Clinical Enzymology

Enzyme Classification and Nomenclature:

 The first digit represents the class of enzymes. The second and third digits represent
subclass of enzymes. The final number represents the serial number specific to each
enzyme.

1. Oxidoreductases. Catalyze an oxidation-reduction reaction between two substrates

2. Transferases. Catalyze the transfer of a group other than hydrogen from one
substrate to another
3. Hydrolases. Catalyze hydrolysis of various bonds
4. Lyases. Catalyze removal of groups from substrates without hydrolysis
5. Isomerases. Catalyze the interconversion of geometric, optical or positional isomers
6. Ligases. Catalyze the joining of two substrate molecules, coupled with breaking of
the pyrophosphate bond in ATP or a similar compound

Factors that Influence Enzyme Reaction:

1. Enzyme and substrate concentration

Michaelis - Menten Theory

V = Vmax [S]
Km + [S]
Where V stands for velocity, Vmax for maximum velocity, S for substrate and
Km stands for Michaelis-Menten constant of enzyme for specific substrate

 Addition of substrate concentration will lead to increase in the rate of reaction

E > S = ↑ S  ↑ rate of reaction (FIRST-ORDER KINETICS)
 The reaction rate depends on enzyme concentration, enzyme becomes the rate-limiting
factor
S > E (ZERO-ORDER KINETICS)

2. pH
 Optimum range for most enzymes is at 7.0 – 8.0
 Sudden changes may cause denaturation or alter the charge of amino acid residue on the
active site; however, it can be prevented by means of buffer solutions

3. Temperature
 Enzyme are active at 5C, 30C, or 37C
 37C is the optimum temperature for enzymatic activity
 The rate of denaturation is significant at 40 – 50C
 60 – 65C may cause inactivation of enzymes
 Temperature coefficient (Q10) – for every 10C increase in temperature, enzyme reaction
doubles
 In lab determinations, temp should not deviate from + 0.1C from the required temp to
maintain accuracy of results
o Creatine kinase – 37C
o Amylase – 40C

4. Storage
 Repeated freezing and thawing denatures enzymes
 -20C – preservation for longer period of time
  2 – 8C – ideal storage temp for substrate and coenzymes
 RT – ideal storage for LDH4 and LDH5; should not be stored less than 0C without loss
of enzyme activity

5. Cofactors – nonprotein substances that may be necessary for enzyme reaction to take place
 Inorganic cofactors/activators – calcium, magnesium, manganese and chloride
 Organic cofactors/coenzymes
a. NAD and flavine – required by oxidoreductases and dehydrogenases
b. Pyridoxal phosphate – required by transaminases
 Metalloenzymes – inorganic ion attached to a molecule (catalase and cobalt)
 Hydrolases require no cofactors

Coenzyme Reaction Type Deficiency

Thiamine pyrophosphate Aldehyde transfer Beri-beri
Folic acid coenzymes One-C transfer Megaloblastic anemia
Cobamide (B12) Alkylation Pernicious anemia
Nicotinamide Coenzyme Redox Pellagra

6. Inhibitors
a. Competitive inhibition
 With a substrate concentration higher than the inhibitor concentration, the inhibition
is reversible
 Physically binds to the active site of an enzyme
b. Non-competitive inhibition
 Binds an enzyme at a place other than the active site
 Increasing substrate concentration does not reverse the inhibition
c. Uncompetitive inhibition
 Inhibitor binds to enzyme-substrate complex
 Increasing the substrate concentration results in more ES complices thereby
increasing inhibition
7. Hemolysis – falsely elevates most enzyme
8. Lactescence – falsely decreases enzyme concentration

Measurement of Enzyme Activity

1. Fixed-time / Endpoint Method

 Determines concentration of substrate or product at specific time after addition of sample
 Reaction proceeds for a designated time
 Weak acid is added to stop reaction
2. Continuous Monitoring / Kinetic Assay
 Multiple measurements at specific time intervals by using continuously recording
spectrophotometer

Tissue Specificity of Enzymes

High Specificity ACP Prostate, erythrocytes

ALT Liver
Amylase Pancreas, salivary gland
Moderate Specificity AST Liver, heart, skeletal muscles
CK Bone, heart, skeletal muscles
Low Specificity ALP Liver, bone, kidney
LD All tissues
ALKALINE PHOSPHATASE

Major tissue source: Liver, bone, intestine, placenta

Other tissue source: kidney, pancreas
Clinical Significance:
1. ↑ 3 – 10x ULN in HEPATOBILIARY DISEASE (biliary cirrhosis, bile stone,
cholelithiasis)
2. ↑ Paget’s disease (highest elevation), osteomalacia, osteogenic sarcoma, hyperthyroidism,
rickets
3. Between 16 – 20 weeks of pregnancy
4. B and O groups increases intestinal ALP after consumption of fatty meal

PRONOUNCED MODERATE ELEVATION SLIGHT ELEVATION

ELEVATION
(5x or more X ULN)
Biliary cirrhosis
Osteitis deformans (Pagets)
Bile duct obstruction
Hyperparathyroidism
Osteogenic sarcoma
(3-5X ULN) Up to 3X ULN
Granulomatous or infiltrative Viral hepatitis
disease of liver Cirrhosis
Infectious mononucleosis Pregnancy
Metastatic bone carcinoma Normal growth pattern in
Metabolic bone disease children
(rickets, osteomalacia) Healing fractures

Methods:
1. Electrophoresis – L (most anodal) BPI
2. Heat Stability
56C for 10 minutes P (same as carcinoplacental isoenzymes) ILB
65C for 30 minutes (Placental ALP resists denaturation at this temp)
3. Chemical Inhibition
 All are inhibited by phenylalanine
 Liver and bone – inhibited by Levamisole reagent
 Bone – inhibited by 3M urea
4. Requires a pH of 9 - 10

Carcinoplacental Isoenzymes
1. Regan – found in lung, breast and gynecological cancers
2. Nagao – found in adenocarcinoma of pancreas, and bile duct, and pleural cancer,
inhibited by leucine
**Same structure and heat stability with PLACENTAL isoenzyme but same mobility
with BONE isoenzyme

Measurement of Total ALP Activity

Method Substrate Comments
Shinowara-Jones-Reinhart Beta-glycerophosphate Long incubation time; ↑ blank
Bodansky values
Bessy, Lowry, and Brock P-nitrophenylphosphate Endpt or kinetic, rapid
King-Armstrong Phenylphosphate Endpt, requires protein
removal
Bowers-McComb PNPP Uses phosphate-accepting
buffer; reference method
Huggins and Talalay Phenolphthalein diphosphate Phenolphthalein red
Moss Alpha-naphthol phosphate Alpha-naphthol
Klein, Bobson and Read Buffered phenolphthalein Free phenolphthalein
phosphate

ACID PHOSPHATASE

Richest source: Prostate

Other tissue source: RBCs, liver, bone, kidneys, spleen and platelets
Clinical Significance:
1. Tumor marker for PROSTATIC CARCINOMA. ACP is tissue specific but not cancer
specific because it also shows elevated amounts in BENIGN HYPERPLASIA OF THE
PROSTATE
2. RAPE CASES – can persist up to 4 days in the vagina
3. Paget’s disease
4. Gaucher’s disease
5. ITP

Methods:
1. Requires a pH of 5.0
2. Inhibited by fluoride, oxalate, heparin and prolonged storage at RT and tartrate

Measurement of Total ACP Activity

Method Substrate Comments
Bodansky Beta-glycerophosphate Length assay, nonpecific
Gutman, King-Armstrong Phenylphosphate Nonspecific
Bobson and Reed Alpha-naphthylphosphate Less sensitive, complicated
(continuous monitoring)
Hudson PNPP Nonspecific, rapid
ROY THYMOLPHTHALEIN MORE SPECIFIC FOR
MONOPHOSPHATE PROSTATIC FORM (endpt
monitoring)
Reitz, Guilbault 4- Fluorescent, some improved
methylumbelliferonephosphate sensitivity

