaemia
Galactorrhoea
What level on a blood test would indicate hyperprolactinaemia?
Basal plasma prolactin >550mu/l
What further investigations should be undertaken to decide the cause of the hyperprolactinaemia?
Prolactin stimulation test (Metoclopramide)
MRI scanning of the pituitary gland
Testing of the thyroid & kidneys
Test for polycystic ovarian syndrome
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?
1st line — Dopamine agonists (Bromocriptine, Cabergoline)
Surgery — for prolactinoma (rarely used, often only in cases where there is contraindications)
Significance of planned pregnancy and hyperprolactinaemia
tumour may grow during pregnancy
macroadenomas signs and symptoms:
report sudden/unusual headaches or visual concerns
= IMAGING AND BROMORIPTINE (dopamine agonist)
Visual disturbance associated with hyperprolactinaemia
bitemporal hemianopia
Other complications with hyperprolactinaemia
pregnancy considerations
osteoporosis risk d/t reduced oestrogen/testosterone
>exercise and calcium intake through diet or supplementation, and by avoiding smoking
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?
Cushing’s Syndrome d/t
- LT steroid use (glucocorticoid)
- pit tumour (cushings disease)
- ectopic ACTH-prod. tumour
- adrenal tumour = adrenal hyperplasia!
What physical abnormalities would you expect if you were to examine Mr D? (cushings)
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
What are the differential diagnosis of Cushing’s Syndrome?
Obesity
Depression
Alcoholism
Eating Disorders
How is Cushing syndrome diagnosed?
- 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
- MRI confirms pituitary adenoma
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?
As the adrenal glands have been removed Mr D. should begin immediate steroid replacement therapy.
