Week 4 - F - Pituitary endocrine, end of week tutorial

Question 1

This lady complains of excessive sweating and extreme tiredness What is the differential diagnosis based on these symptoms ?

Answer 1

Functoning pituitary tumour secreting GH - causing acromegaly Only other causes i can think of causing acromegaly are Carney complex and McCune Albright Syndrome

Question 2

Her shoe size has increased from 5 to 7 in the past 3 years and she is unable to wear her wedding ring. What is now the likely diagnosis? What clinical signs are demonstrated here? What other symptoms might this patient have? What other investigations should you perform?

Answer 2

Acromegaly Enlarged hands and feet Other symptoms - enlarged jaw, difficulty sleeping, protruding lips Perform an IGF1 test to screen for increase and perform a diagnostic GTT to show continual increased growth hormone

Question 3

What clinical sign is demonstrated ? Name 4 potential underlying causes

Answer 3

Galactorrhea 4 causes Hyperprolactinaemia Pregnancy Underactive thyroid Excessive breast stimulation

Question 4

Here is a normal pituitary on MRI Name the structure below the pituitary arrowed A. What is the structure arrowed B? What is the round dark ‘object’ arrowed C on either side of the pituitary?

Answer 4

A - Sphenoid sinus B - optic chiasm C - internal carotid arteries

Question 5

Pituitary tumours can expand laterally into the cavernous system Name the contents of the cavernous system. (Clue there is one artery, a venous system and 5nerves)

Answer 5

The artery is the internal carotid artery Venous system is the dural venous sinus Nerves - CN III, IV, CN V1&2 CNVI

Question 6

The nerve contents of the cavernous sinus from top to bottom go from nerve CN III to CN VI What is the mnemonic to remember the nerves and artery?

Answer 6

O culomotor - CN III T rochlear CN IV O pthalmic CN V1 M axillary - CN V2 C arotid artery A bducens - CN VI

Question 7

What is the curve of the internal carotid artery in the cavernous sinus known as?

Answer 7

The carotid siphon

Question 8

pituitary tumours which have invaded the cavernous system. Name the cranial nerve involved in this eye defect Eye is lateral/little bit in

Answer 8

Cranial nerve III palsy Since the cranial nerve III is not working, the eye is now only controlled by the abducent and trochlear moving the eye laterally and down

Question 9

pituitary tumours which have invaded the cavernous system. Name the cranial nerve involved in this eye defect Eye is pointing downward and inward?

Answer 9

Trochlear nerve - CN IV COntrols downwards and outward movement of the eye When damaged will cause the eye to move down and in

Question 10

This middle-aged obese woman presented with hypertension and weight gain. What is the differential diagnosis of the hypertension and obesity ?

Answer 10

Differential is Cushing’s sydnrome

Question 11

She has also lost hair from her scalp. What is this sign called ?

Answer 11

Alopecia Hair loss in women due to cushing’s

Question 12

She has back pain. What do these X-rays show? (if you could see an Xray) What is the likely diagnosis ? What are the possible underlying causes ? name 3 What investigations should be performed ?

Answer 12

Osteoporsis Likely diagnoses is Cushings Underlying causes - ACTH producing pituitary tmuour High dose steroid use leading to excess cortisol Ectopic ACTH producing tumour

Question 13

What are 4 underlying causes of Addison’s disease?

Answer 13

Autoimmune disease preventing hormones being produced TB Pituitary failure resulting in decreased ACTH production Exogenous steroid use (adrenals are not producing steroid themselves)

Question 14

This 24 year old woman presented with amenorrhoea for 3 months. Prior to this her periods were irregular since menarche. Her Body Mass Index is 36. A pregnancy test is negative. Consider the differential diagnosis of ammenorrhea What abnormality is demonstrated in the above image ? What is the likely diagnosis ? Name 2 drugs that might be helpful.

Answer 14

Abnormality is hirstuism Likely diagnoses is prolactinoma 2 drugs - bromocriptine and cabergoline

Question 15

This middle-aged man noticed that he was slowing down at work and was forgetful. He was of short stature and had a high-pitched voice. He never shaved, and on examination had infantile genitalia and no axillary or pubic hair. Diagnoses?

Answer 15

Panhypopituitarism

Question 16

What are possible causes of panhypopituitarism?

Answer 16

commonly caused by tumours, surgery or radiotherapy - can be due to trauma

Question 17

What can cause symtpoms in panhypopituitarism?

Answer 17

 Hypothyroidism – weight gain, cognitively slow, dry skin and cold intolerance  Hypoadrenalism – mild hypotension, hyponatraemia, cardiovascular collapse  Gonadotrophin and gonadal deficiencies - libido (reduced sex drive/desire), loss of secondary sexual hair, amenorrhoea and erectile dysfunction  Hyperprolactinaemia – galactorrhoea and hypogonadism  GH deficiency – growth failure in children and impaired wellbeing in some adults  Weight may increase  Panhypopituitarism – classic picture of pallor with hairlessness

Question 18

A young boys mum had recently been found to have a medullary thyroid cancer and the family were called for genetic screening. He was found to be asthenic and marfinoid in appearance. His tongue showed small neuromata on the tip with larger neuromata involving the gums. Initial blood investigations revealed a mildly elevated serum calcium What other blood tests should you check? What other investigations should be considered?

Answer 18

Boy seems to have MEN2b - elevated - mucosal neuroma, marfinoid, medullary thyroid cancer Blood tests - done calcium for caclitonin Check catecholamine levels Check for RET gene mutation

Question 19

This middle aged lady is known to be hypertensive. She complains of intermittent attacks during which she sweats and feels “dreadful”. Her family have noticed that she becomes pale. She has another long-standing condition associated with café-au-lait skin patches and ‘lumps’ just below the skin. What is the cause of her sweating attacks? What investigations should be done?

Answer 19

Cause of her sweating attacks is a phaeochromcytoma leading to increased adrenaline production causing the sweating attacks Investigations - measure the catecholamine levels Check for NF1 gene mutation