1/9. adrenal insufficiency caused by primary aggressive non-Hodgkin's lymphoma of bilateral adrenal glands: report of a case and literature review.A 64-year-old woman was hospitalized because of poor general condition, gastrointestinal upset, unexplained fever, electrolyte imbalances, and an incidental finding of bilateral huge adrenal masses on computerized tomography (CT) of the abdomen. Non-Hodgkin's lymphoma (NHL) of B-cell origin was proven by ultrasound-guided aspiration biopsy of the left adrenal gland. Meanwhile, primary adrenal insufficiency was confirmed by her low serum cortisol level, high ACTH level, and inadequate adrenal response to the rapid ACTH stimulation test. The diagnosis of primary adrenal NHL was supported by detailed physical examinations, bone marrow examination, and such imaging studies as CT scan and sonography. She received three courses of chemotherapy with cyclophosphamide, vincristine, and prednisolone and there was an initial transient response, but she died of sepsis and progression of NHL three and a half months later.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
2/9. Adrenal suppression secondary to inhaled fluticasone propionate.BACKGROUND: Inhaled glucocorticoids are the medical treatment of choice in many of patients with asthma. Fluticasone propionate is an inhaled glucocorticoid with little systemic bioavailability via the oral route and infrequent association with systemic adverse effects at the recommended dosage. OBJECTIVE: To report a case of adrenal suppression and exogenous glucocorticoid excess from inhaled fluticasone propionate. methods: A 9-year-old girl with a previous history of episodic asthma was placed on 550 microg of fluticasone propionate daily for severe labile asthma diagnosed by history and methacholine challenge. The patient returned 6 months later with complaints of increased appetite, nausea, and feeling "hot and flushed." On physical exam she had stigmata of Cushing's syndrome. The patient subsequently developed orthostatic hypotension and moderate dehydration following a viral illness. After a long taper of fluticasone propionate the patient' s adrenal function returned to normal and she had no acute or chronic exacerbations of her asthma. RESULTS: Her 8 AM cortisol was undetectable with an ACTH of 21 pg/mL. The serum prolactin, TSH, free thyroxine, insulin-like growth factor i, and renin activity were all normal. An MRI study of her head was also normal. Repeat methacholine challenges while receiving a much smaller dose fluticasone propionate showed a significant decrease in airway reactivity. CONCLUSION: Adrenal suppression can occur from inhaled fluticasone propionate at a dosage less than has been previously reported.- - - - - - - - - - ranking = 0.11315638515234keywords = physical (Clic here for more details about this article) |
3/9. Preoperative hyponatremia as a clinical characteristic in elderly patients with large pituitary tumor.This study investigated the pathophysiology of preoperative hyponatremia in elderly patients with a large pituitary tumor. The tumor size, initial symptoms, and preoperative pituitary hormonal function were analyzed in 96 patients, consisting of 82 younger than 70 years old (mean age 49.7 years) and 14 older than 70 years old (mean age 72.0 years). There was no difference in tumor size between the two age groups. The initial symptom of all younger patients was visual disturbance. Preoperative hormonal evaluations revealed subclinical panhypopituitarism in four patients (4.9%). Five of the 14 older patients had severe hyponatremia (107-117 mEq/l) based on panhypopituitarism, and four of these five patients showed consciousness disturbance as the initial symptom, initiated by physical and/or psychological stress, or occurrence of intratumoral hemorrhage. Preoperative subclinical panhypopituitarism was found in another patient. The overall occurrence rate of preoperative panhypopituitarism in the older patients was 42.9%. The difference in the frequency of preoperative panhypopituitarism was statistically significant between the two groups. Preoperative severe hyponatremia associated with a large pituitary tumor is characteristic of elderly patients. The number of receptors for adrenocorticotropic hormone in the adrenal cortex decreases during the aging process. Additional physical and/or psychological stress prompts pituitary dysfunction in such patients, causing the manifestation of acute symptoms of adrenal insufficiency based on panhypopituitarism. Primary care using high dose hydrocortisone and electrolyte fluid is critical.- - - - - - - - - - ranking = 0.22631277030467keywords = physical (Clic here for more details about this article) |
4/9. Adrenal functions in children with adrenoleukodystrophy.BACKGROUND: adrenoleukodystrophy refers to an inherited disorder that mainly affects the adrenal gland, and the nervous system. The most common type is X-linked adrenoleukodystrophy (XALD). The main presenting symptoms are behavioral changes. However, endocrinological manifestations are also important and need to be clarified especially adrenal insufficiency which is a lifethreatening condition that can be prevented. OBJECTIVE: To review the endocrinological and the adrenal functions in X-linked ALD. SUBJECTS AND METHOD: The medical records of four patients diagnosed with ALD at the endocrinology and Metabolic Unit, Department of pediatrics, King Chulalongkorn Memorial Hospital between 1998 and 2000 were reviewed. The diagnoses were confirmed by elevated very long chain fatty acid (VLCFA) levels and the typical changes seen on magnetic resonance imaging (MRI) of the brain. The adrenal functions in these patients were studied. RESULTS: All patients presented between 7-11 years of age with learning problems and behavioral changes, without symptoms of adrenal insufficiency such as nausea, vomiting and abdominal pain. However, the physical signs of adrenal insufficiency such as generalized hyperpigmentation particularly on the nipples, skin creases and genitalia were present. The laboratory investigations revealed normal blood sugar and serum electrolytes. The adrenal functions were revealed as follows. Basal ACTH levels were high in 2 cases (290, > 1,250 pg/mL). Basal cortisol level was low in 1 case. ACTH stimulation tests revealed subnormal responses in 3 cases. magnetic resonance imaging of the brain showed white matter degeneration in the occipital area in 2 cases and frontal area in 2 cases. CONCLUSION: adrenal insufficiency can be detected by laboratory evaluation despite the lack of symptoms, therefore, the adrenal function should be evaluated in X-ALD at diagnosis for proper management.- - - - - - - - - - ranking = 0.11315638515234keywords = physical (Clic here for more details about this article) |
