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ENDOCRINOLOGY SIGNS AND SYMPTOMS UNINTENDED WEIGHT LOSS The

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Title: ENDOCRINOLOGY SIGNS AND SYMPTOMS UNINTENDED WEIGHT LOSS The


1
ENDOCRINOLOGY
  • SIGNS AND SYMPTOMS

2
UNINTENDED WEIGHT LOSS
  • The most common causes
  • Uncontrolled DM
  • Addisons Disease
  • DD
  • Cancer (about 30)
  • Gastrointestinal disorders (about 15) and
  • Dementia or depression (about 15)

3
Abnormal Skin Pigmentation
  • Excessive ACTH secretion-
  • Addisons Disease
  • Chloasma Mask of Pregnancy
  • Acanthosis nigricans
  • Hemochromatosis- bronze diabetes
  • Thiamine/ Niacin deficiency
  • Vitiligo- Addisons, B12 deficiency
  • Dialysis patients, sprue, HIV
  • Drugs

4
Pigmentation Picture Gallery
5
Acanthosis Nigricans
This healthy 16 year old adolescent developed
acanthosis nigricans after gaining over 30 pounds
during the preceding year
6
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7
Drugs causing pigmentation
  • amiodarone, arsenic, bleomycin, busulfan,
    clofazimine, hydroxychloroquine, chlorpromazine,
    doxorubicin (nail beds), imipramine, methimazole,
    minocycline, niacin, primaquine,
    propylthiouracil, topical tretinoin, and
    zidovudine

8
Gynecomastia
  • Female appearing male breast
  • Pubertal gynecomastia is common (teenagers who
    are very tall or overweight)
  • Athletes abusing androgens
  • Klinefelter's syndrome (47,XXY)

9
Klinefelters Syndrome
  • Male hypogonadism and infertility
  • Enlarged breasts, sparse facial and body hair,
    small testes, and inability to produce sperm and
    psychosocial problems (anxiety, depression,
    neurosis, and psychosis)
  • 1 in 500-1,000 males is born with an extra sex
    chromosome over 3,000 affected males are born
    yearly.
  • The prevalence is 5-20 times higher in the
    mentally retarded than in the general newborn
    population.
  • MVP/ Tall stature/ eunochoid appearance

10
Gynecomastia Labworkup
  • Plasma Prolactin levels increased
  • ß HCG levels decreased
  • Low plasma testosterone levels
  • TREATMENT
  • Pubertal variety resolves within 1-2 years
  • Drug induced (Spironolactone) stop it
  • Persistent GM treat with SERM drug Raloxifene
    (Evista)
  • ? Liposuction

11
Muscle Cramps Tetany
  • Occupational
  • Night cramps-
  • Diabetes mellitus
  • Parkinson's disease
  • Central nervous system or spinal cord lesions
  • Peripheral neuropathy
  • Hemodialysis
  • Peripheral vascular disease, and
  • Cisplatin or vincristine

12
Remember!
  • A common cause for muscle pain, though not
    usually with cramping, is 3-hydroxy-3-methylglutar
    yl coenzyme A (HMG-CoA) reductase inhibitor
    (statin) therapy for hyperlipidemia

13
  • Diffuse, recurrent, or severe muscle cramping
    requires evaluation for hypocalcemia/
    Hypomagnesemia

14
Mental Changes- Evaluate
  • Nervousness, irritability, apathy, and depression
    Hypogonadic states/ Post partum (15)/
    Premenstrual
  • Anxiety and extreme irritability Hyperthyroid
  • Cretin-mental slowness-depression-lethargy
    Hypothyrodism (Myxedema madness)
  • Hypoglycemic states
  • Altered steroid status
  • B1, B2, B3, B6, B12 deficiencies

15
PITUITARY DISORDERS
  • WSO 411

16
Endocrine Control Negative feedback
17
ANATOMY
18
PITUITARY TUMOR
19
NORMAL Vs. ABNORMAL
20
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21
Pituitary Control
  • Only the secretion of prolactin is increased in
    the absence of hypothalamic influence
  • It is mainly under tonic suppression through the
    prolactin inhibitory factor
  • All anterior pituitary hormones are secreted in a
    pulsatile fashion and tend to follow a diurnal
    pattern

22
PITUITARY TUMORS
  • Adenomas Prevalence 20 cases per 100,000
  • Incidence of 0.5 to 7.4 per 100,000 population

23
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24
Hyperprolactinemia
  • Women Menstrual cycle disturbances
    (oligomenorrhea, amenorrhea) galactorrhea
    infertility.
  • Men Hypogonadism decreased libido and erectile
    dysfunction infertility.
  • Elevated serum PRL.
  • CT scan or MRI often demonstrates pituitary
    adenoma.

