bluuebunny/crossref_metadata_2025_split huggingface dataset:
Corticosteroids Replacement in a Patient With Panhypopituitarism and COVID-19 Infection
Authors: Karuppasamy Gowri , Alamer Zaina Abdelhalim , Rose Samman , Al-Janahi Ibrahim Abdulla 
Published: May 2021

Abstract
Background: Hypopituitarism refers to complete or partial insufficiency of pituitary hormone secretion and patients require lifelong hormone replacement. Those with ACTH deficiency rely on exogenous glucocorticoids and at times of intercurrent illness require stress doses to prevent an adrenal crisis. The benefits and adverse effects of corticosteroids for treatment of COVID-19 pneumonia are currently under investigation. We report our experience in a patient with COVID-19 pneumonia who received high dose corticosteroids for panhypopituitarism. Clinical Case: A 51-year-old man presented with one-week history of fever and generalized weakness. He had been diagnosed with a non-functional pituitary macro-adenoma causing panhypopituitarism 1 year ago when he developed generalized tonic-clonic seizures. He underwent trans-sphenoidal resection of the pituitary adenoma. However, he then discontinued his hormonal therapy and was lost to follow up. He had postural hypotension but was not tachypneic or hypoxemic. He tested positive for COVID-19 and chest x-ray showed prominent bilateral broncho-vascular markings; he was hospitalized as mild COVID-19 pneumonia. Laboratory investigations revealed secondary adrenal insufficiency, secondary hypothyroidism and hypogonadotropic hypogonadism. MRI of the pituitary now showed persistence of the pituitary macroadenoma, measuring 3.5 x 3.7 x 2.4 cm in dimensions, causing sellar obliteration and left cavernous sinus invasion. Treatment with stress dose steroids, Hydrocortisone 50 mg 4 times daily was initiated, followed by thyroid hormone replacement with Levothyroxine 125 mcg daily. He also received antivirals and
supportive care for COVID-19, guided by local hospital protocol. After significant clinical improvement, steroids were tapered down and he was discharged on a maintenance dose of 20 mg hydrocortisone per day in divided doses. The patient was stable at outpatient follow up after one month. He was started on testosterone replacement for erectile dysfunction due to hypogonadotropic hypogonadism. He was offered surgery for complete resection of the residual pituitary adenoma, but he declined and preferred to continue medical therapy. Conclusion: Hypopituitarism is associated with significant morbidity and premature mortality, a key risk factor being cortisol deficiency. Adrenal crisis is a life-threatening medical emergency and remains an important cause of death in patients with adrenal insufficiency. These patients are also vulnerable to develop severe complications from COVID-19 infection due to the absence of normal cortisol responses to stress. Despite receiving stress dose corticosteroids, this high-risk patient recovered from COVID-19 pneumonia without complications. These findings support the use of corticosteroids when necessary for treatment of coexisting conditions in patients with COVID-19.
Cushing’s Disease Presenting With Severe Weight Loss, Anorexia and Refractory Psychotic Depression
Authors: McDonnell Tara Muire , Lockhart Michael , Kennedy Carmel , Cussen Leanne , Roberts Graham , Smith Diarmuid , Javadpour Mohsen , Agha Amar 
Published: May 2021

Abstract
Introduction: In this paper we report an unusual case of Cushing’s disease presenting with psychotic depression, paranoia, anorexia leading to severe weight loss culminating in 18% of her body weight. Case: A 22 year old female admitted with first episode psychosis to her local hospital displaying psychotic depressive symptoms, low mood, severe anorexia and mood congruent delusions regarding food contamination. Clinical manifestations of Cushing’s were recognised: cushingoid facies, facial plethora, hirsutism with striae and proximal myopathy. The degree of weight loss (70kg to 57kg) and paranoid ideation surrounding food necessitated caloric supplementation parenterally. Laboratory indices notable for hypokalaemia of 2.7nmol/l, male range testosterone level of 10.7nmol/l, DHEAS&gt;27.1umol and suppressed gonadotrophins. Urine Free Cortisol was &gt;25 times normal. Late night salivary cortisol was 13.4nmol/L(&lt;2.6nmol/L). ACTH was raised at 74.0pg/ml in keeping ACTH dependent Cushing’s. MRI pituitary showed a bulky pituitary. CRF testing and Inferior Petrosal Sinus Sampling both indicated pituitary dependent Cushing’s disease. Following Metyrapone therapy and nutritional treatment the patient condition improved. She proceeded to transphenoidal pituitary exploration. Intraoperatively a very soft central lesion was excised and neuropathology confirmed a corticotroph adenoma. Post-operative morning cortisol at day 3 was 31nmol/l indicating early remission. 3 months post-operative there was remarkable improvement in mood, weight, cessation of anti-psychotics with normal diet and return of menses. She remained severely hypocortisolaemic 6 months post-op Conclusion: Cushing’s disease may present with severe psychiatric manifestation and significant weight loss. Clinicians need to be vigilant of psychosis as the primary presentation of Cushing’s disease.
