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207 Cards in this Set

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what type of gland is the thyroid gland?
ENDOCRINE
What are the glands inside the thyroid gland?
Parathyroid glands
What is the histological composition of a thyroid gland?
Follicles
what are the follicle cells lined by?
Cuboidal cells
what is the function of the cuboidal cell
thyroxine (T4)
Where does the thryoxine get stored?
in the follicle in the COLLOID
what is the mechanism with which the colloid exits the gland and enters the blood stream?
Pinocytosis- binds to membrane proton and goes to organ
Once the membrane bound colloid has reached the organ what does it do?
It converts the T4 to its T3 active form
What is the function of T3
activates:
in children: brain tissue and muscle tissue
in adults: primarily muscle tissue
Why is the thyroid important in children
it is important to produce effective neurological functioning in the child
What is thyrotoxicosis?
when the patient has high levels of free T3/T4 in the serum and causing organ involment
What are the effects of Thyrotoxicosis?
GIT- steatorhea, malabsorption diarrhea
Cardiac: palpitation, tachycardia, atrial fibrillation
Constitutional: heat intolerance, weight loss despite increased appetite, sweating
Thyroid Myopathy (muscle breakdown-proximal muscle weakness)
Tremor(76%)
Staring gaze and lid lag
How can thyrotoxicosis produce sudden death
Atrial fibrillations
What can Thyrotoxicosis cause with hyperthyroidism?
1.) Graves disease (Ab +ve)
2.) Toxic MNG
3.) Toxic adenoma
ALL lead to increase in I141 uptake
What is produced by basophilic cells of the anterior pituitary?
TSH
what is produced by parafollicular or C cells?
Calcitonin
What is the etiology of Primary hyperthyroidism?
Autoimmune
What is another name of Primary hyperthyrodism?
Grave's disease
30yr old Female, exopthalamus( accumulation of fat retro orbital),
pretibial myxedema( dermal accumulation of myxoid tissue) and diffuse symmetric hyperplasia of thyroid gland.
Grave's disease/ Primary hyperthyroidism
What are the different autoimmune etiologies of Grave's disease
-Thyroid stimulating immunoglobulin(TSI)
- Thyroid growth stimulating immunoglobulin (TGI)
- TSH- receptor binding inhibitory immunoglobulin
What is the mechanism of TSH receptor binding inhibitory immunoglobulin.
blocks binding of TSH to TSH-R but stimulates thyroid gland
- fibroblastogenic- stimulates fibroblast change to adipocytes- myxedema and periorbital edema(exophthalamus)
What are the associations of Primary hyperthyroidism?
SLE, pernicious anemia
What is the morphology of Grave's disease?
-follicles lined by columnar cells
- papillary projections
- "scalloped" appearance in follicles: devoid of colloid
What are the lab findings of Grave's disease?
-Low TSH, high free T3 or T4
-Auto antibodies +
-Diffuse increase I131 uptake
- increase in resin T3 uptake
What are the complications of Primary hyperthyroidism?
Thyroid storm: sudden onset of sweating, palpitation, hyperthermia (greater than105F), atrial fibrillation increase cardiac arrest
What is the I131 Uptake in Grave's disease?
There is diffuse increased uptake
What is the I131 uptake in Primary hypothyroidism?
diffuse reduced uptake
what is the I131 uptake in exogenous thyroid hormone?
reduce uptake
What is the I131 in a toxic Adenoma?
Localized increase uptake
What is the pathogenesis behind secondary hyperthyroidism?
Pituitary adenoma of the basophilic cells - increase in TSH
What are the lab findings of Secondary hyperthyroidism?
normal or high TSH- highly elevated T3/T4
What are the lab findings of primary hypothyroidism
increase in TSH, decrease in T3/T4
What are the lab findings of secondary hypothyroidism?
decrease in TSH, decrease in T3/T4
What are the etiologies of primary hypothyroidism?
-Cretinism
- iodine defny (Sub himalayan- Goiter)
-Hashimotos Thyroiditis: goiter
idiopathic (MC in USA: no change in shape/size of gland
What causes secondary hypothyroidism?
hypothalamic failure or pituitary necrosis- sheehan's syndrome..
What are the clinical fts of hypothyroidism?
