scholarly journals Clinical syndromes of compression and surgical transection of the pituitary stalk

2018 ◽  
Vol 64 (1) ◽  
pp. 4-13 ◽  
Author(s):  
Ludmila I. Astafyeva ◽  
Boris A. Kadashev ◽  
Pavel L. Kalinin ◽  
Maxim A. Kutin ◽  
Irina S. Klochkova ◽  
...  
Keyword(s):  
Pituitary Adenoma ◽  
Diabetes Insipidus ◽  
Tumor Resection ◽  
Pituitary Stalk ◽  
Endocrine Disorders ◽  
Free T4 ◽  
Clinical Syndromes ◽  
Hypothalamic Nuclei ◽  
Dopamine Transport ◽  
The Difference

Background. The pituitary stalk (PS) is an anatomical structure consisting of the portal vessel system and axons of the hypothalamic nuclei terminating in the posterior pituitary lobe. Surgical injury or compression (by a tumor or another space-occupying process) of the PS can lead to hypopituitarism, diabetes insipidus, and hyperprolactinemia. However, the literature lacks studies on the extent of these disorders depending on PS injury or compression in clinical practice. Aim. The study aim was to investigate pre- and postoperative endocrine disorders in patients with chiasmo-sellar region (CSR) tumors and the PS compressed and preserved or involuntarily transected during neurosurgery. Material and methods. The PS compressed before surgery was preserved in 82 patients (41 patients with non-functioning endosuprasellar adenoma and 41 — with suprasellar meningioma). The PS was transected during transcranial surgery in 57 patients (46 patients with pituitary stalk craniopharyngioma and 11 patients with non-functioning endosupresellar pituitary adenoma). All patients underwent blood tests for prolactin (PRL), TSH, LH, FSH, free T4, cortisol, testosterone, or estradiol levels before and 6 months after surgery. Results. Hyperprolactinemia was detected in 37.4% of patients with CSR tumors compressing the PS. Elimination of PS compression led to normalization of the PRL level in most patients and was not accompanied by worsening of hypopituitarism symptoms. Transection of the PS resulted in panhypopituitarism in 100% of patients and diabetes insipidus in 93% of cases. There was no evidence of hyperprolactinemia in 58.7% of patients with craniopharyngiomas and 81.9% of patients with non-functioning pituitary adenomas. Conclusion. Given the difference in symptoms, we distinguished two syndromes: PS compression syndrome and PS transection syndrome. Syndrome of PS compression by a CSR tumor was characterized mainly by hyperprolactinemia (37.4% of cases); elimination of PS compression due to tumor resection led to normalization of the PRL level in most patients and was not accompanied by worsening of hypopituitarism symptoms. Syndrome of surgical PS transection in patients with craniopharyngioma (CP) and non-functioning pituitary adenoma (NFPA) manifested as panhypopituitarism in all patients and as permanent diabetes insipidus in most of them. The causes for the absence of hyperprolactinemia in many patients with the transected PS require further research. We can not exclude both adenohypophysis ischemia (due to its impaired blood supply) with partial or complete atrophy of lactotrophic cells and pituitary revascularization with restoration of dopamine transport.

scholarly journals Clinical syndromes of compression and surgical transection of the pituitary stalk

2018 ◽  
Vol 64 (1) ◽  
pp. 4-13
Author(s):  
Ludmila I. Astafyeva ◽  
Boris A. Kadashev ◽  
Pavel L. Kalinin ◽  
Maxim A. Kutin ◽  
Irina S. Klochkova ◽  
...  
Keyword(s):  
Pituitary Adenoma ◽  
Diabetes Insipidus ◽  
Tumor Resection ◽  
Pituitary Stalk ◽  
Endocrine Disorders ◽  
Free T4 ◽  
Clinical Syndromes ◽  
Hypothalamic Nuclei ◽  
Dopamine Transport ◽  
The Difference