ACP Isoenzyme Techniques

Chemical Inhibition Cumbersome, nonspecific
Electrophoresis Not easily reproduced, too
complicated for routine clinical use
Immunoassay Best approach for prostatic isoenzyme

ASPARTATE AMINOTRANSFERASE

Tissue source: Liver, skeletal muscle, cardiac muscle

Other sources: Kidneys, red cells, pancreas

Clinical Significance:
PRONOUNCED MODERATE ELEVATION SLIGHT ELEVATION
ELEVATION
(5x or more X ULN) (3-5X ULN) Up to 3X ULN
Acute hepatocellular damage Biliary tract obstruction Pericarditis
 Viral hepatitis Cardiac arrhythmias Cirrhosis
100XULN Congestive heart failure Pulmonary infarction
 Cirrhosis 4XULN Metastatic tumor in liver Delirium tremens
Myocardial infarction Muscular dystrophy Cardiovascular accident
Circulatory collapse (shock)
Acute pancreatitis
IM

Isoenzyme of AST:
1. Cytoplasmic / Extramitochondrial AST
 More predominant in plasma or serum
 Half-life 17 hours
2. Mitochondrial AST
 Cause of tissue necrosis
 Half-life 87 hours
Method:
1. Karmen Method
 pH 7.5
 Uses malate dehydrogenase

ALANINE AMINOTRANSFERASE
 Most liver specific and more sensitive screening test for post-transfusion hepatitis or
occupational toxic exposure

Clinical Significance:
1. In acute hepatocellular injury, in < 24 hours
AST > ALT
In 24 – 48 hours following onset of injury
ALT > AST – except in alcohol-induced liver damage / cirrhosis
De Ritis Ratio: ALT/AST 3 – 4: 1

AST/SGOT ALT/SGPT
Major organ affected Heart Liver
Substrate Aspartic alphaketoglutaric Alanine alphaketoglutaric acid
acid
End-product Glutamic acid + Oxaloacetic Glutamic acid + Pyruvic acid
acid
Color developer 2,4 – DNPH
Color intensifier 0.4 N Sodium hydroxide
Method REITMAN AND FRANKEL

AMYLASE (smallest enzyme in size)

Tissue source: Major – Acinar cells (glandular cells) of pancreas and salivary glands
Minor – fallopian tube, small intestine
Clinical Significance:
1. Acute pancreatitis (earliest) 2.5 X ULN
 Elevates at 2 – 12 hours; peaks at 24 hours and normalizes in 3 – 5 days
2. Salivary gland disorders(mumps, parotitis) intestinal disorders, ruptured ectopic
pregnancy

Isoenzymes:
1. P (amylopsin)
 Secreted by pancreas; major isoenzyme present in the urine
 Slower in electrophoresis
2. S (ptyalin)
 Secreted by salivary glands; 2/3 of AMS activity in normal serum
 P3 is most specific to acute pancreatitis
 Macroamylasemia – amylase becomes large when complexed with Ig; increased
amylase level due to ↓ renal clearance

Measurement of Amylase Activity

Amyloclastic Measures amylase activity following decreases in substrate
concentration
Saccharogenic Classic reference method; measures amount of reducing sugars
produced by the hydrolysis of starch
Chromogenic Measure amylase activity by the increase in color intensity
Coupled-enzyme Measured by continuous monitoring technique; pH 6.9

LIPASE

Tissue source: Pancreas, stomach, small intestine

 L2 – most specific for acute pancreatitis
 LPS levels rise 6 hours, peak at 24 hours, remains elevated for 7 days, and normalizes in 8 –
14 days
 ↑ peptic ulcer, duodenal ulcer, acute cholecystitis, intestinal obstruction

Methods:
1. Titrimetric – hydrolyzed into monoglyceride, diglycerdie and FFA
2. Turbidimetric – triglyceride form emulsions that scatter light
3. Colorimetric:
 Cherry-Crandal (reference method)
 Hydrolysis of olive oil after incubation for 24 hours at 37C and titration of fatty acids
using sodium hydroxide
 Substrate: 50% olive oil (now – triolein)
4. Tietz and Fiereck
5. Peroxidase coupling – most commonly used method, does not use olive oil

LACTATE DEHYDROGENASE

Isoenzyme Chain composition Tissue Disorder

LD1 HHHH Heart, brain, RBCs MI
Hemolytic anemia
LD2 HHHM Heart, brain, RBCs Megaloblastic anemia
Acute renal infarction
Hemolyzed specimen
LD3 HHMM Lungs, lymphocytes, Pulmonary embolism
spleen, pancreas Pulmonary pneumonia
Lymphocytosis
Acute pancreatitis
Carcinoma
LD4 HMMM Liver Hepatic injury
LD5 MMMM Skeletal muscles Skeletal muscle disorder

PRONOUNCED MODERATE ELEVATION SLIGHT ELEVATION

ELEVATION
(5x or more X ULN) (3-5X ULN) Up to 3X ULN
Megaloblastic anemia Myocardial infarction Most liver disease
Hepatic metastases Pulmonary infarction Nephrotic syndrome
Systemic shock and hypoxia Hemolytic conditions Hypothyroidism
Hepatitis Leukemias Cholangitis
Renal infarction IM
Delirium tremens
Muscular dystrophy

Notes:
1. Highest elevation is seen in PERNICIOUS ANEMIA
2. LDH-2 is the major isoenzyme in normal serum
Normal: LDH2 > LDH1
Flipped pattern: LDH1 > LDH2 – seen in AMI and hemolytic disorders
** In AMI, LDH levels begin to rise within 12-24 hour, reach peak levels within 48-72
hours, and may remain elevated for 10 days
3. H has greater affinity for lactate (forward)
4. M has greater affinity for pyruvate (reverse)
5. LDH-6 – alcohol dehydrogenase (arteriosclerotic cardiovascular failure)

Methods:
1. Forward reaction (WACKER) – reaction at pH 8.8

Lactate + NAD Pyruvate + NADH at 340nm

2. Reverse reaction (WROBLEUSKI LA DUE) – reaction at pH 7.2

 Pyruvate + NADH  Lactate + NAD

3. Wrobleuski Cabaud
4. Berger-Broida
5. Alpha-hydroxybutyrate dehydrogenase represents LD-1 activity

CREATINE KINASE

Major tissue source: Brain, smooth and skeletal muscles,and cardiac muscles
Isoenzyme Tissue Condition
CK-MM Heart, skeletal muscles Myocardial infarction
Malignant hyperthermia
Muscular dystrophy
Physical activity
Polymyositis
Hypothyroidism
Skeletal muscle disorder
Intramuscular injection
CK-MB Heart, skeletal muscles Myocardial infarction
Malignant hyperthermia
Ischemia
Angina
Reye’s syndrome
Rocky Mountain SF
Polymyositis
Muscular dystrophy-
Duchenne
Inflammatory heart disease
Cardiac surgery
Carbon monoxide poisoning
CK-BB Colon, stomach, brain, Seizure
bladder, lung, uterus, prostate, Placenta or uterine trauma
thyroid Anoxic encephalopathy
Reye’s syndrome
Malignant hyperthermia
Acute or chronic renal failure
Cerebrovascular accident
CNS shock
Carcinoma
Carbon monoxide poisoning
PRONOUNCED ELEVATION MILD OR MODERATE ELEVATION
5 or ↑ X ULN 2 – 4 X ULN
Duchenne’s muscular dystrophy Severe execise, trauma, surgical procedure,
Polymyositis intramuscular injection
Dermatomyositis Delirium tremens, alcoholic myopathy
Myocardial infarction Myocardial infarction, severe ischemic injury
Pulmonary infarction
Pulmonary edema
Hypothyroidism
Acute agitated psychoses

