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Strayer D, et al., eds. Rubin’s Pathology. Clinicopathologic Foundations of Medicine, 6th ed. Baltimore: Wolters Kluwer Health, 2012.
Marc Imhotep Cray, MD Merali Z, Woodfine JD (eds.) Toronto Notes 2016, 33rd Ed. Toronto, Ontario, Canada, 2016. 13
Overview of Endocrine Disease/Disorders
Endocrine system plays an important part in regulation of
reproduction, growth and development, maintenance of internal
environment, and energy production, utilization and storage
Causes of hyperfunction
• Adenoma (most common), acute inflammation,
Marc Imhotep Cray, MD hyperplasia, cancer 19
Overview of Endocrine Disease (7)
Also remember, it is important to understand
hypothalamic-pituitary axis so you can distinguish 1°
from 2° disorders
primary diseases are diseases that originate within gland in
question
e.g., primary hyperthyroidism is due to a defect in thyroid gland),
and
secondary diseases represent change in one organ as a result
of disease in another organ
e.g., secondary hyperthyroidism may be due to a TSH-secreting
pituitary adenoma
Widmaier EP, Raff H & Strang KT. Vander’s Human Physiology : The Mechanisms of Body Function,
Marc Imhotep Cray, MD 11th ed. New York, NY: McGraw-Hill, 2008. 28
The Pituitary Gland
Topics discussed Outline:
Anatomy: Gross and Microscopic and
Hypothalamic–Pituitary Axis
Anterior Pituitary Tumors
Pituitary Adenomas: General Features
Functioning Adenomas and Hyperpituatarism
Hypopituitarism
Posterior Pituitary Syndromes
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. Philadelphia: Saunders, 2015.
33
Normal pituitary, microscopic
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. Philadelphia: Saunders, 2015. 34
Normal pituitary, microscopic (2)
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. Philadelphia: Saunders, 2015.
35
Pituitary Gland (6)
Histologic sections of anterior pituitary reveals cells that contain
eosinophilic cytoplasm (acidophil), basophilic cytoplasm (basophil), or
poorly staining cytoplasm (chromophobe) cells
Note also presence of a fine reticulin network between cells
Basophils:
FSH, LH, ACTH, TSH (B-FLAT)
Acidophils:
GH, PRL
Kumar V, Abbas AK, Aster JC. Robbins and Cotran Pathologic Basis of
Marc Imhotep Cray, MD Disease, 9th ed. Philadelphia: Saunders-Elsevier, 2015. 36
Hypothalamic–Pituitary Axis
Endocrine function responds to feedback control
Hypothalamus, pituitary stalk and pituitary gland
constitute an anatomically and functionally integrated
“neuroendocrine system”
Neuron groups in hypothalamus secrete a number of
factors that stimulate anterior pituitary secretion of
hypothalamic factors, in turn, are antagonized by
hormones secreted by peripheral target organs, thereby
completing a feedback loop
In addition, specific hypothalamic inhibitory hormones
have been identified
o For example, dopamine inhibits pituitary secretion of prolactin
Marc Imhotep Cray, MD 37
Hypothalamic-pituitary axis cont.
Hypothalamus regulates secretion of hormones from
adenohypophysis (anterior pituitary gland) by releasing
stimulatory factors (corticotropin-releasing hormone, CRH;
growth hormone-releasing hormone, GHRH; gonadotropin-
releasing hormone, GnRH; thyrotropin-releasing hormone TRH,
and
inhibitory factors (growth hormone inhibitory hormone, GHIH
or somatostatin; prolactin inhibitory factor, PIF or dopamine)
these in turn modulate release of six hormones from anterior
pituitary (next slide)
Hall JE. Guyton and Hall Textbook of Medical Physiology, 13e. Philadelphia: Elsevier , 2016.
