Endocrine cases. Cindy Chin, MD Pediatrics in the Red Rocks 2015

Transcription

1 Endocrine cases Cindy Chin, MD Pediatrics in the Red Rocks 2015

2 Objectives 1. Interpret thyroid function tests. 2. Identify growth curves worrisome for endocrine causes of short stature. 3. Define what constitutes precocious and delayed puberty. 4. Discuss endocrine workup for obesity

3 Outline Thyroid Growth Puberty Obesity

4 Thyroid Hypothalamic-pituitary-thyroid axis Thyroid labs Thyroid lab interpretation Treatment Summary Cases

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6 TSH: Marker of thyroid function

7 Total T 4 versus Free T 4 TBG T 3 T 4 Various metabolic effects Protein synthesis mrna DNA T 4 I T 3 Blood Tissue Target cell ssl.com/images/upload-

8 Factors that affect TBG affect Total T 4, Total T 3

9 T 4 metabolism T 3 + reverse T 3 T 4 (active) T (inactive) reverse T 3 3 T 2

10 Thyroid lab interpretation CONDITION: Normal Hyperthyroidism ( ) Hypothyroidism ( ) Primary Hypothyroidism ( ) Secondary TSH Normal Low ( ) High ( ) Low ( ) / T 4 (free) Normal High ( ) Low ( ) nl Low ( )

11 Thyroid lab interpretation CONDITION: Normal TSH Normal Hyperthyroidism ( ) Subclinical Low ( ) Hypothyroidism ( ) Subclinical High ( ) T 4 (free) Normal Normal Normal Adapted from

12 Treatment: Hypothyroidism Levothyroxine (LT 4 ) Administration Tablet only Crushed, mixed with a little milk/water Take from spoon (± syringe) Avoid calcium, iron, soy, and fiber Time of day:? (Some think it is stimulating)

13 Hypothyroidism: Treatment Levothyroxine (LT 4 ) Dosing Newborn: μg/kg/day 6-12 mo: 6-8 μg/kg/day 1-5 yo: 4-6 μg/kg/day 6-12 yo: 3-5 μg/kg/day 12 yo-adult: 2-4 μg/kg/day adult: average 1.75 μg/kg/day Adjust dose based on biochemical and clinical response. Too much, too quickly can adversely affect final adult height. Hypothyroidism: Delayed bone age Excessive treatment Bone age advancement > Height catch-up

14 Hypothyroidism: Treatment T 4 T 3 Human production ~ 10 1 Levothyroxine 100% Liothyronine (Cytomel) 100% Liotrix (Thyrolar) 4 1 Desiccated thyroid extract - Beef, pork (Armour, Westhroid, Nature-throid) ~ 4 1

15 Hyperthyroidism: Treatment Anti-thyroid drug (ATD) Methimazole: mg/kg/day (daily or BID) MOA: Inhibit thyroid hormone synthesis (mainly on TPO) Propylthiouracil: 5-10 mg/kg/day (TID) Black box warning: Liver toxicity MOA: Inhibit thyroid hormone synthesis (mainly on TPO), Inhibit peripheral T 4 T 3

16 Hyperthyroidism: Treatment β blocker For CV, neuromuscular overactivity Stop when euthyroid Atenolol: mg po daily Propanolol: 20 mg BID-QID Inhibit peripheral T 4 T 3 Do not use in asthma patients

17 Thyroid: Summary Primary method to evaluate thyroid function TSH, free T4 (± T 3 in hyperthyroidism) Interpretation of lab results Free T 4 Normal, subclinical, hypo-/hyper-thyroid TSH The cause (1 vs. 2 ) 1 st line therapy Hypothyroidism: Levothyroxine Hyperthyroidism: Methimazole

18 Thyroid: Case 1 TSH ( ) Free T 4 ( ) Total T 4 ( ) Decide if labs are: Normal Hypothyroidism: 1 versus 2 Hyperthyroidism Subclinical: Hypothyroidism versus Hyperthyroidism

19 Thyroid: Case 2 TSH ( ) Free T 4 ( ) Total T 4 (4.5-12) Initial mo later mo later Decide if labs are: Normal Hypothyroidism: 1 versus 2 Hyperthyroidism Subclinical: Hypothyroidism versus Hyperthyroidism

20 Thyroid: Case 3 TSH ( ) Free T 4 ( ) 4 weeks old weeks old weeks old Decide if labs are: Normal Hypothyroidism: 1 versus 2 Hyperthyroidism Subclinical: Hypothyroidism versus Hyperthyroidism

