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Hypopituitarism diagnosis and management (1)

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common causes of hypopituitarism and management for the same has been discussed in this presentation

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Hypopituitarism diagnosis and management (1)

  1. 1. Hypopituitarism Diagnosis and Management Jeetam Singh Rajput Jr 3 Internal medicine
  2. 2. Moderator: Prof Sarita Bajaj DM Director & Head of department PG Dept of Medicine MLN Medical college Allahabad
  3. 3. Definition
  4. 4. Anterior Pituitary Cell types Hormone synthesize Acidophilic cells 1. Somatotrophs Growth hormone(GH) 2. Lactotrophs (mammotrophs) Prolactin(PRL) Basophilic cells 1. Corticotrophs POMC, ACTH, MSH, endorphins, lipotropin 2. Thyrotrophs TSH 3. Gonadotrophs FSH, LH
  5. 5. Hormone Features of deficiency GH Children: growth retardation Adults: muscle bulk↓ Tendency to hypoglycaemia. Prolactin Failure of lactation Gonadotrophins Children: delayed puberty Female: oligomenorrhoea, infertility,atrophy of breast & genitalia, los of libido Male:Impotence,azoospermia,testicular atrophy, loss of libido Both sexes: Loss of libido,Loss of body hair ACTH Weight loss, hypotension, hypoglycaemia, decrease skin pigmentation, hyponatremia, nausea, vomiting TSH Weight gain, cold intolerence,fatique, hair loss, constipation, dry skin, hoarseness,bradycardia, fatigue Vasopressin Thirst, polyuria
  6. 6. Aetiology - Hypopituitarism 1.Developmental/Structural a) Pituitary dysplasia/Aplasia b) Encephalocele, congenital empty sella c) Congenital hypothalamus disorder i) Septo- optic dysplasia ii) Prader- willi syndrome iii) Kallmann syndrome iv) Laurence-moon-beidl syndrome 2. Neoplastic a) Pituitary adenoma b) Parasellar mass( eg: germinoma, glioma, ependymoma)
  7. 7. Contd.. c) Craniopharyngioma d) Rathke’s cyst e) Other Tm:- Mets, lymphoma, Leukemia, Meningioma 3. Vascular a) Pituitary apoplexy b) Seehan’s syndrome(Postpartum necrosis) c) Sickle cell disease d) Arteritis 4. Traumatic Injury, surgical resection, Radiation damage
  8. 8. Contd.. 5. Inflammatory a) Hypophisitis:- Lymhocytic & granulomatous hypophisitis b) Other causes:- Hemochromatosis,Sarcoidosis, Histiocytosis, Amyloidosis 6. Infections a) Fungal(Histoplasmosis) b) Parasitis(Toxoplasma) c) Tuberculosis d) Pnumocystis carinii
  9. 9. Septo-Optic Dysplasia  Hypothalamic dysfunction and hypopituitarism  may result from dysgenesis of the septum pellucidum or corpus callosum  Affected children have mutations in the HESX1 gene  These children exhibit variable combinations of:  cleft palate  syndactyly  ear deformities  optic atrophy  micropenis  anosmia  Pituitary dysfunction  Diabetes insipidus  GH deficiency and short stature  Occasionally TSH deficiency
  10. 10. Prader Willi Syndrome • Result from deletion of patternal copy of SRNPN and NECDIN gene (chr 15q). • Clinical feature:- Hypogonadotropic Hypogonadism, Hyperphagia, obesity, muscle hypotonia , mental retardation, T2DM.
