endocrine case studies
DESCRIPTION
ENDOCRINE CASE STUDIES. Dr SUNIL ZACHARIAH Consultant Endocrinologist Spire Gatwick Park and ESH. CASE-1. 23 year old lady 3 months post delivery Presents with palpitations and loose stools FT4=32.6 pmol/L TSHTRANSCRIPT
ENDOCRINE CASE ENDOCRINE CASE STUDIESSTUDIES
Dr SUNIL ZACHARIAHDr SUNIL ZACHARIAH Consultant EndocrinologistConsultant Endocrinologist
Spire Gatwick Park and ESHSpire Gatwick Park and ESH
CASE-1CASE-1 23 year old lady23 year old lady 3 months post delivery3 months post delivery Presents with palpitations and loose Presents with palpitations and loose
stoolsstools FT4=32.6 pmol/LFT4=32.6 pmol/L TSH<0.01 mU/LTSH<0.01 mU/L
POSTPARTUM THYROIDITISPOSTPARTUM THYROIDITIS
Incidence varies from 5-11%Incidence varies from 5-11% More common in women with a More common in women with a
family history of hypothyroidism and family history of hypothyroidism and positive TPO antibodiespositive TPO antibodies
CLINICAL FEATURESCLINICAL FEATURES
Presentation is usually 3-4 months Presentation is usually 3-4 months postpartumpostpartum
Can be hypothyroidism (40%), Can be hypothyroidism (40%), hyperthyroidism (40%) or hyperthyroidism (40%) or biphasic(20%)biphasic(20%)
Goiter is present in 50% of patientsGoiter is present in 50% of patients To distinguish from Graves disease use To distinguish from Graves disease use
thyroid isotope scan and TSH receptor thyroid isotope scan and TSH receptor AbAb
PathogenesisPathogenesis
Destructive autoimmune thyroiditis Destructive autoimmune thyroiditis causing first release of thyroxine and causing first release of thyroxine and then hypothyroidism as the thyroid then hypothyroidism as the thyroid reserve is depletedreserve is depleted
FNAC shows lymphocytic thyroiditisFNAC shows lymphocytic thyroiditis
ManagementManagement Most patients recover spontaneously Most patients recover spontaneously
without requiring treatmentwithout requiring treatment If hyperthyroid use beta blockers rather If hyperthyroid use beta blockers rather
than antithyroid drugs as the problem is than antithyroid drugs as the problem is increased release, not synthesisincreased release, not synthesis
Hypothyroid phase is more likely to require Hypothyroid phase is more likely to require treatmenttreatment
Only 3-4% remain permanently hypothyroidOnly 3-4% remain permanently hypothyroid 10-25% will recur in future pregnancies10-25% will recur in future pregnancies
Case Study-2Case Study-2 60 year old Type 2 Diabetes60 year old Type 2 Diabetes Last HbA1c=8%(64 mmol/mol)Last HbA1c=8%(64 mmol/mol) Presents with erectile dysfunctionPresents with erectile dysfunction Not much benefit from ViagraNot much benefit from Viagra Testosterone level 8 nmol/LTestosterone level 8 nmol/L
Hypogonadism in Type 2 Hypogonadism in Type 2 DiabetesDiabetes
Low testosterone levels are common in Low testosterone levels are common in people with type 2 diabetespeople with type 2 diabetes
Effect of testosterone replacement on Effect of testosterone replacement on glycaemic control remains uncertainglycaemic control remains uncertain
If androgen deficiency is suspected If androgen deficiency is suspected then do at least two 9 am testosterone then do at least two 9 am testosterone levels. If first sample is low , then levels. If first sample is low , then check LH, FSH, SHBG, ferritin and check LH, FSH, SHBG, ferritin and prolactin as well in the 2prolactin as well in the 2ndnd sample sample
