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ENDOCRINE CASE STUDIES

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 TSH<0.01 mU/L. POSTPARTUM THYROIDITIS.

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ENDOCRINE CASE STUDIES

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  1. ENDOCRINE CASE STUDIES Dr SUNIL ZACHARIAH Consultant Endocrinologist Spire Gatwick Park and ESH

  2. CASE-1 • 23 year old lady • 3 months post delivery • Presents with palpitations and loose stools • FT4=32.6 pmol/L • TSH<0.01 mU/L

  3. POSTPARTUM THYROIDITIS • Incidence varies from 5-11% • More common in women with a family history of hypothyroidism and positive TPO antibodies

  4. CLINICAL FEATURES • Presentation is usually 3-4 months postpartum • Can be hypothyroidism (40%), hyperthyroidism (40%) or biphasic(20%) • Goiter is present in 50% of patients • To distinguish from Graves disease use thyroid isotope scan and TSH receptor Ab

  5. Pathogenesis • Destructive autoimmune thyroiditis causing first release of thyroxine and then hypothyroidism as the thyroid reserve is depleted • FNAC shows lymphocytic thyroiditis

  6. Management • Most patients recover spontaneously without requiring treatment • If hyperthyroid use beta blockers rather than antithyroid drugs as the problem is increased release, not synthesis • Hypothyroid phase is more likely to require treatment • Only 3-4% remain permanently hypothyroid • 10-25% will recur in future pregnancies

  7. Case Study-2 • 60 year old Type 2 Diabetes • Last HbA1c=8%(64 mmol/mol) • Presents with erectile dysfunction • Not much benefit from Viagra • Testosterone level 8 nmol/L

  8. Hypogonadism in Type 2 Diabetes • Low testosterone levels are common in people with type 2 diabetes • Effect of testosterone replacement on glycaemic control remains uncertain • If androgen deficiency is suspected then do at least two 9 am testosterone levels. If first sample is low , then check LH, FSH, SHBG, ferritin and prolactin as well in the 2nd sample

  9. If testosterone level is between 8 and 12 nmol/L in a symptomatic individual, then a trial of testosterone replacement is warranted • If the man has tried a phosphodiesterase inhibitor without success and has a total testosterone of <12 nmol/L, then a 6 month trial of testosterone is warranted

  10. Case Study 3 • 27 year old female • Follicular Cancer of Thyroid • Post surgery, post radioiodine ablation • On Thyroxine replacement (175 mcg) • FT4 19.8 • TSH 0.05

  11. Follow up of thyroid Cancer • Original diagnosis and treatment • If total thyroidectomy and ablative radioiodine, thyroglobulins usually undetectable if TSH unrecordable • Maintain TSH<0.05

  12. Case 4 • 50 year old man • Ventricular tachycardia with poor LV function • Controlled on Amiodarone • FT4 50 • FT3 7 • TSH<0.01

  13. Amiodarone and Thyroid • Inhibits thyroidal iodide uptake • Inhibits conversion of T4 to T3 intracellularly • Inhibits T4 entry into cells • Direct T3 antagonism at level of cardiac tissue

  14. Amiodarone induced hyperthyroidism • 2-12% • Type 1: Iodine overload in abnormal gland, treat with carbimazole or lithium • Type 2: Glandular damage, release of preformed hormones, treat with prednisolone 0.5-1.25 mg/kg for 3-6 weeks • Management of tachyarrhythmia's: beta blockers if not in CCF • ?total thyroidectomy (not radioiodine)

  15. CASE 5 • 32 year old female • BMI=25 • Detected to have blood pressure of 210/100 mm Hg • History of palpitations, abdominal discomfort • Investigated for secondary causes of hypertension

  16. 24hr Urinary collections

  17. L.L. CT Scan 1998

  18. L.L. MIGB Scan 1998

  19. Management of Phaeochromocytoma • Commenced on alpha and beta blockade • Referred for surgery

  20. DEFINITION • Phaeochromocytomas are adrenomedullary catecholamine secreting tumours • Paragangliomas are tumours arising from extra-adrenal medullary neural crest derivatives, e.g. sympathetic or carotid body, aorticopulmonary, intravagal or parasympathetic

  21. INCIDENCE • Rare tumours • Accounting for <0.1% of causes of hypertension • Can be fatal if undiagnosed

  22. EPIDEMIOLOGY • Equal sex distribution • Most commonly in 3rd and 4th decades • Majority(90%) are sporadic, 10% are inherited

  23. PATHOPHYSIOLOGY • Sporadic tumours are usually unilateral and <10 cm diameter • 10-20% are malignant • Paragangliomas are more likely to be malignant

  24. CLINICAL FEATURES • Sustained or episodic hypertension • Sweating and heat intolerance(80%) • Headache(65%) • Palpitations(65%) • Abdominal pain • Constipation

  25. COMPLICATIONS • CVS: LVF, dilated cardiomyopathy • Resp: Pulmonary oedema • Neuro: Cerebrovascular, hypertensive encephalopathy

  26. Who should be screened? • Family history of MEN, VHL, Neurofibromatosis • Paroxysmal symptoms • Young hypertensive • Patient developing HT crisis during GA • Unexplained heart failure

  27. INVESTIGATIONS • 24 hour urine collection for catecholamines. Because of episodic nature at least two 24 hour samples • Plasma catecholamines: Limited use because of intermittent secretion. Useful if patient having a crisis • Screening for associated conditions

  28. LOCALIZATION • MRI or CT scan • MIBG scan: Meta-iodobenzylguanidine is a chromaffin-seeking analogue. Positive in 60-80%.

