Download Pituitary Disease

ENDOCRINE
Group 10
Pituitary Disease
Panhypopituitarism
 Which
hormones are lost first?
The least life threatening lost first: FSH, LH
 Which
pituitary disorder affects the
pituitary gland itself?
Secondary disorders
 A patient
comes to you complaining of loss
of axillary, pubic and body hair. He also
complains of losing his sense of smell.
What is the most likely diagnosis?
Kallman’s syndrome
 True

or false:
In adrenal deficiency there will be
hyperpigmentation.
• FALSE
 Most
common tumor causing
hypopituitarism in children
Craniopharyngioma
 Common
signs and symptoms of a basilar
skull fracture:
Bilateral ecchymosis
“Battle sign”-ecchymosis of mastoid
Clear otorrhea or rhinorrhea
 Patient
comes in one week after delivering
her baby complaining of no lactation and
loss of pubic and axillary hair. What is the
diagnosis?
Sheehan’s syndrome
 What
is the treatment of choice for a
pituitary adenoma?
Transphenoidal microsurgery
Hyperprolactinemia
 What
is prolactin inhibitory factor (PIF)?
Dopamine
 Treatment
of choice?
Medical preferred over surgical
• Bromocriptine
 Patient
comes to your office complaining
that recently he has had trouble fitting in
his gloves, hat and shoes. Upon physical
exam you notice protrusion of the jaw and
enlargening of the tongue. What is your
diagnosis?
Acromegaly
 True

or false:
Desmopressin is used for the treatment of
nephrogenic Diabetes insipidus
• FALSE- it it used for central diabetes insipidus
where the production of ADH is deficient
• In nephrogenic DI, ADH levels are normal, but
there is a defect in kidney tubules that interferes
with water reabsorption
 Secondary
causes of nephrogenic DI:
Hypercalcemia
Hypokalemia
 A euvolemic
hyponatremia is common in
which disease?
SIADHSyndrome of Inappropriate Antidiuretic
Hormone Secretion
 What
is a complication of correcting
SIADH too rapidly?
Contraction of brain cells resulting in
demyelination
ADRENAL
 What
hormone causes reabsorption of Na
at the level of the kidney?
Aldosterone
Two major causes for aldosterone release?
Hypovolemia or hypokalemia
 What
hormone counters insulin’s effects, is
increased with stress/trauma, with a
diurnal pattern?
Cortisol
How does it counter insulin’s effects in the
body?
Hyperglycemia, increases hepatic
gluconeogenesis.
What hormone is responsible for the
development of secondary sex
characteristic?
Androgens
These hormones are also neurotransmitters in
the CNS?
Catecholamines:
Epinephrine, Norepinephrine
MCC of hyperaldosteronism?
 Conn’s syndrome.
Etiology?
 Unilateral adrenal aldosterone producing
adenoma
Aldosterone to renin ratio in primary
hyperaldosteronism?
Increases plasma aldosterone to renin ratio
How do you perform a aldosterone suppression
test?
Give Na and aldosterone is not suppressed.
Central obesity with striae and thin
extremities, HTN, DM, glucose
intolerance, proximal muscle weakness?
Hypercortisolism
Two additional common signs?
Moon face, buffalo hump.
 Prolonged
use of exogenous steroids or
ACTH causes?
Cushing’s Syndrome
What causes Cushing’s Disease?
Increased pituitary secretion of ACTH
Common etiology?
Pituitary adenoma
First diagnostic test for Cushing’s?
24 hr urine cortisol
Second Test?
Low dose dexamethasone for suppression
Third diagnostic test? ACTH
If decreased, then? It’s adrenal.
Fourth diagnostic test?
High dose dexamethasone.
If it doesn’t suppress ACTH then what?
Tumor is ectopic.
Weight loss, salt cravings, hyperpigmentation,
abdominal pain?
Addison’s
MCC Addison’s in US?
Autoimmune
Worldwide?
TB
What are the two stimulation diagnostic tests
for Addison’s?
Cosyntropin and Metyrapone
Increased K, decreased Na, decreased
cortisol, decreased aldosterone,
decreased androgen, ACTH increased?
Primary or secondary Addison’s?
Primary
Paroxysmal HTN, sweating, headache,
palpitations, hyperglycemia, flushing, orthostatic
hypotension?
Pheochromocytoma
Diagnostic TOC?
Metanephrine and vanillylmandelic acid
TOC
pre-op a-blockers and b-blockers, w/venous
ligation and removal of gland
Parahyperthyroidism, pancreatic islet cell
tumor, pituitary tumor
MEN I- Wermer’s presentation
Parahyperthyroidism, adrenal tumor, thyroid
(medullary carcinoma)
MEN IIA- Sipple syndrome
Mucosal/GI, Marfanoid, adrenal
(pheochromocytoma), thyroid (medullary
carcinoma)
MEN IIB- Mucosal and GI
Increased blood Ca, increased PTH?
Hyperparathyroidism
Manifestation?
Stones, bones, groans, psychic
overtones, and short Q-T
What substance do you take into account
when measuring the Ca level?
Albumin
Decreased Ca, prolonged Q-T,
paresthesias, muscles cramps, hyperactive
DTRs?
Hypoparathyroidism
What special signs can you test for in PE?
Chvostek’s and Trousseau’s
Chovostek’s sign- is a carpal spasm with
use of BP cuff. True/False?
False
 Decreased
Ca, increase PTH, short
stature, round face, short 4th metacarpal,
and mental retardation?
Pseudo- hypoparathyroidism
THYROID DISEASES
 Where

The Hypothalmus
 Where

is TSH released from?
Anterior Pituitary
 Where

is TRH released from?
is T3 & T4 released from?
Thyroid
 What
is the major hormone secreted into
circulation and converted in the cell?

