Endocrine Case Presentations - PBworks

Endocrine

Case Presentations

Matt Bouchonville

Endocrinology Division

Family Medicine Resident School

March 19, 2014

Learning Objectives

1. Understand the evaluation and management of

common thyroid disorders

2. Understand the evaluation and management of

male hypogonadism

Case #1

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


nodule

• PMH

• HTN

• GERD

• Meds

• HCTZ

• Ranitidine

• SocHx

• Teaches elementary school. No EtOH, tobacco.

• FamHx

• Negative for thyroid cancer.


nodule

• Physical

• Vitals normal

• No lid lag/stare

• No cervical

lymphadenopathy

• No palpable thyroid

nodules

• Labs

• TSH normal

• Thyroid U/S

• L 1.6 cm hypoechoic nodule

• R 0.6 cm hypoechoic nodule

Next step:

Observation? Uptake/scan? FNA?

U/S-guided FNA

Cooper. Thyroid 2009;20(6):674.

FNA?

U/S-guided FNA


Nodule features

Threshold

size for FNA

U/S-guided FNA


“High-risk patients”

• History of thyroid cancer in 1st degree relative

• External beam/ionizing radiation in youth

• Prior hemithyroidectomy with history of thyroid cancer

• 18FDG avidity on PET scan

• History of MEN2

• Calcitonin >100 pg/mL

U/S-guided FNA


Nodule features – HIGH RISK

Threshold

size for FNA

“Suspicious sonographic features”

• Microcalcifications

• Hypoechoic

• Increased vascularity

• Infiltrative margins

• Shape taller than width

Case #1: FNA results

• Cytology:

• Positive for papillary thyroid cancer

Differentiated thyroid cancer

• Treatment:

• Total thyroidectomy

• +/- Lymph node dissection

• +/- I-131 treatment

• TSH suppression

Thyroid hormone suppression

therapy (THST)

Jonklaas. Thyroid 2006;16(12):1229.

High/intermediate risk:

Goal TSH <0.1

Low risk:

Goal TSH 0.1-0.4

Case #2

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


• Physical

• Obtunded

• Hypoxic

• Hypothermic

• Bradycardic

• Low normal BP

• Diminished heart sounds

• Nonpitting edema

• Vitiligo

• Labs

• Pending

• CXR

• Enlarged cardiac silhouette


• Treatment

• IV thyroid replacement

• Supportive therapy

• MICU admission

• Intubation

• Careful IVF therapy

• Empiric antibiotics

• Passive rewarming

Develops refractory hypotension/shock:

What happened?

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

APS type 2

• Primary adrenal insufficiency

• Hypothyroidism

• Type 1 diabetes

• Other:

• Pernicious anemia

• Vitiligo

• Alopecia

• Celiac disease

• Primary biliary cirrhosis

• Myasthenia gravis

• ITP

• Premature ovarian failure

Case #3

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”

Case #3

• PMH

• None

• Meds

• None

• SocHx

• +Tobacco use

• FamHx

• +Thyroid problem in the sister

Case #3

• Physical

• Mild tachycardia

• Mild-moderate proptosis; EOMI, no conjunctival

injection, no periorbital edema

• 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

Is a thyroid uptake/scan indicated for this

patient?

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.

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?

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

Prummel. JAMA 1993;269(4):479.

Szucs-Farkas. Thyroid 2005;15(2):146.

Case #3: 4 weeks later

• Follow up labs:

• TSH undetectable

• Free T4 0.7 (reference 0.7-1.6 ng/dL)

Next step:

Increase methimazole?

Decrease methimazole?

No change?

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.

Case #4

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)

Case #4: Panhypopituitarism

• Labs

• Lytes, LFT’s, CBC normal

• Testosterone normal

• TSH 0.12 (reference 0.36-3.74 UIU/mL)

• Levothyroxine decreased to 150 mcg/day

• 8 weeks later

• TSH 0.36 UIU/mL

Reports worsening fatigue – what is the

likely explanation?

Monitoring of thyroid replacement

in panhypopituitarism

Shimon. Thyroid 2002;12(9):823.

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

Case #5

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

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.

Chronic opioids and testosterone

Finch. Clin J Pain 2000;16(3):251-4.

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

• FamHx

• Unremarkable


• SocHx

• No EtOH, tobacco, recreational drugs

• Physical

• Visual fields intact, normal thyroid, no gynecomastia

• Normal secondary sexual characteristics

• Testes 15 mL bilaterally

• Labs

• CBC, Chem7, LFT’s normal

• TSH normal

• Total testosterone 103 ng/dL (low)


Endocrine Society Guidelines

Bhasin. J Clin Endocrinol Metab 2010;95:2536-2559.

• 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

Is pituitary MRI necessary?

• 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

Pituitary abnormalities (MRI) more common

in severe secondary hypogonadism

0

5

10

15

20

25

Total

testosterone

<150 ng/dL

Total

testosterone

>150 ng/dL

Pre

va

len

ce

of p

itu

ita

ry

abnorm

alit

ies

Citron. J Urol. 1996;155(2):529-33.

MRI

demonstrates

normal

pituitary gland

Case #5: Treatment


Case #5: Treatment


Check testosterone level 3-6 months later:

Target range 400-700 ng/dL

Intramuscular:

Check midway between injections

Transdermal:

3-12 hrs after application (patch)


Contraindications

for starting

testosterone

therapy

www.urospec.com/uro/Forms/ipss.pdf


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)

Vigen. JAMA 2013;310(17):1829-36.

Cardiovascular risks of testosterone

replacement in older men?

29% increase in adverse

cardiovascular outcomes in those treated

with testosterone

Case #5: Feeling good

Questions?

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