  11. 11. Kallman Syndrome • Defective hypothalamic gonadotropin-releasing hormone (GnRH) synthesis • Associated with anosmia or hyposmia due to olfactory bulb agenesis or hypoplasia • May also be associated with: color blindness,optic atrophy, nerve deafness, cleft palate, renal abnormalities, cryptorchidism • GnRH deficiency prevents progression through puberty • Characterized by  low LH and FSH levels  low concentrations of sex steroids
  12. 12. Kallman Syndrome • Males patients  Delayed puberty and hypogonadism(small testis), including micropenis  Long-term treatment: • human chorionic gonadotropin (hCG) or testosterone • Female patients  Primary amenorrhea and failure of secondary sexual development  Long-term treatment: • cyclic estrogen and progestin • Repetitive GnRH administration restores normal fertility • Fertility may also be restored by the administration of gonadotropins or by using a portable infusion pump to deliver subcutaneous, pulsatile GnRH
  13. 13. Laurence-Moon-Bardet-Biedl Syndrome • Rare autosomal recessive disorder • Clinical feature:- Retinal degenration, Renal abnormality, Retardation(Mental), obesity • other: hexadactyly/ brachydactyly/ syndactyly • Central diabetes insipidus may or may not be associated • GnRH deficiency occurs in 75% of males and half of affected females • Retinal degeneration begins in early childhood – most patients are blind by age 30
  14. 14. Hypopituitarism (Acquired Causes) 1. Neoplastic 2. Vascular Pituitary Apoplexy, sheehan’s syndrome 3. Infiltrative/inflammatory disorder Lymphocytic hypophysitis 4. Trauma, Cranial irradiation,Surgical resection 5. Empty Sella syndrome 6. Infections
  15. 15. Order of hormone deficiencies • GH • Gonadotropins (FSH, LH) • TSH • ACTH • Prolactin • Posterior pituitary hormones
  16. 16. Pituitary adenoma(Non functioning) • Consist of 10% of all intracranial neoplasm. • 25-35% are nonfunctioning . • Most of them arise from gonadotropin cells & monoclonal in origin. • Most of them are macroadenoma. • Usually discovered because of space-occupying effects, or inadvertently.
  17. 17. Management of nonfunctioning pituitary adenoma Non functioning pit. adenoma MRI differential diagnosis Asses pituitary function Nonfunctioning pituitary adenoma Macroadenoma Transspenoidal surgery Follow up: MRI at 1,2,5 year Reasses if symptomatic Microadenoma Observe MRI and hormone testing every 6 month for 2yr, anually thereafter, hormone replacement if required
  18. 18. Pituitary Apoplexy • Spontaneous hemorrhage in pituitary adenoma/tumor • Considered as a neurosurgical emergency • Presentation: Variable onset of severe headache Nausea and vomiting Meningismus Vertigo  Visual defects  Altered consciousness • Symptoms may occur immediately or may develop over 1-2 days
  19. 19. Pituitary Apoplexy • Risk factors: DM, HTN Sicle cell anemia Anticoagulant use:- Warfarin, Heprin • Usually resolve completely • Transient or permanent hypopituitarism is possible undiagnosed acute adrenal insufficiency • Diagnose with CT/MRI • Differentiate from leaking aneurysm • Treatment: If visual defects and altered consciousness then Surgical – Transsphenoidal decompression • Medical therapy – if symptoms are mild Corticosteroids
  20. 20. Normal MRI imaging of Pituitary T 1 image sagittal section T1 image coronal section
  21. 21. Pituitary Apoplexy Coronal & sagittal section of brain(MRI) showing pituitary haemorrhage
  22. 22. Sheehan’s Syndrome • Infarction of pituitary after substantial blood loss during childbirth • Incidence: 3.6% • No correlation between severity of hemorrhage and symptoms • Severe: recognised month to years postpartum period – Lethargy, anorexia, weight loss, unable to breast feeding
  23. 23. Sheehan’s Syndrome • Typically long interval between obstetric event and diagnosis( months to years) • Of total patients:  50% permanent amenorrhea  The rest had scanty-rare menses  Mostly lactation was poor to absent • Dx: MRI empty sella turcica • T/t: Hormone replacement & Corticosteroids
  24. 24. Lymphocytic Hypophysitis • Etiology Presumed to be autoimmune • Clinical Presentation Women, during postpartum period Mass effect (sellar mass) Deficiency of one or more anterior pituitary hormones  ACTH deficiency is the most common • Diagnosis MRI - may be indistinguishable from pituitary adenoma ↑ ESR • Treatment Non compressive symptoms→Hormone support + Steroid Compressive symptoms→ Surgery(TSS)
  25. 25. Lymphocytic Hypophysitis HPE of Pituitary MRI brain (coronal & sagittal section)
  26. 26. Trauma • The pituitary may be partially or totally damaged by birth trauma, cranial hemorrhage, fetal asphyxia, or breech delivery. • Head trauma can lead to direct pituitary damage by 1) Sella turcica fracture, 2) Pituitary stalk section 3) Trauma-induced vasopasm, or ischemic infarction • The most common traumatic cause of compromised pituitary function in the adult is iatrogenic neurosurgical trauma.
