#40: Pseudo endocrine disorders, fatigue, and the Schmerbsiders?

May 22, 2017 | By Matthew Watto, MD

Learn “weird” endocrine stuff! How to approach vague complaints like fatigue and weight gain. Reverse T3 syndrome, Wilson’s T3 syndrome, and adrenal fatigue; Do they exist? Learn how to help the challenging patient who is convinced they have an endocrine disorder in this discussion recorded live from AACE 2017 with Dr. Michael T. McDermott, Professor of Medicine, University of Colorado Denver School of Medicine.

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Case: 35 year old female presents with 10 years of chronic fatigue and difficulty losing weight. She ordered her own lab tests online and came to the office with some minimal lab abnormalities that she’d like explained.

Clinical Pearls:

1. Dr. McDermott’s big six causes of fatigue: Poor sleep, inactivity/lack of exercise, poor diet, high stress level, mood disorder, or other medical illnesses.
2. Fatigue: “A multifactorial symptom that requires a multifactorial approach and patience and time.” -Dr. McDermott
3. Diagnosis: Basic workup = CBC, CMP, B12, Vitamin D, TSH; Screen for sleep disorder e.g. STOP-BANG questionnaire or overnight pulse oximetry
4. Reverse T3 (rT3): Not a useful test for outpatients. Only helpful if patient hospitalized and euthyroid sick syndrome suspected. An rT3 can help differentiate euthyroid sick syndrome (high rT3) from central hypothyroidism (low rT3).
5. T3: Free T3 level assay is not accurate or helpful. Levels vary widely. Check a total T3 in the appropriate setting.
6. Euthyroid sick syndrome: Occurs in hospitalized “sick” patient. Levels of total T4, free T4, total T3 and TSH often low or low normal while rT3 levels become high. Mortality increases if treated with supplemental hormone. DON’T do it!
7. Central hypothyroidism: Low levels of T4, T3, and TSH. Reverse T3 levels also low (as opposed to euthyroid sick syndrome) due to lack of substrate, T4.
8. Reverse T3 syndrome: High rT3 compete with active T3 hormone causing “hypothyroidism”. This condition is not real! In fact, T3 has 100 times the affinity for thyroid receptor as reverse T3!
9. Wilson’s low T3 syndrome: Has never been proven to exist. Alleges inability to convert T4 into T3. Thus lack of T3 causes fatigue. Proposes axillary body temperature below certain level indicates “low T3 syndrome”. Treated with supplemental T3.
10. Adrenal insufficiency (AI): Primary AI: loss of production of adrenal hormones. Secondary/tertiary AI: central loss of corticotropin releasing hormone or ACTH. Diagnosis: 8am cortisol, and plasma ACTH.  Confirm with 250 mcg ACTH stimulation test with cortisol 60 minutes later.
11. Adrenal fatigue: Has never been proven to exist. Salivary cortisol profile samples taken hourly for 24 hours then plotted. Those who fall below the normal line (or curve) are said to have “adrenal fatigue”.
12. Growth hormone deficiency: Growth hormone (GH) varies throughout the day. GH stimulates IGF-1 production by the liver. IGF-1 levels are more stable throughout the day. GH deficiency in adult rarely occurs unless patient has pituitary disease.

Goal: Listeners will develop a framework for the diagnosis and management of vague multisystem complaints that could be endocrine related.

Learning objectives:
By the end of this podcast listeners will:

1. Define the pseudo endocrine disorder
2. Recognize and manage the pseudo endocrine patient
3. Dispel the reverse T3 syndrome
4. Recall that adrenal fatigue is not a scientifically validated condition
5. Describe the physiology of growth hormone
6. List Dr. McDermott’s “big 6” causes of fatigue
7. Develop a basic approach to workup fatigue
8. Counsel patients with multisystem complaints

Disclosures:
Dr. McDermott is the author of Endocrine Secrets, but has no other relevant financial disclosures pertaining to this episode.

Time Stamps
00:00 Intro
05:36 Guest intro
07:50 Definition of “pseudo” endocrine
10:02 Case introduction
13:39 “Reverse T3 Syndrome”, the thyroid and fatigue
20:45 Growth hormone
25:10 Fatigue, and where to start
33:00 Adrenal fatigue
38:00 Lab testing
39:34 Take home points
42:12 Stuart on the thyroid and reverse T3
45:30 Paul’s approach to multisystem complaints
51:12 Outro

Links from the show:

1. Lawrence of Arabia (film) from Amazon.com
2. Endocrine Secrets, 6th Edition by Michael T. McDermott
3. STOP-BANG Questionnaire article ; Get PDF copy here
4. Euthyroid sick syndrome article and graphic from Medscape
5. Dr. Colburn’s New Patient Endocrinology Questionnaire