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BOOK 1

- Genetics -
- Microbiology -
- Endocrinology -
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BOOK 1




























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Copyright © USMLE Success Academy, All Rights Reserved

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TABLE OF CONTENTS


Genetics……………………………………………………………………………………………………………………..…… 1
AD disorders……………………………………………………………………………………………………………..… 19
AR disorders……………………………………………………………………………………………………………..… 50
X-linked disorders……………………………………………………………………………………………………..… 90
Mitochondrial disorders………………………………………………………………………………………..……. 104
Monosomies & Trisomies……………………………………………………………………………………………. 109
Imprinting…………………………………………………………………………………………………………………… 123
Hardy-Weinberg…………………………………………………………………………………………………………. 126


Microbiology…………………………………………………………………………………………………………………. 129
Bacteria……………………………………………………………………………………………………………………… 130
Gram-positive bacteria…………………………………………………………………………………………....… 148
Gram-negative bacteria……………………………………………………………………………………………... 171
Mycology…………………………………………………………………………………………………………………... 201
Parasites……………………………………………………………………………………………………………………. 216
Virology…………………………………………………………………………………………………………………….. 235


Endocrinology………………………………………………………………………………………………………………. 275
Pituitary……………………………………………………………………………………………………………………. 277
Thyroid…………………………………………………………………………………………………………………….. 289
Adrenals…………………………………………………………………………………………………………………… 303
Kidneys……...……………………………………………………………………………………………………………. 314
Pancreas………………………………………………………………………………………………………………….. 315
Reproductive…………………………………………………………………………………………………………… 326















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ENDOCRINE

Topics of discussion:

à Introduction
à Pituitary gland
à Thyroid gland
à Adrenal glands
à Kidneys & pancreas
à Endocrine pharmacology
à Reproductive endocrinology
à Female reproductive cancers

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INTRODUCTORY PRINCIPLES OF ENDOCRINOLOGY

Different types of glandular secretion:

§ Exocrine: secretion onto epithelial surface through a duct
§ Exocrine glands include the sweat glands, salivary glands, and
mammary glands
§ Endocrine: secretion of hormones directly into the blood
§ Endocrine glands include the pancreas, pituitary, thyroid, and pineal
gland
§ Paracrine: secreted products are going to stay local, working within
the vicinity
§ Autocrine: hormones secreted from a cell work on that same cell by
binding to its receptors
§ Apocrine: products secreted by cell budding off of the cytoplasm
(pinches off and into the lumen)
§ Holocrine: secretions made in cell’s cytoplasm, released via plasma
membrane rupture

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THE PITUITARY

§ Controlled by the hypothalamus
§ Anterior pituitary derived from ______________
growth known as Rathke’s pouch
§ Posterior pituitary derived from ventral
evagination of ectodermal tissue from
______________________
§ Two separate structures, the anterior and
posterior pituitary become tightly bound together Fig 3.01: Anterior and posterior pituitary
(Fig 3.01)
§ Craniopharyngioma is a remnant of Rathke’s pouch

Craniopharyngioma:
§ Calcified cystic tumors most commonly located in the suprasellar
region
§ Histology: Cystic or partially cystic with solid areas
§ Light microscopy: Cysts lined with stratified squamous epithelium,
keratin pearls, cysts filled with yellow fluid rich in cholesterol
§ Seen mainly in childhood between ____-____ years of age
§ Three main components of the craniopharyngioma:
I. Solid portion (comprises the tumor cells)
II. Cystic portion (machinery oil liquid)
III. Calcified portion

§ Symptoms of craniopharyngioma may include any of the following:
ü Headache & visual field deficits
ü Hypopituitarism
ü Hormonal imbalances (growth delay)

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Anatomy of the pituitary:

§ Small gland at the base of the hypothalamus, rests in the sella tursica
(bony cavity in sphenoid bone)
§ Gland is covered and protected by the diaphragma sella
§ Connected to hypothalamus via the pituitary stalk, secretes nine
hormones which are controlled by the hypothalamus
§ Anterior pituitary (adenohypophysis) receives majority of blood
supply from the paired superior _____________________ arteries
(arise from medial aspect of internal carotid arteries)
§ Posterior pituitary (neurohypophysis) receives its blood supply from
the inferior ___________________ arteries
§ Empty sella syndrome characterized by a lack of pituitary gland in the
sella tursica, and is commonly either:
I. Primary ESS: Due to anatomical defect above the pituitary,
results in increased pressure in the sella, causing it to
flatten
II. Secondary ESS: Due to regression of the pituitary gland
after injury, surgery, or radiation. Symptoms characteristic
of pituitary deficiency (fatigue, amenorrhea, infertility),
children with early-onset puberty

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A closer look at the gross anatomy of the pituitary (Fig 3.02):

Fig 3.02: Gross anatomy of the pituitary

§ Posterior lobe composed of axons radiating from neuronal cell bodies
in the _____________________ and _________________________
nuclei, as well as pituicytes (no hormones made within posterior
pituitary)
§ Neurophysin proteins carry ________________________ and
_______________________ produced inside the neuronal cell bodies
of paraventricular and supraoptic nuclei

Location of pituitary gland relative to other anatomical structure (Fig 3.03):

Fig 3.03: Anatomical location of the pituitary

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The anterior pituitary:

§ Three distinct parts make up the anterior pituitary:
I. Pars distalis: makes up the bulk of the anterior pituitary,
most hormone production occurs here
II. Pars tuberalis: function not completely known
III. Pars intermedia: sits between pars distalis and posterior
pituitary

Hormones secreted by the anterior pituitary:
§ Released via signals from the hypothalamo-hypophyseal-portal
system; signals received through this series of capillaries
§ Hormone secretion from anterior pituitary regulated by hypothalamic
hormones
§ All anterior hormones stain basophilic, except for _________ and
____________________ (stain acidophilic)

Hormones: Polypeptide or Glycoprotein:
§ Polypeptide hormones of the anterior pituitary:
ü ACTH
ü GH
ü Prolactin
§ Glycoprotein hormones of the anterior pituitary:
ü TSH
ü LH
ü FSH

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Hypothalamic hormones à pituitary hormones:

§ CRH à ______ and ______
§ TRH à ______ and ______
§ GHRH à ______
§ GnRH à ______, ______
§ Prolactin à ¯ ______
§ Somatostatin à ¯ ______, ______
§ Prolactin is structurally similar to GH, playing a role in milk production
in the breast. In males, prolactin inhibits spermatogenesis while in
females it inhibits ovulation (due to inhibitory effects on GnRH
synthesis and release)
§ Prolactin secretion inhibited by Dopamine (from tuberoinfundibulum
neurons of the arcuate nucleus in hypothalamus)

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The anterior pituitary hormones (Fig 3.04):

§ Hormones made of five cell types:
Ø Lactotrophs à __________
Ø Gonadotrophs à _____, _____
Ø Corticotrophs à ______
Ø Somatotrophs à ______
Ø Thyrotrophs à ______

Fig 3.04: Hormones of the anterior pituitary

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Review of Important Lecture Points

(Use this page to create a bullet-point list of the lecture’s important points)


•

USMLE Success Academy - Book 1 283

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§ LH: Testes, uterus, and ovary

Ø Testes: stimulates testosterone secretion
Ø Uterus: prepares uterus for implantation of fertilized ovum
Ø Ovary: stimulates ovulation formation/secretion of hormones
by ovaries



LH, FSH, and the testes (Fig 3.05):
§ LH from pituitary goes to ___________ cells of the
testes to stimulate testosterone synthesis and
release
§ Testosterone acts on both the pituitary and
hypothalamus to prevent further release of GnRH
(hypothalamus) and LH (pituitary)
§ Sertoli cells stimulated by FSH and then releases
Inhibin, which suppresses the release of FSH from
the pituitary
§ LH/FSH stimulated by _________, which comes
from the hypothalamus (GnRH is administered in Fig 3.05: FSH, LH and the testes

pulsatile fashion to increase LH and FSH release from the pituitary)

