Other titles published Case Presentations in Clinical Geriatric Medicine Case Presentations in Gastrointestinal Disease Case Presentations in General Surgery Case Presentations in Heart Disease Case Presentations in Neurology Case Presentations in Paediatrics Case Presentations in Renal Medicine Case Presentations in Urology In preparation Case Presentations in Respiratory Medicine Case Presentations in Endocrinology and Diabetes P. H. Baylis, MD, FRCP Reader in Endocrinology and Consultant Physician, Endocrine Unit, Royal Victoria Infirmary, Newcastle upon Tyne G. V. Gill, MSc, MD, MRCP, DTM&H Consultant Physician, Department of Medicine, Arrowe Park Hospital, Wirral, Merseyside P. Kendall-Taylor, MD, DCH, FRCP Professor of Endocrinology and Consultant Physician, Royal Victoria Infirmary, Newcastle upon Tyne Butterworths London Boston Singapore Sydney Toronto Wellington All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, including photocopying and recording, without the written permission of the copyright holder, application for which should be addressed to the Publishers. Such written permission must also be obtained before any part of this publication is stored in a retrieval system of any nature. This book is sold subject to the Standard Conditions of Sale of Net Books and may not be re-sold in the UK below the net price given by the Publishers in their current price list. First published 1988 © Butterworth & Co. (Publishers) Ltd. 1988 British Library Cataloguing in Publication Data Baylis, P. H. Case presentations in endocrinology and diabetes. 1. Endocrine glands—Diseases—Cases, clinical reports, statistics 2. Diabetes—Cases, clinical reports, statistics I. Title II. Kendall-Taylor, P. III. Gill, Geoffrey V. 616.4Ό9 RC648 ISBN 0-407-00543-9 Library of Congress Cataloging-in-Publication Data Baylis, Peter H., 1946- Case presentations in endocrinology and diabetes/ P. H. Baylis, P. Kendall-Taylor, G. V. Gill p. cm. Bibliography: p. Includes index. ISBN 0-407-00543-9 1. Endocrine glands—Diseases—Case studies. 2. Diabetes—Case studies. I. Kendall-Taylor, P. II. Gill, Geoffrey V. III. Title. [DNLM: 1. Diabetes Mellitus—case studies. 2. Diabetes Mellitus—examination questions. 3. Endocrinology— case studies. 4. Endocrinology—examination questions. WK 18 B358c] RC649.5.B39 1988 616.4—dc 19 DNLM/DC for Library of Congress 87-30916 CIP Photoset by Butterworths Litho Preparation Department Printed and bound by Butler & Tanner Ltd., Frome and London Preface This book is a collection of reports on patients suffering from a variety of disorders which may be seen in a busy endocrine and diabetes unit. We have endeavoured to comment on the difficult and controversial areas associated with the diagnosis and management of each patient. By no means is this intended to be a textbook of endocrinology and diabetes, of which there are many, but rather an insight into the clinical practice of the specialty; as such, we have not included examples of all possible endocrine disease. We see this as a book to complement the formal reading and training in endocrinology and diabetes - a book to be enjoyed and yet to promote thought. The volume should interest all those training in clinical medicine up to the level of membership of the Royal Colleges, but may be particularly relevant to those pursuing a career in endocrinology and diabetes. We wish to thank Dr D. G. Johnston, Dr A. Murdoch and Dr M. C. White for their contributions to the book. We are grateful to Miss W. Pearson and Mrs A. Potts for secretarial assistance and to the Audio Visual Centre, University of Newcastle upon Tyne for the preparation of photographs and figures. P. H. Baylis G. V. Gill P. Kendall-Taylor ν Reference ranges Electrolytes, Renal, Liver and Pancreatic Function Tests Serum Sodium 136-142 mmol/1 Potassium 3.4-4.4 mmol/1 Chloride 100-108mmol/l Bicarbonate 25-32 mmol/1 Urea 2.8-7.7 mmol/1 Creatinine 61-125 μπιοΐ/ΐ Calcium 2.18-2.54 mmol/1 Ionized calcium 1.19-1.37 mmol/1 Phosphate 0.75-1.33 mmol/1 Bilirubin 3-21μτηο1/1 Aspartate transaminase <37UA γ-glutamyl transaminase: male <70U/1 female <40U/1 Total protein 62-79 g/1 Albumin 39-51 g/1 Amylase 70-300 U/l Plasma osmolality 282-294 mOsmol/kg Blood glucose 3.3-5.0 mmol/1 Steroid hormones Plasma np-Oestradiol: male <220pmol/l female: follicular phase 70-370 pmol/1 luteal phase 90-870 pmol/1 Progesterone: female: pre-ovulation <5 nmol/1 post-ovulation >20nmol/l Testosterone: male 10-28.4 nmol/1 female <3.1 nmol/1 IX Reference ranges continued Sex hormone binding globulin: male 10-40 mmol/1 female 20-95 mmol/1 Androstenedione <12nmol/l 17 a-Hydroxyprogesterone: male <10nmol/l female <14nmol/l Dehydroepiandrosterone: male 10.3-35.8 nmol/1 female 8.3-46.7 nmol/1 Plasma Dehydroepiandrosterone sulphate: male 2.2-1ΙΛμπιοΙΛ female 0.8-9.3 μιηοΐ/ΐ Cortisol: 9.00 a.m. 190-720 nmol/1 midnight <220 nmol/1 response to Synacthen or hypoglycaemia >600 nmol/1 (blood glucose <2 mmol/1) Urinary 100-370 nmol/24h Free Cortisol 20-60 pmol/24h 