Clinical Case

Group consisting of Fabian Nelson, Maximous Philobos, Sonny Brar and

Ajay Singh

Clincial Case Intro

• A 43 year old woman is brought to the emergency department 1 hour after a stranger stole her purse. She is agaitated and extremely upset. She is 163 cm (5 ft 4 in) tall and weight 91 kg (200 lb); BMI is 34 kg/m2. Physical examination show no other abnormalities. Her blood glucose concentration is increased.

Which of the following is the most likely explanation for her symptoms?

• B-cell hypersecretion

• Cushing disease

• Glucagon-secreting adenoma

• Pancreatitis

• Normal stress hormone response

Beta-Cell hypersecretion

Beta- Cell hypersecretion is an excess secretion of insulin from the beta cells of the pancreas. A tumor of the inslet beta cells will cause an overproduction of insulin. Causing hypoglycemia, there is a very low incidence of this condition.

Symptoms

1. Anxiety and sweating.2. Body tremors3. Elevated body temperature4. Disorientation5. The patient can go into Insulin shock due to

brain hypoglycemia.

Treatment

In patients with indolent, slow-growing metastatic islet cell tumors, the best therapy may be careful observation, and no treatment until palliation is required. Chemotherapy, and in some instances surgery is necessary.

Prognosis

They are uncommon cancers with about 1,000 new cases per year in the United States. They account for 3% to 5% of pancreatic malignancies and overall have a better prognosis than the more common pancreatic exocrine tumors. Five-year survival is about 55% when the tumors are localized and resected but only about 15% when the tumors are not resectable. Overall 5-year survival rate is about 42%.

Cushing Disease Definition

• AKA Cushing Syndrome or Hypercortisolism

• Occurs when your body is exposed to high levels of cortisol for an extended time.

• Most common cause is use of oral corticosteroid medication.

• Condition can also occur when body makes to much cortisol.

Cushing Disease Definition (Cont.)

• Hallmark signs:• Fatty hump between shoulders

• Rounded face

• Pink or purple stretch marks on skin

• Can also result in:• High blood pressure

• Bone loss

• Diabetes on occasion

Cushing Disease Definition (Cont.)

• Treatments for disease can return body’s cortisol levels to normal

• Noticeably improve the symptoms

• Also, the earlier treatment begins, the better chance are for recovery.

Common signs and symptoms

• Involves progressive and skin changes that are as follows:

• Weight gain and fatty tissue deposits, particularly around the midsection and upper back, in the face (moon face), and between the shoulders (buffalo hump)

• Pink or purple stretch marks (striae) on the skin of the abdomen, thighs, breasts and arms

• Thinning, fragile skin that bruises easily

• Slow healing of cuts, insect bites and infections

• Acne

Common signs and symptoms (Cont.)

• Women with Cushing Disease:• Thicker or more visible body and facial hair (hirsutism)

• Irregular or absent menstrual periods

• Men with Cushing Disease:• Decreased libido

• Decreased fertility

• Erectile dysfunction

Common signs and symptoms (Cont.)

• Additional signs and symptoms:

• Fatigue

• Muscle weakness

• Depression, anxiety and irritability

• Loss of emotional control

• Cognitive difficulties

• New or worsened high blood pressure

• Glucose intolerance that may lead to diabetes

• Headache

• Bone loss, leading to fractures over time

Causes of Cushing Disease

• Results from excess levels of cortisol in body

• Endocrine system consists of glands that regulate processes throughout our bodies

• The glands are:• Adrenal glands

• Pituitary gland

• Thyroid gland

• Parathyroid gland

• Pancreas

• Ovaries

• Testicles

Causes of Cushing Disease (Cont.)

