Teaching Cases
Siara Teelucksingh
20th August 2015
Case 1
A 31-year-old man is referred to the local Hypertension Clinic because of
recently discovered hypertension that is labile and difficult to control.
On seeing him his Blood Pressure is 210/170 mmHg.
Serum Creatinine is 1.5 mg/dL and Serum Potassium is 3.2 mmol/L.
He is on Enalapril 10mg po od, Nifedipine 20mg po bd and Atenolol 50mg po
od, but not on any diuretic.
Question
Which of the following is the most likely diagnosis?
- Pheochromocytoma
- Cushings Syndrome
- Conns Syndrome
- Addisons Disease
- Essential Hypertension
Discussion: Secondary Causes of Hypertension
- Pheochromocytoma
- Cushings Syndrome
- Conns Syndrome- HTN, HypoK (Muscle cramps, Weakness, Arrhythmias)
- Diff to Treat HTN - Ensure no Diuretics - wean off AntiHTNsives x 4-6/52 -
PRA, Aldosterone - USS/CT/MRI Adrenal Adenoma or Adrenal Hyperplasia
- Renal Artery Stenosis
- Coarctation of the Aorta
Case 2
A 35 year old female presents with failure to lose weight after giving birth to a
baby 6 weeks prior. She complains of dry skin, feeling cold when others are fine
and constipation. On examination, she is hoarse, has evidence of hair thinning
and has a firm, painless swelling in her neck. She has a family history of
hypothyroidism.
Question
Which of the following is the most likely cause of her presentation?
Hashimotos Thyroiditis
de Quervains Thyroiditis
Postpartum Thyroiditis
Euthyroid Sick Syndrome
Sheehan Syndrome
Discussion: Hypothyroidism
- Hashimotos Thyroiditis
- Most common cause - Runs in Families - Positive Anti-TPO antibodies
- Insidious Onset
- Postpartum Thyroiditis
- Occurs within 6/12 postpartum - firm painless swelling - more common
in patients with anti-TPO positive - usually self-limiting - Sometimes
permanent hypothyroidism
Case 3
An 18 year old female presents with tremor, anxiety, heat intolerance,
palpitations, shortness of breath and a diffuse swelling in her neck.
She has noticed that her eyes appeared bright over the last few weeks.
Question
The following image is of her Thyroid Scintigraphy.
Graves disease
Toxic Nodule
Multinodular Goitre
de Quervains (Subacute Viral) Thyroiditis
Follicular Adenoma
Discussion: Hyperthyroidism
Causes of Hyperthyroidism
- Graves Disease
- Anti-TPO positive, Thyroid Scintigraphy shows diffuse uptake,
Associated with Thyroid Eye Disease, Responds well to Radioiodine
- Toxic Nodule
- Multinodular Goitre
- de Quervains (Subacute Viral) Thyroiditis
- Presents usually with pain, tender goitre and thyrotoxicosis - ESR
elevated - Treat with Prednisolone
Discussion
Thyroid Storm
- Unusual presentation of thyrotoxicosis and is precipitated by acute stress
in a previously undiagnosed patient
- Causes include infection, MI, DKA
- Inadequate adherence to therapy in an already diagnosed patient is
another cause
- Symptoms: Fever, Anxiety, Agitation, Sweating, Marked proximal
weakness, Tachycardias, Diarrhea, Heart Failure
- Mx: Carbimazole, B-Blockade, Digitalisation of AF, Corticosteroids
- Lugols iodine with Carbimazole achieves more rapid resolution
Case 4
A 55-year-old female presents with a 6 week history of nausea, abdominal pain,
constipation and right sided loin to groin pain associated with hematuria.
Renal ultrasound reveals bilateral renal calculi and routine biochemistry reveals
an elevated serum calcium of 11 mg/dL.
Her parathyroid hormone (PTH) level was found to be elevated.
A Tc99 Sestamibi Scan of Head/Neck/Upper Thorax revealed a parathyroid
adenoma.
Question
What is the most likely cause of her presentation?
Vitamin D toxicity
Primary hyperparathyroidism
Metastatic Breast Cancer
Sarcoidosis
Multiple Myeloma
Discussion: Hypercalcemia
The Tourniquet Effect can be a reason for hypercalcemia and as such, a first
elevated reading of Serum Calcium should be confirmed with a repeat sample
drawn without a tourniquet.
Intravenous Fluids
Insulin
Potassium
Bicarbonate
Antibiotics
Discussion: DKA - A Diabetic Emergency
Diabetic Ketoacidosis (DKA) is more common in T1DM than in T2DM.
Inadequate insulin causes lipolysis leading to ketosis and acidosis.
Common precipitating factors include: Inadequate insulin administration,
infections (eg. pneumonia, urinary tract infection), myocardial infarction, stroke,
gangrene.
Treatment is directed at the underlying cause and correction of the ketoacidotic
state. Here, the underlying cause, pneumonia, is treated with antibiotics. The
most important aspect of management is to give intravenous fluids as normal
saline, along with regular insulin. When the fluid balance is restored, the initially
high potassium concentration can fall and thus be corrected on its own or
monitored and supplemented as required.
Acidosis corrects itself, bicarbonate administration can impair cardiac function.
Case 12
A 25-year-old woman presents to the Reproductive Endocrinology Clinic with a
history of being unable to conceive after 2 years of using no contraception.
Normal
Primary Polydipsia
Osmotic diuresis
Pituitary diabetes insipidus
Nephrogenic diabetes insipidus
Discussion: Polyuria
Diabetes Insipidus (DI) is suspected when the urine output is >50 mL/kg/day
(>3000mL for a 60kg female). If the basal urine osmolality is <300 mOsmol/kg,
it suggests an osmotic diuresis.
If fluid deprivation causes a urine osmolality >300 mOsmol/kg, it suggests
psychogenic (primary) polydipsia.
If not, it is either pituitary (neurogenic) or nephrogenic DI.
These are differentiated by the administration of subcutaneous DDAVP, which
causes an increased urine osmolality to >300 mOsmol/kg in neurogenic DI.
MEN 1
Multiple Endocrine Neoplasia type 1 (MEN 1 or Werner Syndrome) has an
autosomal dominant mode of inheritance and involves the three Ps: Parathyroid,
Pituitary, Pancreas
- Hyperparathyroidism is the most common manifestation in MEN 1
- Prolactinomas are the most common in the pituitary gland
- The pancreas is the second most commonly involved organ in MEN 1.
Pancreatic tumours are associated with
- Pancreatic Polypeptide (75-85%
- Gastrin (Zollinger-Ellison Syndrome) - Recurrent Peptic Ulcers
- Insulinoma - Hypoglycemia
- Glucagonoma - Hyperglycemia & Rash (Necrolytic Migratory Erythema)
- VIPoma (Vasoactive Intestinal Peptide Secreting Tumour) - Diarrhea &
Hypokalemia
MEN 2
MEN 2 usually involves the thyroid and parathyroid glands and
pheochromocytoma.
- MEN 2A is characterised by medullary thyroid carcinoma, parathyroid
hyperplasia/adenoma and pheochromocytoma
- MEN 2B is associated with mucosal and gastrointestinal neuromas and
Marfanoid features