Chapter 40: Disorders of Endocrine Function

Manifestation of Cushing's Syndrome:

-Round face with flushed cheeks(Moon face) -weight gain with excess total body fat, particularly in the abdomen -Cervical fat pad -Formation of purple Striae -Ecchymoses over abdomen, arms, and thighs -Decreased muscle mass -Glucose intolerant -Hypertension -Hyperglycemia

Secondary Hyperparathyroidism:

-Secondary to conditions that cause Chronic Hypercalcemia of Nonparathyroid cause

Diagnosis of Cushing's Syndrome:

-ACTH measurement -Primary = low ACTH -Secondary = high ACTH -Urinary free cortisol levels -Dexamethasone suppression test

what is Acromegaly?

-Abnormal growth of hands, feet, and face caused by hypersecretion of Growth Hormone(GH) -Excessive amount of somatotrophin(GH) AFTER Epiphyseal closure

Diseases of Anterior Pituitary Gland Include:

-Acromegaly -Giantism

Pheochromocytoma Etiology and Pathogenesis:

-Adrenal Medulla Hyperfunction -caused by Tumors derived from the Chromatin cells of the Adrenal Medulla. -Secrete Catecholamines on a continuous or episodic basis.

Adrenocortical Hormone Disorders include:

-Adrenocortical Insufficiency(Addison's Disease) -Congenital Adrenal Hyperplasia -Hypercortisolism(Cushing's Syndrome) -hyperaldosteronism(Conn Syndrome)

Treatment of Thyroid Storm:

-Aggressive manangement to achieve Metabolic Balance -Antithyroid drugs are given followed by iodine administration -Beta-blockers to alleviate symptoms -Antipyretic therapy -Fluid Replacement -Glucocorticoids

Hyperaldosteronism:

-Aldosterone facilitates salt and water retention by the Kidneys with resultant Potassium excretion -Typically low Potassium Levels

Graves Disease Treatment

-Anti-Thyroid Drugs -Surgery -Radioactive Iodine ablation

Regulation of Blood Calcium: Calcitonin

-Calcitonin produced by thyroid parafollicular cells also influences the processing of calcium by bone cells -Calcitonin controls calcium content of blood by increasing bone formation by osteoblasts and inhibiting bone breakdown by osteoclasts -Calcitonin decreases blood calcium levels and promotes conservation of hard bone matrix

Clinical Manifestation of Hyperthyroidism:

-Changes in Behavior -Insomnia -Tremors -Irritability -Palpitations -Heat Intolerant -Diaphoresis -Inability to concentrate -Increased Basal Metabolic Rate which leads to weightloss -Increase in appetite -Amenorrhea/Scant Menses

Etiology of Hypothyroidism:

-Congenital -Acquired

Etiology of Endocrine Disorders can be:

-Congenital (present form Birth) -Infectious -AutoImmune -Neoplastic -Idiopathic -Iatrogenic (Illness caused by medical Examination or Treatment)

Types of Hyperadrenalism:

-Cushing's Syndrome -Primary Hyperaldosteronism(Conn's Syndrome) -Congenital adrenal hyperplasia

Clinical Manifestations of Hypothyroidism in Children/Adults:

-Decreased Basal Metabolic Rate -Weakness, Lethargy, Cold intolerant, and Decreased appetite -Bradycardia, Narrowed pulse pressure, and mild/moderate weight gain -Elevated serum cholesterol and triglyceride -Enlarged Thyroid, Dry skin, Constipation -Depression, difficulties with concentration/memory -Menstrual irregularity

Antidiuretic Hormone Disorders include:

-Diabetes Insipidus -Syndrome of Inappropriate Antidiuretic Hormone Secretion

Regulation of Blood Calcium: Parathyroid Hormone

-Serum calcium levels provide the feedback to regulate parathyroid hormone (PTH) secretion -Decrease in calcium causes PTH release -Elevated calcium levels lead to suppression of PTH secretion -PTH acts on bones, intestine, and renal tubules to increase calcium levels -In bone, PTH increases osteoclastic activity -PTH increases renal calcium reabsorption

Treatment for Hyperaldosteronism:

-Spironolactone to increase Sodium excretion and Potassium retention -Sodium restrictions and Potassium replacement may be necessary

Hyperparathyroidism Treatment:

-Surgical Removal of Parathyroid Gland -Medical management includes Hydration and ambulation to maintain Bone density

Pheochromocytoma Treatment includes:

-Sympathetic Blocking Medications to manage blood pressure -Surgical removal of Tumor

Treatment for Hyperthyroidism:

-Symptomatic Relief- Beta-Blockers -Reduce Circulating Hormones- Mehtimazole and Propylthioricil -More permanent treatment- Surgical removal of Thyroid, Radioactive Iodine

