js5217icacuk MENTI CODE Thyroid amp Misc Endo A MedED LECTURE SESSION STRUCTURE Quick recap of hyperhypothyroidism Understand what is meant by thyroid eye disease Recall the symptoms and investigations for the following conditions ID: 1047390
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1. Jed Valentiner Shrewsburyjs5217@ic.ac.ukMENTI CODEThyroid & Misc EndoA MedED LECTURE
2. SESSION STRUCTUREQuick recap of hyper/hypothyroidismUnderstand what is meant by thyroid eye diseaseRecall the symptoms and investigations for the following conditions:Thyroid CancerMEN SyndromeCarcinoid SyndromeHypogonadismRemember the symptoms, investigations, and management of acromegaly
3. What antibody is most associated with Grave’s disease?Anti-TPO antibodiesAnti-nuclear antibodiesAnti-TSH receptor antibodiesAnti-CCP antibodiesAnti-AChR antibodiesSBA 1Q
4. Hyper/Hypothyroidism (Review)TSHFollicular cellsParafollicular cells(C-cells)T4 & T3+-HyperthyroidismTremorAnxietyPalpitationsHeat intoleranceDiarrhoeaOligomenorrhoeaCauses:Grave’s DiseaseToxic multinodular goitreThyroiditisDrugs (i.e. amiodarone)Management:PropanololCarbimazole (TPO inhibitor)RadioiodineT4/T3 act to ↑metabolic rateT4 is converted to more bioactive T3HypothyroidismLethargyCold intoleranceWeight gainConstipationMenorrhagia↓Deep tendon reflexesCauses:Hashimoto’s thyroiditisSubacute (de Quervain’s) thyroiditisDrugs (i.e. amiodarone, lithium)Iodine deficiencyManagement:LevothyroxineT4↑TSH↓T4↓TSH↑Anti-TSH receptor antibodiesAnti-TPO antibodiesSide effects: Agranulocytosis(i.e. no neutrophils)+-
5. Thyroid Eye DiseaseBilateral ExophthalmosAnti-TSH receptor antibodiesTSH receptor++++Seen in 25-50% of Grave’s Disease patientsFeatures:DiplopiaConjunctival oedema (chemosis)OphthalmalgiaExposure keratopathyOptic Neuropathy (e.g. blurred vision)https://collections.lib.utah.edu/ark:/87278/s6sn36kf Lid lag (and retraction)
6. A 41-year-old female presents to her GP with a 4-month history of unintentional weight loss and difficulty swallowing. Friends have said her voice sounds different. On examination, a firm non-tender nodule is palpated in the front of her neck. What is the most likely diagnosis?Anaplastic carcinomaOesophageal carcinomaFollicular carcinomaHürthle cell carcinomaPapillary carcinomaSBA 2Q
7. Thyroid CancerFeatures:Non-functional, painless, rapidly growingSolitary, irregular (nodular) shape Palpable nodule, hard and fixedHoarse voiceDysphagiaHaemoptysisAirway obstructionCervical lymphadenopathyLeft recurrent laryngeal nerveRight recurrent laryngeal nerveTracheaCommonPapillary carcinoma (70%)Follicular carcinoma (20%)Medullary carcinoma (5%)Anaplastic carcinoma (1%)Lymphoma (rare)35-year-old female with childhood radiation exposure50-year-old female with low dietary iodine intakeAssociated with MEN 2A & MEN 2BNB: Hürthle cell carcinoma is a rare variant of follicular carcinomaIx: FNAB w/ USS, CT/PET, Thyroid scan~TFTs may be useful to exclude benign (functional) nodulesPsammoma BodyDoes anyone know what this is showing?