25
Hypopituitarism
  • Growth Hormone Deficiency
  • Decreased muscle strength and exercise tolerance
    and
  • A reduced sense of well-being (eg, diminished
    libido, social isolation)
  • Increased body fat

26
Hypopituitarism
  • Gonadotropin Deficiency
  • Infertility and oligomenorrhea or amenorrhea
  • Lack of libido, hot flashes, and dyspareunia

27
Hypopituitarism
  • Adrenocorticotropic Hormone Deficiency
  • Chronic malaise, fatigue, anorexia, and
    hypoglycemia.
  • Severe hypotension, hyperkalemia, and
    hyperpigmentation
  • May lead to hyponatremia

28
Hypopituitarism
  • Thyrotropin (TSH) Deficiency
  • Malaise, leg cramps, fatigue, dry skin, and cold
    intolerance.

29
Pituitary Excess Hormone Secretion
  • Prolactinoma oligomenorrhea, amenorrhea,
    galactorrhea, or infertility
  • Men impotence and decreased libido

30
ACROMEGALY
31
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32
Cushing's Disease
33
DIAGNOSIS
  • Usually a delay in diagnosis
  • Pituitary MRI is the preferred diagnostic imaging
    technique in patients with visual loss or
    hypopituitarism suggestive of a pituitary tumor
  • HORMONE ASSAYS

34
THERAPY
  • Reduction or complete removal of tumor
  • Elimination of mass effect if present
  • Normalization of hormone hypersecretion, and
  • Restoration of normal pituitary function
  • Medical, surgical, and radiation therapy
  • Availability of a good neurosurgeon

35
THERAPY
  • For Prolactinoma tumor shrinkage by medical
    therapy with Bromocriptine (Parlodel), and
    cabergoline (Dostinex)
  • Radiosurgery (gamma knife)

36
THYROID DISORDERS
37
TSH and FT4
  • TSH levels 0.45.5 mU/L.
  • FT4 is a direct measurement of the serum
    concentration of free (unbound) T4

38
THYROID GOITER
  • Single or multiple thyroid nodules are commonly
    found with careful thyroid examinations.
  • Thyroid function tests mandatory.
  • Thyroid biopsy for single or dominant nodules or
    for a history of prior headneck or
    chestshoulder radiation.
  • Ultrasound examination useful for biopsy and
    follow-up.
  • Clinical follow-up required.

39
GOITER
  • 4
  • Presence of iodine deficiency
  • Graves and Hashimotos may have goiter
  • ?cancer- if prior radiation/ FH of Thyroid
    cancer/ personal cancer/ presence of lymphnodes
    and non mobile thyroid nodule is felt.

40
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41
Other Tests for nodules
  • FNAC
  • US- irregular margins/ microcalcifications
  • RAI (123 I / 131I) scans for hot vs cold
    nodules

42
Thyroid Cancer
  • Painless swelling in region of thyroid.
  • Thyroid function tests usually normal.
  • Past history of irradiation to head and neck
    region may be present.
  • Positive thyroid needle aspiration.

43
Thyroid Cancer
  • FM 31
  • 1/250
  • Papillary type most common
  • Solitary nodule
  • Past exposure of head and neck to radiation
  • Chernobyl Age 5 at exposure 6-7 yrs later had
    cancer
  • Spreads to lung

44
Thyroid Cancer Prognosis
  • lt45-TNM T1 N1 M0- 98 10 yr survival
  • lt45-T1 N1 M1 5 yr 99 85 10 yr
  • gt45- T1 N0 M0
  • gt45 T1 N0 M0- 95 5 yr 7010yr
  • gt45 T N M- 80 5 yr 61 10 yr

45
Hypothyroidism Myxedema
  • Weakness, fatigue, cold intolerance,
    constipation, weight change, depression,
    menorrhagia, hoarseness.
  • Dry skin, bradycardia, delayed return of deep
    tendon reflexes.
  • Anemia, hyponatremia.
  • T4 and RAI uptake usually low.
  • TSH elevated in primary hypothyroidism.

