MR with Ryan and Dr. Kanter: Hypopituitarism and sellar mass

An elderly man with a hx of HTN, HLD who presented to clinic with decreased vision and hypogonadism – MRI demonstrated a 3 cm sellar mass compressing the optic chiasm.  He underwent transsphenoidal resection, which was complicated by hypopituitarism necessitating hormone replacement with levothyroxine, hydrocortisone, and testosterone.

 

DDx for visual field cut -> pituitary adenoma, sellar mass, glaucoma

DDx for sellar mass -> pituitary adenoma, prolactinoma, brain metastases, meningioma/craniopharyngioma, granulomatous disease (sarcoid, TB)

Any sellar mass that causes visual field deficits

Macradenoma vs. Microadenoma – Microadenomas should not cause visual symptoms – and are defined as < 1 cm

A common/serious complication of transphenoidal resection is a CSF leak

TSH will NOT be accurate in pituitary adenoma – you have to test the free T4 as well to determine hyperthyroid state

MR with Sonia and Dr. Tibuni-Sanders: Secondary Amenorrhea and Osteomalacia

A young female with a 2 year history of abdominal pain who presented 4 months after a laparoscopic cholecystectomy with ongoing abdominal pain, amenorrhea, significant variations in her weight.  She appeared bow legged and kyphotic on exam.  She had severe metabolic derangements including an incredibly low calcium and vitamin D.  Imaging demonstrated sacral fractures.  Further history elicited that the patient had a very limited dietary intake.

 

*In patients presenting with secondary amenorrhea ALWAYS ask about diet. One of the most common causes of functional hypothalamic amenorrhea is eating diosrders. In this case, we failed to ask this question as a group!

*Osteomalacia is a disorder of decreased mineralization of newly formed osteoid at sites of bone turnover

-Mineralization abnormalities occur as a consequence of inadequate calcium, phosphate – or in the presence of abnormal bone matrix or direct inhibition of the mineralization process

-Several difference disorders cause osteomalacia: severe vitamin D deficiency secondary to inadequate dietary intake, lack of sun exposure, gastric bypass or malabsorption – vit D deficiency is the MOST common cause

MR with Nishant + Dr. Kanter: Hyponatremia and Adrenal Incidentaloma

An elderly female with depression presents with fall, found to be hyponatremic to 112. This was ultimately though secondary to celexa, and improved with gentle fluids as well as holding that medication. During her work-up, an adrenal incidentaloma was discovered; we discussed the recommended management of these.

*When is hyponatremia severe enough to merit use of hypertonic saline?

-although expert panel recommendations include the use of hypertonic saline for a range of symptoms and sodium levels (see below), it is onlyabsolutely indicated for patients with acute hyponatremia w/ severe symptoms (coma, seizures, obtundation, respiratory arrest)

-see review for recommended rates of correction and what to do when someone is correcting too quickly

*Approach to adrenal incidentaloma:

-incidental benign adrenal nodes are COMMON, especially as people get older

-Dr. Kanter quoted 4cm as the size above which adrenal nodes should be surgically removed

8/8 Morning Report w/ Liezel and Dr. Kanter: Hyperthyroidism

A middle aged female with no PMHx presents with anxiety and palpitations, found to have mild sinus tachycardia (HR 129) without evidence of thyroid storm.

*Teaching points:

1) Thyroid storm is a CLINICAL diagnosis that requires AMS + FEVER. TSH/T4/T3 levels do not help distinguish storm from other hyperthyroid conditions.

2) The two most common causes of hyperthyroidism are GRAVES and THYROIDITIS. Time course helps distinguish these (Graves is chronic, Thyroiditis acute to subacute)*

There was a great review article on Hyperthyroidism in The Lancet this year (see attached)

8/2 Morning Report w/ Kat Iwata: Hypercalcemia

An elderly gentleman with a pmh of CAD who presented with 6 months of progressive confusion and global weakness admitted for hypercalcemia also found to have a new anemia and AKI.

Know workup of hypercalcemia – think about malignancy in hospitalized patients!

-PTH

-PTHrP

-1,25 Vit D for granulomatous process (sarcoid)

-25 Vit D level for vitamin D toxicity

-SPEP/UPEP

DDx

-Malignancy

-Multiple Myeloma

-Milk Alkali Syndrome

-Hyperparathyroidism

Acute treatment of hypercalcemia -> fluids, fluids, fluids — In this case aggressive fluid resuscitation threw this patient into pulmonary edema.  Remember that pamidronate takes 2-3 days to work.

Update: SPEP came back with M spike and increased lamda light chains highly suggestive of multiple myeloma.  He is now out of the ICU and s/p bone barrow biopsy to seal the diagnosis. (To diagnose multiple myeloma you need a bone marrow biopsy looking  for > 10% clonal plasma cells).

7/15 Morning Report with Alice Zhang and Dr. Sanders

An elderly man with a history Alzheimer’s and UC s/p colectomy presents from a nursing facility with nausea and vomiting for 1 week.  Found to have a calcium level of 18.

Know the DDx of Hypercalcemia

Hypercalcemia of malignancy (mets, PTHrp)

Hyperparathyroidism

Vit D Toxicity

Renal Failure

Multiple Myeloma

Milk Alkali Syndrome

Granulomatous Disease (1,25 mediated) – TB, Sarcoid

*Hyperthyroidism can also cause Hyper Ca via increased osteoclastic activity

In this case, the patient was on high doses of calcium supplements and had developed milk-alkali syndrome with a metabolic alkalosis.

EKG Findings of Hypercalcemia -> Shortened QT, Osborne Waves

Management

Treatment:  Fluids, fluids, fluids —- see how the calcium level is responding before giving Lasix;

Think about the mechanism that is causing the hypercalcemia – if due to increased osteoclastic activity give a bisphosphonate – this will take 1-2 days to work

Calcitonin:  If not responding to fluids – calcitonin works quickly

This patient’s calcium level corrected over the course of a couple days with a total of 6-7 L of fluid and 2 doses of calcitonin.