• women >50yo
• causes: parathyroid adenoma (80%), hyperplasia, carcinoma
• multiglandular disease and carcinoma more common in persons younger than 30yo

• hypercalcemia
• polydispsia and poluria from hypercalcemia-induced nephrogenic diabetes insipidus
• nephrocalcinosis adn renal failure from excessive calcium and phosphate excretion
• bone pain and arthrlagias-cortical bone or diffuse bone demineralization, trabecular bone increase, pathologic bone fractures, cystic bone lesions (jaw most common)

• thirst
• anorexia
• N/V
• abdominal pain
• constipation
• fatigue
• anemia
• weight loss
• PUD
• pancreatitis
• HTN
• depressed DTRs
• depression
• muscle weakness
• nephrolithiasis
• cataracts

• acute renal failure
• malignant tumors (breast, lung, pancreas, uterus)
• multiple myeloma (older persons)
• granulomatous disorders
• calcium or vitamin D ingestion
• familial hypocalciuric hypercalcemia
• adrenal insufficiency
• hyperthyroidism
• certain medications--lithium
• prolonged bed rest

• inappropriately high iPTH despite high serum calcium; low urinary calcium; hereditary
• about 15% of Asian and Native American men with thyrotoxicosis may develop this
• lasts 7-72 hours
• often after IV dextrose, oral carbohydrate, or vigorous exercise

• parathyroid radionucleotide scan
• hydration status is important
• bisphosphonates useful once hydration status normal
• post-op vit D, calcium +/- magnesium replacement after surgery

• phosphate binders
• vitamin D analogs
• calcimimetics (cinacalcet = sensipar)

Ca2+ >10.5mg/dL

serum phosphate often less than 2.5mg/dL

• prolonged PR interval
• shortened QT interval
• bradyarrhythmias
• heart block
• asystole

• surgery-hypocalcemia is complication
• hydration
• bisphosphonates
• avoid large doses vitamin A and D, thiazide diuretics

• most commonly found after thyroidectomy
• heavy metal toxicity
• granulomas
• Reidel's thyroiditis
• tumors
• infection
• autoimmune problems
• neck irradiation
• alkalosis
• hyperkalemia
• vitamin D deficiency

• hypoparathyroidism
• congenital facial and cardiac anomalies

• PERIORAL NUMBNESS
• tetany
• carpopedal spasm
• cramping
• convulsions
• circumoral and distal ext tingling
• irritability
• muscle cramps
• fatigue

• dry skin
• psoriasis, dermatits
• brittle nails
• coarse hair
• ectopic calcification in cornea--cataracts
• teeth defects

• corrected serum calcium, urinary calcium, PTH levels low
• serum magnesium low
• serum phosphate high
• alk phos normal
• CT skull-basal ganglia calcifications

• prolonged QT intervals

T-wave abnormalities

• emergency = airway maintenance and slow admin IV calcium gluconate
• calcium 1-2 g/day), vitamin D preparations, calcitril
• magnesium supplementation

• autimimmune disorder in which autoantibodies attack to the TSH receptors and stimulate thyroid hyperfunctioning--anti-TSH antibodies
• women 20-40
• familial tendency- HLA-B8 and HLA-DR3
• also found in pernicious anemia, myasthenia gravis, DM
• at increased risk for Addison's disease, alopecia areata, celiac disease, cardiomyopathy, hypokalemic periodic paralysis
• eye disease, clubbing, vitiligo, goiter, loss of color vision

• grave's disease
• toxic nodular goiter
• thyroiditis
• amiodarone
• subacute thyroiditis-De Quervain's
• postpartum thyroiditis
• iodine excess
• TSHoma
• exogenous intake thyroxine

• weight loss despite good appetite
• failure to thrive in infants
• heat intolerance
• sweating
• palpitations
• agitation
• emotional lability
• poor concentration/memory
• diarrhea
• pruritis
• muscle weakness
• oliigomenorrhea
• fine tremor
• goiter
• tachycardia
• bounding pule/wide pulse pressure
• a-fib
• high-output cardiac failure
• lid retraction
• gynecomastia
• muscle wasting
• warm, moist skin
• fine hair
• stare
• hyperreflexia

• low TSH
• increased T3, T4, free T4
• high TSH receptor antibody
• high antithyroglublin antibody
• high antithyroperoxidase antibody