46
  • May affect almost all body functions
  • Interstitial accumulation of hydrophilic
    mucopolysaccharides leads to fluid retention
    (lymphedema)
  • Hashimotos Drugs- lithium, amiodarone,
  • foods- turnips, cassavas
  • Chronic HCV patients treated with interferon

47
Lab workup
  • FT4 low/ normal
  • TSH increased
  • High cholesterol
  • Thyroid antibodies- Hashimotos
  • Differential Diagnosis unexplained menstrual
    disorders, myalgias, constipation, weight change,
    hyperlipidemia, ascites, heart failure and
    anemia.

48
Complications
  • Cardiac- CAD, CHF
  • Infection risk
  • Madness
  • Infertility/ miscarriage
  • Coma (rare)

49
Treatment
  • Levothyroxine 50-100 mcg/day
  • (max 1.6 mcg/kg/day)
  • Slowly increase the dose every
  • 1-3 weeks (75250 mcg oral)
  • Estre Levo-T Levothroid Levoxyl
    Synthroid Thyro-Tabs Unithroid

50
Hyperthyroidism (Thyrotoxicosis)
  • Sweating, weight loss or gain, anxiety, loose
    stools, heat intolerance, irritability, fatigue,
    weakness, menstrual irregularity.
  • Tachycardia warm, moist skin stare tremor.
  • In Graves' disease goiter (often with bruit)
    ophthalmopathy.
  • Suppressed TSH in primary hyperthyroidism
    increased T4, FT4, T3, FT3.

51
Graves' Disease
  • Autoimmune, Familial
  • FM 81, Age 20-40
  • Exophthalmos
  • Pernicious anemia
  • Myasthenia gravis
  • Risk of Addisons,
  • Celiac,
  • DM T1,

52
Thyrotoxicosis Factitia
  • Eating ground beef containing bovine thyroid gland

53
  • Nervousness, restlessness, heat intolerance,
    increased sweating, fatigue, weakness, muscle
    cramps, frequent bowel movements, or weight
    change (usually loss), palpitations or angina
    pectoris, menstrual irregularities.
  • Hypokalemic periodic paralysis (15) Asians/
    Native Americans

54
  • stare and lid lag, fine resting finger tremors,
    moist warm skin, hyperreflexia, fine hair, and
    onycholysis
  • CVSforceful heart beat,
  • premature atrial
  • contractions, and sinus
  • tachycardia.
  • Atrial fibrillation or
  • atrial tachycardia occurs
  • in about 8 (older men)

55
Ophthalmopathy
  • 20-40
  • Chemosis
  • Conjunctivitis
  • Proptosis
  • Exophthalmos
  • Maximum normal
  • eye protrusion
  • 22 mm for blacks,
  • 20 mm for whites, and
  • 18 mm for Asians.

56
CT Scan
57
Pretibial Myxedema
58
Complications
  • Atrial fibrillation
  • THERAPY choice of methods
  • ?Drugs- Symptomatic
  • PropranololInderal Inderal LA InnoPran XL
    Pronol
  • Effectively relieves the tachycardia, tremor,
    diaphoresis, and anxiety

59
Thiourea drugs
  • Methimazole Tapazole
  • Propylthiouracil, PTU
  • For mild thyrotoxicosis, small goiters, or fear
    of isotopes
  • Usually continued for 1224 months before being
    discontinued (50 relapse)
  • Side Effects BMD- 0.3-0.4 pruritus, allergic
    dermatitis, nausea, and dyspepsia

60
Radioactive iodine (131I)
  • Safe Should not be given to pregnant women
  • Thyroid surgery performed les frequently

61
Hashimotos Thyroiditis
  • Swelling of thyroid gland, sometimes causing
    pressure symptoms in acute and subacute forms
    painless enlargement and rubbery firmness in
    chronic form.
  • Thyroid function tests variable.
  • Serum antithyroperoxidase and antithyroglobulin
    antibody levels usually elevated in Hashimoto's
    thyroiditis.

62
Hashimotos
  • Autoimmune condition and the
  • most common thyroid disorder in the USA
  • Familial FM 61
  • Dietary iodine supplementation.
  • Certain drugs (amiodarone, interferon,
    interleukin-2, G-CSF) frequently
  • induce thyroid autoantibodies
  • Smokersgt Non smokers
  • (thiocyanates in cigarettes is antithyroid)

63
Hypoparathyroidism
64
HYPOCALCEMIA
  • Tetany, carpopedal spasms, tingling of lips and
    hands, muscle and abdominal cramps, psychological
    changes.
  • Positive Chvostek's sign and Trousseau's
    phenomenon defective nails and teeth cataracts.
  • Serum calcium low serum phosphate high alkaline
    phosphatase normal urine calcium excretion
    reduced.
  • Serum magnesium may be low.