21 Thyroid: Case 4 TSH ( ) Total T 4 (4.5-12) Total T 3 (71-180) < Decide if labs are: Normal Hypothyroidism: 1 versus 2 Hyperthyroidism Subclinical: Hypothyroidism versus Hyperthyroidism

22 Thyroid: Case 5 TSH ( ) Free T 4 ( ) Decide if labs are: Normal Hypothyroidism: 1 versus 2 Hyperthyroidism Subclinical: Hypothyroidism versus Hyperthyroidism

23 Growth: Case 1 11 yo M: Concern for short stature

24 Short stature Birth history Skeletal maturation/potential Habits/other history Growth pattern Suspected endocrinopathy

25 Birth history Short stature Pregnancy complications Birth Anthropometrics: Length, weight Prematurity Abnormalities Midline defects Hypoglycemia/jitteriness Significant jaundice Male: Microphallus Female: Puffiness of hands/feet, neck webbing SGA without catch-up growth by 2-4 yo GH indication Raise concern for hypopituitarism - GH deficiency - TSH deficiency - ACTH deficiency Turner syndrome

26 Short stature Skeletal maturation/potential 1 st tooth eruption 1 st tooth shedding Genetic height potential Parental heights (if possible measure yourself) Mid-parental height Familial puberty timing Maternal/sister s menarche When father/brother stopped growing

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28 Mid-parental height If not enough time to calculate, here is a calculator:

29 Rose SR et al. Peds in Review, 2005, 26: 414

30 Rose SR et al. Peds in Review, 2005, 26: 414

31 Habits Nutrition Sleep Other history Short stature Head trauma (e.g., meningitis, loss of consciousness) Co-morbidities (e.g., asthma, ADHD, CV/renal/other)

32 Rose SR et al. Peds in Review, 2005, 26: 414

33 Normal growth 0-1 yo months months months Age Weight velocity Height velocity 30 g/day 20 g/day 10 g/day 25 cm/yr (10 inch/yr) 1-2 years 2 kg/yr 10 cm/yr (4 inch/yr) 2-4 years 2 kg/yr 7.5 cm/yr (3 inch/yr) 4 years - puberty 2 kg/yr 5 cm/yr (2 inch/yr) Puberty 10 cm/yr (4 inch/yr)

34 Growth velocity Boy (similar one exists for girls)

35 Supine length: Until 2 years old

36 Standing height: Average of 3 measurements (within 0.3 cm of each other) Look straight ahead Shoulders relaxed Arms at sides Shoulder blades, buttocks, and heels touching measurement surface Legs straight, knees together Feet flat, heels almost together, feet pointed outward at 60 angle

37 Growth: Case 1 11 yo M: Concern for short stature MPH

38 Growth: Case 1 11 yo M: Concern for short stature MPH x x x

39 Growth: Case 1 11 yo M: Concern for short stature MPH MPH x x x If referring to pediatric endocrinology, please send growth charts/measurements.

40 Upper:lower segment ratio Standing height lower segment Upper segment Pubic symphysis Lower segment Distance from pubic symphysis to floor Feet together

41 Arm span Fingertip to fingertip

42 Rose SR et al. Peds in Review, 2005, 26: 414

43 Rose SR et al. Peds in Review, 2005, 26: 414

44 Endocrinopathy Short stature Treatment initiation Rose SR et al. Peds in Review, 2005, 26: 414

45 GH deficiency

46 GH deficiency: Treated

47 Physical exam General Features of specific syndromes Upper:lower segment calculation, arm span Face/ENT Midline defects Teeth development Tonsillar hypertrophy Neck Webbing Thyromegaly Chest Nipple placement/shield chest CV Edema in hands/feet Murmur MSK n/skillsmodules/content/physical- assessment-child/images/pa-child- HFN_t2.jpg Hands: Shortening of metacarpals, clinodactyly, palmar crease Pectus carinatum/excavatum Pubertal staging Neuro (for potential CNS cause)

48 Endocrine short stature workup Bone Age General CBC, CMP, ESR, urinalysis Growth hormone IGF-1, IGFBP-3 Thyroid TSH, free T4 Cushing Midnight salivary cortisol, 24h urine free cortisol Celiac disease: IgA, ttg IgA If girl: Karyotype

49 Birth history Summary Birth parameters SGA? Concerns for hypopituitarism? Syndromic features? Skeletal maturation/potential Teeth development Parental heights Mid-parental height Parental puberty pattern Habits: Diet, sleep Co-morbidities & medications Growth pattern Referral necessary? To whom?

