Based on the information provided:- The patient was diagnosed with primary atrophic hypothyroidism 12 months ago- Her current TSH is elevated at 12.5 mU/L (reference range is usually 0.5-5.5 mU/L) despite being on levothyroxine therapy- However, her free T4 is within the reference range at 14 pmol/L This suggests that while her levothyroxine dose of 75 mcg daily has normalized her free T4, it has not fully suppressed her TSH. The most likely interpretation is that her levothyroxine dose needs increasing to fully treat her hypothyroidism, as evidenced by the still
Similar to Based on the information provided:- The patient was diagnosed with primary atrophic hypothyroidism 12 months ago- Her current TSH is elevated at 12.5 mU/L (reference range is usually 0.5-5.5 mU/L) despite being on levothyroxine therapy- However, her free T4 is within the reference range at 14 pmol/L This suggests that while her levothyroxine dose of 75 mcg daily has normalized her free T4, it has not fully suppressed her TSH. The most likely interpretation is that her levothyroxine dose needs increasing to fully treat her hypothyroidism, as evidenced by the still
HYPOTHYROIDIM Made Easy –Through Case Studies, Dr. Sharda jain Lifecare Centre
Similar to Based on the information provided:- The patient was diagnosed with primary atrophic hypothyroidism 12 months ago- Her current TSH is elevated at 12.5 mU/L (reference range is usually 0.5-5.5 mU/L) despite being on levothyroxine therapy- However, her free T4 is within the reference range at 14 pmol/L This suggests that while her levothyroxine dose of 75 mcg daily has normalized her free T4, it has not fully suppressed her TSH. The most likely interpretation is that her levothyroxine dose needs increasing to fully treat her hypothyroidism, as evidenced by the still (20)
Based on the information provided:- The patient was diagnosed with primary atrophic hypothyroidism 12 months ago- Her current TSH is elevated at 12.5 mU/L (reference range is usually 0.5-5.5 mU/L) despite being on levothyroxine therapy- However, her free T4 is within the reference range at 14 pmol/L This suggests that while her levothyroxine dose of 75 mcg daily has normalized her free T4, it has not fully suppressed her TSH. The most likely interpretation is that her levothyroxine dose needs increasing to fully treat her hypothyroidism, as evidenced by the still
1. Objectives
• Revise the pathways involved in Adrenal
Function
• Define the clinical features associated with
common Adrenal Pathologies
• Interpret the investigations used in
Adrenocortical abnormalities
• Outline the management of an Addisonian
Crisis
4. 35 year old female.........
• feels like she has put on weight particularly
on chest, stomach & face
• noticed bruising and “stretch marks”
• feels down and has no energy
• periods have been quite irregular
10. Plasma Levels Cortisol ACTH
Normal
high at 8am, low at
midnight
Normal (i.e. not
raised)
Steroid Therapy variable
Normal/Undetecta
ble
Cushing’s
syndrome(pituitary
origin)
High High
Cushing’s
syndrome (adrenal
origin)
High Undetectable
Cushing’s
syndrome (ectopic
ACTH secretion)
High Very High
15. • Advice
• Do not abruptly stop steroids
• Give steroid card-show to doctor/dentist
etc.
• Double steroids in febrile illness, injury,
stress
• Add 5-10mg hydrocortisone to daily intake
before strenuous exercise
18. Summary
• Describe the clinical features of the two main Adrenal
abnormalities
• Know that the dexamethasone suppression test is
used in Cushing’s syndrome.
• Localise the lesion responsible for excess cortisol
production based on plasma cortisol and ACTH levels
• Know that the short synacthen test is used in
Addison’s disease
• Outline the management of an Addisonian Crisis.
20. Objectives
• Understand what the thyroid and parathyroid do
and how
• Get to grips with calcium homeostasis
• Learn the features of thyroid and parathyroid
disease
• Understand how these diseases are treated
24. Hyperthyroidism - causes
• Autoimmune = Graves disease
• Infective = De Quervain’s thyroiditis
• Neoplastic = toxic adenoma
• Iatrogenic = drugs such as amiodarone or
lithium. Also from over treating
hypothyroidism
37. Hyperparathyroidism -
symptoms
• bones = pain, fractures, osteopaenia and lytic
lesions from bone reabsorption
• stones = kidney stones
• moans = feeling crap due to depression,
tiredness, weakness
• groans = abdo pain and acute abdomen
(pancreatitis, duodenal ulcers, constipation)
38. Hyperparathyroidism
PTH Calcium Cause
Primary solitary adenoma, hyperplasia, carcinoma
Secondary normal response to a low
Tertiary in response to long standing secondary
hyperparathyroidism glands become
hyperplasic
Malignant parathyroid related protein (PTrP) released by
squamous cell carcinoma of lung which mimics
PTH. PTrP not detected by PTH assay
39. Hyperparathyroidism -
tests• calcium and PTH
• ALP would be increased because of bone
activity
• DEXA scan shows osteoporosis
• 24 hour urinary calcium
42. Hypoparathyroidism
PTH Calcium Cause
Primary Gland failure – autoimmune eg DiGeorge
syndrome
Secondary Radiation or surgery or hypomagnesia
Pseudo Failure of target cell response to PTH.
