Thomas Thornton, Bri Armand, and Beth Morrison

Endocrine Case Studies:

Case 1
Thomas L. a 28-year-old male, complained of abrupt polydipsia and polyuria. Blood and urine
analyses provided the following results:
Fasting blood glucose 93 mg/dL
Serum sodium 145 mEq/L
Serum potassium 2.8 mEq/L
Urine osmolality <200 mOsm/L
Urine volume 15 L/day
Urine glucose 0
Water deprivation and hypertonic saline infusion do not cause a significant reduction in the
polyuria and concentration of urine. Complete water-deprivation results in the following: Urine
osmolality 225 mOsm/L. However, there is a significant concentration of the urine and a
decrease in urinary output following administration of ADH.
1. Define polydipsia and polyuria.
Polydipsia is an excessive thirst and polyuria is a condition normally defined as an
excessive production of urine.
2. Why did the water deprivation and hypertonic saline infusion not result in concentrated urine?
The water deprivation and hypertonic saline infusion did not result in concentrated urine
because the kidneys could not adequately respond to a period without high water volume intake.
3. Describe the location of the disorder in Thomas L.
ADH deficiency occurs in the hypothalamus and posterior pituitary gland.
4. Diagram the hypothalamic-pituitary-target organ pathway for this individual and indicate the
normal and pathophysiological conditions involved.
ADH is one of the posterior pituitary hormones. The neuronal signaling pathways begin
in the hypothalamus and can follow a multitude of directions down the brain stem, however this
one ends up in the posterior pituitary.
Case 2
Hazel C. a 30-year-old female demonstrated a subtle onset of the following symptoms: dull
facial expression; droopy eyelids; puffiness of the face and periorbital swelling; sparse, dry hair;
dry, scaly skin; evidence of intellectual impairment; lethargy; a change of personality;
bradycardia (60 b/min); a blood pressure of 90/70; constipation, and hypothermia. Plasma
concentrations of total and free T4 and T3 follow:
Radioimmunoassay (RIA) of peripheral blood indicated elevated TSH levels. A TSH stimulation
test did not increase the output of thyroid hormones from the thyroid gland.
1. Why does Hazel have a lower-than-normal body temperature?
Hazel could be experiencing hypothyroidism, which causes the body temperature to
drop under certain circumstances.

2. What is a TSH stimulation test and how are the results interpreted?
A Thyroid-Stimulating Hormone test is a test used to check for thyroid gland problems.
The test first injects a small amount of TRH into the veins, and then evaluates the levels of TSH
located within the blood. If the increase in TSH following TRH injection is in relatively small
amounts, then the cause of the hypothyroidism is from the anterior pituitary gland not secreting
TSH.
3. Is this a primary or secondary disorder? How is this determined?
This specific disorder is primary. This can be determined because primary disorders
result in excess excretion of TSH, while secondary disorders result in in-excessive excretion of
TSH.
4. Describe the feedback loop involved. Predict whether you'd expect TSH levels to be normal,
high, or low?
Rising blood levels of thyroid hormones act on the pituitary and hypothalamus to block
the release of TSH. TSH levels would hopefully be dropping.
5. What is the most likely diagnosis for Hazel?
Hazels diagnosis would most likely be hypothyroidism.
6. Would you expect to find a palpable goiter? Explain your answer.
Yes you would expect to find a palpable goiter because when a thyroid cell is exposed to
abnormally high levels of TSH, it will undergo hypertrophy, and the entire gland will eventually
enlarge.
7. What is the most likely explanation for the bradycardia and low blood pressure?
8. Describe a suitable treatment for Hazel.
Two common symptoms of hypothyroidism is bradycardia and low blood pressure. The
most common treatment plan would be a thyroid replacement hormone, or thyroid hormone
medicine. Regular visits with the doctor will be mandatory to insure regular intake of doses.
9. Is this treatment expected to return blood pressure and heart rate to normal? Why or why
not?
The treatment will most likely return blood pressure and heart rate back to normal.
However, in some cases cholesterol levels do not always return to normal, thus promoting
higher cholesterol levels within the heart meaning that the levels will not always return exactly to
normal.
Case 3
Oscar T. a 45-year-old male from the Midwest presented with the following symptoms during
February: weakness, fatigue, orthostatic hypotension, weight loss, dehydration, and decreased
cold tolerance. His blood chemistry values follow:
Serum sodium 128 mEq/L
Serum potassium 6.3 mEq/L
Fasting blood glucose 65 mg/dL
Serum creatinine 0.5 mg/dL
Hematology tests resulted in the following values: Hematocrit 50%; Leukocytes 5000/cu mm

