endocrine case presentations - pbworks
TRANSCRIPT
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Endocrine
Case Presentations
Matt Bouchonville
Endocrinology Division
Family Medicine Resident School
March 19, 2014
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Learning Objectives
1. Understand the evaluation and management of
common thyroid disorders
2. Understand the evaluation and management of
male hypogonadism
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Case #1
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Case #1: The incidental thyroid
nodule
• HPI
• 58 yo F
• Incidental thyroid nodule on CT scan performed in ER
after MVA
• No obstructive symptoms
• No hyperthyroid symptoms
• Denies history of ionizing radiation to the head/neck
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Case #1: The incidental thyroid
nodule
• PMH
• HTN
• GERD
• Meds
• HCTZ
• Ranitidine
• SocHx
• Teaches elementary school. No EtOH, tobacco.
• FamHx
• Negative for thyroid cancer.
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Case #1: The incidental thyroid
nodule
• Physical
• Vitals normal
• No lid lag/stare
• No cervical
lymphadenopathy
• No palpable thyroid
nodules
• Labs
• TSH normal
• Thyroid U/S
• L 1.6 cm hypoechoic nodule
• R 0.6 cm hypoechoic nodule
Next step:
Observation? Uptake/scan? FNA?
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U/S-guided FNA
Cooper. Thyroid 2009;20(6):674.
FNA?
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U/S-guided FNA
Cooper. Thyroid 2009;20(6):674.
Nodule features
Threshold
size for FNA
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U/S-guided FNA
Cooper. Thyroid 2009;20(6):674.
“High-risk patients”
• History of thyroid cancer in 1st degree relative
• External beam/ionizing radiation in youth
• Prior hemithyroidectomy with history of thyroid cancer
• 18FDG avidity on PET scan
• History of MEN2
• Calcitonin >100 pg/mL
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U/S-guided FNA
Cooper. Thyroid 2009;20(6):674.
Nodule features – HIGH RISK
Threshold
size for FNA
“Suspicious sonographic features”
• Microcalcifications
• Hypoechoic
• Increased vascularity
• Infiltrative margins
• Shape taller than width
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Case #1: FNA results
• Cytology:
• Positive for papillary thyroid cancer
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Differentiated thyroid cancer
• Treatment:
• Total thyroidectomy
• +/- Lymph node dissection
• +/- I-131 treatment
• TSH suppression
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Thyroid hormone suppression
therapy (THST)
Jonklaas. Thyroid 2006;16(12):1229.
High/intermediate risk:
Goal TSH <0.1
Low risk:
Goal TSH 0.1-0.4
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Case #2
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Case #2: “Found down”
• HPI
• 49 yo F
• Brought in by EMS after discovered by visiting family
member. POC glucose 73 mg/dL.
• Unresponsive
• Family member describes history of “Hashimoto’s” and
problems with medication adherence
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Case #2: “Found down”
• Physical
• Obtunded
• Hypoxic
• Hypothermic
• Bradycardic
• Low normal BP
• Diminished heart sounds
• Nonpitting edema
• Vitiligo
• Labs
• Pending
• CXR
• Enlarged cardiac silhouette
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Case #2: “Found down”
• Treatment
• IV thyroid replacement
• Supportive therapy
• MICU admission
• Intubation
• Careful IVF therapy
• Empiric antibiotics
• Passive rewarming
Develops refractory hypotension/shock:
What happened?
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Precipitation of adrenal crisis
• Sudden increase in cortisol metabolism in patient
with undiagnosed adrenal insufficiency with
initiation of thyroid replacement
• Adrenal insufficiency seen more commonly in
hypothyroid patients
• Pituitary pathology (secondary hypothyroidism)
• Autoimmune polyglandular syndrome type 2
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APS type 2
• Primary adrenal insufficiency
• Hypothyroidism
• Type 1 diabetes
• Other:
• Pernicious anemia
• Vitiligo
• Alopecia
• Celiac disease
• Primary biliary cirrhosis
• Myasthenia gravis
• ITP
• Premature ovarian failure
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Case #3
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Case #3
• HPI
• 53 yo F
• Tremors, palpitations x 3 months
• Weight loss x 6 months (20 lbs)
• “Always been a little bug-eyed but it’s been getting
worse this year”
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Case #3
• PMH
• None
• Meds
• None
• SocHx
• +Tobacco use
• FamHx
• +Thyroid problem in the sister
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Case #3
• Physical
• Mild tachycardia
• Mild-moderate proptosis; EOMI, no conjunctival
injection, no periorbital edema
• Thyroid diffusely enlarged to 2X’s ULN; no nodules,
bruits
• Mild resting tremor
• Labs
• TSH undetectable, total T3 high normal, free T4 3.4
• CBC normal, LFT’s normal
Is a thyroid uptake/scan indicated for this
patient?
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AACE/ATA Guidelines
• Radioiodine uptake/scan appropriate in the
following hyperthyroid settings:
• Absence of clinical evidence of Graves’ disease
• Presence of nodular thyroid disease
• Uncertainty regarding state of high/normal vs low iodine
uptake (which would influence therapy)
Bahn. Endocr Pract 2011;17(3):457.
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Case #3
• Treatment
• Methimazole 20 mg po daily
• Atenolol 25 mg po daily
Is there anything the patient can do to
prevent worsening eye involvement?