• BB
• methimazole or PTU
• PTU if pregnant or breasfeeding
• RAI-radioactive iodine ablation preferred surgery for permanent control-CI in pregnancy
• ophthalmology responds to steroids

• methimazole if not pregnant
• PTU if pregnancy
• propranolol for sx control

• abrupt onset of more florid sx of thyrotoxicosis
• follows stressful illness, thyroid surgery, radioactive iodine administration

• high fever
• tachycardia
• vomiting
• diarrhea
• dehydration
• marked weakness
• muscle wasting
• extreme restlessness
• confusion
• delirium
• emotional lability

• automonous adenoma with thyrotoxicosis
• tx = methimazole or PTU (same as graves)

• tx sx with corticosteroids and NSAIDs
• ***ANY HYPERTHYROID STATE WARRANTS RADIOIODINE UPTAKE AND SCAN!!!***

• graves disease
• toxic multinodular goiter
• autonomous thyroid nodules
• TSHoma

• thyroiditis
• severe iodine excess
• amiodarone-induced thyrotoxicosis type 2

*ALMOST ALWAYS RESULTS FROM AUTOIMMUNE THYROIDITIS, PREVIOUS THYROID SURGERY, OR RADIATION THERAPY

• Hashimotos thyroiditis- autoimmune destruction
• radioiodine
• thyroid surgery
• antithyroid drugs, amiodarone, lithium
• infiltrative disease (amyloidosis, sarcoidosis)
• dysgenesis (congenital)
• thyroid hormone resistance (acquired-autoimmune)
• iodine deficiency or excess

• fatigue
• lethargy
• anorexia
• constipation
• depression
• menstrual abnormalities
• muscle stiffness
• memory impairment
• cold intolerance
• dry dkin
• peripheral edema
• weight gain
• thinning hair
• weakness
• hypotension
• bradycardia
• hyporeflexia
• dementia
• psychosis

• elevated TSH
• low total T4 and free T4
• T3 might be normal
• presence of antithyroid peroxidase and antithyroglobulin antibodies in serum confirms autoimmune disease
• treatment with synthetic T4 is best monitored by serum TSH levels

• most common thyroid disorder in the US
• may be a/w other autoimmune or polyglandular syndromes

• affects 1% of pop
• affects 5% over age 65
• tends to be familial
• more common in women and pts with hepatitis C
• frequency increases with excess dietary iodine supplementation and exposure to head and neck radiation during childhood
• certain drugs, such as amiodarone, interleukins, and interferon are also a/w thyroiditis

• thyroid is enlarged, firm, finely modular
• changes may be asymmetric
• S&S are usually of hypothyroidism (more likely in smokers), but transient thyrotoxicosis can occur
• usually not painful, although neck tightness occurs
• depression and chronic fatigue are common and may persist after treatment
• in the elderly, the gland is atrophic and fibrotic

• xerostomia
• keratoconjunctivitis
• mild myasthenia gravis
• IBD
• celiac disease

• antithyroid perioxidase and antithyroglobulin antibodies
• increase in T4 greater than T3
• suppressed TSH levels

• ultrasonography helps distinguish thyroiditis from goiter or nodules and helps guide fine needle biopsies of suspicious nodules
• color flow doppler is used to distinguish thyroiditis from graves disease
• radioactive iodine uptake

• granulomatous
• de Quervain's
• giant cell

• most common in young or middle-aged children
• viral cause is suspected
• incidence peaks in summer

• acute, painful glandular enlargement with dysphagia, low-grade fever, fatigue, malaise
• radiation of pain to ears common
• most common in young and middle-aged women
• patients may have thyrotoxicosis followed by hypothyroidism
• manifestations last from weeks to months
• usually resolve in 12 months

• aspirin
• symptomatic

• occurs soon after partuition
• usually resolves completely
• painless, self-limiting
• manifests with hyperthyroidism 1-6 months after delivery
• lasts for 1-2 months
• may not require therapy
• propranolol is used for cardiac sx

suppurative (infectious) thyroiditis

Reidel's (invasive fibrous, woody, ligneous) thyroiditis

• rare
• fever, pain, redness, and fluccuant neck mass common
• a/w with bacterial, parasitic, fungal causes
• tx is abx and surgical drainage