If testosterone level is between 8 and If testosterone level is between 8 and 12 nmol/L in a symptomatic 12 nmol/L in a symptomatic individual, then a trial of testosterone individual, then a trial of testosterone replacement is warrantedreplacement is warranted
If the man has tried a If the man has tried a phosphodiesterase inhibitor without phosphodiesterase inhibitor without success and has a total testosterone success and has a total testosterone of <12 nmol/L, then a 6 month trial of of <12 nmol/L, then a 6 month trial of testosterone is warrantedtestosterone is warranted
Case Study 3Case Study 3 27 year old female27 year old female Follicular Cancer of ThyroidFollicular Cancer of Thyroid Post surgery, post radioiodine Post surgery, post radioiodine
ablationablation On Thyroxine replacement (175 On Thyroxine replacement (175
mcg)mcg) FT4 19.8FT4 19.8 TSH 0.05TSH 0.05
Follow up of thyroid Follow up of thyroid CancerCancer
Original diagnosis and treatmentOriginal diagnosis and treatment If total thyroidectomy and ablative If total thyroidectomy and ablative
radioiodine, thyroglobulins usually radioiodine, thyroglobulins usually undetectable if TSH unrecordableundetectable if TSH unrecordable
Maintain TSH<0.05Maintain TSH<0.05
Case 4Case 4 50 year old man50 year old man Ventricular tachycardia with poor LV Ventricular tachycardia with poor LV
function function Controlled on AmiodaroneControlled on Amiodarone FT4 50FT4 50 FT3 7FT3 7 TSH<0.01TSH<0.01
Amiodarone and ThyroidAmiodarone and Thyroid Inhibits thyroidal iodide uptakeInhibits thyroidal iodide uptake Inhibits conversion of T4 to T3 Inhibits conversion of T4 to T3
intracellularlyintracellularly Inhibits T4 entry into cellsInhibits T4 entry into cells Direct T3 antagonism at level of Direct T3 antagonism at level of
cardiac tissuecardiac tissue
Amiodarone induced Amiodarone induced hyperthyroidismhyperthyroidism
2-12%2-12% Type 1: Iodine overload in abnormal Type 1: Iodine overload in abnormal
gland, treat with carbimazole or lithiumgland, treat with carbimazole or lithium Type 2: Glandular damage, release of Type 2: Glandular damage, release of
preformed hormones, treat with preformed hormones, treat with prednisolone 0.5-1.25 mg/kg for 3-6 prednisolone 0.5-1.25 mg/kg for 3-6 weeksweeks
Management of tachyarrhythmia's: beta Management of tachyarrhythmia's: beta blockers if not in CCFblockers if not in CCF
?total thyroidectomy (not radioiodine)?total thyroidectomy (not radioiodine)
CASE 5CASE 5 32 year old female32 year old female BMI=25BMI=25 Detected to have blood pressure of Detected to have blood pressure of
210/100 mm Hg210/100 mm Hg History of palpitations, abdominal History of palpitations, abdominal
discomfortdiscomfort Investigated for secondary causes of Investigated for secondary causes of
hypertensionhypertension
24hr Urinary collections24hr Urinary collections
6/3/986/3/98 8/3/988/3/98 11/3/9811/3/98
VMA VMA (5-35)(5-35)
154154 225225 192192
NormetanephrineNormetanephrine(0.1 – 1.3)(0.1 – 1.3)
34.834.8 59.559.5 54.954.9MetanephrineMetanephrine(0.1 – 1.3)(0.1 – 1.3)
0.40.4 0.60.6 0.70.7
3-3-methoxytyraninemethoxytyranine(0.1 – 2.0)(0.1 – 2.0)
4.84.8 5.65.6 6,56,5
L.L. L.L. CTCT Scan 1998 Scan 1998
L.L.
MIG
B S
can
1998
L.L.
