Endo Block 1 Flashcards
Facts about polypeptide/protein hormones
Facts about Steroids/Thyronines
Large and insoluble
Interact w/ receptors on surfaces
Binding causes cascades of events
Small and lipid soluble that can’t pass through membranes, require ‘chaperone’ to go directly to nucleus and cause change
What is the body’s negative feedback response when hormones levels are high or low?
What is the body’s positive feedback response when hormone levels are high or low?
High- dec production
Low- inc production
High- stimulate release
Low- inhibit release
What are the three hyperfunction alterations in endocrine tissue function?
Primary- alteration of the hormone secreting gland
Secondary- alteration in pituitary* or hypothalamus
Ectopic- hormone secreted from tissue other than usual source
What are the 3 hypofunction alterations in endocrine tissue function?
Primary- alteration of the hormone secreting gland
Secondary- alteration in pituitary/hypothalamus
Resistance- inability of target tissue to recognize the hormones
Define Adenoma
Define Neoplasm
Benign enlargement of cluster of glandular cells
Abnormal new grwoth of tissue, usually malignant
Define Hyperplasia
Define Atrophy
Benign enlargement of the entire gland
Wasting away of existing cells, hypoplasia form is congenital
What are the hormone levels in hypothyroidism?
Primary hypofunction
Starts in thyroid not secreting T3
Hyperplasia of thyroid
High TRH
High TSH
Low T3
A high serum osmolality correlates to a high serum ? level?
What medications/drugs stimulate ADH secreation?
Na
SSRI/TCA Ecstasy/MDMA NSAIDs Amiodarone Neuroleptics
What are the CNS/pulmonary Dzs that can cause SIADH?
Trauma STEMS
Trauma Stroke, Tumor, Encephalitis, Meningitis, SAH
No Pos TP
Neoplasm Pos Press Ventilation TB Pneumonia
All PTs with unexplained hyponatremia and oliguria/anuria need to get what test?
What medications can cause SIADH
Chest CT/MRI
MOAAN MDMA- inc ADH release Opiates Antineoplastics- powerful Antidepressants- TCA, SSRI, MAOIs NSAIDs- inc ADH via prostaglandin inhibition
Since SIADH is a ? problem, not a ? problem, what S/Sxs will they present with?
What will their serum Na be at?
Water, not Na
Fatigue, HA, Nausea
125-135 (N=135-145)
How is euvolemic/ASx/Mild SIADH Tx?
How are Sev cases Tx?
Water restriction (500-1L/day) Democlocycline if PT can't tolerate water restriction Dietary Na intake
Raise serum Na by 0.5-1mEq/hr w/:
3% hypertonic saline
Furosemide- H2O excretion
Tulvaptan- V2 antagonist
What are the etiologies of central DI?
Brain surgery
Damage to infundibulum
Infection
Pituitary infarct- Sheehan Syndrome
What are the etiologies of nephrogenic DI?
Meds: Lithium, Demeclocycline, Orilistat, Caffeine
Hypercalcemia
Hypokalemia
Renal Dz
What labs are ordered when working a PT up for suspected DI?
What results will normally be seen?
24hr UA (<2L/day rules out DI Dx) CMP w/ uric acid and osmolality
Labs will be normal except high Uric Acid and Na
How are PTs tested for central DI?
12hr urine measurement
Desmopressin acetate administration
12hr urine measurement
+ test= dec thirst, dec urine output, inc urine osmolality
How are PTs tested for nephrogenic DI?
What are 3 DDx for PTs w/ DI?
Measure serum vasopressin during fluid restriction, elevated= + test
Psychogenic water drinker
DM Type 1
Cushing’s Syndrome
How is Central DI Tx?
DDAVP w/ E+ monitoring @ lowest possible dose 2-3x/day
Avoid N/V/D or exertion
Acute= Indomethacin Chronic= Nephrologist for Indomethacin and HCTZ, Desmopressin Acetate/Amiloride combo
What is the overall function of the anterior pituitary?
Command center of majority of endocrine organs
Regulates Adrenal, Thyroid, Gonads, and GH and Prolactin release
What hormones are released by the Ant Pit?
FSH/LH ACTH TSH PRL Endorphines GH
What hormones are produced in the AntPit?
Most hormone release are controlled by ? with ? big exception
GH, ACTCH, TSH, PRL, FSH, LG, MSH
Stimulating hormones
Prolactin- continuous secretion unless inhibited by Prolactin Inhibitory Hormone (dopamine)
What are the S/Sxs of an adenoma that begins to cause space occupying effects?
What are 3 types of vision defects that could be seen?
CSF rhinorrhea
HA
Unilateral CN3-6 defects
Bitemporal hemianopsia
Unilateral field loss
Bitemporal/Homonymous hemianopsia
Any PT w/ HA or visual field defects need to have ? issue ruled out?
How are pituitary adenomas Tx?
Pituitary/Hypothalamus masses via MRI
Surgery
Except- prolactinomas- Tx w/ medical therapy w/ Dopamine agonists and Somatostatin analogs
Prolactin release is normally stimulated by ?
