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-As the name implies, patients with pseudohypoparathyroidism have signs and symptoms characteristic of hypoparathyroidism
-PHP may be associated by a characteristic phenotype known as Albright Hereditary Osteodystrophy (AHO) which includes short stature, round facies, shortening of the fourth metacarpals (brachydactyly), and osteoma cutis
-Examination of the clenched fist reveals a characteristic depression where the knuckle of the fourth metacarpal should be located.
-A high concentration of serum PTH, low serum calcium, high phosphate, and
signs and symptoms of hypoparathyroidism
-patients with pseudohypoparathyroidism do not respond to infused PTH
Treatment is the same as for hypoparathyroidism
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-The four parathyroid glands produce and secrete PTH
-Hypoparathyroidism develops when the parathyroid glands fail to secrete sufficient quantities of PTH, resulting in a low calcium level and a high phosphorus level
-The most common cause of hypoparathyroidism is neck surgery with removal or destruction of the parathyroid glands
-Other causes include congenital abnormalities of the third and fourth pharyngeal pouches (DiGeorge syndrome), autoimmune or drug induced or radiation induced hypothyroidism
Skin: Dry, scaly skin, coarse hair
Ocular: Cataracts, Papilledema
Dental: enamel hypoplasia, defective root formation, delayed teeth eruption
Respiratory: Bronchospasm, laryngospasm, stridor
Cardiac: Heart failure, Prolonged QT interval on ECG
Psychological: Confusion, behavioral changes, psychosis
Neuromuscular: numbness, tingling, carpopedal spasms, seizures, Parkinsonism
Tetany: Spontaneous tonic muscular contractions; Classically diagnosed by Chvostek sign and Trousseau sign
Chvostek sign: twitching or contraction of the facial muscles in response to tapping the facial nerve at a point anterior to the ear and above the zygomatic bone
Trousseau sign: it is elicited by inflating the sphygmomanometer with the cuff around the arm above the systolic blood pressure for 3 min; The wrist and metacarpophalangeal joints flex, the DIP and PIP joints extend, and the fingers adduct
Labs: Inappropriately low or undetectable PTH level, low calcium level, high phosphorus level
EKG: a prolonged QT interval on the ECG
Treatment
Thyroid cancer is the most common malignancy of the endocrine system
-Most thyroid cancers occur in the young with only one-third of cases occurring after age 55
-Thyroid cancer can be of follicular cell origin or C-cell origin or lymphoid origin.
Originating from follicular cells
Papillary 80%
Follicular 11%
Hürthle cell 3%
Anaplastic 2%
Originating from C-cells or parafollicular cells
Medullary 4%
Originating from lymphoid cells
Thyroid lymphoma 1%
Most of these carcinomas are treated by surgery, radioiodine, and levothyroxine to suppress TSH
Introduction
Toxic multinodular goiter refers to autonomous hyperfunctioning thyroid nodules that produce hyperthyroidism
-it is more common in women over the age of 60 and in iodine-deficient regions
-it is the second most common cause of hyperthyroidism after Graves disease
Symptoms & Signs
Symptoms and signs of hyperthyroidism are similar to Graves’ disease: weight loss, nervousness, weakness, tremors, sweats, tachycardia, heart failure, arrhythmias, atrial fibrillation, congestive heart failure
Physical examination reveals a multinodular goiter which may extend substernally
Diagnosis
Labs: low or undetectable TSH, elevation in serum serum T3 levels, with less striking elevation of serum T4
Radioiodine scan: multiple functioning nodules in the gland with iodine localized to active nodules
Treatment
methimazole (preferable) or propylthiouracil followed by subtotal thyroidectomy; RAI therapy
Introduction
-Thyroid nodules is the most common endocrinopathy
-They are extremely common, particularly among women
– About 90% of palpable thyroid nodules are benign adenomas, colloid nodules, or cysts, but some are malignancies
-Most patients with a thyroid nodule are euthyroid, but some are hypothyroid or hyperthyroid
-The most common neoplasm is the follicular adenoma (benign thyroid nodule)
– A thyroid nodule is more likely to be a cancer in a man than in a woman and in young patients (under 20 years) and older patients (over 60 years)
Symptoms & Signs
-Thyroid nodules usually are asymptomatic
-neck discomfort, dysphagia, choking sensation, hoarseness
-Large substernal goiters can cause superior vena cava syndrome, characterized by facial erythema and jugular vein distention that progress to cyanosis and facial edema when both arms are kept raised over the head (Pemberton sign)
