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Adrenal Insufficiency Secondary to Hypopituitarism


Presentation

  • Clinical presentation depends on the etiology and hormonal axis involved. We describe a case of panhypopituitarism presenting with severe recurrent hypoglycemia as the only presenting manifestation.[medcraveonline.com]
  • Common chemical abnormalities include metabolic acidosis and prerenal azotemia, while hyponatremia, hypoglycemia, and hyperkalemia may also be present.[news-medical.net]
  • Hypopituitarism can present either acutely, with symptoms of sudden mass effect and secondary adrenal crisis, or more commonly as a subacute or chronic condition.[endocrinologytoday.com.au]
  • A 62 year-old female with no known past medical history presented to our emergency room with altered mental status.[austinpublishinggroup.com]
  • Presentation in part depends on the rapidity of loss of adrenal function: Acute : presentation may be as a crisis precipitated by infection, surgery or trauma.[patient.info]
Fatigue
  • Symptoms and Signs of Pituitary Hormone Deficiency Pituitary Hormone Target Organs Effect of Deficiency ACTH Adrenal glands: cortisol and DHEA Fatigue, low sodium in blood, weight loss, skin pallor TSH Thyroid gland: thyroid hormone Fatigue, weight gain[pituitarysociety.org]
  • John’s wort Pregnant women with unexplained fatigue, constant nausea, and hypotension Laboratory Testing Patients in acute adrenal crisis require prompt treatment and stabilization prior to diagnostic evaluation.[arupconsult.com]
  • Symptoms include dizziness, nausea and vomiting, and extreme fatigue, which usually follows a stress on the body such as dehydration, infection, or another illness or injury.[uclahealth.org]
  • Fatigue, for instance, goes hand in hand with being a new mother. You might not realize you have Sheehan's syndrome until you need treatment for thyroid or adrenal insufficiency.[mayoclinic.org]
  • Symptoms are the same as for Addison disease and include fatigue, weakness, weight loss, nausea, vomiting, and diarrhea, but there is usually less hypovolemia.[merckmanuals.com]
Weight Loss
  • Symptoms and Signs of Pituitary Hormone Deficiency Pituitary Hormone Target Organs Effect of Deficiency ACTH Adrenal glands: cortisol and DHEA Fatigue, low sodium in blood, weight loss, skin pallor TSH Thyroid gland: thyroid hormone Fatigue, weight gain[pituitarysociety.org]
  • Symptoms are the same as for Addison disease and include fatigue, weakness, weight loss, nausea, vomiting, and diarrhea, but there is usually less hypovolemia.[merckmanuals.com]
  • Lots of ACTH lots of melanocytes hyper pigmentation) Hypotension Hypoglycemia Postural symptoms Gastrointestinal symptoms Primary adrenal Insufficiency: Signs Weight loss (Failure to thrive or growth retardation) -100% Hyperpigmentation- 90% (no tan lines[quizlet.com]
  • They include Weakness Fatigue Loss of appetite and weight loss Nausea Musculoskeletal pain Dizziness Symptoms suggestive of PAI include Extracellular fluid volume reduction Abdominal pain Hypotension Hyponatremia Hyperkalemia Fever Hyperpigmentation Hypoglycemia[arupconsult.com]
  • Symptoms include weight loss, lack of appetite (anorexia), muscle weakness, nausea and vomiting, and low blood pressure (hypotension).[rarediseases.org]
Schmidt Syndrome
  • Type II, often called Schmidts syndrome, usually afflicts young adults. Features of type II may include an underactive thyroid gland, slow sexual development, and diabetes mellitus.[pituitary.org]
Hypothermia
  • Other causes include physiological stress including surgery, anesthesia, fluid volume loss, trauma, asthma, hypothermia, alcohol abuse, myocardial infarction, fever, hypoglycemia, pain, and depression.[medical-dictionary.thefreedictionary.com]
Loss of Appetite
  • They include Weakness Fatigue Loss of appetite and weight loss Nausea Musculoskeletal pain Dizziness Symptoms suggestive of PAI include Extracellular fluid volume reduction Abdominal pain Hypotension Hyponatremia Hyperkalemia Fever Hyperpigmentation Hypoglycemia[arupconsult.com]
  • People with insufficient cortisol production may exhibit symptoms such as: Muscle weakness Fatigue Weight loss Increased skin pigmentation, even in areas not exposed to the sun Loss of appetite Diarrhea, nausea and vomiting Dizziness Salt cravings These[labtestsonline.org]
  • However, they should be evaluated if they’re progressive and interfere with your daily activities and normal functioning: unexplained weight loss low blood pressure loss of appetite muscle weakness muscle and joint pain fatigue darkening discoloration[healthline.com]
  • Chronic, worsening fatigue and muscle weakness, loss of appetite, and weight loss are characteristic of the disease. Nausea, vomiting, and diarrhea occur in about 50 percent of cases.[pituitary.org]
Hypotension
  • Lots of ACTH lots of melanocytes hyper pigmentation) Hypotension Hypoglycemia Postural symptoms Gastrointestinal symptoms Primary adrenal Insufficiency: Signs Weight loss (Failure to thrive or growth retardation) -100% Hyperpigmentation- 90% (no tan lines[quizlet.com]
  • Patients with long-standing adrenal insufficiency may present with postural hypotension, nausea, vomiting, weight loss, anorexia, lethargy, depression, and/or chronic hyponatremia.[amboss.com]
  • John’s wort Pregnant women with unexplained fatigue, constant nausea, and hypotension Laboratory Testing Patients in acute adrenal crisis require prompt treatment and stabilization prior to diagnostic evaluation.[arupconsult.com]
  • Hypotension. Postural hypotension. Other situations which should provoke consideration of Addison's disease include: People with hypothyroidism in whom symptoms get worse when thyroxine treatment is commenced.[patient.info]
  • Clinical symptoms include hyperkalemia, sodium-wasting, hypotension, and sometimes metabolic acidosis.[icd10data.com]
Orthostatic Hypotension
  • hypotension, nausea, vomiting, diarrhea, hyponatremia, hypoglycemia, mild anemia, increased WBCs, eosinophilia 2 0 adrenal insufficiency Pallor of skin, amenorrhea, libido, axillary and pubic hair, small testicles, 2º hyperthyroidism, defect in prepubertal[medical-dictionary.thefreedictionary.com]
  • Additional signs and symptoms include weakness, tiredness, dizziness, low blood pressure that falls further when standing ( orthostatic hypotension ), cardiovascular collapse muscle aches, nausea, vomiting, and diarrhea.[ipfs.io]
  • Additional signs and symptoms include weakness, tiredness, dizziness, low blood pressure that falls further when standing ( orthostatic hypotension ), cardiovascular collapse, muscle aches, nausea, vomiting, and diarrhea.[en.wikipedia.org]
Hypertension
  • Munich MARCELLA RIETSCHEL 1898 Department of Psychiatry 1899 SOPHIE NICOLE Germany 1901 ALFRIED KOHLSCHÜTTER 1918 GIORA Z FEUERSTEIN Department of Dermatology Venerology and Allergy University Hospital SchleswigHolstein 1925 Division of Nephrology and Hypertension[books.google.com]
  • On day #3: collect 24-hour urine aldosterone, urine creatinine, urine sodium Suspect hyperaldosteronism if aldosterone 14 ug/d day with urinary sodium excretion 200 mmol per 24 hour More convenient for patients than IV NS loading Must monitor for hypertension[quizlet.com]

