STUDENT CASE

ENDOCRINE & METABOLIC BLOCK

WEEK 1: Pituitary & hypothalamus
HAGRID, the tall boy

Overall week objectives:

1. Describe the embryology, anatomy, histology and function of the hypothalamus, pituitary,
and pineal gland including their blood supply
2. Describe the topography of hypothalamus and pituitary and their correlation with the
surrounding structures
3. Describe the anatomic and functional relations of the pituitary gland with the hypothalamus
4. List the hormones secreted by anterior and posterior pituitary and describe the function
and control of each (GH, FSH, LH, TSH, ACTH, prolactine, vasopressin, oxytocin)
5. Describe hypothalmo-pituitary axis and feedback mechanism
6. Describe the hormone secreted by pineal gland and its correlation with circadian rhythms.
7. In histological slide, recognize the adeno and neurohypophysis; identify the principal cell
types in both. Relate the different cell types to hormone production.
8. Describe the patophysiology of disorders which caused by pituitary-hormone-secreting
disorder
9. Describe the natural history of pituitary tumour and its classification
10. Describe correlation of clinical finding with hypothalamus-hypophysis disorders

Case Objectives:
1. Describe the embryology, anatomy, histology and function of the pituitary gland
2. Describe the anatomic and functional relations of the pituitary gland with the hypothalamus
3. List the hormones secreted by anterior and posterior pituitary and describe the function
and control of each
4. Describe the role of Growth Hormone in growth and metabolism
5. Describe Growth-promoting action of GH on bones and tissue
6. Correlate clinical findings with abnormal secretion of GH and describe the natural history of
untreated acromegaly/gigantism
7. Describe the mechanism of action of drugs used in the management of pituitary disorders

TUTORIAL 1
Page 1 1

Hagrid is a 16 years old student from SPH who present with his mother to the neurology clinic at
Siloam Hospital because of frontal headache and blurred vision for the past 2 months. He has otherwise
felt well. You are sitting at the desk when Hagrid and his mother walk into the room. (Please see the
Questions:

1. What are Hagrid’s problems?

2. What are the possible causes for his problem?

3. What is the possible mechanism of the causes?

Tutorial 1
Page 2
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Hagrid tells you that he has grown very quickly in the past 2 years. Two years ago, his height was
160 cm but has increased 20 cm in a year and increased another 30 cm this recent year. He has also
noted that his fingers became longer and enlarged in the past year and he now needs a very large pairs
of shoes (size 14).
Qustions:

1. How does the information help you?

2. How do you explain the findings in this case?

3. What further information do you need to understand this case?

TUTORIAL 2
Page 1
3
Laboratory examination showed the following result:
Hb : 13,2 g/dl Ureum : 17 mg/dl
Ht : 43 % Creatinin : 0,4 mg/dl
WBC : 8.000 /mm3 Random Blood Glucose : 153 g/dl
Platelet : 289.000 /mm3 SGOT : 16 U/L; SGPT: 9 U/L
Questions:

1. What is your interpretation of these test results?

2. What further information do you want?

TUTORIAL 2
Page 2
4
The imaging examination showed the following result:
Questions:

1. How do these results help you?

2. What is now your probable diagnosis?

3. What further information do you want?

TUTORIAL 2
Page 3
Further laboratory results become available 1 week later :
TSH : 1,35 mU/L (0,4 – 5,0 mIU/L) 5
FSH : 4,96 mIU/mL (0,9 – 15 mIU/mL)
Prolactine : 63,15 ng/mL (2 – 15 ng/mL)
GH : 48,0 ng/mL (< 10 ng/mL)
Cortisol : 11 µg/dL (5 – 25 µg/dL)
Questions:

1. What does this tell you about the cause of Hagrid,s problem ?

2. How do you correlate this with the clinical features of the disease?

3. What is the natural course and prognosis of this condition?

4. What is the probable treatment for Hagrid?

TUTORIAL 3
Page 1
Then Hagrid undergo microsurgery by transphenoidal approach. The biopsy result shows the
following microscopic picture:

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Questions:

1. How does this result say to you?

TUTORIAL 3
Page 2

The pathology report results returned:

Microscopic examination revealed solid islands of tumor cells with round to oval nuclei and
moderately abundant eosinophilic cytoplasm. Histochemical staining was consistent with a Growth
Hormone producing adenoma.
One day following the surgery, Hagrid complains that he is very thirsty, drinking all the time and
has urination frequently. The urine volume was 8500 cc/24 hours; fluid balance was -6250 cc.
The laboratory results:

Serum sodium : 155 meq/L (135 – 145 mEq/L )

Serum potassium : 3,7 meq/L (3,5 – 5 mEq/L )
Serum chloride : 133 meq/L (95 – 105 mEq/L)
plasma osmolality : 321 mOsm/kg
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Urine specific gravity : 1, 001 (1,002 – 1,028)
Urine osmolality : 210 mOsm/kg
Urine sodium : 18 (40-220 mmol/24h)
Urine potassium : 9 (25-125 mmol/24h)
Questions:

1. What this information say to you?

2. What is the possible mechanism of the causes?

3. What are the options for treatment for Hagrid?

EPILOGUE
Hagrid was encouraged to drink water as much as he could and was given DDAVP 0,2 ml twice
daily by nasal spray. His urinary volumes decreased after about 2 weeks, he was able to drink enough
without difficulty and the DDAVP was no longer needed. He was prescribed somatostatin analog 50 ug
3x daily and follow up Growth hormone levels were normal.

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