scholarly journals A rare case of hypopituitarism with psychosis

2013 ◽  
Vol 2013 ◽  
Author(s):  
M Nwokolo ◽  
J Fletcher
Keyword(s):  
Adrenal Insufficiency ◽  
Fluid Resuscitation ◽  
Dynamic Testing ◽  
Rare Complication ◽  
False Negative ◽  
Sella Turcica ◽  
Empty Sella ◽  
Electrolyte Imbalance ◽  
List Type ◽  
Presumptive Diagnosis

Summary A 46-year-old woman presented multiple times in a 4-month period with hypotension, sepsis, hypoglycaemia and psychosis. A low random cortisol in combination with her presenting complaint made adrenal insufficiency the likely diagnosis. Fluid resuscitation and i.v. steroid therapy led to clinical improvement; however, a short synacthen test (SST) demonstrated an apparently satisfactory cortisol response. The test was repeated on a later admission and revealed a peak cortisol level of 25 nmol/l (>550 nmol/l). Concurrent treatment with i.v. hydrocortisone had led to a false-negative SST. ACTH was <5 ng/l (>10 ng/l), indicating secondary adrenal failure. We discuss the challenges surrounding the diagnosis of adrenal insufficiency and hypopituitarism, the rare complication of psychosis and a presumptive diagnosis of autoimmune lymphocytic hypophysitis (ALH). Learning points Adrenocortical insufficiency must be considered in the shocked, hypovolaemic and hypoglycaemic patient with electrolyte imbalance. Rapid treatment with fluid resuscitation and i.v. corticosteroids is vital. Polymorphic presentations to multiple specialities are common. Generalised myalgia, abdominal pain and delirium are well recognised, psychosis is rare. A random cortisol can be taken with baseline bloods. Once the patient is stable, meticulous dynamic testing must follow to confirm the clinical diagnosis. The chronic disease progression of ALH is hypothesised to be expansion then atrophy of the pituitary gland resulting in empty sella turcica and hypopituitarism. If hypopituitarism is suspected, an ACTH deficiency should be treated prior to commencing thyroxine (T4) therapy as unopposed T4 may worsen features of cortisol deficiency.

scholarly journals Empty Sella Syndrome in a Postmenopausal Woman

2012 ◽  
Vol 2 (1) ◽  
pp. 52-55
Author(s):  
Sultana Marufa Shefin ◽  
Nazmul Kabir Qureshi
Keyword(s):  
Postmenopausal Woman ◽  
Adrenal Insufficiency ◽  
Postural Hypotension ◽  
Empty Sella ◽  
Electrolyte Imbalance ◽  
Diabetic Woman ◽  
Premature Menopause ◽  
Early Menopause ◽  
Empty Sella Syndrome ◽  
Parasellar Region

A 50-year-old, prematurely postmenopausal diabetic woman was admitted in the Endocrinology department of BIRDEM with the complaints of vomiting, loose motion, lethargy, profound weakness. Previously she suffered from several episodes of electrolyte imbalance and after investigations adrenal insufficiency was diagnosed on 2010. No evaluation was done for her premature menopause. During this episode of illness, she was found with postural hypotension, hyponatremia, dyslipidemia and panhypopituitarism. MRI of sella and parasellar region was done which revealed features suggestive of empty sella. This case gives insight that early menopause warrants proper evaluation and during evaluation, along with other factors hypopituitarism should be considered as an etiology for this condition. DOI: http://dx.doi.org/10.3329/birdem.v2i1.12362 Birdem Med J 2012; 2(1) 52-55

scholarly journals Empty Sella Turcica Syndrome: About a Case Revealed by Adrenal Insufficiency

2021 ◽  
Vol 11 (02) ◽  
pp. 68-72
Author(s):  
Sow Maïmouna ◽  
Diagne Nafissatou ◽  
Ndao Awa Cheikh ◽  
Thiam Mbaye ◽  
Faye Atoumane ◽  
...  
Keyword(s):  
Adrenal Insufficiency ◽  
Sella Turcica ◽  
Empty Sella

scholarly journals Addison’s disease in antiphospholipid syndrome: a rare complication

2018 ◽  
Vol 2018 ◽  
Author(s):  
Diana Oliveira ◽  
Mara Ventura ◽  
Miguel Melo ◽  
Sandra Paiva ◽  
Francisco Carrilho
Keyword(s):  
Adrenal Insufficiency ◽  
Antiphospholipid Syndrome ◽  
Rare Complication ◽  
Addison’S Disease ◽  
Addison's Disease ◽  
List Type ◽  
Adrenal Imaging ◽  
Significant Clinical Improvement ◽  
Life Threatening ◽  
High Index Of Suspicion