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Smoking and Graves’ Orbitopathy
• Cigarette smoking
• Stimulates GAG production, adipogenesis
• Increases orbital connective tissue volume
• Associated with increased prevalence (OR 7.7)
and severity of Graves’ orbitopathy
Prummel. JAMA 1993;269(4):479.
Szucs-Farkas. Thyroid 2005;15(2):146.
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Case #3: 4 weeks later
• Follow up labs:
• TSH undetectable
• Free T4 0.7 (reference 0.7-1.6 ng/dL)
Next step:
Increase methimazole?
Decrease methimazole?
No change?
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Persistent TSH suppression
• Recovery of pituitary thyrotroph secretion after
tonic suppression from excess thyroid hormone
may take several months
• Free T4 should be used instead of TSH for guidance of
anti-thyroid therapy in hyperthyroidism
Pantalone. Cleve Clin J Med 2010;77(11):803.
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Case #4
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Case #4: Panhypopituitarism
• HPI
• 38 yo M
• Reports increasing fatigue x 2 months
• Status post craniopharyngioma resection at age 14 with
resulting panhypopituitarism
• Hydrocortisone 15mg po qam, 5mg po qpm
• Testosterone 100mg IM qweek
• Levothyroxine 175 mcg po daily (recent reduction)
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Case #4: Panhypopituitarism
• Labs
• Lytes, LFT’s, CBC normal
• Testosterone normal
• TSH 0.12 (reference 0.36-3.74 UIU/mL)
• Levothyroxine decreased to 150 mcg/day
• 8 weeks later
• TSH 0.36 UIU/mL
Reports worsening fatigue – what is the
likely explanation?
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Monitoring of thyroid replacement
in panhypopituitarism
Shimon. Thyroid 2002;12(9):823.
TSH is suppressed to <0.1 in nearly all patients
with central hypothyroidism on doses of thyroid
replacement sufficient to raise free T4 to normal
range
• Free T4 more appropriate for monitoring
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Case #5
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Case #5: Fatigue and depression
• HPI
• 26 yo M
• Constitutional symptoms of 6 months duration
• No headaches, visual disturbances
• Libido, sexual function intact
• PMH
• Chronic back pain
• Meds
• Oxycodone
• Ibuprofen
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Chronic opioids and testosterone
Serum testosterone
values in 10 male
subjects receiving
intrathecal morphine
([white circle]) and 10
male controls with
chronic pain but not
receiving opioids
plotted against an
envelope of normal
expected values Finch. Clin J Pain 2000;16(3):251-4.
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Chronic opioids and testosterone
Finch. Clin J Pain 2000;16(3):251-4.
Serum FSH levels in 12
postmenopausal subjects
receiving intrathecal morphine
([white circle]) and 10
postmenopausal controls with
chronic pain but not receiving
opioids plotted against the
lower limit of the normal range
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• FamHx
• Unremarkable
Case #5: Fatigue and depression
• SocHx
• No EtOH, tobacco, recreational drugs
• Physical
• Visual fields intact, normal thyroid, no gynecomastia
• Normal secondary sexual characteristics
• Testes 15 mL bilaterally
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• Labs
• CBC, Chem7, LFT’s normal
• TSH normal
• Total testosterone 103 ng/dL (low)
Case #5: Fatigue and depression
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Endocrine Society Guidelines
Bhasin. J Clin Endocrinol Metab 2010;95:2536-2559.
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• Labs (8 am)
• Total testosterone 112 ng/dL
• Free testosterone low
• LH normal
• FSH normal
• Prolactin normal
Case #5: Fatigue and depression
• Additional labs
• Cortisol normal
• Free T4 normal
• Ferritin normal
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Is pituitary MRI necessary?
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• Indications for pituitary imaging (secondary
hypogonadism):
• S/Sx of tumor mass effect (headache, visual changes)
• Evidence of panhypopituitarism
• Persistent hyperprolactinemia
• “Severe” secondary hypogonadism; testo < 150 ng/dL
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Pituitary abnormalities (MRI) more common
in severe secondary hypogonadism
0
5
10
15
20
25
Total
testosterone
<150 ng/dL
Total
testosterone
>150 ng/dL
Pre
va
len
ce
of p
itu
ita
ry
abnorm
alit
ies
Citron. J Urol. 1996;155(2):529-33.
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MRI
demonstrates
normal
pituitary gland
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Case #5: Treatment
Bhasin. J Clin Endocrinol Metab 2010;95:2536-2559.
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Case #5: Treatment
Bhasin. J Clin Endocrinol Metab 2010;95:2536-2559.
Check testosterone level 3-6 months later:
Target range 400-700 ng/dL
Intramuscular:
Check midway between injections
Transdermal:
3-12 hrs after application (patch)
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Bhasin. J Clin Endocrinol Metab 2010;95:2536-2559.
Contraindications
for starting
testosterone
therapy
www.urospec.com/uro/Forms/ipss.pdf
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Bhasin. J Clin Endocrinol Metab 2010;95:2536-2559.
Surveillance while on therapy (Baseline, 3-6
months, then annually)
• Hematocrit
• >54%?
• Prostate
• Palpable abnormality?
• PSA increase of >1.4 ng/mL within any 12-month period
of therapy?
• PSA velocity >0.4 ng/mL per year using the PSA level
after 6 months of therapy as a reference? (only valid if at
least 2 years of values available)
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Vigen. JAMA 2013;310(17):1829-36.
Cardiovascular risks of testosterone
replacement in older men?
29% increase in adverse
cardiovascular outcomes in those treated
with testosterone
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Case #5: Feeling good
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Questions?