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Ovid: Oxford Handbook of Acute Medicine

Editors: Ramrakha, Punit S.; Moore, Kevin P. Title: Oxford Handbook of Acute Medicine, 2nd Edition Copyright ©1997,2004 Oxford University Press (Copyright 1997, 2004 by Punit S Ramrakha and Kevin P Moore) > Table of Contents > Chapter 9 – Endocrine emergencies > Hypopituitary coma Hypopituitary coma Hypopituitarism does not become evident until 75% of the adenohypophysis is destroyed, and at least 90% destruction is required for total loss of pituitary secretion. Complete loss of hormone secretion can rapidly become life threatening and requires immediate therapy. In a mild or incomplete form, hypopituitarism can remain unsuspected for years. Presentation In the absence of stress, patients with severe hypopituitarism may have few symptoms or signs. A general anaesthetic or infection may precipitate hypoglycaemia and coma, due to the combination of a lack of GH, cortisol, and thyroxine, all of which have a counter-regulatory effect on insulin. Clues from the history include

  • Known pituitary adenoma
  • Recent difficult delivery: pituitary infarction following postpartum haemorrhage and vascular collapse is still the commonest cause of hypopituitarism. Features include failure of lactation (deficiency of prolactin ± oxytocin), failure of menstruation (lack of gonadotrophins), non-specific features, e.g. tiredness, weakness, loss of body hair, and loss of libido (due to ACTH deficiency, hypothyroidism, and gonadotrophin deficiency)
  • Men may give a history of impotence, lethargy, and loss of body hair
  • Women report loss of menstruation.

Examination

  • Examination of the comatose patient is discussed on P406–15
  • Examine specifically for secondary sexual characteristics and physical signs of myxoedema
  • Consider other causes for coma (P406).

Investigations

  • General investigations for patients in coma are discussed on P408
  • Take blood for baseline cortisol, ACTH, thyroid function, LH, FSH, prolactin, and GH
  • Short synacthen® test must be performed to test for adrenocortical reserve (P586)
  • LHRH and TRH test can be performed at the same time as the short Synacthen® test
  • Defer formal pituitary function testing until the patient is stable
  • CT scan of pituitary (tumour or empty sella)
  • MRI scan may give additional information.

Management

  • General measures are as for any patient in coma (P406)
  • Give iv colloids ± saline to restore BP if the patient is in shock
  • Give glucose if the patient is hypoglycaemic
  • Hydrocortisone 100mg iv should be administered if the diagnosis is suspected and continued (100mg iv tds, see P586)
  • Start tri-iodothyronine (10µg bd) after hydrocortisone is started
  • Investigate and treat any precipitating intercurrent infection
  • P.597

  • If the patient fails to improve, consider other causes for coma (see P406)
  • Long term, the patients will require replacement with hydrocortisone or prednisolone, thyroxine, testosterone, oestrogen/progesterone ± GH.

Causes of panhypopituitarism Pituitary

  • Mass lesions (adenomata, cysts)
  • Pituitary surgery or irradiation
  • Infiltrative (haemochromatosis)
  • Infarction (Sheehan’s)
  • Apoplexy (haemorrhage)
  • Empty sella syndrome

Hypothalamic

  • Mass lesions (metastases, e.g. breast, lung; craniopharyngiomas)
  • Radiotherapy
  • Infiltration (sarcoid, histiocytosis)
  • Trauma, e.g. fractured skull base
  • Infections (TB)

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