Diagnosis of a Rare Case of Acromegaly Secondary to Pituitary Macroadenoma Debuting as Sudden DKA
Authors: Rivera Nazario Ivan Augusto , Moya Kyomara Hernandez , Ortiz Arnaldo Nieves , Rivera Jose Ayala , Figueroa Arnaldo Rojas , Cintron-Colon Hector R , Miranda Maria De Lourdes 
Published: May 2021

Abstract
Acromegaly is an uncommon clinical syndrome that results from excessive secretion of growth hormone with an annual incidence of 6 to 8 cases per 1 million of individuals with a mean age of diagnosis between 40-45 years. Pituitary adenomas can be the principal reason for an overgrowth of the anterior pituitary somatotroph cells, and account for approximately one-third of all hormone-secreting pituitary adenomas with a prevalence of about 38-69 cases per 1 million and an incidence of 3-4 cases per 1 million individuals. The onset of acromegaly is insidious, and its progression is usually very slow. At the moment of diagnosis, approximately 75% of patients have presence of macro adenomas, but most cases are diagnosed after several laboratory workups and incidental brain imaging. A characteristic clinical presentation of pituitary adenomas could be secondary to mass effect. Metabolic presentation such as diabetes is one of the most common related conditions preceding the diagnosis of acromegaly. Clinical presentation with abrupt onset of DKA could be a determining factor on disease progression due to higher GH levels correlating with an increased prevalence of insulin resistance. We present a rare case of a 28y/o female G5P3A2 without previous PMHx who presented to ER with abdominal pain, general malaise, slurred speech, headache and gait difficulty of 3 days of evolution. Upon initial evaluation at ER patient was found with hyperglycemia of 317mg/dL, low central bicarbonate, high anion gap and positive serum ketones suggestive of DKA de novo. Based on neurological complaints, head CT performed showed an incidental parasellar/suprasellar/temporal hyperdense mass measuring 2.5cm x 2.6cm with optic chiasm compression features. Upon further specific questioning patient referred amenorrhea for the past 3 years, bitemporal hemianopsia, galactorrhea and marked facial feature changes, frontal bossing, weight gain, and acanthosis nigricans, for the past year. Pituitary adenoma workup revealed low prolactin levels (1.38), markedly increased growth hormone (501) and IGF-1 (893) suggesting diagnosis of acromegaly, most likely secondary to a functioning macroadenoma. Patient initially treated with Cabergoline, uncontrolled diabetes was managed and was referred to Neurosurgery service for further evaluation and tumor removal. Based on current literature, the incidence of acromegaly cases is low, more specifically when presenting with new onset diabetic ketoacidosis, insulin resistance and secondary to functioning macroadenomas. Medical awareness should be promoted to assess for careful consideration of signs and symptoms, workup, management and treatment to assess and minimize further health complications and physical burdens acromegaly and pituitary adenomas could pose for affected individuals.
Does Pituitary Dysfunction Always Occur Following Penetrating Head Trauma?