Oscar also noticed increased pigmentation (tanning) of both exposed and nonexposed portions
of the body and back. A plasma cortisol determination indicated a low cortisol level. Following
administration of ACTH, plasma cortisol did not rise significantly after sixty and ninety minutes.
Endogenous circulating levels of ACTH were later determined to be significantly elevated.
1. What endocrine organ is the site of the malfunction? Is this a primary or secondary
disturbance?
There are a few endocrine organs that have a role with this malfunction including the
hypothalamus, the anterior pituitary, and the adrenal glands, but the most important is the
hypothalamus. This is a primary disturbance because ACTH levels are still high, but not a lot of
cortisol is being produced.
2. What is the name of this disorder?
The name of this disorder is Primary Adrenal Insufficiency disorder, or Addisons
Disease.
3. Discuss the electrolyte (Na+ and K+) disturbances resulting from this disorder. Which
hormone is involved, and are the levels of this hormone abnormally high or abnormally low?
Deficiency results in increased excretion of Na+ and decreased excretion of K+. ACTH is
the primary hormone responsible for the influence on Na and K. Inadequate production of
ACTH causes in-deficiencies in the secretion of Na and K.
4. Discuss the metabolic disturbances resulting from this disorder. Which hormone is
responsible?
Addisons disease tends to become clinically apparent during metabolic trauma or
stress. It can produce disturbances in protein metabolism. ATCH is also the main hormone
here.
5. What is the cause of Oscar's tanning?
Oscars hyper-pigmentation is caused by the release of excess ATCH that binds to the
surface of melanocytes.
6. What type of replacement therapy would be required for Oscar? 7. Diagram the feedback
loop for this endocrine disorder.
Oscars most typical replacement therapy would insist on him taking oral corticosteroids.
If he were too ill to take oral corticosteroids, then he would have to take corticosteroid injections.
The negative feedback loop for this system is as follows: hypothalamus > CRH > Anterior
pituitary > ACTH > Adrenal gland > Cortisol (inhibits here and cycles back to
hypothalamus) > Target tissue
8. What is the long-term outlook for Oscar? Might one expect Oscar's abnormal pigmentation to
resolve? Explain.
Most people who receive proper medical treatment can expect an active life along with a
normal life expectancy. Depending on the treatment Oscar receives, his hyper pigmentation
could disappear. Simple creams and pills will not entirely wipe away his pigmentation, but there
are surgeries that one can undergo to make the pigmentation almost entirely unnoticeable.

Case 4
A 50-year-old male (Horace C.) had a total thyroidectomy followed by thyroid hormonereplacement therapy. Thirty-six hours later he developed laryngeal spasms, a mild tetany, and
cramps in the muscles of the hands and arms. The following tests were performed:
Urine calcium 20 mg/dL
Urine phosphorus 0.1 g/day
Plasma calcium 7.0 mg/dL
Plasma phosphorus 5.0 mg/dL
Calcium gluconate and vitamin D (calcitriol) were given orally each day and the tetany and
laryngeal spasms were alleviated.
(Your textbook will prove particularly useful in this case.)
1. What endocrine disorder is present in Horace?
The endocrine disorder that is present in Horace is Hypoparathyroidism.
2. What is the purpose of vitamin D administration with the calcium?
Vitamin D increases calcium absorption. It acts as a cofactor to facilitate the absorption
of calcium in the intestines.
3. What caused Horace's tetany and laryngeal spasms?
Horaces tetany and laryngeal spasms were caused by hypocalcemias increased
actives of the neurons.
4. How is blood calcium normally maintained at its physiological level?
Calcitonin is produced by the thyroid gland and lowers the amount of blood calcium by
inhibiting osteoclasts. The parathyroid hormone increases blood calcium levels in a multitude of
ways. Some of which include increasing the amount of osteoclast activity, slowing the rate at
which calcium is lost to the kidneys in urine, and it stimulates the production of calcitriol that
increases the rate of Ca2+ absorption.
5. Diagram the negative feedback loop for the hormone(s) involved.
Falling blood calcium levels trigger PTH release, and rising blood calcium levels inhibit
the release of PTH.
6. Is hormone replacement therapy necessary for Horace or could his case be managed by
nutritional supplements?
Hormone replacement therapy would be the suggested way to approach recovery, but
there are other means of treatment such as nutritional supplements.
Case 5 (requires some knowledge of pulmonary physiology)
A 21-year-old noncompliant male with a history of type I (insulin-dependent) diabetes mellitus
was found in a coma. His blood glucose was high, as well as his urine glucose, urine ketones,
and serum ketones. His serum bicarbonate was <12 mEq/L. His respiration was exaggerated
and his breath had an acetone odor. His blood pressure was 90/60 and his pulse weak and
rapid (120).
1. Define noncompliant.
Noncompliant has many definitions, but in this situation it is referring to a patient who
refuses to take his medicine that he is prescribed to.

