endocrine cases Flashcards
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
Addisons Disease
define Addisons disease?
Cortisol & aldosterone deficiency due to destruction of the adrenal cortex
causes of addisons disease?
Autoimmunity, TB.
Rarer causes include
Adrenal bleeds
metastases
adrenoleucodystrophy
What signs would you expect to see in a patient with Addisons?
Darker Skin
Buccal Mucosa Hyperpigmentation
Palmar crease & scar darkening
Postural Hypotension
what blood results would you expect to see in a patient with Addisons?
Na, Glu
K, Ca
Uraemia
Eosinophillia
Anaemia
what test should be ordered for suspected Addisons?
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
recommended treatment for Addisons?
Hydrocortisone 15-30mg daily
what follow up should be done for Addisons disease?
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)
when is treatment steroid dose needed to be increased?
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
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?
Addisonian Crisis
Hypoglycaemia & hypotension risks
how do you treat addisonian crisis?
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
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?
Acromegaly
define acromegaly?
increased secretion of growth hormone causing changes in appearance
what blood test results would you expect to see in acromegaly?
IGF1 increased
what other tests should be done for acromegaly?
Glu, Ca, PO4
Oral glucose tolerance test
Visual field examination
GH levels- because they are often fluctuating unreliable
how is the oral glucose tolerance test done for patients with acromegaly?
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.
What hospital based test should you order after confirming GH excess?
MRI of pituitary fossa
Confirming the diagnosis of Acromegaly what is the three part treatment of the disease?
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.
Patients should be counselled about the potential side effects of SSAs what are these?
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.
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?
Hyperprolactinaemia
Galactorrhoea
what follow up should be done for patient with acromegaly?
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
What level on a blood test would indicate hyperprolactinaemia?
Basal plasma prolactin >550mu/l
causes of hyperprolactinaemia?
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.
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)
Advice should be given to patients wishing to conceive while effected by tumour induced hyperprolactinaemia as the tumour may grow during pregnancy.
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.
What signs and symptoms would occur in hyperprolactinaemia if the patient was male?
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)
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?
Cushings syndrome
why do hyperprolactinaemia patients have a risk of osteoporosis?
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
what is the science behind glucocorticoid excess?
What physical abnormalities would you expect if you were to examine a patient with Cushings syndrome?
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
What are the differential diagnosis of Cushing’s Syndrome?
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.
how is cushings syndrome tested for?
What tests will confirm Cushing’s Syndrome?
Low Dose Dexamethasone suppression test
Urinary Free Cortisol
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.
Urinary Free Cortisol
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
Mr. D’s test indicate a serum cortisol >50nmol/l and an increase urinary free cortisol.
What other tests would be needed?
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
Localisation of Cushing’s Syndrome
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.
Cushing’s Disease
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.
is metformin first line for type 2?
no
lifestyle
is aim of type 2 treatment to have normal blood glucose levels?
no
achievable goals
also a patients main aim may be to become asymptomatic
enhance growth of beta cells
canaglifloxin
empaglifloxin (sglt2 inhibitor)
not semaglutide or canagliflozin
not pioglitazone
not alogliptan
metformin
canagliflozin
glimepiride
pioglitazone
stagliptin