Isoenzymes:
1. CK-1 – most anodal and labile isoenzyme (CK-BB)
2. CK-3 – least anodal and major isoenzyme (CK-MM)
Highest elevation is seen in DMD (total CK)
3. Macro-CK – CK-BB complexed with IgG/IgA; migrates midway between CK-MM and
CK-MB
4. CK-Mi – associated with external surface of inner mitochondrial membrane of the brain,
muscle, liver cells; cathodal to CK-MM

Methods:
 1. Forward reaction: TANZER-GILBARG pH = 9.0
Creatine is converted to creatine phosphate
2. Reverse reaction: OLIVER-ROSALKI pH = 6.8
Creatine is produced from creatine phosphate

Note:
1. Light and pH sensitive; lost with excessive storage
2. N-acetylcysteine is added to CK reagent to activate the enzyme and partially reversed the
inhibition of oxidized sulfhydryl groups
3. Following myocardial infarction, the CK-MB levels begin to rise within 4 to 8 hours,
peak at 12 to 24 hours, and return to normal levels within 48 to 72 hours.

ALDOLASE

Isoenzymes: Aldolase A – skeletal muscles

Aldolase B – WBC, liver, kidney
Aldolase C – brain
Significance: ↑ skeletal muscle disease, leukemia, hemolytic anemia, and hepatic cancer

GAMMAGLUTAMYL TRANSFERASE

Tissue source: liver (major), kidney, brain, prostate, pancreas

Significance: ↑ hepatobiliary disease ( >10 X ULN)
↑ chronic alcoholism and intake of certain drugs (2-3X ULN)
Overdosage: Warfarin, phenobarbital, phenytoin, carbamazepine
Method: Szass, Rosalki and Tarrow, Orlowski

5’ NUCLEOTIDASE

Tissue: Liver, associated with canaculi membrane; widely distributed

Significance: ↑ hepatobiliary disease
N in pregnancy and bone disorders

PSEUDOCHOLINESTERASE

Tissue source: Liver, myocardium, pancreas

Pathological levels are decreased from the normal values by as much as 80 – 90%
Significance:
1. Reflects synthetic function of the liver rather than injury
2. Marker for insecticide poisoning which are cholinesterase inhibitors (organic phosphates,
carbamates)
3. Monitor the effects of muscle relaxants (succinylcholine)

Assay Techniques for Cholinesterase

Principle Comment
Michel pH change Temperature, sensitive, much variability
among different labs
Ellman Colorimetic. Thiocholine Sensitive, rapid, widely used and
derivatives recommended method

GLUCOSE-6-PHOSPHATE DEHYDROGENASE

Tissue source: Adrenal cortex, spleen, RBC, lungs, thymus, lactating mammary glands
Significance: ↑ Hepatic disorder and AMI
Deficiency may lead to drug-induced hemolytic anemia (quinine and sulfonamides)
Favism
ELECTROLYTES
Volume and Osmotic regulation (Na+, K+, Cl-)
Maintainance of acid-base balance (HCO3-, K+,Cl-)
Myocardial rhythm and neuromuscular excitability (K+, Mg++, Ca++)
Cofactors in enzyme activation (Mg++, Ca++, Zn++)
Production and use of ATP from glucose (Mg++, PO4-3)
Regulation of ATPase ion pumps (Na+, K+, Ca++, Mg++)
Blood coagulation (Ca++, Mg++)

 Hypovolemia activates THIRST MECHANISM. Hypovolemia causes decreased renal

perfusion. Stimulates the kidneys to release RENIN in response to decreased blood
volume. Converts ANGIOTENSINOGEN to ANGIOTENSIN I. Acted upon by the ACE
by the lungs to become ANGIOTENSIN II which CAUSES VASOCONSTRICTION
WHICH QUICKLY INCREASED BLOOD PRESSURE and STIMULATES
ADRENAL GLANDS TO RELEASE ALDOSTERONE WHICH PROMOTES
SODIUM RETENTION AND POTASSIUM EXCRETION
 Hypervolemia stimulates the heart to release ATRIAL NATRIURETIC PEPTIDE for
SODIUM AND WATER EXCRETION AND VASODILATION
 Hyperosmolality and hypernatremia activates thirst mechanism and ADH secretion for
INCREASED WATER RETENTION, as water is conserved, osmolality decreases.

Sodium
 90% of total plasma volume
 Major extracellular cation and major determinant of plasma osmolality
 Glass membrane is used for ISE determination
 Reference range: 135 – 145 mmol/L
< 125 – neuromuscular injury
< 120 – need immediate attention

Regulation:
1. Intake of water in response to thirst
2. Blood volume states
3. Excretion of water

Hypernatremia Hyponatremia
1. Excess water loss 1. Increased sodium loss
Diabetes insipidus Diuretic use
Renal tubular disorder Saline infusion
Prolonged diarrhea 2. Increased water retention
Profused sweating Renal failure (RTA)
Severe burns Nephrotic syndrome
Vomiting Aldosterone deficiency
Fever Cancer
Hyperventilation Syndrome of inappropriate ADH
2. Decreased water intake secretion
3. Increased intake or retention Hepatic cirrhosis
Hyperaldosteronism (Conn’s disease) Primary polydipsia
Sodium bicarbonate infusion CNS abnormalities – meningitis,
Increased oral or IV intake of NaCl encephalitis, MS
Ingestion of sea water Myxedema

Categories of Hypernatremia
1. Hypernatremia with < 300 mOsm/kg
 Diabetes insipidus
2. Hypernatremia with 300 – 700 mOsm/kg
 Osmotic diuresis of patients with DM and partial ADH defect
3. Hypernatremia with > 700 mOsm/kg
 Insensible loss of water, GI loss of hypotonic fluid
Potassium
 Major intracellular cation
 Regulation of volume and osmolality, myocardial contraction and neuromuscular excitability
along with calcium and magnesium
 Valinomycin membrane is used for ISE determination
 Reference range: 3.5 – 5.1 mmol/L
< 3 mmol/L – muscle weakness and paralysis; kalium administration
> 10 mmol/L – cardiac arrest
8 mmol/L – neuromuscular injury

Regulation:
1. Na-K ATPase pump – loss occurs when inhibited by hypoxia, hypomagnesemia, and
digoxin toxicity
2. Beta-blockers – (propranolol) group of antihypertensives which impairs cellular entry of
potassium
3. Insulin – promotes entry of K into skeletal muscle and liver
4. Catecholamines – promotes cellular entry of K
5. Exercise

Hyperkalemia Hypokalemia
1. Decreased renal excretion 1. Gastrointestinal loss
Acute or chronic renal failure Gastric suction and laxative abuse
Severe dehydration Intestinal tumor and malabsorption
Addison’s disease Cancer and radiotherapy
2. Extracellulat shift Vomiting and diarrhea
Acidosis 2. Renal loss
Muscle/cellular injury Diuretics use (thiazides)
Vigorous exercise Hyperaldosteronism
Digitalis intoxication Cushing’s syndrome
3. Increased intake – oral or IV Leukemia
infusion Bartter’s syndrome
4. Use of immunosuppressive drugs Gitelman’s syndrome
Tacrolimus and cyclosporine Liddle syndrome
Malignant hypertension
3. Intracellular shift – alkalosis and
insulin overdose
Pseudohyperkalemia – associated with sample hemolysis, thrombocytosis, prolonged
tourniquet application, fist clenching, blood stored in ice, IV fluid and high blast counts in acute
or accelerated phase leukemias