5/9. Mood disorder and secondary adrenal insufficiency after pituitary tumor operation and radiotherapy.Psychological manifestations can be noted in patients with pituitary hypofunction or injuries after surgery and radiotherapy. We report on a 38-year-old female with acute adrenal insufficiency who presented with an affective disorder. The patient was brought to our emergency department because of general weakness and fever. Low plasma glucose concentration and low blood pressure were noted at arrival. She expressed mood change and persecutive thoughts. The brain MRI demonstrated no obvious brain damage except empty sella. The cortisol level was undetectable. Intravenous hydrocortisone was administered after the diagnosis of acute adrenal insufficiency. The patient improved physically after treatment, but social withdrawal and inappropriate affect persisted. We present the case and review the relevant literature to impress on physicians that the cognitive disorders in hypopituitarism can result from not only hormone insufficiency, but also the influences of pituitary tumor surgery and radiotherapy on neuropsychological functions.- - - - - - - - - - ranking = 0.11315638515234keywords = physical (Clic here for more details about this article) |
6/9. brain tumor presenting as anorexia nervosa in a 19-year-old man.Slow-growing brain tumors can produce disturbances of food intake and endocrine dysfunction. We report a case of slow-growing midline brain tumor in a patient with clinical presentation of anorexia nervosa (AN). A 19-year-old man was referred from a general practitioner to a psychiatric clinic due to illness behavior and psychopathological characteristics of AN. His body weight had decreased from 52 kg to 40 kg within 6 months. Laboratory tests showed hypernatremia (160 mmol/L), adrenal insufficiency (adrenocorticotrophic hormone, 11.4 pg/mL; 8 am cortisol, 1.4 microg/dL; 4 pm cortisol, 11.4 microg/dL) and hypogonadotropic hypogonadism (testosterone < 0.5 ng/mL, follicle-stimulating hormone < 0.1 mIU/mL, luteinizing hormone < 0.7 mIU/mL). brain magnetic resonance imaging showed an extensive mass lesion at suprasellar, hypothalamic region, third ventricle, pineal region, lateral ventricle, and corpus callosum. Owing to central herniation during physical assessment, he died of unknown intracranial pathology. This case suggests that an intracranial tumor near the hypothalamus should be included in the differential diagnosis of AN. Any male adolescent with the clinical impression of AN should receive periodic re-evaluation, including neurological, endocrinological and, if necessary, neuroimaging study.- - - - - - - - - - ranking = 0.11315638515234keywords = physical (Clic here for more details about this article) |
7/9. Chronic fentanyl application induces adrenocortical insufficiency.We report a case of a 64-year-old man with secondary adrenocortical insufficiency who has been on a chronic transdermal fentanyl treatment because of sciatic pain syndrome. Shortly before admission to our hospital, the patient had discontinued his hydrocortisone medication. Adrenal crisis was assumed and during therapy with hydrocortisone infusion, the patient recovered. We suspected an opiate-induced suppression of the hypothalamus-pituitary-adrenal (HPA) axis. Therefore, we gradually reduced the opiate dosage. After 1 week, HPA axis function was markedly improved. We conclude that opiate medication may inhibit - in a life-threatening way - the organism's ability to respond to physical, emotional or metabolic stressors.- - - - - - - - - - ranking = 0.11315638515234keywords = physical (Clic here for more details about this article) |
8/9. Adrenal crisis.In the case study presented in this article, the patient had many of the historical risk factors for bilateral adrenal hemorrhage that Rao outlined. He had recently undergone surgery and was receiving heparin for anticoagulation for a thromboembolic event. Further clues included his fever, hypotension refractory to pressors, and abdominal discomfort. In addition, he had received a blood transfusion in the early 1980s, putting him at risk for the development of human immunodeficiency virus infection. His low baseline cortisol level and the lack of ACTH stimulation confirmed the diagnosis of adrenal insufficiency, probably on the basis of bilateral adrenal hemorrhage given his presentation. Although true adrenal insufficiency is an uncommon event in the intensive care unit, the question of its presence is often considered. In addition, the use of exogenous glucocorticoids is so widespread that the possibility of secondary adrenal insufficiency is a frequent concern. Careful history taking and physical examination complemented by review of the laboratory data and the awareness of certain risk factors should help identify most cases. However, the presentation is often not classical and empiric therapy may be required while awaiting results of diagnostic testing.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
9/9. Approach to a dark spot on the conjunctiva.Although malignant melanoma most often develops in the skin, it can also arise in several layers of the eye. Therefore, new dark brown or black spots on the conjunctiva must be recognized during physical examination and then evaluated. When melanoma is suspected, there should be no hesitation in performing excisional biopsy under local anesthesia. The differential diagnosis includes melanocytic nevi and primary or secondary melanosis.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |