bluuebunny/crossref_metadata_2025_split huggingface dataset:
A Follicular Stimulating Hormone Secreting Adenoma
Authors: De Croos Mary , Vender John , Elshimy Ghada , Stachura Maximillian 
Published: May 2021

Abstract
A gonadotroph secreting pituitary adenoma, a rare endocrinopathy, is often overlooked due to ambiguous symptoms leading to other diagnoses, such as ovarian hyperstimulation syndrome (OHSS).
A 53 year old African American woman presented for evaluation of a 4 month history of right hemianopsia. Her past medical history included a total hysterectomy and bilateral oophorosalpingectomy for recurrent ovarian cysts 11 years prior. Initial MRI:4.1x3.6x3.9 cm pituitary macroadenoma with prechiasmtic optic nerve compression. Initial laboratory studies: follicular stimulating hormone (FSH) level 186.83 mIU/mL (RR:23.0-116.3 mIU/mL) and luteinizing hormone (LH) 14.44 mIU/mL (RR:15.9-54.0 mIU/mL). Other pituitary labs were unremarkable. Debulking surgery was performed to relieve mass effect; pathology showed an FSH immunoreactive adenoma. Postoperatively, FSH was 2.55 mIU/mL and LH was 0.75 mIU/mL.
The prevalence of pituitary adenomas is 80-100 per 100,000 persons; 15-30% are non-functional. The majority of gonadotroph adenomas are difficult to identify because they may not produce biologically active hormones. Clinically functioning gonadotroph adenomas are very rare, often macroadenomas when found, most often found in reproductive age women, and preferentially secrete FSH. In reproductive age women, a FSH secreting adenomas may present clinically with OHSS, with multiple large ovarian cysts found on ultrasound for menstrual or pelvic complaints as seen in our patient. While OHSS is a known complication of assisted reproductive procedures, spontaneous OHSS is atypical and suggests need for evaluation of a FSH-secreting adenoma. Men may present with macroorchidism. Children may present with precocious puberty.
The treatment of choice is surgical removal of the adenoma, normalizing FSH to an age appropriate level. When OHSS is present, this results in a rapid decline in estradiol level and regression of ovarian cysts. Medical treatment, if surgery is contraindicated, is limited to cabergoline, which can initially decrease FSH and estradiol levels. In patients with normal pituitary function, gonadotropin-releasing hormone agonists acutely stimulate LH and FSH, thereby desensitizing GnRH receptors and decreasing gonadotropin secretion. In patients with FSH-secreting adenomas, they may have a persistent stimulatory effect, and in rare cases, result in pituitary apoplexy. Tumors that cannot be completely surgically removed may be treated by adjuvant radiotherapy or radiosurgery.
Discordance Between Prolactinoma Size and Prolactin Level: An Unusual Laboratory Finding
Authors: Dawaher Wafa , Patel Sabah , Unjom Zubina , Moid Alvia , Gilden Janice L , Trendafilova Victoria 
Published: May 2021

Abstract
Background: Prolactinomas are a common cause of hyperprolactinemia. Prolactin (PRL) level higher than 250 mcg/L is associated with a prolactinoma and serum prolactin levels generally correlate with tumor size. It is unusual to find a PRL level that is markedly elevated out of proportion to prolactinoma size. We present the case of a 32-year-old man who was referred to Endocrinology Clinic with fatigue and low testosterone, found to have a PRL level of 1302 mcg/L with a 9 x 8 x 9 mm microprolactinoma.
Clinical Case: A 32-year-old man with past medical history of migraines reported fatigue, weight gain, low libido and erectile dysfunction and was referred to Endocrinology Clinic due to PRL elevation. His medications included a multivitamin and chasteberry herbal supplement. Physical exam was unremarkable and no visual field abnormalities were detected. Baseline lab results showed PRL: &gt;1000 mcg/L and 1302 mcg/L after serial dilutions, FSH: 1.8 mIU/mL [0.7- 10.8 mIU/ml], LH:0.9 L [1.2- 10.6 mIU/ml], total testosterone 136 ng/dL [250-1100 ng/dl], free testosterone: 32 [35- 155 pg/ml], with normal cortisol, ACTH, IGF-1, TSH and Free T4 levels. MRI pituitary revealed a 9 mm x 8 mm x 9 mm microadenoma on the right side of the pituitary gland without optic chiasm compression. He was diagnosed with microprolactinoma, with very high PRL level causing secondary hypogonadism. Cabergoline 0.25 mg twice weekly resulted in significant improvement in PRL level. With dose increment to 0.5 mg twice weekly, PRL level improved further along with improvement in symptoms related to hypogonadism. Five months after initiation of treatment, total PRL was 58 ng/mL with monomeric PRL of 41 mcg/L, indicating only trace contribution of macroprolactin to the total PRL level.
Review of the Literature: In a retrospective study by Colao et al. (2003), men with hyperprolactinemia due to micro-prolactinoma had average pre-treatment PRL levels of 187.7 mcg/L (SD 51.8 mcg/L) and average pre-treatment diameter of 8.0 mm (SD 1.4 mm). A retrospective study of 1234 patients by Vilar et al. (2008) reported similar findings: microprolactinomas had average baseline PRL of 165.6 mcg/L (SD 255.1 mcg/L) and the highest reported level of PRL due to microprolactinoma was 525 mcg/L. Conclusion: Our case illustrates that assumptions about prolactinoma size should not be made based on laboratory findings alone. References: Melmed S. et al, Diagnosis and Treatment of Hyperprolactinemia: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 96: 273-288, 2011.Colao A. et al. Gender differences in the prevalence, clinical features and response to cabergoline in hyperprolactinemia. European Journal of Endocrinology 148: 325-331.Vilar L. et al. Diagnosis and Management of Hyperprolactinemia: Results of a Brazilian Multicenter Study with 1234 Patients. J Endocrinol Invest 31:436-444.
Giant Pituitary Adenoma Presenting With Disinhibition: A Case Report of a 25-Year-Old Male
Authors: Nottingham Saleen , Boyle Veronica , Tamatea Jade , du Toit Stephen Andrew , Wolmarans Louise , Elston Marianne Susan 
Published: May 2021

Abstract
Background: Giant growth hormone secreting pituitary adenomas (defined by a diameter &gt;4cm) are rare and difficult to treat (1). These typically invade surrounding structures, making surgery challenging or impossible (1). This report highlights a giant mammosomatotrophinoma with an unusual clinical presentation. Clinical Case: A 25-year-old male presented with personality changes, disinhibition and executive dysfunction progressing over a 3 to 4-year period. Further enquiry elicited a history of increasing headaches and significant visual loss, on the background of unilateral childhood visual loss in the contralateral eye. He was noted to have clinical features of acromegaly and complete temporal visual field loss in the left eye. On initial testing plasma IGF-1 was 137 nmol/L (reference interval [RI] 13-43nmol/L), GH &gt;100 ug/L and prolactin 23,900 mIU/L (RI 0-400mIU/L). GH remained &gt;100ug/L at 120 minutes after a 75g oral glucose load. He has hypogonadotropic hypogonadism, however thyrotropic and corticotropic function remained normal. MRI of the brain with contrast revealed an 8.0 x 7.1 x 7.4 cm mass arising from the pituitary fossa, extending into the suprasellar region and displacing both frontal lobes. The mass encased the basilar and right internal carotid arteries. It was deemed inoperable due to its exceptionally large size and encasement of vascular structures. Medical treatment was initiated with cabergoline (3.5mg per week in divided doses) and octreotide LAR, initially 30mg then increased to 60mg 4-weekly. A weaning course of steroids was initiated for oedema of his optic nerve. Within one month of treatment there was improvement of clinical symptoms of headaches, sweating, irritable mood and disinhibition with associated modest biochemical improvement (reduction of IGF-1 to 129 nmol/L and prolactin reduction to 2119 mIU/L). MRI of the brain revealed a reduction in the size of the adenoma to 7.8 x 7.1 x 6.3 cm, with a reduction in the mass effect on the frontal lobes. The patient continues medical management and close clinical monitoring with the aim of ongoing tumour shrinkage to allow reassessment for possible surgical debulking. Conclusion: This unique case of a GH and prolactin co-secreting giant pituitary adenoma posed a therapeutic challenge due to the significant surgical risk, limiting treatment to aggressive medical therapy. The cognitive and behavioral changes experienced due to tumour size and location added to the management complexity. Although early on in the treatment course, there is improvement of symptoms and tumour size on cabergoline and octreotide LAR injections. (1) Iglesias P, Rodríguez Berrocal V, Díez JJ. Giant pituitary adenoma: histological types, clinical features and therapeutic approaches. Endocrine. 2018 Sep;61(3):407-421.
