Sukumbis Review of Endocrine

Slide 1
Shows 2 pictures of the same lady taken at different
times. Her complaint included new onset hypertension,
diabetes mellitus & onset of gaps.
Which of the following will you be interested in checking?
Basal level of growth hormone, blood glucose level,
blood level of insulin, blood level of insulin-like growth
factor
Insulin-like growth factor that is produced by the liver. This woman has acromegaly, do not pick
growth hormone, b/c this is released in a pulsatile manner, would not indicate properly
The MC cause of death in patients with acromegaly is which of the following? Chronic renal
failure, MI, congestive heart failure, stroke, natural death
**congestive heart failure**
The MC cause of such a change is in which of the following? Carcinoma of the pituitary gland,
adenoma of prolactin secreting cells, adenoma of somatotrophs, adenoma of corticotrophs
Adenoma of somatotrophs, it is usually a benign growth. Acromegaly occurs in patients who
already have fusion of the epiphysis, so bones can get fatter, but not longer
Look at the R slide, the face contour if very coarse and the jaw is widened. You might see
some elongation of the jaw, called prognathism. Her fingers are broad & described as
sausage-shaped. Also on the inside the woman has organomegaly enlarged organs
Prolactinoma is the MC pituitary growth. Remember that GH is an antagonist to insulin &
that it is a metabolic hormone that affects all organ systems. This patient could possibly have
hypertension.
Sometimes the location of the tumor rises above the sella turcica & can compress the optic
chiasma affecting CN II bitemporal hemianopsia
EXTRA
34 y/o lady with a history of infertility was accompanied to the hospital by her husband. She has
amenorrhea, lost libido, & the husband noticed she had a lot of milk in her breasts (shes
lactating). She is not on any medication and further tests revealed the fact that she is not
pregnant.
Which of the following will be your best approach in managing your patient? Irradiation, surgery,
antibiotics, bromocriptin
Bromocriptin, this woman has prolactinoma, a tumor of the pituitary. The MC presentation of
this is described in the question.
Note that sometimes, medication can cause this kind of condition.
Will have no ovulation, no libido, will be infertile. Patients usually will come to the hospital
before it becomes a macroadenoma (tumor of pituitary that is > 10mm), otherwise it is a
microadenoma. You would not use radiation for a microadenoma. Bromocriptin is like
dopamine, it is an antagonist, it will inhibit the proliferation of the glands tissues.

Sukumbis Review of Endocrine

Slide 2
Related to slide above, another picture of acromegaly.
Blood glucose, GH, **insulin-like growth factor is elevated**
Look at slide thickened supraorbital ridge
Slide 3
39 y/o lady shown here before & after treatment for Dx
of Cushings disease.
This implies what? She has been taking excess cortisol
orally, she has adrenal gland adenoma, she has oat cell
carcinoma of the lung that is producing ACTH, has a
pituitary adenoma that is producing ACTH
Pituitary hypothalamic problem, the other things listed
as answer choices can deal with Cushings SYNDROME, we are talking about Cushings
DISEASE.
They will also have DM xs glucose in the blood. This patient would have osteoporosis.
Would have a problem climbing stairs b/c it affects the proximal muscles the hamstrings &
quadriceps will atrophy proximal myopathy of Cushings
Slide 4
This is Cushings syndrome.
Striae breaking down the collagen .: the skin is
breaking down.
She has weight gain, **truncal obesity**, proximal
myopathy, features of DM, moonfaced, & you think she
has Cushings syndrome.
What is the first thing you do?
Ask her about medication, because the MC cause of Cushings is the administration of
exogenous cortisol. She could be taking steroids for asthma, lupus, etc.
If no medication 24 hour urine estimation for cortisol & its metabolites. If it is , then there
is xs cortisol & you must do a low-dose dexamethasone administration test. Give this
woman a low-dose, after 24 hours get a urine sample again & estimate the cortisol. If the
cortisol this woman does NOT have a pituitary adenoma b/c adenomas do not respond to
low-dose dexamethasone.
If on the other hand, you do the same thing & there is no change in the urine cortisol urine
level do a high-dose dexamethasone if there is a change in the 24 hour cortisol urine
level, then the woman has a problem in the pituitary causing excess cortisol.
Now what if you give both low-dose & high-doses & there is still no change? Then may have an
ectopic source or an adenoma of the adrenal gland itself.

