scholarly journals Successful Treatment of Myxedema Coma Using Liothyronine in the Setting of Adrenal Crisis

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A612-A613
Author(s):  
Omar Elghawy ◽  
Alexander C Hafey ◽  
Christopher Rolland McCartney ◽  
Jeremy R Steinman
Keyword(s):  
Post Partum ◽  
Vital Signs ◽  
Pituitary Surgery ◽  
Serum Cortisol ◽  
Empty Sella ◽  
Severe Illness ◽  
Adrenal Crisis ◽  
High Dose ◽  
Compensatory Mechanisms ◽  
Myxedema Coma

Abstract Background: Myxedema coma (MC) represents severe decompensated hypothyroidism and is associated with mortality rates up to 50%. It is precipitated by an acute event which disrupts compensatory mechanisms present in severe hypothyroidism. Treatment includes IV levothyroxine (LT4) with consideration of liothyronine (LT3) therapy and management of any underlying stressor. Here we present a case of MC and adrenal crisis due to pituitary dysfunction successfully treated with IV LT4 and LT3. Case: A 55-year-old female with no pertinent medical history presented with two weeks of shortness of breath, anorexia, fatigue, and unexplained falls. Her initial vital signs were notable for a blood pressure of 86/60, temperature of 36.3 °C, heart rate of 59, SpO2 of 86 on room air, and respiratory rate of 21. Exam was notable for altered mentation, respiratory distress, decreased bowel sounds, and edematous facies. Initial serum studies were notable for sodium of 133 mmol/L (135-145 mmol/L), blood glucose of 50 mg/dL (74-99 mg/dL), TSH of 2.1 mIU/L (0.45-4.50 mIU/L), and blood gas showed pH of 7.27 and PaCO2 of 84.7 mmHg. She was intubated, started on vasopressors, and IV hydrocortisone 100 mg was administered. Her pretreatment serum cortisol was unmeasurable (below 0.5 mcg/dL) and ACTH resulted at 2.0 pg/mL (7-63 pg/mL). Despite hydrocortisone 50 mg q8h, her vitals worsened with HR to 40 bpm and temperature to 34.4 °C. Given concerns for MC, free and total T4 tests were obtained and both were undetectable (below 0.4 ng/dL and 4.0 ug/dL, respectively), so 300 mcg IV LT4 was administered. The next day, the patient’s vasopressor requirement increased, so 5 mcg IV LT3 q8h was added and IV LT4 was maintained at 100 mcg/day. Total T4 and T3 were measured daily and increased into the reference range over the course of 8 days and 2 days, respectively. LT3 was discontinued after 8 days and LT4 was converted to oral regimen of 125 mcg LT4 (weight expected 115 mcg) on day 14 after extubation; her hydrocortisone was tapered to a daily total of 30 mg PO. An MRI of pituitary showed an empty sella with a thin rim of normal appearing tissue without other lesions. The patient later denied any history of post-partum hemorrhage, idiopathic intracranial hypertension, pituitary surgery, radiation, or trauma. She is currently doing well on LT4 and hydrocortisone replacement. Conclusion: This case highlights the successful use of combined LT4 and LT3 in the treatment of MC with concomitant adrenal crisis. LT3 therapy may have been particularly beneficial in this case as conversion of T4 to T3 may be limited in setting of severe illness and high-dose glucocorticoid administration. Limited observational literature suggests that LT3 use can have clinical benefit, although excessive LT3 dosing may be associated with increased mortality. Further research is required to elucidate the benefits of empiric LT3 use in MC with concurrent adrenal insufficiency.

scholarly journals SAT-469 Vitals for the Prompt Recognition of Myxedema Crisis in a Critically Ill Patient

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Katalina Funke ◽  
Faisal Aljehani ◽  
Aundrea Loftley
Keyword(s):  
Vital Signs ◽  
Critically Ill Patient ◽  
Severe Illness ◽  
High Likelihood ◽  
Myxedema Coma ◽  
Threatening Condition ◽  
Life Threatening ◽  
Low Threshold ◽  
High Level ◽  
Neuroscience Intensive Care Unit

Abstract Myxedema coma is a rare but life-threatening condition if not treated promptly. The time from initial presentation to diagnosis may be prolonged in patients with severe illness whose presenting features are common to myxedema crisis. A 94-year-old male admitted to the neuroscience intensive care unit for acute stroke monitoring after intra arterial thrombolysis was treated for myxedema three days after initial labs revealed severe hypothyroidism and a myxedema score greater than 60. A diagnostic scoring system for the diagnosis of myxedema coma gives points for the following to easily identify patients with high likelihood of decompensated state of extreme hypothyroidism. Given the potential for under recognition of myxedema crisis in severe illness the clinician must pay close attention to vital signs and have a high level of suspicion for myxedema crisis and low threshold for treatment if myxedema score indicates high likelihood despite concomitant critical illness

scholarly journals P34 Characteristics, diagnosis and management of Cushing’s disease - A systematic review and meta-analysis

