Diagnosis of a Rare Case of Acromegaly Secondary to Pituitary Macroadenoma Debuting as Sudden DKA

Abstract Acromegaly is an uncommon clinical syndrome that results from excessive secretion of growth hormone with an annual incidence of 6 to 8 cases per 1 million of individuals with a mean age of diagnosis between 40-45 years. Pituitary adenomas can be the principal reason for an overgrowth of the anterior pituitary somatotroph cells, and account for approximately one-third of all hormone-secreting pituitary adenomas with a prevalence of about 38-69 cases per 1 million and an incidence of 3-4 cases per 1 million individuals. The onset of acromegaly is insidious, and its progression is usually very slow. At the moment of diagnosis, approximately 75% of patients have presence of macro adenomas, but most cases are diagnosed after several laboratory workups and incidental brain imaging. A characteristic clinical presentation of pituitary adenomas could be secondary to mass effect. Metabolic presentation such as diabetes is one of the most common related conditions preceding the diagnosis of acromegaly. Clinical presentation with abrupt onset of DKA could be a determining factor on disease progression due to higher GH levels correlating with an increased prevalence of insulin resistance. We present a rare case of a 28y/o female G5P3A2 without previous PMHx who presented to ER with abdominal pain, general malaise, slurred speech, headache and gait difficulty of 3 days of evolution. Upon initial evaluation at ER patient was found with hyperglycemia of 317mg/dL, low central bicarbonate, high anion gap and positive serum ketones suggestive of DKA de novo. Based on neurological complaints, head CT performed showed an incidental parasellar/suprasellar/temporal hyperdense mass measuring 2.5cm x 2.6cm with optic chiasm compression features. Upon further specific questioning patient referred amenorrhea for the past 3 years, bitemporal hemianopsia, galactorrhea and marked facial feature changes, frontal bossing, weight gain, and acanthosis nigricans, for the past year. Pituitary adenoma workup revealed low prolactin levels (1.38), markedly increased growth hormone (501) and IGF-1 (893) suggesting diagnosis of acromegaly, most likely secondary to a functioning macroadenoma. Patient initially treated with Cabergoline, uncontrolled diabetes was managed and was referred to Neurosurgery service for further evaluation and tumor removal. Based on current literature, the incidence of acromegaly cases is low, more specifically when presenting with new onset diabetic ketoacidosis, insulin resistance and secondary to functioning macroadenomas. Medical awareness should be promoted to assess for careful consideration of signs and symptoms, workup, management and treatment to assess and minimize further health complications and physical burdens acromegaly and pituitary adenomas could pose for affected individuals.

Download Full-text

Cerebellar Infarction — Review of Recent Experiences

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/s0317167100023465 ◽

1980 ◽

Vol 7 (2) ◽

pp. 97-99 ◽

Cited By ~ 8

Author(s):

W.B. Woodhurst

Keyword(s):

Clinical Presentation ◽

Clinical Signs ◽

Signs And Symptoms ◽

Clinical Syndrome ◽

Clinical Suspicion ◽

Cerebellar Infarction ◽

Tissue Mass ◽

Clinical Signs And Symptoms ◽

High Level ◽

Infarcted Tissue

SUMMARY:Six cases of acute cerebellar infarction seen on a neurosurgery service in a general hospital during a twenty-six month period are reviewed. The clinical presentation, course, and treatment are presented and discussed. This is an important clinical syndrome which requires a high level of clinical suspicion for detection. The diagnosis rests primarily upon the clinical signs and symptoms. The C.T. Scan may provide useful confirmatory evidence and clarifies the differential diagnosis. Surgial treatment by resection of the infarcted tissue — mass lesion is urgently required for those patients who deteriorate progressively.

Download Full-text

The clinical, pathological, and genetic features of familial isolated pituitary adenomas

Acta Endocrinologica ◽

10.1530/eje-07-0348 ◽

2007 ◽

Vol 157 (4) ◽

pp. 371-382 ◽

Cited By ~ 102

Author(s):

Albert Beckers ◽

Adrian F Daly

Keyword(s):