Pregnancy/Feeding Piercing/Surgery Chronic chest wall stimulation Hypothyroidism- TSH stimulates PRL Infundibulum lesion Prolactinoma
How are prolactinomas Tx?
What are the indications for surgery?
TOC= Cabergoline, Bromocriptine
Unresponsive to medical therapy
Significant visual loss
Apoplexy- hemorrhage leading to stroke
Radiation if macroadenomais enlarging while on medical Tx meds
What are the two surgical procedures done for prolactinomas?
What are the second most common secreting pituitary adenomas?
Transsphenoidal resection
- common postop DI to SIADH
Tranfrontal craniotomy- if extra sellar extesnion is present
GH secreting- 20% also secrete prolactin
GH is stimulated by ?
It is inhibited by ?
Any process requiring higher metabolic rate
Hypothyroid
Somatostatin inhib peptide, Hyperglycemia, Glucocorticoids, Inc IGF-1
What are the A-Js of Acromegaly?
Athropathy, Boggy hands
Carpal Tunnel, DM
Enlarged tongue, Fields of vision defects, Gynecomastia, HTN, Inc Hat, shoe, ring size, Jaw enlargement
How is acromegaly Dx?
What is the imaging modality of choice for Dx acromegaly?
Random IGF-1
Abnormal= fasting IGF-1
Elevated= give 100g of glucose, re-test 60min
GH >1ng/mL=Dx
Normally, glucose suppress GH, should be <0.3ng/mL
MRI or,
CT w/ contrast
What are the subtle Sxs of acromegaly?
How is it Tx?
HA, Obstructive apnea, Hand numbness, DMT2
Transsphenoidal resection- TOC
Rx if incomplete/inadequate surgery= Cabernoline/Bromocriptine, Octreotide/Lanretide, Pegcisomant
If meds and surgery fail- stereotactic radiosurgery
What type of f/u schedule is needed for acromegaly PTs?
What physical features regress or are permanent after Tx?
IGF-1 annually
Cardiac monitoring
Soft tissue improves
Permanent bone changes
What is the 3rd most common cause of AntPit d/os?
What PT population is it more common in?
Corticotropic Adenoma
W>M w/ microadenoma more common
What happens in PTs w/ Corticotropic Adenomas?
Cushing’s Syndrome can be caused by what 4 things?
Pituitary tumor releases ACTH, stimulates adrenal glands to release cortisol causing Cushing’s Dz
Pituitary tumor secreting ACTH
Adrenal gland hyper/neoplasia
Ectopic ACTH secretion
CCS use
What are the early signs of Cushings Syndrome?
What are the later sings?
HTN, weight gain
Truncal obesity
Moon face
Buffalo hump
What are the effects seen from hypercortisolism?
PTs w/ Cushings have signs of excess ? and ?
Proximal muscle weakness
Thin skin/easy bruising
HTN
Glucose intolerance
Cortisol AND Androgens
What are the 3 Dx tests done for Cushings Dz?
Dexamethasone @ 11pm
Serum cortisol @ 8AM
Inc cortisol= Dx
24hr urine free cortisol and plasma ACTH- 1, 2 or ectopic
Night salivary cortisol test
How is Cushings Dz Tx?
What causes most gonadotropic adenomas to be detected on imaging?
Transsphenoidal surgery
Radiation
Possible adrenalectomy
Large enough to cause visual disturbances
What are the clinical features of gonadotropic adenomas?
Pituitary failure d/os can present in what 3 ways as a result of failure where?
HA, Visual disturbance, Hypogonadism
Isolated hormone
Multiple hormones
Panhypopituitary
Hypothalamic or pituitary dysfunction
What is the most common cause of primary putuitary failure/
What are the 9 I’s of pituitary failure d/os?
Invasion of adenoma/CNS tumor
Invasion*, Infarct, Injury, Infection, Iatrogenic, Immune, Idiopathic, Isolated, Infiltrative
What causes Sheehan syndrome?
What are the S/Sxs?
Post-partum hemorrhage and HOTN causing vasospasm in the pituitary vessels
Failure to lactate
Prolonged amenorrhea
S/Sxs of hypothyroid or glucocorticoid insufficiency
Acute (delayed lactation) or delayed presentation (10-15yrs)
Pituitary has a large reserve and can maintain function until _% is lost?
Define Empty Sella Syndrome
75%
Subarachnoid space extends into sella turcica and fills it w/ CSF causing a flattening of the pituitary gland leading to pituitary failure
How will PTs w/ Sheehan’s syndrome that have glucocorticoid insufficiency present?
How does a pituitary infarct/apoplexy present and what does it cause?
Shock w/ HOTN, Bradycardia that don’t respond to fluids/meds
Sudden severe HA, AMS, Vomit, Diplopia/Bitemporal hemianopsia, unresponsive HOTN to fluids/meds
Pituitary infarct/apoplexy that causes acute hypopituitarism is Tx how?
Head injury/trauma usually affects ? part of the brain and presents how?