65
HYPOPARATHYROIDISMChronic disease
  • lethargy,
  • personality changes,
  • anxiety state,
  • blurring of vision due to cataracts,
  • parkinsonism, and
  • mental retardation.

66
Chvostek's sign
  • facial muscle contraction on tapping the facial
    nerve in front of the ear
  • Trousseau's phenomenon
  • carpal spasm after application of a cuff

67
CARPOPEDAL SPASM
68
Laboratory Findings
  • Serum calcium is low,
  • serum phosphate high,
  • urinary calcium low, and
  • alkaline phosphatase normal.
  • PTH levels are low.
  • ? Serum magnesium

69
HYPOCALCEMIA DUE TO DRUGS
  • Loop diureticsEthacrynic AcidEdecrin /
    FurosemideDelone Furocot Furosemide
    Lasix
  • Phenytoin Di-Phen Dilantin
  • Alendronate Fosamax
  • Foscarnet Foscavir

70
Treatment for tetany
  • Intravenous calcium gluconate
  • Calcium gluconate, 1020 mL of 10 solution
    intravenously

71
THERAPY
  • Oral calcium
  • Calcium salts 12 g of calcium daily.
  • Liquid calcium carbonate (Titralac Plus), 500
    mg/5 mL, may be especially useful. The dosage is
    13 g calcium daily.
  • Calcium citrate contains 21 calcium, but a
    higher proportion is absorbed with less
    gastrointestinal intolerance.
  • Active metabolite of vitamin D
    1,25-dihydroxycholecalciferol (calcitriol),
  • Calcifediol Calderol (D3) rapid onset of
    action
  • Ergocalciferol(D2)Calciferol Deltalin
    Drisdol Ergo D Vitamin D for chronic cases
    slow acting

72
Hyperparathyroidism
  • Frequently asymptomatic, detected by screening.
  • Renal stones, polyuria, hypertension,
    constipation, fatigue, mental changes.
  • Bone pain rarely, cystic lesions and pathologic
    fractures.
  • Serum and urine calcium elevated urine phosphate
    high with low to normal serum phosphate alkaline
    phosphatase normal to elevated.
  • Elevated PTH.

73
  • "bones, stones, abdominal groans, psychic moans,
    with fatigue overtones."

74
Signs of Hypercalcemia
  • thirst,
  • anorexia,
  • nausea, and vomiting
  • Constipation,
  • fatigue, anemia, weight loss, and hypertension
  • Pancreatitis occurs in 3.

75
  • 0.1 incidence
  • gt50 FM 31
  • Due to adenoma of parathyroid gland
  • 5 of renal stones due to this condition

76
X-Rays
77
Reduction of plasma phosphate with aluminum
hydroxide gel / Aloh-Gel Alternagel
Alu-Cap
78
Complications
  • Pathologic fractures
  • Renal failure and uremia
  • Peptic ulcer and pancreatitis

79
Other causes for High Calcium
  • Calcium or Vitamin D Ingestion
  • Cancer breast, lung, pancreas, uterus,
    hypernephroma
  • Sarcoidosis
  • Multiple myeloma
  • Thiazides/Lithium

80
  • Bisphosphnates
  • Raloxifene

81
OSTEOPOROSIS
  • FACTS AND FEATURES

82
DEFINITION
  • A metabolic bone disease
  • Low bone mass and microarchitectural
    deterioration of bone tissue
  • Leads to enhanced bone fragility and increased
    fracture risk

83
Osteoporosis types
  • Primary osteoporosis bone mass loss-
  • 1 Unassociated with any other
  • chronic illness
  • 2 Related to aging and loss of the gonadal
    function in females and
  • 3 The aging process in males.
  • Secondary osteoporosis results from-
  • 1 a variety of chronic conditions leads to
    bone mineral loss
  • 2 effects of medications and nutritional
    deficiencies

84
Causes of Secondary Osteoporosis Chronic
Diseases
  • Cushing syndrome
  • Anorexia nervosa
  • Hyperthyroidism
  • Hyperparathyroidism
  • Hypophosphatasia
  • Marfan syndrome
  • Osteogenesis imperfecta
  • Chronic renal insufficiency
  • Chronic liver disease
  • Hemochromatosis
  • Hyperprolactinemia
  • Multiple myeloma
  • Disseminated carcinomatosis

