Clinical Case
Group consisting of Fabian Nelson,
Maximous Philobos, Sonny Brar and
Ajay Singh
Clincial Case Intro
• A 43 year old woman is brought to the
emergency department 1 hour after a stranger
stole her purse. ...
Which of the following is the most
likely explanation for her symptoms?
•
•
•
•
•

B-cell hypersecretion
Cushing disease
G...
Beta-Cell hypersecretion

Beta- Cell hypersecretion is an excess secretion
of insulin from the beta cells of the pancreas....
Symptoms
1.
2.
3.
4.
5.

Anxiety and sweating.
Body tremors
Elevated body temperature
Disorientation
The patient can go in...
Treatment
In patients with indolent, slow-growing
metastatic islet cell tumors, the best therapy
may be careful observatio...
Prognosis
They are uncommon cancers with about 1,000
new cases per year in the United States. They
account for 3% to 5% of...
Cushing Disease Definition
• AKA Cushing Syndrome or Hypercortisolism
• Occurs when your body is exposed to high
levels of...
Cushing Disease Definition (Cont.)
• Hallmark signs:
• Fatty hump between shoulders
• Rounded face
• Pink or purple stretc...
Cushing Disease Definition (Cont.)
• Treatments for disease can return body’s
cortisol levels to normal
• Noticeably impro...
Common signs and symptoms
• Involves progressive and skin changes that are
as follows:
• Weight gain and fatty tissue depo...
Common signs and symptoms (Cont.)
• Women with Cushing Disease:
• Thicker or more visible body and facial hair (hirsutism)...
Common signs and symptoms (Cont.)
• Additional signs and
symptoms:
• Fatigue
• Muscle weakness
• Depression, anxiety
and i...
Causes of Cushing Disease
• Results from excess levels of cortisol in body
• Endocrine system consists of glands that regu...
Causes of Cushing Disease (Cont.)
• Adrenal gland secretes cortisol and many
other hormones
• Cortisol has a variety of ro...
Corticosteroids role
• Disease can develop from cause that comes
from outside our body (exogenous Cushing
Disease)
• High ...
Corticosteroids role (Cont.)
• They may be prescribed by a doctor to treat:
• Inflammatory diseases (Ex: Rheumatoid Arthri...
Corticosteroids role (Cont.)
• Certain inhaled steroid medicines (taken for
Asthma)
• Steroid skin creams used for skin ma...
Our Body’s own Overproduction
• The disease can result from our body’s own
overproduction of cortisol (endogenous
Cushing ...
Complications
• Do not receive immediate treatment, other
complications may occur:
• Bone loss (osteoporosis), which can r...
Glaucagon-secreting adenoma
A glucagonoma is a tumor that secretes
glucagon, a hormone normally produced in the
pancreas a...
What is the occurrence of Glucagonoma?
Overall glucagonomas are rare neuroendocrine
tumors. It only accounts for about 1% ...
Symptoms
•
•
•
•
•

Unintentional weight loss
Inflamed mouth
Diarrhea
Increased appetite
Anemia
Causes
The causes of a glucagonoma are unknown.
Patients may have a family history of glucagonoma.
The condition is also a...
Diagnosis
A diagnosis of glucagonoma is often missed as
these tumors are rare. The presence of the 4 D’s
– diabetes, derma...
Treatment
• Octreotide is a drug that inhibits the secretion of glucagon. It can
help relieve some of the symptoms associa...
Prognosis
The survival rate for a glucagonoma is poor. The
tumor grows very slowly so there are cases
where patients live ...
Pancreatitis
• Pancreatitis is inflammation in the pancreas
• The pancreas is a long, flat, mixed exocrine
and endocrine g...
Pancreatic Enzymes
• Pancreas secretes three important enzymes:
– Protease: digestion of proteins
– Lipase: hydrolysis of ...
What happens in Pancreatitis?
• Pancreatitis occurs when digestive enzymes
produced in the pancreas become activated
while...
Trypsin and Chymotrypsin
• Both enzymes are synthesized in their inactive forms:
– Trypsinogen
– Chymotrypsinogen