MIG
B S
can
1998
Management of Management of PhaeochromocytomaPhaeochromocytoma
Commenced on alpha and beta blockadeCommenced on alpha and beta blockade
Referred for surgeryReferred for surgery
DEFINITIONDEFINITION Phaeochromocytomas are Phaeochromocytomas are
adrenomedullary catecholamine adrenomedullary catecholamine secreting tumourssecreting tumours
Paragangliomas are tumours arising Paragangliomas are tumours arising from extra-adrenal medullary neural from extra-adrenal medullary neural crest derivatives, e.g. sympathetic or crest derivatives, e.g. sympathetic or carotid body, aorticopulmonary, carotid body, aorticopulmonary, intravagal or parasympatheticintravagal or parasympathetic
INCIDENCEINCIDENCE Rare tumoursRare tumours Accounting for <0.1% of causes of Accounting for <0.1% of causes of
hypertensionhypertension Can be fatal if undiagnosedCan be fatal if undiagnosed
EPIDEMIOLOGYEPIDEMIOLOGY Equal sex distributionEqual sex distribution Most commonly in 3Most commonly in 3rdrd and 4 and 4thth
decadesdecades Majority(90%) are sporadic, 10% are Majority(90%) are sporadic, 10% are
inheritedinherited
PATHOPHYSIOLOGYPATHOPHYSIOLOGY Sporadic tumours are usually Sporadic tumours are usually
unilateral and <10 cm diameterunilateral and <10 cm diameter 10-20% are malignant10-20% are malignant Paragangliomas are more likely to Paragangliomas are more likely to
be malignantbe malignant
CLINICAL FEATURESCLINICAL FEATURES Sustained or episodic hypertensionSustained or episodic hypertension Sweating and heat intolerance(80%)Sweating and heat intolerance(80%) Headache(65%)Headache(65%) Palpitations(65%)Palpitations(65%) Abdominal painAbdominal pain ConstipationConstipation
COMPLICATIONSCOMPLICATIONS CVS: LVF, dilated cardiomyopathyCVS: LVF, dilated cardiomyopathy Resp: Pulmonary oedemaResp: Pulmonary oedema Neuro: Cerebrovascular, Neuro: Cerebrovascular,
hypertensive encephalopathyhypertensive encephalopathy
Who should be screened?Who should be screened? Family history of MEN, VHL, Family history of MEN, VHL,
NeurofibromatosisNeurofibromatosis Paroxysmal symptomsParoxysmal symptoms Young hypertensiveYoung hypertensive Patient developing HT crisis during Patient developing HT crisis during
GAGA Unexplained heart failureUnexplained heart failure
INVESTIGATIONSINVESTIGATIONS 24 hour urine collection for 24 hour urine collection for
catecholamines. Because of episodic catecholamines. Because of episodic nature at least two 24 hour samplesnature at least two 24 hour samples
Plasma catecholamines: Limited use Plasma catecholamines: Limited use because of intermittent secretion. because of intermittent secretion. Useful if patient having a crisisUseful if patient having a crisis
Screening for associated conditionsScreening for associated conditions
LOCALIZATIONLOCALIZATION MRI or CT scanMRI or CT scan MIBG scan: Meta-MIBG scan: Meta-
iodobenzylguanidine is a chromaffin-iodobenzylguanidine is a chromaffin-seeking analogue. Positive in 60-seeking analogue. Positive in 60-80%.80%.
MANAGEMENTMANAGEMENT Alfa-blockade (Phenoxybenzamine) Alfa-blockade (Phenoxybenzamine)
must be commenced before beta-must be commenced before beta-blockade to avoid precipitating a blockade to avoid precipitating a hypertensive crisis due to unopposed hypertensive crisis due to unopposed alfa-adrenergic stimulationalfa-adrenergic stimulation
Surgical resection (open or Surgical resection (open or laparoscopic)laparoscopic)
Malignancy: High dose MIBG therapy, Malignancy: High dose MIBG therapy, Chemotherapy, Octreotide therapyChemotherapy, Octreotide therapy
Case Study 6Case Study 6 49 year old 49 year old HGV DriverHGV Driver Diagnosed type 2 diabetes 8 years agoDiagnosed type 2 diabetes 8 years ago Diet controlled for 1 yearDiet controlled for 1 year Check’s Blood Glucose once a day (8-Check’s Blood Glucose once a day (8-
13)13) On tablets since thenOn tablets since then Yearly retinal screeningYearly retinal screening
MEDICATIONSMEDICATIONS Metformin 1 gm bdMetformin 1 gm bd Pioglitazone 45 mg odPioglitazone 45 mg od Gliclazide 80 mg bdGliclazide 80 mg bd Lipitor 40 mg odLipitor 40 mg od Perindopril 4 mg odPerindopril 4 mg od Aspirin 75 mg odAspirin 75 mg od
Hba1c=9.2%Hba1c=9.2% Creatinine=90, GFR=76Creatinine=90, GFR=76 ?Next Step?Next Step
The incretin effect is reduced The incretin effect is reduced in patients with type 2 in patients with type 2
diabetesdiabetes
0
20
40
60
80
Insu
lin (m
U/L
)
0 30 60 90 120 150 180Time (min)
** * ** * *
0
20
40
60
80
0 30 60 90 120 150 180Time (min)
**
*
*P ≤.05 compared with respective value after oral load. Nauck MA, et al. Diabetologia 1986;29:46–52.