T4
 Why

is thyroid hormone critical in children?
Brain and musculoskeletal development.
 What


happen without it?
Growth impairment and mental retardation
What form of hypothyroidism is this?

Congenital
 Tx:

prompt T4
 What
substance is required to produce
thyroid hormone?

Iodide
 Where

do we get it?
Salt
 Iodine
deficiency is the MCC of primary
hypothyroidism in the US? True or False


False
It is, however, the MCC worldwide
 Patient
presents with fatigue, SOB, hair
loss and cold intolerance? DX?

Hypothyroidism
 Other

Slow movement/speech, weight gain
 PE

will reveal…
Delayed DTRs, non-pitting edema, cool pale
skin, loss of lateral 1/3 of eyebrow
 Labs

reveal:
Low TSH
 MCC

symptoms include?
of primary hypothyroidism
Hashimotos’s
 Etiology?

Autoimmune
 What
is the most severe form of
Hypothyroidism?

Myexedema Coma.
 Presentation?

Hypothermia, respiratory depression,
cardio collapse
 Patient
presents with anxiousness,
thinning hair, muscle weakness and heat
intolerance. DX?

Hyperthyroidism
 Additional

Increased appetite and weight loss
 PE

reveals?
Warm and moist skin, tachycardia,
hyperreflexia, and exophthalmus
 Initial


lab indicator?
Low TSH; Why?
negative feedback
 Second

symptoms include?
lab:
T4 high
 What
will be seen on radioactive iodine
uptake?

Increased uptake.
 TOC

radioiodine ablation
 MCC

for hyperthyroidism?
of hyperthyroidism?
Grave’s disease
 Patient
presents with exaggerated
hyperthyroidism plus delirium, CHF, stupor
and fever. Dx?

Thyroid storm
 Tx:



beta- blockers
anti-thyroid agents
Dexamethasone
 Supportive

Tx:
IV fluids and cooling blankets
 Can
you name a rare cause
hyperthyroidism….
 Hint: it has nothing to do with the thyroid
gland?

Ovarian dermoid tumor containing thyroid tissue.
 What
is the most common cause of
diabetic hospital admissions?

Problems with the feet- peripheral neuropathy
 Stocking
and glove distribution refers to
what?

Loss of perception of vibrations, temperature,
touch, position sense, and altered pain
perception
 Where
are the most common area for an
ulcer in diabetic patients?

Dorsal portion of toes, plantar of metatarsal
heads and heel
 Your
patient has just been diagnosed with
diabetes- educate the patient on changes
that may need to be made.





Shoes
Checking feet regularly for ulcers
Moisturizers
Glucose control
Yearly podiatry assessments
Gonadal Dysfunction
 Total
Chromosomal number and sex
chromosome in females
• 46 and XX
 Total
Chromosomal number and sex
chromosome in males?
• 46 and XY
 A tall





person comes to your office with…
decrease facial and axillary hair
Gynecomastia
High voice
Decrease libido
Small/firm testes
 What
would you predict the person’s
chromosome are?
46 and XXX
 What
would you notice in the physical of a
person with turner’s syndrome?




Webbing of the neck
Short stature
Short 4th metacarpal
Mutiple congenital abnormalites to heart and
kidney.
 What