Chloride
 Major extracellular anion
 Involved in the maintainance of osmolality, blood volume and electric neutrality
 It is the chief counterion of sodium in the ECF. It promotes maintenance of water balance in
conjunction with sodium and the only anion to serve as an enzyme activator.
 Reference range: 98 – 107 mmol/L

Hyperchloremia Hypochloremia
Renal tubular acidosis – alkaline urine due to Prolonged vomiting
wasting of bicarbonate ions Aldosterone deficiency
Diabetes insipidus Metabolic alkalosis
Salicylate intoxication Salt-losing nephritis
Primary hyperparathyroidism
Metabolic acidosis
Prolonged diarrhea

 Chloride maintains electric neutrality in 2 ways: (1) Sodium is reabsorbed with chloride
in the PCT. (2) Carbon dioxide from cellular metabolism enters the cell to form carbonic
acid by the action of carbonic anhydrase. Carbonic acid splits into hydrogen ions and
bicarbonate which diffuses into the plasma and chloride enters the cell (chloride shift)
  Chloride is inversely related to bicarbonate ions

Magnesium
 2nd most abundant intracellular cation
 Reference range: 0.63 – 1.0 mmol/L
 Distribution:
1. Bones – 53%
2. Muscles and tissues – 46%
3. Plasma – 1%
a. 61% - free; ionized (most active)
b. 34% - protein-bound
c. 5% - bound to ions including phosphate and citrate

Regulation:
1. Diet
2. Intestinal absorption – PTH increases absorption
3. Renal reabsorption – PTH increases absorption
4. Renal excretion affected by hormones – aldosterone and thyroxine promotes renal
excretion

Calcium

Distribution:
1. 99% - skeleton
2. 1% - ECF, plasma
a. 50% - ionized
b. 40% - bound to proteins
c. 10% - bound to ions

Regulation:
Parathyroid hormone Enhance resorption from bone
Stimulate Vitamin D synthesis
Enhance renal tubular reabsorption
Calcitonin Stimulate calcium uptake by bone
Decrease renal tubular reabsorption (promotes
renal excretion of calcium)
Vitamin D metabolites Enhance intestinal absorption
Enhance resorption from bone
Increase renal tubular reabsorption

Hypercalcemia Hypocalcemia
Cancer Calcitonin
Hyperthyroidism Hypoparathyroidism
Iatrogenic disease Alkalosis
Multiple myeloma Renal failure
Hyperparathyroidism Vitamin D deficit
Sarcoidosis

Phosphate
 Omnipresent in living cells; predominant intracellular anion
 It is inversely related to calcium. It is essential for the insulin mediated entry of glucose into
cells by a process involving phosphorylation
 Common phosphate esters: DNA, RNA, ATP, creatine phosphate, phosphoenolpyruvate

Regulation:
1. PTH – promotes renal excretion of phosphate
2. Vitamin D – promotes intestinal absorption and renal reabsorption of phosphate
3. Calcitonin – inhibits bone resorption
4. Growth hormone – decrease renal excretion of phosphate
 Hyperphosphatemia Hypophosphatemia
Hypoparathyroidism Alcohol-abuse – most common cause
Renal failure (tubular failure) Primary hyperparathyroidism
Lymphoblastic leukemia Avitaminosis D
Hypervitaminosis D Myxedema

DKA, COPD, IBD, anorexia nervosa

Decreased absorption (rickets)

Bicarbonate
 Second most abundant extracellular anion
 Represents more than 90% of plasma carbon dioxide
 Plays a role in the maintenance of acid-base balance
 Clinical significance:
a. ↑ - metabolic alkalosis
b. ↓ - metabolic acidosis

Lactate
 By-product of anaerobic glycolysis
 Removed from the blood by the liver (gluconeogenesis)
 Clinical significance:
a. ↑ lactate – sensitive indicator of tissue hypoxia
1. Type A lactic acidosis (hypoxic)
 Hypovolemic or hemorrhagic shock, congestive heart failure, pulmonary edema,
severe blood loss
2. Type B lactic acidosis (metabolic)
 Leukemia, diabetes mellitus, severe infections, liver and renal disease, alcohol or
salicylate poisoning

** Normal: 1 mol of glucose (aerobic)  pyruvate – acetyl CoA  citric acid cycle produces 38
moles of ATP
** Under hypoxic conditions, acetyl CoA does not occur, so NADH accumulates. Conversion of
pyruvate to lactate under anaerobic metabolism (2 moles of ATP)

ANION GAP
 Difference between unmeasured cation (Na+ and/or K+) and unmeasured anions (Cl and HCO3)
 Reflects the concentration of unmeasured ions
 There is a gap because the unmeasured cations and anions are not considered

AG = (Na + K) – (Cl + HCO3)

Reference range: 10 – 20 mmol/L

AG = Na – (Cl + HCO3)
Reference range: 7 – 16 mmol/L

Clinical significance: Increased anion gap

 Uremia / renal failure – increased retention of anion particularly sulfates and phosphates
 Ketoacidosis
 Lactic acidosis
 Alcohol or salicylate poisoning
 Instrument error

ESSENTIAL TRACE ELEMENTS

ELEMENT BIOCHEMISTRY FUNCTIONS TOXICITY DEFICIENCY

COPPER Component of Cellular respiration, Increased intake: Malnutrition /
 several neurotransmitter Symptoms: Nausea, malabsorption
metalloenzymes regulation, collagen vomiting epigastric pain Chronic copper loss
(cytochrome synthesis, Increased intake of zinc
oxidase, SOD, development of Wilson’s disease or – hypochromic anemia
tyrosinase, vascular and hepatolenticular Aceruloplasminemia
dopamine-B- skeletal structures degeneration (failure to
hydroxylase/ and CNS, excrete Cu in bile; Menke’s syndrome –
monooxygenase, protection from excess Cu in liver, brain, failure of Cu absorption
lysyl oxidase – free radical damage eyes) Symptoms: kinky hair,
collagen synthesis) Symptoms: cirrhosis, CT abnormalities,
brain lesions, Kayser- mental retardation
Bound to Fleischer rings in the
ceruloplasmin, cornea
albumin and
transcuprein
ZINC Cofactor for >300 Growth, wound Administration of high Acrodermatitis
enzymes healing, doses enteropathica
Transported by reproductive Symptoms: Nausea, (malabsorption), chronic
albumin and a-2- function, amino vomiting, GI irritation, liver and kidney disease,
macroglobulin acid and free copper deficiency may alcoholism, diets in low
radical metabolism lead to anemia; zinc
decreased heme
synthesis Symptoms: Growth
retardation, impotence
Exposure to ZnO fumes and infertility,
Symptoms: Zinc fume susceptibility to
fever – chemically- infections, delayed
induced pneumonia, wound healing,
pulmonary dermatitis, osteoporosis;
inflammation, cough, testicular atrophy;
chest pain, fever sensory alterations (loss
of muscles coordinations
– ataxia) carcinogenesis
IRON Component of Oxygen transport, Hemochromatosis: Increased blood loss,
hemoglobin, respiration, characterized by decreased intake,
myoglobin, and oxidative increased acc of iron in decreased release from
heme-containing phosphorylation, tissues and ferritin
enzymes amino acid and free hyperpigmentation of
Delivered to tissues radical metabolism the skin Characterized by
bound to transferrin Treated with therapeutic microcytic hypochromic
and stored as ferritin phlebotomy; chelation anemia
or hemosiderin with deferoxamine;
administration of
transferrin in case of
atransferrinemia

Primary – genetic,
autosomal recessive
Secondary – acquired,
iron overload (increased
dietary intake,
transfusion); metabolic
dysfunction – liver
disease and porphyria
cutanea tarda