Authors: Agarwal Shubham , Patel Sabah , Hammad Faiza , Gilden Janice L 
Published: May 2021

Abstract
Background: Pituitary dysfunction and panhypopituitarism remain underdiagnosed in penetrating and blunt head trauma and can occur in both acute and chronic settings. Case: A 56 years old male with no significant PMH was admitted with a gunshot wound to the left T9 rib paraspinally with bullet deflection cranially along the left lung, left sternocleidomastoid, and resting anterior to the suprasellar cistern just above the midline of the sphenoid sinus close to the pituitary gland. Moderate volume pneumocephalus, chest hemopneumothorax, and sudden loss of right-sided vision required neurosurgical and pulmonary intervention. Endocrinology was consulted to evaluate pituitary function in the context of the bullet within the cranium. Physical examination showed intact mental status, non-focal exam, right-sided blindness, and foley catheter with normal urine output. Laboratory hormonal assessment for hypothalamic-pituitary axis (HPA) was performed consistent with normal sodium, potassium, FSH of 14.2 mIU/ml (1.0-13.0 mIU/ml), LH of 4.5 mIU/ml (1.0-9.0 mIU/ml), AM cortisol of 13.6 ug/dl (5-25 ug/dl), free cortisol of 2.06, ACTH of 10 pg/ml (10-60 pg/ml), IGF-1 of 80 ng/ml (78-220 ng/ml), TSH 1.93 mIU/L (0.5-5.0 mIU/L), FT4 1.05 ng/dl (0.8-1.8 ng/dl), Prolactin of 14.2 ng/ml (4-23 ng/ml) and HbA1c 5.1%. He reported no symptoms of adrenal insufficiency and remained hemodynamically stable. He was monitored for symptoms of pituitary insufficiency and suppression of the HPA axis along with urine output which remained normal and reassuring for the absence of central DI. The patient will continue outpatient endocrine surveillance. Discussion: The development of hormone deficiencies is directly related to the severity of head trauma. Mild traumatic brain injury (TBI) patients discharged from the ED, without loss of consciousness or post-traumatic amnesia less than 30 minutes do not require endocrine surveillance. Pituitary dysfunction occurs in 20-40% of patients with moderate to severe TBI. Pituitary ischemia leads to pituitary injury, due to changes in cerebral blood flow, cerebral hypoxia, and increased intracranial pressure. Compressive effects on the stalk from increased intracranial pressure is another indirect mechanism for pituitary dysfunction. Hospitalizations longer than 48 hours following TBI, require pituitary screening at 3-6 months. Chronic hypopituitarism develops in 15-20% of patients within 2-3 years with ACTH and GH deficiencies. Other changes in LH, FSH, TSH, and development of central diabetes insipidus can occur. However, despite severe TBI, acute pituitary hormonal involvement may not always occur, as in our patient. References: Tan CL, Alavi SA, Baldeweg SE, et al. The screening and management of pituitary dysfunction following traumatic brain injury in adults: British Neurotrauma Group guidance. J Neurol Neurosurg Psychiatry. 2017 Nov;88(11):971-981.
Growth Hormone (GH) and Thyroid Stimulating Hormone (TSH) Co-Secreting Pituitary Macroadenoma
Authors: Maliakal Alvin , Antony McAnto , Jackson Bethany Ann , Mathew Anu Alvin 
Published: May 2021

Abstract
Background: TSH secreting pituitary adenomas are rare and accounts for 0.5-3% of all pituitary adenomas. Only 20-25% of those adenomas co-secrete other hormones like growth hormone or prolactin. Mixed GH and TSH secreting adenomas present with symptoms from tumor growth and features of both acromegaly and hyperthyroidism.
Clinical Case: A 57 years old woman with a past medical history of chronic joint pains and bilateral knee swelling presented to her PCP with complaints of chronic fatigue. Evaluation revealed a normal TSH level and MNG and patient did not have any further work-up. She reported undergoing periodic knee arthrocentesis which gave her only temporary pain relief. Two years later, patient presented with complaints of unintentional weight loss, tremors and palpitations. She also reported enlargement in the size of hands, feet and forehead and no improvement in the knee swelling after multiple arthrocentesis. Lab evaluation revealed high free T4 2.31ng/dl (0.58-1.64), high free T3 6.44pg/ml (2.50-4.30), non-suppressed TSH 1.32mU/L (0.34-5.00), elevated IGF-1 415ng/ml (47-236), GH 7.76ng/ml (0.01-3.61) and prolactin 6.69ng/mL (2.74-26.72). Neck USG showed multiple nodules and 24hr radioactive iodine uptake scan showed increased uptake at 43%. 75gm OGTT showed non-suppression of GH level. MRI of brain showed 1.8 cm pituitary macroadenoma. Patient underwent transsphenoidal pituitary resection in January 2018 and the final pathology showed positive tumor staining for GH and TSH. Following surgery, patient reported improvement in symptoms. Lab work-up from October 2018 showed normal IGF 189 ng/ml (47-236), normal GH 0.35(0.01-3.61), Free T4 0.80(0.58-1.64), Free T3 2.41(2.50-4.30), TSH 0.06(0.34-5.00) and MRI from August 2020 showed no evidence of residual pituitary tumor.
Conclusion: This is a rare case of a GH and TSH co-secreting pituitary macroadenoma. This case highlights the importance of considering acromegaly early in the differential diagnosis of patients presenting with chronic musculoskeletal symptoms and to pursue work up for central hyperthyroidism in a hyperthyroid patient presenting with a non-suppressed TSH level.