Immediate gluccocorticoids followed by surgery
AntPit w/ GH and gonadotropins deficiency
Neuro-Endocrine Dysfunction can present acutely or not for ? long?
What labs are used for screening?
3yrs
0800 cortisol TSH, T4 IGF-1 LH/FSH Testosterone/Estradiol
Pituitary failure usually present with gradual loss of normal pituitary function starting w/ ? hormones?
Which one is last/life threatening if decreasing?
GH, Gonadotropins, TSH, ACTH
PRL
How will hypopituitary show across the 5 hormones?
GH:
Kids= hypoglycemia, short
Adults= inc fat, LDL, BP
Gonadotropin-
Lack of development/regression of sexual characteristics
TSH-
Hypothyroid w/ low TSH, T3, T4
ACTH- Weak, HOTN, CV collapse or Addisons
PRL- ASx
If post partum- ceased lactation
How is hypopituitarism Tx?
GH: only if Sxs, hGH injections
Gonadotropin: Estrogen or Testosterone
TSH: Levothyroixine
ACTH: Prednisone, Hydrocortisone
What are the 4 thyroid hormones?
TRH
TSH
Thyroxine- T4, major secretory product of thyroid
Triiodothyronine- T3, form from de-iodination of T4 and physiologically active form hormone
What are the physiologic functions of T3?
What are the different lab results seen in hypopituitary hypothyroidism and primary hypothyroidism?
Inc O2 consumption, metabolic rate, heat, lipid synthesis, cholesterol excretion, protein synthesis/degradation
Hypopituitary- Low TSH, T3, T4
Primary hypothyroid- High TSH, Low T3, T4
99% of thyroid hormone in circulation is bound to one of what 3 proteins?
Thyroxine binding globulin- TBG
Thyroxine binding prealbuminum- TBPA
Albumin
What is the single most useful thyroid function test?
When will serum TSH be low or High?
TSH and Serum free T4
Low:
Primary Hyperthyroid
Exogenous hormone
Panhypopituitarism
High:
Primary Hypothyroid
Secondary Hyperthyroid
Resistance to T3
When will serum free T4 be low or high?
When will serum free T3 be high?
Low- hypothyroidism
High- Hyperthyroidism/Thyrotoxicosis
High- thyrotoxicosis
What is Anti-Thyroid Peroxidase Abs used to test for?
What are Anti-thyroglobulin Abs used to test for?
Hashimotos thyroiditis
Graves Dz
Hashimotos but less sensitive than anti-TPO
Graves Dz
What is anti-thyrotropin receptor Abs used to test for?
What are the 3 thyroid autoimmunity tests?
Dx Graves
Absent in other forms of thyrotoxicosis
anti-TPO: Hashimotos/Graves
anti-Tg- Hashimotos/Graves but less than anti-TPO
anti-TSH- Dx Graves, absent in other forms of thyrotoxicosis
When are RAIU using I-123 scans used?
Thyrotoxicosis Sxs
Measure amount of radioiodine needed for hyperthyroidism Tx
Nodule/CA evaluation
Ectopic tissue evaluation
What causes high levels of uptake?
What causes low levels of uptake?
Graves
Toxic multi-nodular goiter Toxic nodule
Dietary iodine insufficiency
Exogenous hormone Subacute thyroiditis Anti-thyroid drugs Iodide medications Damage
What are the different RAIU results in subacute thyroiditis and thyrotoxicosis
Graves/thyrotoxicosis has high uptake
Subacute thyroiditis has little/no uptake
Define Hot Nodule
Define Cold Nodule
Take up iodine, least likely to be malignant, recommended to do no further tests
Little isotope uptake, 30% more likely to be CA
Hyperthyroid toxicosis is seen as excess ? and ?
What is the most common cause of thyrotoxicosis?
T3 and T4
Graves Dz
What are the 4 causes of hyperthyroid thyrotoxicosis?
What are the 4 causes of non-hyperthyroid thyrotoxicosis
Graves
Apathetic hyperthyroidism
Pituitary tumor secreting TSH
Toxic multinodular goiter
PASH Thyroiditis Postpartum thyroiditis Acute suppurative thyroiditis Subacute thyroiditis Hashimotos thyroiditis
What are the two Sxs associated w/ Hyperthyroidism?
What are 4 Signs seen and highlighted here?
Palpitations
Resting tremor
Rapid DTR relaxation
Tachy
HTN
A-Fib*
Graves Dz is a ? form of thyrotoxicosis and is the most common cause of ?
What PT population does it affect?
Autoimmune
Thyrotoxicosis/hyperthyroidism
F>M between 20-40
What are the chemical levels in Graves?
What are the 4 parts of this Dz seen on PE?
Low TSH, High T3 and T4
High anti-TSH
Thyrotixic Sxs
Smooth goiter, bruit
Ophthalmopathy
Dermopathy- non-pitting edema and thickening of skin on anterior tibia
Why do PTs eyes have proptosis (bulging) with Graves Dz?
What visual issues can occur?
Inflammation of eye muscles due to lymphocyte infiltration
Diplopia
Optic nerve compression leads to blindness
What has more severe Sxs, Thyroiditis or Graves and why?