  27. 27. • Hypopituitarism following head trauma usually appears within a year after the insult. • Virtually all patients with subsequent pituitary failure have a history of loss of consciousness following trauma. • 1/2 pt has documented skull fracture. • 1/3rd of these patients have demonstrable signs of hypothalamic or post pituitary hemorrhage (or both) or ant lobe infarction on MRI. • Diabetes insipidus is the most common endocrine disorder, encountered in about 30% of these patients, later on other hormone deficiency may also occurs. • 75% of patients have evidence of hypopituitarism, and the degree of pituitary failure correlates with severity of head trauma.
  28. 28. Cranial Irradiation • Children and adolescents, are more susceptible to pituitary & hypothalamic failure after whole-brain or head and neck therapeutic irradiation. • The development of hormonal abnormalities correlates strongly with irradiation dosage. • Up to two-thirds of patients ultimately develop hormone insufficiency after a median dose of 50 Gy (5000 rad) . • The development of hypopituitarism occurs over 5–15 years and usually reflects hypothalamic damage rather than primary destruction of pituitary cells. • GH deficiency is most common, followed by gonadotropin and ACTH deficiency. • Replace therapy instituted when appropriate .
  29. 29. Empty Sella Syndrome • An empty sella can develop as a consequence of a primary congenital weakness of the diaphragm Damage to the sellar diaphragm can lead to arachnoid herniation into the sella. • Usually have normal pituitary function(incidental finding) Implying that the surrounding rim of pituitary tissue is fully functional • Hypopituitarism may develop insidiously. • Rarely, functional pituitary adenomas may arise within the rim of pituitary tissue, and these are not always visible on MRI. • Aetiology:- 1. Congenital 2. Primary hypophisitis 3. Pituitary Adenoma(silent infarction) 4. Other: Trauma, Surgery, Radiation
  30. 30. Empty Sella Syndrome Often an incidental MRI finding
  31. 31. Clinical Presentation • Can present with features of deficiency of one or more anterior pituitary hormones. • Up to 50% of patients with primary empty sella have associated benign intracranial hypertension • Clinical presentation depends on:  Age at onset  Hormone affected, extent  Speed of onset  Duration of the deficiency
  32. 32. Empty Sella Syndrome MRI brain(sagittal section) Specimen showing empty pit fossa
  33. 33. Specific Hormone Deficiencies
  34. 34. Growth Hormone Deficiency Children • Short stature • Micropenis • Increased fat • High-pitched voice • Propensity to hypoglycemia Adult • Reduced lean body mass • Increased fat mass with selective deposition of intra-abdominal visceral fat • Increased waist-to-hip ratio • Hyperlipidemia • Left ventricular dysfunction • Hypertension • Increased plasma fibrinogen levels • ↓ BMD
  35. 35. Diagnosis of GH Deficiency Test Blood sample timing Interpretation Insulin tolerance test: Regular insulin(.05-.15U/kg I.V.) -30,0,30,60,120 min for glucose & GH Glu 40mg/dl˂ GH 3µg/L-Normal˃ Clonidine stimulation test: Clonidine 150 µg/m2 orally 0,30,60,90,120,150,180 min GH >7µg/L- Normal GHRH test: 1µg/kg I.V. 0,15,30,45,60,120 min GH 3µg/L-Normal˃ L-Arginine test:30gm I.V. over 30min 0,30,60,120 min GH 3µg/L-Normal˃ L-Dopa test:500mg PO 0,30,60,120 min GH 3µg/L-Normal˃