Background. The pituitary stalk (PS) is an anatomical structure consisting of the portal vessel system and axons of the hypothalamic nuclei terminating in the posterior pituitary lobe. Surgical injury or compression (by a tumor or another space-occupying process) of the PS can lead to hypopituitarism, diabetes insipidus, and hyperprolactinemia. However, the literature lacks studies on the extent of these disorders depending on PS injury or compression in clinical practice. Aim. The study aim was to investigate pre- and postoperative endocrine disorders in patients with chiasmo-sellar region (CSR) tumors and the PS compressed and preserved or involuntarily transected during neurosurgery. Material and methods. The PS compressed before surgery was preserved in 82 patients (41 patients with non-functioning endosuprasellar adenoma and 41 — with suprasellar meningioma). The PS was transected during transcranial surgery in 57 patients (46 patients with pituitary stalk craniopharyngioma and 11 patients with non-functioning endosupresellar pituitary adenoma). All patients underwent blood tests for prolactin (PRL), TSH, LH, FSH, free T4, cortisol, testosterone, or estradiol levels before and 6 months after surgery. Results. Hyperprolactinemia was detected in 37.4% of patients with CSR tumors compressing the PS. Elimination of PS compression led to normalization of the PRL level in most patients and was not accompanied by worsening of hypopituitarism symptoms. Transection of the PS resulted in panhypopituitarism in 100% of patients and diabetes insipidus in 93% of cases. There was no evidence of hyperprolactinemia in 58.7% of patients with craniopharyngiomas and 81.9% of patients with non-functioning pituitary adenomas. Conclusion. Given the difference in symptoms, we distinguished two syndromes: PS compression syndrome and PS transection syndrome. Syndrome of PS compression by a CSR tumor was characterized mainly by hyperprolactinemia (37.4% of cases); elimination of PS compression due to tumor resection led to normalization of the PRL level in most patients and was not accompanied by worsening of hypopituitarism symptoms. Syndrome of surgical PS transection in patients with craniopharyngioma (CP) and non-functioning pituitary adenoma (NFPA) manifested as panhypopituitarism in all patients and as permanent diabetes insipidus in most of them. The causes for the absence of hyperprolactinemia in many patients with the transected PS require further research. We can not exclude both adenohypophysis ischemia (due to its impaired blood supply) with partial or complete atrophy of lactotrophic cells and pituitary revascularization with restoration of dopamine transport.

Endocrine disorders with craniopharyngioma in adults before and after surgery

2016 ◽  
Vol 62 (5) ◽  
pp. 61-62 ◽  
Author(s):  
Irina S. Klochkova ◽  
Lyudmila I. Astafieva ◽  
Alexsander N. Konovalov ◽  
Pavel L. Kalinin ◽  
Maksim A. Kutin ◽  
...  
Keyword(s):  
Endocrine Function ◽  
Pituitary Stalk ◽  
Hormone Deficiency ◽  
Endocrine Disorders ◽  
Free T4 ◽  
Group 4 ◽  
Before And After ◽  
Group 2 ◽  
Secondary Hypoadrenalism ◽  
Secondary Hypogonadism

Background. Craniopharyngiomas (CF) - a benign tumor of the embryologic origin. The surgical method of treatment is basic.Aim: to estimate dynamics of endocrine disorders before and after surgical treatment of CF at different topographical variations.Methods.The research involved 42 patients older than 18 years (25 women and 17 men) with a mean age - 41 [21; 69] with a verified diagnosis of CF. All patients were operated in 28 cases – total resection, in 7 - the pituitary stalk was saved. Before and 6 months after the surgery all patients were examined by means of hormonal blood tests (TSH, free T4, cortisol, prolactin, LH , FSH, estradiol, testosterone, IGF-1). By tumor localizing patients were divided into 4 groups: 1 – intra-suprasellar (2) 2 – at location of the pituitary stalk (15), 3 – combined «the pituitary stalk» and ventricular (10), 4 –intra-ventricular (15).Results. In group 1: panhypopituitarism -2 (100%), diabetes insipidus (DI) – 0. Both patients had subtotal ablation. After the surgery the nature of disturbance has not changed. In group 2: secondary hypoadrenalism - 9 (60%), hypothyroidism - 11 (73%), hypogonadism - 12 (80%), DI - 7 (46%), hyperprolactinemia - 9 (60%). After the surgery panhypopituitarism - 15 (100%), DI - 14 (93%), hyperprolactinemia - 4 (26 %). In group 3: secondary hypoadrenalism - 3 (30%), hypothyroidism - 6 (60%), hypogonadism - 6 (60%), DI - 2 (20%), hyperprolactinemia - 3 (30%). After the surgery panhypopituitarism - 10 (100%), DI - 10 (100%), hyperprolactinemia - 3 (30 %). In group 4: secondary hypoadrenalism - 6 (40%), hypothyroidism - 9 (60%), hypogonadism - 12 (80%), DI - 5 (33%), hyperprolactinemia - 8 (53%). After the surgery panhypopituitarism - 10 (71%), secondary hypoadrenalism - 12 (85%), hypothyroidism - 13 (92%), hypogonadism - 11 (79%), DI - 11 (78%), hyperprolactinemia - 8 (53%).Conclusion. The high incidence of endocrine disorders is caused by the localization of the CF with predominance of secondary hypogonadism and hypothyroidism. After the surgery worsening hormone deficiency was mentioned, also while preserving the pituitary stalk. Non-radical ablation of ventricular CF can partially maintain endocrine function.