What will be seen on RAIU in Graves PTs?
Graves, T3 is more active
Increase diffuse uptake
What are the 3 Tx methods of Thyrotoxicosis
Sx control: Propanolol Methimazole Propylthiouracil Oragrafin Telepaque
I-131: ablation of thyroid and TOC for Graves in adults; c/i pregnancy and feeding; contraceptive uses for both genders x 6mon
Surgery- large/obstructive gland
Pregnant uncontrolled PTu
Significant chance of malignancy\
What are the MOAs of Methimazole, Propylthiouracil, Oragrafin, Telepaque?
Which one is safe for pregnancy?
M: inhibits T4 production
P: inhibits T4 production and conversion of T4 to T3
O/T: blocks T4 to T3 conversion in peripheral tissues
Propylthiouracil
What are the s/e of anti-thyroid drugs?
When are the iodinated contrast agents Oragrafin and Telepaque used?
Rash- exfoliative dermatitis
Agranulocytosis= (Pancytopenia)
Nausea/Dyspepsia
Severe Sxs and usually as bridge therapy pre-surgery
What are the potential complications of removing the thyroid gland in Graves Dz?
Damage to recurrent laryngeal nerve= hoarseness
Parathyroid damage
Hypothyroidism
Continued hyperthyroidism
Define Apathetic hyperthyroidism
How does it present?
Thyrotoxicosis in older PTs
Depression/New mood d/o, Angina Pectoris, Lethargy/Fatigue, Weight loss
Define Thyroiditis
How does it present?
Inflammation and enlargement of the thyroid
Sxs of mild hyperthyroidism w/ depression and chronic fatigue w/ passive release of stored T4
Define Acute Suppurative Thyroiditis
What PT population is it seen in?
Bacterial infection of thyroid by Streptococcus
Immunocompromised
Elderly
Pre-existing thyroid Dz
What is the hallmark of Suppurative Thyroiditis?
What labs are drawn for Dx?
Painful thyroid gland
CBC, ESR, Culture, FNA
How is Suppurative Thyroidits Tx?
Subacute Thyroiditis is AKA?
IV ABX guided by Gram Stain and culture
Surgical drainage
deQuervan’s thyroiditis
What PT population does Subacute Thyroiditis usually affect?
What are the S/Sxs?
Young/middle aged females after viral respiratory infection*
Painful gland, transient hyperthyroidism, dysphagia, pharyngitis
What labs are drawn for subacute thyroiditis?
What is the Tx?
ESR, CRP, TSH/T4
ASA- DOC Usually self resolving Propanolol Oragraf/Telepaque Levothyroxine if transient state has Sxs
Chronic Lymphocytic Thyroiditis is AKA ?
Who does it appear in and what finding is Dx?
Hashimotos Thyroiditis
Most common form of thyroiditis
Female, anti-TPO Abs is hallmark
Hashimoto’s usually co-exists with what other type of Dzs?
How does it present?
Autoimmune
Hyper to hypo thyroid
Fatigue, weight gain, dry skin, constipation
Non-tender goiter from lymphocytes infiltrating gland
Why is RAIU imaging not useful in chronic Hashimotos?
How is it Dx and Tx?
Diffuse uptake from normal to high
Dx w/ anti-TPO
Levothyroxine if clinical hypothyroidism is present
What is the major complication that can arise from Hashimoto’s Thyroiditis?
Postpartum thyroiditis is AkA ?
Primary hypothyroidism
Silent/painless thyroiditis
Subcategory of chronic lymphocytic thyroiditis
How does Postpartum thyroiditis present?
How are they Tx?
Possible goiter
Hyperthyroid within 6mon of delivery lasting 1-2mon
Hypothyroid- lasting 4-8mon post delivery
Hyper- Sx treatment
Hypo- Tx as needed
Define Reidel’s Thyroiditis
How does Reidel’s present?
Fibrous infiltrates in thyroid of middle aged/elderly female PTs
Stony mass within thyroid
Possible dysphagia, dysphonea, pain
How is Riedel’s Dx’d?
How is Reide’s Tx?
Open biopsy, FNA doesn’t get enough of a sample
Surgery- relieves compression
Tamoxifen- reduces fibroids
CCS- short term for pain/compression Sxs
Define Goiter
What are the two causes of it?
Diffuse or nodular enlargement of thyroid gland
Inc TSH stimulation
Thyroid stimulating immunoglobulins
Goiters can be present in what two cases?
Simple/non-toxic goiters are a response to ? and most commonly due to ?
Thyroiditis
Iodine deficiency
Inadequate synthesis of thyroid hormone
Iodine deficiency
How are benign multinodular goiters Tx?
Most goiters respond to Tx of ?
Elevated TSH= Levothyroxine
Euthyroid goiters= observation
Hypo or Hyper thyroid states
What is the most common cause of elderly hyperthyroidism?
Where does it usually present?
Toxic multinodular goiter
> 50y/o w/ history of benign multinodular goiters w/ normal function tests
What will labs show in Toxic Multinodular goiters?