  36. 36. GH replacement therapy • The starting dose Adult:- 0.1 -0.2mg/d should be titrated (up to a maximum of 1.25 mg/d) to maintain IGF-I levels in the mid- normal range for age- and sex-matched controls. • Children:- 0.02-0.05 mg/kg/day • Brand available in india:- Norditropin, Eutropin, Saizen, zomacton Contraindication Side effect Active intracranial neoplasm Hypertension ,Tachycardia Intracranial hypertension Headache, paresthesia, dizziness, Diabetic retinopathy Acne, alopecia, bullous eruption Uncontrolled diabetes Mellitus Gynecomastia, gastritis, abnormal urine, Otitis media ,ear disorders , pharyngitis
  37. 37. Gonadotropin Deficiency Women  Oligomenorrhea or amenorrhea  Loss of libido  Vaginal dryness or dyspareunia  Loss of secondary sex characteristics (estrogen deficiency) Men  Loss of libido  Erectile dysfunction  Infertility  Loss of secondary sex characteristics  Atrophy of the testes  Gynecomastia (testosterone deficiency)
  38. 38. Diagnosis & Management • Diagnosis: • GnRH stimulation test: • Intravenous GnRH ( 100ug) • LH and FSH measured at 0,30,60 min • Normal response LH ↑ by 10 IU/L FSH ↑ by 2 IU/L • Treatment: MALE 1.Testosterone gel→ 5-10 g/d 2.Testosterone patch→ 5mg/d 3.Testosteron enanthate → 200mg IM every 2 wk FEMALE Cyclic estrogen and progesterone BOTH 1.Gonadotropin inj(hCG or hMG) for 12-18 month for fertility 2. GnRH Pulse therapy → 25- 150ng/kg every 2h S.C.
  39. 39. ACTH Deficiency • Results in hypocortisolism  Malaise  Anorexia  Weight-loss,weakness  Gastrointestinal disturbances- Nausea , Vomiting  Hyponatremia , hypoglycemia, hyperkalemia • Pale complexion  Unable to tan or maintain a tan  Not accompanied by hyperpigmentation • No features of mineralocorticoid deficiency  Aldosterone secretion unaffected
  40. 40. Diagnosis of Hypocortisolism • Basal ACTH secretion Cortisol < 3 μg/dL, cortisol deficiency Cortisol > 18μg/dL, sufficient ACTH Cortisol > 3 μd/dL but < 18 μg/dL - test ACTH reserve
  41. 41. Test Time of Sample collection Result(normal response) ITT: regular insulin (0.05-0.15U/Kg I.V.) -30,0,30,60,90 min for glucose and cortisol 1. Glucose<40mg/dl 2. Cortisol↑ by >7ug/dl or to>20ug/dl CRH Test: 1ug/kg CRH I.V. at 8am 0,15,30,60,90,120 min for ACTH and Cortisol 1. ACTH↑ 2 to 4 fold 2. Cortisol level>20-25 ug/dl Metyrapone test: Metyrapone 30mg/kg at midnight Plasma 11-deoxycortisol, ACTH, cortisol at 8 am 1. Cortisol< 4g/dl 2. 11-deoxycortisol>7.5ug/dl 3. ACTH> 75pg/ml Std ACTH stimulation test : ACTH(1-24 cosyntropin) 0.25mg IM or IV 0,30,60min for cortisol and aldosterone 1. Cortisol >21g/dl 2. Aldosterone >4ng/dl above baseline Low dose ACTH test: ACTH 1ug IV 0,30,60 min for cortisol Cortisol >21g/dl 3 day ACTH stimulation test: 0.25mg ACTH I.V. 8 hrly Cortisol >21g/dl •ACTH Reserve
  42. 42. Treatment of ACTH deficiency 1. Hydrocortisone: 10mg a.m. 5mg at noon and 5mg at evening 2. Cortisone acetate: 25mg a.m. and 12.5mg p.m. 3. Prednisone: 5mg a.m. & 2.5mg p.m.