scholarly journals Improvement in attention  following surgery treatment in pituitary adenoma patients: an evidence from ERP study

2020 ◽  
Author(s):  
Chenglong Cao ◽  
Jian Song ◽  
Yujing Huang ◽  
Binbin Liu ◽  
Yu Wang ◽  
...  
Keyword(s):  
Pituitary Adenoma ◽  
Cognitive Abilities ◽  
Tumor Resection ◽  
Event Related Potentials ◽  
Mass Effect ◽  
Endocrine Disorders ◽  
Healthy Controls ◽  
Hormone Levels ◽  
Transsphenoidal Adenomectomy ◽  
Related Potentials

Abstract Background: Cognitive abilities are impaired in patients with pituitary adenoma, which are mostly treated with surgery. However, the study on neurocognitive recovery after transsphenoidal adenomectomy is lacking. The study aims to identify the electrophysiological change that relates to the attention function of pituitary adenoma patients after treatment. Methods: 27 preoperative pituitary patients and 25 follow up postoperative patients were recruited. 27 healthy controls (HCs) were matched to the patients with age, sex, and education. All the pituitary adenoma patients had successfully gone through transsphenoidal adenomectomy under microscope or endoscope. Event-related potentials were used to investigate the cognitive processes of attention for preoperative patients, postoperative patients and healthy controls. In addition, eyesight and blood hormone levels were examined. Six months after surgery, blood hormone levels, pituitary MRI and electrophysiological tests were re-examined. Results: Across three groups, all emotional stimuli could evoke P200 components. Compared with HCs or postoperative patients, the amplitudes of P200 in the preoperative patients were higher. Moreover, The amplitude of P200 decreased in postoperative patients, which was similar to that in HCs. The attention was improved after surgery, but no significant differences were detected between postoperative patients and HCs. Conclusion: The tumor mass effect and abnormal hormone may be relevant to the factors that impair the attention. Compared with that of the HCs and postoperative patients, the P200 component elicited by negative stimuli is higher in preoperative patients, which is associated with the attention impairments. Furthermore, these data indicate the improvement in attention may be attributed to the tumor resection and the amelioration of endocrine disorders. This study shows that P200 component can be used to diagnose the attention in preoperative pituitary patients, and prove the improvement of the attention in postoperative patients.

scholarly journals Pituitary Metastasis of Lung Neuroendocrine Carcinoma Mimicking Pituitary Adenoma:Case Report and Literature Review

2021 ◽  
Vol 12 ◽  
Author(s):  
Xiaohai Liu ◽  
Renzhi Wang ◽  
Mingchu Li ◽  
Ge Chen
Keyword(s):  
Pituitary Adenoma ◽  
Diabetes Insipidus ◽  
Tumor Resection ◽  
Unknown Primary ◽  
Sellar Region ◽  
Asymptomatic Patients ◽  
Level Of Consciousness ◽  
Multiple Metastases ◽  
Lung Neuroendocrine Tumor ◽  
Pituitary Metastasis

Pituitary metastasis is an unusual situation in clinical practice, while the incidence is increasing with age. Breast cancer for women and lung cancer for men were the most frequent primary origins of pituitary metastasis. Diagnosing asymptomatic patients with unknown primary malignant origin is difficult, thus pituitary metastasis may be diagnosed as primary pituitary adenoma. Here, we report a case of a 65-year-old patient with visual changes and diabetes insipidus, showing an extensive mass in the sellar region which was initially thought to be a primary pituitary adenoma. Patient corticotropic deficits were corrected, and transnasal transsphenoidal surgery was adopted, leading to total tumor resection. Tumor texture during surgical procedure was similar to that of pituitary adenoma. However, the histopathological and immunohistochemistry results suggested it as a pituitary metastasis from lung neuroendocrine tumor. Postoperative chest CT scan confirmed a pulmonary mass consistent with primary neoplasm. Abdominal CT further detected multiple metastases in liver, pancreas, and colon. Despite intensive treatment, the patient continued to show decreased level of consciousness due to cachexia, resulting in death 1 week after surgery. This case highlights the importance of differential diagnosis of invasive lesions of the sellar region, especially in individuals over 60 years of age with diabetes insipidus.