50 Rose SR et al. Peds in Review, 2005, 26: 414

51 Cause Bone Age Growth Velocity Constitutional Growth delay Familial short stature? FHx? Proportionate growth Delayed Normal Yes Yes Normal Normal Yes Yes Chronic disease Delayed Decreased (wgt> hgt) Depends on underlying cause Endocrinopathy Delayed Decreased Usually none Yes (except hypothyroid) Syndromic causes Normal Decreased Depends on underlying cause Yes Often not (esp if skeletal dysplasia) Adapted from

52 Growth: Case 1 11 yo M: Concern for short stature MPH MPH

53 For each of the following cases: Does the growth fit a pattern? Constitutional growth delay Familial short stature Chronic disease Endocrinopathy Syndrome Refer? To whom?

54 Growth: Case 1 11 yo M: Concern for short stature MPH

55 For each of the following cases: Does the growth fit a pattern? Constitutional growth delay Familial short stature Chronic disease Endocrinopathy Syndrome Refer? To whom?

56 Male Growth: Case 2

57 For each of the following cases: Does the growth fit a pattern? Constitutional growth delay Familial short stature Chronic disease Endocrinopathy Syndrome Refer? To whom?

58 Growth: Case 3 Female

59 For each of the following cases: Does the growth fit a pattern? Constitutional growth delay Familial short stature Chronic disease Endocrinopathy Syndrome Refer? To whom?

60 Male Growth: Case 4

61 For each of the following cases: Does the growth fit a pattern? Constitutional growth delay Familial short stature Chronic disease Endocrinopathy Syndrome Refer? To whom?

62 Growth: Case 4 Male

63 Growth: Case 5 Female

64 For each of the following cases: Does the growth fit a pattern? Constitutional growth delay Familial short stature Chronic disease Endocrinopathy Syndrome Refer? To whom?

65 Puberty Normal puberty Precocious puberty Delayed puberty Cases

66 Hypothalamic-pituitary-gonadal axis

67 Timing of puberty

68 Gonadotropin (LH and FSH) production Mini-puberty of infancy 2 weeks 2 months 9-10 years Time after birth

69 Timing of puberty: Mediating factors Family patterns: Early/late bloomers Father: When stopped growing Mother: Age at menarche Skeletal maturation Hormone deficiencies or chronic illness Delayed bone age Delayed onset of puberty Nutritional status Higher BMI Earlier puberty

70 Puberty: Normal Range for Onset Girls Youngest 6 years in African Americans 7 years in Caucasians Classic teaching: 8 years Mean: 9-10 years Oldest: 13 years

71 Signs of Puberty: Female 1 st visible sign

72 Tanner stages: Female

73 Signs of Puberty: Male 1 st visible sign

74 Tanner stages: Male

75 Testicular Volume Tanner stage Volume (ml) <

76 Puberty: Female vs. Male

77 Precocious puberty Signs of sexual maturation (androgen and estrogen activity) at an earlier than normal age.

78 Precocious puberty Girls: Any breast/pubic hair: <7 yo (Caucasian), <6 yo (AA) 7 yo (Caucasian) 6 yo (AA) Rapid progression of puberty Rapid bone age advancement New CNS findings Emotional state adversely affected Boys: <9 yo

79 Precocious puberty Differential diagnosis Normal variant Premature thelarche Premature adrenarche Hypothyroidism True precocious puberty

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81 Precocious puberty: Central vs. peripheral

82 True precocious puberty: Differential diagnoses Central Idiopathic (girls) CNS tumor Other CNS disorder hcg producing tumor (boys) Genetic Peripheral Congenital adrenal hyperplasia McCune-Albright syndrome Testotoxicosis Gonadal tumor Adrenal tumor

83 Precocious puberty Potential workup Bone age FSH, LH, estradiol/testosterone (on pediatric assays) 17-OH progesterone, androstenedione, DHEA-S TSH, free T 4

84 Delayed puberty No secondary sexual characteristics Girls (no thelarche): > 13 years Boys (testes < 4 ml): > 14 years Primary amenorrhea (No menarche: ) By 16 years Within 3 years of thelarche

85 Delayed puberty Differential diagnosis Normal variant/constitutional growth delay Secondary to chronic illness Hypergonadotropic hypogonadism Hypogonadotropic hypogonadism Hypothyroidism Prolactinoma Turner syndrome