Diagnosis
-Serum TSH, thyroid ultrasound, Fine-needle aspiration (FNA)
-radionuclide thyroid scanning
-the diagnostic procedure of choice is FNA
Treatment
Medical therapy, levothyroxine suppressive therapy, surgery, RAI therapy, Ultrasound-guided radiofrequency ablation
-thyroid surgery is indicated for patients with Graves disease, toxic multinodular goiter, toxic adenoma, Reidel’s thyroiditis, goiter, thyroid nodules benign and malignant thyroid tumors
-Complications of thyroid surgery: injury to recurrent laryngeal nerve with resultant vocal cord paralysis, hypoparathyroidism, injury to cervical sympathetic trunk resulting in Horner’s syndrome
Radioactive iodine-131 is used for treatment of thyrotoxicosis, thyroid cancer and for diagnostic thyroid scanning
-It is effective in ablating the thyroid gland and producing permanent hypothyroidism
-In North America, RAI forms the mainstay of Graves’ disease
– the only isotope used for treatment of thyrotoxicosis is 131I
-RAI is most often used in older patients or those who have relapsed after medical or surgical therapy or in whom medical or surgical therapy is contraindicated
-Radioactive iodine should not be given to pregnant women due to the potential teratogenic effects for the fetus’s growth
-all women of childbearing age must have a negative pregnancy test prior to treatment
-After RAI, wait for 6 months before conceiving
-Absolute contraindications to RAI: pregnancy or planning pregnancy within 6 months of treatment, breastfeeding
-Relative contraindications to RAI: children, adolescents, those with ophthalmopathy
-After RAI treatment, most patients become euthyroid within 2 months
-The most common complication of RAI is hypothyroidism
-RAI can exacerbate Graves’ ophthalmopathy especially if the patient is a smoker
Introduction
Grave’s disease is an autoimmune thyroid disorder characterized
by circulating antibodies that stimulate the TSH receptor, resulting in the increase in synthesis and release of thyroid hormones
-it is the most common cause of hyperthyroidism and thyrotoxicosis
-It is more common in women than in men with onset usually between 20 and 40 years of age
-Dietary iodine supplementation can trigger Graves disease
-Thyrotoxicosis: clinical state resulting from inappropriately high thyroid hormone levels
hyperthyroidism: thyrotoxicosis caused by elevated synthesis and secretion of thyroid hormone
Symptoms & Signs
General: fatigue, fever, heat intolerance, weight change, irritability, intolerance
Thyroid: diffusely enlarged thyroid often with a loud bruit
Eyes: infiltrative ophthalmopathy (Graves exophthalmos),spasm of the upper eyelid revealing the sclera above the corneoscleral limbus (Dalrymple’s sign) , lid lag with downward gaze (von Graefe sign), a staring appearance (Kocher sign), conjunctival swelling and congestion, keratitis, papilledema, permanent visual loss
Nervous: Restlessness, nervousness, fine resting tremors
Cardiac: palpitations, angina,exertional dyspnea, atrial fibrillation, premature atrial contractions, atrial tachycardia, ischemic or valvular heart disease, pulmonary hypertension
Gastrointestinal: dysphagia, frequent bowel movements, diarrhea
Musculoskeletal: muscle weakness, cramps, osteoporosis
Dermatologic: facial flushing, moist warm skin, pruritis, increased sweating, fine hair, onycholysis,bony involvement leads to subperiosteal bone formation and swelling in the metacarpals (thyroid acropachy), infiltrative dermopathy (pretibial myxedema)
Genitourinary: menstrual irregularities amenorrhea, decreased fertility, and an increased incidence of miscarriages
Diagnosis
Serum TSH: low or undetectable
free T4 or T3: elevated
Thyroid receptor antibodies (TRAbs): elevated
RAI scan: elevated uptake and a homogeneous pattern
Technetium scintigraphy: increased or normal thyroid uptake of technetium
Treatment
Symptomatic treatment: beta blockers, calcium blockers
Antithyroid drugs: Methimazole, carbimazole, propylthiouracil
Radioactive iodine (131I, RAI): the most commonly prescribed treatment in the United States, but is contraindicated in pregnancy or with breastfeeding
surgery: a total resection of one lobe and a subtotal resection of the other lobe
Introduction
Euthyroid sick syndrome is a clinical condition characterized by low thyroid hormone levels in clinically euthyroid patients with nonthyroidal systemic illness
-it can be precipitated by stresses such as chronic liver failure, renal failure, malnutrition, fasting, starvation, anorexia, diabetic ketosis, and sepsis
-The first testing abnormality to manifest is low T3 level
Symptoms & Signs
No signs or symptoms of thyroid dysfunction