• congenital hypothyroidism
• usually asymptomatic at birth-transplacental cross of maternal thyroxine
• neonatal jaundice, feeding difficulties, choking spells, sluggishness, macroglossia, decreased crying, umbilical hernias, constipation, hypothermia, bradycardia occur first
• failure to thrive and myxedema, hair and skin coarsening occur later, along with decreased muscle tone

• thyroxine
• check TSH 6 weeks from initiating, then at least every 6 months
• keep TSH below 2.0 for best long-term outcome

• untreated/undertreated hypothyroidism
• occurs in elderly, often worsened by medication or infection
• char by AMS, hypothermia, respiratory depression, CHF, hypoglycemia, hyponatremia
• tx = IV levothyroxine +/- leothyronine (T3)

• elevated TSH
• fT4 and/or T3 and TSH low
• CBC-normocytic anemia
• electrolytes-low sodium
• liver-elevated transaminases
• cortisol, B12- co-autoimmune diease
• EKG- occult heart disease

papillary carcinoma (80%)-least aggressive

• others = follicular, medullary, anaplastic-most aggressive, lymphoma/metastatic disease
• all a/e genetic mutations and translocations

• women 3x more than men
• increases with age

• childhood neck or head irradiation
• exposure to radioactive isotopes of iodine
• peak 20-25 years later
• a/w MED 2

• painless neck swelling
• single, palpable, nontender, firm nodule
• hoarseness
• neck discomfort
• dysphagia
• nodule may enlarge over short period of time
• may have evidence of mets, including thyrotoxicosis
• gland often stony and hard

• flushing
• diarrhea
• fatigue
• Cushing's syndrome

• signs of pressure or invasion
• recurrent laryngeal nerve palsy (hoarseness)

• thyroid function tests often normal
• TSH
• elevated serum thyroglobulin in metastatic papillary and follicular cancers
• FINE-NEEDLE BIOPSY ESSENTIAL
• medullary tumors have high serum calcitonin and CEA
• hot nodules on radionucleotide scanning usually benign
• ultrasound of neck useful for size, location, local mets
• others = radioisotope scanning, CXR, MRI, CT, PET

• surgical resection and near-total thyroidectomy
• followed by radiation
• monitor for post-op hypocalcemia
• radioactive iodine ablation for residual disease
• mets to bone tx with external radiation
• mets to brain tx with gamma knife radiation therapy

• chronic adrenocortical insufficiency
• most common cause = autoimmune destruction of adrenal cortex (80%)
• tuberculosis is leading cause in areas of prevalence

may be precipitated by:

• infection
• trauma
• surgery
• stress
• lymphoma
• metastatic cancer
• amyloidosis
• scleroderma
• hemochromatosis
• cessation of corticosteroid medication

• fatigue and weakness
• anorexia and weight loss
• irritability/anxiety
• myalgias and arthralgias
• may GI sx
• amenorrhea common in females
• sensory hypersensitivities
• salt craving
• orthostatic hypotension-SBP <110
• delayed DTRs
• hyperpigmentation in primary disease (elevated ACTH)-most marked in skin creases, pressure areas, nipple areas
• other findings = small heart, hyperplasia of lymphoid tissue, scant axillary and pubic hair, hypogonadism

• hypotension
• acute pain (abdomen, low back)
• vomitting
• diarrhea
• dehydration
• hypotension
• AMS
• if untreated, can be fatal

• hyperkalemia
• hyponatremia
• hypoglycemia
• hypercalcemia
• low BUN
• eosinophilia
• neutropenia
• mild anemia
• relative lymphocytosis

• low 8am plasma cortisol (<3)
• elevated ACTH (>200)
• simplified cosyntropin stimulation test- serum cortison rise >20 is normal, anything less is suspicious
• antiadrenal antibodies in 50%
• antithyroid antibodies in 45%
• serum DHEA <1000- a level higher excludes addisons

• oral hydrocortisone or prednisone
• many also require fludricortisone acetate for its sodium-retaining effect
• DHEA given to women with adrenal insufficiency

• requires IV saline, glucose, glucocorticoids
• treat underlying cause

• hypercortisolism
• may me exogenous or endogenous
• exogenous form = chronic excess glucocorticoid, most commonly from corticosteroid drugs used to tx other dz

