scholarly journals Hyponatremia with Rhabdomyolysis - Unusual Presentation of Pituitary Apoplexy

2019 ◽  
Vol 20 (1) ◽  
pp. 49-51
Author(s):  
Peter George ◽  
Neema Montadka Lingappa Gowda
Keyword(s):  
Creatine Phosphokinase ◽  
Pituitary Apoplexy ◽  
Urine Osmolality ◽  
Clinical History ◽  
Blood Chemistry ◽  
Cystic Mass ◽  
Medical Emergency ◽  
Severe Hyponatremia ◽  
Sodium Correction ◽  
Calf Pain

Hyponatremia is increasingly being identified among hospitalized patients. It significantly alters outcome either by itself or by inappropriate correction. We report a 29-year-old man, who presented to the out-patient services with headache of 1 week and projectile vomiting of 2 days. He also had cramps in calf since a day. Had no fever and had received intramuscular injection for calf pain. Clinical examination including fundoscopy were normal except for irritability and calf tenderness. Blood chemistry and haematology were normal, except for hyponatremia (110 m Eq/L) and elevated CPK (creatine phosphokinase). SIADH was considered as he was euvolemic with low serum osmolality and high urine osmolality. Further evaluation showed hypoadrenalism and hypothyroidism suggestive of hypopituitarism. Subsequent MRI of sella revealed a 1 cm3 cystic mass with features of haemorrhage. Pituitary apoplexy with hypopituitarism was definitive, considering the acute presentation. Supplementation of steroids and thyroxine along with sodium correction improved him symptomatically. Trans-sphenoidal resection of the sellar cystic lesion was performed. Often a good clinical history, assessment and judicious investigations can identify the cause for hyponatremia. Rhabdomyolysis is known to occur in severe hyponatremia and adrenal insufficiency as with the present case. In literature, there are reports of pituitary apoplexy presenting with rhabdomyolysis and hyponatremia. Pituitary apoplexy is a medical emergency which requires early identification, hormonal supplementation and supportive care for better outcome. J MEDICINE JUL 2019; 20 (1) : 49-51

A case of pituitary apoplexy. a acute medical emergency and restitutio ad integrum

2017 ◽  
Author(s):  
Pilar Rodriguez ◽  
Maria Lainez ◽  
Maria Jose Lopez ◽  
Eloisa Roldan ◽  
Isabel Rebollo
Keyword(s):  
Pituitary Apoplexy ◽  
Medical Emergency ◽  
Restitutio Ad Integrum

scholarly journals Multidisciplinary Management of Pituitary Apoplexy

2016 ◽  
Vol 2016 ◽  
pp. 1-11 ◽  
Author(s):  
Adriana Albani ◽  
Francesco Ferraù ◽  
Filippo Flavio Angileri ◽  
Felice Esposito ◽  
Francesca Granata ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Pituitary Gland ◽  
Multidisciplinary Approach ◽  
Pituitary Apoplexy ◽  
Clinical Syndrome ◽  
Surgical Decompression ◽  
Medical Emergency ◽  
Multidisciplinary Management ◽  
Pituitary Tumours ◽  
Haemorrhagic Necrosis

Pituitary apoplexy is a rare clinical syndrome due to ischemic or haemorrhagic necrosis of the pituitary gland which complicates 2–12% of pituitary tumours, especially nonfunctioning adenomas. In many cases, it results in severe neurological, ophthalmological, and endocrinological consequences and may require prompt surgical decompression. Pituitary apoplexy represents a rare medical emergency that necessitates a multidisciplinary approach. Modalities of treatment and times of intervention are still largely debated. Therefore, the management of patients with pituitary apoplexy is often empirically individualized and clinical outcome is inevitably related to the multidisciplinary team’s skills and experience. This review aims to highlight the importance of a multidisciplinary approach in the management of pituitary apoplexy and to discuss modalities of presentation, treatment, and times of intervention.

