(a bit of) endocrine
DESCRIPTION
(a bit of) Endocrine. Dr Alex Smith 12 th March 2013. Overview. What this will cover Cases: Thyroid disease Pituitary disease Adrenal disease A few quiz questions (if time allows) Eponymous syndromes game (woo) What I won’t cover Diabetes and DM emergencies. - PowerPoint PPT PresentationTRANSCRIPT
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(A BIT OF) ENDOCRINE
Dr Alex Smith 12th March 2013
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OVERVIEW What this will cover Cases:
Thyroid diseasePituitary diseaseAdrenal disease
A few quiz questions (if time allows) Eponymous syndromes game (woo)
What I won’t coverDiabetes and DM emergencies
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CASE 1 – A LUMP IN THE NECK A 27 year old woman presented to her GP
with an increase in the size of a longstanding lump in her neck.
She had first noticed it four years ago, as a small right sided lump, but in recent months it had increased in size to cause obvious asymmetry.
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NECK LUMPS How do you assess?
Differential Diagnosis?
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CASE 1 On examination, she had a single well
defined lump in the right anterior triangle, extending down to her clavicle. She was clinically euthyroid and thyroid function tests were unremarkable.
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CASE 1 What is the differential diagnosis in a young
woman with these symptoms? In a young euthyroid patient, a neoplastic thyroid
lesion should be excluded first.
What symptoms would require urgent investigation? Local symptoms such as voice changes, dysphagia Cervical lymphadenopathy Associated red flags e.g. Weight loss History of rapid enlargement Stridor Any nodule in a child
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CASE 1 What is the diagnostic investigation of
choice?Fine needle aspiration is the investigation of
choice for a definitive histological diagnosis.
What other investigations might add to the clinical picture?Ultrasound of the neck will help localise the
anatomical origin
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NECK LUMPS Congenital
Branchial cyst Cystic hygroma Parotid tumour
Carotid body tumour Endemic Thyroid:
Thyroiditis Hashimoto’s disease Physiological Multinodular goitre
Single thyroid lumpCystAdenomaMalignancy (papillary,
follicular, medullary, anaplastic, lymphoma)
Smooth toxic goitreGraves’ diseaseDiscrete nodule in
multinodular goitreGoitrogens
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THYROID CAPapillary thyroid carcinoma (PTC) This is the commonest form of thyroid cancer. It usually presents between 35 and 40 years of
age and is 3 times more common in women. It tends to spread locally in the neck,
compressing the trachea and possibly involving the recurrent laryngeal nerve.
It can metastasise to lung and bone.
Follicular thyroid carcinoma (FTC) This is the second commonest form of thyroid
cancer at about 10%. It tends to occur in areas of low iodine. It is 3 times as common in women and tends
to strike between 30 and 60 years of age. It may infiltrate the neck as does papillary
carcinoma but it has a greater propensity to metastasise to lung and bones.
Medullary cell carcinoma This is about 5% of thyroid cancers. About 25% of patients give a family history. Female prepronderance is less marked. Prophylactic thyroidectomy is advocated for
those at risk. The familial form is discussed in the article
Multiple Endocrine Neoplasia Type 2 (MEN2).
Thyroid lymphomas Thyroid lymphomas are almost always non-Hodgkin
lymphomas, representing 4 to 10% of thyroid malignancies.
Mainly women over 50 are affected and they often have Hashimoto's thyroiditis.
Patients usually present with a rapidly growing mass in the neck, which may cause symptoms of obstruction such as dyspnoea and dysphagia.
Thyroid lymphoma arises in a pre-existing chronic thyroiditis with subclinical or overt hypothyroidism in 70 to 80%.
The prognosis depends on the stage of the disease at diagnosis.
The 5-year survival rate ranges from 89% in early disease to 5% in disseminated disease.
Hurthle cell carcinoma About 2 to 5% of thyroid cancers are Hurthle cell
carcinoma.6
There is a female preponderance - mainly in their 40s.
They are composed of 75 to 100% Hurthle cells. It is impossible to distinguish benign from malignant
tumours on fine needle aspiration (FNA). They do not take up iodine nor respond to TSH. 5-year survival rate is around 50%.
Anaplastic carcinoma This represents less than 2% of thyroid cancers. Women are affected more often than men. It is found aged 50 to 60. Half have metastases at presentation and prognosis
is poor.
