endocrine cases

Question 1

Mr A., a 35 year old man with no relevant medical history is referred to your clinic by his GP with the following symptoms:

Unintentional Loss of weight
Diarrhoea
Depression & lack of energy
Tanned Skin & darkened scarring
In the referral letter the GP has stated that his appearance has influenced the referral

Answer 1

Addisons Disease

Question 2

define Addisons disease?

Answer 2

Cortisol & aldosterone deficiency due to destruction of the adrenal cortex

Question 3

causes of addisons disease?

Answer 3

Autoimmunity, TB.
Rarer causes include

Adrenal bleeds
metastases
adrenoleucodystrophy

Question 4

What signs would you expect to see in a patient with Addisons?

Answer 4

Darker Skin
Buccal Mucosa Hyperpigmentation
Palmar crease & scar darkening
Postural Hypotension

Question 5

what blood results would you expect to see in a patient with Addisons?

Answer 5

Na, Glu
K, Ca
Uraemia
Eosinophillia
Anaemia

Question 6

what test should be ordered for suspected Addisons?

Answer 6

Synacthen Test (ACTH stimulation test)

Plasma cortisol level before & ½ hour after Synacthen administration (tetracosactide). Addison’s is excluded if 2nd cortisol is >550nmol/l

Question 7

recommended treatment for Addisons?

Answer 7

Hydrocortisone 15-30mg daily

Question 8

what follow up should be done for Addisons disease?

Answer 8

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 9

when is treatment steroid dose needed to be increased?

Answer 9

Infections
Double or triple dose steroids for 3-5 days
Surgery — Minor
Hydrocortisone 100mg i.m or i.v at induction anaesthetia and double oral dose for 24-48 hours
Surgery — Major
Hydrocortisone 100 i.m or i.v at induction of anaesthetia and 6 hourly till oral intake, then double oral dose for 24-48 hours and taper

Question 10

Mr A presents to A&E 2 months later. He is exhausted, confused, and has a HR of 140. He has recently been ill with a chest infection but he did not increase his hydrocortisone.

What is he experiencing?

Answer 10

Addisonian Crisis

Hypoglycaemia & hypotension risks

Question 11

how do you treat addisonian crisis?

Answer 11

Treat before biochemistry if suspected
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

Question 12

During your normal general practice clinics you are visited by Mrs B, 29, and her husband. She discusses with you a long history of:

Back and headaches
Joint pain
Weight gain
Amenorrhea
Her husband also says that since they were married 4 years ago her hair has changed and she has lost her libido. She also says that she cannot wear her wedding ring anymore and always seems to need bigger shoes.

What endocrine disorder presents with these symptoms?

Answer 12

Acromegaly

Question 13

define acromegaly?

Answer 13

increased secretion of growth hormone causing changes in appearance

Question 14

what blood test results would you expect to see in acromegaly?

Answer 14

IGF1 increased

Question 15

what other tests should be done for acromegaly?

Answer 15

Glu, Ca, PO4
Oral glucose tolerance test
Visual field examination

GH levels- because they are often fluctuating unreliable

Question 16

how is the oral glucose tolerance test done for patients with acromegaly?

Answer 16

A baseline blood sample is drawn
The patient is given a measured dose of glucose(in UK general practice is 394ml of lucozade original is used)
Blood is drawn at intervals for measurement of glucose
From this test we can determine how quickly glucose is cleared from the blood

In acromegaly testing, samples are taken at 0mins, and every 30mins up to 150mins. GH is also tested and a lowest GH level greater then 1ug/l confirms Acromegaly.

Question 17

What hospital based test should you order after confirming GH excess?

Answer 17

MRI of pituitary fossa

Question 18

Confirming the diagnosis of Acromegaly what is the three part treatment of the disease?

Answer 18

Removal of tumour through surgery
If surgery fails to correct the GH/IGF-1 hypersecretion, Somatisation analogues (monthly IM Sandostatin)
If also unsuccessful, GH inhibition (Pegvisomant)
A further option is dopamine agonists as they supress GH secretion. They are often used as adjuvant therapy.

Question 18

Patients should be counselled about the potential side effects of SSAs what are these?

Answer 18

gastrointestinal upset, malabsorption, constipation, gallbladder disease, hair loss, and bradycardia. It is not recommended that patients have close radiologic imaging surveillance for symptomatic gallbladder disease, but patients should be queried about potential symptoms during follow-up appointments.

Question 19

Mrs C., a 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 19

Hyperprolactinaemia
Galactorrhoea

Question 19

what follow up should be done for patient with acromegaly?

Answer 19

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 20

What level on a blood test would indicate hyperprolactinaemia?

Answer 20

Basal plasma prolactin >550mu/l

Question 21

causes of hyperprolactinaemia?

Answer 21

Tumours arising in pituitary (prolactin secreting adenoma)
Medications which suppress dopamine levels (tranquilizers & antipsychotic drugs)
Larger pituitary tumour disrupting the hypothalamic control mechanism (dopamine inhibition): Disconnection hyperprolactinaemia
Chronic renal failure, hypothyroidism
Some women with polycystic ovary syndrome may have mildly-elevated prolactin levels.

