Thyrotoxicosis is any syndrome caused by excess thyroid hormone and
can be related to excess hormone production (hyperthyroidism).It is Also called as overactive thyroid.Symptoms include unexpected weight loss, rapid or irregular heartbeat, sweating and irritability, although the elderly often experience no symptoms.
Treatments include radioactive iodine, medication and sometimes surgery.
Thyrotoxicosis is any syndrome caused by excess thyroid hormone and
can be related to excess hormone production (hyperthyroidism).It is Also called as overactive thyroid.Symptoms include unexpected weight loss, rapid or irregular heartbeat, sweating and irritability, although the elderly often experience no symptoms.
Treatments include radioactive iodine, medication and sometimes surgery.
Hyperthyroidism, Reference: Hyperthyroid, Harrison's Principles of Internal Medicine, Soheil Elahi, Islamic Azad University of Medicine- International Branch (IAUM-int)
Hashimoto's thyroiditis (HT) is one of the most common human autoimmune
diseases responsible for numerous morbidity in women. Hashimoto’s disease
is also called Hashimoto’s thyroiditis, chronic lymphocytic thyroiditis, or
autoimmune thyroiditis. Hashimoto’s disease is at least 8 times more common
in women than men. Although the disease may occur in teens or young women,
it more often appears between ages 40 and 60. Your possibility of developing
Hashimoto’s thyroiditis increases if other family members have the disease.
It is an organ-specific T-cell mediated disease that affects the thyroid gland,
and genetics play a contributory role in its complexity. To date, significant
progress has been made in identifying and characterizing those genes involved
in the disease.
Chronic lymphocytic thyroiditis (hashimoto thyroiditis, autoimmuneDr. Saad Saleh Al Ani
Chronic lymphocytic thyroiditis (Hashimoto Thyroiditis ) The most common cause of thyroid disease in children and adolescents and the most common cause of acquired hypothyroidism, with or without goiter. Approximately 60% of infiltrating lymphoid cells are T cells, and approximately 30% express B-cell markers.A variety of different thyroid antigen autoantibodies are involved
Hypothyroidism Diagnosis, Etiopathogenesis and TreatmentPranatiChavan
Hypothyroidism is a condition in which the thyroid gland doesn't produce enough thyroid hormone.
Hypothyroidism's deficiency of thyroid hormones can disrupt such things as heart rate, body temperature and all aspects of metabolism. Hypothyroidism is most prevalent in older women.
Major symptoms include fatigue, cold sensitivity, constipation, dry skin and unexplained weight gain.
Treatment consists of thyroid hormone replacement.
Graves’ disease is a type of autoimmune problem that causes the thyroid gland to produce too much thyroid hormone, which is called hyperthyroidism. Graves’ disease is often the underlying cause of hyperthyroidism.
Hyperthyroidism, Reference: Hyperthyroid, Harrison's Principles of Internal Medicine, Soheil Elahi, Islamic Azad University of Medicine- International Branch (IAUM-int)
Hashimoto's thyroiditis (HT) is one of the most common human autoimmune
diseases responsible for numerous morbidity in women. Hashimoto’s disease
is also called Hashimoto’s thyroiditis, chronic lymphocytic thyroiditis, or
autoimmune thyroiditis. Hashimoto’s disease is at least 8 times more common
in women than men. Although the disease may occur in teens or young women,
it more often appears between ages 40 and 60. Your possibility of developing
Hashimoto’s thyroiditis increases if other family members have the disease.
It is an organ-specific T-cell mediated disease that affects the thyroid gland,
and genetics play a contributory role in its complexity. To date, significant
progress has been made in identifying and characterizing those genes involved
in the disease.
Chronic lymphocytic thyroiditis (hashimoto thyroiditis, autoimmuneDr. Saad Saleh Al Ani
Chronic lymphocytic thyroiditis (Hashimoto Thyroiditis ) The most common cause of thyroid disease in children and adolescents and the most common cause of acquired hypothyroidism, with or without goiter. Approximately 60% of infiltrating lymphoid cells are T cells, and approximately 30% express B-cell markers.A variety of different thyroid antigen autoantibodies are involved
Hypothyroidism Diagnosis, Etiopathogenesis and TreatmentPranatiChavan
Hypothyroidism is a condition in which the thyroid gland doesn't produce enough thyroid hormone.