BJS Open ◽  
2021 ◽  
Vol 5 (Supplement_1) ◽  
Author(s):  
Chan Hee Koh ◽  
Danyal Z Khan ◽  
Ronneil Digpal ◽  
Hugo Layard Horsfall ◽  
Hani J Marcus ◽  
...  
Keyword(s):  
Clinical Practice ◽  
Cushing’S Disease ◽  
Meta Analysis ◽  
A Priori ◽  
Pituitary Surgery ◽  
Serum Cortisol ◽  
Cushing's Disease ◽  
Diagnosis And Management ◽  
Over Time

Abstract Introduction The clinical practice and research in the diagnosis and management of Cushing’s disease remains heterogeneous and challenging to this day. We sought to establish the characteristics of Cushing’s disease, and the trends in diagnosis, management and reporting in this field. Methods Searches of PubMed and Embase were conducted. Study protocol was registered a-priori. Random-effects analyses were conducted to establish numerical estimates. Results Our screening returned 159 papers. The average age of adult patients with Cushing’s disease was 39.3, and 13.6 for children. The male:female ratio was 1:3. 8% of patients had undergone previous transsphenoidal resection. The ratio of macroadenomas: microadenomas:imaging-undetectable adenomas was 18:53:29. The most commonly reported preoperative biochemical investigations were serum cortisol (average 26.4µg/dL) and ACTH (77.5pg/dL). Postoperative cortisol was most frequently used to define remission (74.8%), most commonly with threshold of 5µg/dL (44.8%). Average remission rates were 77.8% with recurrence rate of 13.9%. Median follow-up was 38 months. Majority of papers reported age (81.9%) and sex (79.4%). Only 56.6% reported whether their patients had previous pituitary surgery. 45.3% reported whether their adenomas were macroadenoma, microadenoma or undetectable. Only 24.1% reported preoperative cortisol, and this did not improve over time. 60.4% reported numerical thresholds for cortisol in defining remission, and this improved significantly over time (p = 0.004). Visual inspection of bubbleplots showed increasing preference for threshold of 5µg/dL. 70.4% reported the length of follow up. Conclusion We quantified the characteristics of Cushing’s disease, and analysed the trends in investigation and reporting. This review may help to inform future efforts in forming guidelines for research and clinical practice.

Solumedrol Treatment for Severe Sepsis in Humans with a Blunted Adrenocorticotropic Hormone-Cortisol Response: A Prospective Randomized Double-Blind Placebo-Controlled Pilot Clinical Trial

2021 ◽  
pp. 088506662110388
Author(s):  
Divya Birudaraju ◽  
Sajad Hamal ◽  
John A. Tayek
Keyword(s):  
Blood Pressure ◽  
Clinical Trial ◽  
Adrenocorticotropic Hormone ◽  
Serum Cortisol ◽  
High Dose ◽  
Cortisol Response ◽  
Acth Stimulation ◽  
Double Blind ◽  
Significant Difference ◽  
To Receive

Purpose To test the benefits of Solumedrol treatment in sepsis patients with a blunted adrenocorticotropic hormone (ACTH)-cortisol response (delta <13 µg/dL) with regard to the number of days on ventilator, days on intravenous blood pressure support, length of time in an intensive care unit (ICU), 14-day mortality, and 28-day mortality. The trial was prospective, randomized, and double-blind. As part of a larger sepsis trial, 54 patients with sepsis had an intravenous ACTH stimulation test using 250 µg of ACTH, and serum cortisol was measured at times 0, 30, and 60 min. Eleven patients failed to increase their cortisol concentration above 19.9 µg/dL and were excluded from the clinical trial as they were considered to have adrenal insufficiency. The remaining 43 patients had a baseline cortisol of 32 ± 1 µg/dL increased to 38 ± 3 µg/dL at 30 min and 40 ± 3 at 60 min. All cortisol responses were <12.9 µg/dL between time 0 and time 60, which is defined as a blunted cortisol response to intravenous ACTH administration. Twenty-one were randomized to receive 20 mg of intravenous Solumedrol and 22 were randomized to receive a matching placebo every 8 h for 7-days. There was no significant difference between the two randomized groups. Data analysis was carried out bya two-tailed test and P < .05 as significant. Results Results: The mean age was 51 ± 2 (mean ± SEM) with 61% female. Groups were well matched with regard to APACHE III score in Solumedrol versus placebo (59 ± 6 vs 59 ± 6), white blood cell count (18.8 ± 2.2 vs 18.6 ± 2.6), and incidence of bacteremia (29 vs 39%). The 28-day mortality rate was reduced in the Solumedrol treated arm (43 ± 11 vs 73 ± 10%; P < .05). There was no change in days in ICU, days on blood pressure agents, or days on ventilator. Seven days of high-dose intravenous Solumedrol treatment (20 mg every 8 h) in patients with a blunted cortisol response to ACTH was associated with an improved 28-day survival. This small study suggests that an inability to increase endogenous cortisol production in patients with sepsis who are then provided steroid treatment could improve survival.

