1/11. myxedema coma of both primary and secondary origin, with non-classic presentation and extremely elevated creatine kinase.myxedema coma is a rare, often fatal endocrine emergency that concerns elderly patients with long-standing primary hypothyroidism; myxedema coma of central origin is exceedingly rare. Here, we report a 37-year-old woman in whom classical symptoms of hypothyroidism had been absent. Six years earlier, she had severe obstetric hemorrhage and, shortly after, two subsequent episodes of pericardial effusion. On the day of admission, pericardiocentesis was performed for the third episode of pericardial effusion. Because of the subsequent grave arrhythmias and unconsciousness, she was transferred to our ICU. Prior to the endocrine consultation, a silent myocardial infarction had been suspected, based on the extremely high serum levels of creatine kinase (CK) and isoenzyme CK-MB. However, based on thyroid sonography, pituitary computed tomography, elevated titers of antithyroid antibodies and pituitary stimulation tests, the final diagnosis was myxedema coma of dual origin: an atrophic variant of Hashimoto's thyroiditis and post-necrotic pituitary atrophy (Sheehan syndrome). Substitutive therapy caused a prompt clinical amelioration and normalization of CK levels. Our patient is the first case of myxedema coma of double etiology, and illustrates how its presentation deviates markedly from the one endocrinologists and physicians at ICU are prepared to encounter. In addition, cardiac problems as those of our patient should not discourage from substitutive treatment (using L-thyroxine and the gastrointestinal route of absorption), if the age is relatively low.- - - - - - - - - - ranking = 1keywords = coma (Clic here for more details about this article) |
2/11. Post-traumatic hypopituitarism. Six cases and a review of the literature.The typical patient with post-traumatic hypopituitarism is a young adult male presenting months to years after an automobile accident, following which he was unconscious for several days. He will probably have sustained a fracture of the base of the skull and on recovery is likely to have permanent visual or other neurological sequelae. Temporary or permanent diabetes insipidus may have occurred. The features of panhypopituitarism such as weight loss, fatigue, faintness, loss of libido, and impotence may have been ascribed to depression or the "postconcussion syndrome" and often inappropriate treatment and rehabilitation advised. The striking feature on review of the literature is that the pathological consequences of head injury to the pituitary and hypothalamus have been well described, while only 47 cases of traumatic hypopituitarism have been reported. The most likely reason for this disparity is that head injury of sufficient severity to cause hypothalamic and pituitary damage commonly led to death. More patients now survive, owing to the availability of intensive care; accordingly, most cases have been reported in the last 15 years. However, several patients are described in whom the initiating head injury was not associated with a skull fracture or followed by coma. We recommend that patients with major head injury (defined by post-traumatic amnesia greater than 24 hours), and in particular those with fractures of the base of the skull or diabetes insipidus should be closely monitored for symptoms and signs of endocrine dysfunction and appropriate dynamic pituitary-function tests performed.- - - - - - - - - - ranking = 0.125keywords = coma (Clic here for more details about this article) |
3/11. Pituitary coma with continuing menstruation.A case of pituitary coma with continuing menstruation is presented. This association is extremely rare, but a history of recent menstrual periods does not exclude advanced hypopituitarism from the differential diagnosis of severe hyponatraemia.- - - - - - - - - - ranking = 0.625keywords = coma (Clic here for more details about this article) |
4/11. Spontaneous hypoglycemic seizures in pregnancy. A manifestation of panhypopituitarism.A 32-year-old woman had seizures and coma due to severe hypoglycemia (26 mg/dL) in the 32nd week of an otherwise uncomplicated pregnancy. She responded dramatically to the administration of cortisol. Initial endocrine evaluation disclosed prolactin (PRL), corticotropin, and thyrotropin (TSH) deficiencies. The patient recovered completely with cortisol and thyroid hormone therapy and was delivered of a healthy male child at term. Endocrine reevaluations one week and six months postpartum disclosed luteinizing hormone, follicle-stimulating hormone, growth hormone, PRL, corticotropin, and probable TSH deficiencies. The cause of this panhypopituitarism has not been determined. This case suggests that the appropriate initial treatment for spontaneous symptomatic hypoglycemia in pregnancy, while awaiting further endocrine evaluation, is the administration of cortisol.- - - - - - - - - - ranking = 0.125keywords = coma (Clic here for more details about this article) |
5/11. diabetes mellitus and hypopituitarism.A 38-year-old diabetic woman developed hyponatraemia and fatal non-ketotic coma after elective cholecystectomy. At the autopsy, it was revealed that the immediate cause of death was cerebral oedema with secondary pontine haemorrhage. The cerebral oedema was associated with severe hyponatraemia and atrophy of the endocrine organs, including the adrenal glands. Biochemical analysis of serum taken immediately before death indicated that the primary defect was pituitary insufficiency, a recognised but rare complication of diabetes.- - - - - - - - - - ranking = 0.125keywords = coma (Clic here for more details about this article) |