8. A 27-year-old tall, thin man attends A&E with severe right-sided loin pain that “comes and goes”. He also complains of new-onset ‘heart burn’ and abdominal pain. He explains that his father recently had surgery on his neck. What is the most likely diagnosis?MEN 2B SyndromeMEN 1 SyndromePrimary hyperparathyroidismCarcinoid SyndromeMEN 2A SyndromeSBA 3QCa2+3.1 mmol/L(2.2-2.6)PTH1.7 pmol/L(1.6-6.9)
9. MEN SyndromeMEN 1ParathyroidPancreaticPituitaryOthers (e.g. carcinoid*, adrenal, thyroid)MEN1 mutation = high penetrance(Develop syndrome in early life)Ix: CT/MRI (whole body), genetics~Zollinger-Ellison syndrome = non-MEN1 gastrinomasMEN 2AParathyroidPhaeochromocytomaNB: Both MEN 2A & 2B present later in life than MEN 1MEN 2A > MEN 2BMEN 2BPhaeochromocytomaNeuromasMarfanoid habitus*HyperPTH + ↑↑Ca2+Peptic ulcers“Stones, groans, bones, and moans”↓Libido, Mass effectMedullary thyroid cancer +3 P’s2 P’s1 P’sWhat are the symptoms of hypercalcaemia?MEN 2A & 2BIx: Genetic testing (RET oncogene), calcitonin, urine catecholamines, CT/MRI
10. MEN Syndrome Summary3 P’s2 P’s1 P’s
11. What is the most common presenting feature of carcinoid syndrome?ItchingShortness of breathDiarrhoeaFlushingAbdominal painSBA 4Q
12. Carcinoid SyndromeFeatures:FlushingDiarrhoeaSOBPulmonary stenosisAbdo painItchingNeuroendocrine cellUncontrolled cell divisionCarcinoid Tumour*Metastasise to liver*Increased circulating hormone↑ Serotonin ↑ Bradykinin↑ HistamineOther facts:Tumours are slow-growingAdults >> ChildrenMEN 1 gene mutation5-Hydroxyindole acetic acid (5-HIAA)SerotoninNeuroendocrine cellDoes anyone know what hormone inhibits serotonin release?SerotoninSomatostatin-Investigations:Urinary 5-HIAA (screening)CT scanOctreotide scanEtc.OctreotideUrine
13. HPG AxisHypothalamusAnterior pituitaryGonadootrophsGnRHTestosterone++LH/FSHOestrogen & ProgesteroneLH → Leydig cells → TestosteroneFSH → Sertoli cells → SpermatogenesisLH → Theca cells → ProgesteroneFSH → Granulosa cells → Oestrogen
14. A 26-year-old woman sees her GP as she has been struggling to conceive for over 14 months whilst having regular sexual intercourse. Her PMH includes acne and irregular periods. On examination, she is overweight and has abnormal hair growth on the sides of her cheeks. What is the most likely diagnosis?Turner’s SyndromePCOSPrimary ovarian failureHypothyroidismHypothalamic amenorrhoeaSBA 5Q
15. HPG AxisHypothalamusAnterior pituitaryGonadootrophsGnRHTestosterone++LH/FSHOestrogen & Progesterone
16. Hypogonadism (Female)HypothalamusAnterior pituitaryGonadootrophsGnRHTestosterone++LH/FSHOestrogen & ProgesteronePhysiologicalPregnancyPrimaryGonadal dysgenesis (e.g. Turner’s Syndrome)Gonadal damagePrimary ovarian failurePCOSSecondaryKallmann SyndromePituitary/hypothalamic tumourHyperprolactinaemiaFunctional (i.e. hypothalamic amenorrhoea)Low BMI, excess exercise, stress Contraceptive pill useWhat karyotype is Turner’s Syndrome characterised by?What symptom typically presents with hypogonadism in Kallmann Syndrome?
17. HPG AxisHypothalamusAnterior pituitaryGonadootrophsGnRHTestosterone++LH/FSHOestrogen & Progesterone
18. Hypogonadism (Male)HypothalamusAnterior pituitaryGonadootrophsGnRHTestosterone++LH/FSHOestrogen & ProgesteronePrimaryGonadal dysgenesis (e.g. Klinefelter’s Syndrome, cryptorchidism)Gonadal damagePost-orchitis (i.e. Mumps)SecondaryKallmann SyndromePituitary/hypothalamic tumourHyperprolactinaemiaWhat karyotype is Klinefelter’s Syndrome characterised by?