Diagnosis
Patient’s setting: critical illness, chronic illness, ICU admission etc
No clinical manifestations of thyroid dysfunction
Labs: TSH: Normal or low
T4 : Normal or low
T3, total and free : Low
Reverse T3 (rT3): High or normal
Treatment:
-Treat the underlying nonthyroid illness
-Thyroid hormone replacement is not beneficial
Introduction
Riedel’s thyroiditis is a chronic inflammatory disease associated with fibrosis or woody enlargement of all or part of the thyroid gland
-it is now considered a IgG4-related systemic disease
-Women in midlife are most often affected
Symptoms & Signs
-Symptoms of hypothyroidism when enough thyroid tissue is replaced by fibrous tissue; compressive symptoms of the esophagus, trachea such as dysphagia, dyspnea, hoarseness; a hard, ‘woody’ thyroid gland
Diagnosis
Gross exam: hard, fixed, ‘woody’ thyroid gland
Labs: normal or low thyroid hormones, normal or elevated TSH, normal or elevated IgG4 levels
Open thyroid biopsy: a dense lymphoplasmacytic infiltrate rich in IgG4 plasma cells, storiform fibrosis, and obliterative phlebitis
Treatment
Surgery: decompression through thyroidectomy Hypothyroidism: thyroid hormone replacement
Introduction
Subacute thyroiditis is an acute painful disease of the thyroid probably caused by a virus or postinfectious inflammation
-Measles, mumps, influenza, adenoviruses are among the commonly blamed viruses
-It occurs between 30 and 50 years of age; it is three to five times more common in females than in males
-It is often associated with HLA-B35
Symptoms & Signs
Fever, anterior neck pain, aggravated by swallowing; pain frequently refers to the ear; a markedly tender thyroid gland upon palpation with one or more nodules; in the acute phase the patient may be euthyroid or hyperthyroid
Diagnosis
Labs: Early hyperthyroidism is followed by a hypothyroid phase and later euthyroid phase
Biopsy: Lymphocytes and multinucleated giant cells
Treatment
Aspirin, NSAIDS, glucocorticoids, β-adrenergic blockers; monitor TSH, T4 every two weeks; Complete recovery in most cases
Introduction
Hypothyroidism is a clinical syndrome caused by insufficient thyroid hormone production
-it is 10 times more common in females than in males
-Thyroxine (T4) and triiodothyronine (T3) are the thyroid hormones
-Peripherally, thyroxine T4 is converted to the active triiodothyronine T3
-T3 is three to four times more potent than thyroxine T4.
-Primary hypothyroidism is caused by the intrinsic dysfunction of the thyroid gland. -The most common cause is Hashimoto’s thyroiditis
-other causes: surgical removal, ablation of thyroid gland
Secondary hypothyroidism is caused by a deficiency of thyroid-stimulating hormone (TSH) from the pituitary gland or deficiency of thyrotropin-releasing hormone from the hypothalamus
Drug induced hypothyroidism: Amiodarone, lithium, α-interferon, interleukin etc can also cause hypothyroidism
Symptoms & Signs
Symptoms: headaches, hair loss, fatigue,lethargy, depression, shortness of breath, constipation, weight gain, menstrual irregularities, infertility, muscle cramps, joint pains, paresthesias, cold intolerance, carpal tunnel syndrome, dysphagia, neck discomfort, decreased hearing
Signs: Puffy face, periorbital puffiness, loss of outer third of eyebrows, pallor, thickening of the tongue, hoarseness, bradycardia, diastolic hypertension, hypoventilation, absent or decreased bowel sounds, edema, delayed relaxation of ankle jerks, peripheral neuropathy, cool, rough, dry skin, yellowing of skin, thin brittle nails, hypothermia, thinning of hair, peripheral edema, delayed relaxation of deep tendon reflexes, cardiac enlargement (myxedema heart), psychosis (myxedema madness), altered mental status (myxedema coma)
Diagnosis
-The single best screening test for hypothyroidism is the serum TSH
-Primary hypothyroidism: High TSH (stimulating the failing gland), with low total or free thyroxine T4 and triiodothyronine T3
-Secondary hypothyroidism: Low TSH with low total or free thyroxine T4 and triiodothyronine T3
-Imaging: CT or MRI may show a goiter in the neck, pituitary hyperplasia
Treatment
Synthetic levothyroxine is the preferred medication for treating hypothyroidism
Introduction
-Hashimoto thyroiditis is a common chronic autoimmune inflammatory disease
-It is the most common thyroid disorder in the United States
-it is the most common cause of hypothyroidism
-it is caused by an autoimmune attack on the thyroid
-it is associated with a host of other autoimmune diseases
-Autoantibodies in Hashimoto thyroiditis are thyroglobulin antibody (Tg Ab), thyroidal peroxidase antibody (TPO Ab) and the TSH receptor–blocking antibody (TSH-R [block] Ab).