Hyponatremia and Isolated Free T4 Elevation in a Patient With Acute Intermittent Porphyria
Authors: Gandhi Anand , Mortensen Michael , Alsayed Mahmoud , Kumar Aditi , Targovnik Jerome H 
Published: May 2021

Abstract
Background: Porphyrias represent a spectrum of diseases that stem from dysfunction within the heme biosynthetic pathway. Acute intermittent porphyria (AIP) is the most common type of porphyria due to a genetic deficiency of porphobilinogen deaminase which results in a wide range of neurovisceral symptoms. Hyponatremia and abnormalities with thyroid function have been found in AIP but the mechanisms behind these processes are unclear. Clinical Case: A 26-year-old male with a history of chronic, recurrent abdominal pain presented with 10 days of progressively worsening periumbilical abdominal pain and constipation. He describes that preceding the onset of symptoms he had been binging 5-10 standard alcoholic drinks each day for a few days. Initial laboratory workup demonstrated hyponatremia with Na 114 mmol/L (n: 134 – 137 mmol/L), hypochloremia with Cl 76 mmol/L (n: 95 – 108 mmol/L), and hyperbilirubinemia with total bilirubin 2.5 mg/dL (n: 0.2 – 1.3 mg/dL). CT abdomen/pelvis was negative for any concerning pathology. Further studies showed low serum osmolality at 243 mOsm/kg (n: 275 – 295 mOsm/kg), urine Na 62 mmol/L (n &gt; 20mmol/L), and urine osmolality at 394 mOsm/kg (n: 300 – 900 mOsm/kg) consistent with SIADH. The patient was treated with 3% NaCl and free water restriction to 1.2L/day with improvement in Na levels. Further laboratory workup demonstrated normal TSH, but persistently elevated free T4 with maximum free T4 of 2.77 ng/dL (n: 0.80 – 1.70 ng/dL) which downtrended to 1.99 ng/dL by discharge. Thyroid ultrasound was unremarkable. Pituitary evaluation via hormonal workup and MRI brain was negative for any abnormalities. Given the symptomatology and laboratory findings, the patient was evaluated for porphyria. Laboratory evaluation demonstrated severe elevations in urine porphyrins, urine delta aminolevulinic acid (56.8 mg/24h, n &lt; 4.5 mg/24h), and urine porphobilinogen (82.5 mg/g, n &lt; 2.3 mg/g) consistent with AIP. The patient was treated with four days of hematin infusions which resolved his abdominal pain and was discharged in an improved state. Conclusion: AIP is a rare entity brought out by a deficiency in porphobilinogen deaminase, a key enzyme in the heme biosynthesis pathway. Various metabolic disturbances have been described in AIP including hyponatremia and alterations in thyroid function tests suggestive of thyrotoxicosis. Hyponatremia in our patient was likely due to SIADH from neurovisceral pain. Our patient displayed isolated free T4 elevation as well. We hypothesize this developed due to his acute illness causing a greater decrease in D2 deiodinase activity compared to any concomitant increase in D3 deiodinase activity. This was supported by his free T4 level downtrending following treatment of his AIP attack. More research is needed to further elucidate the mechanism behind these derangements in biochemical markers and their impact on patient prognosis.
Intrasellar Cavernous Hemangioma, a Rare Condition Causing Both Radiological And Clinical Difficulties- a Case Report
Authors: Nowak Andrzej Jerzy , Grochowska Anna , Adamek Dariusz , Godlewska Magdalena , Motyka Marcin , Gilis-Januszewska Aleksandra , Hubalewska-Dydejczyk Alicja 
Published: May 2021

Abstract
Introduction: Intrasellar cavernous hemangiomas constitute an extremely rare group of findings in endocrinological practice. Diagnosis remains challenging due to non-characteristic symptoms and neuroradiological features which may resemble those of pituitary adenomas.
Presentation of the Case: We present a case of female born in 1941, diagnosed with a hemangioma cavernosum located in the Sella turcica. In 2004 our patient presented with uncharacteristic symptoms: syncopes and chronic headaches. Computed tomography (CT) of the head revealed an intrasellar hyperdense tumor mass with radiological features suggesting a pituitary adenoma. In 2005 the patient underwent transcranial resection of the sellar mass, with subsequent oculomotor nerve palsy. In histopathological examination, diagnosis of cavernous hemangioma was determined. Between 2005 and 2020 patient was asymptomatic, with multiple follow-up head MRIs scans, showing gradual progression in size of the intrasellar tumor. The patient was consulted by a neurosurgeon, with no direct indications for surgical approach found. Furthermore, due to suprasellar expansion into the direct proximity of the right optic nerve, the patient was disqualified for Gamma-Knife radiotherapy.