-fatigue and lethargy
- sensitivity to cold
-alopecia
- increased cholestral and TG- weight gain (chance of coronary ath)
-reduced cardiac output-Myxedema
What is myxedema?
accumulation of mucopolysaccharide in subcutaneous tissue
- may progress to myxedema coma- end stage of severe long standing hypothyroidism
-mental obtundation, bradycardia, hypotension, hypothermia..
Child has a low level of T4 and goiter. His IQ is very low, and has a pot belly, with an umbilical hernia, and a protruded tongue. He is very short (dwarf)
Cretinism
What is another name for inflammation of the thyroid gland. follicles?
Hashimoto's thyroiditis
What is the pathogenesis behind Hashimoto's thyroiditis?
Autoimmune: T cell stimulated B cells to produce AB locally:
- antithyroglobulin: Ab to colloid
-Antimicrosoma: Ab to thyroid peroxidase in cuboidal epithelium
-Anti- TSH receptor inhibitory antibody: Ab to TSH receptor
What is Hashimoto's associated with?
Rheumatic Arthritis and SLE
What is the morph of Hashimoto's?
symmetrical enlargedment of gland
-Hurthle cells: degenerated follicular cells
-Diffuse infiltrate of lymphoid follicles in thyroid (CD8 and CD4)
Female 45-65y/o, presents with painless diffuse enlargement of gland.
Hashimoto's thyroiditis
What is the genetic association with Hashimoto's
HLA DR3 and HLA DR5
what is the d/d of myxedema in an adult suffering of hypothyroidism?
Secondary- Hypopituitarism( decrease in T4 AND T3 AND TSH)

Primary thyroid disease- Autoimmune vs non autoimmune thyroiditis ( decrease in t4, t3 and increase in TSH)
What is there an increased risk of developing in a Hashimoto's patient?
Non Hoddgkin's lymphoma
What is the most common cause of hypothyroidism in adults
Hashimoto's thyroidititis
What happens when there is an increase in T3/T4 in hashimoto's?
Hashitoxicosis (due to release of thyroxin form damaged follicles), it is followed by persistent hypothyroidism
when do you get temporary loss of colloid cells?
Hashitoxicosis
What is the etiology of Subacute granulomatous thyroiditis?
Post viral infection
What is another name for De Quervin's disease?
Subacute Granulomatous thyroiditis
Female 30-50yr, has a tender, firm, enlarged gland. She has been feeling hot, sweating, has palpitations, tremors and diarrhea with an increased wbc count and ESR
Subacute granulomatous thryoidiits
What is the morphology of DeQuervin's disease
prescence of large foreign body giant cells and granuloma with inflammatory destruction of thyroid follicles.
What it the pathogenesis of Reidal thyroidititis?
dense fibrosis in thyroid and around trachea and esophagus.
Pt. presents with stridor, dyspnea, and dysphagia
Riedel thryoiditis
What is riedel thyroiditis associated wtih?
retroperitoneal and severe mediastinal fibrosis (Idiopathic pulmonary Fibrosis/ scleroderma- ANA's)
Pt. has hx of pneumonia/ septicimea, malnutrition, starvation. what might they suffer from later?
Euthyroid Sick Syndrome
Pt presents with hypothyroid like ft. with low T3 and normal T4 and TSH
Euthyroid Sick Syndrome
What is the pathogenesis of Euthyroid Sick Syndrome?
Destruction of T3 by INF- alpha and IL-2
Why is there myxedema in both Hyperthyrodism and hyperthyrodism?
This is because they both have an activate TSH-R Ab which activates a fibroblast in soft tissue, causing the production of lymphocytes and the myxedema
What receptors are found in soft tissues of fibroblast as well?
TSH-R Ab.
What happens when you activate the fibroblast TSH-R in tissue cells?
It causes production of soft tissue matrix- known as proteoglycan
Is TSH-R localised to follicular cells in the thyroid?
No it can be found in soft tissue
Hypothyroidism myxedema
is generalised all over the body
what happens in proptosis?
same as myxedema- seen in Hypo and hyper. same mechanism.
Fat/Adipose tissue accumulates behind the eye causing the protrusion
Is the accumulation of fat + lymphocytes behind the eyes reversible or irreversible in proptosis?
irreversible
Is the accumulation of proteoglycan and matrix formation reversible or irreversible?
reversible if treated properly.
