Hypopit and DI (Darrow) - SRS

Question 1

In what order are the pituitary hormones lost in pituitary insufficiency?

Answer 1

1. GH
2. GN (LH/FSH)
3. TSH
4. ACTH

Question 2

What is the acronym for the causes of anterior pituitary failure?

Answer 2

Vindicatedd

1. Vascular
2. Infection/Infiltrative diseases
3. Neoplastic disorders
4. Degenerative/deficiency states
5. Idiopathic (empty sella)
6. Congenital/Famillial/genetic disorders
7. Allergic/Autoimmune
8. Trauma
9. Endocrine/metabolic disorders
10. Drugs/Depression

Question 3

What are the 6 things (two underlined) Darrow lumped into the vascular causes of anterior pit. failure?

Answer 3

1. Pit. apoplexy
2. sheehan’s
3. carotid aneurysms including SAH
4. Ischemic strokes
5. SS disease
6. DM

Question 4

Infective causes of anterior pituitary failure includ syphilis, TB, bacterial abcess, fungi and parasites. What are the infiltrative diseases Darrow mentioned that cause ant. pit. failure?

7, two underlined

Answer 4

1. Sarcoid
2. Langerhans cell histiocytosis
3. Wegeners
4. Leukemia
5. Lymphoma
6. Hemochromatosis
7. Amyloid

Question 5

What are the neoplastic disorders Darrow highlighted that cause ant. pit. failure?

Answer 5

1. Adenoma
2. Metastasis
3. meningoma
4. optic glioma
5. craniopharyngioma
6. nasopharyngeal carcinoma
7. pineal dysgerminoma

Question 6

What are the Congenital, familial or genetic disorders Darrow mentioned that cause ant. pit. failure?

Answer 6

Kallman Syndrome - Gnrh

PROP 1 gene mutation

DAX1 gene mutation Prader-willi syndrome

Question 7

What is an example of allergic/autoimmune causes of ant. pit failure?

Answer 7

Lymphocytic hypophysitis

Question 8

What are the major causes of trauma to the pituitary?

Answer 8

1. Surgery
2. post CABG
3. Head trauma
4. Labor
5. Irradiation

Question 9

You should assume that GH is low if you find what on lab work?

Answer 9

3 other pituitary hormones are low

Question 10

If a patient’s 8 a.m. cortisol is under what level, do they have a deficiency?

Answer 10

3 ug/dL

Question 11

If a patient with an 8 a.m. cortisol of 2.9 ug/dL what should be done to further the differential?

What would the abnormal result be?

Answer 11

Use ACTH stimulation to test for adrenal insufficiency.

If in 45 minutes the serum cortisol is less than 18 ug/dL, then the dx is made as adrenal insufficiency.

Question 12

What is normal TSH?

Answer 12

.35 - 5 mIU/L

Question 13

What is normal testosterone?

Answer 13

280 - 1100 ng/dL

Question 14

What is normal ACTH?

Answer 14

9 - 52 pg/mL

Question 15

What is normal serum cortisol?

Answer 15

3- 23 ug/dL

Question 16

Why am I bothering you with all these normal value q’s?

Answer 16

hahaha - June/July

Question 17

If a patient loses cortisol d/t adrenal insufficiency, what other hormones will become deregulated?

Answer 17

So many, but lets focus on…

• CRH and ADH will both become unchained and run wild since they are co-secreted.
• Also, epinephrine cannot be produced in the absence of cortisol

Question 18

If you have a euvolemic patient with hyponatremia and a urine osmolality greater than 150 - 200 mOsm/L then what should you be thinking?

Answer 18

SIADH

Question 19

How does hypothyroidism lead to hyponatremia?

Answer 19

Hypothyroidism leads to decreased cardiac output and ECV, which leads to increased ADH to retain water and dilution of plasma.

Similar to decreased cortisol levels but without the CRH/ADH cosecretion mechanism

Question 20

What are four counterregulatory hormones used to keep blood glucose from dropping too low?

Answer 20

1. Epinephrine
2. Glucagon
3. Cortisol
4. GH

Question 21

If lab testing confirms hypopituitarism, what should be ordered?

Answer 21

MRI

Question 22

Lets say we have a patient with general hypopituitarism… what four replacement hormones should we give them?