Sukumbis Review of Endocrine

Now measure the ACTH in the blood & see if there is an ectopic source of this like oat cell
carcinoma. Sometimes it is an adenoma of the adrenal gland do imaging to Dx the
adrenal gland
Remember that high stress will cause an extensive release of cortisol into the body.
Cushing syndrome glucose, water, & Na, BUT prolactin is not in any type of Cushing
syndrome.
*They can ask you a question just as simple as: What cancer of the lung does this patient have?
Small cell carcinoma of the lung
Upon examination of a Cushings syndrome patient, you find hyperpigmentation of her skin
most likely to be from pituitary b/c high stimulation of pituitary will also release MSH, causing
darkened skin. Remember, MSH is synthesized from the same precursor molecule that
produces ACTH. They sometimes use the slides from the lab video, picture of 2 hands, 1
normal and 1 pigmented.
If the source in this patient is exogenous cortisol then the adrenal gland will atrophy, b/c
its the release of ACTH that keeps the gland level at normal
Slide 5
42 y/o man has just been diagnosed w/ HTN. His blood
pressure was 170/105 mm Hg. He was started on
thiazide diuretics, and on the 3rd day he became very
weak, lethargic & severely constipated. His serum
Na was normal, serum K lower than normal, serum
renin activity was on the lower side. An image study
was done & shown on the slide.
Which does he most likely have? Pheocytochroma, neofibroma, Addisons disease, Conns
syndrome, hypertension
Conns/1 hyperaldosteronism overproduction of aldosterone renin b/c the
aldosterone suppresses the RAS
HTN, losing hydrogen & K metabolic alkalosis. Must remove the tumor for these patients.
Most of the time it is an adenoma of zona glomerulosa.
This picture can also be used with a pheochromocytoma question.
Slide 6
Gross specimen of the adrenal gland w/ a wellcircumscribed mass in the middle. Cortical part of
adrenal gland.
How do you determine if it is benign or malignant?
Absence of capsule, it is always benign, presence of
metastasis
Metastasis is the best predictor of malignancy
Slide 7
Specimen removed from a 42 y/o lady who was
diagnosed w/ HTN. In addition, she has palpitations,
occasional chest pain, & sweating. This was removed
from her abdomen.
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Sukumbis Review of Endocrine

What do you expect to find in the urine of this patient? C-peptide, glucagons, VMA, IGF
VMA (Vanillomendallic acid). This is pheochromocytoma overproduction of catecholamines
.: find catecholamines & their metabolites VMA & metanephrines. Know the 10% rule
10% bilateral, 10% malignant (presence of metastasis), 10% Familial, 10% Extra-adrenal.
Neural crest cells are the cell of origin for this kind of tumor.
Slide 8
Woman w/ a staring appearance. *Take note of the
visible sclera above the iris of the eyes.
What is responsible for her staring look? Accumulation
of mucopolysaccharides in the upper eyelids, in the
retroorbital space, or excess sympathetic activity
Excess of sympathetic activity keeps their eyelid in an
excited state lid lag. If you are talking about
exophthalmos, then the problem deposition of GAGs, swelling of extra-ocular muscles, LC
infiltration, & edema pushing the eyeball from the back. You have to look from the top or
side to check for exophthalmos.
If this patient has Graves, what is true about the thyroid gland? She is likely going to have a hot
spot on her radioiodine scanning, a diffusely cold picture, one lobe hot and other lobe cold, have
a diffusely hot picture
**it will be diffusely hot** the thyroid follicles are taking up the iodine & functioning. If one
side is hot & one side is cold, it is NOT Graves disease. If you get all cold spots, it is NOT
Graves. You will find **TSI antibodies** in this patient stimulates the thyroid follicles to
convert the colloid into thyroxin thyrotoxicosis d/t hyperthyroidism. It will be a T2HS.
Other symptoms of hyperthyroidism tremors, sweating, flushed warm skin, diarrhea,
weight loss, excess eating & heat intolerance
Apart from Graves, what are other causes of hyperthyroidism? People who are trying to lose
weight will take thyroxin called factitious hyperthyroidism
Slide 9
Related to slide above.
This shows pretibial myxedema, the dermopathy
assoc w/ Graves local accum of GAGs localized
thickening & hyperpigmentation of the skin on the
anterior feet & lower legs.
Caused by stimulation of Ab. Generalized
myxedema is seen in hypothyroidism & is an accum of
MPS face of this patient will be edematous.
Slide 10
Remember that a patient who is diabetic, the MC cause
of fainting & going into coma is hypoglycemia. .: put
sugar under the patients tongue
If a patient is breathing very deeply/hyperventilating, has
a very ketoacidic smell DKA w/ Kussmaul breathing
Hyperglycemic hyperosmolarity can cause a
coma
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Sukumbis Review of Endocrine

