This document provides a series of clinical pathology cases related to disorders of the endocrine system. It presents patients' histories, examination findings, imaging and biopsy/histopathology results and asks the reader to identify the most likely diagnosis for each case and explain relevant clinical, laboratory and pathological findings. The cases cover a wide range of endocrine disorders including diseases of the thyroid, pituitary, adrenal glands and parathyroid.

1. “Be more dedicated to making solid achievements than in running after swift but synthetic happiness.” - Wings of Fire: An Autobiography of Dr. APJ Abdul Kalam.

2. Quick Pathology Review Pathology of Endocrine System System : Endocrine Class : Endocrine Disorders Topic : Thyroid Pathology & other common. Shashidhar Venkatesh Murthy A/Prof.& Head of Pathology School of Medicine & Dentistry James Cook University Australia.

3. CPC 31-Endo: Core Learning Issues (CLI) Major CLI: Endocrine System – Anatomy & Physiology Pathology of Thyroid disorders: Hyper/ Hypo/ Euthyroid. Thyroiditis: Graves, Hashimoto’s disease, others. Hyperplasia: multinodular goitre - Iodine Tumors: Cysts, adenoma, Carcinoma (papillary, follicular) Pituitary disorders – hyperplasia, adenoma, infarction. Minor CLI: Sheehan’s syndrome, gigantism, cushing’s disease. Adrenal disorders: Cushing’s sy, addison’s, Pheochromocytoma. Hyperparathyroidim. Multiple Endocrine Neoplasms (MEN syndromes)

4. A 40 year old woman has Tremors, palpitations and congestive cardiac failure. She has diffusely enlarged thyroid gland. Serum TSH is low but T3 & T4 are high. Image shows biopsy of thyroid. Most likely diagnosis ? Functioning Papillary carcinoma Hot nodule - Thyroid adenoma Hashimoto’s disease Graves disease Multinodular goitre, functioning. Explain the laboratory findings ? What is the diagnosis if TSH levels were high? What complications she is likely to develop?

5. A 46 year old woman presents with painless left thyroid nodule. Serum TSH & T3, T4 are normal. Image shows her thyroid scintigraphy (RAIU). What is the most likely diagnosis ? Papillary carcinoma. Thyroid simple cyst. Large nodule of multinodular goitre Non Functioning Adenoma A Cold nodule. Explain the appearance of the lesion ? What are the most likely differential diagnoses? What are the chances it being benign or malignant? What microscopic finding do you expect to see?

6. A 52 year old man with a 8 month h/o anxiety, insomnia, palpitations, diarrhoea & tremors. O/E he has a nodule in his right thyroid region. His serum TSH is low, T4 is normal and T3 is increased . Images show gross, clinical & thyroid scan appearance.What is the most likely diagnosis ? Toxic adenoma. Thyroid simple cyst. Nodule of multinodular goitre Non functioning Adenoma A Cold nodule. Explain her signs & symptoms? List likely differential diagnoses? Explain laboratory findings & likely diagnosis? What microscopic finding do you expect to see?

7. A 48 year old woman with left thyroid lobe nodule and a large non tender left anterior cervical lymph node, has normal TSH and T3, T4 levels. Image shows her resected thyroid gland and Microscopic appearance. Most likely diagnosis ? Simple cyst. Papillary cystadenoma. Lymphocytic thyroiditis. Non functioning Adenoma Papillary carcinoma. Explain her signs & symptoms? List differential diagnosis? List three gross features shown? List three microscopic features shown?

8. A 51 year old woman, one year history of fatigue, apathy and cold intolerance. Examination reveals diffusely enlarged thyroid. Microscopic appearance of her thyroid biopsy is shown in the image. What is the most likely diagnosis ? Grave’s Disease. Non functioning adenoma. Hashimoto’s disease. Multinodular goitre. Follicular Carcinoma.. Explain her signs & symptoms? List differential diagnosis? List Laboratory findings expected in her? List three microscopic features shown?

9. A 38 year old man is noticing changes in his appearance with coarse facial features and shoes that no longer fit. He has polyarthritis with joint deformity. His brain MRI and appearances are shown. What is the most likely diagnosis ? Gigantism. Hyperpituitarism. Acromegaly. Prolactinoma. Pituitary adenoma. Explain her signs & symptoms? List differential diagnosis? List Laboratory findings expected in her? List three microscopic features shown?

10. A 56 year old post menopausal female presents with breast engorgement with milk production. HPE difficulty in driving due to poor vision since 3 months, vision test reported as bi-temporal hemianopia. Image shows MRI of her head and biopsy from the lesion. What is the most likely diagnosis ? Cushing’s disease. Pituitary Adenoma. Sheehan’s syndrome. Marfan’s syndrome. Pituitary prolactinoma. Explain her signs & symptoms? List differential diagnosis? List Laboratory findings expected in her? List three microscopic features shown?