• Adrenal gland secretes cortisol and many other hormones

• Cortisol has a variety of roles in our body:• helps regulate your blood pressure and keeps your

cardiovascular system functioning normally

• helps your body respond to stress and regulates the way you convert (metabolize) proteins, carbohydrates and fats in your diet into usable energy

Corticosteroids role

• Disease can develop from cause that comes from outside our body (exogenous Cushing Disease)

• High does of corticosteriods taken over long periods can result in the disease

• These meds like prednisone have the same effects the cortisol produced by our body

Corticosteroids role (Cont.)

• They may be prescribed by a doctor to treat:• Inflammatory diseases (Ex: Rheumatoid Arthritis)

• Lupus and Asthma

• Prevent the rejection of transplanted organ

• Develop disease from injectable corticosteroids:

• Repeated injections for joint pain, bursitis and back pain

Corticosteroids role (Cont.)

• Certain inhaled steroid medicines (taken for Asthma)

• Steroid skin creams used for skin maladies like eczema

• Important to note that this is less likely to cause Cushing’s Disease but in same general category of drugs

• But the disease might occur in some individuals if drugs are taken in high doses

Our Body’s own Overproduction

• The disease can result from our body’s own overproduction of cortisol (endogenous Cushing Disease):

• Pituitary gland tumor (pituitary adenoma)

• Ectopic ACTH-secreting tumor

• Primary adrenal gland disease

• Familial Cushing Disease

Complications

• Do not receive immediate treatment, other complications may occur:

• Bone loss (osteoporosis), which can result in unusual bone fractures, such as rib fractures and fractures of the bones in the feet

• High blood pressure (hypertension)• Diabetes• Frequent or unusual infections• Loss of muscle mass and strength

• If cause is a pituitary tumor, this can lead to other problems such as disrupting the production of other hormones that the pituitary controls

Glaucagon-secreting adenoma

A glucagonoma is a tumor that secretes glucagon, a hormone normally produced in the pancreas and responsible for raising blood sugar (glucose) levels. Glucagonomas are almost entirely found in the pancreas, arising from the alpha-2 cells of the gland, and about 80% of these tumors are malignant (cancerous). The tumor can cause elevated blood glucose levels known as glucagonoma syndrome but this is not present in every case.

What is the occurrence of Glucagonoma?

Overall glucagonomas are rare neuroendocrine tumors. It only accounts for about 1% of all neuroendocrine tumors. The incidence of glucagonomas is estimated to be about 1 in 20 million people. The high risk age group is between 40 to 70 years with the average age of onset being 55 years. Women seem to be more likely than men to develop glucagonomas.

Symptoms

• Unintentional weight loss

• Inflamed mouth

• Diarrhea

• Increased appetite

• Anemia

Causes

The causes of a glucagonoma are unknown. Patients may have a family history of glucagonoma. The condition is also associated with multiple endocrine neoplasia (MEN) type I which is a known risk factor. A glucagonoma is a neuroendocrine tumor that is localized to the pancreas in almost all cases. Secretion of glucagon arises either as a result of the mass apply pressure on the glucagon-secreting alpha-2 pancreatic cells or the tumor cells itself producing and secreting glucagon independently.

Diagnosis

A diagnosis of glucagonoma is often missed as these tumors are rare. The presence of the 4 D’s – diabetes, dermatitis (necrolytic migratory erythema), deep vein thrombosis and depression – should raise the concern about a glucagonoma. The confirmation of the diagnosis involves several investigations such as Blood Test and Scans.

Treatment

• Octreotide is a drug that inhibits the secretion of glucagon. It can help relieve some of the symptoms associated with a glucagonomabut may worsen diabetes.

• Chemotherapy is reserved for cases where surgery is not possible or the cancer has already spread (metastasis). However, chemotherapy has a very limited use in the treatment of glucagonomas.

• Surgery is ideal in that the tumor can be removed and all symptoms will resolve thereafter. Due to the high chance of spread and often late diagnosis, some of the healthy tissue surrounding the tumor and regional lymph nodes are resected as well

Prognosis

The survival rate for a glucagonoma is poor. The tumor grows very slowly so there are cases where patients live for 15 years or more after diagnosis. The 5 year survival rate is about 85% after surgery where the tumor was localized to the pancreas and successfully removed.