What happens in a thyroglossal duct cyst?
accumulation of atrophic thryoid tissue around the thryoid.
where does the thyroglossal duct cysts arise from?
Foramena cecum, midline of neck below the hyoid bone, and moves with deglutination
What is a branchial cyst
is infront of the SCM(lateral portion)
Huge amts of lymphoctes/plasma cells accumulate here and hence it can be confused for a lymph node.
What is the d/d of a branchial cyst?
Reactive Lymph node
Fluctuant, non tender, smooth mass
Branchial Cyst
Definition of Goiter
Enlargement of thyroid gland due to any cause
what is the most common cause of goiter?
prolonger iodine defny (seen in areas surrounded by large land masses, away from the sea, oceans)
What are the types of Goiter?
-Colloid goiter: single nodule, euthryoid- huge amts of thyroxine

-Multiple Nodular Goiter(MNG) usually non toxic and euthyroid
What is the purpose of goiter formation?
To physiologically balance out the thyroxine level
If you see a goiter what do you not expect to see
Hypothyroidism
What are the complications of Multiple Nodular Goiter?
- Plummer Syndrome- nodules of MNG become toxic- produce T4 and develop hyperthyroidism

- Follicular Carcinoma
What is the morphology of goiter?
Gross: enlarged thyroid gland with multiple colloid nodule (not deficient of thyroxine)
Micro: Follicles of varying size, calcification, and fibrosis
What is I131 scan finding in MNG?
usually non-toxic and euthyroid (pt. can live with it for years)
What is the primary problem of MNG?
cosmetic effect
What does I131 tell you?
The functioning of the gland
What happens as a result of the patient developing Plummer Syndrome
Increased chance of thyroid storm and death by hyperpyrexia
What is the cause of death in a thyroid storm?
Hyperpyrexia
What is the cause of the hyper functioning of the Goiter in Plummer Syndrome
It is genetic, the same gene that is responsible for causing Glioblastoma Mulitforme of the brain
What is the age group of plummer syndrome patients?
Elderly
What type of calcifications is seen in multiple nodular goiter?
Dystrophic
What is "hot" thyroid?
produces more T3/T4( hyper functioning)- thryotoxicosis, taking up MORE I131
usually non neoplastic lesion
What is "cold" thyroid?
Produces less T3/T4 (non functional)- takes up LESS I131
usually neoplastic(adenoma/carcinoma)
What is the name of a benign thyroid tumor?
Adenoma
What is the most common type of thyroid adenoma
Follicular adenoma ( involves follicular cells)
What are the ft s of a thyroid adenoma?
usually single,
capsulated
firm
"cold"- non functional: neoplastic.
what happens when a thyroid adenoma is active?
It becomes "HOT" but it is still single, capsulated and firm.
What is another name for a "HOT" thyroid adenoma?
toxic adenoma
What is the etiology of papillary carcinoma?
radiation therapy early in life due to having a cancer and getting chemotherapy.
more common in females
Pt has a painless mass in anterior neck, it has metastasized to the enlarged cervical LN
Papillary Carcinoma
What is the gene specifically related to papillary carcinoma?
rearrangements of Tyrosine Kinase receptors of RET gene
What is the morphology of papillary carcinoma?
- psammoma body
- intranuclear pseuodoinclusion
- Orphan Annie nucleus (hypochromic nuclues)
What are the I131 findings of papillary carcinoma?
It is "COLD"
What is the age group where you would find papillary carcinoma
2nd decade and 5th decade
What is d/d of papillary carcinoma?
-Thyroglossal cyst
-Branchial(cleft) cyst
- thyroid adenoma
Why is FNAC(fine needle aspiration cytology) used to see in papillary carcinoma
pseudo inclusion
which cancers are produced by follicular cells?
Papillary carcinoma
Follicular carcinoma
Anaplastic carcinoma
What is the percentage of cases where you end up with papillary carcinoma?s
75-85%
What cancers are produced by C cells of parafollicular cells
Medullary carcinoma
Which is tumor in the thyroid is neuroendocrine in nature?
Medullary carcinoma
What is the etiology of follicular carcinoma?
iodine defny i.e. Multiple nodular goiter
What kind of spread is involved in papillary carcinoma?
lymphatics- to regional LN(cervical group)
what are the C/F of follicular carcinoma
- greater in females than males
- btw age 40-60
what are the I131 findings of follicular carcinoma?