scholarly journals Spontaneous remission of hypercortisolism presumed due to asymptomatic tumor apoplexy in ACTH-producing pituitary macroadenoma

2013 ◽  
Vol 57 (6) ◽  
pp. 486-489 ◽  
Author(s):  
Marcio Carlos Machado ◽  
Patricia Sampaio Gadelha ◽  
Marcello Delano Bronstein ◽  
Maria Candida Barisson Vilares Fragoso
Keyword(s):  
Salivary Cortisol ◽  
Signs And Symptoms ◽  
Spontaneous Remission ◽  
Pituitary Surgery ◽  
Serum Cortisol ◽  
Urinary Free Cortisol ◽  
High Plasma ◽  
Imaging Data ◽  
Cystic Component ◽  
Free Cortisol

Cushing's disease (CD) is usually caused by secretion of ACTH by a pituitary corticotroph microadenoma. Nevertheless, 7%-20% of patients present with ACTH-secreting macroadenomas. Our aim is to report a 36-year-old female patient with CD due to solid-cystic ACTH-macroadenoma followed up during 34 months. The patient presented spontaneous remission due to presumed asymptomatic tumor apoplexy. She showed typical signs and symptoms of Cushing's syndrome (CS). Initial tests were consistent with ACTH-dependent CS: elevated urinary free cortisol, abnormal serum cortisol after low dose dexamethasone suppression test, and elevated midnight salivary cortisol, associated with high plasma ACTH levels. Pituitary magnetic resonance imaging (MRI) showed a sellar mass of 1.2 x 0.8 x 0.8 cm of diameter with supra-sellar extension leading to slight chiasmatic impingement, and showing hyperintensity on T2-weighted imaging, suggesting a cystic component. She had no visual impairment. After two months, while waiting for pituitary surgery, she presented spontaneous resolution of CS. Tests were consistent with remission of hypercortisolism: normal 24-h total urinary cortisol and normal midnight salivary cortisol. Pituitary MRI showed shrinkage of the tumor with disappearance of the chiasmatic compression. She has been free from the disease for 28 months (without hypercortisolism or hypopituitarism). The hormonal and imaging data suggested that silent apoplexy of pituitary tumor led to spontaneous remission of CS. However, recurrence of CS was described in cases following pituitary apoplexy. Therefore, careful long-term follow-up is required.

scholarly journals A woman with visual loss, amenorrhoea and polyuria: the first reported case of nodular lymphocyte-predominant Hodgkin lymphoma presenting with hypopituitarism

2021 ◽  
Vol 2021 ◽  
Author(s):  
Matthew Seymour ◽  
Thomas Robertson ◽  
Jason Papacostas ◽  
Kirk Morris ◽  
Jennifer Gillespie ◽  
...  
Keyword(s):  
Hodgkin Lymphoma ◽  
Visual Loss ◽  
Post Partum ◽  
Bone Lesion ◽  
Optic Chiasm ◽  
High Dose ◽  
List Type ◽  
Sellar Mass ◽  
Blurred Vision ◽  
Surgical Biopsy