Genetic.
pseudopseudo - - Similar to pseudo but normal
biochemistry
45. 3. A 36-year-old woman presents with feeling tired and
cold all the time. On examination a firm, non-tender
goitre is noted. Blood tests reveal the following:
TSH- 34.2 mU/l
Free T4 - 5.4 pmol/l
What is the most likely diagnosis?
A. Primary atrophic hypothyroidism
B. Pituitary failure
C. De Quervain's thyroiditis
D. Iodine deficiency
E. Hashimoto's thyroiditis
46. A 34-year-old woman who takes hydrocortisone and fludrocortisone replacement
therapy for Addison's disease presents for review. She has a three-day history of a
productive cough associated with feeling hot. On examination the chest is clear,
her pulse is 84 / min and temperature is 37.7ºC. You elect to prescribe an
antibiotic given her medical history. What is the most appropriate advice with
regard to her adrenal replacement therapy:
a)Keep the same hydrocortisone and fludrocortisone dose
b)Double both the hydrocortisone and fludrocortisone dose
c)Double the hydrocortisone dose, keep the same fludrocortisone dose
d)Convert her to prednisolone for the duration of the illness
e)Stop the hydrocortisone and fludrocortisone until the patient recovers
47. 2. A 33-year-old female is referred by her GP with
thyrotoxicosis. Following a discussion of management
options she elects to have radioiodine therapy.
Which one of the following is the most likely adverse
effect?
A. Hypothyroidism
B. Thyroid malignancy
C. Agranulocytosis
D. Oesophagitis
E. Precipitation of thyroid eye disease
48. A 45-year-old woman is investigated for weight gain. She had had
been unwell for around four months and described a combination of
symptoms including depression, facial male-pattern hair growth and
reduced libido. During the work-up she was found to be
hypertensive with a blood pressure of 170/100 mmHg. Which one of
the following tests is most likely to be diagnostic?
a)Renin:aldosterone levels
b)High-dose dexamethasone suppression test
c)Pelvic ultrasound
d)Overnight dexamethasone suppression test
e)24 hr urinary free cortisol
49. A 23-year-old woman presents with sweating and tremor. Her
thyroid function tests are as follows:
TSH - <0.05 mU/l
Free T4 - 25 pmol/l
What is the most common cause of this presentation?
A. Hashimoto's thyroiditis
B. Graves' disease
C. Toxic nodular goitre
D. De Quervain's thyroiditis
E. Toxic adenoma
50. 4. A 43-year-old woman presents for follow-up in clinic.
She was diagnosed with Hashimoto's thyroiditis four
months ago and is currently being treated with
levothyroxine 75 mcg od. What is the single most
important blood test to assess her response to
treatment?
A. ESR
B. TSH
C. Free T4
D. Total T4
E. Free T3
51. Which one of the following is the cause of Cushing's disease?
a)Ectopic ACTH production
b)Adrenal adenoma
c)Micronodular adrenal dysplasia
d)Adrenal carcinoma
e)Pituitary tumour
52. 5. A 40-year-old woman complains of feeling tired all the time and putting on weight.
On examination a diffuse, non-tender goitre is noted. Blood tests are ordered:
TSH - 15.1 mU/l
Free T4 - 7.1 pmol/l
ESR - 14 mm/hr
Anti-TSH receptor stimulating antibodies - Negative
Anti-thyroid peroxidase antibodies - Positive
What is the most likely diagnosis?
A. Pituitary failure
B. Primary atrophic hypothyroidism
C. De Quervain's thyroiditis
D. Hashimoto's thyroiditis
E. Grave's disease
53. A 30 year old hypertensive man presents with the following blood
results:
Na 147mmol/L
K 2.8 mmol/L
Ur 4.0 mmol/L
Cr 50 micromol/L
Glucose 4 mmol/L
What is the diagnosis?
a) Coarctation of the aorta
b) Conn’s syndrome
c) Cushing’s disease/syndrome
d) Polycystic kidney disease
e) Primary (essential) hypertension
54. 6. A 52-year-old woman who was diagnosed as having primary atrophic
hypothyroidism 12 months ago is reviewed following recent thyroid function
tests (TFTs):
TSH - 12.5 mU/l
Free T4 - 14 pmol/l
She is currently taking 75mcg of levothyroxine once a day. How should these
results be interpreted?