What will be seen on RAIUs?
Inc T3, T4
Low TSH
Diffuse patchy uptake
How are Toxic Multinodular Goiters Tx?
Hyper Sxs= Propranolol
Propothyouracil and Mehimazole
RAI ablation- definitive,
especially in elderly in leu of surgery
Subtotal thyroidectomy- pressure and cosmetic indications
What is a beneficial fact about thyroid nodules?
If there is a single thyroid nodule it is one of what 3 things?
95% are benign and not associated w/ lymphadenopathy
Benign adenoma- Common
Cyst
Malignancy
Benign thyroid nodules are usually smaller than ?
Where are malignant thyroid nodules more common?
<1cm
Young adults/men
What are the Hx factors indicating malignant neck nodules?
What 3 Sxs are unique and concerning?
What is one Sx that is not associated w/ benign nodules?
Malignancy/Irradiation
Tonsilitis
Dysphagia
Dysphonia
Dyspnea
No lymphadenopathy
What are the common Sxs of malignant thyroid nodules?
How are thyroid nodules assessed?
Single, Firm, Fixed, Larger than 4.5cm
Function w/ TSH
Low TSH- RAIU and US
Hot RAIU- stop, rarely malignant
Normal/High RAIU- US
What US findings are suspicious for malignant thyroid nodules?
Hetergenous echogenecity- non-uniform, hypo and hyper echoic Irregular margin Microcalcification Complex Vascularity Diamter >1cm
What is the preferred procedure for assessing thyroid nodules and what are the criteria for performing it?
What type of nodules don’t need this procedure?
FNAB
Suspicious US
Abnormal cervical nodes
>1.5cm diameter mixed/solid
>2cm with benign features
Pure cystic nodule (spongiform)
How are thyroid nodules classified?
Bethesda Classification 2- Benign 3- Atypical 4- Suspicious, follicular 5- Suspicious for malignancy 6- Malignant
What determines the treatment schedule of thyroid nodules?
How are benign nodules managed?
Biopsy results
US Q6mon FNA if increases in size Levothyroxine if TSH is elevated or hypothyroid Surgery- benign but suspicious Total thyroidectomy- malignant
When is RAI the procedure of choice when teating thyroid nodules?
What are the 4 types of thyroid cancer?
Toxic adenomas
MNG
Graves
Papillary- most freq, low agg
Follicular- can metastasize
Medullary- more aggressive
Anaplastic- most aggressive, least frequent
Papillary thyroid cancer
Radiation exposure (Chernobyl) in childhood Genetic mutations/familial syndromes
What two thyroid cancers absorb iodine?
Papillary
Follicular
Follicular thyroid cancer
2nd most common
Typically metastasizes to neck nodes, bone and lung
Medullary Thyroid cancer
No iodine absorption
Strong familial ties
Arises from parafollicular cells secreting calcitonin
Tx- prophylactic thyroidectomy
Anaplastic thyroid cancer
Non absorptive
Older PTs w/ goiter Hx
What will lab results who in thyroid CA?
Normal
Exceptions: concomitant thyroiditis, follicular CA
Thyroglobulin- inc w/ papillary and follicular CA, useful monitoring tool
Calcitonin- inc in medullary CA
Carcinoembryonic Ag- elevated in any type
What is the TOC for thyroid cancer?
Surgery
Anaplastic- local resection w/ radiation
Medullary- only surgery
Papillary and Follicular- surgery w/ RAI
When is post-surgery RAI used in thyroid CA?
What medication is given to post-thyroid CA PTs?
Papillary and Follicular
Levothyroxine
Define Hypothyroidism
What is the most common cause?
Primary- failure of thyroid to secrete T3 and T4
Secondary- failure of pituitary to secrete TSH
Hashimotos
Why is hypothyroidism during pregnancy dangerous?
What are the 4 less common Sxs of hypo thyroid?
Lower IQ scores
Dec appetite
Dec taste/smell
Hoarseness
Dysphagia
What are the key PE findings of hypothyroidism?
What is the single best test for hypothyroid?
Diastolic HTN
Delayed DTR relaxation
Bradycardia
Thin hair/brittle nails
TSH
What will lab results show in primary and secondary hypothyroidism?
What are the 4 less likely seen results but usually seen in severe cases?
Primary- inc TSH
Secondary- low
Low/N T4
Inc cholesterol/prolactin
Hypo Na
Hypo sugar
Anemia
Abnormal sperm morphology
What complications can arise from hypothyroidism?
Cardiac mostly Inc infection risk Megacolon Organic psychosis w/ paranoia "myxedema madness" Infertilit/miscarriage Coma
How is hypothyroidism Tx?
What important PT education piece needs to be given?
T4 replacement Levothyroxine
Wait 5wks after adjusting dose to recheck levels
Must take in AM w/ only water
What 5 things needs to be avoided when taking Levothyroxine?
Fe/Ca
Antacid
PPI
OCPs
How much Levothyroxine is used when starting?
How much Levothyroxine is given to adults and kids?