19. HypogonadismFeatures:Delayed pubertyInfertility↓ LibidoAmenorrhoeaNight sweats/hot flushesErectile dysfunctionSymptoms of causeMale-specificFemale-specificInvestigations:Pregnancy testLH/FSHProlactinTestosterone/OestradiolTFTsKaryotypingMRIBlood tests
20. HPS AxisHypothalamusAnterior pituitarySomatotrophsGHSomatostatinGHRHIGF-1Insulin-like growth factor 1+++↑ Cell division↓ Apoptosis↑ Cellular metabolism↑ Blood glucose↑ Insulin resistance↑ Muscle growth↑ Bone thickness
21. SBA 6QWhat would an OGTT show in a patient with severe acromegaly?Increased glucoseDecreased GHIncreased GHIncreased insulinDecreased glucose
22. AcromegalyAcromegalyPituitary adenoma(of somatotrophs)↑↑ GH↑↑ IGF-1Features:Coarse facial featuresPrognathism & large tongueSpade-like hands & large feetExcessive sweatingOrganomegalyGigantism → growth of long bonesInvestigations:OGTTPlasma IGF-1MRIManagement:Trans-sphenoidal surgeryRadiotherapySomatostatin analoguesDopamine receptor agonistsGH-receptor antagonistsComplications:Carpal tunnel syndromeHypertensionDiabetes mellitusCardiomyopathyColorectal cancerDoes anyone know a complication of acromegaly?HeadachesVisual disturbanceHyperprolactinaemiaHypopituitarism“Paradoxical rise”What visual disturbance would be seen?Bitemporal hemianopiaName a somatostatin analogue
23. What antibody is most associated with Grave’s disease?Anti-TPO antibodiesAnti-nuclear antibodiesAnti-TSH receptor antibodiesAnti-CCP antibodiesAnti-AChR antibodiesSBA 1Hashimoto’s thyroiditis (hypothyroidism)SLE (anti-dsDNA antibodies)Rheumatoid arthritisMyasthenia gravisAAnti-TSH receptor antibodiesTSH receptor+EXOMPHTHALMOS
24. A 41-year-old female presents to her GP with a 4-month history of unintentional weight loss and difficulty swallowing. Friends have said her voice sounds different. On examination, a firm non-tender nodule is palpated in the front of her neck. What is the most likely diagnosis?Anaplastic carcinomaOesophageal carcinomaFollicular carcinomaHürthle cell carcinomaPapillary carcinomaSBA 2A
25. A 27-year-old tall, thin man attends A&E with severe right-sided loin pain that “comes and goes”. He also complains of new-onset ‘heart burn’ and abdominal pain. He explains that his father recently had surgery on his neck. What is the most likely diagnosis?MEN 2B SyndromeMEN 1 SyndromePrimary hyperparathyroidismCarcinoid SyndromeMEN 2A SyndromeSBA 3Ca2+3.1 mmol/L(2.2-2.6)PTH1.7 pmol/L(1.6-6.9)APrimary hyperparathyroidism“PTH is inappropriately normal”What does this calcium study show?
26. What is the most common presenting feature of carcinoid syndrome?ItchingShortness of breathDiarrhoeaFlushingAbdominal painSBA 4A
27. A 26-year-old woman sees her GP as she has been struggling to conceive for over 14 months whilst having regular sexual intercourse. Her PMH includes acne and irregular periods. On examination, she is overweight and has abnormal hair growth on the sides of her cheeks. What is the most likely diagnosis?Turner’s SyndromePCOSPrimary ovarian failureHypothyroidismHypothalamic amenorrhoeaSBA 5Q
28. AcromegalyControlSBA 6What would an OGTT show in a patient with severe acromegaly?Increased glucoseDecreased GHIncreased GHIncreased insulinDecreased glucoseA“Paradoxical rise”
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