Marc Imhotep Cray, MD 40
Hypothalamic-pituitary axis illustrated
Production of pituitary hormones is controlled by positively
and negatively acting factors from hypothalamus carried
to anterior pituitary by a portal vascular system
Kumar V, Abbas AK, Aster JC. Robbins and Cotran Pathologic Basis of Disease, 9th ed. Philadelphia: Saunders-Elsevier, 2015.
Kumar V, Abbas AK, Aster JC. Robbins and Cotran Pathologic Basis of Disease, 9th ed. Philadelphia: Saunders-Elsevier, 2015.
Note: PRL producing adenomas are most common hormone secreting tumors in
both adults and children. Gonadotroph adenomas are more common in elderly.
50
CT scan (a) of a large pituitary adenoma Large pituitary adenoma was an incidental finding at
(A) expanding upwards to compress optic autopsy. As would be suggested by size of tumor, this
chiasma (arrows) pituitary adenoma did not secrete any hormones.
Stevens A, Lowe J, Scott I. Core Pathology, 3rd Ed. St. Kemp WL, Burns DK, Brown TG, Pathology: The Big Picture.
Marc Imhotep Cray, MD New York:McGraw-Hill,2008. 51
Louis: Mosby-Elsevier, 2009.
Important point regarding pituitary adenomas:
Stalk effect
Secretion of all of AP hormones, except prolactin, is stimulated
by delivery of releasing hormones including TRH, GnRH, and
CRH, from hypothalamus via hypophyseal portal system
Brown TA, Brown D. USMLE Step 1 Secrets, 3rd Ed. Saunders, 2013.
Marc Imhotep Cray, MD 61
Functioning Adenomas & Hyperpituatarism (4)
Somatotroph Adenomas cont.
Persistent GH excess stimulates hepatic secretion of
insulin-like growth factor 1 (IGF1), which acts in
conjunction w GH to induce overgrowth of bones and
muscle
If a growth hormone-secreting adenoma develops
before epiphyses close, as is case in prepubertal
children, result in gigantism
o Characterized by a generalized increase in body size, with
disproportionately long arms and legs
Marc Imhotep Cray, MD 62
Functioning Adenomas & Hyperpituatarism (5)
Somatotroph Adenomas cont.
If elevated levels of GH and IGF1
persist or develop after closure
of epiphyses, affected individuals
develop acromegaly
o growth is most conspicuous in soft
tissues, skin, viscera, and bones of
face, hands, and feet
o Enlargement of jaw results in its
protrusion (prognathism),
broadening of lower face, and
separation of teeth
o hands and feet are enlarged, and
fingers are broad and sausage-like
Strayer D, et al., eds. Rubin’s Pathology. Clinicopathologic Foundations 63
Marc Imhotep Cray, MD
of Medicine, 6th ed. Baltimore: Wolters Kluwer Health, 2012.
Functioning Adenomas & Hyperpituatarism (6)
Somatotroph Adenomas cont.
Persistent GH excess also is associated w metabolic
abnormalities most important is diabetes mellitus
o DM arises b/c of growth hormone-induced peripheral
insulin resistance “blunts” body’s response to elevated
glucose levels=GH is diabetogenic
• Failure to suppress GH production in response to an oral load of
glucose is one of most specific tests to Dx acromegaly
• IGF1 provides most sensitive lab test for the Dx of acromegaly
Note: One good way to diagnose this disorder is to look at an old picture of pt.
and compare it w patient’s current appearance. Because physical changes take
place over decades, family members and friends often do not recognize them.
Marc Imhotep Cray, MD 65
A. A 26-year-old attractive woman prior to acromegaly changes.
B. Facial changes 20 years later in the same woman.
Note the coarse facial features with large nose, lips, and chin.
Protrusion of lower jaw is visible.
Marc Imhotep Cray, MD Usatine RP etal. (Eds.) The Color Atlas of Family Medicine. New York: McGraw-Hill, 2013 66
Features of acromegaly /gigantism
A 22-year-old man w
gigantism due to excess GH
is shown to left of his
identical twin
increased height and
prognathism (A) and
enlarged hand (B) and foot
(C) of affected twin are
apparent
Their clinical features began
to diverge at age of approx.