Hypothyroidism's deficiency of thyroid hormones can disrupt such things as heart rate, body temperature and all aspects of metabolism. Hypothyroidism is most prevalent in older women.
Major symptoms include fatigue, cold sensitivity, constipation, dry skin and unexplained weight gain.
Treatment consists of thyroid hormone replacement.
Graves’ disease is a type of autoimmune problem that causes the thyroid gland to produce too much thyroid hormone, which is called hyperthyroidism. Graves’ disease is often the underlying cause of hyperthyroidism.
A brief overview of pituitary adenomas, their subtypes, classification, investigation protocols, radiological evaluation, and their medical management.
thyrotoxicosis in special situation the let.pptHamedRashad1
how thyroid hyperfunction affects children and elderly , when to suspect and how to treat Summary of clinical manifestations and how to peck and diagnose and methods of treatment
2012 Clinical Practice guidelines for hypothyroidism in adults: American Asso...Jibran Mohsin
This is presentation format of 2012 Clinical Practice guidelines for hypothyroidism in adults: American Association of Clinical Endocrinologists (AACE) / American Thyroid Association (ATA)
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Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
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2. How to cite this article: Pınar T T, Aykut T, Ozge T, Dogan N B, Sevnaz S. Hypopituitarism Associated with a Microadenoma in an Elderly Patient. Gerontol &
Geriatric stud. 1(3). GGS.000513. 2017. DOI: 10.31031/GGS.2017.01.000513
Gerontology & Geriatrics studies
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Gerontol & Geriatric stud
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was 36.8 °C, heart rate was 56/minute, respiratory rate was 18/
minute, and arterial blood pressure was 80/50mmHg. The patient
exhibited dry skin and alopecia. Her medical and family histories
were unremarkable. She was admitted to the geriatric inpatient
unit with a prediagnosis of malnutrition.
The results of the first laboratory tests conducted after
admission Table 1 suggested prerenal acute kidney injury (AKI)
and intravenous fluid treatment was initiated.
Table 1: The patient’s blood analysis results at time of hospital
admission.
Parameter Value (normal range)
WBC count (103
/µL) 5.16(3.91-12.68)
Hemoglobin (g/dl) 11.4(11.9-16.9)
Platelet count (103
/µL) 190(166-390)
CRP (mg/dl) 1.7(0-5)
Sedimentation rate (mm/h) 68(0-20)
Creatinine (mg/dl) 4.22(0.57-1.11)
BUN (mg/dl) 137(7-20)
Sodium (mmol/l) 126(136-145)
Potassium (mmol/l) 6.78(3.5-5.1)
WBC- White blood cell; CRP- C-reactive protein; BUN- Blood urea
nitrogen.
Table 2: The patient’s pituitary hormone levels.
Parameter Value (normal range)
Estradiol (pg/ml) <10 (Post-menopausal phase: 10-28)
FSH (mIU/ml) 9.30 (Post-menopausal phase: 23-116.3)
LH (mIU/ml)
4.87 (Post-menopausal phase: 0.57-
61.99)
Cortisol (µg/dl) 1.1 (Before midday: 3.7-19.4)
ACTH (pg/ml) <5.00(0-46)
TSH: (µIU/ml) 0.266(0.35-4.94)
FT4 (ng/dl) 0.68(0.70-1.48)
FT3 (pg/ml) <1.00(1.71-3.71)
Growth hormone (ng/ml) 0.41(0-8)
IGF (ng/ml) 1.32(17-323)
FSH- Follicle stimulating hormone; LH- Luteinizing hormone;
ACTH- Adrenocorticotropic hormone; TSH- Thyroid stimulating
hormone; FT4- Free thyroxine; FT3- Free triiodothyronine; IGF-
Insulin-like growth factor.