Treatment for Lymphocytic Thyroiditis (Hashimoto's or Autoimmune Thyroiditis)

-Thyroid Hormone Replacement

Treatment for Hypothyroidism:

-Treatment goal is to return to a Euthyroid State -Oral Levothyroxine is used to replace Hormone production -Resolution of symptoms occurs over weeks -Intravenous Levothyroxine is used for Myxedema coma

Cushing's Syndrom Treatment:

-Treatment is based on etiology -Exogenous dose reduction -Pituitary adenomas are treated surgically with transsphenoidal hypophysectomy, laser ablation, or radiation -Adrenal tumor is treated with unilateral adrenalectomy -Chemotherapeutic agents block cortisol production

Diagnosis of Hyperthyroidism:

-Undetectable Thyroid-Stimulating Hormone(TSH) levels -Elevated Serum Triiodothyronine(T3) and Thyroxine(T4)

Secondary Adrenal Insufficiency (Hypothalamic-Pituitary Dysfunction)

-Usually Iatrogenic, related to corticosteroid therapy, which surprises Adrenocorticotropic Hormone(ACTH) and Corticotropin-Releasing Hormone(CRH) -may also occur due to damage of the Anterior Pituitary Gland or Hypothalamus by: -Tremors -Infection -Radiation -Postpartum Necrosis -Trauma -Surgery

Causes of Secondary Hyperparathyroidism:

-Vitamin D-Metabolite deficiencies -High Phosphorous load

Graves Disease Diagnosis

-Diagnosis often made on Clinical Symptoms alone -Elevated Triiodothyronine(T3) And Thyroxine(T4) -Decreased Thyroid-Stimulating Hormone(TSH)

symptoms of Lymphocytic Thyroiditis (Hashimoto's or Autoimmune Thyroiditis)

-Dry skin -Tiredness -Weight Gain -Puffy Face -Intolerant to cold -Mild Depression

Clinical Manifestations of Hypothyroidism in Infants:

-Dull appearance, Thick, protuberant tongue, and thick lips -Prolonged neonatal jaundice -Poor muscle tone -Bradycardia (slower than normal heart rate), mottled extremities -Umbilical Hernias -Hoarse cry

Graves Disease is characterized by:

-Edema of the eyes -Exophthalmos(Protrusion of eyes) -Extraocular muscle weakness

Clinical Manifestation of Thyroid Storm:

-Elevated temperatures -Tachycardia (Abnormally fast Heart beat) -Arrhythmias (Abnormal Heart Rhythm) -Extreme restlessness -Agitation -Psychosis -Vomiting -Nausea -Diarrhea -Jaundice

Clinical Manifestation of Pheochromocytoma:

-Episodic or sustained Hypertension -Headache -Sweating -Palpitations with or without Tachycardia -Nervousness -Weightloss -Nausea -Fatigue

What is Giantism?

-Excessive growth due to Hypersecretion of Growth Hormone(GH) in children and adolescents. -Excessive amounts of somatotrophin(GH) BEFORE Epiphyseal closure.

Elevated or Depressed Hormone levels can be caused by:

-Failure of Feedback System -Dysfunction of Endocrine Gland -Secretory cells are unable to produce, obtain, and convert Hormone Precursors -The Endocrine Gland synthesizes or releases and excessive amount of Hormones, or Not enough Hormones -Increased Hormone Degradation or inactivation -Ectopic (In an abnormal place or position) Hormone Release -Target Cell failure

Etiology of Hyperparathyroidism:

-Genetic origin -Parathyroid Adenomas -Hyperplasia of Parathyroid Gland

Growth Hormone Disorders include:

-Growth Hormone Deficiency -Growth Hormone Excess

Endocrine Disorders include:

-Growth Hormone Deficiency -Growth Hormone Excess (Acromegaly, Giantism) -Hypothyroidism (Lymphocytic Thyroiditis, Secondary, and Myxedema) -Hyperthyroidism (grave's Disease, Thyroid Storm) -Adrenocortical Insufficiency(Addison's Disease, Hypothalamic-Pituitary Dysfunction) -Congenital Adrenal Hyperplasia -Hypercortisolism (Cushing's Syndrome) -Hyperaldosteronism (Conn Syndrome) -Pheochromocytoma -Hyperparathyroidism -Hypoparathyroidism -Diabetes Insipidus -Syndrome of Inappropriate Antidiuretic Hormone Secretion

Parathyroid Disorders:

-Hyperparathyroidism -Hypoparathyroidism

Parathyroid Gland Disorders include:

-Hyperparathyroidism -Hypoparathyroidism

Disorders of the Adrenal Cortex:

-Hypoadrenalism -Hyperadrenalism

Etiology of Endocrine Disorders

-Hyposecretion -Hypersecretion

where can Hyposecretion and Hypersecretion occur?