The anterior pituitary hormones, continued:
§ TSH: stimulated by ______ from the hypothalamus
§ TSH stimulates the thyroid gland’s production _____ and _____,
which play an important role in controlling the body’s metabolism
§ ACTH: stimulated by ______ from the hypothalamus
§ ACTH’s role is to stimulate the adrenal gland to release ____________

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§ Prolactin: initiates milk production in the mammary glands (under

constant inhibition from DA)
§ High levels of prolactin can suppress ____________ secretion from
the hypothalamus (¯ estrogen stimulation in females)
§ DA inhibits prolactin production by acting on DA receptors in pituitary
§ GH: 191 amino acid structure
§ GH stimulates bone growth (­ linear growth of long bones by
stimulating _______ from liver)
§ GH: Associated with Gigantism, Acromegaly, Dwarfism
Ø Gigantism: excessive GH secreted prior to epiphyseal
closure; tall stature, long limbs
Ø Acromegaly: excessive GH secretion after epiphyseal
closure; deep voice, large hands/feet, large tongue with
deep furrow
Ø Dwarfism: defect in GH receptor leading to a decrease in
linear growth (Fig 3.06); characterized by high serum
_____ and low levels of ________

Fig 3.06: Dwarfism caused by
defect in GH receptor
Three important dopaminergic systems:
I. Mesolimbic-mesocortical: __________________ regulation
II. Nigrostriatal pathway: co-ordinates __________________ movement
III. Tuberoinfundibular system: controls __________________ secretion

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Dopamine agonists & prolactinoma:

§ Dopamine agonists can inhibit lactation
§ If pituitary tumor suspected, consider ________ syndrome
(Parathyroid and Pancreas)
§ Prolactinomas (common pituitary tumor), can inhibit GnRH leading to
galactorrhea and amenorrhea (females), can lead to accelerated bone
loss and increase risk of fragility fracture

Dopamine agonists:
§ L-dopa/Carbidopa: L-dopa peripherally converted to DA, thus a
DOPA decarboxylase inhibitor such as Carbidopa is added, allowing
L-dopa to cross the blood-brain barrier and convert to DA inside
the brain
§ Selegeline: MAOB inhibitor (Fig 3.07), prevents breakdown of DA
to DOPAC; shown to delay the need for L-dopa by several months
§ Amantadine: anti-viral medication that can also increase the release
Fig 3.07: Location of MOA of
of DA from the _____________________________, and may also Selegeline
decrease amount of DA re-uptake
§ Tolcapone: blocks the peripheral breakdown of DA into 3-MT

Pituitary prolactinoma:
§ Functional pituitary tumor
§ Excessive prolactin results in the stimulation of breast milk
production
§ Female patients experience _________________ and _____________
§ Male patients experience erectile dysfunction, hypogonadism, and
gynecomastia
§ Mass-effect à optic chiasm compression à bitemporal hemianopsia

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The posterior pituitary (Fig 3.08):

§ Also known as the neurohypophysis (collection
of axonal projections from the hypothalamus)
§ Posterior lobe further divided into the following
three parts:
I. Pars nervosa (majority of posterior
lobe)
II. Infundibular stalk (pituitary stalk) Fig 3.08: The posterior lobe of the pituitary
III. Median eminence

Hormones secreted by the posterior pituitary:
§ Secretes __________________ and ______________________
§ Oxytocin responsible for uterine contraction and milk letdown
(prolactin makes the milk, oxytocin releases it)
§ Vasopressin targets the kidney and arterioles; stimulates water
retention and increases blood pressure
§ ___________________ of Vasopressin leads to diabetes insipidus
(cannot concentrate urine, loss of large volume of dilute urine)
§ ___________________ of Vasopressin leads to SIADH (Syndrome of
inappropriate anti-diuretic hormone secretion – urine is highly
concentrated and blood is dilute)

Common complications associated with pituitary undersecretion:
§ Sheehan syndrome: ischemia of the pituitary due to heavy post-
partum bleeding (large pituitary exposed to hypoperfusion)
§ Empty sella syndrome: atrophy and/or compression of pituitary leads
to lack of hormone secretion
§ Pituitary apoplexy: sudden pituitary hemorrhage commonly
associated with pituitary adenoma; visual impairment, HA, etc

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Review of Important Lecture Points

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THE THYROID

Anatomy & embryology:
§ Thyroid tissue derived from the __________________
§ Parafollicular C cells of the thyroid derived from neural crest cells
§ Thyroid diverticulum arises from floor of primitive pharynx,
descending into the neck (connection to tongue via thyroglossal duct)
§ Duct normally disappears, however if it persists there may be
formation of a __________________ cyst (neck mass, irregular,
anterior/midline)
§ Ectopic thyroid tissue most likely to be in the _____________

Blood & nerve supply:
§ Highly vascularized structure
§ Supplied by the
_____________________ and
_________________ thyroid arteries (Fig
3.09)
§ Superior thyroid artery is first branch of
the ___________________ carotid artery
and supplies top half of thyroid
§ Anteriorly, right and left branches
anastomose with each other
Fig 3.09: Vascular supply to the thyroid gland
§ Inferior thyroid artery supplies lower half, is
major branch of the ________________________ trunk (from
subclavian artery)

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§ Three main veins: Superior, middle,

inferior thyroid veins
Ø Superior/middle thyroid
veins drain into the internal
jugular vein
Ø Inferior thyroid vein drains
into the brachiocephalic
veins
§ Thyroid innervated by sympathetic and
parasympathetic nervous system (Fig
3.10)
Fig 3.10: Nerve supply to the thyroid gland
§ Sympathetic nervous system innervates
thyroid through superior/middle/inferior sympathetic ganglia
§ Parasympathetic nervous system innervates thyroid through the
____________________ nerve
§ Both nerves (above) run alongside blood vessels (via superior/inferior
periarterial plexi), there are surgical risks associated with the thyroid
gland
§ Inferior thyroid artery closely associated with the recurrent laryngeal
nerve
Ø Left-sided recurrent laryngeal nerve courses beneath the
arch of the aorta
Ø Right-sided recurrent laryngeal nerve hooks beneath the
right subclavian artery
Ø Recurrent laryngeal nerves innervate the intrinsic muscles
of the larynx (except the cricothyroid – superior laryngeal
nerve)

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HIGH-YIELD NUGGET:






§ Thyroid hormones under control of hypothalamic hormones (TRH)
and pituitary hormones (TSH); both begin secreting at approximately
____-____ weeks gestation


Thyroid histology (Fig 3.11):
§ Three main features:
I. Follicles (spherical follicles selectively
absorb iodide (I-))
II. Follicular epithelial cells (single layer
of thyroid epithelium that secretes
T3 & T4); when active become tall
columnar cells
Fig 3.11: Histology of the thyroid gland: 1) Follicles, 2)
III. Parafollicular (clear) cells (secrete Follcular cells, 3) Endothelial cells
calcitonin that counter-regulates Photo courtesy of Uve Gilla

PTH)

Roles of thyroid hormone:
§ Regulation of the basal metabolic rate
§ Affects protein synthesis
§ Regulates bone growth (along with GH)
§ Increases sensitivity to ____________________
§ Generation of heat

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§ Regulates metabolism of protein, carbohydrates, and fats

Thyroid hormone synthesis (Fig 3.12):
§ Organification of iodine:
Ø Iodide taken in, converted to iodine, condensed onto
Tyrosine residues
Ø Creates mono-iodinated (MIT) or di-iodinated tyrosine
(DIT) incorporated into thyroglobulin (part of colloid
material, present in follicle of thyroid unit)
Ø Coupling reactions to form either T4 (combination of 2 di-
iodotyrosines), or T3 (di-iodotyrosine and mono-
iodotyrosine)
§ Major coupling reaction is the formation of two di-iodotyrosines in
the formation of _____
§ T3 is more biologically active than T4, however major production of
T3 occurs outside of the thyroid gland
§ Released thyroid hormones bound to thyroid hormone binding
proteins; major thyroid hormone binding protein is thyroxine binding
globulin (TBG), which accounts for approximately ____% of bound
thyroid hormone








