Download Hypothyroidism - Bharat Medicos

Endocrinology
NRIMC
HYPOPITUITARISM
Dr Srikanth M.D., D.M.
Associate Professor
Dept. of Endocrinology
NRIAS
Dr Sirisha M.D.
Senior Resident
Dept. of Endocrinology
NRIAS
Endocrinology
Hypopituitarism
NRIMC
• Underdiagnosed entity
• Diagnosis Requires
–
–
–
–
High index of suspicion
Low threshold for investigations
Availability of all dynamic endocrine investigations
Endocrine expertise while carrying out investigations
• Not so rare
Endocrinology
NRIMC
A 26 year old male patient, a product of
consangenous parentage presented with
 Growth Retardation
 Failure to develop secondary sexual characters
normally
.
 Decreased frequency of nocturnal erections
 Reduced exercise capacity
Endocrinology
NRIMC
No H/o head injury
 No H/o Anosmia / Visual abnormalities
 No evidence of Chronic illness / Viral infection
 No H/o any drug abuse
Endocrinology
• General Examination:
.
NRIMC
 PR – 88/min
 BP – 110/70 mm Hg without any postural variation
 Weight
– 42 Kg
 Height
– 152 Cm
• US
–
65 cm
• LS
_
87 cm
• Arm span – 158 cms
Endocrinology
• Genital Examination:
.
NRIMC
 Pubic Hair – P2
 SPL – 10cm
 Testes Volume – Prepubertal
 No facial hair & hair in other androgen dependent areas
Axillary hair – present but minimal
 Other systemic examination is normal
Anosmia –ve, CNS - Normal
Endocrinology
Bone age
NRIMC
• Bone age -
13 years
– Delayed
– Chronological age – 26 years
– Epiphyses – still unfused
Endocrinology
NRIMC
Thyroid function tests
Parameter
Result
Units
Normal range
T3
0.92
ng/ml
0.8-1.81
FT3
2.38
pg/ml
0.92-11.25
T4
3.3
gm/dl
4.0 -12.6
FT4
0.29
ng/dl
0.89-1.76
TSH
11.34
IU/ml
0.35 -5.50
Comment
Central Hypothyroidism / Primary hypothyroidism
Endocrinology
NRIMC
Gonadal axis evaluation
Parameter
Result
Units
Comment
FSH
0.60
mIU/ml
Low
LH
0.29
U/L
Low
Testosterone
0.02
ng/ml
Low
Impression
Central Hypogonadism
Endocrinology
Growth Axis
NRIMC
• IGF 1
– Active form of GH
– < 25 ng/ml
– Normal range ( 116-358 ng/ml)
Endocrinology
NRIMC
Parameter
Adrenal axis evaluation
Result
27
•
ACTH
Basal Cortisol
2.0
ACTH
Stim cortisol
Units
27Pg/ml
pg/ml
g/dl
Comment
Normal
Normal
4.3- 22.4
Low
Not done
• Basal cortisol
2.0 mcg/dl Low
Central Hypocortisolism !
Impression
Endocrinology
NRIMC
Endocrinology
NRIMC
• Empty sella appearance
Endocrinology
NRIMC
Endocrinology
• A 42 year old Female Patient presented with
.
NRIMC
 Recurrent episodes of facial puffiness of 10 years duration
 Dryness of skin associated with scaling & itching
 Amenorrhoea of 10 years duration
 Loss of pubic hair & axillary hair
 Weakness, fatiguability, depression & impaired memory
 Previous H/o PPH and Lactation failure
Endocrinology
• General Examination
.