Pituitary Adenoma ◽

Pituitary Adenomas ◽

Multiple Endocrine Neoplasia Type ◽

Clinical Syndrome ◽

Clinical Approach ◽

Interacting Protein ◽

The Past ◽

Aryl Hydrocarbon ◽

Genetic Features

Pituitary adenomas occur in a familial setting in multiple endocrine neoplasia type 1 (MEN1) and Carney’s complex (CNC), which occur due to mutations in the genes MEN1 and PRKAR1A respectively. Isolated familial somatotropinoma (IFS) is also a well-described clinical syndrome related only to patients with acrogigantism. Pituitary adenomas of all types – not limited to IFS – can occur in a familial setting in the absence of MEN1 and CNC; this phenotype is termed familial isolated pituitary adenomas (FIPA). Over the past 7 years, we have described over 90 FIPA kindreds. In FIPA, both homogeneous and heterogeneous pituitary adenoma phenotypes can occur within families; virtually all FIPA kindreds contain at least one prolactinoma or somatotropinoma. FIPA differs from MEN1 in terms of a lower proportion of prolactinomas and more frequent somatotropinomas in the FIPA cohort. Patients with FIPA are significantly younger at diagnosis and have significantly larger pituitary adenomas than matched sporadic pituitary adenoma counterparts. A minority of FIPA families overall (15%) exhibit mutations in the aryl hydrocarbon receptor-interacting protein (AIP) gene; AIP mutations are present in only half of IFS kindreds occurring as part of the FIPA cohort. In families with AIP mutations, pituitary adenomas have a penetrance of over 50%. AIP mutations are extremely rare in patients with sporadic pituitary adenomas. This review deals with pituitary adenomas that occur in a familial setting, describes in detail the clinical, pathological, and genetic features of FIPA, and addresses aspects of the clinical approach to FIPA families with and without AIP mutations.

Download Full-text

A Rare Corticotroph-Secreting Tumor with Coexisting Prolactin and Growth Hormone Staining Cells

Case Reports in Endocrinology ◽

10.1155/2012/529730 ◽

2012 ◽

Vol 2012 ◽

pp. 1-5 ◽

Cited By ~ 2

Author(s):

Subramanian Kannan ◽

Susan M. Staugaitis ◽

Robert J. Weil ◽

Betul Hatipoglu

Keyword(s):

Growth Hormone ◽

Transcription Factors ◽

Pituitary Adenoma ◽

Pituitary Adenomas ◽

Rare Case ◽

Pituitary Hormones ◽

Review Literature ◽

Pituitary Cells ◽

Biological Mechanisms

Pituitary adenomas can express and secrete different hormones. Expression of pituitary hormones in nonneoplastic pituitary cells is regulated by different transcription factors. Some pituitary adenomas show plurihormonal expression. The most commonly reported plurihormonal adenomas are composed of somatotrophs, lactotrophs, thyrotrophs and gonadotrophs. Pituitary adenomas composed of both corticotroph and somatolactotroph secreting cells are not common because transcription factors regulating the expression of these hormones are different. We report a rare case of pituitary adenoma with concomitant corticotroph, prolactin, and growth hormone staining cells, review literature on similar cases, and discuss possible biological mechanisms underlying these plurihormonal tumors.

Download Full-text

SAT-276 Co-Secreting TSH and Growth Hormone Pituitary Adenoma

Journal of the Endocrine Society ◽

10.1210/jendso/bvaa046.674 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

Author(s):

Hatem Eid

Keyword(s):

Growth Hormone ◽

Pituitary Adenoma ◽

Pituitary Adenomas ◽

Case Reports ◽

Somatostatin Analogs ◽

Signs And Symptoms ◽

Pituitary Hormones ◽

Oral Glucose ◽

Pituitary Macroadenoma ◽

Α Subunit

Abstract Introduction: Secreting pituitary adenoma is exceedingly rare. Less than 15 cases having been reported. Its clinical presentation and diagnosis is challenging. We report a case of pituitary macroadenoma, with features of acromegaly and hyperthyroidism. Case report: A 75 years’ old man presented with new onset atrial fibrillation. He had high FT4 with normal TSH. His ultrasound scan of the neck showed a solitary nodule. He had ablation twice and was started on bisoprolol and anticoagulant. He had MRI scan for headaches and this showed a pituitary macroadenoma. He had high IGF-1. His oral glucose tolerance showed failure of GH suppression. His FT4 was persistently high with normal TSH and he had high a subunits. This suggested the diagnosis of TSH and GH secreting pituitary adenoma. Discussion: TSH-secreting pituitary adenomas are rare and not uncommonly, they co-secrete other pituitary hormones including growth hormones. Somatotrophs and lactotrops share common transcription factors with thyrotrophs. TSH-secreting adenomas are benign but 60% of them are locally invasive. TSH-secreting pituitary adenomas typically present with either symptoms of tumor growth like headache or visual field disturbance or symptoms of hyperthyroidism. Thyroid nodules are common in patients with TSHomas. In patients with TSH-secreting pituitary adenomas, majority will need only surgery and radiation. The medical treatment used to normalize TSH and FT4 levels is somatostatin analogs. This is effective in about 90% of patients with TSH secreting pituitary adenomas TSHoma should be differentiated from resistance to thyroid (RTH). The main difference between TSHoma and RTH is the presence of signs and symptoms of hyperthyroidism in patients with TSHoma, absence of a family history, normal thyroid hormone levels in family members, and the presence of an elevated glycoprotein α-subunit in patients with pituitary tumor. Reference: H Adams and D Adams. A case of a co-secreting TSH and growth hormone pituitary adenoma presenting with a thyroid nodule. EDM case reports 2018 [email protected]