-Hypothalamus -Pituitary Gland -Hormone Producing Gland -Target Tissues

Thyroid Hormone Disorders include:

-Hypothyroidism -Hyperthyroidism

Thyroid Hormone Disorders:

-Hypothyroidism -Hyperthyroidism

Primary Hyperparathyroidism:

-Increases Parathyroid Hormone(PTH) -Increases Calcium -Decreases Phosphorous -Causes demineralization -Extensive Resorption -Hypercalcemia mostly affects the Nervous System and Kidneys

What does the Parathyroid Gland do?

-Increases Serum Calcium and decreases Serum Phosphate -Increases Bone reabsorption of Calcium -Increases Kidney reabsorption of Calcium -Decreases Kidney reabsorption of Calcium -Increases Vitamin D production in the Kidneys

Clinical Manifestation of Addison's Disease:

-Insufficient Adrenal Hormones -Chronic Fatigue -Muscle weakness -Loss of appetite -Low Blood Pressure -Dehydration -Cardia Arrhythmia's -bronzed appearance

Etiology and Pathogenesis of Primary Hypothyroidism:

-Iodine is essential for Triiodothyronine(T3) and Thyroxine(T4) Synthesis -Deficiency in Iodine leads to lack of Triiodothyronine(T3) and Thyroxine(T4) but does not affect Thyroglobulin levels -Insufficient Hormone is available to inhibit production of Thyroid-Stimulating Hormone(TSH) -Increased Thyroid-Stimulating Hormone(TSH) causes Thyroid cells to secrete large amounts of Thyroglobulin, Which leads to Goiter.

Clinical Manifestations of Hyperparathyroidism:

-Kidney Stones -Demineralization of Bone (Osteoporosis) -Polyuria and Dehydration -Anorexia, Nausea, Vomiting -Constipation -Bradycardia, Heart Block, Cardiac Arrest

Lymphocytic Thyroiditis (Hashimoto's or Autoimmune Thyroiditis) is Caused by:

-Lymphocytic Infiltration

Types of Acquired Hypothyroidism:

-Lymphocytic thyroiditis(Hashimoto or autoimmune Thyroiditis) -Irradiation of thyroid Gland -Surgical removal of Thyroid tissue -Iodine deficiency

Graves Disease Symptoms include:

-Nervousness -Fatigue -Weightloss

Clinical Feature of Graves Disease

-Onset of Disease - 20-50 years of age -10 times more common in Females then in Males -Patients have Goiter with Thyroid Gland 2-3 times the normal size

Clinical Features of Lymphocytic Thyroiditis (Hashimoto's or Autoimmune Thyroiditis)

-Onset of Disease - 30-60 years of age -5 times more common in females then in males -Patients have decreased Thyroxine(T4) levels and increased Thyroid-Stimulating Hormone levels -Patients have Enlarged Thyroid Gland(Goiter) -

ENDOCRINE DISORDER CALSSIFICATION: Endocrine Disorders involving Control by Anterior Pituitary Gland are classified as:

-PRIMARY- Intrinsic Malformation of the Hormone-Producing target Gland -SECONDARY- Malformation of the Hypothalamus/Pituitary cells that control the Hormone-producing target Gland

Etiology and Pathogenesis of Hyperthyroidism:

-Pituitary Adenoma -Thyroid Carcinoma -Autoantibodies that bind and stimulate Thyroid-Stimulating Hormone(TSH) receptors on the Thyroid Gland leading to a diffuse toxic Goiter (Graves Disease) -Ingestion of Thyroid Hormone preparations or Excessive Iodides

Types of Hypercortisolism:

-Primary -Secondary -Tertiary

Types of Hypoadrenalism:

-Primary Adrenal Insufficiency(Addisons Disease) -Secondary Adrenal Insufficiency(Hypothalamic-Pituitary Dysfunction)

Diagnosis of Hypothyroidism:

-Primary Hypothyroidism will show elevated Thyroid-Stimulating Hormones(TSH) -Low levels of Triiodothyronine(T3) and Thyroxine(T4) may not show until later in the disease course -Hypothalamic-Pituitary Dysfunction results in low levels of Thyroid-Stimulating Hormone(TSH) and Thyroxine(T4)

Type of Hyperaldosteronism:

-Primary(Conn Syndrome) -Secondary

Types of Hyperthyroidism:

-Primary- Autonomous -Secondary- Mediated through Thyroid-Stimulating Hormones(TSH) -Autoimmune- Related to thyroid-Stimulating Hormone(TSH) Antibodies

What is Congenital Adrenal hyperplasia?