• In no...
Trypsin and Chymotrypsin (Cont.)
• Once trypsinogen and chymotrypsinogen are
released into the lumen of the small intestin...
What Goes Wrong?
• In pancreatitis, the enzymes become activated
while still in the pancreas.
• Causing the enzymes to irr...
Causes
•
•
•
•
•
•
•
•
•

Alcoholism
Gallstones
Abdominal surgery
Medications
Smoking
Cystic fibrosis
Family history
High ...
Forms of Pancreatitis
• Acute:
– Upper abdominal pain
– Abdominal pain that radiates to the back
– Abdominal pain that fee...
Forms of Pancreatitis (Cont.)
• Chronic:
– Upper abdominal pain
– Indigestion
– Losing weight without trying
– Oily, smell...
Complications
•
•
•
•
•
•
•

Breathing problems
Diabetes
Infection
Kidney failure
Malnutrition
Pancreatic cancer
Pancreati...
Normal Stress Hormone Response
• When you encounter a perceived threat
(robbery in this case)
• The hypothalamus, a tiny r...
Hormones
• Some of the hormones release:
– Adrenaline: increases heart rate, elevates blood
pressure and boosts energy sup...
Other Effects of Cortisol
• Alters immune system responses
• Suppresses the digestive system, the
reproductive system and ...
When the Natural Stress Response
Goes Haywire!
• The body's stress-response system is usually
self-limiting
• However over...
Long Term Complications
•
•
•
•
•
•
•

Anxiety
Depression
Digestive problems
Heart disease
Sleep problems
Weight gain
Memo...
In Conclusion
• Collectively, we feel the appropriate choice to
the case would be the normal stress hormone
response.
• In...
Normal Stress Hormone Response
The normal stress hormone response is
initially very debilitating but recovery will
occur w...
Treatment
• If the patient manifests PTSD, treatment
would depend on the symptoms and how
soon they occurred after the inc...
6 Phases of Cognitive Behavioral
Therapy
1.
2.
3.
4.
5.
6.

Assessment or psychological assessment
Reconceptualization
Ski...
Paroxetine
• Belongs to selective-serotonin reuptake
inhibitors
• Used to treat mental depression, obsessivecompulsive dis...
Mirtazapine
• Belongs to tetracyclic antidepressants
• Works on CNS to make certain chemicals in
the brain stronger
• Used...
THE END
Just kidding
Sources
• Bowen, R. "Exocrine Secretions of the Pancreas." Exocrine
Secretions of the Pancreas. Colorado State University,...
Sources (Cont.)
• Staff, Mayo Clinic. ”Cushing Syndrome." Mayo
Clinic. Mayo Foundation for Medical Education
and Research,...
• Tammy. “Dealing with stress.”
Tammysyoga.co.uk. 13 Jun 2013. Web. 17 Nov
2013. “Post-traumatic stress disorder.” NHS
Cho...
• “Mirtazapine (Oral Route).” Mayo
Foundation for Medical Education and
Research. 13 Jul 2013. Web. 17 Nov 2013.
• “Paroxe...
A 43 year old woman is brought to the emergency department 1 hour after a stranger stole her purse.
A 43 year old woman is brought to the emergency department 1 hour after a stranger stole her purse.
A 43 year old woman is brought to the emergency department 1 hour after a stranger stole her purse.
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A 43 year old woman is brought to the emergency department 1 hour after a stranger stole her purse.

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A 43 year old woman is brought to the emergency department 1 hour after a stranger stole her purse. She is agaitated and extremely upset. She is 163 cm (5 ft 4 in) tall and weight 91 kg (200 lb); BMI is 34 kg/m2. Physical examination show no other abnormalities. Her blood glucose concentration is increased.

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A 43 year old woman is brought to the emergency department 1 hour after a stranger stole her purse.