Download Full-text

Rare presentation of the great imitator: a rare case report

International Journal of Research in Dermatology ◽

10.18203/issn.2455-4529.intjresdermatol20173929 ◽

2017 ◽

Vol 3 (3) ◽

pp. 453

Author(s):

Ravindranath Brahmadeo Chavan ◽

Vasudha Abhijit Belgaumkar ◽

Aarti Sudam Salunke ◽

Sharada Shivaji Chirame

Keyword(s):

Primary Care ◽

Health Care ◽

Rare Case ◽

Signs And Symptoms ◽

Rare Presentation ◽

The Past ◽

Modern Health Care ◽

Rare Case Report ◽

Life Threatening ◽

Primary Care Clinicians

<span>Syphilis is often thought to be a disease of the past, largely eradicated in modern health care; however, the rates are still extremely high in certain populations. The diagnosis of syphilis may be overlooked by primary-care clinicians due to the presence of nonspecific signs and symptoms that may be indistinguishable from other diseases. Left undiagnosed and untreated, life-threatening complications, including hepatitis, stroke, and nervous system damage, may occur particularly in immuno-compromised individuals. We present a case of lues maligna an extremely rare presentation of syphilis.</span>

Download Full-text

Hepatobiliary strongyloidiasis presenting as an ampullary lesion on esophagogastroduodenoscopy/endoscopic ultrasound

Gastroenterology Report ◽

10.1093/gastro/goy002 ◽

2018 ◽

Vol 7 (5) ◽

pp. 367-370 ◽

Cited By ~ 1

Author(s):

Emmanuel Ofori ◽

Daryl Ramai ◽

Alisha Khan ◽

Philip Xiao ◽

Madhavi Reddy ◽

...

Keyword(s):

Endoscopic Ultrasound ◽

Rare Case ◽

Pancreatic Cyst ◽

Clinical Presentation ◽

Strongyloides Stercoralis ◽

Parasitic Nematodes ◽

Stool Examination ◽

Intestinal Infection ◽

The Past ◽

Immunodeficiency Virus

Abstract Strongyloidiasis is an intestinal infection caused by the parasitic nematodes of the Strongyloides species, most commonly Strongyloides stercoralis. We report a case of a 66-year-old immigrant male from Haiti who presented with complaints of diarrhea and an unintentional 80-lb weight loss over the past 5 years. Stool examination was positive for strongyloidiasis. Following albendazole therapy, esophagogastroduodenoscopy (EGD) showed a unique ampullary lesion. Histopathology of the ampullary lesion showed reactive epithelium with Strongyloides larva. In addition, endoscopic ultrasound (EUS) detected a large pancreatic cyst. Both these findings were absent on EGD 5 years previously, prior to the onset of his symptoms. This paper documents a rare case of an ampullary lesion and pancreatic cyst secondary to hepatobiliary strongyloidiasis in a non-Human Immunodeficiency Virus (HIV) patient. We review the epidemiology, life cycle, clinical presentation and treatment of strongyloidiasis.

Download Full-text

Uncommon causes of dementia: rare, but not marginal

International Psychogeriatrics ◽

10.1017/s1041610205001742 ◽

2005 ◽

Vol 17 (s1) ◽

pp. S1-S2 ◽

Cited By ~ 3

Author(s):

OSVALDO P. ALMEIDA ◽

LEON FLICKER ◽

NICOLA T. LAUTENSCHLAGER

Keyword(s):

Clinical Presentation ◽

Memory Loss ◽

Signs And Symptoms ◽

Later Life ◽

Diagnostic Methods ◽

Typical Pattern ◽

Behavioral Disturbances ◽

Cognitive Domains ◽

The Past ◽

Professional Interest

Dementia is one of the most frequent and disabling health problems of our times. During the past twenty years, we have witnessed growing public and professional interest in dementia, its diagnosis and causes. This has led to the introduction of better methods of detection of cognitive impairment, coupled with early diagnosis of Alzheimer's disease and, to a lesser degree, of other forms of dementia. However, if the clinical presentation of patients does not follow the typical pattern of progressive memory loss starting in later life, then currently available diagnostic methods are less likely to be useful and patients with dementia may go unidentified for prolonged periods of time. Some of the less frequent causes of dementia may initially present with psychological or behavioral disturbances, others are associated with prominent neurological signs and symptoms. Patients may also present with marked deficits in cognitive domains other than memory, such as impaired language, which makes the diagnostic workup more difficult and onerous.

Download Full-text