Endocrinology Flashcards
What is the definition, aetiology and epidemiology of Acromegaly?
Acromegaly is the constellation signs and symptoms that are caused by hypersecretion of growth hormone (GH) in adults (if this happens before puberty it is known as gigantism). It is rare, incidence is 5 in 1,000,000.
Most commonly caused by GH-secreting pituitary adenoma. Rarely caused by GHRH (growth hormone releasing hormone) secretion, leading to somatotroph (cells in anterior pituitary that produce GH) hyperplasia, by hypothalamic ganglioneuroma, bronchial carcinoid or pancreatic tumours.
What are the symptoms of Acromegaly?
Patient may present with a very gradual onset of symptoms (often only detectable on serial photographs).
• Patient may complain of rings and shoes becoming tight
• ↑sweating, headache and carpel tunnel syndrome
• Coarsening of facial features, soft tissue and skin changes.
• Joint pain and dysfunction
• Snoring
Other symptoms include:
• Hypoprolactinaemia (oligomenorrhoea, decreased libido, impotence)
• Fatigue (common)
• Hypertension and arrhythmias (common)
• Increased appetite, polyuria/polydypsia
More uncommon symptoms include:
• Symptoms of hypopituitarism due to compression of the adenohypophysis
• Visual field defects due to compression of optic chiasm
What are the examination findings of Acromegaly?
Hands and feet are enlarged, with thick greasy skin.
Signs of carpal tunnel syndrome may be found.
Face looks characteristic, with prominent eyebrow ridge and cheeks, thick lips, gaps between teeth, large tongue and husky voice.
What are the potential complications of Acromegaly?
CVS: Cardiomyopathy, hypertension
GI: Colonic polyps
Reproductive: hyperprolactinaemia
Metabolic: hypercalcaemia, hyperphosophataemia, renal stones, diabetes mellitus, hypertiglyceridaemia.
How can Acromegaly be investigated?
A serum IGF-1 test (Insulin-like Growth Factor is secreted due to GH stimulation) will show elevated levels of IGF-1.
Oral glucose tolerance test can also be done; glucose suppresses GH release, if GH is still elevated, this confirms a diagnosis of acromegaly.
A pituitary CT or MRI can also be done to confirm the presence of a pituitary adenoma. If this is normal, can measure GHRH (Growth Hormone Releasing Hormone) - if elevated, points to a ectopic GH-releasing source.
How is Acromegaly managed?
Surgical removal is the only curative treatment (trans-sphenoidal hypophysectomy). Radiation can be an adjunct to surgery.
If surgery cannot be performed or fails, a somatostatin analogue (such as octreotide) is indicated to suppress GH release.
Dopamine agonists (bromocriptine or cabergoline) also reduce GH secretion, and can be used in treatment. Has an important side-effect profile.
GH receptor antagonist can be used if developed resistance to somatostatin analogues.
What is the definition of Adrenal Insufficiency?
Adrenal insufficiency is the deficiency of adrenocortical hormones (mineralocorticoids, glucocorticoids and androgens).
What is the aetiology of Adrenal Insufficiency?
Primary causes (problem with endocrine organ itself) - called Addison’s disease include:
• Autoimmune destruction of the adrenal cortex (>70% of cases)
• Infections such as tuberculosis, meningococcal septicaemia, CMV (HIV patients), histoplasmosis
• Can be caused by infarction, and congenital (adrenoleukodystrophy)
Secondary causes include due to pituitary or hypothalamic disease.
The most common cause is iatrogenic - where cortisol production is suppressed due to long-term steroid use, leading to negative feedback on hypothalamic-pituitary-axis. This results in decreased CRH (corticotrophin releasing hormone) and decreased ACTH production.
What are the clinical features of Adrenal Insufficiency?
Chronically presents with non-specific symptoms: dizziness, anorexia (causing weight loss), diarrhoea and vomiting (unknown reason), abdominal pain, lethargy, weakness and depression.
On examination:
• Postural hypotension
• Increased pigmentation (more noticeable in buccal mucosa, scars, skin creases, nails and pressure points) - this is absent in secondary causes (iatrogenic) as ACTH production is also dampened.
• Loss of body hair in women (due to androgen deficiency)
Can present with other autoimmune conditions such as vitiligo.
What are the clinical features of Addisonian crisis?
Acute presentation (Addisonian crisis): Acute adrenal insufficiency with major haemodynamic collapse often precipitated by stress (e.g. infection or surgery). On examination: tachycardia, pale, cold, clammy, oliguria.
What are the potential complications of Adrenal Insufficiency?
- Hyperkalaemia
* Death during Addisonian crisis.
How can Adrenal insufficiency be investigated?
Start with a 9am serum cortisol test. If <110 nanomol/L, likely adrenal failure. If >550, likely normal response. If between, do a short synACTHen test.
Identify the cause:
• Autoantibodies (against 21-hydroxylase).