13 years
67
Functioning Adenomas & Hyperpituatarism(10)
Corticotroph Adenomas
Excess production of ACTH by functioning corticotroph
adenomas leads to adrenal hypersecretion of cortisol
and development of hypercortisolism (also known as
Cushing syndrome)
o Cushing syndrome (discussed later w diseases of adrenal
gland) may be caused by other conditions as well
o When hypercortisolism is caused by excessive production
of ACTH by pituitary, it is called Cushing disease after
neurosurgeon Harvey Cushing who first described disorder
Buja LM, Krueger GR. Netter’s Illustrated Human Pathology, 2nd Ed. Philadelphia: Saunders-Elsevier, 2014. 75
Hypopituitarism, Moderate
Buja LM, Krueger GR. Netter’s Illustrated Human Pathology, 2nd Ed. Philadelphia: Saunders-Elsevier, 2014. 76
Hypopituitarism: Severe
Raff RB, Rawls SM, Beyzarov EP. Netter's Illustrated Pharmacology, Updated Edition. Philadelphia: Saunders-Elsevier, 2014. 77
Hypopituitarism, Pituitary Cachexia
Raff RB, Rawls SM, Beyzarov EP. Netter's Illustrated Pharmacology, Updated Edition. Philadelphia: Saunders-Elsevier, 2014. 78
Question
A 53-year-old woman is diagnosed with hypopituitarism.
Which of the following hormones is most likely to be
affected first?
A. Follicle stimulating hormone (FSH) and luteinizing
hormone (LH)
B. Thyroid stimulating hormone (TSH)
C. Adrenocorticotropic hormone (ACTH)
D. Prolactin
E. Growth hormone
Management
Desmopressin acetate (ADH analog) along w
hydration Tx for central DI
HCTZ or amiloride along w hydration, dietary
salt restriction, & avoidance of offending
agent Tx for Nephrogenic DI
Rubin R , Strayer DS Eds. Rubin’s Pathology:
Clinicopathologic Foundations of Medicine, 6th Ed.
Marc Imhotep Cray, MD Baltimore: Lippincott Williams & Wilkins, 2012. 92
Syndrome of inappropriate antidiuretic
hormone secretion (SIADH)
SIADH is characterized by:
Excessive free water retention
Euvolemic hyponatremia w continued urinary Na + excretion
Urine osmolality > serum osmolality
Mulroney SE & Myers AK. Netter's Essential Physiology 2nd Ed. Philadelphia: Elsevier, 2016.
98
Normal thyroid in situ, gross
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. Philadelphia: Saunders, 2015.
99
Normal thyroid, microscopic
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. Philadelphia: Saunders, 2015.
100
Function of Thyroid hormone
Thyroid hormone affects almost all organs
It stimulates basal metabolic rate (BMR) and metabolism of
carbohydrates, lipids and proteins
It increases body heat and hepatic glucose production by increasing
gluconeogenesis and glycogenolysis
It promotes synthesis of many structural proteins, enzymes and
other hormones
Glucose use, fatty acid synthesis in liver, and adipose tissue lipolysis
are all increased
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. Philadelphia: Saunders, 2015.
Marc Imhotep Cray, MD 109
Hypothyroidism
Hypothyroidism refers to clinical manifestations of thyroid
hormone deficiency can be consequence of three general
processes:
1. Defective thyroid hormone synthesis, w compensatory
goitrogenesis (goitrous hypothyroidism)
2. Inadequate thyroid function, usually due to thyroiditis,
surgical resection of gland or therapeutic administration of
radioiodine
3. Inadequate secretion of TSH by pituitary or TRH by
hypothalamus
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. Philadelphia: Saunders, 2015.
114
Hashimoto thyroiditis, gross
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. Philadelphia: Saunders, 2015.