Despite a downward trend in the patient’s creatinine level, her
hypotension did not improve. Electrocardiographic examination for
differential diagnoses revealed no pathology. Due to the patient’s
persistent hypotension, pituitary hormone levels were assessed
and the adrenocorticotropic hormone (ACTH) stimulation test
was performed (Table 2). Based on the results of these tests, the
patient was diagnosed with hypopituitarism. Treatment with
methylprednisolone(60mg,1mg/kg)wasinitiated.Thehypotension
resolved on the second day of treatment and oral nutrition was
resumed. On the fourth day of treatment, levothyroxine sodium was
initiated and methylprednisolone was gradually reduced.
Magnetic resonance imaging (MRI) of the pituitary gland for
differential diagnosis of hypopituitarism revealed a microadenoma
8x3 mm in size in the posterior aspect of the anterior pituitary.
The patient was diagnosed with hypopituitarism associated with
micro adenoma (Figures 1&2). No pathology was detected in visual
field testing. On day 14 of treatment with methylprednisolone and
levothyroxine sodium, the patient’s bradycardia, hypotension, and
hyponatremia had fully resolved, and her general condition and
laboratory values had were improved. She was discharged and
followed on an outpatient basis.
Figure 1: The patient was diagnosed with hypopituitarism
associated with microadenoma.
Figure 2: The patient was diagnosed with hypopituitarism
associated with microadenoma.
Discussion
Hypopituitarism may develop rapidly or slowly depending on
the underlying etiology and may involve one, multiple, or all of the
pituitary hormones. The latter is called panhypopituitarism. Clinical
signs and symptoms may be secondary to hormonal insufficiency
or pressure symptoms caused by pituitary or hypothalamic tumor.
3. How to cite this article: Pınar T T, Aykut T, Ozge T, Dogan N B, Sevnaz S. Hypopituitarism Associated with a Microadenoma in an Elderly Patient. Gerontol &
Geriatric stud. 1(3). GGS.000513. 2017. DOI: 10.31031/GGS.2017.01.000513
3/4
Gerontol & Geriatric studGerontology & Geriatrics studies
Volume 1 - Issue 3
Common pressure symptoms are changes in vision,
typically bitemporal hemianopsia, and headache. In addition,
hyperprolactinemia is a common finding with macroadenomas
that do not produce prolactin, due to pituitary stalk compression
and impaired dopaminergic inhibition [5]. High prolactin, through
either direct or indirect inhibition of GnRH, may induce secretion of
luteinizing hormone, which leads to low levels of testosterone and
subsequent reduced libido, thus causing male sexual dysfunction.
Hypopituitarism generally causes nonspecific symptoms
which are also signs of normal aging, such as fatigue, low energy,
weight loss, and reduced appetite. Therefore, hypopituitarism is
not easily diagnosed in the older population. Details of the clinical
presentation of specific hormonal deficiencies are discussed below
[6].
Nearly all the symptoms of ACTH deficiency are due to cortisol
deficiency. This is the most critical of all pituitary hormone
deficiencies. It can manifest with orthostatic hypotension,
fatigue, nausea, vomiting, dizziness, hypoglycemia, or nonspecific
abdominal pain.
Secondary hypothyroidism is rare. Clinical findings like low
energy levels, weight gain, cold intolerance, constipation, dry skin,
alopecia, and bradycardia occur due to low thyroxine (T4) level.
Diagnosis of male hypogonadism is based on a combination
of low androgen levels and symptoms of hypogonadism. The
testicles are soft and have reduced volume. Other signs include
slow facial hair growth, erectile dysfunction, decreased libido,
decreased muscle and bone mass, or anemia, and erythropoiesis
may be reduced [7]. Older women with hypogonadism exhibit
osteoporosis, decreased libido, vaginal dryness, and chest atrophy,
which are indistinguishable from menopausal symptoms [1].
The activity of the GH-IGF-1 axis decreases in parallel with
the normal age-related reduction in insulin-like growth factor
1 (IGF-1) levels seen in older patients [8]. Some authors have
attributed this reduction to decreases in GHRH-secreting neurons
or somatostatinergic hyperactivity [9]. Clinically, patients may
experience changes in body composition such as increased fat
mass, reduced muscle mass and strength, fatigue, or lower bone
mineral density.
Antidiuretic hormone (ADH) deficiency manifests as polyuria
and polydipsia with a continuous desire to drink cold beverages,
and is associated with diabetes insipidus [1].