Summary Addison’s disease (AD) is the most common endocrine manifestation of antiphospholipid syndrome (APS), but it remains a very rare complication of the syndrome. It is caused by adrenal venous thrombosis and consequent hemorrhagic infarction or by spontaneous (without thrombosis) adrenal hemorrhage, usually occurring after surgery or anticoagulant therapy. We present a clinical case of a 36-year-old female patient with a previous diagnosis of APS. She presented with multiple thrombotic events, including spontaneous abortions. During evaluation by the third episode of abortion, a CT imaging revealed an adrenal hematoma, but the patient was discharged without further investigation. A few weeks later, she presented in the emergency department with manifestations suggestive of adrenal insufficiency. Based on that assumption, she started therapy with glucocorticoids, with significant clinical improvement. After stabilization, additional investigation confirmed AD and excluded other etiologies; she also started mineralocorticoid replacement. This case illustrates a rare complication of APS that, if misdiagnosed, may be life threatening. A high index of suspicion is necessary for its diagnosis, and prompt treatment is crucial to reduce the morbidity and mortality potentially associated. Learning points: AD is a rare but life-threatening complication of APS. It is important to look for AD in patients with APS and a suggestive clinical scenario. APS must be excluded in patients with primary adrenal insufficiency and adrenal imaging revealing thrombosis/hemorrhage. Glucocorticoid therapy should be promptly initiated when AD is suspected. Mineralocorticoid replacement must be started when there is confirmed aldosterone deficiency. Hypertension is a common feature of APS; in patients with APS and AD, replacement therapy with glucocorticoids and mineralocorticoids may jeopardize hypertension management.

Secondary hypothyroidism following head trauma in a cat

2005 ◽  
Vol 7 (2) ◽  
pp. 135-139 ◽  
Author(s):  
Richard J Mellanby ◽  
Nic D. Jeffery ◽  
Matt S Gopal ◽  
Michael E. Herrtage
Keyword(s):  
Head Trauma ◽  
Sella Turcica ◽  
Thyroid Stimulating Hormone ◽  
Magnetic Resonance Images ◽  
Empty Sella ◽  
Presumptive Diagnosis ◽  
Stunted Growth ◽  
Low Concentrations ◽  
Secondary Hypothyroidism ◽  
Open Physis

An 18-month-old female neutered domestic short hair cat was examined because of marked polydipsia and stunted growth following head trauma when it was 8 weeks old. Diagnostic evaluation revealed hyposthenuric urine, low concentrations of thyroid hormone and undetectable thyroid stimulating hormone concentrations which did not rise following thyroid releasing hormone administration. Lateral radiographs of the left and right tibiae revealed incomplete mineralisation of the greater tubercle and open physis. An almost empty sella turcica and a greatly reduced pituitary were visible on magnetic resonance images of the brain. A presumptive diagnosis of secondary hypothyroidism and central diabetes insipidus following head trauma was made.

scholarly journals Acromegaly with empty sella syndrome

2021 ◽  
Vol 2021 ◽  
Author(s):  
Reyna Daya ◽  
Faheem Seedat ◽  
Khushica Purbhoo ◽  
Saajidah Bulbulia ◽  
Zaheer Bayat
Keyword(s):  
Growth Hormone ◽  
Past History ◽  
Sella Turcica ◽  
Primary Treatment ◽  
Empty Sella ◽  
Oral Glucose ◽  
List Type ◽  
Biochemical Tests ◽  
Ectopic Production