Fig 3.12: Synthesis of thyroid hormone

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Pathology of the thyroid gland:

§ Hyperthyroidism, hypothyroidism, and cancer
§ Hyperthyroid conditions include Grave’s disease, toxic multi-nodular
goiter, and toxic thyroid adenoma
§ Hypothyroid conditions include Hashimoto’s disease, DeQuervain’s
disease, and Lymphocytic thyroiditis

Grave’s disease:
§ Overproduction of thyroid hormone
§ Excess thyroid hormone leads to the following symptoms:
ü Sympathetic hyperactivity
ü Exophthalmos (bulging eyes)
ü Weight loss
ü Heat intolerance
ü Tremors
ü Pretibial myxedema
ü Myopathy
ü Periorbital & conjunctival edema

§ Autoantibodies to ___________________ receptor (TRAb)
stimulates synthesis and release of thyroid hormone and
growth of the thyroid (causes goiter formation)
§ Grave’s distinguished from other types of hyperthyroidism
by presence of TRAb in serum plus exophthalmos
§ Seen more commonly in females > ____ years of age
§ Strong genetic component
§ Lab values: ­Thyroid hormone, ¯ TRH, ¯ TSH (Fig 3.13)
Fig 3.13: Lab values in Grave’s disease

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Management of Grave’s disease:

§ Manage acutely with a _________________
§ Methimazole or Propylthiouracil (PTU); actively transported into
gland to inhibit organification of iodine to tyrosine and coupling of
iodotyrosines
§ _____________________ is preferred to _____________________
because it works faster and produces fewer adverse effects
§ In 1st trimester of pregnancy choose PTU; Methimazole unsafe during
this period of pregnancy


Toxic multinodular goiter:
§ Common cause of hyperthyroidism characterized by
presence of isolated nodules that secrete thyroid hormone
(excessively)
§ ‘Hot nodule’ is indicative of a functional nodule that is taking
up iodine; more often than not they are benign (Fig 3.14)
§ Cold nodules take up less iodine than the rest of the thyroid;
approximately ____% become malignant

Fig 3.14: Scintigraphy of thyroid
demonstrates two nodules
Toxic thyroid adenoma:
§ Adenoma usually of the _______________ cells
§ Is the result of a genetic mutation
§ Seen more likely as a solitary nodule (as opposed to toxic
multinodular goiter)

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Subacute thyroiditis:
§ Subacute granulomatous thyroiditis
§ Less common cause of hyperthyroidism
§ Affects women more than men
§ Characterized by the following:
ü Neck pain
ü Tender/diffuse goiter
ü Specific course of action (hyperthyroidism à euthyroidism
à hypothyroidism à normal function)

§ Commonly the result of viral infection or post-viral inflammatory
process (URI commonly)
§ Thyroid inflammation damages thyroid follicles, activates proteolysis
of stored thyroglobulin, unregulated release of thyroxine leads to
symptoms of hyperthyroidism

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Hypothyroidism:
§ Thyroid gland cannot produce sufficient thyroid
hormone
§ Classic findings associated with hypothyroidism (Fig
3.15)
ü Fatigue
ü Myalgias
ü Cramping
ü Cold intolerance
ü Weight gain
ü Coarse/brittle nails and hair
Fig 3.15: Common signs & symptoms associated
with hypothyroidism

1°, 2°, & 3° hypothyroidism (Fig 3.16):
§ 1° hypothyroidism: problem originates in the thyroid gland
§ 2° hypothyroidism: problem originates in the pituitary
§ 3° hypothyroidism: problem originates in the hypothalamus
















Fig 3.16: Explaining the different
causes of hypothyroidism

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Review of Important Lecture Points

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•

USMLE Success Academy - Book 1 297

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Causes of hypothyroidism:
§ Hashimoto’s thyroiditis
§ Subacute granulomatous thyroiditis
§ Silent lymphocytic thyroiditis
§ Cretinism
§ Euthyroid sick syndrome


Hashimoto’s thyroiditis (autoimmune hypothyroidism):
§ Autoimmune attack against thyroid peroxidase and/or thyroglobulin,
leading to gradual destruction of thyroid follicles
§ Presence of hypothyroid signs/symptoms plus a firm, large, lobulated
thyroid gland (due to lymphocytic infiltration and fibrosis), is telling of
Hashimoto’s thyroiditis

Subacute granulomatous thyroiditis (DeQuervain’s):
§ Sub-acute thyroiditis usually seen during/after viral infection
§ Hyperthyroid initially, followed by hypothyroidism, then resolution

Silent lymphocytic thyroiditis:
§ Occurs post-partum (5-10% of patients)
§ Not associated with neck pain
§ Lymphocytic infiltration without scarring
§ Characterized by hyperthyroidism for few weeks, followed by
hypothyroidism, followed by resolution

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Cretinism:
§ Maternal hypothyroidism leads to congenital hypothyroidism
§ Stunting of baby’s physical and mental development
§ Early diagnosis and ______________ replacement = good prognosis
§ If diagnosis not made early, patient likely to suffer from intellectual
disabilities

Euthyroid sick syndrome:
§ Commonly in hospitalized patients and/or those with recent trauma
§ Patient appears to be hypothyroid, however TSH and thyroid
hormone levels are normal (T3 commonly low)
§ If ____ is low, prognosis is worsened

Hypothyroid management:
§ Problem often chronic requiring life-long treatment
§ Goal is to return patient to euthyroid state
§ Oral synthetic T4 (Levothyroxine)
§ Levothyroxine is deiodinated in peripheral tissue to form T3

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Cancers of the thyroid gland:

§ Common forms include Papillary, Follicular, Medullary, and Anaplastic

Papillary thyroid cancer:
§ Most common type of thyroid cancer
§ Seen mainly in younger patients with metastasis to the
______________________
§ Histology: branching papillae with a fibrovascular stalk lined by single
or multiple layers of ___________________ epithelium (nuclei with
ground-glass appearance)
§ __________________ bodies also characteristic of this type of cancer

Follicular thyroid cancer:
§ Seen more commonly in older patients
§ Known to metastasize to the _____________

Medullary thyroid cancer:
§ Affects the parafollicular C-cells (calcitonin-secreting)
§ Causes extracellular deposit of amyloid
§ Majority of cases are sporadic (~ 80%)
§ ~ 20% of cases inherited and linked to _______ syndrome
§ Germline mutation of the _______ proto-oncogene in most cases

Anaplastic thyroid cancer:
§ Affects older population
§ Has the worst prognosis due to invasion of local vascular supply
§ Does not metastasize

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The parathyroid glands:

§ Four small glands on the posterior aspect of the thyroid (Fig
3.17)
§ Superior parathyroids develop from the ______ pharyngeal
pouch
§ Inferior parathyroids develop from the ______ pharyngeal
pouch
§ PTH comes from the parathyroid’s ____________ cells
§ PTH acts indirectly on osteoclasts through osteoblasts
§ PTH causes osteoblasts to increase production of Fig 3.17: Posterior view of thyroid
gland demonstrating parathyroid
_________________ and monocyte colony-stimulating factor glands
(M-CSF); both of these stimulate osteoclast precursors to
differentiate into bone-resorbing, mature osteoclasts

PTH regulation (Fig 3.18):
§ PTH is stimulated by low serum ____________________, mild
decrease in ___________________, and high serum P04-
§ PTH is inhibited by high serum ______________________, severely
decreased magnesium, and lower serum P04-
§ PTH also works in the late DCT









Fig 3.18: Mechanisms by which PTH increases serum calcium

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USMLE Success Academy - Book 1 302

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THE ADRENAL GLANDS

§ Suprarenal structures producing a variety of hormones, including:
ü Aldosterone
ü Cortisol
ü Sex steroids
ü Catecholamines

