Pituitary Gland Questions

A 45-year-old man with an incidental finding of a 3mm anterior pituitary adenoma is referred to you. Patient has no clinical features based on history and physical examination, to suggest a functional pituitary lesion such as a prolactinoma, acromegaly, TSHoma or Cushing’s disease. What will be the next step in your clinical evaluation?

Which of these is NOT part of the diagnostic criteria for the syndrome of inappropriate ADH secretion?

45-year-old Caucasian male with symptoms suggestive of hypogonadism and bitemporal hemianopsia on confrontation was diagnosed with a macroprolactinoma impinging on the optic chiasm. Patient’s visual field defects completely resolved three weeks after initiating dopaminergic agonist therapy. Serum prolactin levels improved to the lower limit of the normal reference range and remained stable within 5 weeks of starting treatment. He was noted to have deterioration of his visual fields five months after initiating dopaminergic agonist therapy.

An urgent CT scan to exclude pituitary hemorrhage or infarction showed a large central empty sella. Serum prolactin levels were within the normal reference range. A dedicated pituitary MRI was remarkable for herniation of the optic chiasm into the pituitary fossa. Urgent visual field testing demonstrated recurrence of bitemporal hemianopsia. The patient was referred to the neurosurgical service. However, the consulting neurosurgeon advised against acute neurosurgical intervention. What did he recommend?

Which of these is not a cause of central diabetes insipidus?

A 25-year-old female with amenorrhea and expressive galactorrhea. Anterior pituitary hormonal function testing was unremarkable except for an elevated prolactin level, high TSH and a low free T4. Pituitary MRI revealed a large intrasellar mass expanding beyond the sella. There was homogenous contrast enhancement of the entire pituitary gland, suggestive of pituitary hyperplasia. What is the primary diagnosis?

A patient with type 2 diabetes mellitus and acromegaly is started on pegvisomant by his treating endocrinologist. Which of these clinical features is not expected after the initiation of this medication

A 40-year-old male with a history of mild obstructive sleep apnea, resistant hypertension and diabetes mellitus. The patient was diagnosed with acromegaly. His IGF-1 levels were more than 3 times the upper limit of normal and failure of the oral glucose tolerance challenge test. A dedicated pituitary MRI revealed 7mm anterior pituitary adenoma. What is the next step in management?

Which of these drug-drug interaction scenarios is inaccurate with regards to the management of panhypopituitarism?

A 52-year-old woman with a history of depression, hypertension and poorly controlled diabetes mellitus presented to his primary care doctor’s office with a 3-month history of progressive headaches and blurred vision. His medications include venlafaxine, multiple daily injections of insulin, metformin, aspirin, lisinopril, and amlodipine. Physical exam was remarkable for numerous skin tags, malocclusion of the jaw and proximal myopathy. His IGF-1 level was normal, but due to the high index of suspicion for acromegaly, his primary care doctor referred him to an endocrinologist for further evaluation. Repeat serum IGF-1 was this time low (below the reference range), dynamic testing with a 75gram oral glucose load, was however significant for a nonsuppressed growth hormone level of 3ng/mL (normal suppression is <1ng/mL at 2hours). What is the cause of these laboratory findings?

An 18-year-old man with isolated growth hormone deficiency transitions from pediatric to adult endocrinology care. He received GH replacement during childhood. He reports stagnation of growth despite being on GH replacement therapy. He is concerned about the utility of ongoing therapy. What is the next step in the management of this patient?

There are multiple adjunctive therapies in the management of acromegaly. Which of these pairs comparing a form of treatment with its associated side effect is inaccurate?

An 82-year-old woman with metastatic melanoma presents to the emergency room with nausea, colicky abdominal pain, and postural dizziness. He completed his third cycle of ipilimumab 1 week ago. There is evidence of anterior pituitary hormonal insufficiencies involving the cortisol, thyroid, gonadal and growth hormone axes. In addition, he is noted to have central diabetes insipidus. A dedicated pituitary MRI is remarkable for diffuse enlargement of the pituitary gland and stalk. What is the most likely diagnosis?