  1. 1. Clinical Case Group consisting of Fabian Nelson, Maximous Philobos, Sonny Brar and Ajay Singh
  2. 2. Clincial Case Intro • A 43 year old woman is brought to the emergency department 1 hour after a stranger stole her purse. She is agaitated and extremely upset. She is 163 cm (5 ft 4 in) tall and weight 91 kg (200 lb); BMI is 34 kg/m2. Physical examination show no other abnormalities. Her blood glucose concentration is increased.
  3. 3. Which of the following is the most likely explanation for her symptoms? • • • • • B-cell hypersecretion Cushing disease Glucagon-secreting adenoma Pancreatitis Normal stress hormone response
  4. 4. Beta-Cell hypersecretion Beta- Cell hypersecretion is an excess secretion of insulin from the beta cells of the pancreas. A tumor of the inslet beta cells will cause an overproduction of insulin. Causing hypoglycemia, there is a very low incidence of this condition.
  5. 5. Symptoms 1. 2. 3. 4. 5. Anxiety and sweating. Body tremors Elevated body temperature Disorientation The patient can go into Insulin shock due to brain hypoglycemia.
  6. 6. Treatment In patients with indolent, slow-growing metastatic islet cell tumors, the best therapy may be careful observation, and no treatment until palliation is required. Chemotherapy, and in some instances surgery is necessary.
  7. 7. Prognosis They are uncommon cancers with about 1,000 new cases per year in the United States. They account for 3% to 5% of pancreatic malignancies and overall have a better prognosis than the more common pancreatic exocrine tumors. Fiveyear survival is about 55% when the tumors are localized and resected but only about 15% when the tumors are not resectable. Overall 5-year survival rate is about 42%.
  8. 8. Cushing Disease Definition • AKA Cushing Syndrome or Hypercortisolism • Occurs when your body is exposed to high levels of cortisol for an extended time. • Most common cause is use of oral corticosteroid medication. • Condition can also occur when body makes to much cortisol.
  9. 9. Cushing Disease Definition (Cont.) • Hallmark signs: • Fatty hump between shoulders • Rounded face • Pink or purple stretch marks on skin • Can also result in: • High blood pressure • Bone loss • Diabetes on occasion
  10. 10. Cushing Disease Definition (Cont.) • Treatments for disease can return body’s cortisol levels to normal • Noticeably improve the symptoms • Also, the earlier treatment begins, the better chance are for recovery.
  11. 11. Common signs and symptoms • Involves progressive and skin changes that are as follows: • Weight gain and fatty tissue deposits, particularly around the midsection and upper back, in the face (moon face), and between the shoulders (buffalo hump) • Pink or purple stretch marks (striae) on the skin of the abdomen, thighs, breasts and arms • Thinning, fragile skin that bruises easily • Slow healing of cuts, insect bites and infections • Acne
  12. 12. Common signs and symptoms (Cont.) • Women with Cushing Disease: • Thicker or more visible body and facial hair (hirsutism) • Irregular or absent menstrual periods • Men with Cushing Disease: • Decreased libido • Decreased fertility • Erectile dysfunction
  13. 13. Common signs and symptoms (Cont.) • Additional signs and symptoms: • Fatigue • Muscle weakness • Depression, anxiety and irritability • Loss of emotional control • Cognitive difficulties • New or worsened high blood pressure • Glucose intolerance that may lead to diabetes • Headache • Bone loss, leading to fractures over time
  14. 14. Causes of Cushing Disease • Results from excess levels of cortisol in body • Endocrine system consists of glands that regulate processes throughout our bodies • The glands are: • • • • • • • Adrenal glands Pituitary gland Thyroid gland Parathyroid gland Pancreas Ovaries Testicles
  15. 15. Causes of Cushing Disease (Cont.) • Adrenal gland secretes cortisol and many other hormones • Cortisol has a variety of roles in our body: • helps regulate your blood pressure and keeps your cardiovascular system functioning normally • helps your body respond to stress and regulates the way you convert (metabolize) proteins, carbohydrates and fats in your diet into usable energy