85
Causes of Secondary OsteoporosisMedications
  • Steroids
  • Excess thyroid hormones
  • GnRH agonists
  • Cyclosporine
  • Methotrexate
  • Phenobarbital
  • Phenytoin
  • Phenothiazines
  • Heparin

86
Conditions Causing Nutritional Deficiencies
  • Malabsorption syndromes
  • Vitamin D deficiency
  • Calcium deficiency
  • Gastric and bowel resections
  • Alcoholism

87
Other Causes
  • Athletic amenorrhea
  • Tobacco use
  • Pregnancy
  • Carbonated fizzydrinks

88
WHO definition
  • Bone density (BD) that is 2.5 standard deviation
    (SD) or more below the young adult mean value
    (T-score lt -2.5)
  • BD between 1 and 2.5 SD below average (T-score
    -1 to -2.5) Osteopenia
  • Lead to increased risk for bone fracture

89
Prevalence
  • Primarily white women
  • 54 of postmenopausal Osteopenia
  • 30 have osteoporosis
  • 1.3 million osteoporotic fractures annually
  • 50 Vertebral 60
  • 25 Hip 70
  • 25 Colless (wrist) 50

90
?Men
  • an important health problem
  • 30 of all hip
  • 20 of all vertebral

91
Pathophysioloy
  • Poor bone mass acquisition during growth in early
    years
  • Accelerated bone loss post menopausal
  • ?Environmental (nutritional, behavioral, and
    medications)
  • ?Genetic (40-80)

92
Nutritional Factors
  • Dietary calcium intake, Vitamin D status, protein
    and calorie intake
  • Trace elements
  • Phosphorus
  • Vitamins C and K,
  • Copper, zinc, and manganese

93
Calcium
  • Got milk?- during adolescence helps
  • Low calcium intake in childhood increases later
    life fractures
  • Supplementation reduces fractures in elderly

94
?Diet
  • Typical U.S. diet is sodium and protein rich,
    both of which increase urinary calcium excretion,
    thus increasing dietary calcium requirements

95
?Protein
  • malnutrition predisposes to falls and diminishes
    soft tissue cover.
  • serum albumin level is the single best predictor
    of survival
  • body weight history of females with anorexia
    nervosa predicts osteoporosis risk

96
?Behavior
  • physical activity, smoking, and alcohol
    consumption
  • athletes engaging in strength training increase
    bone mass
  • Chronic alcohol abuse has been associated with
    decreased BMD in the femoral neck and lumbar
    spine and is commonly listed as a risk factor for
    osteoporosis (28-52)

97
?Glucocortiocids (aka. Steroids)
  • Most important cause
  • vertebrae, ribs, and ends of the long bones
    (20-40)
  • Estrogen deficiency

98
Risk Factors seen in Osteoporosis
  • Modifiable
  • Sedentary lifestyle
  • Smoking
  • Excessive alcohol intake
  • Estrogen-deficient states
  • Non-Modifiable-
  • Age
  • Caucasian or
  • Asian race
  • Low body weight
  • Family history of osteoporosis
  • Nulliparity
  • Calcium deficient diet
  • Use of medications

99
SIGNS AND SYMPTOMS
  • Skeletal fracture- vertebral most common- usually
    lower thoraic(T8)
  • or lumbar
  • Acute pain can get chronic
  • Multiple fractures on x-ray
  • Kyphosis (Dowagers hump) caused by vertebral
    collapse

100
SIGNS AND SYMPTOMS
  • Hip fractures 80
  • trivial falls lead to it
  • Colles fracture
  • Tests
  • Urine/Serum
  • Bone Density Measurements
  • ?US (evaluated)/ DEXA- Spine and hip (measures
    apparent bone density) or Quantitative CT (QCT)
    measures true bone density

101
THERAPY
  • AT ALL AGES- CALCIUM INTAKE
  • Diet or calcium supplements
  • Vit D 800 IU/day if needed

102
THERAPY
  • Good general nutrition
  • Stop tobacco
  • Limit alcohol intake
  • Exercise helps
  • HRT does not reduce fractures occurrence
  • Raloxifene (Evista) SERM preserves bone
    density, decreases total cholesterol
  • Bisphosphonates

103
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104
Outcomes
  • Raloxifene reduces risk by 0.7
  • Bisphosphoantes by 41-49

105
ADRENAL DISORDERS
106
Adrenal Crisis
  • Weakness, abdominal pain, fever, confusion,
    nausea, vomiting, and diarrhea.
  • Low blood pressure, dehydration skin
    pigmentation may be increased.
  • Serum potassium high, sodium low, BUN high.
  • Cosyntropin (ACTH124) unable to stimulate a
    normal increase in serum cortisol.