ESSENTIAL ULTRATRACE ELEMENTS

ELEMENT BIOCHEMISTRY FUNCTIONS TOXICITY DEFICIENCY
Chromium Important Potentiates insulin Skin ulcers (allergic Impaired glucose
 component of action dermatitis) tolerance, insulin
glucose tolerance Glucose and lipid Airway irritation, lung resistance, peripheral
factor (Cr III) metabolism cancer neuropathy
Recognized Renal and hepatic Hyperglycemia
allergen, respiratory necrosis Hyperlipidemia
tract irritant (Cr VI
and carcinogen
Cobalt Component of Folate metabolism Cardiomyopathy Megaloblastic anemia
vitamin B12 Erythropoiesis Heart failure, vomiting
(cobalamin) diarrhes
Iodine Component of Synthesis of thyroid Thyrotoxicosis Goiter, hypothyroidism,
iodothyronines hormones cretinism myxedema
Manganese Component of Oxidative Neurologic symptoms Skeletal and cartilage
metalloenzymes phosphorylation (resembles Parkinson’s defects
(oxidoreductases, Cholesterol and disease) Hypocholesterolemis
lipase, pyruvate mucopolysaccharide Psychosis (locura Bleeding disorders
carboxylase, metabolism mnganica – manganese Disorder in
superoxide Bone and madness) spermatogenesis
dismutase and connective tissue Memory and speech
arginase) development disturbances
Growth and
reproduction
Molybdenum Component of Xanthine Hyeruricemia Growth depression,
xanthine oxidase metabolism of uric Hyperoxypurinemia mental disturbance,
and sulfite oxidase acid production defective keratin
formation, anterior lens
discoloration
Selenium Component of Protection against Hair and nail loss, Cardiomyopathy
glutathione oxidative damage tooth decay, garlic Cardiomegaly, heart
peroxidase (in the (free radicals) breath failure (Keshan disease)
form of Regulation of Neuropathy Osteoarthritis (Kashin-
selenocysteine) thyroid hormone GI and cardiovascular Beck disease)
action symptoms Carcinogenesis
Skeletal muscle
disorders

BLOOD GASES AND pH MEASUREMENTS

 In the lungs, elimination of excess CO2 maintains the bicarbonate-carbonic acid levels at 20:1
 Slow or non-removal of CO2 by the lungs results to increase in H+ concentration –
respiratory acidosis
 Rapid elimination of CO2 by the lungs results to decrease H+ concentration – respiratory
alkalosis
 In the kidneys, acid-base balance is maintained by excretion of acid and reabsorption of
bicarbonate ions

PATHOLOGIC STATES CONDITIONS COMPENSATORY

Metabolic acidosis Bicarbonate deficiency
Diabetic ketoacidosis
Lactic acidosis
Renal failure
Diarrhea
Metabolic alkalosis Bicarbonate excess
Vomiting (loss of chloride
from stomach)
Respiratory acidosis Carbon dioxide excess
MECHANISM
Hyperventilation
↓ HCO3 +↓ pCO2 + pH < 7.4
Hypoventilation
↑ HCO3 + ↑ pCO2 + pH > 7.4
Bicarbonate retention
 COPD
Drugs overdose (morphine, ↑ HCO3 + ↑ pCO2 + pH < 7.4
barbiturates, and opiates)
Respiratory alkalosis Carbon dioxide loss Bicarbonate excretion
Anxiety and severe pain
Aspirin overdosage ↓ HCO3 +↓ pCO2 + pH > 7.4
Salicylate and progesterone
drugs

HENDERSON-HASSELBACH EQUATION:
 Represents acid-base balance relationship: 20:1 ratio of bicarbonate-carbonic acid buffer.

pH = pKa + log conjugate base

weak acid

where:
pKa = is 6.1; combine hydration and dissociation constants for carbon dioxide in blood
conjugate base = bicarbonate
weak acid = carbonic acid

EVALUATION OF ACID-BASE BALANCE

1. pH
 Normal pH: 7.35 – 7.45
 < 7.35 – acidosis
 > 7.45 – alkalosis

 Silver-silver chloride electrode – reference electrode (potentiometry)

 Calomel electrode – reference electrode
 Gas electrode – most commonly used for pH

2. pCO2
 Normal: 35 – 45 mmHg
 < 35 mmHg – Respiratory alkalosis
 > 45 mmHg – Repiratory acidosis

 Severinghaus electrode (potentiometry)

3. HCO3
 Normal: 21 – 28 mEq/L
 < 21 mEq/L – Metabolic acidosis
 > 28 mEq/L – Metabolic alkalosis

4. Degree of Hypoxemia
 Normal: pO2 – 80 – 100 mmHg
 61 – 80 mmHg – MILD
 41 – 60 mmHg – MODERATE
 40 mmHg or less – SEVERE

 Clark electrode (polarography-amperometry)

NOTES:
1. For every degree of fever in the patient, pO2 will fall 7% and pCO2 will rise 3%

TUMOR MARKERS

 Substances which are used to diagnose the presence of cancer

Tumor Marker Associated Conditions

 Alpha-fetoprotein Primary hepatoma
Prostate-specific antigen Prostate cancer
CA-125 Ovarian carcinoma
CA 549 / CA 15-3 Breast carcinoma
CA 195 / CA 19-9a Pancreatic and gastric carcinoma
CA 72-4 Gastric carcinoma
Amylase Pancreatic carcinoma
Chromogranin Neuroendocrine cell carcinoma
Calcitonin Medullary thyroid cancer
CEA Breast, lung, colorectal and stomach
carcinoma
HER-2 Breast cancer
NMP Urinary bladder cancer

ENDOCRINOLOGY
 Denotes secretion of biologically active substances
 Controls flow of information between cells and tissues
 Releases hormones into the circulation to convey information to target cells that contain
cognate hormone receptors

ROLES OF HORMONES:
1. PARACRINE – when hormones act on neighboring cells
2. JUXTACRINE – when hormones remain bound in the membrane of 1 cell and react with a
receptor on a juxtaposed cell
3. AUTOCRINE – when hormones are released and act on receptors located on the same cell
4. INTRACRINE – when hormones act inside the cell without being released

Structure Hormones
Peptide Insulin, PTH, LH, FSH, TSH, TRH, ACTH, prolactin, GH,
calcitonin, glucagon
Steroid Cortisol, progesterone, estrone, estradiol, testosterone, aldosterone
Amino acids Epinephrine, norepinephrine, T4 and T3
Fatty acids Prostaglandins

A. PITUITARY GLAND – “SPIT MUCUS”

 “master gland”
 Hypophysis (growth beneath the hypothalamus)
 Translates neural input into a hormonal or an endocrinologic product.
 Activity of thyroid gland, adrenal cortex, and gonads is controlled by feedback effects of their
circulating hormones on the hypothalamic-pituitary axis.