115
Hypothyroidism
Laboratory findings include increased TSH and low free
T4 levels
Pts. w primary hypothyroidism have decreased T3 and T4
levels and elevated TSH
Pts. w pituitary (secondary) hypothyroidism and
hypothalamic (tertiary) hypothyroidism have decreased T3,
T4, and TSH
Anemia = typically normocytic or macrocytic
See: WHO and the International Council for the Control of Iodine Deficiency Disorders
Marc Imhotep Cray, MD (http://indorgs.virginia.edu/iccidd/mi/cidds.html) 120
Endemic goiter
Massive goiter in an
Ethiopian woman who
lives in an endemic area
for goiters
Resulting overstimulation of thyroid can Widmaier EP, Raff H & Strang KT. Vander’s Human Physiology : The
Mechanisms of Body Function, 11th ed. New York, NY: McGraw-Hill, 2008.
produce goiters that can achieve astounding
sizes if untreated
Note: This form of hypothyroidism is reversible if iodine is added to diet. 122
Thyroid, goiter, microscopic
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. Philadelphia: Saunders, 2015.
123
Myxedema
Can be described as hypothyroidism of adult
Causes
Hashimoto thyroiditis
Idiopathic causes
Iodine deficiency
o A problem in geographic areas with poor nutrition
o Deficiency in pregnant women can lead to cretinism in
child (remember, TH is vital to CNS development)
Paradoxically, high doses of iodine lead to a ↓ in TH
production
Over-irradiation of thyroid using iodine-131 for treatment
of hyperthyroidism
Marc Imhotep Cray, MD 124
Myxedema coma
Myxedema coma is a state of decompensated hypothyroidism
It is a medical emergency with a high mortality rate
Patient may have lab values identical to a "normal" hypothyroid state
but a stressful event (infection, myocardial infarction or stroke)
precipitates myxedema coma state, usually in elderly
Treatment Levothyroxine IV
Note: Myxedema, although included in name,
Marc Imhotep Cray, MD is not necessarily seen in myxedema coma. 125
Congenital Hypothyroidism (Cretinism)
Cretinism (infantile hypothyroidism) severe fetal hypothyroidism
due to maternal hypothyroidism
may be endemic, sporadic or familial
twice as frequent in girls as boys
In nonendemic regions, 90% of cases result from developmental
defects of thyroid (dysgenesis/agenesis)
remainder have a variety of inherited metabolic defects including
mutations in genes for TRH and its receptor, TSH and its receptor,
sodium-iodide symporter, thyroglobulin and thyroid oxidase
By 6 months clinical syndrome is well developed
Mental retardation, stunted growth (owing to defective osseous
maturation) and characteristic facies are evident
Serum T4 and T3 are low, and TSH levels high (unless problem relates to a
lack of TSH secretion itself)
Marc Imhotep Cray, MD 126
Sx and Sn of infantile hypothyroidism
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. Philadelphia: Saunders, 2015.
130
Graves disease, microscopic (2)
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. Philadelphia: Saunders, 2015.
131
Hyperthyroidism (5)
Symptoms of hyperthyroidism include goiter, exophthalmos,
nervousness, heat intolerance, palpitations, weight loss,
insomnia, and new or worsening cardiac findings (atrial
fibrillation, angina)
Etiopathogenesis
As explained above, multiple autoimmune mechanisms account
for thyroid injury, including cytotoxicity mediated by CD8+ T cells,
Marc Imhotep Cray, MD
cytokines (IFN-γ), and anti-thyroid antibodies 140
Thyroiditis (3)
3. Subacute granulomatous (de Quervain) thyroiditis is a self-
limited disease secondary to a viral infection (e.g. mumps,
coxsackie virus, adenovirus), and is characterized by pain and
presence of a granulomatous inflammation in thyroid
Clinical Correlation:
FINE-NEEDLE ASPIRATION OF THYROID NODULES
Fifteen percent of people have a detectable nodule in thyroid, either
by palpation, or by ultrasound imaging
Fine-needle aspiration (FNA) is a minimally invasive method to biopsy
Marcnodules and
Imhotep Cray, MDscreen for rare cases of carcinoma 146
Thyroid Ca (4) Etiopathogenesis
Most important environmental factor is external
radiation
1. External radiation single most important environmental
factor assoc. w increased risk of developing thyroid
carcinoma esp. many years of exposure to of high dose
Rubin R , Strayer DS Eds. Rubin’s Pathology: Clinicopathologic Foundations of Medicine, 6th Ed. Baltimore: Lippincott Williams &
Wilkins, 2012.