11. A 23 year old primigravida has placental abruption at term. She is unable to lactate postpartum and has amenorrhea, lethargy, hyperkalemia and hypotension. Image shows pathologic features in the Brain MRI & Pituitary gland. What is the most likely diagnosis ? Cushing’s disease. Pituitary Adenoma. Sheehan’s syndrome. Marfan’s syndrome. Pituitary prolactinoma. What laboratory findings could she have? Why & How did this occur? Does she have sufficient ADH? Explain?

12. A 32 year old man presents with Anxiety, tremors & tachycardia. He is also becoming periodically hypertensive. His abdominal CT scan & biopsy from the tumor is shown. What is the most likely diagnosis ? Addison’s disease. Pheochromocytoma. Pancreatic adenoma. Parathyroid Adenoma. Prolactinoma. Explain the pathogenesis of symptoms? What laboratory findings are likely? Name associated inherited disorders? (MEN II, VHL)

13. A 61 year old man, a business executive, presents with poorly controlled hypertension in spite of taking his medications regularly. Following a routine examination, he is found to have an incidental adrenal lesion confirmed on CT scan. Image shows his resected adrenal gland. What is the most likely diagnosis ? Addison’s disease. Pheochromocytoma. Conn syndrome. Adrenal gland adenoma. Cushing’s Syndrome. What is the diagnosis if he also has hypokalemia? What is the diagnosis if he has glucose intolerance, buffalo-hump, plethora and osteoporosis? What is the diagnosis if there are no other associated findings?

14. A 26 year old woman presents to ER with high fever, severe headache since two days. Examination reveals palpable purpura all over body, and her coagulation tests are all prolonged. Despite treatment she dies next day in the ER. Image shows her adrenals at autopsy. What is the most likely diagnosis ? Addison’s disease. Adrenal carcinoma. Conn syndrome. Waterhouse-Friedrichsensy. Acute Adrenal Infarction. What has happened in her adrenal glands? Explain the pathogenesis of this condition? What further laboratory findings are expected in her?

15. A 56 year old woman from Atherton presents with 6 month history of neck discomfort, dysphagia and wheezing. History reveals progressively enlarging neck mass since 8 years. Her TSH and T3, T4 levels are within normal limits. She does not have heat or cold intolerance. Image shows her neck appearance & MRI. What is the most likely diagnosis ? Large simple cyst of thyroid. Non functioning adenoma. Low grade papillary carcinoma. Benign lymphocytic thyroiditis. Multinodular goitre. What has happened in her thyroid gland? Explain MRI findings? Explain the pathogenesis of this condition? What is the significance of her place? What further laboratory findings are expected in her?

16. A 56 year old woman with 6 month history of Diarrhoea, fatigue, anorexia weight loss & skin hyperpigmentation. Image shows appearance of her mouth & fingers & likely appearance of her adrenals (left) compared with normal (right). What is the most likely diagnosis ? Patient Normal Conn Syndrome. Cushing’s disease. Tuberculosis of Adrenal glands. Primary adrenal insufficiency. Cushing’s syndrome. What has happened in her thyroid gland? Explain MRI findings? Explain the pathogenesis of this condition? What is the significance of her place? What further laboratory findings are expected in her?

17. A 32 year old G5 P5 obese woman develops amenorrhoea, lethargy, cold intolerance, weakness and diffuse skin pigmentation. MRI of her head is shown in the image.What is the most likely diagnosis ? Conn Syndrome. Addison’s disease. Sheehan’s syndrome. Empty sella syndrome. Cushing’s syndrome. Explain MRI findings? What has happened? What is panhypopituitarism? List causes of panhypopituitarism? What laboratory findings are expected in her?

18. A 45 year old woman. Urolithiasis, bone pain, peptic ulcers, constipation, arrhythmia, weakness & depression over 4 months. Xray shows osteitisfibrosacystica. MRI shows solitary oval well circumscribed mass posterior to thyroid (Image). Her serum calcium levels are high. What is the most likely diagnosis ? Pituitary adenoma. Thyroid C cell adenoma. Medullary carcinoma. Parathyroid adenoma. Metastatic Follicular carcinoma . What is “Osteitisfibrosa cystic” ? Briefly explain. Differentiate Primary, Secondary, Tertiary & Quarternary hyperparathyroidism? What other laboratory findings are expected in her?

19. “Great dreams of great dreamers are always transcended.” - Wings of Fire: An Autobiography of Dr. APJ Abdul Kalam.