Mostly "cold", but sometimes "hot"
What is the means of spread of follicular carcinoma?
Hematogenous spread to bone and lung
what is prognosis of papillary carcinoma?
Good, despite early metastasis
what can be seen on the microscopy of a follicular carcinoma?
capsular and vascular invasion
What disesase comes before follicular carcinoma?
MNG
What is the mutation involved in follicular carcinoma?
KRAS, HRAS, AND NRAS- therefore it is an adenocarcinoma of the thyroid gland
why is the scan finding important clinically in follicular carcinoma?
you can measure the anticancer drug uptake with I131 to kill cancer more effectively

- helps to measure metastasis- acts as an area of single uptake
What is prognosis of follicular carcinoma?
bad
What must you do to help diagnose follicular carcinoma?
A full body scan with I131
what type of carcinoma is a follicular carcinoma?
adenocarcinoma
Explain the mechanism by which capsular invasion takes place
-tumor cells express laminin receptors
- tumor cells anchors into the laminin in the receptors
- it produces collagenase 4 and Cathepsin D
-t hese enzymes break through protein
What is produced by medullary thyroid carcinoma?
Calcitonin
Thyroid storm vs myxedema coma what is the difference?
high temperature, diarrhea, taccychardia,atrial fibrillations
in thyroid storm
but in myxedema coma: there is loss of brain functioning, cold intolerance, weight gain, lethargy, fatigue, constipation, headaches
What are the associations responsible for Medullary carcinoma?
MEN 2A: medullary carcinoma and pheochromocytoma + hyperparathyroidism
MEN IIB: medullary carcinoma+ pheochromocytoma + neuroma of GIT/schwannoma
What are the other neuroendocrine tumors?
- carcinoid
-Small cell carcinoma
-Pheochromocytoma
-Neuroblastoma
-Medullary thyroid carcinoma
Does the calcitonin produced by medullary thyroid carcinoma cause changes in the body?
No, because it is localised to the tumor, and does not cause an increase in the serum levels of calcitonin
What is the mode of inheritance in Medullary Thyroid Carcinoma?
old age= sporadic
young patient= autosomal dominant familial
What is the gene mutation involved in Medullary carcinoma?
RET gene mutation
What are the associations of MEN IIA
Medullary carcinoma+ pheochromocytoma+ hyperparathyroidism
What are the associations of MEN IIB
meduallary carcinoma+ pheochromocytoma+ neuroma of GIT /schwanoma
What is the morphology of medullary thyroid carcinoma?
spindle cells and amyloid stroma (calcitonin acts like this)
what are the fts of MEN IIA?
Episodic fluctuating HTN, hypercalcemia
what are the findings of schwanoma?
Antony A area, Antony B area and Vercay bodies
what is an important marker to differentiate between MEN IIA and MEN IIB?
Calcium, as it is elevated in A and normal in B
what is the full form of MEN
multiple endocrine neoplasia
How do you manage thyroid carcinoma?
-total or partial resection
-Thyroxine replacement
1.)basal ganglia calcification- muscle rigidity
2.) overdose
- check parathyroid status after sx- hypocalcemia produces tetany
what structure in Medullary Carcinoma acts like amyloid
calcitonin
What is intact PTH
broken down product of PTH release from parathyroid gland (used PTH by tissues)
How does a surgeon recognize a parathyroid and thyroid?
parathyroid- typically looks golden yellow
thyroid- looks pink
What is PTH-related protein?
it is due to paraneoplastic syndrome- sq c carcinoma of lung, RCC
How does PTH act on the tubules of the kidney/
increase in phosphate excretion
absorption of calcium
How does PTH act on the bone?
Resorption of calcium- takes calcium out of the bone
How does PTH affect the GIT
It is in conjunction with Vit d- REUPTAKES calcium in the GIT
what does parathyroid look like histologically?
typically has a capsule
what are the two cells that make the parathyroid
chief cells
clear cells
what is the additional tissue you can see in the parathyroid gland?
adipose tissue, a lot of it around the chief cells and clear cells
which is the only organ in the body which has a normal amount of adipose tissue?
parathyroid gland
what is hyperparathyroidism?
increased levels of PTH
What is the most common cause of Primary hyperparathyroidism?