§ Different layers of the adrenal glands (Fig 3.19):
ü Zona glomerulosa
ü Zona fasciculata
ü Zona reticularis
ü Medulla



HIGH-YIELD NUGGET:

Fig 3.19: Different layers of the adrenal glands and their products

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Zona glomerulosa (Fig 3.20):

§ Responsible for production of
______________________, which is stimulated by the
Renin-Angiotensin-Aldosterone system (RAAS)
§ Aldosterone stimulated by any of the following:
ü Hypovolemia
ü Hyponatremia
Fig 3.20: Zona glomerulosa layer of the
ü Hyperkalemia adrenal gland

§ Aldosterone exerts its effects by acting on the thick ascending limb &
the DCT and the ________________ cells of the collecting ducts
§ Maintains adequate volume by regulating the amount of sodium
reabsorbed in the kidney tubules by increasing the number of _____
channels in the apical surface of the principal cells
§ Also increases the number of Na/K pumps on basolateral surface of
these cells

The RAAS:
§ Low volume detected by the JG apparatus (Fig 3.21)
§ Renin secreted à liver (Angiotensinogen) à A1 à Lungs
(ACE) à A2
§ A2 à ______________ à Aldosterone (Fig 3.22)
§ Volume/BP regulated via the following four mechanisms:
I. Angiotensin 2 causes a__ vasoconstriction
II. Aldosterone reabsorbs sodium and water
III. Posterior pituitary stimulated to release ADH,
which increases the number of V2 aquaporins
IV. Thirst center in brain is stimulated Fig 3.21: The JG apparatus

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Fig 3.22: The renin-angiotensin-aldosterone (RAAS) system

Primary Aldosteronism (Conn syndrome):
§ Excessive aldosterone exerting its effects on the body
§ The effects of excessive aldosterone include the following (Fig 3.23):
Ø K+ concentration inside principal cell increases
Ø K+ forced into lumen (down its
gradient)
Ø K+ brought back into principal cell
in exchange for H+ (creates an
alkalosis)

§ Three problems associated with this
excessive aldosterone:
I. Hypernatremia Fig 3.23: Physiology of primary hyperaldosteronism
II. Hypokalemia
III. Alkalosis

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§ Secondary hyperaldosteronism also associated with elevated serum

aldosterone, in addition to increased serum renin (not found in 1°
type)
§ Common causes of secondary hyperaldosteronism include:
ü Renovascular hypertension (atherosclerosis, fibromuscular
dysplasia)
ü Diuretics
ü Malignant hypertension
ü Reninoma (renin-secreting tumor)


Congenital adrenal hyperplasia:
§ Autosomal recessive group of disorders characterized by deficiency of
enzymes required for synthesis of adrenal products
§ Includes deficiencies of any of the following enzymes (Fig 3.24):
Ø 21-OH
Ø 11-OH
Ø 17-OH

Fig 3.24: Pathway involved in congenital adrenal hyperplasia

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§ 21-OH deficiency leads to virilization + ______________________

§ 11-OH deficiency leads to virilization + ______________________

Zona fasciculata (Fig 3.25):

§ Responsible for production of
_____________________
§ Is stimulated by both _______________ and
hypoglycemia
§ Is inhibited by _____________________
§ Major cortisol effect is sensitizing the vascular
system to the effects of catecholamines (NE, E), Fig 3.25: Zona fasciculata layer of the adrenal
gland
thus cortisol + NE leads to greater
vasoconstriction that NE alone (permissive
effect)
§ Cortisol also increases insulin resistance,
gluconeogenesis, lipolysis, and proteolysis
§ Cortisol decreases fibroblast activity à leads to
striae
§ Cortisol decreases the inflammatory and
immune responses
§ Cortisol decreases bone formation by
decreasing ________________ activity
§ Too much cortisol à Cushing’s syndrome
§ Too little cortisol à Adrenal insufficiency
(Addison’s disease)
§ CRH (hypothalamus) stimulates ACTH (pituitary),
Fig 3.26: Process of normal cortisol release
which stimulates Cortisol release (adrenals) – Fig
3.26

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Cushing’s syndrome:
§ Cushing’s ______________ represents an ectopic
source of cortisol
§ Cushing’s ______________ represents an adrenal
dysfunction
§ Prolonged _________ stimulation causes
hyperplasia of the zona fasciculata à excessive
cortisol production
§ Pituitary adenoma (disease) would lead to increased
ACTH and Cortisol, with decreased CRH (Fig 3.27)
§ Important physical findings of Cushing’s syndrome Fig 3.27: Effects of ACTH-stimulating pituitary
lesion
include:
Ø Buffalo hump
Ø Truncal obesity
Ø Striae

Diagnosing the source of the problem:
§ Diagnosis based on findings of the Dexamethasone suppression test
§ Dexamethasone (exogenous steroid) provides negative feedback to
pituitary (should suppress ACTH secretion); is targeted towards the
hypothalamic-pituitary-adrenal axis (most specific to pituitary)
§ Under normal conditions, administration of Dexamethasone should
suppress ACTH secretion from pituitary (thus lowering cortisol as
well)
§ Overnight low-dose Dexamethasone, under normal circumstances,
should suppress ACTH (if ACTH suppressed, problem likely adrenal)
§ If overnight low-dose Dexamethasone doesn’t suppress ACTH, must
distinguish between disease (pituitary) and ectopic source with higher
dose, as well as the CRH stimulation test

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§ High-dose Dexamethasone should suppress pituitary cause of

increased ACTH; if high-dose doesn’t lower ACTH, consider ectopic
source such as small cell lung cancer

Breaking down results of the Dexamethasone suppression test:
§ Low-dose: if suppression of ACTH, consider adrenal source
§ Low-dose: if no suppression of ACTH, consider pituitary or ectopic
source and perform high-dose test
§ High-dose: if suppression of ACTH, consider pituitary source
§ High-dose: if no suppression of ACTH, ectopic source likely


Addison’s disease (primary adrenal insufficiency):
§ Inadequate amount of Aldosterone and Cortisol produced due to a
loss of glandular function
§ Acutely may be due to massive bleeding (shock à adrenal crisis)
§ Chronically à Addison’s disease (destruction of adrenal gland(s) due
to disease or atrophy)
§ Autoimmune diseases are a common cause of adrenal destruction
§ Polyglandular autoimmune syndrome type 2 is a common cause of
primary adrenal insufficiency (antibodies to steroidogenic enzymes
also present)

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§ Signs and symptoms of adrenal insufficiency

include (Fig 3.28):
ü Weakness and fatigue
ü Orthostatic hypotension
ü Myalgia
ü Weight loss
ü GI disturbances
ü Blood sugar and sodium
imbalances

§ Worsening condition à Adrenal crisis, Fig 3.28: Common findings associated with adrenal
insufficiency
characterized by:
ü Fever
ü Loss of consciousness
ü Hypoglycemia and/or hyponatremia
ü Severe vomiting
ü Diarrhea


Zona reticularis (Fig 3.29):
§ Third layer of the adrenal gland
§ Produces androgens
§ Is stimulated by _________ from pituitary
§ Androgens (DHEA, DHEA-S) sent to tissues and
converted into usable steroids
Fig 3.29: Zona reticularis layer of the adrenal gland

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Adrenal medulla (Fig 3.30):

§ Innermost layer of the adrenal gland
§ Responsible for producing Epinephrine and
Norepinephrine
§ __________________________ chiefly
produced in medulla, while
__________________________ is also produced Fig 3.30: Adrenal medulla of the adrenal gland
in the CNS & PNS
§ ______________________ is the precursor to NE
§ Phenylalanine is the first step in production of NE/E (Fig 3.31)

