17-Oxogenic steroids 10-60 μιηο1/24ίΐ 17-Oxosteroids Thyroid tests Serum Thyroxine 63-131 nmol/1 Free thyroxine index 21-36 Tri-iodothyronine 1.2-3.0 nmol/1 TSH l-6mU/l TBII index <18 Thyroglobulin <5-90 μgΛ 20 minute technetium uptake by thyroid <3% Pituitary function tests Serum Prolactin <450mU/l Growth hormone: suppression with 75 g oral glucose <2mU/l stimulation after hypoglycaemia >20mU/l (blood glucose <2 mmol/1) χ Reference ranges continued Gonadotropins: LH male 1-6 U/l female: follicular phase 1-6 U/l luteal phase 1-3 U/l mid-cycle Up to 25 U/l FSH male 1-7 U/l female: follicular phase 1-8 U/l luteal phase 0.5-3 U/l mid-cycle Up to 15 U/l Responses to LHRH (100 μg i. v.) LH male female 20min 7-27 U/l 2.4-13.2 U/l 60min 4-15U/1 3.4-10.2 U/l FSH 20 min 3.3-8.9 U/l 3.3-8.9 U/l 60min 2.9-7.3 U/l 2.9-7.3 U/l TSHresponse to TRH(200 ngi.v.) TSH male female 20 min 3.5-15.6 mU/1 6.5-20.5 mU/1 60 min 2.0-11.5mU/l 4.0-15.6mU/l Plasma ACTH 20-80 ng/1 Miscellaneous Serum Parathyroid hormone 0.3-1.4 U/l 25-Hydroxy vitamin D (adult): Summer 22-75 nmol/1 Winter 15-60 nmol/1 Somatomedin C (adult) 12-48 nmol/1 β-HCG 0-4 U/l α-Fetoprotein 0-15 U/ml Plasma Glycosylated haemoglobin (HbAi) 5-7.5% Insulin (fasting) c 2.8-13.5 mU/1 xi Reference ranges continued Urinary Calcium 2.5-7.5 mmol/24h HMMA <42 μηιο1/24]ι Seminal analysis Count >20 x 106/ml Motility >80% Abnormal forms <20% xii 3 Case 1 A 47-year-old divorced lady was referred to the endocrine clinic by her general practitioner with a five-year history of progressive tiredness. She found it difficult to cope at her work and tended to become rather sleepy in the evening. When she awoke in the morning she was full of energy, but soon tired during the day. She also noted that she took a long time to get over colds and minor illnesses. Twenty years previously she had had tuberculous meningitis and had been treated with a full course of streptomycin, isoniazid and PAS together with intrathecal streptomycin. She recalled that for a while during the illness, she had developed marked thirst and polyuria which had been treated by injections of Pitressin. This treatment was stopped after one year and she had had no further symptoms. For the past ten years she had always had rather dry skin, which for the past five years had also remained pale. When she went on holiday, she noticed that she did not develop a good sun-tan. Her periods stopped shortly after the treatment for her tuberculosis. At about that time she got divorced. She had no children. She was currently taking no medication. On examination this was a rather thin patient, weighing 47 kg, height 1.57 m. Although not clinically anaemic, her skin was pale and she had no hair in the axillary or pubic areas. Blood pressure was 130/80 mmHg lying, which fell to 115/70 mmHg when standing. The rest of her cardiovascular and respiratory system was quite normal. She had no galactorrhoea but her breasts were rather atrophic. Abdominal examination was unremarkable. External genitalia showed an atrophic vulva and vagina. There were no abnormal neurological signs and her visual fields were full to confrontation. Fundoscopy was unremarkable. Her haemoglobin was 11.7 g/dl with normal blood indices and a white cell count of 4.0 x 109/1. Plasma sodium was 138 mmol/1, potassium 3.4 mmol/1 and urea 4.5 mmol/1. Total serum thyroxine was 100 nmol/1 with a free thyroxine index in the normal range at 97. A random Cortisol performed in the clinic was 295 nmol/1 but her 24-hour urine collection showed a urinary free Cortisol of less than 60nmol/24h. Plasma 17p-oestradiol was less than 125pmol/l and plasma progesterone was 0.8 nmol/1. She had a normal response of plasma Cortisol to Synacthen with a peak level of 4 652 nmol/1. She was admitted for further evaluation and the results of her pituitary function tests are given in Table la. Chest X-ray showed that she had a calcified focus in the left upper zone. X-ray of her skull showed no abnormality and the pituitary fossa was Table la Results of pituitary function tests Insulin stress test (i.v. insulin 0.05 U/kg given at time 0): Time (mm) Blood glucose (mmol/1) Cortisol (nmol/1) Growth hormone (mU/1) 0 3.7 120 0.7 30 1.9 165 4.2 60 2.1 230 3.6 90 2.1 185 1.8 120 2.8 155 1.7 LHRH test (100 μg LHRH given at time TRH test (200 μg TRH given at time 0): 0): Time (mm) LH (U/l) FSH (U/l) TSH (m\J/\) 0 1.0 <0.6 <1.5 20 1.8 <0.6 <1.5 60 2.0 <0.6 <1.5 Cannulated prolactin: Time (min) PRL (mU/1) 0 335 1 300 2 315 normal in size. CT scans of the pituitary and hypothalamic area were also normal. Perimetry of visual fields showed no abnormality. After starting replacement therapy, her 24-hour urine output ranged between 1.6 and 1.81/24 h. Questions 1. What biochemical evidence does this patient have of hypopituitarism and what is its likely cause? 2. What are the possible electrolyte disturbances associated with hypopituitarism?

Case Presentations in Endocrinology and Diabetes

Similar Case Presentations in Endocrinology and Diabetes