• excess secretion of ACTH by pituitary
• often results in small, benign pituitary adenoma
• Cushing's disease = major cause of endogenous Cushing's syndrome
• most common in premenopausal women
• adrenocortical tumors
• nonpituitary ACTH-producing tumors (small cell lung carcinoma)

hypercortisolism

• obesity-centripetal, extremities appear wasted
• fat deposition- buffalo hump, mood facies, supraclavicular pads
• hypertension
• thirst
• polyuria with or without glucosuria
• proximal muscle weakness
• pigmented striae >1cm wide
• may present with backache, headache
• oligomenorrhea or amenorrhea and ED common
• disorders of calcium- osteoporosis, vertebral fx, hypercalciuria, kidney stones, AVN
• impaired wound healing, acne, easy bruisability, superficial skin infections
• emotional lability to psychosis

• excretion of free cortisol in urine >125 in 24 hours
• >95 mcg of cortisol per gram of creatinine
• low dose dexamethasone suppression test
• MRI identifies primary tumors

• transsphenoidal resection of pituitary adenoma
• hydrocortisol replacement
• surgical removal is TOC for cushings syndrome
• adrenal inhibitors = metyrapone and/or ketoconazole may suppress hypercortisolism; parenteral octreotide suppresses ACTH

• almost always caused by pituitary adenoma
• involves excessive growth hormone
• usually sporadic, but may be familial
• a/w MEN 1

• excessive growth of hands, feet, jaw, internal organs
• gigantism = disease before closure of epiphyses
• doughy, moist handshake
• macroglossia
• capral tunnel syndrome
• deep, coarse voice
• OSA
• goiter
• HTN and cardiomegaly
• weight gain and insulin resistance
• arthralgias and arthritis
• colon polyps
• hyperhydrosis
• cystic acne
• acanthosis nigricans
• headaches
• spinal stenosis
• temporal hemianopsia
• decreased libido
• ED
• menstrual abnormalities

• serum prolactin, ILGF-1, glucose, liver enzymes, BUN, TSH, free T4, inorganic phosphorus, calcium measured after an overnight fast
• serum GH measured 1 hour after glucose syrup ingestion
• MRI superior to CT for pituitary adenomas- enlarged sella turcica, thickened skull, tufting of terminal phalanges, and thickening of heel pad

• endoscopic transnasal transsphenoidal pituitary microsurgery to remove ademona
• dopamine agonists if fail surgery
• somatostatin analongs for persistent disease
• pegvisomant, growth hormone antagonist, provides sx relief and normalized ILGF-1 in 90%
• stereotactic radiosurgery for tx failure

• the prototype chondroplasia is achondroplasia- the most common nolethal type

• short limbs
• long, narrow trunks
• large heads with midface hypoplasia
• prominent brows
• intelligence is normal
• neurologic complications, bowing of legs, obesity, dental problems, frequent OM

• substantial reduction in height in T1DM children
• although not apparent at birth, pituitary dwarfism may present in male infants with hypoglycemia and micropenis
• children with constitutional growth delay are small, but otherwise normal appearance

• surgical correction of orthopedic problems indicated in achondroplasia
• use of human GH controversial

• uncommon
• caused by deficiency of or resistance to vasopressin(ADH)
• secondary Di due to hypothalamic or pituitary pathology- tumor, anoxic encephalopathy, surgery, accidental trauma, infection, sarcoidosis, multifocal Langerhans cell granulomatosis, or metastatic disease
• vasopressinase-induced DI in late pregnancy and puerperium
• nephrogenic DI in presence of normal secretion of vasopressin with inappropriate response by kidney

• intense thirst with fluid intake of 2-20L/day
• craving for ice water
• large volume polyuria
• hypernatremia and dehydration

no single lab test can diagnose DI

• glucose
• BUN
• calcium
• uric acid
• potassium
• sodium

24 urine collecction

low SG less than 1.006

• desmopressin acetate = TOC for central DI
• mild cases require no tx- except adequate hydration
• central and nephrogenic DI respond partially to HCTZ with potassium
• nephrogenic DI may respond to indomethacin, either alone or in combo with HCTZ, desmopressin, or ameloride

• Milkman lines or Looser zones (pseudofractures) diagnostic