Endocrinology Practice Questions

Q: Adrenal reserve is best tested by means of infusion with

ACTH. ACTH - The **ACTH stimulation test**, also known as the **cosyntropin test**, is the most common dynamic test for assessing adrenal reserve. - Exogenous ACTH (cosyntropin) stimulates the adrenal glands to produce cortisol; a subnormal response indicates adrenal insufficiency. *Corticosteroids* - **Corticosteroids** are hormones (like cortisol) produced by the adrenal glands, or synthetic versions used as medications; they do not test adrenal reserve but rather *replace* adrenal function. - Administering corticosteroids would interfere with, rather than assess, the adrenal gland's ability to produce its own hormones. *LHRH* - **Luteinizing hormone-releasing hormone (LHRH)** is used to assess the function of the anterior pituitary gland and gonads, not the adrenal glands. - An LHRH stimulation test evaluates the pituitary's ability to release LH and FSH, which in turn stimulate gonadal hormone production. *Metyrapone* - The **metyrapone test** assesses the integrity of the **hypothalamic-pituitary-adrenal axis** by blocking cortisol synthesis, which should lead to an increase in ACTH and 11-deoxycortisol [1]. - While it evaluates a part of adrenal function, it is primarily used to differentiate between primary and secondary adrenal insufficiency, and not a direct measure of cortisol production capacity in response to stimulation.

Q: Which of the following is a common finding in patients with Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH)?

Normal BP. ***Normal BP*** - In SIADH, patients are typically **euvolemic** due to the primary issue being water retention rather than salt retention or frank dehydration [2]. - While hyponatremia occurs, the body's compensatory mechanisms usually prevent significant changes in blood pressure, maintaining it within the **normal range**. *Generalized edema* - Generalized edema is uncommon in SIADH because the excessive water retention is initially within the **intravascular compartment**, and the body attempts to excrete the additional volume of water [1]. - Although the patient is effectively retaining water, the osmolality is low, leading to fluid shifts rather than overt edema unless severe, protracted fluid overload occurs. *Ascites* - **Ascites**, which is the accumulation of fluid in the peritoneal cavity, is not a characteristic feature of SIADH [2]. - Ascites is more commonly associated with conditions like **liver cirrhosis**, heart failure, or malignancy. *Dry mucous membrane* - **Dry mucous membranes** are a sign of dehydration and fluid volume deficit. - In contrast, SIADH involves **fluid overload** (though euvolemic), making dry mucous membranes an unlikely finding [2].

Q: Which of the following is not a treatment option for hypercalcemia?

Strontium. ***Strontium*** - **Strontium ranelate** is primarily used in the treatment of **osteoporosis** to promote bone formation and inhibit bone resorption. - It does not have a recognized role in the acute or long-term management of **hypercalcemia** and could potentially worsen it due to its bone-targeting effects if not carefully managed. *Steroids* - **Glucocorticoids** are effective in treating hypercalcemia associated with **granulomatous diseases** (e.g., sarcoidosis) and certain malignancies (e.g., multiple myeloma) by reducing calcitriol production or tumor burden. - They decrease intestinal calcium absorption and increase renal calcium excretion in conditions where 1,25-dihydroxyvitamin D is elevated. *Bisphosphonates* - **Bisphosphonates** (e.g., zoledronic acid, pamidronate) are potent inhibitors of **osteoclast-mediated bone resorption** and are a cornerstone in the treatment of moderate to severe hypercalcemia, especially due to malignancy. [1] - They are administered intravenously and act by inducing osteoclast apoptosis, thereby reducing the release of calcium from bone. [1] *Phosphate* - **Intravenous phosphate** can be used in severe, resistant hypercalcemia, as it promotes calcium deposition into bone and soft tissues, and forms insoluble calcium-phosphate complexes, thus lowering serum calcium. - Its use is limited due to risks of **ectopic calcification**, renal failure, and hypotension, and it is usually reserved for life-threatening situations where other treatments have failed.

Q: Which of the following glands is NOT typically involved in Multiple Endocrine Neoplasia type II A (MEN II A)?

Pituitary gland. ***Pituitary gland*** - The **pituitary gland** is not a characteristic component of **MEN II A**. It is, however, associated with **Multiple Endocrine Neoplasia type I (MEN I)**, which involves the 3 Ps: **pituitary**, **parathyroid**, and **pancreas** [1]. - **MEN IIA** classically involves **medullary thyroid carcinoma**, **pheochromocytoma**, and **parathyroid hyperplasia** [1]. *Thyroid gland* - The **thyroid gland** is centrally involved in MEN IIA, specifically through the development of **medullary thyroid carcinoma (MTC)**, a hallmark feature. - MTC arises from the parafollicular C cells of the thyroid and secretes **calcitonin**. *Parathyroid gland* - The **parathyroid gland** is often involved in MEN IIA, typically presenting as **parathyroid hyperplasia** or adenoma, leading to **primary hyperparathyroidism**. - This typically results in elevated **parathyroid hormone** levels and **hypercalcemia**. *Adrenal gland* - The **adrenal gland** is a key player in MEN IIA due to the occurrence of **pheochromocytoma**, a tumor of the adrenal medulla. - Pheochromocytomas can be bilateral and secrete **catecholamines**, leading to hypertension and other symptoms.

