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Endocrinology Subspecialty Rounds Prudhvi Karumanchi Dr. K. Onyemere 2/26/09

Endocrinology Subspecialty Rounds Prudhvi Karumanchi Dr. K. Onyemere 2/26/09. Case. ID: 46 y/o wm CC: Headache x 1 month HPI: Facial fullness, sinus tenderness and headache x 1 month Significant worsening of headache x 1 day – Frontal Associated With photophobia 6 episodes of vomiting

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Endocrinology Subspecialty Rounds Prudhvi Karumanchi Dr. K. Onyemere 2/26/09

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  1. Endocrinology Subspecialty RoundsPrudhvi KarumanchiDr. K. Onyemere2/26/09

  2. Case • ID:46 y/o wm • CC: Headache x 1 month • HPI: • Facial fullness, sinus tenderness and headache x 1 month • Significant worsening of headache x 1 day – Frontal • Associated With photophobia • 6 episodes of vomiting • Swelling and pain in left eye x 1 day

  3. Case.. • ROS: • Positive for fever, chills, vomiting, hearing loss, nasal congestion, productive cough • Home meds: • Keflex 500 mg po QID • Metformin 500 mg po BID • Pravastatin 40 mg po daily • Tylenol Codeine #3 prn • PMH: • COPD • DM-2 (A1c: 7.9%) • Sleep apnea (uses BiPAP) • Social history: • Quit smoking 5 years ago. Used to smoke 1 ppd x 6 yrs • Occasional alcohol • Family history: • DM-2 in both parents. Cancer in maternal grand father.

  4. Case.. • Physical Exam: • VS: • T: 100.6 F, P: 76, R: 20, O2: 87% on RA, BP: 140/71 • Gen: AOx3, cooperative, fatigued, moderately obese • Head: Atraumatic, sinuses tender to palpation • Eyes: conjunctiva – swollen with hemorrhages. Left eye: Ptosis. protruded and swollen – Deviated inferiorly and laterally • Lungs: CTA bilaterally • Heart: S1, S2, RRR, no murmur • Abd: Soft, ND, NT, BS+ve, no organomegaly • Extr: no edema, palpable pulses • Neuro: Rt pupil: 3 mm reactive, Left pupil: 5 mm – sluggish reaction. Afferent pupillary defect

  5. Visual field testing adadfafasdfadadfa adadfafasdfadadfa

  6. LABS • CBC: • Wbc: 16.3 with N: 71% and L: 21% • Hb: 17.5 • Plt: 259 • CMP: • Na: 130, K: 3.7, Cl: 97, HCO3: 26, BUN: 8, Cr: 0.6 • LFTs: Normal • IMAGING: • CT head: Near complete opacification of the sphenoid sinuses, mucosal thickening of the ethmoid sinuses and left frontal sinus mucous retention cyst. The globes are intact. No intracranial abnormality.

  7. IMAGING

  8. MRI brain

  9. MRI Brain – Coronal

  10. MRI Brain • Hemorrhagic pituitary macroadenoma measuringapproximately 2.3 x 1.8 x 2.4 cm (AP, TR, cc) • Suprasellar component of the mass causes mass effect on optic chiasm • Prominent chronic mucosal disease is present withinsphenoid sinus, which is nearly completely obstructed • Mild mucosal disease is present within ethmoid sinuses bilaterally without significant sinus opacification • MRA brain: Grossly normal study

  11. LABS • Human GH: 0.4 ng/ml (Low - < or = 10) • IGF-1 52 ng/mL (86 - 220) • Prolactin: 0.7 ng/dl (2.6 – 13.1 ng/ml) • FSH: 2 mIU/ml (1.3 – 19.3) • LH: 0.4 mIU/ml (1.2 – 8.6) • Free T4: 0.83 ng/dl (0.61 – 1.12) • TSH: 0.48 mcIU/ml (0.4 – 4) • Cortisol: 3.3 mcg/dl (5:37 am) (5.0-23.0) 8:00 am • Testosterone: < 0.1 (at 5:20 am and 9:20 am) • Normal: 1.75 – 7.81 ng/ml

  12. Pituitary apoplexy • Sudden onset • ACTH deficiency  Decreased Cortisol • At onset, gonadotropin and growth hormone secretion is decreased. • ACTH and TSH deficiency may follow afterwards • Rarely, there is isolated TSH deficiency • Hence, all hormones need to be tested when there is clinical suspicion

  13. Cosyntropin stim test • Cosyntropin – Synthetic ACTH 1-24 • Healthy person – greatest response in morning • Adrenal insufficiency – same response in morning and afternoon • Administer 250 mcg iv bolus • 30 – 60 min  peak cortisol of 18-20 mcg/dL

  14. Hypogonadism • Decreased FSH and LH – Secondary hypogonadism • Inappropriately normal FSH and Low LH with low testosterone indicate developing sec. hypogonadism • Men with hypogonadism • Testicular hypofunction  decreased testosterone • Infertility, decreased energy and libido • Hot flashes is very severe • Decreased bone mineral density • Treatment: • Testosterone replacement if fertility is not desired • Gonadotropins if fertility is desired

  15. Growth hormone deficiency • Clinical features: • Diminished muscle mass and increased fat mass • Increased LDL cholesterol • Decreased bone mineral density • Diminished sense of well being • Increased risk of cardiovascular disease • Increased inflammatory cardiovascular risk markers (IL-6 and C-reactive protein) • Diagnosis: Low IGF-1 level • Treatment • known to improve muscle mass and bone mineral density

  16. Pituitary Apoplexy • Risk Factors: • endocrine stimulation tests  • bleeding disorders • pregnancy • estrogen therapy • head trauma • pituitary radiation • diabetes • surgery • Diagnosis: MRI scan • Treatment: • High dose corticosteroids • When stable, trans-sphenoidal hypophysectomy • Pituitary and visual functions are restored after surgery • Pts with extensive pituitary necrosis require lifelong hormone replacement therapy

  17. Questions

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