86 Delayed puberty: 1 vs. 2 hypogonadism

87 Delayed puberty Potential workup Bone age FSH, LH, estradiol/testosterone (on pediatric assays) TSH, free T 4 Prolactin

88 Case 1 CC: Breast development HPI: 3 yo girl Mother noticed breast development in the newborn period which regressed. Left breast enlarged again at 18 months At 20 months the right enlarged as well months for one month, nipple prominent ROS: No vaginal bleeding, body odor, acne FHx: No one with early puberty Dad: 5 9 Mom: 5 4

89 Case 1 Physical Exam: - Healthy appearing - Breast: Tanner 3, 5cm, nipples small - GU: Tanner 1

90 Puberty case: Framework Age: Early, normal, late Growth velocity: Fast, normal, slow Family history Mid-parental height Puberty Sex hormone activity: Androgen/estrogen/both/neither Proposed workup Refer?

91 CC: Shoulder injury HPI: 6 year old boy Physical exam Case 2 Skin: + Axillary hair GU: Tanner 4 pubic hair Phallic enlargement Testes 2mL bilaterally Further history Always taller than his fraternal twin brother. Gap widening

92 Case 2

93 Puberty case: Framework Age: Early, normal, late Growth velocity: Fast, normal, slow Family history Mid-parental height Puberty Sex hormone activity: Androgen/estrogen/both/neither Proposed workup Refer?

94 Case 3 CC: Well child visit HPI: 14 year old girl Physical exam Breast: Tanner 1 GU: Tanner 1 Extremities: Edema of hands and feet Family history Father: 5 11 Mother: 5 3, menarche 12 years old

95 Puberty case: Framework Age: Early, normal, late Growth velocity: Fast, normal, slow Family history Mid-parental height Puberty Sex hormone activity: Androgen/estrogen/both/neither Proposed workup Refer?

96 Case 4 CC: Lack of menses HPI: 17 year old girl History: Breast development in 3 rd grade Increased body odor in 4 th grade Axillary/pubic hair in 5 th grade ROS: No abdominal cramping, no acne or excess/coarse hair Physical exam BMI: 65 th %ile Breast: Tanner 5 GU: Tanner 5 Family history Father: 6 0 Mother: 5 4, menarche at 10 years old

97 Obesity Genetic causes Co-morbidities Lab evaluation Participant questions

98 Genetic causes of obesity Dysmorphic syndromes Albright hereditary osteodystrophy Alström Bardet-Biedl Carpenter Cohen Prader-Willi Wit JM et al. Hormone Researche, 2007, 68 (Suppl 2):

99 Albright hereditary osteodystrophy

100 Alström Bardet-Biedl Laurence-Moon Type 2 diabetes mellitus x x Hypogonadism x x Mental retardation x x Obesity x x Post-axial polydactyly Renal dysfunction x x Retinitis pigmentosa x x x x Sensorineural hearing loss Spastic paraplegia x x Forsythe E & Beales PL. Eur J Hum Genetics, 2013, 21: 8-13 Marshall JD et al. Curr Genomics, 2011, 12: Wit JM et al. Hormone Research, 2007, 68 (Suppl 2):

101 Bardet-Biedl syndrome A-D: Typical facial features (subtle, not always present). Features include deepset eyes, hypertelorism, downward slanting palpebral fissures, a flat nasal bridge, small mouth, malar hypoplasia and retrognathia. (e) Brachydactyly and scars from excision of accessory digits. (f) Dental crowding. (g) High-arched palate. (h) Fundoscopy demonstrating rod-cone dystrophy. Forsythe E & Beales PL. Eur J Hum Genetics, 2013, 21: 8-13

102 Carpenter syndrome = _humu0032-E2069-f2&req=4

103 Cohen syndrome El Chehadeh-Dhebbar S et al. Eur J Hum Genetics, 2013, 21:

104 Prader Willi syndrome (a) An 8-month-old female with hypotonia and G-tube. (b) A 19-year-old male typical body habitus with fat distributed primarily in abdomen, hips, and thighs. (BMI = 67; Z score = +3.49) (c) A 34-year-old man in relatively good dietary control. (BMI = 30; Z score = +1.66) Cassidy SB et al. Genetics in Medicine, 2012, 14: 10-26

105 Genetic causes of obesity Monogenic obesity Leptin Leptin receptor POMC (Pro-opiomelanocortin) Prohormone convertase MC3R MC4R MC4R MC3R POMC Leptin - R Leptin Speiser PW et al. JCEM, 2005, 90: Seely RJ & Woods SC. Nat Rev Neuroscience, 2003, 4:

106 Genetic causes: Summary Genetic causes of obesity exist. However diagnosis does not yet change management of the obesity.