1. ANTERIOR PITUITARY GLAND (ADENOHYPOPHYSIS) – releases tropic hormone

which acts on another endocrine gland

GROWTH HORMONE / SOMATOTROPIN

 Major effects are directed to the growth of skeletal muscles and long bones of the body
 Directly antagonizes the effect of insulin on glucose metabolism: (a) promotes hepatic
gluconeogenesis (b) promotes lipolysis
 Growth hormone-releasing hormone – stimulates release of GH in the pituitary
 Somatostatin – inhibits the release of somatotropin
 Most reproducible peak: Onset of sleep

MODIFIERS OF GROWTH HORMONE SECRETION

STIMULATORS INHIBITORS
Sleep Glucose loading
Exercise b-agonists (epinephrine)
Physiologic stress a-blockers (phentolamine)
Amino acids Emotional/psychogenic stress
Hypoglycemia Nutritional deficiencies
Sex steroids Insulin deficiency
a-agonists (e.g. norepinephrine) Thyroxine deficiency
b-blockers (e.g. propanolon)

A. HYPERSECRETION

GIGANTISM
 GH-producing tumor before epiphyseal closure (childhood)

ACROMEGALY
 GH-producing tumor after epiphyseal closure (adulthood) ; bony and soft tissue
overgrowth

LAB DIAGNOSIS:
 Screening test: Somatomedic C or Insulin-like Growth Factor I
 Confirmatory test: OGTT (75g oral glucose load)

B. HYPOSECRETION

PITUITARY DWARFISM
 may be due to tumors or inevitable consequence of aging

LAB DIAGNOSIS:
 Screening test: Somatomedin C or Insulin-like Growth Factor I
 Confirmatory test: (1) Insulin Tolerance test (gold standard) (2) Arginine Stimulation
test (2nd confirmatory test)

HYPOPITUITARISM – underfunctioning pituitary gland; lacking of pituitary hormones

SHEEHAN’S SYNDROME
 monotropic hormone deficiency following post-partum ischemic necrosis of the pituitary
following a complicated delivery

KALLMANN’S SYNDROME
 panhypopituitarism; complete loss of pituitary function

PROLACTIN
 Stress hormone
 Has a diffuse target tissue and lacks a single endocrine end organ
 Role in reproduction (lactation)
 TRH and estrogen – directly stimulates prolactin production by lactotropes
 Primary regulation – tonic inhibition by dopamine

HYPERPROLACTINEMIA
 PROLACTINOMA – most common pituitary tumor
 Manifestations include menstrual irregularity, amenorrhea, infertility, reduced libido and
erectile dysfuntion

2. POSTERIOR PITUITARY GLAND (NEUROHYPOPHYSIS) – storage region for ADH

and oxytocin

OXYTOCIN
 Critical role in lactation
 Major role in labor (contraction of gravid uterus) and parturition

VASOPRESSIN / ADH
  Major role in renal free water excretion – reabsorption of water in renal tubules
 Potent pressor agent – effects blood clotting by promoting factor VII release from
hepatocytes and vWf release from the epithelium

A. HYPOSECRETION

DIABETES INSIPIDUS
 Characterized by copious production of urine (polyuria) and intense thirst (polydipsia)

HYPOTHALAMIC DI NEHPROGENIC DI
Decreased ADH production With normal ADH production
No problem with kidney cells Unresponsive kidney cells to ADH produced
by hypothalamus

3. THYROID GLAND
 2 types of cells: (1) thyroid follicular cells - produce T3 and T4 (2) thyroid parafollicular
cells / C-cells – produces calcitonin
 Iodine can be found in dietary iodide such as seafood, salt and dairy products
 Thyroxine (T4) – represents 80% of thyroid hormones; serves as pro-hormone for T3
 Triiodothyronine (T3) – represents 20% of thyroid hormones; produced by conversion of
T4 within the liver and periphery; encourages cell differentiation, tissue growth and
development and calorie metabolism
 Calcitonin – participates in calcium homeostasis by responding to hypercalcemia; inhibits
bone-dissolving activity of osteoclasts

SYNTHESIS OF THYROID HORMONES

 Iodide trapping - active uptake of iodine by a sodium-iodide symporter
 Conversion/oxidation of iodide to iodine – catalyzed by TPO
 Iodination of tyrosine residues at apical/colloid interface and incorporation of iodine
onto tyrosine residues of thyroglobulin to form MIT and DIT
 Coupling of iodinated tyrosines
 Storage of T3 and T4

A. HYPERSECRETION

THYROTOXICOSIS
 Caused by excessive thyroid hormone in the circulation
 Due to pituitary tumors, excessive TSH secretion, thyroid carcinoma, and toxic
multinodular goiter
 ↑ T3 and T4; ↓ TSH and TRH

GRAVE’S DISEASE
 Autoimmune disorder in which immunoglobulins are produced that activate the TSH
receptor

B. HYPOSECRETION
 Serum level of thyroid hormone is insufficient to provide for the metabolic needs of
the cell
 Results in CRETINISM in children and MYXEDEMA in adults

PRIMARY HYPOTHYROIDISM
 Inadequate secretion of thyroid hormones
 ↓ T3 and T4
SECONDARY HYPOTHYROIDISM
 Decrease in production of TSH leading to low serum levels of thyroid hormones
 ↓ TSH ; ↓ T3 and T4 ; compensatory mechanism: ↑ TRH
TERTIARY HYPOTHYROIDISM
 Hypothalamic failure leading to a lack of TRH production
 ↓ TRH ; ↓ TSH ↓ T3 and T4
 CHRONIC IMMUNE THYROIDITIS (HASHIMOTO’S THYROIDITIS)
 Caused by a genetic abnormality in the immune system
 Involves massive infiltration of the thyroid gland by lymphocytes
 Same symptoms with hypothyroidism

C. LABORATORY DIAGNOSIS

1. T3 Resin Uptake
 Analyzes the capacity of thyroid binding globulin to bind thyroid hormones
 Indirect measurement of free binding sites on the TBG molecule

2. Free Thyroxine Index

 Indirectly assess the concentration of circulating free T4
 Calculated by multiplying the value of total T4 by the percentage value of the T3
resin uptake

3. TRH Stimulation Test

 Measures pituitary TSH stores; conclusive of hyperthyroidism
 TRH is injected and blood is assayed for TSH levels
 TSH will rise rapidly in a normal person
 TSH levels will not rise in a hyperthyroid patient

4. Thyroid Needle Biopsy

 Most reliable test to differentiate the “cold nodule” that is cancer from “hot
nodule” that is benign

SUBCLINICAL HYPOTHYROIDISM SUBCLINICAL HYPERTHYROIDISM

Normal T3 and T4 Normal T3 and T4

Slightly elevated TSH Subnormal TSH
No signs and symptoms No signs and symptoms

4. PARATHYROID GLAND
 Parathyroid hormone – involved in the metabolism of both calcium and phosphorus by
the kidneys and bones
 In bone – increases bone resorption of calcium into serum
 In kidneys – increases renal reabsorption of calcium
 PTH, via 1, 25 (OH)2D, promotes intestinal absorption of calcium

A. HYPERSECRETION
 Leads to extreme bone wasting and fractures

PRIMARY HYPERPARATHYROIDISM
 Parathyroid adenoma
 ↑ Calcium ; N to ↓ Phosphorus

SECONDARY HYPERPARATHYROIDISM
 Conditions associated with the attempt to compensate for hypocalcemic states
 ↓ Calcium ; ↑ Phosphorus
B. HYPOSECRETION
 Reults in tetany (involuntary contraction of the muscles of the hand, feet, legs and back
and may cause spasm of the muscles of the wrist and hand (Trousseau’s sign)

5. ADRENAL GLAND

A. ADRENAL CORTEX
  Derived from urogenital ridge ; yellow on autopsy

LAYERS OF THE ADRENAL CORTEX

1. G-zone (zona glomerulosa) – 10%; synthesis of mineralocorticoids -
ALDOSTERONE
2. F-zone (zona fasciculata) – 75%; synthesis of glucocorticoids – CORTISOL
3. R-zone (zona reticularis) – 15%; synthesis of sex steroid precursors –
DEHYRDROEPIANDOSTERONE SULFATE (DHEAS)

ALDOSTERONE
 Regulated by RAAS which is activated by:
o ↓ Plasma osmolality
o ↓ Sodium concentration in the blood
o ↓ Circulating blood volume
o ↓ Blood pressure
 Reabsorption on sodium
 Excretion of potassium
 Excretion of hydrogen ions

A. HYPERSECRETION

CONN’S DISEASE
 Adrenal tumor synthesizing aldosterone autonomously

PRIMARY HYPERALDOSTERONISM
 Localized on the gland (tumors)
SECONDARY HYPERALDOSTERONISM
 Hypersecretion of renin

