Endocrine Case Presentations
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1 Endocrine Case Presentations Matt Bouchonville Endocrinology Division Family Medicine Resident School March 19, 2014
2 Learning Objectives 1. Understand the evaluation and management of common thyroid disorders 2. Understand the evaluation and management of male hypogonadism
3 Case #1
4 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
5 Case #1: The incidental thyroid nodule PMH HTN GERD Meds HCTZ Ranitidine SocHx Teaches elementary school. No EtOH, tobacco. FamHx Negative for thyroid cancer.
6 Case #1: The incidental thyroid nodule Physical Labs Vitals normal No lid lag/stare No cervical lymphadenopathy No palpable thyroid nodules TSH normal Next step: Thyroid U/S Observation? Uptake/scan? FNA? L 1.6 cm hypoechoic nodule R 0.6 cm hypoechoic nodule
7 U/S-guided FNA FNA? Cooper. Thyroid 2009;20(6):674.
8 U/S-guided FNA Nodule features Threshold size for FNA Cooper. Thyroid 2009;20(6):674.
9 U/S-guided FNA High-risk patients History of thyroid cancer in 1 st degree relative External beam/ionizing radiation in youth Prior hemithyroidectomy with history of thyroid cancer 18 FDG avidity on PET scan History of MEN2 Calcitonin >100 pg/ml Cooper. Thyroid 2009;20(6):674.
10 U/S-guided FNA Nodule features HIGH RISK Threshold size for FNA Suspicious sonographic features Microcalcifications Infiltrative margins Hypoechoic Shape taller than width Increased vascularity Cooper. Thyroid 2009;20(6):674.
11 Case #1: FNA results Cytology: Positive for papillary thyroid cancer
12 Differentiated thyroid cancer Treatment: Total thyroidectomy +/- Lymph node dissection +/- I-131 treatment TSH suppression
13 Thyroid hormone suppression therapy (THST) High/intermediate risk: Goal TSH <0.1 Low risk: Goal TSH Jonklaas. Thyroid 2006;16(12):1229.
14 Case #2
15 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
16 Case #2: Found down Physical Obtunded Hypoxic Hypothermic Bradycardic Low normal BP Diminished heart sounds Nonpitting edema Vitiligo Labs Pending CXR Enlarged cardiac silhouette
17 Case #2: Found down Treatment IV thyroid replacement Develops Supportive refractory therapy hypotension/shock: What happened? MICU admission Intubation Careful IVF therapy Empiric antibiotics Passive rewarming
18 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
19 APS type 2 Primary adrenal insufficiency Hypothyroidism Type 1 diabetes Other: Pernicious anemia Primary biliary cirrhosis Vitiligo Myasthenia gravis Alopecia ITP Celiac disease Premature ovarian failure
20 Case #3
21 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
22 Case #3 PMH None Meds None SocHx +Tobacco use FamHx +Thyroid problem in the sister
23 Case #3 Physical Mild tachycardia Mild-moderate proptosis; EOMI, no conjunctival injection, no periorbital edema Is a thyroid uptake/scan indicated for this patient? 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
24 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.
25 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?
26 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 Szucs-Farkas. Thyroid 2005;15(2):146. Prummel. JAMA 1993;269(4):479.
27 Case #3: 4 weeks later Follow up labs: TSH undetectable Free T4 0.7 (reference ng/dl) Next step: Increase methimazole? Decrease methimazole? No change?
28 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.
29 Case #4
30 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)
31 Case #4: Panhypopituitarism Labs Lytes, LFT s, CBC normal Testosterone normal TSH 0.12 (reference UIU/mL) Reports worsening fatigue what is the likely explanation? Levothyroxine decreased to 150 mcg/day 8 weeks later TSH 0.36 UIU/mL
32 Monitoring of thyroid replacement in panhypopituitarism 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 Shimon. Thyroid 2002;12(9):823.
33 Case #5
34 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
35 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.
36 Chronic opioids and testosterone 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 Finch. Clin J Pain 2000;16(3):251-4.
37 Case #5: Fatigue and depression FamHx Unremarkable SocHx No EtOH, tobacco, recreational drugs Physical Visual fields intact, normal thyroid, no gynecomastia Normal secondary sexual characteristics Testes 15 ml bilaterally
38 Case #5: Fatigue and depression Labs CBC, Chem7, LFT s normal TSH normal Total testosterone 103 ng/dl (low)
39 Endocrine Society Guidelines Bhasin. J Clin Endocrinol Metab 2010;95:
40 Case #5: Fatigue and depression Labs (8 am) Total testosterone 112 ng/dl Free testosterone low LH normal FSH normal Prolactin normal Additional labs Cortisol normal Free T4 normal Ferritin normal
41 Is pituitary MRI necessary?
42 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
43 Prevalence of pituitary abnormalities Pituitary abnormalities (MRI) more common in severe secondary hypogonadism Citron. J Urol. 1996;155(2): Total testosterone <150 ng/dl Total testosterone >150 ng/dl
44 MRI demonstrates normal pituitary gland
45 Case #5: Treatment Bhasin. J Clin Endocrinol Metab 2010;95:
46 Case #5: Treatment Check testosterone level 3-6 months later: Target range ng/dl Intramuscular: Check midway between injections Transdermal: 3-12 hrs after application (patch) Bhasin. J Clin Endocrinol Metab 2010;95:
47 Contraindications for starting testosterone therapy Bhasin. J Clin Endocrinol Metab 2010;95:
48 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) Bhasin. J Clin Endocrinol Metab 2010;95:
49 Cardiovascular risks of testosterone replacement in older men? 29% increase in adverse cardiovascular outcomes in those treated with testosterone Vigen. JAMA 2013;310(17):
50 Case #5: Feeling good
51 Questions?
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