-It shows female preponderance and is predominantly a disease of middle age
-It is characterized by destruction of thyroid follicles and infiltration by lymphocytes and plasma cells interspersed by enlarged follicular epithelial oncocytic cells with abundant pink eosinophilic granular cytoplasm (Hürthle cells or Askanazy cells)
-it is associated with an increased incidence of papillary carcinoma of the thyroid and primary thyroid lymphoma
Symptoms & Signs
-Diffusely enlarged, firm, rubbery, nontender and nodular thyroid which becomes smaller with the progression of the disease
-Some patients may develop hypothyroidism or rarely hyperthyroidism and exhibit their clinical manifestations
Diagnosis
Thyroid antibodies: Elevated antithyroglobulin and antithyroid peroxidase antibodies
Laboratory findings vary based on thyroid status
If patient is euthyroid: normal TSH and normal thyroid hormones
if hypothyroid, elevated TSH and low thyroid hormones
if hyperthyroid, suppressed TSH and elevated thyroid hormones
FNAB: thyroid gland infiltrated by lymphocytes and Hürthle cells or Askanazy cells
Treatment
Symptomatic/Cosmetic reasons: Surgery
Hypothyroid status: Thyroid replacement therapy
Introduction
Hyperprolactinemia is a condition of elevated prolactin level in blood
-Prolactin is a pituitary hormone which acts to induce and maintain lactation and to decrease reproductive function and libido via via suppression of gonadotropin-releasing hormone [GnRH]
-Dopamine suppresses the production of prolactin from the anterior pituitary, so dopamine antagonists are associated with hyperprolactinemia
-The most common cause of hyperprolactinemia is a prolactin-secreting pituitary adenoma. Other causes are hypothyroidism, hypothalamic masses,
and medications (risperidone, haloperidol, chlorpromazine, perphenazine, SSRIs, metoclopramide, opiates, H2 antagonists)
Symptoms & Signs
Men: Erectile dysfunction, loss of libido, gynecomastia, headaches, visual symptoms
Women: loss of libido, amenorrhea, oligomenorrhea, infertility, irritability, anxiety, depression, galactorrhea and osteoporosis
Diagnosis
Labs: Fasting prolactin levels; labs to rule out other conditions such as hypothyroidism, pregnancy
Imaging: Pituitary MRI
Treatment
Dopamine agonists: Primary treatment of hyperprolactinemia; cabergoline, bromocriptine, or quinagolide
-Cabergoline is the preferred drug for the treatment of hyperprolactinemia because of greater efficacy and lower adverse effects
-Cabergoline can cause valvular heart disease
Levothyroxine: if hypothyroidism is the cause of hyperprolactinemia
Surgery: Transsphenoidal pituitary surgery for adenomas which are resistant to medical therapy
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Introduction
Acromegaly and gigantism are hormonal disorders caused by excessive growth hormone secretion usually due to a pituitary tumor
-Acromegaly develops if excessive GH exposure occurs after closure of the long bone epiphyses (Adults = Acromegaly); where as gigantism develops if it occurs before closure of the epiphyses
-Grown hormone hypersecretion leads to excessive generation of IGF-1, which acts as the mediator of most of the effects of GH
-The average age at the time of diagnosis is 40 to 45 years
Symptoms & Signs
Facial Features: Frontal bossing, macroglossia, Jaw enlargement (prognathism), widened teeth spacing
Musculoskeletal features: Increased hat, shoe, glove and ring size; Enlargement of hands and feet with a doughy texture; arthropathy, carpal tunnel syndrome, kyphoscoliosis
ENT: Large fleshy nose, deepening of the voice, snoring
Skin: Doughy texture, cutis verticis gyrata, acanthosis nigricans, skin tags, thick heel pads, hyperhidrosis, hirsutism
Eyes: Bitemporal hemianopsia (due to optic chiasm compression from the tumor)
Associated conditions: Diabetes, hypertension, glucose intolerance, cardiomyopathy, left ventricular hypertrophy, diastolic dysfunction
Diagnosis
Insulin-like growth factor – 1 : Elevated levels
Growth hormone: Elevated levels in serial measurements; Failure to suppress Growth hormone levels by oral glucose-tolerance test
Imaging: MRI of the pituitary may show macroadenoma
Treatment
Surgery: Removal of adenoma by transsphenoidal surgery
Somatostatin analogues: Octreotide, lanreotide, pasireotide
Dopamine agonists: Bromocriptine, cabergoline
GH receptor antagonist: Pegvisomant
Radiation: Pituitary irradiation
Q. What is the most important requirement for diagnosis of GH excess? Demonstration of unsuppressable GH secretion
Introduction
Chromoblastomycosis is a chronic progressive subcutaneous mycosis caused by multiple species of pigmented fungi, known as melanized or ‘dematiaceous’ fungi, mainly the Fonsecaea, Phialophora, or Cladosporium species
-the fungi appear as brown, thick-walled, spherical, septal cells in tissues (Medlar bodies or muriform cells)
-it usually affects older male agricultural workers
-it typically occurs on the foot or leg, arms or trunk following tissue injury due to trauma
-it occurs in the Americas, Africa (particularly Madagascar), and South Asia
Symptoms & Signs
-the fungus forms thick-walled single cells or cell clusters (sclerotic or muriform bodies), which may transform into papules, scaly, wart-like structures resembling the tips of a cauliflower, and verrucous plaques with satellite lesions
Diagnosis
Histology: brown-pigmented, thick double-walled, multiseptate, melanized sclerotic, globose structures called muriform bodies.
