ENDOCRINE OVERVIEW

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ENDOCRINE OVERVIEW

• Robert Schmidli
• MB ChB, MRCP, FRACP, PhD
• Consultant endocrinologist

http//www.schmidli.com.au
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Case 1

• A 67 year old man complains of tiredness, cold
  intolerance and a hoarse voice
• Examination
• Cold coarse dry skin
• Slow relaxing reflexes
• Hoarse voice

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Questions

• What is the differential diagnosis
• What tests are required
• What are expected results
• What are the complications
• What treatment is required
• What precautions are needed with treatment
• What is the prognosis

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• Hypothyroidism
• Primary (Hashimoto)
• Secondary (hypopituitarism)
• Tests
• TSH, FT4
• Thyroid antibodies
• Results
• High TSH (low if secondary/pituitary)
• Low FT4 (normal if compensated)
• Positive thyroid antibodies
• Complications
• Angina, arrhythmias rapid correction
• Hypercholesterolaemia
• Confusion

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Treatment

• Thyroxine
• Long half-life
• Infrequent monitoring when stable
• Prognosis
• No complications
• Normal lifespan

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Case 2

• A 32 year-old lady complains of weight gain and
  hirsuitism
• Examination
• Moon facies
• Bruising
• Myopathy
• Buffalo hump

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• What is the likely diagnosis?
• Why the hirsuitism?
• What other clinical signs can occur?
• What investigations are required?
• Treatment?
• Prognosis?

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Cushings syndrome

• Central obesity
• Facial plethora
• Glucose intolerance
• Myopathy
• Hypertension
• Psychological
• Bruising

• Hirsuitism
• Oligo/amenorrhoea
• Impotence
• Acne
• Striae
• Ankle oedema
• Fracture

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Investigations

• Cortisol release
• 24-hour urinary free cortisol
• Overnight dexamethasone suppression test
• Midnight cortisol
• ACTH assay (adrenal vs pituitary/ectopic)
• MRI pituitary/CT adrenals
• Venous sampling
• Complications
• Glucose
• Bone density

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Dexamethasone suppression test
Normal
Cushings disease
Pituitary
Pituitary
Dexamethasone (synthetic steroid)
Dexamethasone (synthetic steroid)
ACTH
ACTH
Adrenal gland
Adrenal gland
Cortisol
Cortisol
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Diurnal cortisol release
Morning peak at 9am
Midnight trough
0600
0600
2400
1800
1200
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Case 3

• A 26-year old man is admitted to the Intensive
  Care Unit
• 3 days vomiting hourly
• Drowsy
• BP 60/30
• Deeply pigmented
• Na 125 mmol/l (N 135-145)
• K 5.4 mmol/l (N 3.5-5.0)

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Questions

• Diagnosis
• Pathogenesis
• What hormone is deficient?
• Diagnostic test
• Treatment
• Complications

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Addisons disease

• Pathogenesis
• Destruction of adrenal glands
• Autoimmune
• Tuberculosis
• Tumour/infiltration
• Infective (meningococcus)
• Hormone deficiency
• Cortisol
• Aldosterone

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• Diagnostic test
• Synacthen test
• Treatment
• Cortisol replacement
• Hydrocortisone/Cortisone
• Aldosterone replacement
• Fludrocortisone
• Complications
• Adrenal crisis intercurrent illness

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Synacthen test

• Baseline cortisol may be normal in Addisons
  disease
• Synacthen test uses synthetic ACTH analogue
• Normal response rise in cortisol

Pituitary
Synacthen (synACTHen)
Adrenal gland
Cortisol
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Case 4

• An 18 year old male presents with headaches,
  visual field disturbances, polyuria (9
  litres/day) and polydipsia
• An MRI head scan shows a large (3cm) suprasellar
  mass compressing the optic chiasm

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• What is the likely diagnosis?
• What sort of pituitary lesions cause this
  syndrome?
• What is the diagnostic test?
• What is the treatment?

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• Diabetes insipidus vasopressin deficiency
• Suprasellar lesions
• Diagnostic test
• Water deprivation test
• Unable to produce concentrated urine after water
  deprivation
• Treatment
• Replacement of vasopressin (nasal/oral/parenteral)

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Case 5

• An 45 year old man complains of sinus problems
• He appears to have acromegaly
• Signs
• Thickened soft tissues
• Enlarge jaw
• Coarse facial features
• Swelling of hands
• MRI pituitary shows 1.5cm pituitary tumour

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• What are other clinical features?
• What are the diagnostic tests?
• What are the treatments?

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Clinical features

• Enlarged jaw, hands feet (shoe/ring size)
• Spreading of teeth
• Coarse facies
• Hypertrophic joint disease
• Hypertension
• LVH

• Gigantism (pre-puberty)
• Pituitary deficit
• Visceral enlargement

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• Investigations
• Growth hormone
• IGF-1
• GH during glucose tolerance test
• Pituitary imaging
• Other pituitary function tests
• Treatment
• Removal of tumour
• Somatostatin analogues
• Radiotherapy

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Growth hormone release
Acromegaly
Normal
0600
0600
2400
1800
1200
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Case 6

• A 27 year-old lady complains of amenorrhoea for 6
  months
• Recently she has noticed a milky breast discharge
  from both breasts
• Clinical examination reveals bilateral breast
  discharge, otherwise normal
• MRI head shows a 1.2cm pituitary adenoma

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• What is the likely diagnosis?
• What investigations would you order?
• What is the treatment?
• What are the complications?
• How does the tumour respond to treatment?

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Hyperprolactinaemia

• Investigations
• Serum prolactin
• MRI pituitary
• Dopamine agonists
• Bromocriptine
• Cabergoline
• Quinagolide

• Complications
• Infertility
• Osteoporosis
• Response to treatment
• Shrinkage of tumour

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Case 7

• An 18 year old girl presents because she has
  never had a period
• Examination
• Underdeveloped breasts (Tanner stage 2)
• Pubic hair Tanner stage 1
• Normal otherwise

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• What is the differential diagnosis?
• What investigations are required?
• How can you distinguish the main types?
• What are the complications?
• What treatment is required?

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Hypogonadism

• Primary gonadal failure
• Premature menopause
• Turner syndrome (XO complete/partial)
• Autoimmune
• Secondary gonadotrophin deficiency
• Pituitary lesion
• Hyperprolactinaemia

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• Primary High LH, FSH
• Secondary Low LH, FSH
• Complications
• Infertility
• Osteoporosis
• Treatment
• Oestrogen/progesterone replacement
• Oral contraceptive
• HRT