Adenoma of parathyroid
if a patient is suffering from primary hyperparathyroidism what are the affects on the renal system?
Calcium Oxalate stone formation
What effects does Primary Hyperparathyroidism have on the GIT system?
-Peptic ulcer- due to hypercalcemia
-pancreatitis
What effect does Primary hyperparathyroidism have on calcium
it increases it
What causes hyper secretion of the PTH in primary hyperparathyrodism?
the adenoma of they parathryoid- increase in bone resorption- increase in GIT absorption, increase in kidney absorption of Calcium
What effects does Primary Hyperparathyroidism have on the GIT system?
-Peptic ulcer- due to hypercalcemia
-pancreatitis
Which MEN is associated with primary hyperparathyrodism?
MEN 2 A
What effect does Primary hyperparathyroidism have on calcium
it increases it
What type of medullary carcinoma do you get in MEN 2A
RET protooncogene- familial
What causes hyper secretion of the PTH in primary hyperparathyrodism?
the adenoma of the parathryoid- increase in bone resorption- increase in GIT absorption, increase in kidney absorption of Calcium
Which MEN is associated with primary hyperparathyrodism?
MEN 2 A
What type of medullary carcinoma do you get in MEN 2A
RET protooncogene- familial
What effects does Primary Hyperparathyroidism have on the GIT system?
-Peptic ulcer- due to hypercalcemia
-pancreatitis
What effect does Primary hyperparathyroidism have on calcium
it increases it
What causes hyper secretion of the PTH in primary hyperparathyrodism?
the adenoma of the parathryoid- increase in bone resorption- increase in GIT absorption, increase in kidney absorption of Calcium
Which MEN is associated with primary hyperparathyrodism?
MEN 2 A
What type of medullary carcinoma do you get in MEN 2A
RET protooncogene- familial
what is the typical morphological finding that is unique to papillary carcinoma?
hypochromatic nucleus
what is the marker for Medullary carcinoma?
Calcitonin
How does I131 differentiate:
a. Grave's disease
b.) Plummer Syndrome
c.) Toxic adenoma
a.) diffuse excess uptake
b.) multiple focal areas of "HOT" uptake
c.) one single area of "hot" uptake
what are the lab findings of Primary Hyperparathyroidism?
increase in PTH, increase in Ca2+ and decrease in Phosphate
What is the most common cause of Secondary Hyperparathyroidism
CRF:
chronic pyelonephritis
chronic GN
Adult polycystic kidney disease
what is the typical morphological finding that is unique to papillary carcinoma?
hypochromatic nucleus
what is the marker for Medullary carcinoma?
Calcitonin
How does I131 differentiate:
a. Grave's disease
b.) Plummer Syndrome
c.) Toxic adenoma
a.) diffuse excess uptake
b.) multiple focal areas of "HOT" uptake
c.) one single area of "hot" uptake
what are the lab findings of Primary Hyperthyroidism?
increase in PTH, increase in Ca2+ and decrease in Phosphate
what is the typical morphological finding that is unique to papillary carcinoma?
hypochromatic nucleus
What is the most common cause of Secondary Hyperparathyroidism
CRF:
chronic pyelonephritis
chronic GN
Adult polycystic kidney disease
what is the marker for Medullary carcinoma?
Calcitonin
How does I131 differentiate:
a. Grave's disease
b.) Plummer Syndrome
c.) Toxic adenoma
a.) diffuse excess uptake
b.) multiple focal areas of "HOT" uptake
c.) one single area of "hot" uptake
what are the lab findings of Primary Hyperthyroidism?
increase in PTH, increase in Ca2+ and decrease in Phosphate
What is the most common cause of Secondary Hyperparathyroidism
CRF:
chronic pyelonephritis
chronic GN
Adult polycystic kidney disease
what are the other causes of Secondary hyperparathyroidism
Malabsorption, as well as Vit D defny
Lack of Vit D= activated parathyroid gland, as there is decreased levels of serum calcium due to lack of absorption
What is the mechanism behind which CRF causes 2dary Hyperparathyroidism?
It causes uremia:
causes: astrexis, there is hyperkalemia, in GIT- there is acute hemorrhagic gastritis, as well as colonic gastritis, In bone- suppresion of it leading to anemia, cardiac- fibrinous pericarditis
What is the morphology of secondary hyperparathyroidism?
produce parathyroid hyperplasia involves multiple glands
what causes primary hyperparathyroidism?
parathyroid adenoma
parathyroid hyperplasia
parathyroid carcinoma
What is a parathyroid adenoma?
