What is the location & characteristic of pheochromocytoma?
- catecholamine secreting tumor in chromaffin cells of adrenal medulla
- 10% extra-adrenal (paragangliomas), bilateral, malignant, NOT associated w/ hypertension
25% familial: neurofibroma type 1, MEN2
What is the classical triad of pheochromocytoma & other symptoms?
Triad: hypertension + headache + sweating
weight loss, Anxiety, palpitations
How is pheochromocytoma diagnosed & treated?
24 hour urinary metanephrines twice
pre-op then laparoscopic surgery : 1. Alpha-blocker (phenoxybenzamine) + beta-blocker (propanol) 2. labetalol (blocks both)
what is Addison’s disease? what are the causes?
- decreased cortisol (glucocorticoid) and aldosterone (mineralocorticoid)
- Autoimmune adrenalitis (destruction to one’s own adrenal cells)
- Malignancy, infectious adrenalitis
When do the symptoms of Addison’s disease start to appear? What are the symptoms?
- 90% destruction of adrenal gland
- Aldosterone: Hyponatremia, hyperkalemia, Hypotension
- Increased ACTH (stimulated cortisol): hyperpigmentation
- Weight Loss, weakness
How is Addison’s disease diagnosed?
Short synACTHen test: stimulated ACTH, cortisol level only increase a little in addison’s patient
What are the treatment options of Addison’s disease?
- Hydrocortisone (c) + fludrocortisone (a)
- If patient have another disease, ie, infection, double hydrocortisone & fludrocortisone stays the same
What is Cushing’s syndrome and disease, what are the 2 main types? Give some examples
High level of cortisol (disease is specific to pituitary problem causing increased ACTH)
Exogenous: glucocorticoid therapy
Endogenous: pituitary adenoma, adrenal adenoma, ectopic ACTH
What are the symptoms of cushing syndrome? MSK manifestations?
- Central weight gain + abdominal striae
- Buffalo hump, easy bruising, proximal limb muscle wasting
- Osteoporosis, decrease libido, hirsutism in female
What is the diagnosis of Cushing’s syndrome? what test is needed to find the cause?
diagnosed by 24 hr urinary cortisol,
High dose dexamethasone test done to find the cause
ACTH & cortisol both suppressed= pituitary adenoma
ACTH & cortisol both NOT suppressed= ectopic ACTH (SCLC)
Only ACTH suppressed= adrenal adenoma
How is Cushing’s syndrome treated? How is it different for different causes?
Surgery: Hypophysectomy, adrenalectomy and/or radiotherapy
Metyrapone: last line OR waiting for radiotherapy
What is the function of parathyroid hormone?
- increase absorption of calcium from diet
- promoting release of calcium from bones, and decreased excretion of calcium by kidneys.
- increase phosphorus excretion by kidneys to balance calcium and phosphorus levels
how is parathyroid hormones stimulated and suppressed?
- Parathyroid gland have chief cells that detect ionized calcium levels in blood, if the level is low, chief cells release PTH
- Thyroid gland release calcitonin which lower calcium in blood and suppress activity of PTH
What are the causes of hyperparathyroidism?
- Primary: Solitary adenoma causing overactive chief cells secreting PTH causing hypercalcemia
- Secondary: hyperplasia from vitamin D deficiency or chronic renal failure leading to decreased calcium absorption, renal resorption, osteoclast activity causing hypocalcaemia, body try to compensate by releasing more PTH leading to hyperplasia of parathyroid gland
- Tertiary: hyperplasia leading to chronic High levels of PTH & hypercalcemia
What are the symptoms and patient profile of hyperparathyroidism?
- Bones, stones, abdominal groans, psychic moans
- Polydipsia, polyuria
- Depression, anorexia
“Elderly female come in very thirsty with normal or raised parathyroid hormones”
What is the investigation for hyperparathyroidism?
- Bloods:increased PTH and calcium in primary & tertiary, increased PTH with low calcium in secondary
- X-ray: osteopenia, pepperpot skull (small spots of lucencies in skull due to resorption of trabecular bone)
What is the treatment for hyperparathyroidism?
- Total parathyroidectomy
- cinacalcet (calcimimetic that activates calcium sensing receptor, used if patient is not suitable for surgery)
- increase vitamin D or kidney transplant (treat underlying cause of hyperplasia)
What are the causes of hypercalcemia?
- Hyperparathyroidism (solitary adenoma)
- Malignancy (squamous cell lung cancer, bone metastases, myeloma )
- Vitamin D, thiazide, lithium
- Sarcoidosis, Familial hypocalciuric hypercalcemia
what are the symptoms of hypercalcemia?
Stones, bones, moans, groans
Short QT interval on ECG
if the patient have hypercalcemia what tests should be done to find the cause?