Pancreatitis

• Pancreatitis is inflammation in the pancreas

• The pancreas is a long, flat, mixed exocrine

and endocrine gland that sits tucked behind

the stomach in the upper abdomen.

• The pancreas produces enzymes that help

digestion and hormones that help regulate the

way the body processes sugar (glucose).

Pancreatic Enzymes

• Pancreas secretes three important enzymes:

– Protease: digestion of proteins

– Lipase: hydrolysis of triglycerides

– Amylase: hydrolysis of starch into maltose (a

glucose-glucose disaccharide)

• Some of which are secreted in active and

inactive forms

What happens in Pancreatitis?

• Pancreatitis occurs when digestive enzymes

produced in the pancreas become activated

while inside the pancreas, causing damage to

the organ.

• The enzymes responsible are proteases:

– Trypsin

– Chymotrypsin

Trypsin and Chymotrypsin

• Both enzymes are synthesized in their inactive forms:– Trypsinogen

– Chymotrypsinogen

• In normal digestion, these Enzymes are synthesized and packaged into secretory vesicles which is a way for the cells to safely handle these enzymes

• secretory vesicles also contain a trypsin inhibitor which serves as an additional safeguard should some of the trypsinogen be activated to trypsin; following exocytosis this inhibitor is diluted out and becomes ineffective to allow for proper function in small Intestine

Trypsin and Chymotrypsin (Cont.)

• Once trypsinogen and chymotrypsinogen are released into the lumen of the small intestine, they must be converted into their active forms in order to digest proteins.

• Trypsinogen is activated by the enzyme enterokinase.

• Once trypsin is formed it activates chymotrypsinogen, as well as additional molecules of trypsinogen.

What Goes Wrong?

• In pancreatitis, the enzymes become activated

while still in the pancreas.

• Causing the enzymes to irritate the cells of the

pancreas, creating inflammation and the signs

and symptoms associated with pancreatitis.

Causes

• Alcoholism

• Gallstones

• Abdominal surgery

• Medications

• Smoking

• Cystic fibrosis

• Family history

• High blood calcium levels (hypercalcemia)

• High levels of parathyroid hormone in the blood (hyperparathyroidism)

• High triglyceride levels in the blood (hypertriglyceridemia)

• Pancreatic cancer

Forms of Pancreatitis

• Acute:

– Upper abdominal pain

– Abdominal pain that radiates to the back

– Abdominal pain that feels worse after eating

– Nausea

– Vomiting

– Tenderness when touching the abdomen

Forms of Pancreatitis (Cont.)

• Chronic:

– Upper abdominal pain

– Indigestion

– Losing weight without trying

– Oily, smelly stools (steatorrhea)

Complications

• Breathing problems

• Diabetes

• Infection

• Kidney failure

• Malnutrition

• Pancreatic cancer

• Pancreatic cysts

Normal Stress Hormone Response

• When you encounter a perceived threat

(robbery in this case)

• The hypothalamus, a tiny region at the base of

the brain, sets off an alarm system in the body.

• Stimulating adrenal glands, located above the

kidneys, to release a surge of hormones,

Hormones

• Some of the hormones release:

– Adrenaline: increases heart rate, elevates blood

pressure and boosts energy supplies

– Cortisol: primary stress hormone, increases sugars

(glucose) in the bloodstream, enhances brain's use

of glucose, and increases the availability of

substances that repair tissues

Other Effects of Cortisol

• Alters immune system responses

• Suppresses the digestive system, the

reproductive system and growth processes

• Communicates with regions of your brain that

control mood, motivation, and fear.

When the Natural Stress Response

Goes Haywire!

• The body's stress-response system is usually

self-limiting

• However over activation of the stress-response

system causes overexposure to adrenaline,

cortisol, and other stress hormones

• Can disrupt almost all the body's processes

causing severe long term health problems

Long Term Complications

• Anxiety

• Depression

• Digestive problems

• Heart disease

• Sleep problems

• Weight gain

• Memory and concentration impairment

In Conclusion

• Collectively, we feel the appropriate choice to the case would be the normal stress hormone response.