Patients with type 2 diabetesControl subjects
Intravenous GlucoseOral Glucose
Insu
lin (m
U/L
)
Incretins and glycaemic Incretins and glycaemic controlcontrol
Adapted from 7. Drucker DJ. Cell Metab. 2006;3:153–165. 8. Miller S, St Onge EL. Ann Pharmacother 2006;40:1336-1343.
Active GLP-1 and
GIP
Release of incretin gut hormones
Pancreas
Bloodglucose control
GI tract
Glucagon from alpha cells
(GLP-1)Glucose
dependent
Alpha cells
Increased insulin and decreasedglucagon reduce hepatic glucose output
Glucose dependent Insulin
from beta cells(GLP-1 and GIP)
Beta cells
Insulinincreases peripheral glucose uptake
Ingestion of food
DPP-4enzyme rapidly
degrades
incretins
CASE STUDY-7CASE STUDY-7
88 year old lady88 year old lady Diarrhoea Diarrhoea Abdominal painAbdominal pain Weight lossWeight loss
PAST MEDICAL HISTORYPAST MEDICAL HISTORY
Extensive Investigations for Chronic Extensive Investigations for Chronic Diarrhoea(5 years)Diarrhoea(5 years)
Diverticular diseaseDiverticular disease HypothyroidismHypothyroidism HypertensionHypertension Ischemic Heart DiseaseIschemic Heart Disease HysterectomyHysterectomy
EXAMINATIONEXAMINATION
Mildly dehydratedMildly dehydrated Hypotensive (94/60 mm Hg)Hypotensive (94/60 mm Hg) Abdomen: Tenderness in Abdomen: Tenderness in
Epigastrium and RUQEpigastrium and RUQ CVS: Soft Systolic murmurCVS: Soft Systolic murmur
INVESTIGATIONSINVESTIGATIONS
Hb: 12.9 Bilirubin: 5Hb: 12.9 Bilirubin: 5 WBC: 14.5 ALT: 61WBC: 14.5 ALT: 61 MCV: 90 Alk PO4: 417MCV: 90 Alk PO4: 417 Platelets: 461 Albumin: 42Platelets: 461 Albumin: 42 Sodium: 134 GammaGT: 533Sodium: 134 GammaGT: 533 Potassium: 3.6 TSH: 3.3Potassium: 3.6 TSH: 3.3 Urea: 12.6 Ft4: 12Urea: 12.6 Ft4: 12 Creatinine: 90 T3: 3.2Creatinine: 90 T3: 3.2 CRP: 138 Calcium: 2.4CRP: 138 Calcium: 2.4
Urine analysis: NADUrine analysis: NAD Stool Culture, toxins and microscopy: Stool Culture, toxins and microscopy:
NegativeNegative
IMAGINGIMAGING CXR: NormalCXR: Normal Ultrasound AbdomenUltrasound Abdomen: :
Hepatomegaly, with multiple Hepatomegaly, with multiple avascular, iso-echoic lesions in both avascular, iso-echoic lesions in both lobes of liver representing lobes of liver representing metastasis. Primary likely to be ?metastasis. Primary likely to be ?colorectal or ?pulmonarycolorectal or ?pulmonary
PATIENT PROGRESSPATIENT PROGRESS
Discussion with patient and familyDiscussion with patient and family Options discussedOptions discussed Patient not keen on further invasive Patient not keen on further invasive
teststests Agreed for CT scanAgreed for CT scan
CT ScanCT Scan No significant lymphadenopathyNo significant lymphadenopathy No significant lung lesionsNo significant lung lesions Liver is replaced by multiple Liver is replaced by multiple
metastasis in both lobesmetastasis in both lobes Normal pancreas and adrenalsNormal pancreas and adrenals No masses in the ovary or large No masses in the ovary or large
bowelbowel
TUMOUR MARKERSTUMOUR MARKERS
CEA: 4.9 (0-15)CEA: 4.9 (0-15) CA-125: 55 (0-35)CA-125: 55 (0-35) CA 19-9: 64 (0-27)CA 19-9: 64 (0-27)
PROGRESSPROGRESS Diarrhoea persistingDiarrhoea persisting General condition of patient, General condition of patient,
however goodhowever good History reviewed with patient: History reviewed with patient:
Feeling flushed for many monthsFeeling flushed for many months Could this be Carcinoid?Could this be Carcinoid?