50mcg/day, inc every 3-6wks
Target dose= 100-250mcg/day (0.1-0.25mg/day)
1/7mcg/kg/d
What is unique when starting young/healthy PTs on this drugs?
How much are older PTs that are sensitive to Levothyroxine started on?
Start at target dose
25-50mcg/day
What monitoring is done on hypothyroid Pts?
What adjustment is done for pregnant PTs?
TSH and Sxs
Keep TSH 0.4mU-2.0mU/L
Inc 20-30% at discovery
Inc at 5th week by 75%
When do hypothyroid PTs need to be referred?
When do they need to be admitted?
Difficulty titrating levo to normal TSH
CADz needing Levo therapy
Myxedema crisis
Hypercapnia
Levothyroxine is known to cause? so watch for ?
Define Cretinism
Weight loss
Fluctuating TSHs
Congenital hypothyroidism due to failure of thyroid to migrate to location
What are the 4 major signs of Cretinism?
Intellectual disability
Puffy hands/face
Thick tongue/poor muscle tone
Deaf/mute
Childhood hypothyroidism usually has what etiology?
How is it Tx?
Hashimotos
Levothyroxine
Define Thyroid Storm
What are 4 precipitating factors that can cause this?
Extreme hyperthyroid/thyrotoxicosis
Most often seen s/ Grave’s
Stress
Thyroid surgery
RAI admission
D/c anti-thyroid drugs
What are the S/Sxs of a thyroid storm?
Dehydration High fever Sweating Tremor Restlessness
Delirium
Tachy
A-Fib
Vomit/Diarrhea
How are thyroid storms Tx?
Admit to ICU Anti-thyroid drugs Potassium Iodine Propanolol Hydrocortisone
PTU is preferred over Methimazole due to blocking conversion of T4 to T3 and inhibiting synthesis of T4
Definitive= I-131 ablation or surgery
Define Myxedema Crisis
Fluid retention from hypothyroidism causing an interstitial accumulation of hydrophilic mucopolysaccharides (lymphocyte infiltration) leading to lymphedema
What is mysedema crisis AKA?
What often triggers a Myxedema Crisis?
Decompensated hypothyroidism
Infection
Cold exposure
Cardiac/CNS illness
Drug use/stopping
Where are myxedema crisis usually seen?
What are the S/Sxs of this crisis?
Older female PTs w/ stroke or stopped using meds
Hypo:
Glycemia, HOTN
temp, resp, Na
How are Myxedema Crisis Tx?
What must be used with caution?
IV Levothyroxine, support and fluids/E+
Opioid sensitivity
What are the 3 layers of the adrenal cortex and what regulates each layer?
What are the functions of glucocorticoids?
Glomerulosa- RAAS, K, ACTH
Fasciculata- ACTH
Reticularis- ACTH
Break down proteins and fat for energy
What can be found in the outer/cortex of the adrenal gland?
Glucocorticoids- cortisol
Mineralcorticoids- aldosterone
Androgens- DHEA, Test/Estrgoen
What gender usually has an androgen d/o?
Where is CRH produced and what does it do?
Females
Hypothalamus
Stims ACTH synthesis and release from AntPit
What inhibits CRH and ACTH?
Where is ADH produced and how is it released?
Cortisol
Pituitary corticotropes of the AntPit
Diurnal rhythm, highest 04-0600, lowest at night
What does ACTH do?
What is the primary aldosterone regulator?
Stims for cortisol production, aldosterone secretion and melanocytes to produce melanin
RAAS
What is the major glucocorticoid secreted by the adrenal cortex?
When is this secretion increased?
Cortisol
Exercise
Trauma
Infection
Stress
The release and level of Cortisol is very similar and mimics what other hormone?
What does Cortisol do in the blood?
ACTH
Breaks down carbs, fats and proteins for energy use
Suppresses inflammation, immune system, bone formation and dec Ca reabsorption
Define Cushing Syndrome
What is the most common cause of spontaneous Cushings Syndrome?
Hypercorticolism
ACTH producing pituitary tumor
Due to it’s dificulty to Dx, what are the 4 goals of ordering all the labs when working a PT up for Cushing’s Syndrome?
No diurnal variation
Reduced cortisol suppression by dexamethasone
Inc cortisol production rate
Supression of plasma ACTH by hypercortisolism from adrenal medulla
What are the 3 initial tests ordered for Hypercorticolism?
What is the final/follow on test ordered?
Dexamethasone suppression test- 11pm administration, 0800 test, Inc AM cortisol= suggestive of Cushings
24hr urine for free cortisol and creatinine- confirms the hypercorticolism
Late night salivary cortisol- inc is suggestive
4th- who to blame
Serum ACTH to differentiate dependent of independent
Define ACTH Dependent causes of hypercorticolism
What are two causes that could be there?
Something is secreting ACTH
Pituitary adenoma
Ectopic- will have 10x ACTH levels
Define ACTH Independent Hypercorticolism
What are two causes of this?
No ACTH is secreted
Exogenous use
Adrenal adenoma/CA
What is the down side to PTs w/ Cushing’s Syndrome that are successfully Tx w/ surgery?