Pituitary Macroadenoma: A Case of Balanced Deficiencies
Authors: Leimbach Robert , Shakir Mohamed K M , Hoang Thanh Duc 
Published: May 2021

Abstract
Introduction: Diabetes insipidus (DI) rarely occurs in pituitary tumors although some patients may develop DI following pituitary tumor resection. However DI is known to occur in patients with tumors metastatic to the pituitary or in infiltrative disorders of the pituitary gland. We are reporting a patient with a 2 cm pituitary macroadenoma whose DI was unmasked by glucocorticoid therapy. Case Presentation: A 61-year-old male with a history of non-functioning pituitary macroadenoma, incidentally discovered on imaging in 2015 and stable at 1.6cm for 4 years, was referred to endocrinology for interval enlargement of his macroadenoma. He had presented to primary care due to new headache during extreme physical exertion, but otherwise denied any symptoms such as vision loss, fatigue, decreased libido, weight loss, or urinary frequency. Repeat MRI indicated growth to 2.1cm in the suprasellar component, no cavernous sinus involvement, and abutting the optic chiasm. Laboratory results revealed new onset central hypothyroidism (FT4 0.21 ng/dL (ref 0.78-2.19) with triiodothyronine 68 ng/dL (ref 80-200) and TSH 1.61 mIU/L (ref 0.47-4.68), central hypogonadism (Testosterone Free 1.3 pg/mL (ref 6.6-18.1)) and concern for adrenal insufficiency with a cortisol of 4.4 mcg/dL. He was empirically started on hydrocortisone replacement until an ACTH stimulation test could be completed, and after 3 days instructed to begin low dose levothyroxine replacement. At close followup, patient revealed that he developed new hourly nocturia causing significant distress. An overnight water deprivation test yielded a serum sodium 152 mmol/L with a urine osmolality 191 mOsm/kg, both rapidly improving with intravenous desmopressin. Copeptin was 4.6 pmol/L. Discussion Diabetes insipidus occurring in pituitary tumors including macroadenomas is extremely rare. Secretion of AVP occurs in the hypothalamic osmoreceptors, supraoptic or paraventricular nuclei, and the superior portion of the supraopticohypophyseal tract. AVP deficiency is most commonly due to damage to these areas either through neurosurgery or trauma, and more rarely tumors or infiltrative disease. However, glucocorticoid and thyroid replacement each may precipitate the development of diabetes insipidus. Well described in literature, glucocorticoid deficiency and hypothyroidism each independently impairs free water excretion. Low cortisol stimulates release of antidiuretic hormone, but this secretion is then inhibited by exogenous steroid replacement. Cortisol interferes with AVP signaling through unclear mechanisms either at the V2 receptor or post-receptor level, decreasing translocation of type 2 aquaporins and therefore reducing free water reabsorption. It is important to recognize that CDI can be unmasked after glucocorticoid or thyroid hormone replacement.