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CASE 2 - THIRST 52 yo overweight man presented to his
GP with a 4 week history of increasing thirst and polyuria. In addition he was also increasingly tired, constipated and suffering from low mood. Initial thoughts?
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CASE 2 - THIRST Urinalysis NAD BM 6.2
Baseline bloods reveal: Adj Calcium 2.8
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PARATHYROID Hyperparathyroid and malignancy together make up
90% of the causes of hypercalcaemia Primary hyperparathyroidism is the commonest single
cause Investigations Serum PTH and calcium. Ultrasound, CT,MRI, isotope MIBI scanning to localise
site of the disease.
Management: Acutely: IV fluids. In severe hypercalcaemia, bisphosphonates
can help reduce bone turnover and decrease calcium. The definitive treatment for parathyroid causes is surgical
exploration of the neck.
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EFFECTS OF PTH
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CASE 3 A 34 year old man was admitted to AMU with a history
of headache and vomiting. He had been experiencing neck pain for the preceding 4
months; his headache had developed gradually over this time but had worsened over the past two weeks. The headache was over the frontal area of the skull radiating to the neck.
The headache was not related to time of day. He also described some pain over his left eye.
He had a two week history of vomiting associated with the headache, but no photophobia.
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CASE 3 O/e: Temperature 36.8°C RR 15 HR 85,
BP 125/65 mmHg
Neuro:PapilloedemaBitemporal hemianopia.
Impression?
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CASE 3 Blood tests initially showed Hb 15.5 WCC 12.0
Neutrophils 10.1 Platelets 225 Urea 5.3 Na 136 K 3.7 HCO3 27
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The MRI scan shows a very large enhancing mass centred on the suprasellar region, markedly expanding the sella and with lateral extension into both cavernous sinuses.
The optic chiasm cannot be identified but is presumably grossly elevated and compressed.
The differential diagnoses that must be considered are pituitary adenoma, craniopharyngioma, chordoma, and meningioma
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CASE 3 - BLOODS Prolactin: 35190 pmol/l (207-725) 8 am: cortisol concentration of 75 nmol/l TSH 0.6 mIU/l (0.5-4.7) Free thyroxine 11 pmol/l (9-24) FSH 3.3 IU/l (1-7) LH 1.4 IU/l (1-8) Testosterone 1.9 nmol/l (8-27)
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CASE 3: TREATMENTWhat treatment should be started?
Dopamine agonist therapy (bromocriptine, cabergoline, or quinagolide) ...(dopamine inhibits prolactin release)
Complications: nausea and vomiting, headache and mood alteration, hypotension.
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PITUITARY TUMOURS Symptoms from:
Excessive hormone production Local effects of the tumour Inadequate hormone production by the remaining
pituitary gland Origins:
Non-functioning adenomas Prolactinomas Growth hormone (GH)-secreting ACTH-secreting Thyroid-stimulating hormone-secreting Leutinising hormone/follicle-stimulating hormone
(LH/FSH)-secreting tumours
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CASE 4 – TIRED ALL THE TIME A 77 yo man presented to his GP for
annual blood pressure check Increasingly tired over last few months. Several episodes of dizziness on
climbing stairs One admission to A&E for a fall
o/e Thin, lightly tanned. Nil else specific. BP 100/76 Pulse 68
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CASE 4 - INVESTIGATIONS Hb 13.5 Na 127 K 5.0 Cr 120 Urea 7
Random cortisol - 250nmol/L
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CASE 4 Short Synacthen tests: Adminstration of synthetic ACTH, and
monitoring cortisol response. 0 min. - baseline blood for cortisol; follow
by 250 micrograms synacthen® IV/IM 30 and 60 minutes: measure cortisol level Cortisol levels > 550nmol/L indicates a
normal response. Peak cortisol levels < 550nmol/L
indicate hypoadrenalism (primary or secondary)
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THE ADRENALS
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ADDISON’S DISEASE Adrenal insufficiency, mostly due to autoimmune
pathology in developed countries. It involves atrophy of the entire adrenal cortex. TB is a major cause globally.
Approximately 80-90% of adrenal tissue in both glands must be affected to destroy adrenal reserve.
Symptoms include: malaise, weight loss, postural hypotension, skin pigmentation, abdominal pain.
Ix: ACTH Usually >50ng/L. If the level is raised, this indicates PRIMARY hypoadrenalism, if it is reduced, SECONDARY hypoadrenalism is likely.