•
Periorbital puffiness
•
Skin – dry, coarse & scaly
•
No axillary and pubic hair
•
Breast atrophy
•
PR – 90/min
•
BP – 100/70 mm Hg without postural variation
NRIMC
• Other Systemic examination is Normal
Endocrinology
NRIMC
Endocrinology
NRIMC
•
•
•
•
Hemogram
Hb 10.6 gm%
WBC count – 4200
Platelets – 2.1 lakh
DC – normal
• Mild normocytic normocytic anemia
Endocrinology
NRIMCParameter
•
•
•
•
•
•
•
•
•
•
Creatinine
Bilirubin
SGOT
SGPT
SAP
:
Total protein
Albumin
Globulin
Na
K
Biochemistry
Result
:
:
:
:
87
:
:
:
:
:
1.1
0.4
115
46
U/L
7.9
4.0
3.9
126
2.6
mg% (
mg%
U/L
U/L
gm/dl
gm/dl
gm/dl
meq/l
meq/l
Normal range
Endocrinology
NRIMC
Thyroid function tests
Parameter
Result
Units
Normal range
T3
< 0.01
ng/ml
0.8-1.81
FT3
1.03
pg/ml
0.92-11.25
T4
< 0.01
gm/dl
4.0 -12.6
FT4
0.11
ng/dl
0.89-1.76
TSH
2.38
IU/ml
0.35 -5.50
Comment
Central Hypothyroidism
Endocrinology
NRIMC
Gonadal axis evaluation
Parameter
Result
Units
Comment
FSH
1.98
mIU/ml
Low
LH
< 0.07
U/L
Low
Estradiol
28.30
pg/ml
Low
Impression
Central Hypogonadism
Endocrinology
NRIMC
Adrenal axis evaluation
Parameter
Result
Units
Comment
ACTH
10
Pg/ml
Low
Basal Cortisol
2.0
g/dl
4.3- 22.4
Low
Stimulated cortisol- 0 min
1.2
g/dl
> 20 g/dl
Low
Stimulated cortisol- 45 min
12.8
g/dl
> 20 g/dl
Low
Stimulated cortisol- 60 min
10.4
g/dl
> 20 g/dl
Low
Stimulated cortisol- 90 min
8.0
g/dl
> 20 g/dl
Low
Stimulation test was done by insulin tolerance test (0.15 U /Kg)
Impression
Central Hypocortisolism
Endocrinology
NRIMC
Growth Hormone axis evaluation
Parameter
Result
Units
Comment
Basal GH
< 0.5
ng/ml
Low
Stimulated GH - 0 min
< 0.5
ng/ml
> 10 ng/ml
Low
Stimulated GH - 45 min
< 0.5
ng/ml
> 10 ng/ml
Low
Stimulated GH - 60 min
< 0.5
ng/ml
> 10 ng/ml
Low
Stimulated GH - 90 min
< 0.5
ng/ml
> 10 ng/ml
Low
Stimulated GH - 120 min
< 0.5
Ng/ml
> 10 ng/ml
Low
IGF -1
Stimulation test was done by insulin tolerance test (0.15 U /Kg)
Peak GH response of > 10 ng/ml is considered normal response
Impression
Adult Growth Hormone deficiency
Endocrinology
Radiological evaluation
NRIMC
MRI of pituitary is suggestive of partial empty sella
Minimal pituitary tissue is present at floor of sella
Endocrinology
Hypothyroidism
NRIMC
1.
2.
3.
4.
5.
6.
7.
Puffiness
Lethargy
Coma
Weakness
Infertility
Cramps
Can not
tolerate LT4
Hypopituitarism
Hypogonadism
1. Pubertal delay
2. Infertility
3. Amenorrhea
* Primary
* Secondary
4. Loss of libido
5. Breast
atrophy
6. Osteoporosis
Hypocortisolism
GH deficiency
Low Prolactin
1.
2.
3.
4.
5.
Children
1.Growth failure
2.Shortstature
Lactational
failure
Weakness
Weight loss
Lethargy
Hypotension
Postural
hypotension
6. Giddiness
7. Vomitings
8. Diarrhea
9. Pain
abdomen
10. Refractory
shock
11. Hyponatremia
Adults
1.Adult growth
hormone
deficiency
No symptoms
in male
Endocrinology
NRIMC
Causes of Hypopituitarism
• Heriditory Pituitary Hormone deficiency ( Pit 1, Prop 1, LHX 3, HESX1)
• Acquired Pituitary hormone deficiency
– Infections – Infiltrative
rare
• Primary Hypophysitis ( Lymphocytic, Granulomatous, Xanthomatous)
• Secondary Hypophysitis ( Histiocytosis X, sarcoidosis )
– Neoplastic
• Pituitary Tumor and parasellar tumors
• Craniopharyngioma etc
• Post Pituitary surgery
– Trauma
• Radiation, surgical resection, brain trauma
– Vascular
• Apoplexy, pregnancy related ( post partum pituitary necrosis), Hypotension
Endocrinology
NRIMC
Summary
• High index of suspicion is required
• Low threshold of investigations
• Seek for endocrine consultation where ever there is a doubt
• Treatment is difficult
– Life threatening hypocortisolemia / hypothyroid coma can occur
– Multiple pituitary hormone replacement is needed in physiological
manner
– Stress advise regarding the steroid replacement is mandatory
– Iatrogenic cushings is possible
– Constant reinforcement is needed for good complaince
– Fertility needs special protocols both in males and females