2. Is this person experiencing ketoacidosis or insulin shock? Explain your answer.

This person is experiencing ketoacidosis. This conclusion can be determined because
insulin shock results from having too much insulin, while ketoacidosis results from not having
enough insulin in your body thus meaning that your blood glucose levels are too high.
3. Why is the serum bicarbonate low?
The serum bicarbonate is low due to the buffering of the keto acids by the bicarbonate
ions.
4. What is the acid-base status of this individual?
The patients acid-base status generally lies towards the more acidic side.
5. What is the cause of the dyspnea, hypotension, and tachycardia?
Dyspnea is caused by the acidosis. Hypotension can result from a loss of fluid from an
osmotic diuresis. Tachycardia occurs as a reflex to overcome the resulting hypotension.
6. What type of treatment does this person need?
The person should immediately seek a fast-paced insulin which will help to reduce blood
glucose levels in the body.
Case 6
A 59 year-old female complains of numbness of the hands, excessive sweating, and an
unpleasant body odor. She also remarked that she has gone up a ring size and shoe size. Upon
examination, she presents with the following symptoms: thick, oily skin; skin tags; impaired
vision; headaches, fatigue, and weakness; and menstrual cycle abnormalities and breast
discharge. Evaluation of a blood sample revealed the following levels:
1. What endocrine organ is involved? How does one determine which it is?
The pituitary gland is involved and this can be determined because it is the one that
produces GH which has an effect like her symptoms.
2. What is the name of this disorder?
The name of this disorder is Acromegaly.
3. What is an explanation for the patient's high blood pressure?
Secretion of GH by the pituitary into the bloodstream signals the liver to release IGF.
High levels of IGF help to inhibit the release of GH, but at the same time, high levels of IGF can
lead to high blood pressure.
4. Give an explanation for the patient's breast discharge and unpleasant body odor? Based on
the site of the disorder, what might the nature of the visual impairment be?
Pressure put on the pituitary tissue can produce different hormones than normal. These
hormones can result in breast discharge and unpleasant body odor. A tumor that is putting
pressure on the optic chasm can damage nerves in that area and thus damage eyesight.
5. What could be a possible cause for the development of this disorder?
A possible cause for the development of this disorder is a pituitary tumor. Another
common cause is the overproduction of GH by the pituitary gland.