  29. MANAGEMENT • Alfa-blockade (Phenoxybenzamine) must be commenced before beta-blockade to avoid precipitating a hypertensive crisis due to unopposed alfa-adrenergic stimulation • Surgical resection (open or laparoscopic) • Malignancy: High dose MIBG therapy, Chemotherapy, Octreotide therapy

  30. Case Study 6 • 49 year old • HGV Driver • Diagnosed type 2 diabetes 8 years ago • Diet controlled for 1 year • Check’s Blood Glucose once a day (8-13) • On tablets since then • Yearly retinal screening

  31. MEDICATIONS • Metformin 1 gm bd • Pioglitazone 45 mg od • Gliclazide 80 mg bd • Lipitor 40 mg od • Perindopril 4 mg od • Aspirin 75 mg od

  32. Hba1c=9.2% • Creatinine=90, GFR=76 • ?Next Step

  33. * * * * * * * * * * The incretin effect is reduced in patients with type 2 diabetes Intravenous Glucose Oral Glucose Control subjects Patients with type 2 diabetes 80 80 60 60 Insulin (mU/L) Insulin (mU/L) 40 40 20 20 0 0 0 30 60 90 120 150 180 0 30 60 90 120 150 180 Time (min) Time (min) *P ≤.05 compared with respective value after oral load. Nauck MA, et al. Diabetologia 1986;29:46–52.

  34. Ingestion of food • Glucose dependent • Insulin from beta cells(GLP-1 and GIP) Insulinincreases peripheral glucose uptake GI tract Pancreas Release of incretin gut hormones Beta cells Alpha cells Active GLP-1 and GIP Increased insulin and decreasedglucagon reduce hepatic glucose output • Glucagon from alpha cells (GLP-1)Glucose dependent Incretins and glycaemic control Bloodglucose control DPP-4enzyme rapidly degrades incretins Adapted from 7. Drucker DJ. Cell Metab. 2006;3:153–165. 8. Miller S, St Onge EL. Ann Pharmacother 2006;40:1336-1343.

  35. CASE STUDY-7 • 88 year old lady • Diarrhoea • Abdominal pain • Weight loss

  36. PAST MEDICAL HISTORY • Extensive Investigations for Chronic Diarrhoea(5 years) • Diverticular disease • Hypothyroidism • Hypertension • Ischemic Heart Disease • Hysterectomy

  37. EXAMINATION • Mildly dehydrated • Hypotensive (94/60 mm Hg) • Abdomen: Tenderness in Epigastrium and RUQ • CVS: Soft Systolic murmur

  38. INVESTIGATIONS • Hb: 12.9 Bilirubin: 5 • WBC: 14.5 ALT: 61 • MCV: 90 Alk PO4: 417 • Platelets: 461 Albumin: 42 • Sodium: 134 GammaGT: 533 • Potassium: 3.6 TSH: 3.3 • Urea: 12.6 Ft4: 12 • Creatinine: 90 T3: 3.2 • CRP: 138 Calcium: 2.4

  39. Urine analysis: NAD • Stool Culture, toxins and microscopy: Negative

  40. IMAGING • CXR: Normal • Ultrasound Abdomen: Hepatomegaly, with multiple avascular, iso-echoic lesions in both lobes of liver representing metastasis. Primary likely to be ?colorectal or ?pulmonary

  41. PATIENT PROGRESS • Discussion with patient and family • Options discussed • Patient not keen on further invasive tests • Agreed for CT scan

  42. CT Scan • No significant lymphadenopathy • No significant lung lesions • Liver is replaced by multiple metastasis in both lobes • Normal pancreas and adrenals • No masses in the ovary or large bowel

  43. TUMOUR MARKERS • CEA: 4.9 (0-15) • CA-125: 55 (0-35) • CA 19-9: 64 (0-27)

  44. PROGRESS • Diarrhoea persisting • General condition of patient, however good • History reviewed with patient: Feeling flushed for many months • Could this be Carcinoid?

  45. 24 hour 5 HIAA requested • Laboratory reluctant • Result: 672 (Normal<31) • Diagnosis of Carcinoid syndrome made • Referral to Oncology and Endocrine team made

  46. TREATMENT • Octreotide injections started • Discharged with District Nurse input and Oncology follow up

  47. EPIDEMIOLOGY • Annual incidence: 1/100000 population • Mean age: 50-60 years • Males=Females • Increased risk of developing other carcinoma’s

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