107
Pattern of plasma ACTH/Cortisolin patients
recovering from prior long-term daily treatment
with large doses of glucocorticoids
108
Adrenal Isufficiency
  • following stress, eg, trauma, surgery, infection,
    or prolonged fasting in a patient with latent
    insufficiency
  • following sudden withdrawal of adrenocortical
    hormone in a patient with chronic insufficiency
  • Following pituitary/ adrenal destruction

109
Addison's Disease
  • Weakness, easy fatigability, anorexia, weight
    loss nausea and vomiting, diarrhea abdominal
    pain, muscle and joint pains amenorrhea.
  • Sparse axillary hair increased skin
    pigmentation, especially of creases, pressure
    areas, and nipples.
  • Hypotension, small heart.
  • Serum sodium may be low potassium, calcium, and
    BUN may be elevated neutropenia, mild anemia,
    eosinophilia, and relative lymphocytosis may be
    present.
  • Plasma cortisol levels are low or fail to rise
    after administration of corticotrophin.
  • Plasma ACTH level is elevated.

110
Addisons Images
111
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112
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113
Thomas Addison (1793-1860). On the constitutional
and local effects of disease of the supra-renal
capsules. London, Samuel Highley, 1855.
114
Addisons Disease
115
Causes Etiology
  • Autoimmune destruction (80)
  • Tuberculosis
  • Hemorrhage into adrenals due to meningococcal
    meningitis (Waterhouse-Friderichsen syndrome)
  • Fungal adrenal destruction in AIDS/HIV

116
coccidioidomycosis
117
  • Vitiligo (10)
  • Orthostatic hypotension
  • Eosinophilia
  • Low sodium
  • High potassium
  • Low plasma cortisol levels

118
Complications
  • Susceptible to infections
  • Leads to crisis precipitation

119
THERAPY
  • Corticosteroid replacement
  • Mineralocorticoid replacement
  • Hydrocrotisone (Cortisone acetate)
  • Prednisone Deltasone Predone Sterapred
  • Fludrocortisone Florinef for salt (sodium)
    retention
  • Prasterone, Dehydroepiandrosterone,
    DHEAPrestara Vitamist DHEA-M for Men
    Vitamist DHEA-W for Women

120
  • medical alert bracelet or medal reading, "Adrenal
    insufficiencytakes hydrocortisone."
  • ?Lorenzos oil -Vitiligo

121
Prognosis
  • With appropriate treatment have normal life
    expectancy.
  • Risk of infection/surgery/stress

122
Cushing's Syndrome (Hypercortisolism)
  • Central obesity, muscle wasting, thin skin, easy
    bruisability, psychological changes, hirsutism,
    purple striae.
  • Osteoporosis, hypertension, poor wound healing.
  • Hyperglycemia, glycosuria, leukocytosis,
    lymphocytopenia, hypokalemia.
  • Elevated serum cortisol and urinary free
    cortisol. Lack of normal suppression by
    dexamethasone.

123
Cushings
  • Syndrome- manifestations of excessive
    corticosteroids, commonly due to supraphysiologic
    doses of corticosteroid drugs / rarely over
    production(15)
  • Disease- 50 Pituitary tumor related
  • A midnight serum cortisol level gt 7.5 mcg/dL is
    indicative of Cushing's syndrome

124
Cushings Disease
125
Cushings Disease
126
Adrenal Tumor
127
Cushings Syndrome
128
Cushings Signs
129
Complications
  • Untreated causes morbidity and death
  • Hypertension or of diabetes
  • Compression fractures of the osteoporotic spine
    and aseptic necrosis of the femoral head
  • Nephrolithiasis and psychosis
  • 5-year survival of 95 and a 10-year survival of
    90

130
Clinical Use of Corticosteroids
131
adverse effects
  • insomnia
  • personality change
  • weight gain
  • muscle weakness
  • polyuria
  • kidney stones
  • diabetes mellitus
  • sex hormone suppression
  • occasional amenorrhea
  • candidiasis and opportunistic infections
  • osteoporosis with fractures, or aseptic necrosis
    of bones

132
Therapy for Osteoporosis
  • Alendronate Fosamax 5-10 mg/daily
  • Risedronate Actonel 35 mg/ weekly
  • Ibandronate Boniva 150 mg/ monthly
  • Pamidronate Aredia infusion
  • Zoledronic Acid Zometa infusion/ monthly
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