MC cause of death in DM patients?
MI after many years, followed by chronic renal failure
43 y/o lady w/ DM who has not been compliant w/ her medication. Each time she comes to
the hospital her blood sugar has been in the normal range.
What will you use to test? Fasting blood sugar, random blood sugar, urinary glucose, glycated
hemoglobin test
Glycated hemoglobin test(HbA1c) tells how much sugar flowing in the body for the last 3
months, normal value should be <6.5 mg/dL. Otherwise this patient has a poor glycemic
control.
A woman was found dead in the morning & at autopsy, she had a little prick in between her toes.
Murder was suspected, maybe insulin was given in her sleep?
What test do you do? Glucose, insulin, creatine, C-peptide
Measure C-peptide, b/c C-peptide rises hand in hand w/ the bodys own insulin production. If Cpeptide was not and it was , then she may have been injected w/ insulin given to her during
sleep.
A patient w/ DM comes to your office w/ the complaint that people who die w/ DM die of RF &
how she can prevent that.
What do you measure for renal failure? Serum creatine, serum albumin, microscopic
albuminuria, monthly biopsy
Microscopic albuminuria look for in diabetic patients. Estimate the amount of protein in her
urine in a 24 hour period & if it is high, then that is the 1st sign that something is going wrong
w/the kidneys.
You must then improve the sugar control.
If you find 4.2 g of protein nephrotic syndrome; give her ACE inhibitors to prevent renal
failure.
Slide 11
Look at the mesangial material that looks like
bubblegum nodular glomerular sclerosis, a severe
hyaline change, the nodules are called **KimmelsteilWilson nodules** Once you see this the patient already
has nephrotic syndrome.
Slide 12
Why do DM patients develop cataracts? Some cells in
the body need insulin to take glucose inside, while some
cells do not
The lens does NOT need insulin to take in glucose.
So glucose is taken into the lens & converted into
**Sorbitol** osmotic pressure in the lens (draws in
water) opaque
If you give a patient exogenous insulin, what will be the blood values of blood glucose, blood
insulin level & C-peptide levels?
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Sukumbis Review of Endocrine

glucose, C-peptide, insulin glucose, insulin secretion b/c insulin secretion is
stimulated by glucose; b/c it is exogenous insulin, C-peptide levels b/c endogenous
insulin production
**You must know that C-peptide rises w/ the bodys insulin production for exam & Step 1**
**Know about AGEs, or advanced glycosylation end
products d/t non-enzymatic glycosylation of
proteins
AGE on collagen causes cross-links between
polypeptides, which can trap plasma & other interstitial
proteins can trap LDLs in the blood vessels
deposition of cholesterol accelerated
atherosclerosis that is seen in DM patients
AGE can also affect the structure of capillaries in the kidney can develop leaky basement
membranes
Slide 14
Shows the face of a middle-aged woman who has been diagnosed
w/ depression & in addition she has cold intolerance, gaining
weight, constipated, sleeps most of the time, has menorrhagia
and her tongue is getting big. Her children also noticed that her
voice is becoming like a frogs sound.
No thyroxin everything concerning metabolism will be slower.
Mucopolysaccharides are accumulating in their vocal cords
leading to a croak voice.
What test do you do first?
TSH if TSH, problem is w/ thyroid gland 1 hypothyroidism.
Next, estimate the amount of thyroxin in the blood, T3 & T4 should
be .
What tells you she might have Hashimotos?
Anti-microsomal Ab would be found, destroys the follicles no production of thyroxin.
29 y/o lady has just recovered from a viral URT infection when she developed pain &
tenderness of her thyroid gland. In addition, she had sweatiness, palpitations. A Bx from the
neck reveals granulomas, WBC count & ESR.
What is your Dx? Postpartum thyroiditis, Hashimotos, Graves, de Quervain thyroiditis
de Quervain thyroiditis subacute or granulomatous thyroiditis **this is often associated
with a URT infection, maybe be viral**
If a story is given about a woman who has just given birth to a baby, then think of postpartum
thyroiditis something happens with the thyroid gland & that can lead to hypothyroidism
lymphocytic infiltration & hyperplastic germinal centers w/in thyroid parenchyma.
Slide 15
Bx specimen from the neck of a 57 y/o lady who had a
goiter affecting her thyroid gland. Histology showed
normal looking follicles with no stromal invasion &
no pleomorphism.
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Sukumbis Review of Endocrine

Follicular adenoma, it is a well circumscribed finding.
Papillary carcinoma is the MC of the thyroid gland. It shows Psammoma bodies. Papillary
carcinoma also has the best prognosis, spreads through local LN, not through the blood
stream.
Follicular carcinoma spreads through the blood & can spread to the lungs & other organs. The
prognosis is poor & have stromal invasion.
Medullary carcinoma affects C-cells which produce calcitonin. Can use calcitonin to monitor
this type of cancer. C-cells are from neural crest cells.
Anaplastic cancer carries the worst prognosis. It metastasizes very early, in elderly.
Patients who has been exposed to excessive radiation or genetic mutations are at risk for
these kinds of cancers.
Plummer syndrome develop cancer from one of the nodules in a multinodular goiter
combo of hyperparathyroidism & goiter, NO exophthalmos
Slide 16
Related to above slides. Shows the thyroid gland &
tumor on one side.