Q: Which of the following statements about hypercalcemia in sarcoidosis is false?

Parathormone level is increased. ***Parathormone level is increased*** - In **sarcoidosis-associated hypercalcemia**, the parathormone (PTH) level is typically **low or suppressed**. [1] - This is because the hypercalcemia is due to **extra-renal 1-$\alpha$ hydroxylation** of 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D (calcitriol) by macrophages in granulomas, not primary hyperparathyroidism. [1] *PTHrP level is increased* - This statement is **false** for sarcoidosis. Elevated **parathyroid hormone-related peptide (PTHrP)** is a common cause of hypercalcemia in **malignancy**, particularly squamous cell carcinomas, but not in sarcoidosis. - Hypercalcemia in sarcoidosis is **PTH-independent** and not mediated by PTHrP. [1] *Oral steroids are useful* - This statement is **true**. **Corticosteroids** (like oral prednisone) are effective in treating hypercalcemia in sarcoidosis. - They work by **inhibiting the activity of 1-$\alpha$ hydroxylase** in alveolar macrophages and reducing intestinal calcium absorption. *Calcitriol level is increased* - This statement is **true**. In sarcoidosis, activated **macrophages within granulomas** aberrantly express **1-$\alpha$ hydroxylase**. [1] - This leads to the **extra-renal synthesis of calcitriol** (1,25-dihydroxyvitamin D), which increases intestinal calcium absorption and bone resorption, causing hypercalcemia. [1]

Q: Autoimmune thyroiditis is associated with all except which of the following?

Psoriasis. ***Psoriasis*** - Psoriasis is generally not associated with **autoimmune thyroiditis**, which is more commonly linked to other autoimmune disorders [1]. - Autoimmune thyroiditis does not typically result in the **skin changes** seen in psoriasis, distinguishing them clinically. *Sly* - Sly syndrome, while a genetic disorder, is not directly connected to **autoimmune thyroiditis**. - Conditions like Sly syndrome are metabolic and do not involve the autoimmune pathways typically seen in thyroiditis. *Myasthenia gravis* - Myasthenia gravis is an **autoimmune neuromuscular disorder** that can occur concurrently with thyroid diseases, particularly **thyroiditis** [1]. - Both conditions arise from **autoimmune processes**, making their association plausible [1]. *DM* - Diabetes Mellitus (DM), particularly Type 1, is often linked with other autoimmune diseases, including **autoimmune thyroiditis** [2]. - They share a common **autoimmune pathway**, making them more likely to co-occur than psoriasis [2].

Q: Chronic atrophy of adrenal gland will result in which hormone deficiency ?

Cortisol. ***Cortisol*** - **Chronic atrophy of the adrenal gland**, often seen in conditions like **Addison's disease** [1], primarily leads to a deficiency of **glucocorticoids**, the main one being cortisol [2]. - **Cortisol** is produced in the **zona fasciculata** of the adrenal cortex, which is highly susceptible to damage in atrophic conditions [2]. *Aldosterone* - While aldosterone is produced in the adrenal cortex (**zona glomerulosa**), its deficiency is more characteristic of primary adrenal insufficiency affecting the entire cortex, not necessarily solely from 'chronic atrophy' which can have varied pathophysiology [2]. - In some autoimmune forms of adrenal atrophy (Addison's disease), **aldosterone deficiency** can occur, but **cortisol deficiency** is a more universal and defining feature [1][3]. *Dehydroepiandrosterone (DHEA)* - **DHEA** is an adrenal androgen produced in the **zona reticularis** of the adrenal cortex [2]. Its deficiency is also common in adrenal atrophy. - However, **cortisol deficiency** generally has more immediate and life-threatening clinical consequences compared to DHEA deficiency. *Epinephrine* - Epinephrine is produced by the **adrenal medulla**, which is distinct from the adrenal cortex where atrophy typically occurs in conditions causing hormone deficiencies. - Therefore, **adrenal gland atrophy** primarily affecting the cortex would not lead to **epinephrine deficiency** as the medulla usually remains functional.

Q: What is the initial drug of choice for a suspected case of acute adrenal insufficiency?

Hydrocortisone. ***Hydrocortisone*** - This is the initial drug of choice due to its **combined mineralocorticoid and glucocorticoid activity**, which effectively replaces the deficient hormones in acute adrenal insufficiency. - It also has a **rapid onset of action** crucial for stabilizing patients in an adrenal crisis. *Norepinephrine* - This is a **vasopressor** used to manage **severe hypotension or shock** by increasing peripheral vascular resistance. - While hypotension is a feature of adrenal insufficiency, norepinephrine does not address the underlying hormonal deficiency directly and is not the primary treatment. *Dexamethasone* - Dexamethasone is a **potent glucocorticoid** and can be used in adrenal insufficiency, but it lacks significant **mineralocorticoid activity**. - Its longer half-life might make it less ideal for immediate, titratable replacement compared to hydrocortisone in an acute setting. *Fludrocortisone* - Fludrocortisone is a **pure mineralocorticoid** primarily used for long-term replacement therapy to manage sodium and potassium balance in adrenal insufficiency. - It does not have sufficient glucocorticoid activity to address the immediate, life-threatening aspects of acute adrenal crisis.