The last MRI of the hypothalamic-pituitary area in 2020 revealed a polycyclic, homogeneous, 33x31x29 mm mass, filling in the space of the Sella turcica, with strong enhancement after contrast administration. Invasion of the surrounding structures, including the clivus, right cavernous sinus and right trigeminal cave were described. Bilaterally, internal carotid arteries and right optic nerve adhered directly to the lesion. Pituitary gland was compressed by the tumor mass. In July 2020, in order to verify the ambiguous radiological and clinical characteristics of the lesion including tumor regrowth and its invasiveness, a transsphenoidal partial resection was performed. Tissue samples were collected for the histopathological examination, which confirmed the initial diagnosis of cavernous hemangioma originating from the cavernous sinus. During a multidisciplinary tumor board, having taken into consideration relatively stable clinical condition and high risk possible surgical complications, the patient was currently disqualified from neurosurgical re-operation nor radiotherapy. Surprisingly, during whole follow up, patients pituitary function remained unimpaired. A watchful waiting approach, with radiological and endocrinological follow up were scheduled. Conclusion: To date, only few cases of intrasellar cavernous hemangiomas have been reported. Intrasellar hemangiomas may originate from the vascular tissue of the cavernous sinus. Surgical removal remains the recommended treatment modality, but radiosurgery could be a therapeutic option as well. Stable patients with no clinical symptoms may remain in observation.
Macroprolactinoma in a Patient With Schizophrenia: A Therapeutic Challenge
Authors: Voelz Eduardo , Matias Luiz Fernando , Student Medicine , Medeiros Mateus , Student Medicine , Pimentel Murilo D 
Published: May 2021

Abstract
Introduction: The most common pituitary tumors are prolactinomas and they are treated with dopamine agonists. In schizophrenia, antipsychotics (dopamine receptor blockers) are used, which can result in hyperprolactinemia. The association of Schizophrenia and prolactinoma represents a clinical challenge, once the treatment of one disease can exacerbate the symptoms of the other.
Clinical Case: A 39-year-old man diagnosed with schizophrenia about 20 years ago, sought medical attention in January 2015, due to frequent headache that worsened in the last 3 years and loss of visual field, with bitemporal hemianopsia. The MRI revealed a pituitary macroadenoma (22x15x27mm) with cavernous sinus invasion and displacement of the optic chiasm. In laboratory tests, the serum prolactin level was 223 ng/ml (reference value up to 20 ng/ml in men), while the others pituitary hormones were normal. Therefore, diagnosed with macroprolactinoma. Surgical resection was suggested, but due to the risks, it was decided to start drug treatment. As an initial treatment, the use of 1 mg/ week cabergoline was chosen. Four months after the first visit, prolactin remained high (203 ng/ml) and the dose was readjusted to 1.5 mg/week. In September, there was a reduction in prolactin (97 ng/ml) and a further increase (2.5 mg/week). Ten months after the first medical appointment, a new MRI was performed with a reduction of the macroadenoma (15x08x16mm), without compression of adjacent structures and prolactin of 68.5 ng/ml. In 2016, the patient had episodes of hallucination and depression, quetiapine 100 mg/day was started and his prolactin was 49,2. In February of the following year, he presented an increase in prolactin (203 ng/ml), due to the possible action of quetiapine and haloperidol parenterally 15/15 days, associated with the irregular use of cabergoline. There was no increase in volume in the MRI. In September, he presented a reduction in prolactin (65.76 ng/ml) and it was chosen to maintain the dosage of cabergoline (2.5 mg/week), injectable haloperidol in 15-15 days and quetiapine 200 mg/day. In 2018, there was an increase in prolactin (200 ng/ml), possibly linked to the increase in doses of antipsychotics. At this time the MRI has not been performed due to financial problems. The following year, MRI showed no progression of the macroadenoma. In 2020, the patient presented central hypothyroidism, (TSH: 1.2 mU/L and free T4: 0.44 ng/dl), starting Levothyroxine 50 mcg. The prolactin was 104 ng/ml in this year.
Conclusion: It is necessary to analyze prolactin levels, imaging tests and the prescription of antipsychotic medications for correct analysis and evaluation of prolactinomas in schizophrenic patients.