Fig 3.31: NE/E synthesis

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Neuroblastoma:
§ Neuroblastoma begins in nerve cells of the embryo or fetus
§ Seen more often in children < ____ years of age
§ Neuroblasts of the sympathetic nervous system
§ Approximately ____% begin in adrenals, approximately ____% overall
begin in sympathetic nerve ganglia in abdomen
§ Presentation is highly variable (some proceed quickly, some proceed
slowly)
§ Symptoms based on location of presentation (abdominal mass,
constipation, Horner syndrome, back pain, bladder dysfunction)
§ Most likely presentation is abdominal distention and a firm/irregular
mass often crossing the midline
§ Hypertension not a unique characteristic (as opposed to
Pheocromocytoma)
§ Diagnosis of Neuroblastoma based on increased levels of
catecholamine metabolites HVA, VMA and histology, which is
characterized by ___________________ Rosettes (differentiated
tumor cells encircling neuropile)
§ Associated with an overexpression of the _________ oncogene
HIGH-YIELD NUGGET (5 P’s)

Pheocromocytoma:
§ Catecholamine-secreting tumor arising from
____________________ cells of the adrenal medulla
§ Most common adrenal tumor seen in adults
§ Episodic hypertension characteristic (NE, E, DA)
§ Measure urinary & plasma catecholamines & metanephrines
§ Resection is necessary (1st – irreversible a-blockade with
Phenoxybenzamine, 2nd - b-blockade)

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Review of Important Lecture Points

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USMLE Success Academy - Book 1 313

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HORMONES OF THE KIDNEY & PANCREAS

The Kidney:
§ Main hormone is Erythropoietin (EPO)
§ EPO stimulates the _______, providing the body with greater 02-
carrying capacity
§ EPO comes from renal parenchymal cells
§ EPO is stimulated by _____________________ conditions
§ Hypoxia à EPO à Bone marrow à RBC’s
§ Excess EPO production leads to a condition known as polycythemia
§ Polycythemia + ­EPO à consider hypoxic conditions or tumor
§ Polycythemia + ¯EPO à consider bone marrow problem
§ Polycythemia rubra vera (itchiness follows hot shower/bath)


The Pancreas:
§ Made up of the head, uncinate process, neck,
body, and tail (Fig 3.32)
§ Head of the pancreas lies within the concavity of
the ______________________
§ Neck of the pancreas is a constricted portion Fig 3.32: Basic anatomy of the pancreas
between head and body
§ Body of the pancreas lies behind the ________________
§ Tail of the pancreas lies in contact with the _______________ and
runs in the _________________________ ligament
§ Pancreas is supplied by the following vessels: Superior
pancreaticoduodenal artery, inferior pancreaticoduodenal artery, and
pancreatic branch of the splenic artery (supplies neck, body, tail)

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Hormones of the pancreas:

§ The following are the most important hormones made and secreted
by the pancreas (Fig 3.33)
Ø Insulin: released from the pancreatic b-cells
Ø Glucagon: released from the pancreatic a-cells
Ø Somatostatin: released from the pancreatic d-cells
Ø Pancreatic polypeptide: released from F-cells (PP cells)

Fig 3.33: Hormones released by the pancreas

Insulin:
§ Begins as ‘Proinsulin’, which is a combination of insulin and
C-peptide (proinsulin is a single-chain polypeptide
precursor)
§ Insulin stimulated by the presence of
___________________
§ Starting material is proinsulin synthesized by the pancreas,
is cleaved via peptidase, releases free c-peptide and insulin
(Fig 3.34)
§ Newly synthesized proinsulin deposited in the RER and
transported within membrane-enclosed organelles to Fig 3.34: Proinsulin à Insulin + c-peptide
the sac of the Golgi (converted into insulin here)

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§ High levels of free fatty acids (FFA) cause insulin resistance (via
phosphorylation of Serine à interferes with downstream signaling
because serine kinase activated instead of tyrosine kinase)
§ Insulin helps move glucose into all cells, except BRICKLE:
ü B
ü R
ü I
ü C
ü K
ü L
ü E


Mechanism of Insulin secretion (Fig 3.35):
§ Glucose transported into the b-cell by facilitated diffusion through
the _________ glucose transporter
§ As glucose concentration increases, the cell begins to accumulate ATP
§ As ATP levels increase, the ATP:ADP ratio increases; this closes the
ATP-sensitive ______ channel













Fig 3.35: Mechanism of Insulin secretion from beta cells

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§ Closure of K+ channel forces K+ to accumulate within the cell,

increasing its positivity (leading to depolarization)
§ Depolarization leads to opening of the Ca2+ channels and influx of
Ca2+ via facilitated diffusion
§ Ca2+ accumulation stimulates release of Insulin into the blood via
secretory vesicles


Insulinoma:
§ Common cause of severe hypoglycemia in a non-diabetic
§ Endogenous source of insulin characterized by presence of c-peptide
§ In children, condition known as Nesidioblastosis (hyperinsulinemic
hypoglycemia), is caused by excessive functioning of the pancreatic b-
cells
§ Histology: islet cell enlargement and dysplasia

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Diabetes (comparing types 1 vs. 2 – Fig 3.36):

Fig 3.36: Comparing types 1 and 2 diabetes

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Diabetic ketoacidosis:
§ Often the result of not complying with one’s medication
§ May be the result of increased insulin requirements (stress, infection)
§ Increased ketone production due to ketogenesis from increased
circulating free fatty acids
§ b-hydroxybutyrate made in greater amounts than acetoacetate
§ DKA is characterized by any of the following:
ü Nausea & vomiting
ü Dehydration
ü Kussmaul breathing
ü Delirium
ü Psychosis
ü Acetone on the breath

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Review of Important Lecture Points

(Use this page to create a bullet-point list of the lecture’s important points)


•

USMLE Success Academy - Book 1 320

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DM 1 medications (Fig 3.37):

Fig 3.37: Type 1 diabetes medications (Insulin)

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DM 2 medications (Fig 3.38):

Fig 3.38: Type 2 diabetes medications (oral medications)

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Glucagon:
§ From the pancreatic a-cells
§ Glucagon stimulated in cases of stress and hypoglycemia
§ Hyperglycemia, Insulin, and Somatostatin will inhibit the release of
glucagon
§ Works through catabolic effects on the body (glycogenolysis, lipolysis,
etc)
§ Glucagonoma may elevate glucagon levels as high as 1000-fold
§ Glucagonoma may be characterized by the following:
ü Weight loss
ü Chronic diarrhea
ü Necrolytic migratory erythema (rash on extremities,
perineum or face)

§ Diagnosis of necrolytic migratory erythema by lesion biopsy, which
demonstrates superficial necrolysis with separation of the outer
epidermal layers with perivascular infiltration with histiocytes and
lymphocytes
§ Diagnosis of glucagonoma based on the following:
Ø Presence of NME
Ø Elevated glucagon levels (500-1000-fold increase)

Somatostatin:
§ Derived from pancreatic d-cells
§ Stimulated by both ____________________ and _________________
§ Works in the vicinity to inhibit insulin and/or glucagon release
§ Somatostatinoma decreases a variety of hormones (Insulin, Glucagon,
CCK, Gastrin, Secretin)
§ Look for glucose intolerance, diabetes, gallstones, or steatorrhea

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Pancreatic polypeptide:
§ Secreted by the _________ of the pancreas
§ Stimulated by the presence of proteins, exercise, fasting, acute
hypoglycemia
§ Inhibited by ______________________ and ___________________
§ Role in glycogenolysis and self-regulation of pancreatic secretions

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Review of Important Lecture Points

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•

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REPRODUCTIVE ENDOCRINOLOGY


Leydig cells (Fig 3.39a):
§ Interstitial cells present between the
seminiferous tubules
§ Round, found together in small groups
§ Secrete testosterone from the ____th week
gestation

Sertoli cells (Fig 3.39b):
§ Parts of the seminiferous tubules
§ Play an important role in aiding
spermatogenesis by nourishing developing
Fig 3.39: Leydig cells (a), and Sertoli cells (b)
sperm as it progresses through different
stages
§ Secrete _____ and __________

Spermatogenesis:
§ As spermatogenesis proceeds, the
germ cells migrate towards the lumen
§ Spermatogenesis occurs over
approximately ____ days and is divided
into four phases, which include mitotic
and meiotic phases (Fig 3.40)
Fig 3.40: Steps of spermatogenesis