Q: Primary hyperparathyroidism is suggested by all of the following, except which of the following?

Low urinary calcium levels. ***Low urinary calcium*** - In primary hyperparathyroidism, **urinary calcium levels are typically elevated** due to increased calcium reabsorption in the kidneys [2]. - **Low urinary calcium levels** would suggest a different condition, such as **hypoparathyroidism** or a renal issue affecting calcium excretion [5]. *Increased PTH* - Primary hyperparathyroidism is characterized by **elevated parathyroid hormone (PTH)** levels, as the parathyroid glands are overactive [1][3]. - High PTH contributes to increased serum calcium and bone resorption [2]. *Increased serum calcium* - A hallmark of primary hyperparathyroidism is **hypercalcemia**, resulting from increased bone resorption and renal tubular reabsorption of calcium [1][2]. - The condition often leads to symptoms such as **kidney stones** and **bone pain** due to elevated serum calcium levels [3][4]. *Increased C-AMP* - Elevated levels of **cyclic AMP (C-AMP)** in urine are observed in primary hyperparathyroidism due to the stimulatory effect of PTH on renal tubular reabsorption of calcium. - Increased C-AMP correlates with the action of PTH in promoting calcium release from the bones [2].

Q: Investigation of choice in pheochromocytoma is:

Urinary catecholamines. ***Urinary catecholamines*** - Measurement of **24-hour urinary fractionated metanephrines and catecholamines** is the initial **biochemical test of choice**. - These biochemical tests are preferred over plasma levels due to the **episodic release** of hormones from a pheochromocytoma, which can lead to high false-negative rates in single plasma measurements. *CT scan* - While a **CT scan** is a crucial **imaging modality** for localizing a pheochromocytoma once the biochemical diagnosis is established [1], it is not the *initial* diagnostic investigation. - Imaging should be performed only after **biochemical confirmation** to avoid unnecessary investigations of incidental adrenal masses [1]. *MIBG scan* - An **MIBG scan** (metaiodobenzylguanidine scan) is a **functional imaging study** used primarily for **localizing metastatic pheochromocytomas** [1] or for cases where CT/MRI is equivocal. - It is not the initial investigation but rather a **secondary imaging test** [1]. *MRI Scan* - **MRI** is an alternative **imaging modality** to CT for localizing pheochromocytomas [1], especially in pregnant women or when radiation exposure is a concern. - Like CT, it serves as a **localization tool** after biochemical confirmation, not the diagnostic test itself.

Question 1

Adrenal reserve is best tested by means of infusion with

Accepted Answer

ACTH

Answer

Metyrapone

Answer

Corticosteroids

Answer

LHRH

Question 2

Which of the following is a common finding in patients with Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH)?

Accepted Answer

Normal BP

Answer

Ascites

Answer

Generalized edema

Answer

Dry mucous membrane

Question 3

Which of the following is not a treatment option for hypercalcemia?

Accepted Answer

Strontium

Answer

Bisphosphonates

Answer

Steroids

Answer

Phosphate

Question 4

Which of the following glands is NOT typically involved in Multiple Endocrine Neoplasia type II A (MEN II A)?

Accepted Answer

Pituitary gland

Answer

Thyroid gland

Answer

Parathyroid gland

Answer

Adrenal gland

Question 5

Which of the following statements about hypercalcemia in sarcoidosis is false?

Accepted Answer

Parathormone level is increased

Answer

PTHrP level is increased

Answer

Oral steroids are useful

Answer

Calcitriol level is increased

Question 6

Autoimmune thyroiditis is associated with all except which of the following?

Accepted Answer

Psoriasis

Answer

DM

Answer

Myasthenia gravis

Answer

SLE

Question 7

Chronic atrophy of adrenal gland will result in which hormone deficiency ?

Accepted Answer

Cortisol

Answer

Aldosterone

Answer

Dehydroepiandrosterone (DHEA)

Answer

Epinephrine

Question 8

What is the initial drug of choice for a suspected case of acute adrenal insufficiency?

Accepted Answer

Hydrocortisone

Answer

Norepinephrine

Answer

Dexamethasone

Answer

Fludrocortisone

Question 9

Primary hyperparathyroidism is suggested by all of the following, except which of the following?

Accepted Answer

Low urinary calcium levels

Answer

Increased serum calcium

Answer

Increased urinary calcium

Answer

Decreased PTH levels

Question 10

Investigation of choice in pheochromocytoma is:

Accepted Answer

Urinary catecholamines

Answer

CT scan

Answer

MIBG scan

Answer

MRI Scan

Endocrinology — MCQs

Endocrinology — MCQs

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