Summary A 34-year-old woman presented 18 months post-partum with blurred vision, polyuria, amenorrhoea, headache and general malaise. Comprehensive clinical examination showed left superior temporal visual loss only. Initial investigations revealed panhypopituitarism and MRI demonstrated a sellar mass involving the infundibulum and hypothalamus. Lymphocytic hypophysitis was suspected and high dose glucocorticoids were commenced along with desmopressin and thyroxine. However, her vision rapidly deteriorated. At surgical biopsy, an irresectable grey amorphous mass involving the optic chiasm was identified. Histopathology was initially reported as granulomatous hypophysitis. Despite the ongoing treatment with glucocorticoids, her vision worsened to light detection only. Histopathological review revised the diagnosis to partially treated lymphoma. A PET scan demonstrated avid uptake in the pituitary gland in addition to splenic involvement, lymphadenopathy above and below the diaphragm, and a bone lesion. Excisional node biopsy of an impalpable infraclavicular lymph node confirmed nodular lymphocyte-predominant Hodgkin lymphoma. Hyper-CVAD chemotherapy was commenced, along with rituximab; fluid-balance management during chemotherapy (with its requisite large fluid volumes) was extremely complex given her diabetes insipidus. The patient is now in clinical remission. Panhypopituitarism persists; however, her vision has recovered sufficiently for reading large print and driving. To the best of our knowledge, this is the first reported case of Hodgkin lymphoma presenting initially as hypopituitarism. Learning points Lymphoma involving the pituitary is exceedingly rare and, to the best of our knowledge, this is the first reported case of nodular lymphocyte-predominant Hodgkin lymphoma presenting as hypopituitarism. There are myriad causes of a sellar mass and this case highlights the importance of reconsidering the diagnosis when patients fail to respond as expected to appropriate therapeutic intervention. This case highlights the difficulties associated with managing panhypopituitary patients receiving chemotherapy, particularly when this involves large volumes of i.v. hydration fluid.

scholarly journals Prevention of adrenal crisis: cortisol responses to major stress compared to stress dose hydrocortisone delivery in adrenal insufficiency

2020 ◽  
Author(s):  
Alessandro Prete ◽  
Angela E Taylor ◽  
Irina Bancos ◽  
David J Smith ◽  
Mark A Foster ◽  
...  
Keyword(s):  
Adrenal Insufficiency ◽  
Intravenous Infusion ◽  
Elective Surgery ◽  
Serum Cortisol ◽  
Total Serum ◽  
Adrenal Crisis ◽  
Bolus Administration ◽  
Continuous Intravenous Infusion ◽  
Pharmacokinetic Modelling ◽  
Linear Pharmacokinetic

ABSTRACTContextPatients with adrenal insufficiency require increased hydrocortisone cover during major stress to avoid life-threatening adrenal crisis. However, current treatment recommendations are not evidence-based.ObjectiveTo identify the most appropriate mode of hydrocortisone delivery in patients with adrenal insufficiency exposed to major stress.Design and ParticipantsCross-sectional study: 122 unstressed healthy subjects and 288 subjects exposed to different stressors (major trauma [N=83], sepsis [N=100], and combat stress [N=105]). Longitudinal study: 22 patients with preserved adrenal function undergoing elective surgery. Pharmacokinetic study: 10 patients with primary adrenal insufficiency undergoing administration of 200mg hydrocortisone over 24 hours in four different delivery modes (continuous intravenous infusion; six-hourly oral, intramuscular or intravenous bolus administration).Main Outcome MeasureWe measured total serum cortisol and cortisone, free serum cortisol and urinary glucocorticoid metabolite excretion by mass spectrometry. Linear pharmacokinetic modelling was used to determine the most appropriate mode and dose of hydrocortisone administration in patients with adrenal insufficiency exposed to major stress.ResultsSerum cortisol was increased in all stress conditions, with the highest values observed in surgery and sepsis. Continuous intravenous hydrocortisone was the only administration mode persistently achieving median cortisol concentrations in the range observed during major stress. Linear pharmacokinetic modelling identified continuous intravenous infusion of 200mg hydrocortisone over 24 hours, preceded by an initial bolus of 50-100mg hydrocortisone, as best suited for maintaining cortisol concentrations in the required range.ConclusionsContinuous intravenous hydrocortisone infusion should be favored over intermittent bolus administration in the prevention and treatment of adrenal crisis during major stress.

scholarly journals Adrenal Crisis in Long Term Use of Exogenous Steroid With Inappropriate Tapering off Process

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A108-A109
Author(s):  
Nani Oktavia ◽  
Chici Pratiwi ◽  
Jerry Nasaruddin ◽  
Muhammad Ikhsan Mokoagow ◽  
Marina Epriliawati ◽  
...  
Keyword(s):  
Abdominal Pain ◽  
Blood Glucose ◽  
Adrenal Insufficiency ◽  
Clinical Manifestations ◽  
Adrenal Crisis ◽  
High Dose ◽  
Symptomatic Therapy ◽  
Bowel Sound ◽  
Primary Adrenal Insufficiency