you would be the treatment?
Estrogen replacement
High dose of recombinant growth hormone
Cardiac and renal evaluation
 What
is the karotype of the following?
 Female pseudohermaphroditism
• 46XX karyotype
 Male
pseudohermaphroditism
• 46XY karyotype
 True
hermaphoditism
• Have both 46XX and 46XY
 Upon
phsical examination you notice
clitoral enlargement and excessive
production of androgens. Your likely dx?
• Female pseudohermaphroditism
 Is
the patient able bear child?
• Yes
What is the likely Dx?
 Upon
•
•
•
•
 Test
physical you note…
Blind vagina
Sparse axillary and pubic hair
Testes are present in abdomen
Breast development
show..
• Testosterone level
• Xy karotyping
• LH high and FSH normal
 Testicular
 What
feminization syndrome
would be your therapy?
• Estrogen
Diabetes Mellitus Type 1
Hyperglycemia is caused from?
 Low
insulin secretion or
 Insulin resistance and low secretion
Most common etiology is?
 Autoimmune
from beta islet cell
destruction
 MC in Scandinavia and northern Europe
 Dependent on insulin for life (unlike
idiopathic form of DM)
What genetic markers predispose
you to DM 1?
 Human
Leukocyte Antigen- 95% have HLA
DR3 or HLA DR4
 Circulating Islet Cell Antibodies- 85% of
patients test in 1st week of onset
What are some common clinical
presentations?
 *Polyphagia,
polydypsia, polyuria
 *Weight loss/inability to gain weight
 Blurry vision
 Diabetic Neuropathy
 *Ketoacidosis
 Abdominal Pain
What are some manifestations of
ketoacidosis?
Deficiency  Lipolysis  Free
Fatty Acids  Ketonemia
 Metabolic Acidosis
 Fruity Breath Odor (acetone)
 Dehydration (hypotension, tachycardia)
 Kussmaul’s Respiration (rapid deep
breathing)- corrects acid base disorder
 Insulin
How do you treat DKA?
 0.9%
NS for 1 hr
 Then 0.45% NS with dextrose (prevent
hypoglycemia) for 3 hrs
 Insulin Replacement
 K+ replacement (as needed)- from fluid
loss and intracellular shift of K+ into cells
due to insulin replacement
 Tx Underlying Cause
What is the best screening test for
DM?
 Fasting
Plasma Glucose
 How long do you fast for?
 Fast for 8 hours prior to the test
What is the reference range of the
fasting plasma glucose?
 FPG
<100mg/dl = reference range
 What is the impaired fasting range?
 FPG ≥ 100 mg/dl = impaired fasting
glucose
 What is the range that is diagnostic for
DM?
 FPG ≥ 126 mg/dl = diagnostic of DM (must
be done 2x)
What is the best test to diagnose
DM?

Oral Glucose
Tolerance Test
 Can you fill in this
chart?
Value after 1 hr of
Fasting
(fasting plasma
glucose)
Reference
Range

Impaired
Glucose
Tolerance
Dx DM
Value after 2 hrs
of glucose
(Glucose Load)
Answers
Value after 1 hr of Fasting
(fasting plasma glucose)
Value after 2 hrs of glucose
(Glucose Load)
Reference Range
< 110 mg/dl
< 140 mg/dl
Impaired Glucose
Tolerance
110-125 mg/dl
≥ 140 and <200 mg/dl
Dx DM
≥ 126 mg/dl
≥ 200 mg/dl
What is measured as a screening
tool for DM to log glycemic control?
 Hemoglobin A1C
(not diagnostic)
 What percent saturation should a diabetic
patient strive for with Hgb A1C?
 Should be saturated < 6.5%
What are some lab findings of DM
1?
 Microalbuminuria
 Ketonuria
 Glucose
in Urine
 Anti-insulin Antibodies
 Hypoinsulinemia
Insulin










What are 2 names of a “rapid form” of insulin?
Rapid- Lispro and Aspart
What is a name of a “short acting” insulin?
Short- Regular
What is a name of an “intermediate acting” insulin?
Intermediate- NPH and Lente
What is a name of a “long acting” insulin?
Long- Ultralente
What is the most commonly used combination amounts
of NPH and Regular?
MC Combination- 70 NPH/30 Regular
What is the pathophysiology of the
Somogyi Effect?
1 patient takes insulin at night 
Patient becomes hypoglycemic 
Counter-Regulatory hormones cortisol and
glucagon are released
 Glucagon  releases glucose from liver
 Cortisol  increases insulin resistance
 Patient awakens with hyperglycemia
 What is the treatment?
 Treatment- Reduce night insulin dose
 DM
What is the Dawn Phenomenon?






Increase in plasma glucose levels between 5
and 9 a.m., without preceding hypoglycemia
Which type of DM does this affect?
DM Type 1 and 2
Why is there hyperglycemia?
Attributed to desensitization effects of growth
hormone and insulin on tissues
May cause mild hyperglycemia or may add to
the Somgyi Effect
What are some Microvascular
Complications of DM 1?
 Retinopathy
 Nephropathy
 Neuropathy
What are some Macrovascular
Complications of DM 1?
 Cardiovascular
Disease
 Cerebrovascular Disease
 Peripheral Vascular Disease
Type II Diabetes
What are some of the clinical features that
are associated with DM 2?
 polydipsia
 polyuria
 Blurry
vision
 Age: greater than 30
 Race: African American, Native
American, Hispanics, Asians
 Associated with HTN, Dyslipidemia
A pregnant 28 y.o presents to your
office with elevated glucose levels
What is the DX?
-Gestational Diabetes
What are some of the
Complications associated
with this disease?
-Birth defects,
-Fatal macrosomnia
-Birth trauma
-Resp. distress
What are some dermatological
findings associated with DM 2?





Acanthosis nicgricans
Xanthomas
Ulcerations
Gangrene
Necrobiosis Lipoidica
What would you expect to see on a
urine dip stick?
 Glycosuria
 Proteinuria
 Very
little ketoneuria
What are some complications that
are associated with DM 2?
 Peripheral
neuropathy
 Atherosclerosis
 Retinopathy
 PVD
 Nephropathy
A patient presents with the
following symptoms:
 Chronic
watery diarrhea
 Weight loss
 Colickly abdominal pain
 *FLUSHING and Dehydration*
What is the Dx? Vipoma