Download ELECTROLYTES WITH A TWIST

ELECTROLYTES WITH A TWIST
Inpatient Wards Case for Primary Care Conference
Dean Keller, M.D.
May 24, 2006
66-year-old woman with chief complaint of altered mental status, confusion, and headache per family. Family
also stated decreased oral intake. Further history was unobtainable from patient.
Past Medical History:
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Progressive multiple sclerosis, wheelchair bound
Suprapubic catheter with history of UTIs
Hyponatremic seizures on hospital admission one month earlier
Headache—many years probable tension
DNR
Medications: (No recent changes) baclofen, celebrex, lasix, potassium, alprazolam, amitriptyline
Allergy: PCN
Social History: Lives at home with family and home health support
Exam:
Afebrile 139/67 oxygen sat RA 99% P 80 resp 12
Awake, but not very responsive, strength decrease with MS
Lungs clear Cor-normal dry mucous membranes
Abdomen—suprapubic catheter
Labs: Na: 127; Potassium: 3.7; Chloride: 88; bicarb: 27; BUN: 12; Cr: 0.4; Glucose: 81;
CBC, CXR unremarkable
CT head—“demyelination—no bleed—unchanged” U/A—grossly positive
Mental status decrease was multifactorial—UTI, hyponatremia, MS
Hospital initial course was fluids ER (felt was dry) and IV antibiotics. Sodium worse on NS, so then fluid
restricted and Na down to 121! Thinking of hypertonic saline and called Endocrine consult—they felt
SIADH, head bleed had been ruled out on CT. Needed to exclude adrenal and thyroid problems—drew a
serum cortisol and started hydrocortisone IV empirically.
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Objectives:
Pituitary apoplexy—understand the definition, clinical features, management and outcome of this disease.
Definition—rapid enlargement of a pituitary adenoma due to hemorrhagic infarction of the tumor. First
reported in 1898. Incidence varies 1-10% in surgically treated adenomas.
Retrospective analysis of 35 patients (Clin Endocrinol, 1999;Aug;51(2):181-8.)
Clinical Features:
Headache: 97% Nausea: 80% Decreased visual fields: 71% Ocular paresis: 67%
Decreased consciousness: 11% Hypertension: 26% Hypocortisolism: 76%
Imaging:
MRI correctly identified pituitary hemorrhage in 88%
CT scanning identified it in only 21%
Management:
With visual acuity changes, transphenoidal surgery indicated urgently. If surgery done <8 days had
complete neuro-ophthalmologic recovery. If surgery done after 8 days, only 46% had recovery. Need to
cover with perioperative steroids.
If no visual acuity changes, conservative therapy with cortisol replacement and close observation can be
recommended. Long term steroid therapy required in 58%, and thyroid replacement in 45% in this series
(4 patients managed conservatively and 31 received surgery at various times).
A smaller series of 8 patients (J Clin Endocrinol Metab 1990 Aug;71(2):323-8) all of whom received
surgery urgently suggests that urgent surgery may also restore pituitary function. Only one patient out of
eight required steroids longer than the perioperative period.
References:
1. Randeva HS, Schoebel J, Byrne J, Esiri M, Adams CB, Wass JA. Classical pituitary apoplexy: clinical
features, management and outcome. Clin Endocrinol, 1999 Aug;51(2):181-8.
2. Arafah BM, Harrington JF, Madhoun ZT, Selman WR. Improvement of pituitary function after surgical
decompression for pituitary tumor apoplexy. J Clin Endocrinol Metab 1990 Aug;71(2):323-8.
MR, MRI Head with & w/o Contrast 1-17-06
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