Workup

  • This case highlights the diagnostic workup of panhypopituitarism in the emergent setting, and demonstrates how this diagnosis maybe masked by other clinical entities.[austinpublishinggroup.com]
  • Addison Disease Workup. Available online at . Accessed Sept. 20, 2012. (April 2012) Cushing’s Syndrome. National Endocrine and Metabolic Diseases Information Service. Available online at . Accessed on Sept.19 2012. (Updated Dec 12, 2011).[labtestsonline.org]
  • Addison Disease workup at eMedicine External links CAH - Congenital adrenal hyperplasia[ipfs.io]
  • Addison Disease workup at eMedicine Further reading [ edit ] Bornstein, SR; Allolio, B; Arlt, W; Barthel, A; Don-Wauchope, A; Hammer, GD; Husebye, ES; Merke, DP; Murad, MH; Stratakis, CA; Torpy, DJ (February 2016).[en.wikipedia.org]
  • .0000000000002872 Research Article: Clinical Case Report Abstract Author Information Authors Article Outline Outline Article Metrics Metrics Hyponatremia may be one of the clinical manifestations of adrenal insufficiency (AI) and during the diagnostic workup[journals.lww.com]
Hyponatremia
  • Drug-induced hyponatremia could only be attributed to citalopram as he was receiving no other drugs causing hyponatremia.[journals.lww.com]
  • […] after recovery from hyponatremia).[thieme-connect.com]
  • Determination of plasma cortisol level in patients with hyponatremia not explained by other causes should always be obtained.[link.springer.com]
  • This is, to our knowledge, the first report of TTC due to hypothyroidism and adrenal insufficiency with no hyponatremia, no evident hypoglycemia and no evident catecholamine overproduction.[endocrine-abstracts.org]
  • Patients with long-standing adrenal insufficiency may present with postural hypotension, nausea, vomiting, weight loss, anorexia, lethargy, depression, and/or chronic hyponatremia.[amboss.com]
Staphylococcus Aureus
  • Preliminary blood cultures grew Methicillinsensitive Staphylococcus aureus (MSSA) and she was switched to Trimethoprime-Sulfamethoxazole (TMP-SMX) based on culture sensitivity.[austinpublishinggroup.com]

Treatment

  • After 1 week of treatment with hydrocortisone (10 mg/day), her symptoms quickly improved. We then added 75 μg/day of thyroid hormone. During the course of her treatment, autoantibodies against VGKC complex were found to be weakly positive.[kyushu-u.pure.elsevier.com]
  • A guideline to treatment is given below. The provider must note that these are simply guidelines for initiating replacement treatment.[clinicaladvisor.com]
  • Higher doses and longer treatment increase the risk. Abrupt cessation of treatment with glucocorticoids is the most common cause of adrenal insufficiency.[uclahealth.org]
  • Results persisted after adjustment for treatment with radiotherapy and sex.[healio.com]
  • Hydrocortisone treatment is very effective.[thieme-connect.com]

