Pituitary Wrap-up 2025 PDF

Pituitary Wrap-up 2025 Drs. Bi, Issar, Sathananthan Case Presentation A 37-year-old man presented to the endocrinology clinic with a 4-year history of excessive sweating, headaches, and joint pain. His wife had also noticed increasing skin folds on his scalp. Physical examination showed thi...

Pituitary Wrap-up 2025 Drs. Bi, Issar, Sathananthan Case Presentation A 37-year-old man presented to the endocrinology clinic with a 4-year history of excessive sweating, headaches, and joint pain. His wife had also noticed increasing skin folds on his scalp. Physical examination showed thickening of the skin on his scalp with ridges and furrows (Panel A, back of head, and Panel B, top of head). Images  What could be going on? wat/hold diabetes insipides , roid they ~ What further history would you get? SIADH , What would you like to examine? What further tests would you like to order? growthmona Case He had enlarged feet and hands and a protruding lower jaw. Findings from laboratory evaluation were notable for an insulin-like growth factor I level of 907 μg per liter (reference range, 82 to 237) and a random measurement of the growth hormone level of 7.3 μg per liter (reference range, 0 to 0.8). What is the underlying mechanism for some of the patient’s presentation? A 37-year-old man presented to the endocrinology clinic with a 4-year history of excessive sweating, headaches, and joint pain. His wife had also noticed increasing skin folds on his scalp. Physical examination showed thickening of the skin on his scalp with ridges and furrows (Panel A, back of head, and Panel B, top of head).  Main biologic effect of the GH-IGF-1 axis Target, Source Parameter Effect Blood and plasma (liver, bone, and IGF-1, acid-labile subunit Increased by GH only bone marrow actions) IGF-binding protein-3 Increased by both GH and IGF-1 Alkaline phosphatase (bone Increase (mainly IGF-1) specific) Sweating Fibrinogen Increase Joint Pain Hemoglobin, hematocrit Increase (mainly IGF-1 action on Skin Folds bone marrow) Cartilage, bone Length (before epiphysial closure), Stimulation (mainly IGF-1) width (periosteal and perichondrial growth) pituitar overgrowth Visceral organs (liver, spleen, Growth Stimulation, organomegaly (both a thymus, thyroid), tongue and GH and IGF-1) heart - Renal 25-hydroxyvitamin D 1α- Plasma calcitriol Increase (mainly GH), promotes hydroxylase activity positive calcium balance Kidney GFR Increase (IGF-1) Skin Hair growth Stimulation (IGF-1?) Sweat glands Hyperplasia, hypertrophy, hyperfunction (GH?) Dermis Thickening (both GH and IGF-1) What is the confirmatory test for Acromegaly? A. Oral Glucose Tolerance Test B. Salt Loading Test C. Cosyntropin Stimulation Test D. Overnight Dexamethasone Suppression test Oral glucose tolerance test:GH Values vary with different assay methods Acromegaly patients show no suppression 75 g glucose 75 g glucose  What would you order further? (select all that apply) A. Pituitary MRI & - Due to microadenoma B. Brain MRI C. Visual Field Testing - optic chiasm compression D. Prolactin Case continued A 75-g oral glucose load did not suppress the growth hormone level and confirmed a diagnosis of acromegaly. Magnetic resonance imaging of the head revealed a pituitary adenoma measuring 27 mm by 22 mm by 25 mm. > km Macro Figure 9-6 Local effects of an expanding pituitary tumor causing visual field defects. A, Normal vision; C, bitemporal hemianopia. (williams) Journal of Medical Case Reports 2007, 1:74 What type of surgery would you recommend?  Transsphenoidal surgery. An endoscope and a curette are inserted through the nose and sphenoid sinus https://www.cancer.gov/public ations/dictionaries/cancer- terms/def/transsphenoidal- surgery  Case follow up The patient underwent transsphenoidal resection of the pituitary adenoma. He had residual tumor and was treated with a somatostatin analogue and a growth hormone receptor antagonist.  Which of the following drug combinations could be prescribed to this patient? (select all that apply) A. Cabergoline and octreotide The patient underwent B. Cabergoline and pegvisomant transsphenoidal resection of the pituitary adenoma. ✓ C. - Octreotide and pegvisomant He had residual tumor and was D. Bromocriptine and octreotide treated with a somatostatin ✓ E. Pasireotide and pegvisomant analogue and a growth hormone -- receptor antagonist  Which of the following is a potential side effect of Octreotide? (check all that apply) ✓ A. Gall stones decr motility , CCK inhibited - B. Dizziness - dopamine agonist C. Valvulopathy ✓ D. Fat malabsorption ✓ E. Glucose intolerance  Somatropin Pegvisomant  What is the management? Therapeutic Agents for Mechanism of Action Side-Effect Other Comments Acromegaly Bromocriptine/cabergoline D2 receptor agonist Central side effects – Bromocriptine avoids risk lightheadedness, fatigue of valvulopathy, off label and dizziness use in pregnancy GI side effects – NVD, abdominal pain SST Analogs – octreotide, SSTR agonist – involves GI side-effects include, Higher incidence of lanreotide, pasireotide G!i subunit that inhibits malabsorption of fat, hyperglycemia w/ formation of cAMP. diarrhea, gall stones (CCK pasireotide inhibition) GH receptor antagonist Antagonizes the actions Injection site pain, of GH on GHR. transaminitis, pituitary tumor growth What could be the complications of his pituitary surgery? Hypopit. a vision leah If the patient developed panhypopituitarism after his surgery what supplements may he need? How would you monitor adequacy of his supplements? Hyphro ↑  If the patient developed panhypopituitarism after his surgery what supplements may he need? How would you monitor adequacy of his supplements? Levothyr. Free T4 Secondary Hypothyroidism NTSA Secondary Hypogonadism WLH/FSH dTesto Secondary Adrenal Insufficiency ↓ Act ↓ cortisol  Case follow up The thickening and furrowing of skin on the scalp, called cutis verticis gyrata, can occur as an isolated finding or may be related to a number of conditions, such as acromegaly, as in this case. He received injections of soft-tissue fillers in an attempt to create a smoother appearance of the scalp, but the injections had only partial effect. N Engl J Med 2019; 380:e31 https://www-nejm-org.proxy.westernu.edu/doi/full/10.1056/NEJMicm1811350  Case A 42-year-old obese woman presents to discuss an elevated prolactin level of 144.8 ng/mL (normal range, 4.8 to 23.3 ng/mL) found by her Ob-Gyn two months ago. She complained of galactorrhea and no menses for one year. A repeat prolactin level was also elevated, at 109 ng/mL. Modified from Clinician Reviews. 2011 November;21(11):8-9 Should you ask about current medications? Why or Why not? antagonist Dopamine Case continued A TSH level was ordered Was this appropriate; why or why not? Yes hypothyroi , d i s m  Which of the following stimulates prolactin release? A. Dopamine B. Somatostatin C. GABA ✓ D. TRH E. Free T4 Prolactin synthesis, function and regulations ¯DA Prolactin: polypeptide of 199 release amino acids; synthesized and Somatostatin-, secreted by lactotrophs. & GABA- Plasma prolactin levels are high during sleep and ½ life is about 20 min. Receptor: class 1 cytokine Prl decreases GnRH super receptor family, thereby inhibits ovulation and activation requires spermatogenesis dimerization and phosphorylation. Functions Case continued A pituitary MRI with contrast showed a “subtle area of delayed enhancement in the right pituitary, consistent with a 5-mm microadenoma.” Case continued A pituitary MRI with contrast showed a “subtle area of delayed enhancement in the right pituitary, consistent with a 5-mm microadenoma.” Given above findings, should you do surgery? A. Yes B. No O  Which of the following drugs can be used to treat excess production of prolactin in the patient? (Check all that apply) A. Somatotropin B. Pegvisomant ✓ C. Cabergoline ✓ D. Octreotide Dopamine agonists E. Bromocriptine Case Continued The patient was prescribed the dopamine agonist cabergoline (0.25 mg, to be taken twice a week), with a plan to follow up in two to three months.  What are the expected centrally mediated side effects of cabergoline? (select all that apply) ✓ A. Dizziness - ✓ B. Nausea V ✓ C. Lightheadedness ~ D. Glucose intolerance E. Intracranial hypertension Case A 36-year-old man presented Increased thirst and urination also developed for 4 months before presentation. He is out on a hike and ran out of water for 8 hours and comes to the urgent care for fatigue. Blood electrolyte levels revealed hypernatremia. What could be a possible diagnosis for the increased thirst and urination? Adenoma DI Follow up. Magnetic resonance imaging of the brain revealed an increased signal in the posterior pituitary and thickening of the infundibulum. Due some dental findings a mandibular biopsy was done and dx of Langerhan’s histocytosis was made. Multiorgan Langerhans’-cell histiocytosis with diabetes insipidus was diagnosed.  Is this patient’s plasma hypotonic, hypertonic, or isotonic? A.Hypotonic ✓ B.Hypertonic Mat C.Isotonic  Antidiuretic functions of AVP (aka ADH) Adenylyl cyclase increased water permeability increased water reabsorption decreased water “ran out of water for 8 excretion hours” increased urine osmolality  Which of the following statements is accurate regarding DI treatment? ✓ A. Desmopressin can be used and given as needed ~ B. Desmopressin should be given q 8 hours C. Desmopressin should be given po only  Desmopressin(Vasopressin analog) increase water reabsorption through? A. Activation of V1R ✓ B. Activation of V2R ~ C. Activation of V3R D. Decreasing AQP2 Expression E. Decreasing AQP 3 Expression  VASOPRESSIN RECEPTOR (V2) AGONIST DRUG MECHANISM OF EFFECTS CLINICAL PK/SE/INTERACTIONS ACTION APPLICATIONS Desmopressin Relatively selective Acts in the kidney Pituitary DI, Administered via i.v., subQ, vasopressin V2 collecting duct cells pediatric oral and intranasal. Nasal receptor agonist to decrease nocturnal bioavailability > oral excretion of water. enuresis. bioavailability. Side-Effects: GI disturbances, hyponatremia, allergic reactions.  Follow up. This patient was treated with desmopressin. Adapted from N Engl J Med 2016; 374:e25 DOI: 10.1056/NEJMicm1512541 This Photo by Unknown Author is licensed under CC BY