Desmopressin to Prevent Rapid Sodium Correction in Severe Hyponatremia: A Systematic Review

2015 ◽  
Vol 128 (12) ◽  
pp. 1362.e15-1362.e24 ◽  
Author(s):  
Thomas E. MacMillan ◽  
Terence Tang ◽  
Rodrigo B. Cavalcanti
Keyword(s):  
Systematic Review ◽  
Severe Hyponatremia ◽  
Sodium Correction

Osmotic demyelination syndrome following slow correction of hyponatraemia

2021 ◽  
Vol 14 (8) ◽  
pp. e241407
Author(s):  
Isabel Saunders ◽  
David M Williams ◽  
Aliya Mohd Ruslan ◽  
Thinzar Min
Keyword(s):  
Antidiuretic Hormone ◽  
Serum Sodium ◽  
Inflammatory Markers ◽  
Urine Osmolality ◽  
Fluid Restriction ◽  
Osmotic Demyelination Syndrome ◽  
Electrolyte Disturbance ◽  
Osmotic Demyelination ◽  
Sodium Correction ◽  
Hospital Inpatients

Hyponatraemia is the most common electrolyte disturbance observed in hospital inpatients. We report a 90-year-old woman admitted generally unwell following a fall with marked confusion. Examination revealed a tender suprapubic region, and investigations observed elevated inflammatory markers and bacteriuria. Admission investigations demonstrated a serum sodium of 110 mmol/L with associated serum osmolality 236 mmol/kg and urine osmolality 346 mmol/kg. She was treated for hyponatraemia secondary to syndrome of inappropriate antidiuretic hormone (SIADH) and urosepsis. However, her serum sodium failed to normalise despite fluid restriction, necessitating treatment with demeclocycline and hypertonic saline. Despite slow reversal of hyponatraemia over 1 month, the patient developed generalised seizures with pontine and thalamic changes on MRI consistent with osmotic demyelination syndrome (ODS). This case highlights the risk of ODS, a rare but devastating consequence of hyponatraemia treatment, despite cautious sodium correction.

scholarly journals Presence of an Isolated Hydatid Cyst in the Left Kidney: Report of a Case of This Rare Condition Managed Surgically

2016 ◽  
Vol 2016 ◽  
pp. 1-4 ◽  
Author(s):  
Daniel Paramythiotis ◽  
Petros Bangeas ◽  
Konstantinia Kofina ◽  
Vassileios Papadopoulos ◽  
Antonios Michalopoulos
Keyword(s):  
Hydatid Cyst ◽  
Left Kidney ◽  
Rare Condition ◽  
Clinical History ◽  
Cystic Mass ◽  
Renal Masses ◽  
Case Presentation ◽  
Radiologic Imaging ◽  
Laboratory Examinations ◽  
Upper Abdominal

Introduction.Hydatid cyst disease caused byEchinococcus granulosusis rarely presented in the kidneys, whereas isolated renal occurrence is estimated to be about as low as 2–4% of all cases. We present a case of a female patient suffering from this condition that was treated successfully in our department.Case Presentation.A 44-year-old woman was incidentally diagnosed with a 14 cm left renal cystic mass through ultrasound imaging performed during upper abdominal pain investigation. Laboratory examinations were normal and CT imaging set the diagnosis of an isolated left renal hydatid cyst. The cyst was excised and the postoperative period was uneventful.Discussion.Isolated renal hydatid cyst is a very rare condition and could possibly be misdiagnosed with other renal masses. The clinical history, laboratory tests, and thorough radiologic imaging are crucial for the accurate preoperative diagnosis.

Serum sodium correction rate and the outcome in severe hyponatremia

2017 ◽  
Vol 35 (11) ◽  
pp. 1691-1694 ◽  
Author(s):  
Mauro Giordano ◽  
Tiziana Ciarambino ◽  
Emanuela Lo Priore ◽  
Pietro Castellino ◽  
Lorenzo Malatino ◽  
...  
Keyword(s):  
Serum Sodium ◽  
Severe Hyponatremia ◽  
Correction Rate ◽  
Sodium Correction

scholarly journals Treatment of Severe Hyponatremia: Conventional and Novel Aspects

2001 ◽  
Vol 12 (suppl 1) ◽  
pp. S10-S14 ◽  
Author(s):  
PETER GROSS ◽  
DOREEN REIMANN ◽  
JANA HENSCHKOWSKI ◽  
MAXWELL DAMIAN
Keyword(s):  
Brain Edema ◽  
Medical Emergency ◽  
Fluid Restriction ◽  
Water Diuresis ◽  
Severe Hyponatremia ◽  
Electrolyte Disorder ◽  
Initial Imaging ◽  
Permanent Brain Damage ◽  
Near Future ◽  
Number Of Authors

