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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3063_Библиотеки_им_академика_М_И_Перельмана
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Case 9
Chief Complaint
Galactorrhea
History and Physical Examination
A 28-year-old woman comes in for the evaluation of milk-like discharge from both
breasts for 3 months. She also reports gradual cessation of menses over the past 4–5
months. Until recently she has had regular menses; her weight and height have been stable.
She reports no fatigue and takes no medications or recreational drugs. She has not noticed
acne or striae. She reports no headaches or visual disturbances. Other than 2 episodes of
UTI a few years ago which were treated effectively with ciprofloxacin, she has no prior
history.
Her family history is significant for hypertension and dyslipidemia. Her BP is 110/70 mm
Hg, pulse 74/min, and respirations 14/min. Physical examination reveals no visual field
defects. Heart and lung exam are normal. There is expressible milk from both breasts but
the rest of the breast exam is unremarkable. Thyroid exam is normal, and abdominal exam
is normal. Formal visual field exam shows no evidence of hemianopsia. An office test for
pregnancy is negative.
Differential Diagnosis
Prolactinoma1.
Hypothyroidism2.
461
Initial Management
Setting: outpatient
Diagnostic/Therapeutic Plan
Test Results
Assessment
Prolactinomas are the most common active (secretory) adenomas of the pituitary. The most
common symptoms of small prolactinomas are amenorrhea, infertility, and galactorrhea. There
are causes of galactorrhea and hyperprolactinemia that are not associated with pituitary
adenomas (secondary hyperprolactinemia).
Causes of secondary hyperprolactinemia are the following:
Pregnancy
3.
Prolactin level
TSH
Pregnancy test (repeat)
Prolactin 260 ng/mL
TSH normal
Repeat pregnancy test negative
Primary hypothyroidism: Due to activation of TRH, the hypothalamic hormone that
activates TSH and prolactin.
1.
Dopamine-inhibiting drugs (haloperidol, metoclopramide, trifluoperazine): Since
prolactin is under constant inhibition from dopamine drugs that inhibit, dopamine will
2.
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In this patient with galactorrhea in the setting of an initial negative pregnancy test and no
history of drug/medication use, the likely diagnosis is a prolactinoma or hypothyroidism. In
secondary hyperprolactinemia, prolactin levels are <200 ng/mL.
Further Management Plan/Results
Treatment Plan
Discussion
Prolactinomas in women cause galactorrhea, oligomenorrhea, amenorrhea, and infertility.
Hypogonadism is thought to result from suppression of GnRH by the elevated prolactin levels.
Large prolactinomas, commonly seen in men, present with bitemporal hemianopsia, headaches,
and blurry vision. Serum prolactin level in prolactinomas is almost always >200 ng/mL.
Pituitary MRI is the most sensitive test for detecting pituitary tumors and determining their size.
MRI scans may be repeated periodically to assess tumor progression and the effects of therapy.
CT scan can also visualize the pituitary but is less sensitive than the MRI.
The goal of treatment in prolactinomas is to reduce prolactin secretion, reduce tumor size, and
correct any visual field defects. In the case of very large tumors, only partial achievement of
this goal is possible. Because dopamine normally inhibits prolactin secretion, treatment with
increase serum prolactin levels. A drug history is very important in this case!
Pregnancy: This must be excluded first in all patients with new-onset galactorrhea.3.
MRI of brain: pituitary microadenoma
Trial of dopamine agonists: cabergoline or bromocriptine (cabergoline preferred due to
better side-effect profile)
Monitor prolactin levels
463
dopamine agonists like bromocriptine or cabergoline is effective and usually the first-step in
the management. These drugs also shrink the tumor and return prolactin levels to normal in
approximately 80% of cases.
Bromocriptine is associated with side effects such as nausea and dizziness. Cabergoline is
associated with the same side effects, but these seem to be less common and less severe than
with bromocriptine. Surgery should be considered if medical therapy cannot be tolerated or if
it fails to reduce prolactin levels and reduce tumor size. Normalization of prolactin levels
always results in restoration of fertility and gonadal function.
CLINICAL PEARL
In patients with galactorrhea:
Final Diagnosis
Prolactinoma
Always exclude primary hypothyroidism and pregnancy
Confirm that patient is not using dopamine-depleting drugs
Prolactinomas cause significantly elevated levels of prolactin (>200 ng/mL)
464
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Case 10
Chief Complaint
Weight loss, weakness, and dizziness
History and Physical Examination
A 42-year-old woman presents with a 2-month history of weight loss (22 lbs), generalized
weakness, and dizziness when standing. Her medical history is negative except for
hypothyroidism, which was diagnosed 4 years ago and is treated with levothyroxine 125
mcg daily. She has had no recent travel. A recent PPD and chest x-ray done while starting
a new job in a hospital were both negative. She takes no medication or recreational drugs.
On physical examination the patient weighs 106 lbs. Her blood pressure is 98/68 mm Hg
with evidence of orthostasis when sitting up. The nails and palms have increased pigment.
Cardiac exam shows evidence of tachycardia at 102/min. Lung and abdominal exam is
unremarkable. Laboratory studies completed at another institution include Na 129 mEq/L,
K 5.2 mEq/L, and glucose 58 mg/dL. CBC is normal except for an increase in peripheral
eosinophils.