24 hour 5 HIAA requested24 hour 5 HIAA requested Laboratory reluctantLaboratory reluctant Result: 672Result: 672 (Normal<31) (Normal<31) Diagnosis of Carcinoid syndrome Diagnosis of Carcinoid syndrome
mademade Referral to Oncology and Endocrine Referral to Oncology and Endocrine
team madeteam made
TREATMENTTREATMENT
Octreotide injections startedOctreotide injections started Discharged with District Nurse input Discharged with District Nurse input
and Oncology follow upand Oncology follow up
EPIDEMIOLOGYEPIDEMIOLOGY
Annual incidence: 1/100000 Annual incidence: 1/100000 populationpopulation
Mean age: 50-60 yearsMean age: 50-60 years Males=FemalesMales=Females Increased risk of developing other Increased risk of developing other
carcinoma’scarcinoma’s
PATHOLOGYPATHOLOGY
Arise from neuroendocrine cellsArise from neuroendocrine cells Characterized histologically by Characterized histologically by
reaction to silver stains and reaction to silver stains and neuroendocrine markers (enolase, neuroendocrine markers (enolase, chromoganin)chromoganin)
SITE OF OCCURENCESITE OF OCCURENCE
Small Intestine: 39%Small Intestine: 39% Appendix: 26%Appendix: 26% Rectum: 15%Rectum: 15% Lungs: 10%Lungs: 10% Rest of GIT: 10%Rest of GIT: 10% Liver: 2%Liver: 2%
CLINICAL PRESENTATIONCLINICAL PRESENTATION
Diarrhoea: 84%Diarrhoea: 84% Flushing: 75%Flushing: 75% Int Obstruction: 44%Int Obstruction: 44% Heart disease: 33%Heart disease: 33% Wheezing: 15%Wheezing: 15% Carcinoid crisisCarcinoid crisis Precipitating factorsPrecipitating factors
BIOCHEMICAL BIOCHEMICAL INVESTIGATIONSINVESTIGATIONS
Urinary 5-HIAA: Sensitivity (70%), Urinary 5-HIAA: Sensitivity (70%), specificity (100%)specificity (100%)
Most sensitive marker is plasma Most sensitive marker is plasma Chromogranin A (100%) but Chromogranin A (100%) but specificity is lowerspecificity is lower
TUMOUR LOCALIZATIONTUMOUR LOCALIZATION
Imaging with CT/MRIImaging with CT/MRI Upper and Lower endoscopeUpper and Lower endoscope Octreotide scan (85%): Positive scan Octreotide scan (85%): Positive scan
indicates good response to indicates good response to treatment with octreotide treatment with octreotide
TREATMENTTREATMENT
Depends on size, location, symptom Depends on size, location, symptom and growthand growth
Surgery: Removal or debulkingSurgery: Removal or debulking Somatostatin analoguesSomatostatin analogues Hepatic embolizationHepatic embolization Chemotherapy/RadiotherapyChemotherapy/Radiotherapy Alfa-InterferonAlfa-Interferon
PROGNOSISPROGNOSIS
If detected early, results in complete If detected early, results in complete and permanent cureand permanent cure
Median survival rate improved to 12 Median survival rate improved to 12 years. especially after introduction years. especially after introduction of somatostatin analoguesof somatostatin analogues
If Liver metastasis, 5 year survival is If Liver metastasis, 5 year survival is 20-40%20-40%
CASE 8CASE 8 15 year old boy 15 year old boy GP referral: Concerns expressed by GP referral: Concerns expressed by
mother regarding height velocitymother regarding height velocity Already 190 cms [Mother 163 cms Already 190 cms [Mother 163 cms
and Father 170 cms]and Father 170 cms] Feet: size 16 Feet: size 16
Had started growing at a rapid pace Had started growing at a rapid pace since the age of 12 (0.5 – 1 inch a since the age of 12 (0.5 – 1 inch a month)month)
