[indian]

I came across this CCS which is really challenging

Patient came with malaise, weight loss, epigastric tenderness, diarrhea, hypercalcemia, hypophosphatemia, normoglycemia, occasional headaches, high prolactin level.

What hormone will be low in this patient?
-Gastrin
-VIP
-Testosterone
-Insulin

I know the answer
let's see if you can guess

 

[hope2inspire]

??

Hypercalcemia & Hypophosphatemia - does it have to do with increased PTH?

 

[indian]

Hypercalcemia & Hypophosphatemia - does it have to do with increased PTH?

Yes,
You are getting closer

 

[hope2inspire]

??

You said I'm getting closer..
But what does high PTH have to do with any of the choices on the list?? Argh!
My final answer is Testosterone.
I came to that conclusion by thinking that since there is a high prolactin level, either there's a benign adenoma or the dopamine from the hypothalamus is not enough to inhibit it. If there is a problem in the hypothalamus, GnRH will be affected, which will affect secretion of LH & FSH and can decrease production of testosterone.
I'm still wondering what the link is between high PTH and the question itself. That explains the hypercalcemia and the hypophosphatemia. Maybe it's a distraction?
Gastrin & VIP - not really related to the lab values. Maybe related to the diarrhea?
Insulin - normoglycemia rules that out.
Curious to know what the answer is

 

[indian]

Your answer is correct

This is a case of multiple endocrine neoplasia type I

There's parathyroid tumor which explains the high calcium low phosphate
There's pancreatic tumor which explains the GIT hormones
There's pituitary tumor which explains the headaches and the high prolactin

Prolactin is inhibitory to GnRH (check it in First Aid) so it inhibits LH, FSH, and testosterone

 

[hope2inspire]

Great Question!
i wouldn't have thought of MEN at all!
Wowwwww!

 

[smile135]

Thanks for sharing a question and explanation that leads to the answer...

good for practice

 

[indian]

Thanks for sharing a question and explanation that leads to the answer...

good for practice

You welcome smile135
Can you help me solve this problem please
http://www.usmle-forums.com/usmle-step-1-forum/609-type-ii-type-iii-hypersensitivity.html

 

[khanar]

This is seriously the most difficult question that I've ever seen so far

 

[ath.pantelis]

When a pt presents with a constellation of heterogenous symptoms, the exam taker should always have in mind two entities: MEN syndromes (esp. type 1) & paraneoplastic syndromes. We could also add autoimmune disease (esp. mixed collagen tissue disease & the correlation between heterogenous autoimmune disease, eg diabetes & autoimmune thyroiditis).

 

[Seetal]

i guessed testosterone for only one reason = high prolactin.

i had no idea this was a MEN I related question!

thanks for the awesome question and explanations guys.

 

[angle]

i guessed testosterone for only one reason = high prolactin.

i had no idea this was a MEN I related question!

thanks for the awesome question and explanations guys.

I THOUGHT THAT TOO