6. Diagram the negative feedback loop for the hormones involved.

Anterior pituitary > GHRH stimulates GH > releases GH > GH reduces IGF >
GHRH sends signal to hypothalamus > Releases GHIH > inhibits GHRH
7. What is a possible treatment for this disorder?
The most preferred option by doctors is to perform surgery. This is so because it gives
the doctors the option to directly remove the tumor or swollen pituitary tissue.
Case 7
A thirty-five year old female visited her gynecologist early one morning and complained of the
following symptoms: fatigue, depression, unexplained weight gain, and an irregular menstrual
cycle. Her doctor ordered a series of tests to determine the cause of her symptoms. The
following were reported:
Serum Human Chorionic Gonadotropin Test: Negative Fasting Blood Glucose: 65 mg/dL
Serum Cortisol: 28 mg/dL
Leukocytes (WBC): 6,500 cu mm
Hematocrit: 43%
The doctor reviewed her results and asked her to return to repeat the test the next afternoon.
The results were nearly identical. Next, a dexamethasone test was ordered for the following
morning and revealed that her cortisol level had decreased to 10 mg/dL.
1) What endocrine gland(s) is/are the site of malfunction?
The thyroid gland is the gland that is under malfunction here.
2) What is the name of this disorder?
The name of this disorder is Hypothyroidism.
3) What are the possible causes of this disorder?
The causes of this disorder include Hashimotos thyroiditis, radiation therapy to the neck,
use of certain medications, thyroid surgery, and too little iodine in your diet.
4) Is there a diurnal cycle for levels of cortisol in a healthy individual? Does this patient have a
normal diurnal cycle?
There is a diurnal cycle for levels of cortisol in a healthy individual. Her cortisol levels
were essentially backwards, her highs should have been in the morning and lows should be at
night.
5) What is a dexamethasone suppression test? Why was it ordered for this patient? How are the
results of this test interpreted?
It is a test that asses adrenal gland function by measuring how cortisol levels change in
response to an injection of dexamethasone. The doctors wanted to see how her cortisol levels
would respond to dexamethasone. If you take dexamethasone, it should decrease the levels of
ACTH located in your body. However, you may have an abnormal condition if your cortisol
levels after injecting dexamethasone are high.
6) What does the dexamethasone suppression test reveal as to the site of endocrine disorder in
this patient?

The dexamethasone suppression test shows that either the anterior pituitary is most
likely damaged or the adrenal gland is damaged. The anterior pituitary secretes ACTH, which
then acts upon the adrenal gland to secrete cortisol.
7) What other tests could be done to determine the exact cause of the malfunction of this
endocrine gland?
To evaluate adrenal insufficiency, you can undergo a ACTH stimulation test which
measures the response to ACTH injection.
8) What are the possible treatments for an individual with this disorder? 9) What is the long-term
outlook for this patient?
Hypothyroidism can be treated through hormone replacement. As long as the patient
gets treatment for the issue early on, they should expect an active and long life.
Case 8
Susie B., a three and a half-year-old female, is brought to the hospital by her parents who are
concerned about her slow growth, night sweats, and craniofacial abnormalities. Blood analyses
provided the following results:
- Fasting Glucose: 42 mg/dL - Serum sodium: 140 mmol/L - 8am Cortisol: 28 mg/dL
- Fasting GH: 9 ng/dL
- IGH-1: 12 ng/dL
Upon observation, craniofacial abnormalities include protruding forehead, small (double) chin,
delayed teething, sparse hair. Slow motor development was also observed.
She was unresponsive to growth hormone therapy treatments. Normalization of growth was
observed with IGH-1 therapy.
Questions:
1. What types of cells are abnormal in this patient? How do you know?
Mutated cancer cells secrete abnormal levels of adrenal cortical hormones.
2. What could be a possible cause of high GH and cortisol levels?
The hypothalamus has an important role in regulating the secretion of GH and cortisol.
The hypothalamus regulates GNRH that in turn secretes GH. It also secretes CRH that affects
the pituitary gland, which secretes ACTH. ACTH then stimulates the adrenal gland to release
cortisol into the blood.
3. What is a possible explanation for retarded growth in the presence of high GH levels?
A possible explanation for this is that the body cannot properly express GH where it is
needed. There is most likely a state of GH insensitivity in the GFR.
4. Describe the feedback loop involved.
GH > Liver > IGF > Inhibit GHRH release; stimulate GHIH release; Inhibit GH
synthesis and release
5. What is the most likely diagnosis for Susie?
Susie most likely has Cushings Syndrome.

6. Why did treatment with IGH-1 work for Susie, while GH therapy did not?
IGH-1 is what causes you to actually grow, while GH is what stimulates IGF. There was
an issue within her body that was producing GH, but not stimulating IGF effectively.
7. What's the prognosis for Susie with AND without IGH-1 treatment?
With the IGH treatment, Susie will most likely be able to continue her growth in a more
hospitable manner. Without IGH, Susies body will not be able to effectively activate her growth
cells. Her bones will not grow to their true potential, and her overall size will not increase
greatly.