What drugs can be used to make the body stop producing cortisol?
Cortisol withdrawal syndrome
Mitatone, Ketoconazole, Metyrapone
When are Cushing’s Syndrome PTs referred?
Historically, what used to be the predominant cause of primary adrenal insufficiency?
Abnormal dexamethasone suppression test
TB
Bilateral adrenal hemorrhage
Congenital adreanl hypoplasia
Why do PTs w/ primary adrenal insufficiency have such a seriour disease when they’re Dx’d?
Often associated with autoimmune endocrine d/os, what can also cause this condition?
90% damage before Sxs show
DM Type 1
Hashimoto’s
Vitiligo
What are two unique S/Sxs that are seen in Addison’s Dz?
What will lab results show?
Anorexia and weight loss
Hypo Na Hyper k Hypoglycemia 0800 cortiosl- low ACTH high meaning primary organ dysfunction
How are Addison’s Dx confirmed after 0800 plasma cortisol is low and ACTH is high?
How is this test done and what results will be seen?
Cosyntropin stimulation test
Done at any time of day ACTH injected Cortisol levels measured 30-60min later Primary adrenal insufficiency= low cortisol Normal= 20mcg or higher
Define Secondary Adrenal Insufficiency
What is the most common cause of this?
Low secretion of ACTH by pituitary galnd
ACTH suppression from persistent suppression of the pituitary after d/c exogenous glucocorticoid meds
What are the S/Sxs of Secondary Adrenal insufficiency?
Same as Primary, but Pallor is present “alabaster” skin due to low ACTH levels not stimulating melanocytes
What images are done for Primary adrenal insufficiency?
What images are done for Secondary adrenal insufficiency?
Abdominal CT- noncalcified adrenal
CXR- for non-autoimmune origins
Eval medications
Pituitary MRI
How is Primary Adrenal Insufficiency Tx?
What are the sick day rules for these PTs?
Glucocorticoid and Aldosterone replacement
Double glucocorticoid dose for short time
Emergency kit= 100mg IM hydrocortison needle
Braelet
How is Secondary Adrenal Insufficiency Tx?
Glucocorticoids
No mineralcorticoid replacement needed
Emergency kit
Bracelet
What is a common Sxs seen in acute adrenal crisis?
How are these crisis’ Tx?
HOTN
Hypoglycemia
Draw cortisol levels but administer Tx without waiting for results
Hydrocrotisone immediately then Q6hrs
Possible broad spectrum ABX
How are adrenal crisis’ Dx?
What causes aldosterone to be secreted and what relationship is seen?
Give ACTH
Pos test= low cortisol
Angiotensins 2 and Kyperkalemia
Inc aldosterone, Low K
Define Primary Hyperaldosteronism
What are the types/causes of primary?
Excess produciton from adrenal gland
Conn syndrome
Adrenal hyperplasia
Adrenocortical CA producing aldosterone
What causes Secondary Hyperaldosteronims?
How does hyperaldosteronism usually present?
Renal artery stenosis
Excess renin
Hypovolemia
CHF
HTN, expecially diastolic
How is hyperaldosteronism Dx?
How are these labs differentiated to differ between Primary and Secondary causes?
Hypokalemia w/out diuretic
Primary- suppressed renin activity, adrenal cortex producing too much
Secondary- inc/normal PRA. Inc renin from renal artery stenosis causing excess aldosterone
How is a hyperaldosteronsim Dx confirmed?
24hr urine, Primary will have elevated aldosterone
Abdomen CT/MRI to r/o adrenal carcinoma/bilateral hyperplasia
How is hyperaldosteronism Tx?
Adenoma= unilateral ectomy
Bilateral hyperplasia= spirinolactone/Eplerenone (better for pregnancy and men)
Stenosis= angioplasty/revascularization
How do women with adrenal androgens present?
What enzyme is required for cortisol synthesis?
Acne, Hair, Virilization
21 Hydroxylase
What are the three most results of defected 21 hydroxylase deficiency?
Inc ACTH
Hyperplasia
Inc 17-Hydroxypreogesterone, the precursor to cortisol and converted to androgens
What are the 2 types of Congenital Adrenal Hyperplasia
Classic- salt wasting
Presents in utero/birth as defifiency of cortisol and aldosterone
Non-Classic-
milder enzyme deficiency
Presents after adrenarche
Most frequent autosomal recessive d/o in humans
What 3 populations is Secondary Congenital Adrenal Hyperplasia seen in?
How does classic congenital adrenal hyperplasia present?
Yupik Alaskan
Ashkenazi Jew
Native La Reunion Islanders
Death of infant
Masculine female genitals**
Precocious development in males
Short stature from early bone closure
How does non-classic congenital hyperplasia present?
Signs of androgen excess
Premature puberty/accelerated growth
Female hair/acne, oligomenorrhea and infertility
How is congenital adrenal hyperplasia Dx?
Why are these results seen?
Measure 17-hydroxyprogesterone, the precursor to 11 Deoxycortisol
Deficiency of 21-hydroxylase leads to ecess 17-hydroxyprogesterone
How is classic congenital adrenal hyperplasia Tx?