Abstract Background: Adrenal crisis is an emergency condition in endocrinology that commonly found in primary adrenal insufficiency but also occur in chronic adrenal insufficiency triggered by various conditions such as sepsis, infection, trauma, burns, surgery, and myocardial infarction. In chronic adrenal insufficiency, adrenal crisis can be induced by excessive reductions or inadequate discontinuation of steroid treatment. Case Illustration: A 40-year old-man admitted with chief complaint abdominal pain since seven days before admission. He felt pain in the umbilical area and slowly radiated to all the part of abdomen. Other than that, he also felt nausea, had vomitus, fever, and constipation for five days. He was immobilized for four months, with muscles weakness and atrophy. He was diagnosed with Focal Segmented Glomerulosclerosis and had a high dose of methylprednisolone (48 mg) for 6 months, 40 mg for the next 2 months and methylprednisolone 12 mg for the last 2 months. The last two month, he began to have severe general weakness and hypotension. On physical examination we found hypotension, fever (38.1o C), pale conjunctiva, moon face, buffalo hump, slightly distended and tenderness of abdomen, normal bowel sound, and purple striae all over the abdomen and extremities. On laboratory examination, Hb was 8.2 (n 11.7 – 15.5 g/dl), leukocytes 10,400 (5.00 – 10.00 x 103/μL), Na 123 (n 135 – 147 mmol/L), random blood glucose 74 (n 70 – 140 mg/dL). On abdominal X ray, there was prominent faecal material and no signs of ileus. No sign of infection found in urinalysis. He had sodium correction, packed red cell transfusion, symptomatic therapy including laxative, methylprednisolone 12 mg, but no improvement of signs and symptoms beside be able to defecate. The abdominal ultrasound gave a normal result. The morning cortisol level was then examined, with the result 14.4 (n 3.7–19.4). The patient was then diagnosed with adrenal crisis based on the clinical manifestations and had hydrocortisone therapy 100 mg a day for 2 consecutive days. After hydrocortisone administration, the symptoms improved, no fever and abdominal pain, he had normotension, increased sodium level 132 (n 135 – 147 mmol/L) and blood glucose level 118 (n 70 – 140 mg/dL). On the third day the patient discharged with oral hydrocortisone 15 mg in the morning and 10 mg in the afternoon. Conclusion: Adrenal crisis was generally found in primary adrenal insufficiency but could also occur in secondary adrenal insufficiency due to inappropriate tapering off process of long term glucocorticoid use.

scholarly journals Effects of Pituitary Surgery and High-Dose Cabergoline Therapy on Metabolic Profile in Patients With Prolactinoma Resistant to Conventional Cabergoline Treatment

2021 ◽  
Vol 12 ◽  
Author(s):  
Rosa Pirchio ◽  
Renata S. Auriemma ◽  
Domenico Solari ◽  
Mauro Arnesi ◽  
Claudia Pivonello ◽  
...  
Keyword(s):  
Medical Therapy ◽  
Metabolic Profile ◽  
Ldl Cholesterol ◽  
Fasting Glucose ◽  
Pituitary Surgery ◽  
High Dose ◽  
Fasting Insulin ◽  
Beneficial Impact ◽  
Group 2 ◽  
Group 1

ObjectiveControl of prolactin excess is associated with the improvement in gluco-insulinemic and lipid profile. The current study aimed at investigating the effects of pituitary surgery and medical therapy with high dose cabergoline (≥2mg/week) on metabolic profile in patients with prolactinoma resistant to cabergoline conventional doses (&lt;2mg/week).DesignThirty-four patients (22 men, 12 women, aged 33.9 ± 12.5 years) with prolactinoma (4 microadenomas and 30 macroadenomas) were included in the present study. Among them 17 (50%) received pituitary surgery (PS, Group1) and 17 (50%) medical therapy with high dose cabergoline (Group 2).MethodsIn the whole patient cohort, anthropometric (weight, BMI) and biochemical (fasting glucose and insulin, triglycerides, total, HDL and LDL-cholesterol, HOMA-IR, HOMA-β and ISI0) parameters were evaluated before and within 12 months after treatment.ResultsIn Group 1, prolactin (p=0.002), total cholesterol (p=0.012), and triglycerides (p=0.030) significantly decreased after pituitary surgery compared to the baseline. Prolactin significantly correlated with fasting glucose (r=0.056, p=0.025). In Group 2, fasting insulin (p=0.033), HOMA-β (p=0.011) and ISI0 (p=0.011) significantly improved compared to baseline. Postoperative cabergoline dose significantly correlated with Δfasting glucose (r=-0.556, p=0.039) and ΔLDL cholesterol (r=- 0.521, p=0.046), and was the best predictor of ΔLDL cholesterol (r2 = 0.59, p=0.002) in Group 1.ConclusionsThe rapid decrease in PRL levels induced by PS might improve lipid metabolism, whereas HD-CAB might exert a beneficial impact on both insulin secretion and peripheral sensitivity, thus inducing a global metabolic improvement.

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