Differential Diagnosis
Primary adrenal insufficiency1.
Small-cell lung cancer secreting ACTH (Cushing’s syndrome)2.
Chronic infectious diseases (tuberculosis, HIV)3.
Malabsorption syndrome (celiac sprue, IBD)4.
465
Initial Management
Setting: outpatient
Diagnostic/Therapeutic Plan
Test Results
Assessment
This patient has the classic features of primary adrenal insufficiency (Addison’s disease):
weakness, orthostasis, hyperpigmentation, electrolyte abnormalities (hyperkalemia and
hyponatremia), and peripheral eosinophilia.
Other diseases that should be considered are paraneoplastic syndrome (small-cell lung cancer)
causing Cushing’s syndrome (less likely with negative smoking history and recent normal chest
x-ray); malabsorption syndromes such as sprue and IBD (less likely given absence of
diarrhea); and TB and HIV, which should always be excluded (though this patient had a recent
PPD that was negative).
Further Management Plan/Results
CT scan of the adrenals Evidence of adrenal atrophy; no evidence of scarring or granulomas
Treatment Plan
Cosyntropin stimulation test
HIV test
Cosyntropin stimulation test: minimal increase in cortisol levels after ACTH stimulation
HIV test negative
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Discussion
Adrenal insufficiency or Addison’s disease is characterized by weakness, weight loss, low BP,
and orthostasis, as well as hyperpigmentation. The symptoms can be non-specific and the
disease sometimes eludes diagnosis. It can occur after recent steroid use (prednisone), but this
should be evident from the history.
In the United States, most cases of adrenal insufficiency are due to autoimmune disorders.
Sometimes it can be part of polyendocrine deficiency syndrome, where adrenal insufficiency is
accompanied by other gland failure (pernicious anemia, hypothyroidism, vitiligo, etc.). In the
developing countries, about 20% of adrenal insufficiency cases are due to TB.
The most specific test to diagnose adrenal insufficiency is the ACTH stimulation test
(cosyntropin test). The test will identify both primary adrenal insufficiency as well as chronic
adrenal insufficiency (the adrenal glands atrophy in the absence of ACTH). Patients with
adrenal insufficiency fail to respond with an increase in cortisol levels after ACTH injection is
given.
Once the diagnosis of adrenal insufficiency is made, additional imaging of the adrenals with
CT scan or MRI is needed. Scarring and calcification of the adrenals may indicate TB and thus
further evaluation may be warranted. Treatment involves replacing the missing hormones.
Hydrocortisone is given to replace cortisol; if aldosterone is missing, fludrocortisone should
be added.
CLINICAL PEARL
Primary adrenal insufficiency (Addison’s disease):
Start hydrocortisone and fludrocortisone1.
467
Secondary adrenal insufficiency (occurs with Sheehan’s syndrome, hemochromatosis,
pituitary apoplexy)
Final Diagnosis
Primary adrenal insufficiency associated with polyendocrine deficiency syndrome
Hyperpigmentation (not evident in secondary adrenal insufficiency)
Hypotension
Hyperkalemia
Eosinophilia
Treat with hydrocortisone +/− fludrocortisone
Other hormones are deficient: LH, FSH, GH, TSH
No evidence of hyperpigmentation
Hypotension and hyperkalemia uncommon
Treat with hydrocortisone
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Case 11
Chief Complaint
Headache and blurry vision
History and Physical Examination
A 52-year-old man with past medical history of pituitary adenoma presents to the
emergency medicine department with a few hours of left eye diplopia, blurry vision, and
ptosis. Prior to this presentation he reported 1 week of constant excruciating occipital
headaches not alleviated by naproxen. The patient denies any focal weakness, sensory
changes, fevers, and vomiting. There is also no report of weight loss, skin changes, recent
travel, or head injury.
On initial presentation his blood pressure is 82/44 mm Hg and he is afebrile. On
examination he has mild neck stiffness. He exhibits left eye ptosis with a left pupil 6 mm
dilated but minimally reactive. The right pupil is 3 mm and strongly reactive to light.
Visual acuity is 20/70 on the right and 20/100 on the left. Extra-ocular movements are
intact on the right but the patient cannot adduct, look superiorly or inferiorly on the left.
Other cranial nerves are intact. The rest of the neurologic and physical exam is normal.
Routine laboratory studies show normal CBC and normal basic metabolic panel and urine
studies.
Differential Diagnosis
Pituitary apoplexy, given history of prior adenoma1.
469
CLINICAL PEARL
Always consider sub-arachnoid bleed and pituitary apoplexy in patients presenting
with acute-onset neck stiffness. Bacterial and viral meningitis typically are associated
with fever and evolve over days.
Initial Management
Setting: emergency department
Diagnostic/Therapeutic Plan
Test Results
CLINICAL PEARL
In patients with neck stiffness, CT scan should be done before lumbar puncture, if the
patient has focal neurologic signs (in this case opthalmoplegia), papilledema, or
immunodeficiency.
Subarachnoid bleed (SAB)
2.
Meningitis
3.
Emergency CT scan of head without contrast
Hyperdense mass with bleeding in area of pituitary gland and optic chiasm
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