Treatment is for life. Hydrocortisone (synthetic cortisol) and fludrocortisone (synthetic aldosterone). Increased in times of physical stress (e.g. Infection, surgery) to avoid adrenal crisis.
Crisis: hypotension, abdominal pain, circulatory collapse
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CASE 5 – HEADACHE A 39 year old woman was referred to the
headache clinic with a 2 year history of episodic headaches, sweating, and palpitations.
The symptoms had intensified over the past 6 months.
Since then she has been experiencing three to four episodes a day, mostly at night, of severe headache, chest tightness, sweating, palpitations, and “churning stomach.”
She had no medical history of note and took no regular drugs.
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CASE 5 CONTINUED O/e BP 100/80 mmHg -no postural drop pulse 86 regular. No associated lymphadenopathy Other examinations unremarkable.
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CASE 5 CONTINUED All bloods normal
24 hour urinary catecholamines: markedly raised noradrenaline (628 nmol/L
reference range 0-450) and adrenaline (722 nmol/L ref 0-100),
suggestive of phaeochromocytoma
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CASE 5 CONTINUED MRI of the adrenals
showed a large mass in the right upper quadrant and a small mass in the left adrenal.
Phaeochromocytoma: a neuroendocrine tumour of the medulla of the adrenal glands (originating in the chromaffin cells)
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CASE 5 CONTINUED Management of phaeochromocytoma
includes α adrenoceptor blockade (with/without β
adrenoceptor blockade)surgical resection
Also associated with thyroid nodules: as part of multiple endocrine neoplasia syndrome type 2 (MEN2).
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ADRENAL GLAND
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CASE 6 51 yr old man presents to GP for review
of hypertension. He is on three agents for BP.
Has been feeling tired, weak, and been having nocturia. BP at review: 160/110mmHgBloods: mild hypokalaemia
Impression?
What investigations are next?
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CONN’S SYNDROME Resistant BP + hypokalaemia Increased aldosterone loss of K and
retention of Na in distal conv tubule – retention.
Polyuria and nocturia can occur if hypokalaemic makes kidney more resistant to ADH (which increases at night)
Ix: Serum aldoseterone, renin, and ratio.
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CASE 6 Management
Spironolactone – (will help electrolytes and BP)
Potassium supplements may be needed in some
Surgery
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QUICK FIRE QUIZ
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The foetal structure that gives rise to the anterior pituitary is called:
Rathke's Pouch
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Which of the following is NOT secreted by the anterior pituitary?
(a) Growth hormone (GH). (b) Adenocorticotrophic hormone
(ACTH). (c) Follicle Stimulating Hormone (FSH). (d) Oxytocin.
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Which of the following is NOT secreted by the anterior pituitary?
(a) Growth hormone (GH). (b) Adenocorticotrophic hormone
(ACTH). (c) Follicle Stimulating Hormone (FSH). (d) Oxytocin.
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The cells of the adrenal cortex, from outermost to innermost, are:
(a) Zona fasciculata, zona glomerulosa, zona reticularis.
(b) Zona glomerulosa, zona fasciculata, zona reticularis.
(c) Zona reticularis, zona fasciculata, zona glomerulosa.
(d) Zona fasciculata, zona reticularis, zona glomerulosa.
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The cells of the adrenal cortex, from outermost to innermost, are:
(a) Zona fasciculata, zona glomerulosa, zona reticularis.
(b) Zona glomerulosa, zona fasciculata, zona reticularis.
(c) Zona reticularis, zona fasciculata, zona glomerulosa.
(d) Zona fasciculata, zona reticularis, zona glomerulosa.
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Which embryological arches do the parathyroids come from?
Superior: from IVth branchial arch Inferior: from IIIrd branchial arch
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What is the difference between Cushing’s Syndrome and Cushing’s Disease?
Cushing’s syndrome = too much cortisol, either exogenous or from adrenals
Cushing’s disease = pituitary adenoma is the cause – inc ACTH.
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How do you tell the difference clinically (investigations)?Low dose dexamethasone test24 hour urinary free cortisol Plasma ACTHHigh dose dexamethasone suppression test
and urinary cortisolACTH Cortisol Site
Low Not suppressed
Primary (adrenal) Cushing’s
N/High Not suppressed
Ectopic ACTH
High Suppressed by high doses
Cushing’s disease (pituitary)
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THANK YOU