  16. 16. Corticosteroids role • Disease can develop from cause that comes from outside our body (exogenous Cushing Disease) • High does of corticosteriods taken over long periods can result in the disease • These meds like prednisone have the same effects the cortisol produced by our body
  17. 17. Corticosteroids role (Cont.) • They may be prescribed by a doctor to treat: • Inflammatory diseases (Ex: Rheumatoid Arthritis) • Lupus and Asthma • Prevent the rejection of transplanted organ • Develop disease from injectable corticosteroids: • Repeated injections for joint pain, bursitis and back pain
  18. 18. Corticosteroids role (Cont.) • Certain inhaled steroid medicines (taken for Asthma) • Steroid skin creams used for skin maladies like eczema • Important to note that this is less likely to cause Cushing’s Disease but in same general category of drugs • But the disease might occur in some individuals if drugs are taken in high doses
  19. 19. Our Body’s own Overproduction • The disease can result from our body’s own overproduction of cortisol (endogenous Cushing Disease): • • • • Pituitary gland tumor (pituitary adenoma) Ectopic ACTH-secreting tumor Primary adrenal gland disease Familial Cushing Disease
  20. 20. Complications • Do not receive immediate treatment, other complications may occur: • Bone loss (osteoporosis), which can result in unusual bone fractures, such as rib fractures and fractures of the bones in the feet • High blood pressure (hypertension) • Diabetes • Frequent or unusual infections • Loss of muscle mass and strength • If cause is a pituitary tumor, this can lead to other problems such as disrupting the production of other hormones that the pituitary controls
  21. 21. Glaucagon-secreting adenoma A glucagonoma is a tumor that secretes glucagon, a hormone normally produced in the pancreas and responsible for raising blood sugar (glucose) levels. Glucagonomas are almost entirely found in the pancreas, arising from the alpha-2 cells of the gland, and about 80% of these tumors are malignant (cancerous). The tumor can cause elevated blood glucose levels known as glucagonoma syndrome but this is not present in every case.
  22. 22. What is the occurrence of Glucagonoma? Overall glucagonomas are rare neuroendocrine tumors. It only accounts for about 1% of all neuroendocrine tumors. The incidence of glucagonomas is estimated to be about 1 in 20 million people. The high risk age group is between 40 to 70 years with the average age of onset being 55 years. Women seem to be more likely than men to develop glucagonomas.
  23. 23. Symptoms • • • • • Unintentional weight loss Inflamed mouth Diarrhea Increased appetite Anemia
  24. 24. Causes The causes of a glucagonoma are unknown. Patients may have a family history of glucagonoma. The condition is also associated with multiple endocrine neoplasia (MEN) type I which is a known risk factor. A glucagonoma is a neuroendocrine tumor that is localized to the pancreas in almost all cases. Secretion of glucagon arises either as a result of the mass apply pressure on the glucagonsecreting alpha-2 pancreatic cells or the tumor cells itself producing and secreting glucagon independently.
  25. 25. Diagnosis A diagnosis of glucagonoma is often missed as these tumors are rare. The presence of the 4 D’s – diabetes, dermatitis (necrolytic migratory erythema), deep vein thrombosis and depression – should raise the concern about a glucagonoma. The confirmation of the diagnosis involves several investigations such as Blood Test and Scans.
  26. 26. Treatment • Octreotide is a drug that inhibits the secretion of glucagon. It can help relieve some of the symptoms associated with a glucagonoma but may worsen diabetes. • Chemotherapy is reserved for cases where surgery is not possible or the cancer has already spread (metastasis). However, chemotherapy has a very limited use in the treatment of glucagonomas. • Surgery is ideal in that the tumor can be removed and all symptoms will resolve thereafter. Due to the high chance of spread and often late diagnosis, some of the healthy tissue surrounding the tumor and regional lymph nodes are resected as well