See:Imhotep
Marc Endocrine Pathology
Cray, MD Case 1 SDL Tutorial (Thyroid nodule) 162
Investigating a thyroid nodule (2)
About 5% of all thyroid nodules are malignant, regardless of size
Be suspicious of cancer in any of following scenarios:
o cold nodule on a nuclear scan
o male patient
o history of childhood irradiation,
o nodule described as “stony hard”
o recent or rapid enlargement, and
o ↑calcitonin level (medullary thyroid cancer usually in pts
w MEN type II)
Next slide shows algorithm for investigation of a thyroid nodule
Check TSH
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. Philadelphia: Saunders, 2015.
167
Physiology of Parathyroid Gland
Parathyroid glands are key regulators of calcium homeostasis
Treatment
Supplementation w Ca+2 & 1,25-dihydroxyvitamin D
Caution w IV calcium admin. can result in
vasodilation, cardiac arrhythmias, decreased BP &
bradycardia
Types of HPT
Primary Hyperparathyroidism
Secondary Hyperparathyroidism
Tertiary Hyperparathyroidism
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. Philadelphia: Saunders, 2015.
177
Parathyroid, adenoma, scintigraphic scan
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. Philadelphia: Saunders, 2015.
178
Parathyroid hyperplasia, gross
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. Philadelphia: Saunders, 2015.
Miksad RA, Meyer GK & DeLaMora PA. Last Minute Internal Medicine. New York: McGraw-Hill, 2008.
Reisner HM. Pathology: A Modern Case Study. New York: McGraw-Hill Education,2015.
191
Normal adrenal gland, gross
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. Philadelphia: Saunders, 2015.
192
Normal adrenal gland, microscopic
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. Philadelphia: Saunders, 2015.
193
Comparison of atrophic, normal,
and hyperplastic adrenal glands
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. Philadelphia: Saunders, 2015.
194
Cortisol
Cortisol is a steroid hormone, in glucocorticoid class of hormones
When used as a medication, known as hydrocortisone
Brown TA, Brown D. USMLE Step 1 Secrets, 3rd Ed. Saunders, 2013.
Rubin R , Strayer DS Eds. Rubin’s Pathology: Clinicopathologic Foundations of Medicine, 6th Ed. Baltimore: Lippincott Williams & Wilkins, 2012.
203
Congenital adrenal hyperplasia
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. Philadelphia: Saunders, 2015.
207
Waterhouse-Friderichsen syndrome, CT
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. Philadelphia: Saunders, 2015.
208
Cushing Syndrome
Cushing syndrome is a group of clinical symptoms that result from
prolonged exposure to excess glucocorticoids
Kumar V, Abbas AK, Aster JC. Robbins and Cotran Pathologic Basis of Disease, 9th ed. Philadelphia: Saunders-Elsevier, 2015.
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. Philadelphia: Saunders, 2015.
212
Buja LM, Krueger GR. Netter’s Illustrated Human Pathology, 2nd Ed. Philadelphia: Saunders-Elsevier, 2014.