Successful Treatment of Myxedema Coma Using Liothyronine in the Setting of Adrenal Crisis
Authors: Elghawy Omar , Hafey Alexander C , McCartney Christopher Rolland , Steinman Jeremy R 
Published: May 2021

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.
Obesity Is Associated With Intensive Care Use and Duration of ICU Stay but Not Mortality Among 3246 Patients Hospitalized With COVID-19
Authors: Kang Yu Mi , Brancale Joseph , Athonvarangkul Diana , Alausa Jameel , Subair Labeebah , Lipska Kasia Joanna , Jastreboff Ania M 
Published: May 2021

Abstract
Obesity is associated with increased severity of viral illnesses, but its impact on outcomes in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is yet to be elucidated. We sought to determine the association of obesity and other clinical factors with outcomes among patients hospitalized for severe coronavirus disease (COVID-19). This study included patients hospitalized between March 1, 2020 and September 17, 2020 in a 5-hospital health care system in Northeast United States, who had a positive RT-PCR assay of nasopharyngeal swabs for SARS-CoV-2 performed during hospitalization. Body mass index (BMI) was calculated using admission weight and height, and the WHO classification was used to define obesity. Both bivariate and multivariate logistic regression analyses were performed to determine the association of obesity and other clinical parameters with mortality (defined as in-hospital death or transition to hospice care) and intensive care use (defined by transfer to intensive care unit [ICU]). Multivariate model was adjusted for demographics and 8 pertinent comorbidities. Among 3246 patients hospitalized with COVID-19, median age was 65 years (interquartile range, 51–78), 49.9% were female, 30.5% overweight, and 43.2% had obesity (20.8%, 12.1%, and 10.4% with class I, II, and III obesity, respectively). A total of 542 (16.7%) patients died or received hospice care, and 811 (25.0%) required ICU care. In unadjusted analyses, patients with obesity had lower mortality compared with normal weight adults (13.0% vs. 23.1%) but a higher risk of ICU care (26.5% vs. 22.5%) and longer duration of ICU stays (9.5±10.6 vs. 6.6±8.5 [days]; all p-values &lt;0.05). Obesity was associated with a higher incidence of hypoxic respiratory failure requiring invasive (17.8% vs. 9.3%) and noninvasive (22.7% vs. 14.0%) ventilatory support. In multivariate analysis, older age, male sex, and diabetes were significantly associated with both mortality and ICU care. In contrast, obesity was not associated with a significantly higher mortality (adjusted odds ratio [OR] 1.14; 95% CI, 0.91–1.43) but was associated with a higher risk of ICU care (OR 1.27; 95% CI 1.07–1.51 for all obesity and OR 2.07; 95% CI 1.51–2.82 for class III obesity compared with normal weight). The association of underweight with mortality (OR 1.56; 95% CI 0.93 - 2.60) and ICU care (OR 1.20; 95% CI, 0.71–1.99) was not statistically significant. This retrospective study of hospitalized patients suggests that obesity is associated with intensive care use and longer duration of ICU stay but not with mortality due to COVID-19. These findings underscore the vulnerability of individuals with obesity during the current pandemic.
Unexpected but Not Uncommon - a Case of Adrenal Insufficiency
Authors: Ariyawansa Chanika , Zhang Rui , Lim Ee Mun , Beilin Jonathan 
Published: May 2021

Abstract
Background: Herbal remedies are widely available and whilst portrayed as generally harmless, they may contain a variety of potent medications that can cause unintended and potentially serious consequences. This danger is further amplified as their use is typically inadvertently not divulged to clinicians, such as in this case.