  27. 27. Prognosis The survival rate for a glucagonoma is poor. The tumor grows very slowly so there are cases where patients live for 15 years or more after diagnosis. The 5 year survival rate is about 85% after surgery where the tumor was localized to the pancreas and successfully removed.
  28. 28. Pancreatitis • Pancreatitis is inflammation in the pancreas • The pancreas is a long, flat, mixed exocrine and endocrine gland that sits tucked behind the stomach in the upper abdomen. • The pancreas produces enzymes that help digestion and hormones that help regulate the way the body processes sugar (glucose).
  29. 29. Pancreatic Enzymes • Pancreas secretes three important enzymes: – Protease: digestion of proteins – Lipase: hydrolysis of triglycerides – Amylase: hydrolysis of starch into maltose (a glucose-glucose disaccharide) • Some of which are secreted in active and inactive forms
  30. 30. What happens in Pancreatitis? • Pancreatitis occurs when digestive enzymes produced in the pancreas become activated while inside the pancreas, causing damage to the organ. • The enzymes responsible are proteases: – Trypsin – Chymotrypsin
  31. 31. Trypsin and Chymotrypsin • Both enzymes are synthesized in their inactive forms: – Trypsinogen – Chymotrypsinogen • In normal digestion, these Enzymes are synthesized and packaged into secretory vesicles which is a way for the cells to safely handle these enzymes • secretory vesicles also contain a trypsin inhibitor which serves as an additional safeguard should some of the trypsinogen be activated to trypsin; following exocytosis this inhibitor is diluted out and becomes ineffective to allow for proper function in small Intestine
  32. 32. Trypsin and Chymotrypsin (Cont.) • Once trypsinogen and chymotrypsinogen are released into the lumen of the small intestine, they must be converted into their active forms in order to digest proteins. • Trypsinogen is activated by the enzyme enterokinase. • Once trypsin is formed it activates chymotrypsinogen, as well as additional molecules of trypsinogen.
  33. 33. What Goes Wrong? • In pancreatitis, the enzymes become activated while still in the pancreas. • Causing the enzymes to irritate the cells of the pancreas, creating inflammation and the signs and symptoms associated with pancreatitis.
  34. 34. Causes • • • • • • • • • Alcoholism Gallstones Abdominal surgery Medications Smoking Cystic fibrosis Family history High blood calcium levels (hypercalcemia) High levels of parathyroid hormone in the blood (hyperparathyroidism) • High triglyceride levels in the blood (hypertriglyceridemia) • Pancreatic cancer
  35. 35. Forms of Pancreatitis • Acute: – Upper abdominal pain – Abdominal pain that radiates to the back – Abdominal pain that feels worse after eating – Nausea – Vomiting – Tenderness when touching the abdomen
  36. 36. Forms of Pancreatitis (Cont.) • Chronic: – Upper abdominal pain – Indigestion – Losing weight without trying – Oily, smelly stools (steatorrhea)
  37. 37. Complications • • • • • • • Breathing problems Diabetes Infection Kidney failure Malnutrition Pancreatic cancer Pancreatic cysts
  38. 38. Normal Stress Hormone Response • When you encounter a perceived threat (robbery in this case) • The hypothalamus, a tiny region at the base of the brain, sets off an alarm system in the body. • Stimulating adrenal glands, located above the kidneys, to release a surge of hormones,
  39. 39. Hormones • Some of the hormones release: – Adrenaline: increases heart rate, elevates blood pressure and boosts energy supplies – Cortisol: primary stress hormone, increases sugars (glucose) in the bloodstream, enhances brain's use of glucose, and increases the availability of substances that repair tissues
  40. 40. Other Effects of Cortisol • Alters immune system responses • Suppresses the digestive system, the reproductive system and growth processes • Communicates with regions of your brain that control mood, motivation, and fear.