Primary Hyperaldosteronism Secondary

Hyperaldosteronism
Plasma renin activity ↓ ↑
Plasma aldosterone ↑ ↑
Na+ levels in blood ↑ ↑ Hypernatremia
K+ excretion ↑ ↑ Hypokalemia
H+ in blood ↓ ↓ Metabolic alkalosis

LABORATORY DIAGNOSIS

1. Screening test: Urinary potassium excretion

 > 30 mEq/day: suggestive of hyperaldosteronism
2. Upright PA/PRA ratio
 PA/PRA ratio greater than 25 suggests Primary hyperaldosteronism
3. Confirmatory test: Captopril Suppresion
 3h 50mg captopril; PA remains increased in Primary hyperaldosteronism

B. HYPOSECRETION

PSEUDOALDOSTERONISM
 Bartter’s syndrome – bumetanide-sensitive chloride channel mutation
 Gitelman’s sundrome – thiazide-sensitive transporter mutation

Primary Hypoaldosteronism Secondary

Plasma aldosterone (PA)
Plasma Renin Activity (PRA)
Na+ levels in blood
Hypoaldosteronism
ADDISON’S DISEASE – ↓
destruction of majority of
adrenal tissue ↓ (cortisol is
also ↓ )
↑ ↓
↓ ↓ Hyponatremia
K+ excretion ↓ ↓ Hyperkalemia
H+ in blood ↑ ↑ Metabolic acidosis

CORTISOL
 Critical to hemodynamic and glucose homeostasis
 Maintain blood glucose by inducing lipolysis and amino acid release from muscle
breakdown for conversion into glucose (gluconeogenesis) and storage as liver glycogen
 Cortisol levels are highest in the morning (8:00 am) and lowest at night (10:00pm – 12:00
am)

A. HYPERSECRETION

Hypertension Primary Secondary

Hyperglycemia Hypercortisolism Hypercortisolism
Morbid obesity CRH ↓ ↓
ACTH ↓ ↑
Adrenal tumor Pituitary tumor
producing cortisol producing cortisol
Ectopic tumors

LABORATORY DIAGNOSIS

1. Screening test:
 24-hr urine free cortisol test – most sensitive and specific; method: HPLC
 Overnight dexamethasone suppression tests – most widely used (1mg)
 Salivary cortisol test

2. Confirmatory test:
 Low-dose dexamethasone suppression test (0.5 mg)
 Midnight plasma cortisol
 CRH Stimulation test

B. HYPOSECRETION

Hypotension Primary Secondary

Hypoglycemia Hypocortisolism Hypocortisolism
CRH ↑ ↑
ACTH ↑ ↓
Adrenal Hypopituitarism
Insufficiency

LABORATORY DIAGNOSIS

1. ACTH Stimulation Test / Cosyntropin Stimulation Test

 Cosyntropin is a synthetic cortisol and aldosterone stimulator
 Differentiates 2o adrenal insufficiency (↓) from 3o adrenal insufficiency (↑)

2. Metyrapone Test
 Inhibitor of 11B-hydroxylase
 Measures the ability of the pituitary gland to respond to declining levels of
circulating cortisol
 Confirmatory for 2o or 3o adrenal insufficiency

ANDROGENS
 Necessary for development of secondary sex characteristics in males and females
 Virilization in men may lead to infertility with feminizing effects due to low testicular
testosterone production, deceased hair growth and loss of muscle mass
 Virilization in women may lead to infertility with masculinizing effects (hirsutism,
menstrual irregularities and male pattern baldness)
 B. ADRENAL MEDULLA
 Derived from the neural crest ; mahogany on autopsy

CATECHOLAMINES
 Norepinephrine and epinephrine (9:1)
 Promotes fight-or-flight response
 Increases cardiac output and blood pressure
 Metabolites: (1) metanephrines (2) vanillylmandelic acid
 DOPAMINE -Catecholamine produced in the body by he decarboxylation of 3,4-
dihydrxyphenylalanine (DOPA)
o Major intact catecholamine in urine
o Major metabolite: Homovanillic acid (HVA)
o Found in high concentrations in urine in children with neuroblastoma

A. HYPERSECRETION

PHEOCHROMOCYTOMA
 Catecholamine-producing tumor arising from chromaffin tissue

LABORATORY DIAGNOSIS

1. HPLC/RIA
 Most specific and sensitive screening test for plasma metanephrines

2. Clonidine Suppression Test

 0.3 mg clonidine; patients with pheochromocytoma fall in plasma total
catecholamines >500pg/mL

6. GONADS

A. TESTES
 Predominant hormone: testosterone
 Controlled by pituitary hormones:
o Follicle-Stimulating hormone (FSH) – acts primarily on germinal stem cells
o Luteinizing hormone (LH) – acts primarily on Leydig cells, located in the
testicular interstitium; synthesize testosterone
 Reflects the parallel rhythyms of FSH and LH levels
o Highest level is found at about 8am
o Lowest level is found at about 8pm

DISORDERS OF TESTICULAR HYPOFUNCTION

1. Hypergonadotropic hypogonadism
 Low testosterone, elevated FSH and LH, and impaired sperm production

A. Testicular Feminization Syndrome

 Most severe form of androgen resistance syndrome
 Physical development pursues the female type (fully developed breast, female
distribution of fat and hair)
 Testicles are often undescended
 No response to administration of exogenous testosterone (N levels of testosterone,
elevated FSH and LH levels)

B. 5-Reductase Deficiency
 Reduction in the levels of 5-reductase – decreased testosterone levels
 During puberty, residual enzyme activity sufficiently converts testosterone to
dihydrotestosterone, resulting in development of a male phenotype

C. Klinefelter’s Syndrome
  Most common karyotype: 47, XY
 Physical manifestations: small and firm testicles, gynecomastia, azoospermia – sterility

D. Myotonic Dystrophy
 Testicular failure typically presents in the fourth decade of life
 Presents hypogonadism, muscle weakness, frontal balding, muscle dystonia

E. Sertoli Cell – Only Syndrome

 Lack of germ cells
 Men present with a small testes – azoospermia but with normal testosterone levels

2. Hypogonadotropic hypogonadism
 Low testosterone levels with low or inappropriately normal FSH or LH levels

A. Kallmann’s Syndrome
 X-linked recessive trait that manifests as hypogonadism during puberty
 Anosmia (inability to smell)
 Midline defects (cleft palate and lip)
 Certain men also have red-green color blindness, congenital deafness and cerebellar
dysfunction

TANNER STAGING OF GENITAL AND PUBIC HAIR DEVELOPMENT IN MALES

STAGES OF GENITAL DEVELOPMENT
1. Prepubertal
2. Enlargement of scrotum and testes
3. Increased length of penis, further
enlargement of testes
4. Enlargement of testes; scrotum, and penis
with growth of glans; darkening of scrotal sac spread to medial thighs
5. Mature genitalia
STAGES OF PUBIC HAIR
DEVELOPMENT
1. Lanugo-type hair (prepubertal)
2. Dark terminal hair at base of penis
3. Darker terminal hair spreading over junction
of pubes
4. Terminal hair covering pubic region, no
5. Mature stage with horizontal distribution of
terminal hair to inner thighs

B. OVARIES

1. ESTROGEN
 Principal estrogen: estradiol
 Promotes breast, uterine and vaginal development
 Responsible for follicular phase changes in uterus
 Deficiency would lead to irregular and incomplete development of endometrium

2. PROGESTERONE
 Produced by the corpus luteum
 Readying the endometrium for embryo implantation
 Dominant hormone responsible for the luteal phase
 Deficiency would lead to failure of implantation of embryo, thickening of cervical mucus
and reduction of uterine contractions

3. INHIBINS A and B
 Produced by the ovaries
 Inhibits FSH production

MENSTRUAL CYCLE
 2 phases of parallel events occurring at the ovaries and endometrium
 Within the ovaries: follicular and luteal phases
 Endometrial events: proliferative and secretory phases