Summary Acromegaly is a rare, chronic progressive disorder with characteristic clinical features caused by persistent hypersecretion of growth hormone (GH), mostly from a pituitary adenoma (95%). Occasionally, ectopic production of GH or growth hormone-releasing hormone (GHRH) with resultant GH hypersecretion may lead to acromegaly. Sometimes localizing the source of GH hypersecretion may prove difficult. Rarely, acromegaly has been found in patients with an empty sella (ES) secondary to prior pituitary radiation and/or surgery. However, acromegaly in patients with primary empty sella (PES) is exceeding rarely and has only been described in a few cases. We describe a 47-year-old male who presented with overt features of acromegaly (macroglossia, prognathism, increased hand and feet size). Biochemically, both the serum GH (21.6 μg/L) and insulin-like growth factor 1 (635 μg/L) were elevated. In addition, there was a paradoxical elevation of GH following a 75 g oral glucose load. Pituitary MRI demonstrated an ES. In order to exclude an ectopic source of GH hypersecretion, further biochemical tests and imaging were done, which were unremarkable. Notably, increased uptake in the sella turcica on the 68Gallium DOTATATE PET/CT confirmed the ES as the likely source of GH secretion. As no overt lesion was noted, medical treatment (octreotide acetate) was initiated with a good clinical and biochemical response. At his 3 month follow-up, he reported an improvement in symptoms (fatigue and headache), however he still complained of low libido. Due to a persistently low testosterone level at follow-up, a long-acting testosterone was initiated. His GH level normalised, and IGF-1 has significantly reduced. Learning points The commonest cause of acromegaly is due to GH hypersecretion from pituitary adenomas (95%). Acromegaly has rarely been found in patients with ES. It is important to exclude a past history suggestive of pituitary apoplexy. Extra-pituitary source of GH such as ectopic production of GHRH with resultant GH hypersecretion needs to be excluded. In such cases, since there is no resectable mass, medical therapy is the primary treatment option.

scholarly journals The Diagnostic Accuracy of Dehydroepiandrosterone Sulfate in Diagnosing Adrenal Insufficiency

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A97-A98
Author(s):  
Malavika Suresh ◽  
Lucinda Gruber ◽  
Irina Bancos
Keyword(s):  
Diagnostic Accuracy ◽  
Adrenal Insufficiency ◽  
False Positive ◽  
Dynamic Testing ◽  
False Positive Rate ◽  
False Negative ◽  
False Negative Rate ◽  
Dehydroepiandrosterone Sulfate ◽  
Negative Rate ◽  
Positive Rate

Abstract Background: Evaluation for adrenal insufficiency (AI) includes dynamic testing that is cumbersome, expensive, and may not always be accessible. Our objective was to evaluate the diagnostic accuracy of dehydroepiandrosterone sulfate (DHEAS) in diagnosing AI. Methods: This is a single-center retrospective study of patients evaluated for AI between July 10th, 2012 to January 7th, 2020 who underwent Cosyntropin stimulation testing (CST) or Insulin tolerance test (ITT), and had baseline measurement of DHEAS. Diagnosis of adrenal insufficiency was based on peak cortisol of &lt;18 ug/dL during either CST or ITT. Results: We identified 491 patients (379 [77.2%] women, median age 42 years [range 18–84]) who met inclusion criteria. Primary adrenal insufficiency (PAI) was diagnosed in 16 (3%) patients, secondary adrenal insufficiency (SAI) was diagnosed in 211 (43%) patients, and AI was excluded in 264 (54%) patients. CST was performed in 478 (97%) patients, ITT was done in 45 (9%) patients, with 32 patients having both CST and ITT performed. Using a peak cortisol of &lt;18 mcg/dl during CST to diagnose AI, ROC analysis of DHEAS demonstrated an area under the curve of 0.79, p&lt;0.0001. A DHEAS cutoff of 100 mcg/dL excluded AI with a sensitivity of 93%, specificity of 41%, and a false negative rate of 3%. A DHEAS cut-off of 25 mcg/dl diagnosed AI with a false positive rate of 9% (Sensitivity 57% and specificity 85%). Notably, of 32 patients who had both CST and ITT performed, the diagnosis of AI was concordant in only 5 patients, while additional 27 patients had discordant results (26 were diagnosed with SAI based on ITT, but with a normal CST, and 1 patient was diagnosed with AI on CST but not on ITT). When excluding the 27 patients with discordant results, the overall performance of DHEAS in diagnosis of AI based on CST has not changed. Conclusion: DHEAS is a valuable baseline diagnostic test for AI. DHEAS &gt;100 mcg/dl predicts a normal response during CST with a false negative rate of 3%, while DHEAS &lt;25 mcg/dl is reflective of underlying adrenal insufficiency and predicts an abnormal CST with a false positive rate of 9%. In these situations, CST can be avoided.