  41. 41. When the Natural Stress Response Goes Haywire! • The body's stress-response system is usually self-limiting • However over activation of the stress-response system causes overexposure to adrenaline, cortisol, and other stress hormones • Can disrupt almost all the body's processes causing severe long term health problems
  42. 42. Long Term Complications • • • • • • • Anxiety Depression Digestive problems Heart disease Sleep problems Weight gain Memory and concentration impairment
  43. 43. In Conclusion • Collectively, we feel the appropriate choice to the case would be the normal stress hormone response. • Increased cortisol answers why her blood glucose would be elevated, and the anger and agitation would cause the increase. Her BMI is high but that is not the reason for her stay.
  44. 44. Normal Stress Hormone Response The normal stress hormone response is initially very debilitating but recovery will occur when the threat is removed. If the threat itself is not removed the patient may manifest PTSD (post-traumatic stress disorder), which may manifest shortly-after the inciting event or weeks to months or even years later. PTSD effects 1 in every 3 individuals with a traumatic experience.
  45. 45. Treatment • If the patient manifests PTSD, treatment would depend on the symptoms and how soon they occurred after the inciting event. • Options of treatment may be waiting to see if symptoms improve without treatment, psychological therapy such as cognitive behavioural therapy (CBT) and/ or eye movement desensitisation and reprocessing (EDMR), and antidepresseant medication such as paroxetine or mirtazapine.
  46. 46. 6 Phases of Cognitive Behavioral Therapy 1. 2. 3. 4. 5. 6. Assessment or psychological assessment Reconceptualization Skills acquisition Skills consolidation and application training. Generalization and maintenance Post-treatment assessment follow-up
  47. 47. Paroxetine • Belongs to selective-serotonin reuptake inhibitors • Used to treat mental depression, obsessivecompulsive disorder, panic disorder, generalized anxiety disorder, social anxiety disorder (aka social phobia), premenstrual dysphoric disorder, and PTSD • US brand name paxil, paxil CR and pexeva
  48. 48. Mirtazapine • Belongs to tetracyclic antidepressants • Works on CNS to make certain chemicals in the brain stronger • Used to treat depression • US brand names are remeron and remeron soltab
  49. 49. THE END
  50. 50. Just kidding
  51. 51. Sources • Bowen, R. "Exocrine Secretions of the Pancreas." Exocrine Secretions of the Pancreas. Colorado State University, 5 July 2006. Web. 13 Nov. 2013. <http://www.vivo.colostate.edu/hbooks/pathphys/digestion/ pancreas/exocrine.html>. • Staff, Mayo Clinic. "Chronic Stress Puts Your Health at Risk." Mayo Clinic. Mayo Foundation for Medical Education and Research, 11 July 2013. Web. 13 Nov. 2013. <http://www.mayoclinic.com/health/stress/SR00001>. • Staff, Mayo Clinic. "Pancreatitis." Mayo Clinic. Mayo Foundation for Medical Education and Research, 15 Jan. 2011. Web. 13 Nov. 2013. <http://www.mayoclinic.com/health/pancreatitis/DS00371> .
  52. 52. Sources (Cont.) • Staff, Mayo Clinic. ”Cushing Syndrome." Mayo Clinic. Mayo Foundation for Medical Education and Research, 28 Mar. 2013. Web. 5 Nov. 2013. <http://www.mayoclinic.com/health/cushingssyndrome/DS00470>. • Marcus, Saul ND. “Adrenal Exhaustion and Chronic Fatigue: The most common reason people feel tired all the time.” Naturopathic Wellness. 2013. Web. 17 Nov 2013.
  53. 53. • Tammy. “Dealing with stress.” Tammysyoga.co.uk. 13 Jun 2013. Web. 17 Nov 2013. “Post-traumatic stress disorder.” NHS Choices. 24 Sep 2013. Web. 17 Nov 2013. • Wikipedia. “Cognitive behavioral therapy.” Wikimedia Foundation, Inc. 4 Nov 2013. Web. 17 Nov 2013.
  54. 54. • “Mirtazapine (Oral Route).” Mayo Foundation for Medical Education and Research. 13 Jul 2013. Web. 17 Nov 2013. • “Paroxetine (Oral Route).” Mayo Foundation for Medical Education and Research. 1 Aug 2013. Web. 17 Nov 2013.

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