scholarly journals Occult Langerhans Cell Histiocytosis Presenting with Papillary Thyroid Carcinoma, a Thickened Pituitary Stalk and Diabetes Insipidus

2016 ◽  
Vol 2016 ◽  
pp. 1-3 ◽  
Author(s):  
Michael S. Gordon ◽  
Murray B. Gordon
Keyword(s):  
Papillary Thyroid Carcinoma ◽  
Thyroid Carcinoma ◽  
Diabetes Insipidus ◽  
Langerhans Cell Histiocytosis ◽  
Hypogonadotropic Hypogonadism ◽  
Langerhans Cell ◽  
Pituitary Stalk ◽  
Bright Spot ◽  
Molecular Testing ◽  
Papillary Thyroid

Etiologies of a thickened stalk include inflammatory, neoplastic, and idiopathic origins, and the underlying diagnosis may remain occult. We report a patient with a thickened pituitary stalk (TPS) and papillary thyroid carcinoma (PTC) whose diagnosis remained obscure until a skin lesion appeared. The patient presented with PTC, status postthyroidectomy, and I131therapy. PTC molecular testing revealed BRAF mutant (V600E, GTC>GAG). She had a 5-year history of polyuria/polydipsia. Overnight dehydration study confirmed diabetes insipidus (DI). MRI revealed TPS with loss of the posterior pituitary bright spot. Evaluation showed hypogonadotropic hypogonadism and low IGF-1. Chest X-ray and ACE levels were normal. Radiographs to evaluate for extrapituitary sites of Langerhans Cell Histiocytosis (LCH) were unremarkable. Germinoma studies were negative: normal serum and CSF beta-hCG, alpha-fetoprotein, and CEA. Three years later, the patient developed vulvar labial lesions followed by inguinal region skin lesions, biopsy of which revealed LCH. Reanalysis of thyroid pathology was consistent with concurrent LCH, PTC, and Hashimoto’s thyroiditis within the thyroid. This case illustrates that one must be vigilant for extrapituitary manifestations of systemic diseases to diagnose the etiology of TPS. An activating mutation of the protooncogene BRAF is a potential unifying etiology of both PTC and LCH.

scholarly journals Metastases to the pituitary gland

2004 ◽  
Vol 16 (4) ◽  
pp. 1-4 ◽  
Author(s):  
Daniel R. Fassett ◽  
William T. Couldwell
Keyword(s):  
Pituitary Gland ◽  
Diabetes Insipidus ◽  
Skull Base ◽  
Survival Rates ◽  
Tumor Resection ◽  
Sella Turcica ◽  
Pituitary Tumors ◽  
Visual Field Defects ◽  
Malignant Neoplasms ◽  
Pituitary Metastases

Only 1% of all pituitary surgeries are performed to treat tumors that have metastasized to the pituitary gland; however, in certain cases of malignant neoplasms pituitary metastases do occur. Breast and lung cancers are the most common diseases that metastasize to the pituitary. Breast cancer metastasizes to the pituitary especially frequently, with reported rates ranging between 6 and 8% of cases. Most pituitary metastases are asymptomatic, with only 7% reported to be symptomatic. Diabetes insipidus, anterior pituitary dysfunction, visual field defects, headache/pain, and ophthalmoplegia are the most commonly reported symptoms. Diabetes insipidus is especially common in this population, occurring in between 29 and 71% of patients who experience symptoms. Differentiation of pituitary metastasis from other pituitary tumors based on neuroimaging alone can be difficult, although certain features, such as thickening of the pituitary stalk, invasion of the cavernous sinus, and sclerosis of the surrounding sella turcica, can indicate metastasis to the pituitary gland. Overall, neurohypophysial involvement seems to be most prevalent, but breast metastases appear to have an affinity for the adenohypophysis. Differentiating metastasis to the pituitary gland from bone metastasis to the skull base, which invades the sella turcica, can also be difficult. In metastasis to the pituitary gland, surrounding sclerosis in the sella turcica is usually minimal compared with metastasis to the skull base. Treatment for these tumors is often multimodal and includes surgery, radiation therapy, and chemotherapy. Tumor invasiveness can make resection difficult. Although surgical series have not shown any significant survival benefits given by tumor resection, the patient's quality of life may be improved. Survival among these patients is poor with mean survival rates reported to range between 6 and 22 months.