• Increased cortisol answers why her blood glucose would be elevated, and the anger and agitation would cause the increase. Her BMI is high but that is not the reason for her stay.

Normal Stress Hormone Response

The normal stress hormone response is initially very debilitating but recovery will occur when the threat is removed.

If the threat itself is not removed the patient may manifest PTSD (post-traumatic stress disorder), which may manifest shortly-after the inciting event or weeks to months or even years later.

PTSD effects 1 in every 3 individuals with a traumatic experience.

Treatment

• If the patient manifests PTSD, treatment would depend on the symptoms and how soon they occurred after the inciting event.

• Options of treatment may be waiting to see if symptoms improve without treatment, psychological therapy such as cognitive behavioural therapy (CBT) and/ or eye movement desensitisation and reprocessing (EDMR), and antidepresseant medication such as paroxetine or mirtazapine.

6 Phases of Cognitive Behavioral Therapy

1. Assessment or psychological assessment

2. Reconceptualization

3. Skills acquisition

4. Skills consolidation and application training.

5. Generalization and maintenance

6. Post-treatment assessment follow-up

Paroxetine

• Belongs to selective-serotonin reuptake inhibitors

• Used to treat mental depression, obsessive-compulsive disorder, panic disorder, generalized anxiety disorder, social anxiety disorder (aka social phobia), premenstrual dysphoric disorder, and PTSD

• US brand name paxil, paxil CR and pexeva

Mirtazapine

• Belongs to tetracyclic antidepressants

• Works on CNS to make certain chemicals in the brain stronger

• Used to treat depression

• US brand names are remeron and remeronsoltab

THE END

Just kidding

Sources

• Bowen, R. "Exocrine Secretions of the Pancreas." Exocrine Secretions of the Pancreas. Colorado State University, 5 July 2006. Web. 13 Nov. 2013. <http://www.vivo.colostate.edu/hbooks/pathphys/digestion/pancreas/exocrine.html>.

• Staff, Mayo Clinic. "Chronic Stress Puts Your Health at Risk." Mayo Clinic. Mayo Foundation for Medical Education and Research, 11 July 2013. Web. 13 Nov. 2013. <http://www.mayoclinic.com/health/stress/SR00001>.

• Staff, Mayo Clinic. "Pancreatitis." Mayo Clinic. Mayo Foundation for Medical Education and Research, 15 Jan. 2011. Web. 13 Nov. 2013. <http://www.mayoclinic.com/health/pancreatitis/DS00371>.

Sources (Cont.)

• Staff, Mayo Clinic. ”Cushing Syndrome." Mayo

Clinic. Mayo Foundation for Medical Education

and Research, 28 Mar. 2013. Web. 5 Nov. 2013.

<http://www.mayoclinic.com/health/cushings-

syndrome/DS00470>.

• Marcus, Saul ND. “Adrenal Exhaustion and

Chronic Fatigue: The most common reason

people feel tired all the time.” Naturopathic

Wellness. 2013. Web. 17 Nov 2013.

• Tammy. “Dealing with stress.”

Tammysyoga.co.uk. 13 Jun 2013. Web. 17 Nov

2013. “Post-traumatic stress disorder.” NHS

Choices. 24 Sep 2013. Web. 17 Nov 2013.

• Wikipedia. “Cognitive behavioral therapy.”

Wikimedia Foundation, Inc. 4 Nov 2013. Web.

17 Nov 2013.

• “Mirtazapine (Oral Route).” Mayo

Foundation for Medical Education and

Research. 13 Jul 2013. Web. 17 Nov 2013.

• “Paroxetine (Oral Route).” Mayo Foundation

for Medical Education and Research. 1 Aug

2013. Web. 17 Nov 2013.