107 Potential co-morbidities Cholelithiasis Dyslipidemia Hypertension Musculoskeletal conditions Non-alcoholic fatty liver disease Obstructive sleep apnea Polycystic ovary syndrome Type 2 diabetes mellitus August GP et al. JCEM, 2008, 93:

108 Endocrine causes of obesity: Lab evaluation Endocrine causes Growth hormone deficiency/hypopituitarism Hypothyroidism Cushing syndrome Usually not recommended unless: Height velocity Growing at lower height %tile than predicted by midparental height August GP et al. JCEM, 2008, 93:

109 Endocrine causes of obesity: Lab evaluation Endocrine causes Growth hormone deficiency/hypopituitarism GH deficiency: IGF-1, IGBP-3 ACTH deficiency: 8 AM serum cortisol Hypothyroidism TSH, free T4 Cushing syndrome Midnight salivary cortisol, 24h urine free cortisol Usually not recommended unless: Height velocity Growing at lower height %tile than predicted by mid-parental height August GP et al. JCEM, 2008, 93:

110 Potential co-morbidities: Lab evaluation Cholelithiasis Dyslipidemia Fasting lipid panel Hypertension Musculoskeletal conditions Non-alcoholic fatty liver disease - CMP Obstructive sleep apnea Polycystic ovary syndrome 17-OHP, androstenedione, DHEA-S, free testosterone TSH, free T4 Prolactin Type 2 diabetes mellitus Hemoglobin A1c, fasting glucose, (not usually 1 st test: 2h OGTT)

111 AAP Vitamin D: Screening No universal screening for children who are: Healthy Dark skinned Obese Endocrine Society Not the general population Pediatrics: Screen those at risk Obese Black, Hispanic Malabsorption Medications: Glucocorticoid, anticonvulsant, antifungal, antiretroviral IOM: No specific screening recommendations Golden NH et al. Pediatrics, 2014, 134: e1229-e1243 Holick MF et al. JCEM, 2011, 96: Institute of Medicine, Dietary Reference Intakes for Calcium and Vitamin D. 2010

112 AAP Vitamin D: Screening No universal screening for: Healthy Dark skinned Obese Mention conditions at risk for reduced bone mass (table) Conditions Associated with Reduced Bone Mass in Children and Adolescents Genetic conditions Osteogenesis imperfecta Idiopathic juvenile osteoporosis Turner syndrome Chronic illness Cystic fibrosis Connective tissue disorders (lupus, juvenile idiopathic arthritis, juvenile dermatomyositis) Inflammatory bowel disease, celiac disease Chronic renal failure Childhood cancer Cerebral palsy Chronic immobilization Eating disorders, including anorexia nervosa, bulimia nervosa, eating disorders NOS, and the female athlete triad Endocrine conditions Cushing syndrome Hypogonadism Hyperthyroidism Hyperparathyroidism Growth hormone deficiency Diabetes mellitus Medications Glucocorticoids Anticonvulsants Chemotherapy Leuprolide acetate Proton pump inhibitors SSRIs DMPA Table adapted from Golden NH et al. Pediatrics, 2014, 134: e1229-e1243

113 Vitamin D Vitamin D level ng/ml (nmol/l) Endocrine Society Institute of Medicine Pediatric Endocrine Society Severe deficiency 5 (12.5) Deficiency < 20 (50) < 12 (30) 15 (37.5) Insufficiency ( ) (30-50) ( ) Sufficiency (75-250) (50-125) (50-250) Excess > 50 (125) > 100 (250) Intoxication > 150 (375) Holick MF et al. JCEM, 2011, 96: Institute of Medicine, Dietary Reference Intakes for Calcium and Vitamin D Misra M et al. Pediatrics, 2009: 122:

114 Vogiatzi MG et al. JCEM, 2014, 99:

115 Lab evaluation: Summary Do not routinely screen for endocrine causes of obesity unless concern for poor height velocity or growing at a lower than expected percentile. Co-morbidity screening CMP, fasting lipid panel, hemoglobin A1c Vitamin D: Screening and sufficiency levels are controversial