• Abdominal CT or MRI
Addisonian crisis:
• FBC (neutropenia)
• U&Es (↑urea, ↓Na+, ↑K+)
• ↑ESR and CRP
CXR can be used to identify cause.
How is Adrenal insufficiency managed?
Chronic: Glucocorticoid replacement with hydrocortisone (three times a day) and mineralocorticoids with fludrocortisone. Hydrocortisone needs to be increased during acute illness or stress.
Give them a steroid warning card (says patient is on steroids), Medic-alert bracelet, emergency hydrocortisone ampule and patient education.
What is the definition and epidemiology of carcinoid syndrome?
Carcinoid syndrome is a constellation of symptoms produced by the systemic release of humoral factors (biogenic amines, polypeptides, prostaglandins) from carcinoid tumours. They are very rare: annual incidence is 1 in 1,000,000. Asymptomatic carcinoid tumours are more likely, and are usually found after rectal biopsy or appendectomy.
What are the clinical features of carcinoid syndrome?
A history of paroxysmal flushing, diarrhoea, crampy abdominal pain, wheeze, sweating and palpitations.
On examination: Note facial flushing, telangiectasia, and wheeze.
Cardiac murmurs such as Tricuspid stenosis and regurgitation or pulmonary stenosis is common because of serotonin and kinins leading to fibrosis of right-sided heart valves.
How can Carcinoid syndrome be investigated?
Investigations
• 24-h urine collection: 5-HIAA levels (a metabolite of serotonin, false positive with high intake of certain fruits e.g. bananas and avocados)
• Blood: plasma chromogranin A and B
• Radioisotope scan: radiolabeled somatostatin analogue helps localise the tumour
What is the definition and epidemiology of Cushing’s Syndrome?
Cushing’s syndrome is the syndrome associated with abnormally elevated levels of cortisol in the body. Cushing’s syndrome is very rare, affecting 2-4/1million. However, exogenous Cushing’s syndrome (due to excess steroid intake) is much more common.
What is the aetiology of Cushing syndrome?
Causes can be broken down into ACTH dependent (80%) or independent (20%). ACTH dependent causes include:
• ACTH secreting Pituitary Adenoma (80%) - Cushing’s disease
• ACTH secreted from an ectopic tumour such as small-cell lung carcinoma (20%)
ACTH independent causes include:
• Adrenal adenoma (60%)
•Adrenal carcinoma (40%)
Exogenous Cushing’s syndrome due to excess steroid intake is much more common.
What are the clinical features of Cushing’s Syndrome?
Patients present with increasing weight, fatigue muscle weakness, myalgia, easy bruising and poor wound healing. Oligo/amenorrhoea is a common complaint. Patient may also complain of depression or psychosis.
You may also notice that patient has glucose intolerance.
On examination:
• Red cheeks, moon face, intrascapular fat pads,
• Bruising, thin skin with red striae on abdomen.
• General thin arms and legs (lemon on sticks) with central obesity.
• Kyphosis
• Hirsutism, acne and frontal bolding.
• Hypertension and ankle oedema (due to excess mineralocorticoids)
• Pigmentation in ACTH-dependent cases.
What are the potential complications of Cushing’s Syndrome?
Complications: Diabetes, osteoporosis, hypertension. Predisposition to infections.
How is Cushing’s Syndrome investigated?
Women of child-baring age should have a pregnancy test when investigating hypercortisolism.
Blood tests may show hyperkalaemia or ↑glucose (due to glucose intolerance).
Urinary free cortisol (measured by 24h urine collection) and late-night salivary cortisol would be elevated. A Low-dose/overnight dexamethasone suppression test would suppress cortisol in a healthy patient, but not in a Cushing’s patient.
To discriminate between ACTH dependent or independent, measure plasma ACTH. If ↓, then CT or MRI the adrenal glands. If ↑ then perform a pituitary MRI. Also can perform inferior petrosal sinus sampling (if central:peripheral ACTH > 2:1, then confirmed pituitary is source). If lung cancer is suspected, then CXR, sputum cytology, bronchoscopy, CT scan.
How is Cushing’s Syndrome managed?
In iatrogenic cases, discontinue or lower steroid use. Use steroid-sparing agent if possible.
Medical treatment is for pre-operative or if patient is unfit for surgery. Inhibit cortisol synthesis with metyrapone or ketaconazole.
Surgical treatments are gold-standard. A trans-sphenoidal adenoma resection for a pituitary adenoma. Adrenalectomy for adrenal adenoma/carcinoma. Remove ectopic tumour if possible.
What is the prognosis of Cushing’s Syndrome?
If untreated, 5-year survival is 50%. Depression usually continues after successful treatment.
What is the definition and epidemiology of Diabetes Insipidus?
Diabetes Insipidus is a disorder of inadequate secretion of, or insensitivity to vasopressin (ADH) leading to hypotonic polyuria. DI is fairly uncommon, and median age of onset is 24 years.