Approach To The Pediatric Patient: Central Diabetes Insipidus

2022 ◽  
Author(s):  
Giuseppa Patti ◽  
Flavia Napoli ◽  
Daniela Fava ◽  
Emilio Casalini ◽  
Natascia Di Iorgi ◽  
...  
Keyword(s):  
Differential Diagnosis ◽  
Diabetes Insipidus ◽  
Central Diabetes Insipidus ◽  
Pituitary Stalk ◽  
Central Nervous System Damage ◽  
Gold Standard Method ◽  
Underlying Condition ◽  
Detailed Medical History ◽  
Over Time

Abstract Central diabetes insipidus (CDI) is a complex disorder in which large volumes of dilute urine are excreted due to arginine-vasopressin deficiency, and it is caused by a variety of disorders affecting the hypothalamic-posterior pituitary network. The differential diagnosis is challenging and requires a detailed medical history, physical examination, biochemical approach, imaging studies and, in some cases, histological confirmation. Magnetic resonance imaging is the gold standard method for evaluating congenital or acquired cerebral and pituitary stalk lesions. Pituitary stalk size at presentation could be normal, but it may change over time, depending on the underlying condition, while other brain areas or organs may become involved during follow up. Early diagnosis and treatment are crucial in order to avoid central nervous system damage, germ cell tumor dissemination, and to minimize complications of multiple pituitary hormone defects. We provide a practical update on the diagnosis and management of patients with CDI and highlight several pitfalls that may complicate the differential diagnosis of conditions presenting with polyuria and polydipsia. The need for a careful and close follow-up of patients with “apparently” idiopathic CDI is particularly emphasized, because the underlying condition may be recognized over time. The clinical scenario that we outline at the beginning of this article represents the basis for the discussion about how the etiological diagnosis of CDI can be overlooked, and demonstrates how a water intake and urine output improvement can be a sign of progressive damage of both hypothalamus and anterior pituitary gland with associated pituitary hormonal deficiencies.

scholarly journals Pituitary Morphology and Function in 43 Children with Central Diabetes Insipidus

2016 ◽  
Vol 2016 ◽  
pp. 1-7 ◽  
Author(s):  
Wendong Liu ◽  
Limin Wang ◽  
Minghua Liu ◽  
Guimei Li
Keyword(s):  
Diabetes Insipidus ◽  
Central Diabetes Insipidus ◽  
Pituitary Function ◽  
Pituitary Stalk ◽  
Hormone Deficiency ◽  
Pituitary Hormone ◽  
Initial Manifestation ◽  
Stalk Diameter ◽  
And Function

Objective. In pediatric central diabetes insipidus (CDI), etiology diagnosis and pituitary function monitoring are usually delayed. This study aimed to illustrate the importance of regular follow-up and pituitary function monitoring in pediatric CDI.Methods. The clinical, hormonal, and neuroradiological characteristics of children with CDI at diagnosis and during 1.5–2-year follow-up were collected and analyzed.Results. The study included 43 CDI patients. The mean interval between initial manifestation and diagnosis was 22.29 ± 3.67 months (range: 2–108 months). The most common complaint was polyuria/polydipsia. Causes included Langerhans cell histiocytosis, germinoma, and craniopharyngioma in 2, 5, and 4 patients; the remaining were idiopathic. No significant changes were found during the 1.5–2 years after CDI diagnosis. Twenty-three of the 43 cases (53.5%) had ≥1 anterior pituitary hormone deficiency. Isolated growth hormone deficiency was the most frequent abnormality (37.5%) and was not associated with pituitary stalk diameter. Multiple pituitary hormone deficiencies were found in 8 cases with pituitary stalk diameter > 4.5 mm.Conclusion. Diagnosis of CDI is usually delayed. CDI with a pituitary stalk diameter > 4.5 mm carries a higher risk of multiple pituitary hormone deficiencies. Long-term MRI and pituitary function follow-ups are necessary for children with idiopathic CDI.

scholarly journals Reversible pituitary stalk enlargement in cranial diabetes insipidus.