6/11. An adult case of neurohypophyseal ectopy presenting ACTH deficiency and partial GH deficiency.A case of ACTH deficiency and partial GH deficiency associated with neurohypophyseal ectopy is described. A 42-year-old woman of short stature was admitted for hypoglycemic coma. The patient had hypocortisolemia, an increase in urinary 17-OHCS after consecutive injections of ACTH-Z, and a low plasma ACTH level which showed no response to corticotropin-releasing factor. This indicated the presence of ACTH deficiency. The plasma GH level showed a blunted response to insulin-induced hypoglycemia, but its response to GRF was preserved. Other hypothalamo-pituitary axes were intact. T1-weighted magnetic resonance imaging demonstrated ectopic neurohypophyseal tissue and a tiny anterior pituitary remnant. ACTH deficiency and partial GH deficiency might have developed as a consequence of pituitary stalk injury and inadequate regeneration of the anterior lobe.- - - - - - - - - - ranking = 0.125keywords = coma (Clic here for more details about this article) |
7/11. Long-term effects on external radiation on the pituitary and thyroid glands.Chronic damage following external irradiation of the normal pituitary and thyroid glands, delivered incidentally during radiotherapy of neoplasms of the head and neck may be more common than has been appreciated in the past. A case of a child who developed pituitary dwarfism 5 1/2 years after radiation therapy has been delivered for an embryonal rhabdomyosarcoma of the naso-pharynx is described. A review of similar cases from the literature is presented. Likewise, external irradiation of the normal thyroid gland produces a spectrum of radiation-induced syndromes. Clinical damage to the pituitary and thyroid glands is usually manifested months to years after treatment and is preceded by a long subclinical phase. A careful exclusion of these glands from radiation treatment fields is recommended whenever possible. An early detection of endocrine function abnormalities in patients receiving radiation to these glands is desirable, since appropriate treatment may prevent the deleterious effects of external irradiation of the pituitary and thyroid glands.- - - - - - - - - - ranking = 0.125keywords = coma (Clic here for more details about this article) |
8/11. Acute hypoglycaemic coma--a rare, potentially lethal form of early onset Sheehan syndrome.This case emphasizes the importance of intensive obstetric management that is required when confronted with prolonged postpartum haemorrhage. Anticipation of the possibility of acute hypoglycaemic coma as an initial manifestation of Sheehan syndrome and prompt recognition may prevent disastrous consequences, including maternal death.- - - - - - - - - - ranking = 0.625keywords = coma (Clic here for more details about this article) |
9/11. Severe hypotension and coma secondary to unrecognized chronic anterior hypophysitis.We report an endocrine emergency of a 52-year-old woman with chronic anterior-pituitary failure of autoimmune origin who developed hypopituitary crisis with coma and severe hypotension provoked by an intercurrent bronchopneumonia. At admission to the ICU hypopituitarism had not been diagnosed and only Hashimoto's thyroiditis with thyroid replacement therapy could be obtained from the patient's history. Although the patient presented with somatic signs suggestive of hypopituitarism, other causes of coma and hypotension had first to be excluded. In the absence of specific treatment the patient died 18 h later with refractory cardiac arrest. diagnosis of acute decompensated chronic hypophyseal failure must be considered if hypothermia, refractory hypotension and signs of infection without fever are associated with a short stature and the loss of axillary and public hair. Waiting for laboratory confirmation of the diagnosis must not delay immediate life-saving specific glucocorticoid treatment.- - - - - - - - - - ranking = 0.75keywords = coma (Clic here for more details about this article) |
10/11. A case of Sheehan's syndrome with delirium.A 53 year old woman was brought to a psychiatric clinic because of delirium. Upon immediate examination, severe hyponatremia (105 mEq/L) was detected. She was suspected of having internal diseases and referred to our university hospital. When she reached our hospital she was delirious and showed excitement and agitation. Her electroencephalogram showed low voltage theta waves (20 microV) in all leads. She was hospitalized and diagnosed with acute tonsillar abscess and panhypopituitarism based on various endocrine tests. Her past history suggested that Sheehan's syndrome had developed after child-bearing at age 31, resulting in panhypopituitarism. After administration of antibiotics, the fever and tonsillar abscess gradually recovered, and the correction of electrolytes improved the level of consciousness, suggesting that the hyponatremia had been closely related to the clouding of consciousness. As the subsequent administration of cortisol kept the patient's serum sodium levels within the normal range, a decrease in plasma cortisol seemed to be the major cause of the hyponatremia. Psychological symptoms of panhypopituitarism often included abulia, apathy and occasionally coma. However, it is rare for a patient with panhypopituitarism to be misdiagnosed as having a psychiatric disease with delirium. This rare case is presented.- - - - - - - - - - ranking = 0.125keywords = coma (Clic here for more details about this article) |
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