Endocrinology

Patient 2 is a 43-year-old-man with hypogonadism due to Klinefelter’s syndrome treated with transdermal testosterone gel. He had done well without adverse drug reactions or side effects of therapy. He had been on the same dose for years; thus, we had decreased the frequency of routine lab testing to annually.

He transitioned over to new insurance. Before agreeing to cover the testosterone therapy, they demanded that I provide copies of his pre-treatment testosterone levels proving that they were below the normal range.

One of the more frustrating aspects of medical practice is fighting with insurance companies to get our patients the care they need. As preventionists, endocrinologists struggle to keep our patients out of the hospital while also trying to minimize health care costs. We spend hours every day completing prior authorization forms, sending letters of appeal to insurance companies and explaining why our patients deserve the care we recommend.

At the same time, we see wasteful over-utilization of resources, unnecessary procedures or imaging studies, and hospitalizations that could possibly have been avoided. And yet, no one questions any of that.

I saw a 32-year-old man in consultation for hyperthyroidism. His thyroid-stimulating hormone was <0.01 and both free T₄ and free T₃ were elevated. He had palpitations, tremor and insomnia but denied other symptoms.  On exam, his thyroid was non-tender and without nodules. More than likely his diagnosis is Graves’ disease, I thought.

After discussing the treatment options in detail, we both leaned towards methimazole (Tamazole, King). At first, I did not think that radioactive iodine uptake and scan would be needed as we were not planning on radioactive iodine therapy.

A young man was referred to me for evaluation of low testosterone and gynecomastia. The initial total testosterone was 57 ng/dL; results of a repeat testosterone assessment were even lower. Prolactin was normal, but follicle-stimulating hormone (FSH) and luteinizing hormone (LH) were both undetectable. Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were previously normal but were now both over 200. His total and LDL cholesterol levels were high; his HDL was low.

He was muscular, physically fit and an avid weight lifter. I questioned him about the use of anabolic steroids. He had not knowingly used any product that was marketed as an anabolic steroid for a few years. He seemed sincere and I believed him.

Cytologically indeterminate fine needle aspiration results are common. From 15% to 30% FNA biopsies of thyroid nodules are indeterminate or suspicious, including atypia or follicular lesions of undetermined significance (AUS/FLUS); follicular or Hürthle cell neoplasms; and FNA suspicious for malignancy. Because the risk for malignancy in an indeterminate FNA may be as high as 30%, most of these patients were traditionally advised to proceed with surgical resection, followed by completion thyroidectomy if malignancy was confirmed.

In this blog post, I present three cases involving patients suspected of having possible acromegaly and discuss follow up. After reading, please share your thoughts.

Case #1

Case #1 is a 51-year-old man who was first referred to me for primary hypothyroidism. However, at our first visit, I was struck by his large hands. Upon further questioning, he reported a history of snoring, sleep apnea and excessive sweating. He no longer was able to wear his wedding ring.

I saw a woman in consultation for a prolactinoma responsive to cabergoline. I noticed, however, that she also had dyslipidemia. Her LDL cholesterol was 180 mg/dL.  I suggested that she consider pharmacotherapy, as she had not responded to dietary and lifestyle modification.

The patient explained that she tried various statins in the past. Because of elevation of liver enzymes, however, she had been told by several other physicians that she must never be on a statin again. In their opinion it could be dangerous and damage her liver.

When we visualize the neck by ultrasound, we occasionally find non-thyroid lesions. The following are two cases recently seen in our practice.

Patient 1 had a neck ultrasound that revealed not only a multinodular thyroid, but also a large cystic lesion in the right lateral neck. The interpreting radiologist thought this lesion could possibly be an abscess, cyst, neoplasm or something else.

A 70-year-old woman had a PET/CT scan to evaluate her prior history of endometrial adenocarcinoma. No evidence of metastatic adenocarcinoma was seen. However there was an incidental finding of a focal area of increased uptake seen in her left thyroid.

The patient was sent to see me in consultation. I performed a thyroid ultrasound and found a left-sided nodule. It had relatively benign appearing characteristics. It was isoechoic, with only peripheral flow, and was well-defined and without calcifications. There were no other thyroid nodules or suspicious cervical lymphadenopathy. Had I not known of the positive uptake on PET scan, this is a nodule I might have chosen to follow by observation instead of biopsy. Nevertheless, given the PET findings, I performed an ultrasound guided fine needle aspiration (FNA). The results were consistent with a benign thyroid nodule.

One of the endocrinologists with whom I work was called by an internal medicine colleague who practices in another state. The internist has a patient who is 31 weeks pregnant with a thyroid-stimulating hormone of 3.31 and a free T4 < 0.1. She is seeing an endocrinologist who has been treating her with intramuscular thyroxine therapy.

We have no other information regarding the patient or her situation. Is there non-compliance involved? Is there severe gastrointestinal malabsorption? I do not know.