If they recover with this treatment but have polyuria, what does this mean?

Answer 22

1. Hydrocortisone
2. thyroxine
3. testosterone
4. GH

Posterior Pituitary failure - cortisol increases the GFR via cardiac output and ECV, leading to an absence of ADH manifesting as polyuria.

Question 23

Central diabetes insipidus does not usually occur with anterior pituitary failure. When it does however, what are three things you should consider?

Answer 23

1. Hypophysitis
2. metastatic cancer
3. sarcoidosis

Question 24

What are some presentations that accompany hemochromatosis? 5

Answer 24

1. Diabetes
2. Gray skin
3. joint pain
4. dilated cardiomyopathy
5. heart rhythm disturbances

Question 25

A female patient with headaches is noticed to have enlargement of the Sella tursica on Xray. Periods are normal. BP and sugars are normal. Complexion and skin are normal. This patient most likely has?

Answer 25

Empty Sella syndrome - sella is filled with CSF

Question 26

Where are the ADH receptors?

Answer 26

V1 - In systemic vasculature V2 - nephron collecting ducts

Question 27

A patient complains of craving ice water, has hyponatremia and serum uric acid is increased. What should come to mind for you?

Answer 27

Diabetes insipidus.

Question 28

What is the pneumonic for causes of polyuria and polydipsia?

Answer 28

C-dripped ## Footnote Cortisol excess DI/DM Recovery from renal failure Ions - **hypo K and hyper Ca**, Iv Infusions (mannitol) Parkinsons (nocturia) Psychogenic polydipsia Enzyme - vasopressinase (autoimmune DI) Drugs - **Lithium, demeclocycline**

Question 29

What would allow you to differentiate between psychogenic polydipsia and DI?

Answer 29

Psychogenic polydipsia would come with hyponatremia d/t excessive fluid intake. DI would hypernatremia d/t the failure of ADH to stimulate H2O reuptake.

Question 30

Which ADH receptors cause uric acid secretion?

Answer 30

V1 receptors

Question 31

If after water restriction a patient's Uosm/Posm remains less than 1 then what are the **only two options?**

Answer 31

Complete central DI Complete renal DI

Question 32

What will be observed on MRI of a patient with central diabetes insipidus?

Answer 32

1. Pituitary Stalk thickening 2. Loss of the bright spot (ADH somehow makes the posterior pituitary show up as a bright spot on MRI)

Question 33

What are some conditions where thickening of the pituitary stalk may be observed?

Answer 33

Autoimmune (apparently just in general) Sarcoidosis Histiocytosis X

Question 34

What is the treatment for DI? What should you watch out for?

Answer 34

Desmopressin acetate 0,05 mg BID orally or nasally to 0,4 mg q 8 hours. Plus hydrochlorthiazide 50-100 mg daily Watch out for suicide with the use of desmopressin acetate.

Question 35

After water restriction the Uosm/Posm for both partial central and partial nephrogenic DI will be greater than 1. What improvements would be seen in both cases with addition of DDAVP?

Answer 35

Nephrogenic = no change Central = 10 - 50% improvement

Question 36

He tossed up the Vindicated thing three times, so I guess he thinks that's pretty good shit. Although in the past his memory devices have been occasionally worth not so much. Regardless, what does it stand for? Also, give examples of each wherever you are able.

Answer 36

* Vascular (SS disease, ATN) * Infectious (pyelonephritis) or Infiltrative (amyloid, Sjögrens, myeloma, sarcoid) * Neoplastic (myeloma, polycystic kidneys) * Degenerative or Deficiency * Idiopathic * Congenital, familial or genetic (X-linked defective X-linked V2 receptor or aquaporin (AQP2) water channels –adults have hyperuricemia as well) * Allergic or Autoimmune * Trauma * Endocrine (corticosteroids) or metabolic (potassium depletion, Mg depletion, hypercalcemia) * Drugs (lithium, demeclocycline, foscarnet, methicillin, amphotericin b) or Depression

Question 37

What are the causes of a positive Tinel's sign? Which one would apply in this class?

Answer 37

Mnenonic is "Median Trap" * Myxedema * Edema * Diabetes * Infiltration * Amyloid * Neoplasms * Trauma * Acromegaly * Pregnancy