Involves single gland, is capsulated and composed of mainly chief cells that release PTH
What happens in primary parathyroid hyperplasia?
it involves multiple glands
occurs as part of MEN 2B
and microscopically you see water clear cell hyperplasia
What happens to the phosphate levels in chronic renal failure?
it is secretion is impaired therefore it is increased..
What is the lab values when a pt suffers of Acute Polycystic kidney disease?
decrease in Hb and RBC, Increase in in K+
it has CRF fts and uremia ft s
What happens as a result of impaired phosphate secretion?
-increase in serum phosphate, decrease in serum calcium
- low Ca++ produces PTH production (constant activation leads to parathyroid hyperplasia)
-Leads to osteopenia (fractures) and increase in serum Ca+
-Eventually as CRF continues you get decrease in Ca++
How does loss of renal substance cause secondary hyperparathyroidism?
Reduced availability of ALFA-1- HYDROYXLASE imp for Vitamin D synthesis. results in
- reduced Ca++ absorption from GIT
-Increase in PTH to increase se. Ca++
- increase in PTH cannot act of failing kidney to excrete Phosphate therefore increase in phosphate
How does malabsorption cause secondary hyperparathyroidism?
Vitamin D defny
Impaired Ca2+ and P uptake in GIT= increase in PTH

High PTH cannot compernsate of loss of Ca2+ but causes excretiong of phosphate from functioning kidney
What are the lab values of 2dary hyperparathyroidism in malabsorption?
increase in PTH, se. Decrease in Ca++ and Phosphate, but urine increase in phospate
What are the skeletal complications of 2dary hyperparathryoidism?
Osteitis fibrosa cystica: diffuse bone loss resulting in osteoclastic resorption and fibrous replacement of bone
What are the characteristics of osteitits fibrosa cystica?
-sub periosteal thinning and bone cysts
what are the xray findings of osteitis fibrosa cystica?
Multiple lytic lesions/fractures and small hemorrhages- brown tumors

effects small bones(phalanges), skull, cetre
What is the composition of brown tumors?
depostion of hemosiderin and formation of osteoclastic giant cells
What are the other findings that are associated with Primary/Tertiary hyperparathyroidism
Moan, Bone, Groans and stones:
- Nephrocalcinosis: metastatic calcifciations
- Peptic ulcer:- G cells stimulates secretion
-Acute pancreatits: trypsinogen stimulation
-Gall stone: calcium+ bilirubin
- Psychic moans: depression, seizures hypotonia
What are the lab findings of Secondary hyperparathyroidism?
increase in serum calcium (action of PTH on bones)
-Radioimmunoassay of PTH (brown tumor)
-Hypophosphatemia
- increased urine phosphate and calcium (Action of PTH on kidney)
What is the etiology of hypoparathyroidism?
-Thyroidectomy
-Di George syndrome
What is the gene association of Di George syndrome?
CATCH 22 (22q11 deletion)
failure or 3rd and 4th pharyngeal pouch
What are the clinical fts of Di George's syndrome?
Cardiac Defects, abnormal face, thymic hypoplasia, cleft palate, hypocalcemia
What are the clinical fts. of hypoparathyroidism
-tetany: tingling sensation with muscle spasm
-prolonged QT interval
-Cataract, dental abnormality
-Positive for Trousseau's and Chvotsek's sign
What are the lab values in hypoparathyroidism?
decrease in Ca++, decrease in PTH, increase in P
What is another name for pseudo- hypoparathyroidism?
Albright's Hereditary Osteodystrophy (lack of response to PTH)
What is the pathogenesis of Pseudo- hypoparathyroidism?
PTH-resistant hypocalcemia(bone, kidney, GIT)
What is Albright's hereditary osteodystrophy associated with?
Resistance to TSH and FSH/LH
What are the c/f of pseudo-hypoparathryoidism?
-short stature, rounded face, shortened 4th metacarpal, obesity, dental hypoplasia
-primary hypothyroidism
-primary hypogonadism
what is the D/D of Albright's osteodystrophy?
-Hypothyroidism
-Cushings's syndrome
-Cretinism