Question 22

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

Answer 22

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

Question 23

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 23

1st line — Dopamine agonists (Bromocriptine, Cabergoline)

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

Question 24

Advice should be given to patients wishing to conceive while effected by tumour induced hyperprolactinaemia as the tumour may grow during pregnancy.

Answer 24

Following conception women with macroadenomas should be monitored for symptoms and signs suggestive of tumour enlargement, but prolactin levels are not accurate for this during pregnancy. Imaging and Bromocriptine may be considered in selected cases.
Microadenomas usually do not need any special attention other than an awareness of the condition with the mother asked to report sudden/unusual headaches or visual concerns

Issues surrounding the treatment of hyperprolactinemia in pregnancy are mainly concerned with the effects of dopamine agonists on the foetus and the possible stimulatory effect of the increased estrogen levels of pregnancy on tumor size.
Although no apparent adverse effects on the pregnancy or foetal development have been found, stopping of medical treatment is recommended.

Question 25

What signs and symptoms would occur in hyperprolactinaemia if the patient was male?

Answer 25

Erectile dysfunction
Decreased facial hair
Lactation
Visual field disturbance (as they present later)
It is also worth noting that a lower BPP level is indicated in male patients (>390 mu/l)

Question 26

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?

Answer 26

Cushings syndrome

Question 26

why do hyperprolactinaemia patients have a risk of osteoporosis?

Answer 26

Hyperprolactinemia can cause reduced oestrogen production in women and reduced testosterone production in men.
Although oestrogen/testosterone production may be restored after treatment for hyperprolactinemia, even a year or two without oestrogen/testosterone can compromise bone strength, and patients should protect themselves from osteoporosis by increasing exercise and calcium intake through diet or supplementation, and by avoiding smoking

Question 27

what is the science behind glucocorticoid excess?

Answer 27

Question 28

What physical abnormalities would you expect if you were to examine a patient with Cushings syndrome?

Answer 28

Easy bruising
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 29

What are the differential diagnosis of Cushing’s Syndrome?

Answer 29

Obesity
Depression
Alcoholism
Eating Disorders
If one of these problems is the causing the Cushing’s like syndrome then the physiological change will disappear when treated.

Question 30

how is cushings syndrome tested for?

Answer 30

Question 31

What tests will confirm Cushing’s Syndrome?

Answer 31

Low Dose Dexamethasone suppression test
Urinary Free Cortisol

Question 32

Low Dose Dexamethasone suppression test

Answer 32

Cortisol measurement taken. Dexamethasone 1mg is given at 11pm and cortisol is measured again @ 8am. Serum cortisol >50nmol/l indicates Cushing’s.

Question 33

Urinary Free Cortisol

Answer 33

Collect urine for 24 hours; at the start of collection, 10 g of boric acid is added as preservative. The test may need to be done three or more separate times to get a more accurate picture of average cortisol production. An increased level of cortisol shows Cushing’s

Question 34

Mr. D’s test indicate a serum cortisol >50nmol/l and an increase urinary free cortisol.
What other tests would be needed?

Answer 34

A high dose dexamethasone test: High dose Dex exerts negative feedback on pituitary ACTH producing cells (suppressing cortisol by>50%) but not on ectopic ACTH producing cells or adrenal adenoma. This allows for localisation of the cause of Cushing’s syndrome.
Other tests include: Corticotrophin releasing hormone (CRH) test and Inferior Petrosal Sinus Sampling

Question 35

Localisation of Cushing’s Syndrome

Answer 35

Cortisol levels not suppressed by high or low doses of dexamethasone indicate an ectopic cause for the symptoms.

Cortisol levels not suppressed by low dose dex. but suppressed by high dose dex. Indicate possible Cushing’s disease because the pituitary still retains some feedback control.

A pituitary MRI would be needed to confirm a pituitary adenoma.

Question 36

Cushing’s Disease

Answer 36

Cushings disease refers to a case Cushing’s syndrome where ACTH is increased due to a pituitary dependant cause (a tumour), causing adrenal glands to produce elevated cortisol. This can cause bilateral adrenal hyperplasia.

Question 37

is metformin first line for type 2?

Answer 37

no
lifestyle

Question 38

is aim of type 2 treatment to have normal blood glucose levels?

Answer 38

no
achievable goals
also a patients main aim may be to become asymptomatic

Question 39

Answer 39

enhance growth of beta cells

Question 40

Answer 40

canaglifloxin

Question 41

Answer 41

empaglifloxin (sglt2 inhibitor)

Question 42

Answer 42

not semaglutide or canagliflozin

Question 43

Answer 43

not pioglitazone

Question 44

Answer 44

not alogliptan

Question 45

Answer 45

metformin

Question 46

Answer 46

canagliflozin

Question 47

Answer 47

glimepiride

Question 48

Answer 48

pioglitazone

Question 49

Answer 49

stagliptin