Abstract.Hyponatremia is a frequent electrolyte disorder. A hyponatremia is called acute severe (<115 mM) when the duration has been <36 to 48 h. Such patients often have advanced symptoms as a result of brain edema. Acute severe hyponatremia is a medical emergency. It should be corrected rapidly to approximately 130 mM to prevent permanent brain damage. In contrast, in chronic severe hyponatremia (>4 to 6 d), there is no brain edema and symptoms are usually mild. In such patients, a number of authors have recommended a correction rate <0.5 mM/h to approximately 130 mM to minimize the risk of cerebral myelinolysis. Sometimes it is not possible to diagnose whether a severe hyponatremia is acute or chronic. In such cases, an initial imaging procedure is helpful in deciding whether rapid or slow correction should be prescribed. The modalities of treatment of severe hyponatremia have so far consisted of infusions of hypertonic saline plus fluid restriction. In the near future, vasopressin antagonists will become available. Preliminary experience has already demonstrated their efficiency of inducing a sustained water diuresis and a correction of hyponatremia.

scholarly journals Hyponatremia as the Initial Presentation of Evolving Pituitary Apoplexy

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A586-A586
Author(s):  
Jovan Milosavljevic ◽  
Asha Mary Thomas
Keyword(s):  
Mental Status ◽  
Pituitary Apoplexy ◽  
Pituitary Tumors ◽  
Altered Mental Status ◽  
Clinical Syndrome ◽  
Medical Emergency ◽  
Fluid Restriction ◽  
Free T4 ◽  
Acute Hemorrhage ◽  
Initial Testing

Abstract Pituitary apoplexy (PA) is a known, often under-recognized medical emergency and is characterized by ischemic or hemorrhagic necrosis of the pituitary gland. It is a rare clinical syndrome that occurs in 2-12% of pituitary tumors. Hyponatremia can occur secondary to hypocortisolism (12-40%) or, rarely, to the syndrome inappropriate antidiuretic hormone (ADH) secretion. We present the case of a 69-year-old man who presented with altered mental status on post-operative day 3 from total knee replacement surgery. Initial testing revealed hyponatremia of 124 mmol/L, low serum osmolality of 266 mOsm/kg, and high urine osmolality of 664 mOsm/kg with urine sodium of 179 mmol/L. Head computerized tomography revealed a sellar mass of 1.8 x 2.4 cm. Initial testing revealed low prolactin (0.7 ng/mL), normal TSH (0.458 mcIU/mL) with borderline low free T4 of 0.72 ng/dL. Morning cortisol was 12.7 mcg/dL with ACTH of 8.5 pg/mL. Cosyntropin stimulation test was done revealing baseline cortisol of 5.8 mcg/dL (at midnight), increasing to 25.8 mcg/dL after 30 minutes and to 30.9 mcg/dL 60 minutes after cosyntropin administration. His sodium and mental status initially improved with fluid restriction and salt tablets, for the assumed syndrome of inappropriate ADH secretion. The patient remained hemodynamically stable. On the fourth day, however, his mental status deteriorated. Magnetic resonance imaging revealed expansion of sella with hyperintense mass 2.2 x 2.0 x 2.8 cm with compression of the optic chiasm. He was given stress dose hydrocortisone and levothyroxine and underwent emergency transsphenoidal resection. Biopsy revealed acute hemorrhage within infarcted adenoma. Postoperatively, both the patient’s sodium and mental status improved significantly and he was discharged to home on hydrocortisone and levothyroxine. The main clinical concern in the management of PA remains under-diagnosis at presentation. Prognosis is dependent on management during the acute phase. PA can present as hyponatremia even in the absence of overt hypocortisolism, presumably due to inappropriate ADH secretion. Therefore, PA should be considered as one of the differential diagnoses in hemodynamically stable patients with altered mental status and hyponatremia.

scholarly journals SUN-276 Pembrolizumab-Induced Secondary Adrenal Insufficiency Presenting as Severe Hyponatremia in an 80-Year-Old Male

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Leslie Daphne R Kawaji ◽  
Mary Grace M Villanueva ◽  
Michael L Villa
Keyword(s):  
Adverse Events ◽  
Adrenal Insufficiency ◽  
Endocrine System ◽  
Stage Iv ◽  
Blood Chemistry ◽  
Oral Feeding ◽  
Low Grade ◽  
Thyroid Function Tests ◽  
Secondary Adrenal Insufficiency ◽  
Severe Hyponatremia

