Question 16#

A 43-year-old man is admitted to hospital with pneumonia. His past medical history includes Addison's disease for which he takes hydrocortisone (20mg in the mornings and 10mg in the afternoon).

What is the most appropriate action with respect to his steroid dose?

A. Continue to take the same dose

Correct Answer B: Patients on long-term steroids should have their doses doubled during intercurrent illness.

Corticosteroids:
Corticosteroids are amongst the most commonly prescribed therapies in clinical practice. They are used both systemically (oral or intravenous) or locally (skin creams, inhalers, eye drops, intraarticular). They augment and in some cases replace the natural glucocorticoid and mineralocorticoid activity of endogenous steroids. 

The relative glucocorticoid and mineralocorticoid activity of commonly used steroids is shown below:

Side-effects:
The side-effects of corticosteroids are numerous and represent the single greatest limitation on their usage. Sideeffects are more common with systemic and prolonged therapy.

Glucocorticoid side-effects:

• Endocrine: impaired glucose regulation, increased appetite/weight gain, hirsutism, hyperlipidaemia
• Cushing's syndrome: moon face, buffalo hump, striae
• Musculoskeletal: osteoporosis, proximal myopathy, avascular necrosis of the femoral head
• Immunosuppression: increased susceptibility to severe infection, reactivation of tuberculosis
• Psychiatric: insomnia, mania, depression
• Gastrointestinal: peptic ulceration, acute pancreatitis
• Ophthalmic: glaucoma, cataracts
• Suppression of growth in children

Mineralocorticoid side-effects:

• Fluid retention
• Hypertension

Selected points on the use of corticosteroids:

• Patients on long-term steroids should have their doses doubled during intercurrent illness
• The BNF suggests gradual withdrawal of systemic corticosteroids if patients have: received more than 40mg prednisolone daily for more than one week, received more than 3 weeks treatment or recently received repeated courses

 

 

Question 17#

What causes increased sweating in patients with acromegaly?

A. Increased sodium content in sweat

Correct Answer E: Acromegaly: increased sweating is caused by sweat gland hypertrophy.

Acromegaly features:
In acromegaly there is excess growth hormone secondary to a pituitary adenoma in over 95% of cases. A minority of cases are caused by ectopic GHRH or GH production by tumours e.g. pancreatic.

Features:

• Coarse facial appearance, spade-like hands, increase in shoe size
• Large tongue, prognathism, interdental spaces
• Excessive sweating and oily skin
• Features of pituitary tumour: hypopituitarism, headaches, bitemporal hemianopia
• Raised prolactin in 1/3 of cases --> galactorrhoea
• 6% of patients have MEN-1

Complications:

• Hypertension
• Diabetes (>10%)
• Cardiomyopathy
• Colorectal cancer

Question 18#

A 46-year-old woman is referred to endocrine with a tender neck swelling. Blood results are as follows:

Technetium thyroid scan shows decreased uptake globally.

What is the most likely diagnosis? 

A. Sick thyroid syndrome

Correct Answer D: Subacute thyroiditis is suggested by the tender goitre, hyperthyroidism and raised ESR. The globally reduced uptake on technetium thyroid scan is also typical.

Subacute (De Quervain's) thyroiditis:

Subacute thyroiditis (also known as De Quervain's thyroiditis) is thought to occur following viral infection and typically presents with hyperthyroidism.

Features:

• Hyperthyroidism
• Painful goitre
• Raised ESR
• Globally reduced uptake on iodine-131 scan 

Management:

• Usually self-limiting - most patients do not require treatment
• Thyroid pain may respond to aspirin or other NSAIDs
• In more severe cases steroids are used, particularly if hypothyroidism develops

Question 19#

A 68-year-old woman is found to have the following blood tests: 

If left untreated, what are the most likely possible consequences?

A. Supraventricular arrhythmias and osteoporosis

Correct Answer A: 

Subclinical hyperthyroidism:

Subclinical hyperthyroidism is an entity which is gaining increasing recognition. It is defined as:

• Normal serum free thyroxine and triiodothyronine levels
• With a thyroid stimulating hormone (TSH) below normal range (usually < 0.1 mu/l) 

Causes:

• Multinodular goitre, particularly in elderly females
• Excessive thyroxine may give a similar biochemical picture

The importance in recognizing subclinical hyperthyroidism lies in the potential effect on the cardiovascular system (atrial fibrillation) and bone metabolism (osteoporosis). It may also impact on quality of life and increase the likelihood of dementia.

Management:

• TSH levels often revert to normal - therefore levels must be persistently low to warrant intervention
• A reasonable treatment option is a therapeutic trial of low-dose antithyroid agents for approximately 6 months in an effort to induce a remission

Question 20#

Which one of the following statements regarding maturity-onset diabetes of the young (MODY) is true?

A. There is usually a strong family history

Correct Answer A: 

Maturity-onset diabetes of the young (MODY):

Maturity-onset diabetes of the young (MODY) is characterized by the development of type 2 diabetes mellitus in patients < 25 years old. It is typically inherited as an autosomal dominant condition.

Over six different genetic mutations have so far been identified as leading to MODY. Ketosis is not a feature at presentation.

MODY 3:

• 60% of cases
• Due to a defect in the HNF-1 alpha gene

MODY 2:

• 20% of cases
• Due to a defect in the glucokinase gene