Prognosis

  • Expectations (prognosis): Patients usually respond to administration of glucocorticoids. Long-term prognosis depends on the degree of dependence on these drugs and any resulting complications.[uclahealth.org]
  • The prognosis for any patient with adrenal insufficiency will depend on the underlying cause. In those patients in whom the prognosis is not affected by the underlying pathology, replacement therapy should result in a return to health.[patient.info]
  • While effective treatment of the underlying hormone deficiencies may improve these risks, it is often necessary to treat them directly. [6] Prognosis [ edit ] Several studies have shown that hypopituitarism is associated with an increased risk of cardiovascular[en.wikipedia.org]

Etiology

  • Furthermore, aldosterone deficiency leads to low levels of sodium and high levels of potassium in the blood. 21-Hydroxylase Antibody Testing A positive 21-hydroxylase antibody test result confirms an autoimmune etiology of PAI, in which the body’s own[arupconsult.com]
  • Collectively, this indicated a central etiology for her hormone deficiencies. There was no evidence of hyperprolactinemia.[austinpublishinggroup.com]
  • Etiology Primary adrenal insufficiency ( Addison disease ) Primary adrenal insufficiency is caused by conditions that directly damage the adrenal gland.[amboss.com]
  • Clinical presentation depends on the etiology and hormonal axis involved. We describe a case of panhypopituitarism presenting with severe recurrent hypoglycemia as the only presenting manifestation.[medcraveonline.com]
  • Clinical Weakness, hypotension, easy fatigability, weight loss, N&V, abdominal pain, muscle and joint pain, amenorrhea, bronzing of the skin and hyperpigmentation-especially at skin folds Management Hydrocortisone, fludrocortisone 1 0 Adrenal insufficiency Etiology[medical-dictionary.thefreedictionary.com]

Epidemiology

  • Hahner S, Loeffler M, Bleicken B, Drechsler C, Milovanovic D, Fassnacht M, Ventz M, Quinkler M, Allolio B: Epidemiology of adrenal crisis in chronic adrenal insufficiency: the need for new prevention strategies. Eur J Endocrinol 2010;162:597-602.[karger.com]
  • Epidemiology [ 1, 2 ] Primary insufficiency - this is a relatively rare condition. The annual incidence is about 1 in 10,000 people, with a prevalence in the UK of about 8,400. Across Europe, prevalence is estimated as 93-144 per million.[patient.info]
  • Epidemiology [ edit ] There is only one study that has measured the prevalence (total number of cases in a population) and incidence (annual number of new cases) of hypopituitarism. [1] This study was conducted in Northern Spain and used hospital records[en.wikipedia.org]
Sex distribution
Age distribution

Pathophysiology

  • In a retrospective study, we screened the files of 185 patients with severe hyponatremia ( In 139 cases, clear allocation of patients to pathophysiological groups representing 1) primary sodium deficiency, 2) edematous disorders, and 3) normovolemic disorders[thieme-connect.com]
  • Pathophysiology 2001, 7: 251–61. PubMed CrossRef Google Scholar Copyright information Italian Society of Endocrinology (SIE) 2007 Authors and Affiliations F. Tarantini 1 Email author S. Fumagalli 1 L. Boncinelli 1 M. C. Cavallini 1 E. Mossello 1 N.[link.springer.com]
  • References: [1] [2] [3] Pathophysiology Clinical features Most cases of adrenal insufficiency are subclinical and only become apparent during periods of stress (e.g., surgery, trauma, infections), when the cortisol requirement is higher![amboss.com]
  • During this recovery time, the patient is vulnerable to adrenal insufficiency during times of stress, such as illness, due to both adrenal atrophy and suppression of CRH and ACTH release. [18] Pathophysiology Hyponatremia can be caused by glucocorticoid[ipfs.io]
  • Pathophysiology [ edit ] The pituitary gland is located at the base of the brain, and intimately connected with the hypothalamus.[en.wikipedia.org]

Prevention

  • […] of HIV HIV Transmission and Prevention in Specific Populations Systematic Review of HIV Behavioral Prevention Research in African Americans Lynae A.[hivinsite.ucsf.edu]
  • There should be a high clinical index for patients with any dose of steroid to recognize early, and prevent fracture and ultimately replacement.[journalmc.org]
  • Treatment involves adequate replacement of deficient hormones and long-term monitoring to prevent associated complications and improve quality of life.[endocrinologytoday.com.au]
  • Adrenal crisis can generally be prevented by increasing (doubling or tripling) the steroid dose during illness or other physical stress.[uclahealth.org]
  • Suggestions for prevention of adrenal crisis in patients at risk are provided for health care professionals and families. adrenal disorders morbidity/mortality adverse outcomes Accepted September 13, 2006.[pediatrics.aappublications.org]

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