A rare cause of Adrenal Insufficiency in Pediatric populations.

What is the Etiology of Graves Disease?

AutoImmune

what is another term used for Congenital Hypothyroidism?

Cretinism

What is another term for Hypercortisolism?

Cushing's Syndrome

What is the most common form of Hyperthyroidism?

Garves Disease

What is Thyroid Dysgenesis?

Lack of Thyroid Gland development.

What is Addisonian Crisis(Acute Adrenal insufficiency)?

Life-Threatening condition caused by inadequate levels of Glucocorticoids and mineralocorticoids in circulation

The most common form of Acquired hypothyroidism is:

Lymphocytic Thyroiditis(Hashimoto or Autoimmune thyroiditis)

A 3-month-old male was diagnosed with congenital hypothyroidism. If left untreated, the child would have:

Mental retardation and stunted growth

A problem associated with chronic hyperparathyroidism is:

Osteoporosis and Pathologic Fractures

Adrenal Medulla Disorders include:

Pheochromocytoma

Congenital Hypothyroidism is typically due to:

Thyroid Dysgenesis (defective development)

What is Cushing's Syndrome?

a metabolic disorder caused by overproduction of corticosteroid hormones by the adrenal cortex and often involving obesity and high blood pressure.

What is Thyroid Storm?

form of life-threatening thyrotoxicosis that occurs when excessive amounts of thyroid hormones are acutely released into circulation

Myxedema can occur in:

severe or Prolonged Thyroid deficiencies

What is Myxedema?

swelling of the skin and underlying tissues giving a waxy consistency.

Primary Adrenocortical insufficiencies is known as:

Addisons Disease

Etiology and Pathogenesis of Primary Hypercortisolism

Adrenocortical Hyperfunction due to disease of the Adrenal Cortex(Adrenal Adenoma)

Primary Hyperaldosteronism(Conn Syndrome) Usually occurs as a result of what?

Aldosterone-Secreting tumors

Pathogenesis of Graves Disease

Antibodies mimic Thyroid-Stimulating Hormones(TSH) by binding to and activating Thyroid-Stimulating Hormone(TSH) Receptors.

How is Pheochromocytoma caused?

Caused by Tumors derived from the Chromatin Cells of the Adrenal Medulla

Primary Adrenocortical insufficiency (Addison's Disease)

Destruction of the Adrenal Gland through: -Idiopathic or Autoimmune mechanisms -Tuberculosis -Trauma or Hemorrhage -Fungal Disease -Neoplasia

Pheochromocytoma Diagnosis

Diagnosed with abnormal CT/MRI

Etiology and Pathogenesis of Secondary Hypercortisolism

Disease caused by Hyperfunction of the Anterior Pituitary Adrenocorticotropic Hormone(ACTH)-secreting cells

Etiology and Pathogenesis of Tertiary Hypercortisolism

Disease caused by Hypothalamic Dysfunction or injury

Lymphocytic thyroiditis(Hashimoto or Autoimmune Thyroiditis) is characterized by what?

Enlarged Thyroid Gland caused by Lymphocytic infiltration

What is the most common cause of Cushing's Syndrome?

Exogenous Steroids

A 35-year-old female with Graves disease is admitted to a medical-surgical unit. Lab tests would most likely reveal:

High levels of Thyroid-Stimulating Antibodies circulating in blood.

Secondary Adrenocortical Insufficiency is known as:

Hypothalamic-Pituitary dysfunction

Secondary Hyperaldosteronism is typically associated with what?

Poor Kidney perfusion that stimulates the Renin-Angiotensin-Aldosterone cascade(Heart Failure, reduced Kidney Perfusion, Cirrhosis)

The great majority of Hypothyroidism are:

Primary due to the intrinsic dysfunction of the Thyroid gland.

Characteristic sign of long-standing Hypothyroidism is:

Puffy face

Etiology and Pathogenesis of Secondary Hypothyroidism:

Secondary Hypothyroidism is caused by defects in Thyroid-Stimulating Hormones(TSH) production and can result from: -Severe Head Trauma -cranial Neoplasms -Brain Infections -Cranial Irradiation -Neurosurgical Procedures

What is Congenital Adrenal Hyperplasia caused by?

Specific Enzymatic defects in biosynthesis of cortisol by the Adrenal Gland.

Goiter can be described as:

Swelling of the neck resulting from enlargement of the Thyroid Gland (Enlarged Thyroid)

Myxedema is caused by:

The accumulation of Glycosaminoglycans in interstitial space

Characteristic physical features of individuals with Cushing syndrome include:

Truncal obesity and thin skin