A diagnosis of hypopituitarism is confirmed biochemically by
baseline hormone levels or by dynamic function tests [9]. However,
there are limited data regarding the validity of these diagnostic
tests in the older population. Most guidelines are based on the
findings observed in younger patients.
The management of hypopituitarism is based on treating the
underlying pathology when possible, and hormone replacement
therapy when needed. The use of therapeutic methods such as
drugs, surgery, or radiotherapy, either singly or in combination,
may be required in order to achieve an optimal result in the
treatment of a pituitary tumor [10-12]. For some tumors, surgery
may be necessary to reduce pressure effects on structures the
optical chiasma or cavernous sinus. On the other hand, immediate
neurosurgery may be needed to prevent compression of nearby
structures (e.g.: the optic chiasma and nerves), as in pituitary
apoplexy [13,14]. Finally, it is crucial to identify cases of life-
threatening hypopituitarism and promptly initiate treatment with
appropriate hormonal replacement therapies. The goal of hormone
replacement therapy is to maintain hormonal physiology to the
extent possible and prevent symptoms associated with deficiency.
In patients with panhypopituitarism or isolated ACTH deficiency,
glucocorticoid replacement is of vital important. Hydrocortisone
is the preferred hormone; other alternatives include prednisone,
methylprednisolone, cortisone, and dexamethasone, which
basically differ in terms of duration of action and glucocorticoid vs
mineralocorticoid effects.
Thyroxine replacement is the treatment for secondary
hypothyroidism. It is very important to start at low doses (0.25-
0.5μg/kg) with elderly patients [15,16]. Levothyroxine can be
gradually increased every 3-4 weeks after the initial dose is
tolerated. Factors such as reduced metabolic clearance, decreased
body mass and other comorbid conditions are among the reasons
for starting treatment with low thyroxine doses in the elderly [17].
Most importantly, thyroxine replacement must not be initiated
before adrenal insufficiency is adequately treated. In patients
with both hypocortisolism and hypothyroidism, treating only the
hypothyroidism may increase the clearance of cortisol, which is
already scarce, which exacerbates the cortisol deficiency and may
in some cases trigger an adrenal crisis [18,19].
The risk of cardiovascular disease and osteoporosis increases
in normal postmenopausal women. It was initially believed that
hormone replacement therapy could lower these risks. However,
various trials conducted in the last 4-5 years were unable to
demonstratethisbeneficialeffect,andthebenefit/riskratiohasbeen
debated. The procoagulant effect is believed to be cardioprotective,
especially in older women after menopause. However, the long-term
effects of estrogen replacement on cardiovascular morbidity or the
development of breast cancer in older women with hypopituitarism
are unknown. Androgen replacement is the standard therapy
for male hypogonadism. Testosterone therapy is recommended
for symptomatic males in order to improve sexual function and
bone mineral density. Androgen therapy has also been shown
to positively impact anthropometric measurements and lipids
[20,21]. Recombinant growth hormone (rhGH) has been available
since 2005. Growth hormone deficiency in adults may result in
reduced IGF-1, increased fat mass, abnormal bone turnover, and
an unfavorable lipid profile compared to healthy adults, and its
replacement is believed to reverse these effects [22,23].
Patients with diagnosed ADH deficiency may be treated with
adequate oral intake of fluids in mild cases, while desmopressin may
be required in severe cases. Desmopressin may be administered via
oral, nasal, or parenteral routes [24].
4. How to cite this article: Pınar T T, Aykut T, Ozge T, Dogan N B, Sevnaz S. Hypopituitarism Associated with a Microadenoma in an Elderly Patient. Gerontol &
Geriatric stud. 1(3). GGS.000513. 2017. DOI: 10.31031/GGS.2017.01.000513
Gerontology & Geriatrics studies
4/4
Gerontol & Geriatric stud
Volume 1 - Issue 3
Conclusion
Hypopituitarism in the elderly can mimic the symptoms of
normal aging. Therefore, clinicians must be vigilant and diagnose
the disease before symptoms progress. Changes in hormonal
axes can be assessed by morning cortisol, thyroid stimulating
hormone, free T4, IGF-1, luteinizing hormone, follicle stimulating
hormone, sex hormones and, if necessary, ACTH stimulation test.