Abstract Background Pembrolizumab is an anti-programmed death 1 (PD-1) antibody designed to incite an immune response against malignant cells. By virtue of this mechanism of action, its use has given rise to immune-related adverse events including those affecting the endocrine system. Adrenal insufficiency can occur rarely with anti-PD-1 therapy, and symptoms are usually non-specific. Clinical Case An 80-year-old male, known case of non-small cell lung cancer stage IV presented with a 2-week history of progressive body weakness with anorexia, shortness of breath and low-grade fever. He had just received the 4th cycle of pembrolizumab prior to the onset of symptoms. Past medical history was significant for hypertension and type 2 diabetes mellitus which were both controlled, and pulmonary tuberculosis with completed treatment. On physical examination, he was drowsy but oriented. He was normotensive (110/70 mmHg) and tachypneic (28 cpm) with rales on both lung fields. Baseline capillary glucose level was 107 mg/dL. Chest radiograph showed hazy opacities in the right upper to middle region. Blood chemistry revealed severe hyponatremia (114 mmol/L, NV 135-145 mmol/L) and low serum osmolality (247 mOsm/kg, NV 280-300 mOsm/kg). Random (taken 1230H) ACTH and cortisol were &lt;5.00 pg/mL (NV &lt;46 pg/mL) and 2.00 μg/dL (NV 4.30-22.40 μg/dL), respectively. Such levels were judged to be low in the background of an acute illness. Thyroid function tests were normal – TSH 0.993 μIU/mL (NV 0.55-4.78 uIU/mL), FT3 3.890 pg/mL (2.30-4.20 pg/mL), FT4 1.450 ng/dL (0.89-1.76 ng/dL). Magnetic resonance imaging of the pituitary gland did not show abnormal parenchymal enhancement or enlargement. Pembrolizumab-induced secondary adrenal insufficiency was the most probable cause of the hyponatremia. He was started on IV hydrocortisone, as well as piperacillin-tazobactam for pneumonia. Oxygen support via nasal cannula was given. Feeding via nasogastric tube was decided to ensure nutrition and prevent aspiration. He was transferred to the intensive care unit for careful monitoring. Serum sodium level was corrected gradually, with marked clinical improvement thereafter. Within 48 hours, he was transferred to regular room and oral feeding commenced. Hydrocortisone was shifted to prednisone on discharge, with steroid tapering schedule and close follow-up with endocrinologist advised. Conclusion We presented a case of secondary adrenal insufficiency which likely resulted from hypophysitis induced by pembrolizumab. Hypophysitis following anti-PD1 treatment occurs in &lt;1% of patients on immunotherapy. In such cases, ACTH deficiency is usually isolated and pituitary imaging is frequently normal. Since more patients are being placed on immune-checkpoint inhibition, clinicians should be vigilant for these adverse events, particularly the endocrinopathies which may have non-specific symptoms and may be irreversible.

Rathke cleft cyst presenting with hyponatremia: an unusual presentation

2011 ◽  
Vol 31 (1) ◽  
pp. E4 ◽  
Author(s):  
Walavan Sivakumar ◽  
Chad D. Cole ◽  
William T. Couldwell
Keyword(s):  
Cystic Lesion ◽  
Pituitary Apoplexy ◽  
Endocrine Function ◽  
Resonance Imaging ◽  
Severe Hyponatremia ◽  
Rathke Cleft Cyst ◽  
Metallic Taste ◽  
Intracystic Hemorrhage ◽  
Visual Changes

The authors report a case of Rathke cleft cyst presenting with severe hyponatremia. A 33-year-old man suffered sudden severe headaches, visual changes, dizziness, nausea, vomiting, and a metallic taste in his mouth. Initial laboratory values demonstrated severe hyponatremia. Magnetic resonance imaging revealed a cystic lesion with questionable intracystic hemorrhage, concerning for pituitary apoplexy. Transsphenoidal decompression and drainage of the cyst confirmed the diagnosis of Rathke cleft cyst and resolved the symptoms. Postoperative follow-up studies at 6 months demonstrated normal endocrine function and no evidence of a cyst.

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