Clinical Case: A 65-year-old gentleman was referred to Endocrinology for assessment of adrenal insufficiency (AI) as a cause of his lethargy. He was found to have serum cortisol levels of 38 nmol/L and 68 nmol/L (150 – 700 nmol/L) on two separate mornings. No identified recent use of inhaled, topical, intra-articular or oral exogenous steroid therapy was noted. He had an inadequate response to Synacthen stimulation with peak serum cortisol of 150 pmol/L at 60-minutes (Adequate response – Post-Synacthen cortisol &gt;430 pmol/L). Baseline plasma ACTH was low - 1.1 pmol/L(2.0 – 10 pmol/L) and secondary (pituitary) AI was suspected. He had normal thyroid function and prolactin. The patient subsequently admitted to taking an herbal medication, “Montalin” for a few months. It was obtained over-the-counter in Indonesia for symptomatic relief of “muscle pains”. The tablet underwent analysis to investigate for presence of corticosteroid components.
An intact Montalin capsule was partly dissolved and the soluble content was diluted and analysed via LCMS/MS. Presence of dexamethasone/betamethasone was confirmed at an approximate concentration of 69.8 nmol/L constituting 0.548mg and 0.81% of the tablet. At the time, betamethasone and dexamethasone could not be distinguished due to stereoisomerism, but since has been confirmed to be dexamethasone.
The patient likely had suppression of the hypothalamic-pituitary-adrenal axis from unintended exogenous corticosteroid use, causing a picture of secondary AI. He requires ongoing corticosteroid replacement pending recovery of endogenous production. Although Montalin is marketed as an herbal over-the-counter medication it was confirmed to be adulterated with a potent corticosteroid. An alert issued by the Singaporean government details two further cases of adverse effects from Montalin and warns against its use.
Conclusion: Herbal remedies with undisclosed potent ingredients may unknowingly cause serious adverse effects. With advances in LCMS/MS technology, laboratory analysis of either the tablets or the patient’s serum could be utilised to identify potential exogenous corticosteroid exposure.
Risk of Complications in Children With Type 1 Diabetes and Covid-19
Authors: Raisingani Manish Gope 
Published: May 2021

Abstract
Background: There is some data available in adults which suggests that Type 1 diabetes may be associated with higher risk with Covid-19 (1). Limited data has been available in pediatric Type 1 diabetes with Covid-19. Methods: We used TriNetX, with a large COVID-19 database, collecting real-time electronic medical records data. We compared children (0–18 years) who were diagnosed with Covid-19 with and without Type 1 diabetes. This database collected information from 54 health care organizations. Results: Mortality rate in children with Covid-19 and Type 1 diabetes was 0.618% (10/1618). Mortality rate in children with Covid-19 without Type 1 diabetes was 0.102% (257/251517). Relative risk of mortality for children with Covid-19 and Type 1 diabetes was 6.05 with a p value of &lt; 0.0001. Endotracheal intubation rate in children with Covid-19 and Type 1 diabetes was 0.618% (10/1618). Endotracheal intubation rate in children with Covid-19 without Type 1 diabetes was 0.071% (178/251517). Relative risk of endotracheal intubation for children with Covid-19 and Type 1 diabetes was 8.73 with a p value of &lt; 0.0001. Pneumonia rate in children with Covid-19 and Type 1 diabetes was 0.804% (13/1618). Pneumonia rate in children with Covid-19 without Type 1 diabetes was 0.562% (1414/251517). Relative risk of pneumonia for children with Covid-19 and Type 1 diabetes was 1.43 with a p value of &lt; 0.1959. Septic shock rate in children with Covid-19 and Type 1 diabetes was 1.05% (17/1618). Septic shock rate in children with Covid-19 without Type 1 diabetes was 0.293% (737/251517). Relative risk of septic shock for children with Covid-19 and Type 1 diabetes was 3.59 with a p value of &lt; 0.00001. Conclusion: Mortality rate, endotracheal and septic shock were increased in children with Type 1 diabetes and Covid-19 versus children with Covid-19 and no Type 1 diabetes. Further studies with larger sample size are needed to study complication rate of Covid-19 and Type 1 diabetes. References 1) Associations of type 1 and type 2 diabetes with COVID-19-related mortality in England: a whole-population study. Lancet Diabetes Endocrinol 2020 Oct;8(10):813–822. doi: 10.1016/S2213-8587(20)30272-2. Epub 2020 Aug 13.