1991 ◽  
Vol 54 (10) ◽  
pp. 937-938 ◽  
Author(s):  
S Teelucksingh ◽  
R Sellar ◽  
J R Seckl ◽  
C R Edwards ◽  
P L Padfield
Keyword(s):  
Diabetes Insipidus ◽  
Pituitary Stalk ◽  
Cranial Diabetes Insipidus

scholarly journals Adrenal Insufficiency Masquerading as Primary Hypothyroidism Following Immune Checkpoint Inhibitors Treatment

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A110-A111
Author(s):  
Michael Salim ◽  
Wafa Dawahir ◽  
Janice L Gilden ◽  
Andriy Havrylyan
Keyword(s):  
Adrenal Insufficiency ◽  
Immune Checkpoint ◽  
Immune Checkpoint Inhibitors ◽  
Cytotoxic T Lymphocyte ◽  
Checkpoint Inhibitors ◽  
Primary Hypothyroidism ◽  
Adrenal Crisis ◽  
Thyroid Peroxidase ◽  
Endocrine Disorders ◽  
Free T4

Abstract Background: Immune checkpoint inhibitors (ICIs) are novel immunotherapy agents that have been used to treat multiple advanced cancer. Even though they confer potential clinical advantages by regulating immune reactions, they have been linked with serious immune-mediated adverse events. Here we present a case of a patient who was treated with ICIs, Nivolumab (programmed death-1 inhibitor) and Ipilimumab (cytotoxic T lymphocyte antigen-4 inhibitor), and subsequently developed two concurrent immune-related endocrine disorders. Clinical Case: An 83-year-old man with advanced renal cell carcinoma presented with generalized weakness. He had finished four cycles of immunotherapy with Nivolumab and Ipilimumab, and Ipilimumab was discontinued afterward. Two days after the fifth cycle of immunotherapy with Nivolumab, he developed worsening fatigue, nausea, and anorexia. He appeared mildly volume depleted with borderline hypotensive (104/63 mmHg). The rest of the physical exam was unremarkable. Initial tests showed elevated levels of TSH (13.15 uIU/mL, ref 0.45–5.33 uIU/L), reduced levels of free T4 (<0.25 ng/dL, ref 0.58–1.64 ng/dL), free T3 (1.72 pg/mL, ref 2.5–3.9 pg/mL), negative thyroglobulin antibody, and elevated levels of thyroid peroxidase antibody (429 IU/mL, ref <9 IU/mL), thus suggesting primary hypothyroidism. Serum levels of sodium and potassium were unremarkable (136 meQ/L, ref 136–145 mEq/L; 3.6 meQ/L, ref 3.5–5.1 meQ/L respectively). His baseline TSH was normal three months prior to arrival (1.31 uIU/mL) and suppressed one month prior to arrival (0.01 uIU/mL). Immune-related thyroiditis with immune checkpoint inhibitors was suspected. He was given levothyroxine and observed in the hospital. After two days of hospitalization, weakness had slightly improved. However, he still had persistent nausea. He also developed low blood pressure (90/47 mmHg) and mild hyponatremia (133 mEq/L) with a normal potassium level. Further investigation showed low cortisol (1.0 ug/dL, ref 5.0–21.0), low ACTH (13 pg/mL, ref 6–50 pg/mL), cortisol level at 30 and 60 minutes post-cosyntropin stimulation test of 10.8 ug/dL (ref 13.0–30.0 ug/dL) and 14.8 ug/dL (ref 14.0–36.0 ug/dL) respectively, and negative adrenal antibodies, suggesting of secondary adrenal insufficiency due to hypophysitis. The patient was started on hydrocortisone, and his symptoms improved afterward. Conclusion: This case report highlights the common pitfall of managing immune-related endocrine disorders of ICIs. Adrenal insufficiency may present with a broad range of nonspecific symptoms, which could be attributed to hypothyroidism, underlying illness, or medications. Although a rare adverse effect, it is prudent to recognize adrenal insufficiency superimposed on primary hypothyroidism. Introducing thyroxine before replacing glucocorticoids can lead to an adrenal crisis.

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