  43. 43. TSH Deficiency • Hypothyroidism • Atrophic thyroid gland • Isolated TSH measurement is not helpful • FT3, FT4, TSH should be measured • Low FT3, FT4, TSH seen • Treatment - Levothyroxine ( 0.075 -0.15 mg daily)
  44. 44. Prolactin Deficiency • Inability to lactate during postpartum period. • Often 1st manifestation of Sheehan syndrome. • Isolated PRL deficiency is very rare. • Prevelence of hypoprolactinemia parallel the prevelence of hypopituitarism. • Normal prolactin>2ug/L and increase > 200% from baseline with TRH stimulation test.
  45. 45. Hormone Replacement
  46. 46. 1. Laron dwarfism is due to? a) GH deficiency b) GHRH deficiency c) GH receptor deficiency d) IGF resistence
  47. 47. Ans C. Laron dwarfism:- Autosomal recessive disorder caused by resistance to action of GH b/c of defect in GH receptor gene. So it is characterised by clinical sign of GH deficiency despite of normal or increase GH but there is low level of IGF-1.
  48. 48. 2. Most common type of Pituitary adenoma? a) Thyrotropinoma b)Gonadotropinoma c) Prolactinoma d)Corticotropinoma
  49. 49. Ans 2. C.
  50. 50. 3. Which drug is essential in Sheehan’s syndrome? a) Estrogen b)Thyroxin c) GH d)Cortisone
  51. 51. Ans 3. D.
  52. 52. 4. Choose false statement a) M/C Pit. Adenoma is prolactenoma b)Most of the adenoma are hyperfunctioning. c) 45% of adenoma are non functioning. d)Non functioning adenoma present with mass effect
  53. 53. Ans 4. C.
  54. 54. 5. Incorrect statement regarding Primary hypophysitis a) There is Lymphocytic infiltration of pituitary seen b)Infiltration by Plasma cells seen c) May present with hypopituitarism d)ESR raised e) Most commonly seen during 2nd trimester of pregnancy
  55. 55. Ans 5. E.
  56. 56. 6. Gold standard test for diagnosis GH deficiency a) GHRH test b)L- Arginine test c) ITT d)L-Dopa test
  57. 57. Ans 6. C.
  58. 58. 7. Most common symptom of non functioning pit. Adenoma a) Pituitary failure b)Visualfield defect c) Seizure d)Opthalmoplegia
  59. 59. Ans7. B.
  60. 60. 8. Reason behind increase in size of pituitary during pregnancy a) PRL mediated b)Estrogen mediated c) Gonadotroph cells proliferation d)NOTA
  61. 61. • Ans. 8. B
  62. 62. 9. Order(decreasing frequency) of hormone deficiency after acute pituitary insult a) GH>TSH>PRL>FSH,LH>ACTH b)GH>FSH,LH>TSH>ACTH>PRL c) GH>ACTH>TSH>FSH,LH>PRL d)GH>PRL>ACTH>TSH>FSH,LH
  63. 63. Ans 9 B
  64. 64. 10. False regarding Prader willi syndrome a) Hypogonadotropic hypogonadism b)Deletion of paternal copy of PENDRIN and NECDIN gene c) T2DM d)Hypotonia e) Hyperphagia
  65. 65. • Ans 10. B.

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