- high PTH: measure urinary Ca+ excretion (high in primary hyperparathyroidism, low in FHH)
- normal PTH: screen malignancy
treatment for hypercalcaemia?
- Rehydration with normal saline
- bisphosphonate or calcitonin or furosemide
- treat underlying cause
What is the cause and treatment for hypoparathyroidism?
- Surgery of the whole thyroid gland causing decreased PTH secretion leading to low calcium and high phosphate
- Treat with alfacalcidol
What is the cause & presentation of pseudoparathyroidism?
- Genetic disorder causing mutation in G-protein receptors responsible of PTH signal transportation to target cells, this leads to PTH resistance, Hypocalcemia, and hyperphosphatemia
- Low IQ, short stature, shortened 4th and 5th metacarpals
What are the causes of hypocalcemia?
- Vitamin D deficiency (osteomalacia/ softening of bones)
- Hypoparathyroidism post thyroid surgery
- chronic kidney disease, Acute pancreatitis
What are the symptoms of hypocalcemia?
- Peripheral paraesthesia (tingling at fingers / toes)
- Chvostek’s sign – spasm of facial muscle on percussion
- Trousseau’s sign – wrist contraction with cuff inflation
- QT prolonged, bradycardia, arrhythmia
What is the management for hypocalcemia?
- IV calcium gluconate with ECG monitoring for Severe (carpopedal spasm, prolonged QT)
- Treat underlying cause
What is the difference between thyrotoxicosis and hyperthyroidism?
- Thyrotoxicosis: tissues exposed to excessive thyroid hormone t3/t4
- Hyperthyroidism: overactivity of thyroid creating excessive hormones
What are the symptoms of grave’s disease?
- eye signs: exophthalmos (protruding eyeballs)
- pretibial myxoedema (plaques of thickened skin + erythema/ red swelling on the leg)
- soft tissue swelling of the hands and feet + digital clubbing
- Hyperthyroidism (nervousness, weight loss, hot intolerance, diarrhea, palpitation)
what is this?
eye sign in grave’s disease: exophthalmos
What are the investigations for grave’s disease?
- TFT: low TSH, high T3/T4
- Antibodies: TSH-receptor stimulating
- Thyroid scintigraphy: diffuse, homogeneous increased uptake of radioactive iodine
What is the treatment for grave’s disease?
- Carbimazole + propanlol
(ATD therapy + beta blocker for initial symptom relief)
- Radioiodine therapy if condition prolapses
What is the cause & symptoms of toxic multinodular goiter?
- Thyroid gland having number of autonomously functioning thyroid nodules
- Hyperthyroidism (nervousness, weight loss, heat intolerance, diarrhea, palpitation, tremor)
- Palpable goiter
What is the investigation & treatment of toxic multinodular goiter?
- TFT (decreasedTSH, increase T3/T4) Thyroid scintigraphy: patchy uptake
- Carbimazole (ATD therapy, not to be used first trimester of pregnancy replace with PTU) + propranolol initially to reduce symptoms in new cases
- Radioiodine therapy
Contrast disease profile of grave’s disease & toxic multinodular goiter
- Toxic multinodular goiter: older adult, not eye signs
- Grave’s disease: eyes protruding, 40-60 female
can you get thyrotoxicosis without hyperthyroidism? If so, what are the symptoms?
- Yes, subacute/ De-quervain’s thyroiditis, occurs post viral infection
1. Temporary hyperthyroidism, painful goiter/ tenderness in neck, raised ESR
3. Thyroid function & structure goes back to normal
What is the investigation & management of subacute/ De-quervain’s thyroiditis?
- Thyroid scintigraphy: homogenous reduced uptake of iodine-131
- Self limiting, aspirin & NSAID for thyroid pain
What are the causes & associated disease of hashimoto thyroiditis?
- Autoimmune disease causes long term hypothyroidism may lead to acute thyrotoxicosis in the early phase due to damage
- Associated with coeliac disease & T1DM, may lead to MALT lymphoma
What are the symptoms of hashimoto thyroiditis?
- Hypothyroidism (fatigue, weight gain, cold intolerance, constipation, depressed mood)
- Firm, non-tender goiter (due to increased TSH stimulation from reduced t3/t4)
What are the investigation & treatment for hashimoto thyroiditis
- TFT: high TSH, low T3/T4
- antibodies: anti-TPO (thyroid peroxidase), anti-Tg (thyroglobulin)
- Give levothyroxine & aim for TSH at normal range (if patient take iron or calcium should be done 4 hours later)
What are the side effects of thyroxine therapy w/ levothyroxine for hypothyroidism?
- Hyperthyroidism: from over treatment, may then lead to reduced bone mineral density (osteoporosis)
- Worsening angina + atrial fibrillation