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Steps of spermatogenesis (Fig 3.41):

Fig 3.41: Spermatogenesis

§ In first mitosis, spermatogonium from type Aà B
§ Primary spermatocyte undergoes meiosis to secondary spermatocyte
(2n à n)
§ Secondary spermatocyte undergoes secondary meiosis, creating
spermatids

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Comparing spermatogenesis with oogenesis (Fig 3.42):

Fig 3.42: Comparing spermatogenesis with oogenesis

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Fertilization (Fig 3.43):

§ Sperms binds to corona radiata (outer layer of follicles surrounding
secondary oocyte)
§ Sperm contains an acrosome cap, which
will help it penetrate
§ As sperm penetrates corona radiata and
encounter the zona pellucida, the
acrosomal reaction is initiated (binding
to ZP3 glycoprotein causes the acrosome
to burst)
§ As sperm penetrates zona pellucida,
cortical reaction whereby granules inside
secondary oocyte fuse with cell’s plasma
membrane (expels enzymes from within
Fig 3.43: Fertilization of egg by sperm
granules)
§ Glycoprotein cross-linking in zona pellucida prevents fertilization by
more than one sperm
§ Once inside the oocyte, the sperm’s outer coating and tail begin to
disintegrate and the second meiotic division occurs (sperm nucleus
fuses with ovum à genetic material fusion)

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Ovulation, fertilization, and implantation (Fig 3.44):

Fig 3.44: Ovulation, fertilization, and implantation

The menstrual cycle:
§ Regulated by FSH, LH, Estrogen, Progesterone (Fig
3.45)
§ Divided into four phases, which are approximately
from the following day ranges:
Ø Day 1-4: Menstrual cycle
Ø Day 5-13: Follicular and proliferative phase
Ø Day 13-16: Ovulatory phase
Ø Day 16-28: Secretory phase
Fig 3.45: Hormones of the menstrual cycle

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Follicular phase:
§ Phase characterized by maturation of
ovarian follicles as egg is prepared for
release (Fig 3.46)
§ Main hormone controlling this phase is
___________________
§ FSH secreted by anterior pituitary, rising
and recruiting ovarian follicles at the
graafian follicle stage
§ FSH induces granulosa cell proliferation Fig 3.46: Development of follicle in ovary

and upregulation/expression of _____ receptors on these cells

§ Under FSH influence, granulosa cells will begin to secrete estrogen,
increases GnRH and thus LH
§ Within theca cells, LH induces androgen synthesis,
stimulates proliferation/differentiation/secretion
of follicular theca cells and increases LH receptor
expression on granulosa cells
§ Throughout entire phase, estrogen stimulates
endometrial growth and causes the endometrial
cells to produce ___________________ receptors
(allows it to respond to progesterone’s rise late in
the phase)
§ Estrogen continues to rise mid-cycle,
endometrium is producing mucus, vagina’s acidity
is lowering, all to create an environment allowing
healthy sperm to penetrate and fertilize the egg
§ Estrogen levels reach their height prior to LH Fig 3.47: Estrogen/LH levels mid-cycle
surge, which occurs immediately before ovulation
(Fig 3.47)

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§ _____ surge occurs before ovulation, at which point

a ________________________ oocyte is released
from the Graafian follicle (Fig 3.48)
§ Oocyte moves into fallopian tube, where it may be
fertilized by a sperm
§ NOTE: Clomiphene inhibits estrogen receptors in
the _____________________, inhibiting negative
feedback and increasing GnRH release, thus
increasing FSH and LH release from pituitary gland

Fig 3.48: Ovulation induced by LH surge
Secretory/Luteal phase:
§ Follicle no longer contains an oocyte and will
begin to secrete progesterone (is now the corpus
luteum)
§ Rise in progesterone and estrogen allow for
growth of the secondary endometrium (decidua
functionalis), preparing it for implantation
§ Progesterone increases the number of spiral
arteries in the endometrium (Fig 3.49), also
stimulates glandular growth in the breast
§ Increased progesterone inhibits the release of FSH
and LH from the pituitary (levels drop during this Fig 3.49: Growth of the decidua functionalis
phase of the menstrual cycle)
§ Corpus luteum maintains the endometrium for fertilization
§ If fertilization occurs, progesterone levels remain high and the
decidua functionalis remains
§ If fertilization does not occur, progesterone levels drop, spiral arteries
recoil, and the decidua functionalis becomes ischemic and sloughs off

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Estrogen’s role during the menstrual cycle:

§ Plays roles in the breast, uterus, and cervix
§ Breast: stimulates ductal growth (fibrous tissue, can cause
fibroadenoma)
§ Uterus: stimulates growth of the decidua functionalis
§ Cervix: estrogen plays a role in thinning the cervical mucus so sperm
can get into the uterus


Contraception:
§ Oral contraceptive, implantable devices, Depo-Provera, Mifepristone

Oral contraceptives:
§ May be combination or progestin-only pills
§ Are the most commonly used type of birth control due to safety and
effectiveness
§ High rate of pregnancy associated with improper use (forgetting to
take pill, taking at different times each day)
§ Work by providing negative feedback in the hypothalamus and
pituitary, decreasing frequency of pulsatile GnRH and thus LH and FSH
(stops follicular development, blocks LH spike necessary for ovulation)

Implantable devices:
§ May be subcutaneous or intrauterine
§ Subcutaneous devices are synthetic polymer capsules and are
implanted into the arm, releasing a continuous low dose of progestin
(low failure rate)
§ Intrauterine devices inserted and left in the endometrial cavity, either
release hormones or induce inflammation (Copper is MC IUD)

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Injection (Depo-Provera):
§ Slow-release Progesterone injection
§ Used more commonly in younger patients who are at greater risk of
non-compliance

Mifepristone:
§ Also known as RU486
§ Is an abortificant that may be used several weeks following unsafe sex
§ Is a progesterone antagonist with strong affinity for progesterone
receptor (5x greater affinity than natural progesterone)
§ Causes necrosis and expulsion of products of conception

Contraindications to OCP usage:
§ Smoker > ____ years of age
§ Pregnancy
§ Liver disease (acute disease)
§ History of estrogen-dependent tumor
§ History of thromboembolic event (stroke)
§ History of hypertriglyceridemia


Menopause:
§ Process whereby the ovary stops producing estrogen
§ May begin anywhere between ____-____ years of age
§ Diagnosis is based on _______ levels; if > ____ is
indicative of menopause
§ Decreased estrogen levels will force the pituitary to
increase its release of FSH (Fig 3.50) Fig 3.50: Decreased estrogen leading
§ Hot flashes characteristic of menopause to increased GnRH and FSH in
menopause

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Fertility medications:
§ Clomiphene (Clomid): blocks ________________ receptors at the
hypothalamus, thus inducing ovulation by increasing pulsatile
__________
§ Leuprolide: is a __________ analog that stimulates the release of FSH
and LH
§ Pergonal: is a mixture of FSH and LH
§ Multiple gestations may be seen in those using Clomiphene and/or
Pergonal (Clomiphene à 10% rate, Pergonal à 20% rate)

Leuprolide:
§ Synthetic injection, is a GnRH analog
§ Is similar to natural brain-produced hormone
§ Used to treat a variety of problems, including:
ü Anemia due to uterine leiomyoma
ü Prostate cancer (advanced, late stage)
ü Central precocious puberty
ü Endometriosis pain

Dysfunctional uterine bleeding:
§ Characterized by irregular menstrual bleeding whereby other causes
have been ruled out
§ Most common cause of DUB is anovulation
§ Bleeding intervals may vary, with the most common intervals being
the following:
ü < 21 days or > 36 days
ü Lasts > 7 days
ü Blood loss > 80ml
§ The most effective management for DUB is the use of OCP’s

