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 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: Home meds: PMH: Social history: Family history:
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: 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
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6. LABS CBC: CMP: IMAGING: 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 measuring approximately 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 within sphenoid 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 ng/mL ( )
Prolactin: ng/dl (2.6 – 13.1 ng/ml)
FSH: 2 mIU/ml (1.3 – 19.3)
LH: mIU/ml (1.2 – 8.6)
Free T4: ng/dl (0.61 – 1.12)
TSH: mcIU/ml (0.4 – 4)
Cortisol: 3.3 mcg/dl (5:37 am) ( ) 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 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: Diagnosis: MRI scan Treatment:
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