A. Follicular Phase
  Begins on the onset of menses and ends on the day of LH surge
 Early in the follicular phase, the ovary secretes very little estrogen or progesterone
 Rise in FSH, however, stimulates estrogen production
 Estrogen secreted by the developing follicle within the ovary stimulates:
o Uterine epithelial cells
o Blood vessel growth
o Endometrial gland development to increase the thickness of the endometrium

B. Luteal Phase
 Start of the luteal phase is marked by the extrusion of the ovum approximately 36 hours
after this LH surge – luteinization of the Graafian follicle to form the corpus luteum
 Corpus luteum secretes progesterone to aid in the implantation of the embryo
 In the absence of fertilization, there is gradual decline in the production of progesterone
and estrogen by the corpus luteum, loss of endometrial blood supply, shedding of the
endometrium approximately 14 days after ovulation occurred.
 Typical duration of menstrual bleeding: 3 – 5 days ; blood loss averaging 50 mL
 Onset of menses marks the end of the luteal phase

TANNER STAGING OF BREAST AND PUBIC HAIR DEVELOPMENT IN FEMALES

STAGES OF BREAST DEVELOPMENT STAGES OF PUBIC HAIR
DEVELOPMENT
1. Prepubertal 1. Lanugo-type hair (prepubertal)
2. Elevation of breast bud and papilla, areolar 2. Dark terminal hair on labia majora
enlargement
3. Elevation of breast tissue nd papilla 3. Terminal hair covering labia majora and
spreading to the mons pubis
4. Elevation of areola and papilla on secondary 4. Terminal hair fully covering the labia majora
mound above the level of the breast and mons pubis
5. Mature stage: recession of areola into the 5. Terminal hair covering the labia majora,
breast with projection of papilla only mons pubis and inner thighs

MENSTRUAL CYCLE ABNORMALITIES

1. Amenorrhea
 Absence of menses
 Primary amenorrhea: has never menstruated
 Secondary amenorrhea: at least one menstrual cycle followed by absences of menses for
a minimum of 3 – 6 months

2. Oligomenorrhea
 Infrequent or irregular menstrual bleeding
 Cycle length in excess of 35-40 days
 Menorrhagia – uterine bleeding in excess of 7 days is dysfunctional

POLYCYSTIC OVARY SYNDROME

 Symptoms: infertility, hirsutism, chronic anovulation, glucose intolerance, hypertension
 Most patients are overweight
 Drug Glucophage (Metformin) – normalizes menstrual cycles, improves conception rates

HIRSUTISM
 Abnormal, abundant androgen-sensitive terminal hair-growth in areas in which terminal hair
follicles are sparsely distributed or not normally found in women

FERRIMAN-GALLWEY SCALE
9 Areas of Assessment:
Lip chin Scale of 1 – 4 based on hair thickness and
Sideburn region pigmentation
Neck
Chest Score of higher than 8 is consistent with a
 Abdomen diagnosis of hirsutism
Upper back
Lower back
Upper thigh
Lower thigh

MISCELLANEOUS ENDOCRINE GLANDS

A. KIDNEYS

1. Renin
 Initial component of renin-angiotensin-aldosterone system
 Produced by the juxtagromerular cells of the renal medulla
 Responds to decreased extracellular fluid volume and low blood pressure

2. Erythropoietin
 Production by cells close to proximal tubules
 Production is regulated by blood oxygen levels – hypoxia prodces increased serum
concentration within 2 hours
 Acts on the erythroid precursors in the bone marrow
 Decreased EPO: Chronic renal insufficiency and anemia

3. 1, 25-dihydroxy Vitamin D3
 Active form of vitamin D
 Determine phosphate and calcium balance
 Bone calcification in the human body
 Osteomalacia – inadequate bone calcification; adult form of rickets – distortion of normal
vitamin D metabolism

4. Prostaglandins
 ↑ Renal blood flow
 ↑ Sodium and water excretion
 ↑ Renin release

B. PANCREAS

1. Secretin
 Responsible for the production of bicarbonate-rich and alkaline pancreatic fluid
 Protects the lining of the intestines from damage
 Synthesized in response to the acidic contents of the stomach reaching the duodenum
 Activated by gastric activity

2. Cholecystokinin
 Formerly called pancreozymin
 In the presence of fats or amino acids in the duodenum, is produced by the cells of the
intestinal mucosa
 Responsible for the release of enzymes from the acinar cells by the pancreas into the
pancreatic fluid

C. GASTROINTESTINAL TRACT

1. Gastrin
 Secreted by specialized G cells in the gastric mucosa and the duodenum
 In response to: vaginal stimulation; contact with secretagogues
 Inhibitory influences include high gastric acidity

2. Gastric Inhibitory Polypeptide

 Secreted by K cells in the middle and distal duodenum and proximal jejunum
  In response to food products such as: fats, glucose and amino acids

D. PLACENTA

1. Human Chorionic Gonadotropin (HCG)

 Produced by chorionic villi of implanted blastocyst and triggers the corpus luteum to
release progesterone and estrogen
 Helps maintain the uterine lining, the endometrium, with an adequate uterine blood
supply until placental synthesis of progesterone begins
 Detectable levels begin at about 22 days from the LMP, which is approximately 8 – 11
days from conception
 Once progesterone is produced by the placenta to maintain uterine function, hCG is no
longer needed and the amount decreases by 12 – 14 weeks gestation

2. Human Placental Lactogen

 Similar structure with growth hormone
 Regulates metabolism of maternal fats and glucose in early pregnancy (inhibiting
maternal insulin and sparing glucose for fetal metabolism)
 At the end of pregnancy, helps prepare the mammary glands for lactation

3. Progesterone
 Made by the placenta from maternal cholesterol
 Helps to maintain the endometrium – promoting growth and thickening of mucosal cells
and adequate uterine blood supply
 Decreased progesterone levels leads to fetal demise; poor uterine blood supply (resulting
to endometrial sloughing) and inhibits further ovarian follicle development

4. Estriol
 Major estrogen produced by the placenta during pregnancy

Therapeutic Drug Monitoring

CARDIOTROPICS Digitalis glycosides: digoxin and digitoxin
Most commonly used to treat congestive heart Procainamide (Pronestyl)
failure and cardiac arrhythmias Quinidine
Lidocaine (Xylocaine)
Propanolol
Disopyramide
ANTICONVULSANTS Phenobarbital
Used in the treatment of seizure disorders, in Phenytoin (Dilantin)
particular grand mal, petit mal, and Primidone (Mysoline)
psychomotor seizures and other generalized Ethosuximide (Zarontin)
seizure disorders such as tic douloreux Carbamazepine (Tegretol)
(trigeminal neuralgia) Valproic acid (Depakene)
ANTIASTHMATICS Theophylline
Most commonly prescribed anti-astmatic drug
Bronchodilator for the treatment of moderate to
severe asthma, both for the prevention of
attacks and for treatment of symptomatic
exacerbations
ANTI-INFLAMMATORY DRUGS Acetaminophen
Acetylsalicylic acid
IMMUNOSUPPRESSIVES Cyclosporine
Prednisone
Cyclophosphamide (Cytoxan)
CHEMOTHERAPEUTIC AGENTS Methotrexate
Anti-neoplastic agent
 Used in the treatment of psoriasis, rheumatoid
arthritis, and some collagen vascular diseases
DRUGS FOR TREATMENT OF MANIC- Lithium – anti-manic agent and are used for the
DEPRESSION prophylaxis and treatment of bipolar disorder
Used in the treatment of psychiatric affective (manic-depressive psychosis)
disorders
Tricyclic antidepressants – Amitriptyline,
Imipramine, Nortriptyline, Desipramine,
Doxepin