Sweaty palmsSweaty palms Pain in knees and wristsPain in knees and wrists Pins needles in both handsPins needles in both hands
No headache or visual symptomsNo headache or visual symptoms Normal pubertal developmentNormal pubertal development 22ndnd tallest in his class!!!!!! tallest in his class!!!!!! Enjoys sports and other activities at Enjoys sports and other activities at
school, but is troubled by knee painschool, but is troubled by knee pain Developmental milestones were Developmental milestones were
normalnormal
Initial Ix done by GP revealed Initial Ix done by GP revealed - Prolactin - Prolactin 1656 mu/L (86-324)1656 mu/L (86-324) - Testosterone: 1.6 nmol (10-28)- Testosterone: 1.6 nmol (10-28) FSH, LH within normal range FSH, LH within normal range - Normal TFT- Normal TFT
IGF-1 IGF-1 151 nmol/L (30-90)151 nmol/L (30-90)
ExaminationExamination Height 190 cms, weight 86 kgHeight 190 cms, weight 86 kg Large hands and feetLarge hands and feet Prominent ridges on foreheadProminent ridges on forehead B/L gynaecomastiaB/L gynaecomastia Visual fields: NormalVisual fields: Normal
Oral GTTOral GTTTime Glucose GHTime Glucose GH 0 4.5 1090 4.5 109 20 - -20 - - 30 4.8 30 4.8 665665 60 7.0 36760 7.0 367 90 4.8 19690 4.8 196 120 5.5 121120 5.5 121
AcromegalyAcromegaly Uncommon condition, new case incidence Uncommon condition, new case incidence
3-4 per million, mean age of diagnosis 40-3-4 per million, mean age of diagnosis 40-4545
More than 95% caused by pituitary More than 95% caused by pituitary adenoma, rarely by ectopic GH or GHRH adenoma, rarely by ectopic GH or GHRH production by malignant tumoursproduction by malignant tumours
All cause mortality rate is twice that of All cause mortality rate is twice that of normal population & is due to cardiac, normal population & is due to cardiac, cerebrovascular, Diabetes & neoplasia cerebrovascular, Diabetes & neoplasia (colon cancer) related(colon cancer) related
Clinical featuresClinical features Due to soft tissue enlargement in all Due to soft tissue enlargement in all
organ systems or due to presence of organ systems or due to presence of tumour in pituitary fossatumour in pituitary fossa
Headache and visual field defectHeadache and visual field defect Increase in ring/shoe size, hyperhidrosis, Increase in ring/shoe size, hyperhidrosis,
coarsening of facial features, coarsening of facial features, prognathism, macroglossia, arthritisprognathism, macroglossia, arthritis
Glucose intolerance or diabetes, Glucose intolerance or diabetes, hypertension, CV disease, cardiomyopathyhypertension, CV disease, cardiomyopathy
Increased incidence of Ca colonIncreased incidence of Ca colon
DiagnosisDiagnosis Oral GTT – Gold standard for diagnosisOral GTT – Gold standard for diagnosis Imaging – MRI should only be done after a Imaging – MRI should only be done after a
firm biochemical diagnosis, because of firm biochemical diagnosis, because of high incidence of non-functioning high incidence of non-functioning adenomasadenomas
IGF 1 – Useful in screening and to monitor IGF 1 – Useful in screening and to monitor RxRx
TreatmentTreatment Transphenoidal surgery is the first line of Transphenoidal surgery is the first line of
treatmenttreatment Medical therapy Medical therapy