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Masculinization syndromes:
§ Virilization and hirsutism
§ Hirsutism is most commonly caused by _________ and adrenal
hyperplasia
§ Important hirsutism information:
Ø Excessive body hair (on female)
Ø Acne
Ø Increased testosterone secretion and/or increased
conversion of testosterone à DHT
Ø Spironolactone can slow the effects due to anti-androgenic
properties
Ø Flutamide blocks testosterone receptors
Ø Finasteride (5-a-reductase inhibitor) blocks conversion of
testosterone à DHT

§ Virilization associated with significant rise in testosterone levels,
leading to the development of male characteristics
§ Virilization is characterized by:
Ø Masculinization in a female
Ø Deepening of the voice
Ø Clitoromegaly
Ø Male-pattern baldness
Ø Remodeling of the bony structure

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Polycystic ovarian syndrome (PCOS):

§ Multiple cysts in the ovary (Fig 3.51) that presents with any of the
following abnormalities:
Ø Menstrual irregularities
Ø Hormonal dysregulation
Ø Increased resistance to insulin
Ø Hirsutism
Ø Acne
Ø Bilateral ovary enlargement

Fig 3.51: Normal follicles (left), polycystic ovary (right)


§ PCOS is caused by increased levels of ____, which results in an
increase in production of Androstenedione and Testosterone by the
ovarian theca cells
§ Androstenedione aromatizes to estrone and converts to estradiol in
the ovarian granulosa cells
§ Elevated estrone suppresses FSH, constant LH stimulation results in
anovulation, leading to the formation of multiple cysts

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§ Testosterone levels typically decrease after ovulation, thus without

ovulation they stay elevated (causes hirsutism)
§ Endocrine abnormalities such as poor glucose tolerance and
hyperinsulinemia
§ Acanthosis nigricans is the result of excessive growth of
keratinocytes, which results in the formation of velvety skin patches

USMLE Success Academy - Book 1 338

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Review of Important Lecture Points

(Use this page to create a bullet-point list of the lecture’s important points)


•

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FEMALE REPRODUCTIVE CANCERS

Vaginal tumors (Fig 3.52):

Fig 3.52: Vaginal tumors

Ovarian cysts (Fig 3.53):

Fig 3.53: Ovarian cysts

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Benign ovarian neoplasms (Fig 3.54):

Fig 3.54: Benign ovarian neoplasms

USMLE Success Academy - Book 1 341

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Malignant ovarian neoplasms (Fig 3.55):

Fig 3.55: Malignant ovarian neoplasms

USMLE Success Academy - Book 1 342

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Benign breast diseases (Fig 3.56):

Fig 3.56: Benign breast diseases

USMLE Success Academy - Book 1 343

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Non-invasive malignant breast tumors (Fig 3.57):

Fig 3.57: Non-invasive malignant breast tumors

Invasive malignant breast tumors (Fig 3.58):

Fig 3.58: Invasive malignant breast tumors

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Endometrial disorders (Fig 3.59):

Fig 3.59: Endometrial disorders

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INDEX Breast tumors (non-invasive Diarrhea (common causes), 143

malignant), 344 Diarrhea toxin, 162
21-OH deficiency, 52 Bronchiolitis, 267 DiGeorge syndrome, 120
AB variant, 74 Brucella, 175 Diphyllobothrium latum, 220
Bunyavirus, 273 Diploid, 109
Acanthosis nigricans, 338
Calicivirus, 260 DNA virus classification, 237
Achondroplasia, 35
California encephalitis, 273 Dopamine agonists, 286
Acid-fast stain, 144AD
disorders, 5 Campylobacter Jejuni, 189 Dopaminergic systems, 285
Actinomyces, 168 Candida albicans, 210 Down syndrome, 116
Acute hemorrhagic Cervicofacial actinomyces, 168 Dubin-Johnson syndrome, 64
conjunctivitis, 259 Chaga’s disease, 230 Duchenne muscular dystrophy,
Chancroid, 194 99
Acute intermittent porphyria,
Chediak-Higashi syndrome, 63 Dysfunctional uterine bleeding,
21
Chlamydia pneumonia, 191 335
Addison’s disease, 309-310
Adenovirus, 253-254 Chlamydia Trachomatis, 190 Eastern equine encephalitis,
Adrenal glands (anatomy of), Chronic granulomatous disease, 264
303 151 Ebola virus, 272
Adrenal medulla, 311 Citrobacter, 182 Echinococcus granulosus, 220
Adult polycystic kidney, 36 Clomiphene, 335 Echovirus, 258
Clonorchis sinensis, 222 E. Coli, 178
Albinism, 56
Clostridium Botulinum, 166 Edwards syndrome, 114
Alkaptonuria, 53
Allele frequency, 126 Clostridium Difficile, 165 Emetic toxin, 162
Alpha-1-antitrypsin deficiency, Clostridium Perfringens, 165 Empty sella syndrome, 278
57 Clostridium Tetani, 165 Endocrine glands, 276
Alpha hemolysis, 153 Coccidioidomycosis, 205 Endometrial disorders, 345
Alport syndrome, 91 Complementation (viral), 235 Entamoeba histolytica, 223
Congenital adrenal hyperplasia, Enterobacter, 182
Ancylostoma duodenale, 217
306 Enterobius vermicularis, 217
Aneuploidy, 109
Angelman syndrome, 124 Conjugation, 131 Enterococcus, 160
Anticipation, 2 Cord factor, 134 Enterohemorrhagic E. Coli, 179
Apocrine glands, 276 Cornybacterium, 163 Enteroinvasive E. Coli, 180
AR disorders, 6 Coronavirus, 272 Enteropathogenic E. Coli, 180
Arenavirus, 272 Coxsackievirus, 259 Enterotoxigenic E. Coli, 179
Craniopharyngioma, 277 Epstein-Barr virus, 250
Aspergillus fumigatus, 209
Cretinism, 299 Erythropoietin, 314
Ataxia-Telangiectasia, 55
Cri-du-chat syndrome, 112 Euploidy, 109
Autocrine glands, 276
Babesia, 227 Crimean-Congo hemorrhagic Euthyroid sick syndrome, 299
Bacillus, 162 fever, 273 Exfoliatin toxin, 151
Bacillus Anthracis, 162 Croup, 266 Exocrine glands, 276
Bacterial pharmacology, 199 Cryptococcus neoformans, 211 Familial adenomatous
Bacteria (shapes), 145 Cryptosporidium, 223 polyposis, 48
Cultures, 145 Fanconi anemia, 67
Bartonella Henselae, 175
Cushing syndrome, 308 Fertilization, 329
Becker muscular dystrophy, 97
Beta hemolysis, 153 Cystic fibrosis, 61 Filovirus, 272
Blastomycosis, 204 Cystinuria, 64 Fitz-Hugh-Curtis syndrome, 173
Bordetella Pertussis, 174 Cytomegalovirus, 251 Flavirvirus, 261
Borrelia burgdorferi, 232 Dengue fever, 261 Fragile X syndrome, 94
Borrelia recurrentis, 232 Depo-Provera, 334 Friedreich’s ataxia, 66
Dexamethasone suppression Fungal pharmacology, 214
Breast diseases (benign), 343
test, 308-309 Galactosemia, 68
Breast tumors (invasive
malignant), 344 Diabetes, 318 Gamma hemolysis, 153
Diabetic ketoacidosis, 319 Gangliosidosis, 73
Diabetes (medications), 321-322 Gaucher disease, 69
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Genital warts, 198 Insulin, 315-317 Mycobacterium Avium