When necessary, glucocorticoids and initially low-dose thyroid
hormone replacement should be initiated. The benefits and risks
of sex hormone replacement should be addressed for each patient
individually. Growth hormone replacement is controversial and
must be closely monitored. Regular follow-up of these patients
is necessary to evaluate the treatment and definitively assess the
associated risks. Long-term studies that assess the benefits and
risks of pituitary hormone replacement, particularly of sex and
growth hormones, are needed in order to better guide physicians’
treatment decisions and achieve optimal outcomes for patients.
References
1. Antonopoulou M, Sharma R, Farag A, Banerji MA, Karam JG, et al. (2012)
Hypopituitarism in the elderly. Maturitas 72(4): 277-285.
2. Lamberts SW, De Herder WW, Van Der Lely AJ (1998) Pituitary
insufficiency. The Lancet 352(9122): 127-134.
3. CohenDL,BevanJS,AdamsCB(1989)Thepresentationandmanagement
of pituitary tumours in the elderly. Age Ageing 18(4): 247-252.
4. Turner HE, Adams CB, Wass JA (1999) Pituitary tumours in the elderly: a
20 year experience. Eur J Endocrinol 140(5): 383-389.
5. Ascoli P, Cavagnini F (2006) Hypopituitarism. Pituitary 9(4): 335-342.
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7. Daniell HW (2006) Erythropoietin resistance during androgen
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8. Florini JR, Prinz PN, Vitiello MV, Hintz RL (1985) Somatomedin-C
levels in healthy young and old men: relationship to peak and 24-hour
integrated levels of growth hormone. J Gerontol 40(1): 2-7.
9. Ghigo E, Arvat E, Gianotti L, Ramunni J, Divito L, et al. (1996) Human
aging and the GH-IGF-I axis. J Pediatr Endocrinol Metab 9 (Suppl 3): 271-
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10. Colao A, Annunziato L, Lombardi G (1998) Treatment of prolactinomas.
Ann Med 30(5): 452-459.
11. Lissett CA, Peacey SR, Laing I, Tetlow L, Davis JR, et al. (1998) The
outcome of surgery for acromegaly: the need for a specialist pituitary
surgeon for all types of growth hormone (GH) secreting adenoma. Clin
Endocrinol (Oxf) 49(5): 653-657.
12. Gittoes NJ, Bates AS, Tse W, Bullivant B, Sheppard MC, et al. (1998)
Radiotherapy for non-function pituitary tumours. Clin Endocrinol (Oxf)
48(3): 331-337.
13. Hasegawa Y, Yano S, Sakurama T, Ohmori Y, Kawano T, et al. (2011)
Endoscopic surgical treatment for pituitary apoplexy in three elderly
patients over the age of 80. Acta Neurochir Suppl 111: 429-433.
14. Turgut M, Ozsunar Y, Başak S, Güney E, Kir E, et al. (2010) Pituitary
apoplexy: an overview of 186 cases published during the last century.
Acta Neurochir (Wien) 152(5): 749-761.
15. Roos A, Linn Rasker SP, van Domburg RT, Tijssen JP, Berghout A, et al.
(2005) The starting dose of levothyroxine in primary hypothyroidism
treatment: a prospective, randomized, double-blind trial. Arch Intern
Med 165(15): 1714-1720.
16. Davis FB, LaMantia RS, Spaulding SW, Wehmann RE, Davis PJ, et al.
(1984) Estimation of a physiologic replacement dose of levothyroxine
in elderly patients with hypothyroidism. Arch Intern Med 144(9): 1752-
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17. Sawin CT, Herman T, Molitch ME, London MH, Kramer SM, et al. (1983)
Aging and the thyroid. Decreased requirement for thyroid hormone in
older hypothyroid patients. Am J Med 75(2): 206-209.
18. Wang G, Cai C, Wu B (2010) Thyroid hormones precipitate subclinical
hypopituitarism resulted in adrenal crisis. J Am Geriatr Soc 58(12):
2441-2442.
19. Graves L, Klein RM, Walling AD (2003) Addisonian crisis precipitated by
thyroxine therapy: a complication of type 2 autoimmune polyglandular
syndrome. South Med J 96(8): 824-827.
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