Clinical findings in Cushing Syndrome
Clinical manifestations affect multiple organ systems and depend
on degree and duration of hypercortisolism
Most common sign is progressive obesity seen in face, neck,
trunk, and abdomen
Facial fat accumulation produces a moon-face appearance,
enlarged dorsocervical fat pad produces a buffalo hump
Other Sx include:
o weight gain
o weakness
o muscle wasting (reduced arm muscle mass)
o osteoporosis
o cardiovascular (hypertension)
o hyperglycemia (insulin resistance)
o amenorrhea
o immunosuppression 213
Diagnosis of Cushing Syndrome
Screening tests include:
increase free cortisol on 24-hr urinalysis
increase midnight salivary cortisol, and no suppression w overnight low-dose
dexamethasone test
Measure ACTH
Suppressed Elevated
ACTH-independent ACTH-dependent
Cushing syndrome Cushing syndrome
Exogenous glucocorticoids
or adrenal tumor High-dose (8mg) dexamethasone CRH stimulation test
(consider adrenal CT to confirm) suppression test
Buja LM, Krueger GR. Netter’s Illustrated Human Pathology, 2nd Ed.
Marc Imhotep Cray, MD 218
Philadelphia: Saunders-Elsevier, 2014.
Pathophysiology of adrenal cortex (2)
2. Secondary adrenocortical insufficiency
Caused by primary deficiency of ACTH
does not exhibit hyperpigmentation (b/c there is a deficiency of
ACTH)
does not exhibit volume contraction, hyperkalemia, or metabolic
acidosis (b/c aldosterone levels are normal)
Symptoms are otherwise similar to those of Addison disease
Incorrect answers
(B) Osteoporosis is a possible result of continued chronic glucocorticoid therapy, not abrupt
cessation.
(C) Increased risk of infection is a result of continued chronic glucocorticoid therapy, not abrupt
cessation.
(D) Insomnia is a possible side effect from short-term oral or parenteral glucocorticoid therapy.
(E) Nausea/vomiting are possible side effects from short-term oral or parenteral glucocorticoid
therapy.
Primary hyperaldosteronism
Seen w adrenal cortex adenoma (Conn syndrome) 33% or
idiopathic bilateral adrenal hyperplasia (66%) ↑aldosterone,
↓renin
Secondary hyperaldosteronism
Seen in pts. w renovascular HTN/renal artery stenosis,
juxtaglomerular cell tumor, edema (eg, cirrhosis, heart failure,
nephrotic syndrome)
due to independent activation of renin-angiotensin-
Marc Imhotep Cray, MD 226
aldosterone system) ↑aldosterone, ↑renin
Clinical Vignette
A 29-year-old man presents to the emergency department
complaining of a crushing headache and heart palpitations. He tells
you that he has had similar episodes in the past. Physical
examination reveals a pulse of 140 and a BP of 200/110. A 24-hour
urine collection reveals increased vanillylmandelic acid (VMA) and
metanephrine levels and blood tests demonstrate increased plasma
catecholamine levels. You immediately prescribe phenoxybenzamine
for the patient and tell him that it is likely that he will need surgery
to definitively treat his condition.
What is the diagnosis?
Stevens A, Lowe J, Scott I. Core Pathology, 3rd Ed. St. Louis: Mosby-Elsevier, 2009.
230
Neuroblastoma (malignant)
Most common tumor of adrenal medulla in children (usually < 4
years old)
Originates from neural crest cells
Occurs anywhere along sympathetic chain
Homer-Wright rosettes
Neuroblastoma (arrows) characteristic of neuroblastoma
Circular grouping of dark tumor cells
surrounding pale neurofibrils
Le T, Bhushan V. First Aid for the USMLE Step 1 2017. New York: McGraw-Hill Education, 2017.