Pituitary abscesses

1977 ◽  
Vol 46 (5) ◽  
pp. 601-608 ◽  
Author(s):  
James N. Domingue ◽  
Charles B. Wilson
Keyword(s):  
Bacterial Meningitis ◽  
Preoperative Diagnosis ◽  
World Literature ◽  
Sella Turcica ◽  
Visual Field Defects ◽  
Pituitary Abscess ◽  
Presumptive Diagnosis ◽  
Content Type ◽  
Purulent Meningitis ◽  
Fine Print

✓ Seven cases of pituitary abscess are presented and the relevant world literature is reviewed. An enlarged sella co-existing with bacterial meningitis, or bacterial meningitis coinciding with a known or suspected pituitary tumor should suggest the diagnosis of pituitary abscess. Visual field defects should evoke similar suspicion when present in a patient with meningitis. This reasoning enabled us to make the first reported preoperative diagnosis of pituitary abscess. Therefore, in the management of purulent meningitis, we recommend the following: first, skull films are mandatory; second, if the sella turcica is abnormal, the correct presumptive diagnosis is pituitary abscess; and third, if prompt improvement does not follow appropriate antibiotic therapy, the suspected abscess should be explored and drained via the transsphenoidal approach.

Adrenocortical Insufficiency in the Critically Ill Patient

1992 ◽  
Vol 3 (3) ◽  
pp. 705-713
Author(s):  
Carol Diane Epstein
Keyword(s):  
Adrenal Insufficiency ◽  
Critically Ill ◽  
Patient Outcomes ◽  
Primary Diagnosis ◽  
Critical Care Nurses ◽  
Electrolyte Imbalance ◽  
Critically Ill Patient ◽  
Patient Assessment ◽  
Multiple Organs ◽  
Adrenocortical Failure

The fluid and electrolyte imbalances associated with adrenocortical failure affect multiple physiologic systems in the critically ill patient. Because of its widespread effect, the objective signs of adrenocortical failure may escape recognition. In the context of shock states affecting the function of multiple organs that have been previously diagnosed, empirical evidence suggesting the presence of adrenal insufficiency may be attributed to the primary diagnosis and illness. However, it is most important that critical care nurses question whether adequate adrenal function is present. When effective patient assessment and management are standard components of care, adrenocortical dysfunction may be reversed, while failure to assess for signs of adrenal insufficiency may lead to irreversible patient outcomes. This paper describes phenomena of adrenocortical failure in critically ill patients and presents the problems of fluid and electrolyte imbalance that accompany them

The potentials of magnetic resonance tomography in the diagnosis of the “empty” sella turcica

1994 ◽  
Vol 24 (3) ◽  
pp. 229-233 ◽  
Author(s):  
I. I. Dedov ◽  
T. S. Zenkova ◽  
G. A. Mel'nichenko ◽  
O. I. Belichenko ◽  
I. D. Fedina
Keyword(s):  
Magnetic Resonance ◽  
Sella Turcica ◽  
Magnetic Resonance Tomography ◽  
Empty Sella

THE PRIMARY EMPTY SELLA AN ENDOCRINE STUDY ON 12 CASES

1976 ◽  
Vol 83 (3) ◽  
pp. 483-492 ◽  
Author(s):  
G. Schaison ◽  
J. Metzger
Keyword(s):  
Prolactin Level ◽  
Sella Turcica ◽  
Empty Sella ◽  
Endocrine Function ◽  
Thyrotrophin Releasing Hormone ◽  
Releasing Hormone ◽  
Group A ◽  
Group B ◽  
Lh Releasing Hormone ◽  
Primary Empty Sella

ABSTRACT Twelve patients (10 women and 2 men) with a primary empty sella turcica were studied. Endocrine function tests were performed as follows: growth hormone (GH) was measured after insulin-induced-hypoglycaemia, luteinizing hormone (LH) and follicle-stimulating hormone (FSH) after LH-releasing hormone, thyrotrophin (TSH) and prolactin after thyrotrophin-releasing hormone; pituitary reserve of adrenocorticotrophin (ACTH) was determined by measurement of plasma cortisol after lysinevasopressin and 11 deoxycortisol after metyrapone. Five of the patients (group A) had no endocrine disturbance. Seven patients (group B) had a hypothalamo-pituitary disorder. Two of them had panhypopituitarism which appeared in one case after meningoencephalitis and in the other after a severe cranial trauma. In two cases an amenorrhoea-galactorrhoea syndrome with increased prolactin level (68 and 230 ng/ml) led to a diagnosis of a prolactin producing adenoma, which was confirmed by surgery. Finally three cases of amenorrhoeagalactorrhoea, with normal prolactin level, and/or diabetes insipidus remained unexplained. However, no causal relationship could be demonstrated between the pituitary disturbance and the "empty sella". Primary empty sella turcica is therefore a neuroanatomical and neuroradiological entity with no endocrine implication. A pituitary disorder might suggest a microadenoma or an incidentally associated disease.

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