How is non-classic Tx?
Replace steroids w/ prednisone, cortisol, dexamethasone
Mineral replacement w/ spirinolactone
Glucocorticoids before pubarche onset
OOCPs for androgen excess
Anti-androfgen like Spirinolactone for women
Catecholamines decrease what 3 functions?
What causes their release?
Visceral blood flow
Urine output
GI motility
Dec BP, Volume, Glucose
Stress, Illness
Pheochromocytoma secretes ?
Paragangliomas secrete ?
Epi and NorEpi
NorEpi only
What is the Sx triad of a pheochromocytoma?
How is it different from panic attacks?
HA, Sweating, Palpitations
Paroxysmal and more severe
What triggers can start a Pheo attack?
What are the major S/Sxs during the attack?
Exertion, stress, Caffeine/Nicotine, Surgery
HTN from excessive NorEpi Pallor/molted cyanosis Tachy Syncope Psychosis/Seizure
What lab result obtained during a Pheo crisis is indicative of no Pheo issue?
If this test is Pos, what is the next test?
Normal metanephrine test
24hr urine for Catecholamine, metanephrines (gold standard)
What is the imaging modality of choice to Dx Pheo?
What if this comes back negative?
CT w/ contrast
CT whole abdomen, pelvis and chest
Why would a RAI scan be ordered for supected Pheo?
MIBG for non-adrenal paraganglioma
Can also be done if abdominal CT is suspicious for secretory paraganglioma
How is Pheo prepared for Tx?
Alpha blockade w/ Phenoxybenzamine or Nifdipine
BP control for 4-7 days minimum
BBs- worsen HTN from unopposed Alpha constriction
Only used in persistent Tachy/arrhythmias and only after alpha blocker and pT is tachy
What is the Tx of choice for Pheo?
What can be used for HTN management during Tx?
Surgery
IV Nicardipine or IV Nitroprusside
What is required for post-op Pheo Tx monitoring?
What is the Tx if the pheo is inoperable?
BP and catecholamines
Metyrosine- reduces synthesis but w/ CNS s/e
Pheo is more likely to be malignant if its bigger than ?
MEN1 is AKA?
> 7cm
Wermer Syndrome
Wermer syndrome is most commonly ? syndrome
95% of PTs present with ?
Multiglandular
Hyperparathyroidism
What is often the first clinical sign seen in MEN1?
What is the second most common finding?
When do Sxs usually appear?
Hypercalcemia
Facial angiogibromas
3-4th decade of life
MEN2a is AKA?
What is the most common and second most common finding?
Sipple Syndrome
Medullary thyroid Ca
Bilateral pheos
How is MEN2a Tx?
What has to be done prior to Tx?
Prophylactic thyroidectomy before 6yrs old
Only after screening for Pheo first
What is major and second major Sx of MEN 3?
How is this form Tx?
Mucosal/GI neuromas
Medullary thryoid CA
Prophylactic thyroidectomy before 6mon
What MEN Syndrome has a Marfan like habitus?
Any adrenal adenoma bigger than ? is removed?
MEN 3
4cm
What three metabolites may be seen in higher amounts/for longer in Pheo Pts?
MEN syndromes are sometimes AKA ?
Metanephrine or Normetenephrine reducing to VMA
Polyglandular Syndromes
How many are there?
How are they passed along through generations?
MEN 1, 2/2a, 3/2b, 4
Autosomal Dominant
What is less severe for medullary thyroid cancer, MEN2a or MEN3?
What is a different finding in MEN2a than other MENs?
MEN2 is less severe than 3
Hischprungs
What is included in MEN4?
Parathyroid, Pancreatic, Pituitary tumors
Adrenal Cortex, Thyroid adenomas
What tumor would most likely be found in PT with MEN1?
Which form of MEN would mucosal/GI tumors be more likely to be found?
Parathyroid
MEN3
What do MEN2 and MEN3 have in common?
Which one is more likely to have each finding
Medullary thyroid CA
Pheo
MEN2- thyroid CA
MEN3- pheo
Which form of MEN would facial angiofibrinomas and colagenomas be more likely?
How often are adrenal incidentalomas found?
MEN1
4% of PTs
Most adrenal incidentalomas are non-functioning but they can be ?
What labs are ordered for these PTs?
Cortisol
Pheo
Aldosteronoma
Metastatic
24hr urine metanephrines, atecholamines- r/o Pheo
Free cortisol- r/o Cushings
Serum K and Aldosterone- r/o Conn syndrome
Plasma renin
How are adrenal incidentalomas managed w/ normal labs?
When is surgery indicated?
Serial CT Q6-12mon
If non-functioning and <4cm, repeat CT Q2-3yrs
> 4cm despite lab results
What are the ‘red flags’ of secondary HTN?
Hypokalemia w/out diuretic Young w/out FamHx of HTN New presentation +50y/o Higher degree of severity if DBP +110 Well controlled gone refractory Paroxysmal BP Absence of obesity