Marc Imhotep Cray, MD Merali Z, Woodfine JD (eds.) Toronto Notes 2016, 33rd Ed. Toronto, Ontario, Canada, 2016. 235
Endocrine pancreas cell types
Islets of Langerhans are collections of α, β, and δ endocrine cells
Islets arise from pancreatic buds
α = glucagon (peripheral)
β = insulin (central)
δ = somatostatin (interspersed)
Marc Imhotep Cray, MD McInnis M., Mehta S. Step-up to USMLE Step 1 2015 Edition. Wolters Kluwer, 2015 237
Lack of lnsulin
Without insulin glucose is not transported across cell
membranes leads to a cascade of metabolic events
Body reacts by inducing gluconeogenesis (liver converts glycogen to
glucose)
To produce energy skeletal muscle converts its structural
proteins to amino acids which are carried to liver where they
are converted to glucose
Resultant excess glucose, still not being used by cells, leads to
hyperglycemia
Rubin R , Strayer DS Eds. Rubin’s Pathology: Clinicopathologic Foundations of Medicine, 6th Ed.
Baltimore: Lippincott Williams & Wilkins, 2012.
Marc Imhotep Cray, MD 252
Type 2 Diabetes Mellitus
Central defects in type 2 DM are decreased insulin
secretion and insulin resistance
Diagnosis
TEST DIAGNOSTIC CUTOFF NOTES
HbA1c ≥ 6.5% Reflects average blood glucose over prior 3 months
Marc Imhotep Cray, MD Kumar V, Abbas AK, Aster JC. Robbins and Cotran Pathologic Basis of Disease, 9th ed. 266
Philadelphia: Saunders-Elsevier, 2015.
DM Chronic Complications cont.
NB: Complications of DM are far less common and less
severe in people who have well-controlled blood sugar
levels hence need for tight control of hyperglycemia
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. Philadelphia: Saunders, 2015.
270
Nodular glomerulosclerosis, microscopic
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. Philadelphia: Saunders, 2015.
271
Atherosclerosis, gross
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. Philadelphia: Saunders, 2015. 272
DM Chronic Complications cont.
Large vessel atherosclerosis= macrovascular
o CAD (NB: MI most common cause of death in DM)
o peripheral vascular occlusive disease
o gangrene limb loss
o cerebrovascular disease stroke
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. Philadelphia: Saunders, 2015.
274
Peripheral vascular disease, grafts, CT image
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. Philadelphia: Saunders, 2015.
275
DM Chronic Complications cont.
Osmotic damage (sorbitol accumulation in organs w
aldose reductase and decrease or absent sorbitol
dehydrogenase):
Neuropathy (motor, sensory [glove and stocking distribution],
and autonomic degeneration)
Cataracts
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. Philadelphia: Saunders, 2015.
277
Cataract, gross
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. Philadelphia: Saunders, 2015.
278
279
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. Philadelphia: Saunders, 2015.
Diabetic retinopathy, funduscopy
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. Philadelphia: Saunders, 2015.
Normal retina, funduscopy
Acute Complications of DM
Diabetic ketoacidosis
Hyperglycemia hyperosmolar state
Hypoglycemia
Diabetic coma
Erectile Dysfunction
Respiratory infections
Periodontal disease
Skin infections
Raff RB, Rawls SM, Beyzarov EP. Netter's Illustrated Pharmacology, Updated Edn. Saunders,283
2014
THE END
See next slide for hypermedia to further study tools and resources.
284
Further study tools and resources:
Inside Endocrine System BMS Cloud Folder:
Endocrine System Pathology Outline
Molecular and Cell Biology of Endocrine System Ppt.
Endocrine Pathology Case 1 SDL Tutorial
Endocrine Pathology Case 2 SDL Tutorial
Endocrinology Tutorial 1 Postpartum Necrosis
Endocrinology Tutorial 2 MEN Syndromes
Endocrinology Tutorial 3 Anterior Pituitary
Diabetes mellitus Type 1 SDL Tutorial
Diabetes mellitus Type 2 SDL Tutorial
Endocrine Pathology Clinical Vignettes
Hormones and Their Actions_Illustrated Notes
Endocrine Pathology Rapid Review Notes
Also see Medical Pathology Cloud Folder
Marc Imhotep Cray, MD 285