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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
Case #1: The incidental thyroid
nodule
• PMH
• HTN
• GERD
• Meds
• HCTZ
• Ranitidine
• SocHx
• Teaches elementary school. No EtOH, tobacco.
• FamHx
• Negative for thyroid cancer.
Case #1: The incidental thyroid
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
Cooper. Thyroid 2009;20(6):674.
Nodule features
Threshold
size for FNA
U/S-guided FNA
Cooper. Thyroid 2009;20(6):674.
“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
Cooper. Thyroid 2009;20(6):674.
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
Case #2: “Found down”
• Physical
• Obtunded
• Hypoxic
• Hypothermic
• Bradycardic
• Low normal BP
• Diminished heart sounds
• Nonpitting edema
• Vitiligo
• Labs
• Pending
• CXR
• Enlarged cardiac silhouette
Case #2: “Found down”
• 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
Case #5: Fatigue and depression
• 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)
Case #5: Fatigue and depression
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
Case #5: Fatigue and depression
• 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
Bhasin. J Clin Endocrinol Metab 2010;95:2536-2559.
Case #5: Treatment
Bhasin. J Clin Endocrinol Metab 2010;95:2536-2559.
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)
Bhasin. J Clin Endocrinol Metab 2010;95:2536-2559.
Contraindications
for starting
testosterone
therapy
www.urospec.com/uro/Forms/ipss.pdf
Bhasin. J Clin Endocrinol Metab 2010;95:2536-2559.
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?