A. Poor compliance with medication
B. Taking extra thyroxine
C. Evidence of recent systemic steroid therapy
D. Keep on same dose
E. T4 to T3 conversion disorder
55. A 30-year-old woman presents to the endocrinology clinic with
bruising, striae, acne and hirsutism. On examination, the patient
appears lethargic and depressed, with centripetal obesity and
demonstrable proximal myopathy. Blood pressure is 165/106
mmHg and blood tests reveal Na+
136 mmol/l, K+
2.8 mmol/l and
random glucose 8.2 mmol/l. A low-dose dexamethasone test and
24-hour urinary cortisol test are ordered.
What is the most common cause of Cushing’s syndrome?
a) ectopic ACTH secretion
b) primary adrenal disorder
c) iatrogenic
d) pituitary dependent
e) pseudo-cushing’s syndrome
Editor's Notes
De Quervain’s thyroiditis - A self limiting, acute, severe post viral hyperthyroidism (coxsackie, adenovirus or URTI). Causes a painful goitre
Hashimoto’s can cause a hyperthyroidism in the acute phase
Toxic adenoma is just an active hormone producing adenoma.
Goitre – typically tender in De Quervain’s
Eyelid retraction is the most common sign of ophthalmopathy. There is a immobility or lagging of the upper eyelid on downward rotation of the eye. Abnormal wideness of the eye due to retraction of both lids is noticed due to large area of whiteness above and below the iris (particularly above).
In moderate active disease, the signs and symptoms are persistent and increasing and include myopathy. The inflammation and edema of the extraocular muscles lead to gaze abnormalities. The inferior rectus muscle is the most commonly affected muscle and patient may experience vertical diplopia on upgaze and limitation of elevation of the eyes due to fibrosis of the muscle
There are lots of descriptive words for eye disease associated with thyroid problems. Chemosis is non secific and refers to conjunctival inflammation/irritation. Protosis is a description of bulging eyes
Pretibial myxoedema - It usually presents itself as a waxy, discolored induration of the skin—classically described as having a so-called peau d&apos;orange (orange peel) appearance
Thyroid acropachy is an extreme manifestation of autoimmune thyroid disease. It presents with digital clubbing, swelling of digits and toes, and periosteal reaction of extremity bones
Thyroid autoantibodies – antithyroid peroxidase and antithyroglobulin antibodies. Maybe increased in autoimmune disease (Hashimotos or Graves). Present in 75% of people with Graves and and can be tested for with ELISA/immunofluorescence
US – determines cystic (usually benign) from solid nodules
Isotope scan – can detect ectopic thyroid tissue or carcinoma. Hot (increased uptake), cold and neutral nodules – hot and neutral nodules are usually not malignant.
Sick euthyroidism = deranged TFTs in illness (usually everything becomes low)
High TSH and high T4 could also be due to poor compliance with thyroxine treatment for hypothyroidism
Antithyroid medicines inhibit thyroid peroxidase
Carbimazole can be titrated or use a block and replace approach. Side effects are agranulocytosis
Radioactive iodine can lead to thyroid storm, and cant be used in pregnancy or lactation. Thyroid storm is an acute, life-threatening, hypermetabolic state induced by excessive release of thyroid hormones (THs) in individuals with thyrotoxicosis
Hashimoto’s thyroiditis – goiter. Destruction of thyroid tissue, mechanism not understood. May start as hyperthyroidism. HLA DR4 and 3. Acute phase may be hyperthyroidism.
Primary myxedema – no goiter, atrophy. Blocking of TSH receptor with autoantibodies (same as Grave’s but opposite effect). HLA DR4
Hashimotos causes a diffuse non-tender goitre
The main action of vitamin D is to assist in calcium absorption in he gut
Calcitonin is the opposite of PTH and decreases calcium
Usually an incidental finding
calcium and PTH (differentials that give similar results are – familial hypocalcaemia, tertiary hyperparathyroidism and certain drugs like thiazides and lithium)
Pseudo - short 4th/5th metacarpals, short stature, mental retardation
this patient has Hashimoto&apos;s thyroiditis, as evidenced by the hypothyroidism, goitre and anti-thyroid peroxidase antibodies. De Quervain&apos;s thyroiditis typically causes a painful goitre and a raised ESR. Around 90% of patients with Grave&apos;s disease have anti-TSH receptor stimulating antibodies.