Giardia Lamblia, 223 Insulinoma, 317 Complex, 169
Glucagon, 323 Job syndrome, 20 Mycobacterium Leprae, 168
Glucose-6-phosphate Kartagener’s syndrome, 79 Mycoplasma pneumonia, 191
dehydrogenase deficiency, 103 Kidney (hormones of), 314 Myotonic dystrophy, 46
Gonococcal arthritis, 173 Klebsiella, 178 Naegleria fowleri, 224
Gram-negative bacteria Klinefelter syndrome, 119 Necatar americanus, 217
algorithm, 171 Krabbe disease, 77 Neisseria Gonorrhea, 173-174
Gram-negative structure, 135, Leber hereditary optic Neisseria Meningitidis, 172
138 neuropathy, 105 Neuroblastoma, 312
Gram-positive algorithm, 148 Legionella, 191 Neurofibromatosis 1, 42
Gram-positive rods, 161 Leigh syndrome, 106 Neurofibromatosis 2, 43
Gram-positive structure, 135 Leishmania donovani, 230 Nocardia, 168
Gram stain, 144 Leptospira, 232 Non-membrane damaging
Granuloma inguinale, 194 Leukocyte adhesion deficiency, toxins, 139
Grave’s disease, 293-294 80 Onchocerca volvulus, 219
Group A Strep (Pyogenes), 157 Leuprolide, 335 Oogenesis, 328
Group B Strep (Agalactiae), 160 Leydig cells, 326 Ornithine transcarbamoylase
Group D Strep (E. Faecalis, E. LH, 284 deficiency, 96
Faecium, Bovis), 160 Li-Fraumeni syndrome, 20 Orthomyxovirus, 265
Haemophilus Influenza, 176 Listeria, 161 Oral contraception, 333
Hand, foot, and mouth disease, Listeria Meningitidis, 161 Osler Weber Rendu, 30
259 Listeria Monocytogenes, 161 Osteogenesis Imperfecta, 30
Hantavirus, 273 Loa Loa, 218 Ovarian cysts, 340
Haploid, 109 Loss of heterozygosity, 2 Ovarian neoplasms (benign),
Hardy-Weinberg, 126, 127 Lymphogranuloma venereum, 341
Hartnup disease, 75 190 Ovarian neoplasms (malignant),
Hashimoto’s thyroiditis, 298 Maple syrup urine disease, 81 342
Hemophilia A, 101 Marburg virus, 272 Ovulation, 330
Hemophilia B 101 Marfan syndrome, 27 Pancreas (anatomy of), 314
Hemochromatosis, 76 Masculinization syndromes, 336 Pancreas (hormones of), 315
Hepatitis, 241-246 Measles (Rubeola), 269 Pancreatic polypeptide, 324
Hereditary spherocytosis, 37 MELAS syndrome, 107 Paracoccidioidomycosis, 207
Herpes simplex virus, 194, 248- Membrane damaging toxins, Paracrine glands, 276
249 139 Parainfluenza, 266
Heteroplasmy, 2 Meningitis (causes by age Paramyxovirus, 266
HHV-6, 251 group), 156 Parasites (introduction), 216
HHV-8, 251 Meningitis (different causes), Parathyroid glands, 301
Hirsutism, 336 156 Parvovirus, 254
Histoplasmosis, 206 Menopause, 334 Pasteurella Multocida, 175
Holocrine glands, 276 Menstrual cycle, 330-333 Patau syndrome, 112
Human papillomavirus, 255 MEN syndromes, 28 Pelvic inflammatory disease,
Huntington’s disease, 32 MERRF syndrome, 106 190
Hurler syndrome, 75 Metachromatic leukodystrophy, Peptidoglycan wall formation,
Hypercholesterolemia, 31 83 136
Hypokalemic periodic paralysis, Mifepristone, 334 Phases of bacterial growth, 144
33 Mitochondrial disorders, 10, Phenotypic mixing (viral), 235
Hypothyroidism, 296 104 Phenylketonuria, 84
Implantable contraceptives, 333 Molluscum contagiosum, 198 Pheocromocytoma, 312
Implantation, 330 Monoploidy, 109 Picornavirus, 257
Imprinting, 2, 123 Mosaicism, 2 Pituitary, 277
Incomplete penetrance, 2 Mucor & Rhizopus, 212 Pituitary (anatomy of), 278
Influenza type A, 265 Mumps, 269-270 Pituitary (anterior), 280-286
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Pituitary (anterior hormones), Sporothrix schenckii, 213 Trematodes, 222

280, 282 Staphylococcus Aureus, 149-150 Trichinella spiralis, 218
Pituitary apoplexy, 287 Staphylococcus Epidermidis, Trichomonas vaginalis, 231
Pituitary (hormones of), 287 149, 152 Trypanosoma brucei, 225
Pituitary (posterior), 287 Staphylococcus Saprophyticus, Trypanosoma cruzi, 230
Pituitary undersecretion, 287 149, 152 Tuberous Sclerosis, 40
Plasmodium, 228-229 Staphylococcus species, 149 Tularemia, 175
Pleiotropy, 2 St. Louis encephalitis, 262 Turner syndrome, 110
Pneumococcal vaccine, 154 Streptococcus Bovis Uniparental disomy, 123
Pneumocystis jirovecii, 212 (Gallolyticus), 160 Ureaplasma urealyticum, 192
Pneumonia, 155 Streptococcus Mutans, 157 Urease-positive bacteria, 146
Poliovirus, 257 Streptococcus Pneumonia, 154 Urinary tract infections, 181
Polycystic ovarian syndrome, Streptococcus Sanguinis, 157 Vaginal tumors, 340
337-338 Streptococcus species, 153 Variable expression, 2
Polyomavirus (JC virus), 256 Strongyloides stercoralis, 217 Varicella zoster virus, 249
Poxvirus, 256 Sturge-Weber syndrome, 39 Vibrio, 189
Prader-Willi syndrome, 124 Subacute granulomatous Viral replication, 239
Primary Aldosteronism (Conn thyroiditis (DeQuervain’s), 298 Virilization, 336
syndrome), 305-306 Subacute thyroiditis, 295 Virulent phage, 130
Prolactinoma (pituitary), 286 Superantigens, 140 Virus classification, 235
Proteus, 188 Superficial cutaneous mycosis, Vitamin D resistant rickets, 93
Pseudomembranous 201 Von Hippel Lindau, 23
pharyngitis, 163 Syphilis, 195-197 Von Willebrand disease, 24
Pseudomonas, 183-184 Taenia solium, 220 Waterhouse-Friderichsen
PTH regulation, 301 Tapeworms, 220 syndrome, 172
Punnet square, 3 Tay-Sachs disease, 74 West Nile virus, 262
Reassortment (viral), 235 Teichoic acid, 133, 136 Whooping cough, 266
Recombination (viral), 235 Temperate phage, 131 Wilson’s disease, 86
Red-green color blindness, 97 Thalassemia, 58 Wuchereria bancrofti, 219
Renin Angiotensin Aldosterone Thyroid anatomy, 289 X-linked dominant disorders, 9,
system (RAAS), 304 Thyroid (blood, nerve supply), 90
Reovirus, 260 289-291 X-linked intellectual disability,
Respiratory syncytial virus, 267 Thyroid cancer, 300 102
Retinoblastoma, 26 Thyroid embryology, 289 X-linked recessive disorders, 7,
Rett syndrome, 92 Thyroid (histology), 291 95
Rhabdovirus, 271 Thyroid hormone (roles of), 291 X-linked SCID, 102
Rhinovirus, 258 Thyroid hormone (synthesis of), Yellow fever, 261
Rickettsia species, 231-232 292 Yersinia Pestis, 188
RNA virus classification, 238, Tinea capitis, 201 Zona fasciculata, 307
257 Tinea corporis, 201 Zona glomerulosa, 304
Roundworms, 217 Tinea cruris, 202 Zona reticularis, 310
Rubella, 264 Tinea manus, 202
Salmonella, 187 Tinea pedis, 202
Sandfly/Rift valley fever, 273 Tinea unguium, 202
Sandhoff disease, 74 Tinea versicolor, 203
Schistosoma, 222 Togavirus, 264
Serratia Marcescens, 182 Toxic multinodular goiter, 294
Sertoli cells, 326 Toxic thyroid adenoma, 294
Sheehan syndrome, 287 Toxocara canis, 219
Shigella, 186 Toxoplasma gondii, 224
Sickle cell disease, 86 Transduction, 130
Somatostatin, 323 Transformation, 130
Spermatogenesis, 326-327 Transposition, 132
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