Culture: fungi grow as darkly pigmented black colonies with a downy surface
Treatment
Antifungals: Itraconazole,voriconazole, terbinafine, flucytosine, amphotericin Procedures: Cryotherapy, curettage, electrodessication, and surgical excision
Introduction
Penicilliosis is a tuberculosis-like fungal disease caused by Talaromyces (formerly Penicillium) marneffei
–It is most common in northeastern India, Thailand, Vietnam,Taiwan, China, and Hong Kong
-it most often affects patients with advanced HIV
-it is a dimorphic fungus; grows as a mold that produces a distinctive rose-colored pigment and as yeast-like cells that reproduce with septal formation
-it is acquired by spore inhalation
Symptoms & Signs
-It usually presents as a pulmonary disease or disseminated disease
-Fever, fatigue, cough, weight loss, lymphadenopathy, hepatosplenomegaly, generalized umbilicated papular rash resembling molluscum contagiosum
Diagnosis
The diagnosis is made by culture or by histology
-it forms characteristic yeast-like cells which are divided by a septum and produce a characteristic red pigment
Treatment
The treatment of choice consists of amphotericin B followed by itraconazole
Introduction
Sporotrichosis is a chronic granulomatous fungal infection caused by Sporothrix schenckii
-it is common among gardeners, florists and agriculture workers
-Infection occurs when the organism is inoculated into the skin during gardening or puncture from a rose thorn
S. schenckii is a thermally dimorphic fungus which produces branching, septate hyphae and conidia
Symptoms & Signs
Sporotrichosis has four clinical presentations:
Fixed: a painless nodule or plaque that may become pustular or ulcerated or verrucous plaque; most common on dorsum of hand or finger
Lymphocutaneous: Erythematous nodules in a linear array in lymphatic channels mostly on the dorsum of the hand and forearm
Pulmonary: inhalation of conidiospores producing pulmonary infection
Disseminated: From lungs,it disseminates hematogenously to joints, eyes and meninges
Diagnosis
Histology: Granulomatous microabscesses
Culture: Most reliable method of diagnosis
Treatment
Itraconazole, fluconazole, terbinafine, Amphotericin B, potassium iodide
Introduction
-Paracoccidioidomycosis is a subacute or chronic systemic mycosis caused by Paracoccidioides brasiliensis
-It occurs in rural areas of South and Central America, thus known as South American blastomycosis
-It is a dimorphic fungus that exists as a mold in soil and as a yeast in tissue
-The mold produces chlamydospores and conidia which enter human body mainly by inhalation
Symptoms & Signs
Asymptomatic form: marked by long asymptomatic periods
Pulmonary form: Cough, weight loss, pulmonary granulomas
Mucocutaneous form: Oropharyngeal lesions are the most common sign on physical examination; they present as small granulomas or painful ulcers over the nose, conjunctivae, mouth, gingiva, lips, pharynx, larynx (dysphonia) or anus
Lymphatic form: Lymphadenopathy, ulceration, draining sinuses
Diagnosis
Histology: Granulomas with central caseation with fibrosis
Culture: A parent round yeast cell surrounded by large numbers of small buds described as ‘Ship captain’s wheel’
Serology: antigen detection, antibodies to paracoccidioidin
Treatment
Effective agents: Itraconazole (the drug of choice), Voriconazole, ketoconazole, trimethoprim-sulfamethoxazole and Amphotericin B