Presentation on theme: "Endocrinology Subspecialty Rounds Prudhvi Karumanchi Dr. K"— Presentation transcript:
1 Endocrinology Subspecialty Rounds Prudhvi Karumanchi Dr. K Endocrinology Subspecialty Rounds Prudhvi Karumanchi Dr. K. Onyemere 2/26/09
2 Case ID: 46 y/o wm CC: Headache x 1 month HPI: Facial fullness, sinus tenderness and headache x 1 monthSignificant worsening of headache x 1 day – FrontalAssociated With photophobia6 episodes of vomitingSwelling and pain in left eye x 1 day
3 Case.. ROS: Home meds: PMH: Social history: Family history: Positive for fever, chills, vomiting, hearing loss, nasal congestion, productive coughHome meds:Keflex 500 mg po QIDMetformin 500 mg po BIDPravastatin 40 mg po dailyTylenol Codeine #3 prnPMH:COPDDM-2 (A1c: 7.9%)Sleep apnea (uses BiPAP)Social history:Quit smoking 5 years ago. Used to smoke 1 ppd x 6 yrsOccasional alcoholFamily history:DM-2 in both parents. Cancer in maternal grand father.
4 Case.. Physical Exam: VS: T: F, P: 76, R: 20, O2: 87% on RA, BP: 140/71Gen: AOx3, cooperative, fatigued, moderately obeseHead: Atraumatic, sinuses tender to palpationEyes: conjunctiva – swollen with hemorrhages. Left eye: Ptosis. protruded and swollen – Deviated inferiorly and laterallyLungs: CTA bilaterallyHeart: S1, S2, RRR, no murmurAbd: Soft, ND, NT, BS+ve, no organomegalyExtr: no edema, palpable pulsesNeuro: Rt pupil: 3 mm reactive, Left pupil: 5 mm – sluggish reaction. Afferent pupillary defect
5 Visual field testingadadfafasdfadadfaadadfafasdfadadfa
6 LABS CBC: CMP: IMAGING: Wbc: 16.3 with N: 71% and L: 21% Hb: 17.5 Plt: 259CMP:Na: 130, K: 3.7, Cl: 97, HCO3: 26, BUN: 8, Cr: 0.6LFTs: NormalIMAGING: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.
10 MRI BrainHemorrhagic pituitary macroadenoma measuring approximately 2.3 x 1.8 x 2.4 cm (AP, TR, cc)Suprasellar component of the mass causes mass effect on optic chiasmProminent chronic mucosal disease is present within sphenoid sinus, which is nearly completely obstructedMild mucosal disease is present within ethmoid sinuses bilaterally without significant sinus opacificationMRA brain: Grossly normal study
12 Pituitary apoplexy Sudden onset ACTH deficiency Decreased Cortisol At onset, gonadotropin and growth hormone secretion is decreased.ACTH and TSH deficiency may follow afterwardsRarely, there is isolated TSH deficiencyHence, 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 morningAdrenal insufficiency – same response in morning and afternoonAdminister 250 mcg iv bolus30 – 60 min peak cortisol of mcg/dL
14 Hypogonadism Decreased FSH and LH – Secondary hypogonadism Inappropriately normal FSH and Low LH with low testosterone indicate developing sec. hypogonadismMen with hypogonadismTesticular hypofunction decreased testosteroneInfertility, decreased energy and libidoHot flashes is very severeDecreased bone mineral densityTreatment:Testosterone replacement if fertility is not desiredGonadotropins if fertility is desired
15 Growth hormone deficiency Clinical features:Diminished muscle mass and increased fat massIncreased LDL cholesterolDecreased bone mineral densityDiminished sense of well beingIncreased risk of cardiovascular diseaseIncreased inflammatory cardiovascular risk markers (IL-6 and C-reactive protein)Diagnosis: Low IGF-1 levelTreatmentknown to improve muscle mass and bone mineral density
16 Pituitary Apoplexy Risk Factors: Diagnosis: MRI scan Treatment: endocrine stimulation tests bleeding disorderspregnancyestrogen therapyhead traumapituitary radiationdiabetessurgeryDiagnosis: MRI scanTreatment:High dose corticosteroidsWhen stable, trans-sphenoidal hypophysectomyPituitary and visual functions are restored after surgeryPts with extensive pituitary necrosis require lifelong hormone replacement therapy