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:

  1. Progressive multiple sclerosis, wheelchair bound
  2. Suprapubic catheter with history of UTIs
  3. Hyponatremic seizures on hospital admission one month earlier
  4. Headache—many years probable tension
  5. 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% Decreasedconsciousness: 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 (4patients 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 Page 2