Table Of ContentOther 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 abnor-
mality.
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 hypo-
pituitarism and what is its likely cause?
2. What are the possible electrolyte disturbances associated with
hypopituitarism?
