Great case today from Tyler about a patient who presented with diarrhea and was found to have adrenal insufficiency!
Take Home Pearls:
- In new diagnosis of adrenal insufficiency, dexamethasone is preferred since it does not interact with serum cortisol assays. However, once the diagnosis is made, hydrocortisone is preferred due to mineralocorticoid effect. Per Tyler and endo, dexamethasone is still okay since it has enough mineralocorticoid effect. Plus, mineralocorticoid replacement is not necessary acutely since it takes days for the salt-retention effect to accur and giving IV saline is enough for sodium
- In panhypopituitarism, the classic teaching is that ACTH is the last hormone to be affected
Additional endocrine learning:
- We raised the possibility of lymphocytic hypophysitis in this patient’s presentation
- Lymphocytic infiltration and enlargement of the pituitary
- Often occurs in late pregnancy or postpartum period
- Unclear etiology but thought to be autoimmune in nature
- Presentation: often with headache and there is preferential hypofunction of ACTH and TSH instead of other things in the pituitary in one paper
- Diagnosis: definitive dx must be made with tissue bx. Otherwise the ddx for pituitary mass with hypopituitarism includes many other things.
- Sheehan’s syndrome: Infarction of the pituitary after postpartum hemorrhage is the classic presentation and causes hypopituitarism.
- For previous morning report about diarrhea, check out this post: https://ucsfmed.wordpress.com/2015/06/20/am-report-pearls-619-diarrhea-framework/
- For a previous morning report about, check out this post with a differential: https://ucsfmed.wordpress.com/2015/07/25/moffitt-morning-report-pearls-724-hypopituitarism-endocrine-report/