A 32-year-old female with known acromegaly on long term medical therapy reports to her endocrinologist’s office due to missing her period recently. She is 9 weeks pregnant and has well-controlled acromegaly on long term lanreotide therapy. Which of these possible considerations by her endocrinologist is inaccurate?

A 48-year-old Hispanic man presents to the emergency room with nausea, abdominal pain, postural dizziness, and polyuria. He is diagnosed with central hypothyroidism, central hypocortisolemia, and central diabetes insipidus. An MRI of the pituitary gland shows a sellar mass. What is the most likely diagnosis?

A 25-year-old man with a diagnosis of adult growth hormone deficiency which occurred after closed head trauma presents to your office to discuss growth hormone replacement therapy. Which of these is not an expected effect of growth hormone replacement therapy?

A patient is status post pituitary adenomectomy for Cushing’s disease. The neurosurgery resident forgot to place orders for steroids in the postoperative period. 6 hours after surgery the covering neurosurgical intern is paged due to progressively worsening dizziness in the patients. The patient is noted to be hypotensive and tachycardic. She is promptly resuscitated with intravenous crystalloids. What should the covering surgical resident do next?

A 26-year-old female with a past medical history of rheumatoid arthritis, Sjogren’s syndrome and poorly controlled type 2 diabetes mellitus is referred to the endocrinology practice for management of diabetes. The patient has a 2-year history of fatigue and general malaise. Her medications include prednisone 10mg daily, methotrexate 15mg per week, SQ Lantus 80units twice a day and SQ Humalog insulin 40units with each meal. Physical exam was significant for a dorsocervical hump, facial plethora, thick violaceous abdominal striae and intense pigmentation of her palmar creases and gingiva. Interestingly, she had a BMI of 17 and was unable to get up from a seated position without assistance. 

What is the most likely diagnosis of this patient?

Patient with pituitary-dependent Cushings undergoes bilateral adrenalectomy due to refractory disease. His current medications include hydrocortisone and fludrocortisone. The patient developed progressively worsening headaches and was noted to have an ACTH level >3 times the upper limit of normal.

What is the diagnosis?

There are multiple adjunctive therapies in the management of Cushing’s disease. Which of these pairs comparing a form of treatment with its associated side effect is inaccurate?

Which of these differential diagnoses of Cushing’s syndrome is not an indication for bilateral adrenalectomy?

Testing of Cushing’s syndrome can be limited in specific patient populations. Which of these pairs comparing particular patient populations and Cushing’s screening test is incorrect?

A 23-year-old with a co-secreting TSH and GH tumor undergoes extensive transsphenoidal surgery. He was noted to be polyuric within the first 24hours; this was attributed to postoperative diuresis. Polyuria resolved within 48hours; however, the patient developed moderate asymptomatic hyponatremia which was managed with salt tablets and fluid restriction from postoperative day 4 to 7. The endocrinology service was consulted 1 week after TSS due to significant hypernatremia (Plasma sodium of 154mEq).

Fluid input 3 Liters and Output 7 Liters over the preceding 24hours
Plasma osmolarity of 320mOsm/kg of H2O
Urine osmolarity 20mOsm/kg of H2O, S.G of <1.005, urine dipstick negative for glucose

What is the diagnosis of this patient?

A 26-year-old female with central diabetes insipidus, well controlled with PO desmopressin 0.1mg q12h presents to her endocrinologist’s office. The Patient has remained eunatremic for several months on this stable dose of DDAVP. She presented to the ED after an episode of tonic-clonic seizures. Her current medications include oral ciprofloxacin for an acute urinary tract infection, ibuprofen prn, and desmopressin. Her plasma sodium was 116mEq (135-145mEq), plasma osmolarity 268 (280-295mOsm/kg), Urine osmolarity of 126mOsm/kg and Urine sodium of 50mmol/L. What is the most likely cause of this patient’s acute presentation?