scholarly journals Management of a microprolactinoma with aripiprazole in a woman with cabergoline-induced mania

2015 ◽  
Vol 2015 ◽  
Author(s):  
Lisa Burback
Keyword(s):  
Low Dose ◽  
Standard Treatment ◽  
Manic Episode ◽  
Good Effect ◽  
List Type ◽  
Manic Symptoms ◽  
Psychiatric Side Effects ◽  
Psychotic Features ◽  
Learning Points

Summary A previously healthy 32-year-old woman developed cyclical mood swings after being prescribed cabergoline for a pituitary microprolactinoma. These mood swings persisted for over 2 years, at which point she developed an acute manic episode with psychotic features and was admitted to a psychiatry unit. Cabergoline was discontinued and replaced with aripiprazole 10 mg/day. Her manic episode quickly resolved, and she was discharged within 6 days of admission. The aripiprazole suppressed her prolactin levels for over 18 months of follow-up, even after the dose was lowered to 2 mg/day. There was no significant change in tumor size over 15 months, treatment was well tolerated. However, after 9 months of taking 2 mg aripiprazole, she developed brief manic symptoms, and the dose was returned to 10 mg daily, with good effect. Learning points Dopamine agonists such as cabergoline, which are a standard treatment for microprolactinomas, can have serious adverse effects such as psychosis or valvular heart disease. Aripiprazole is a well-tolerated atypical antipsychotic that, unlike other antipsychotics, is a partial dopamine agonist capable of suppressing prolactin levels. Adjunctive, low-dose aripiprazole has been utilized to reverse risperidone-induced hyperprolactinemia. This case report demonstrates how aripiprazole monotherapy, in doses ranging from 2 to 10 mg/day, was effective in suppressing prolactin in a woman with a microprolactinoma who developed psychiatric side effects from cabergoline.

scholarly journals Phaeochromocytoma presenting with polyuria: an uncommon presentation of a rare tumour

2014 ◽  
Vol 2014 ◽  
Author(s):  
N Atapattu ◽  
K A C P Imalke ◽  
M Madarasinghe ◽  
A Lamahewage ◽  
K S H de Silva
Keyword(s):  
Correct Diagnosis ◽  
List Type ◽  
Rare Tumour ◽  
Uncommon Presentation ◽  
The Family ◽  
History Of ◽  
Associated Conditions ◽  
Complete Physical Examination ◽  
Learning Points

Summary Children rarely present with phaeochromocytoma. Their presentation differs from that of adults. The classic triad of sweating, headache and palpitation may not always present in children with phaeochromocytoma. In this study, we present a 6-year-old girl who came to us with polyuria and polydipsia for evaluation of suspected diabetes insipidus. She gave a clear history of increased sweating in the recent past. On clinical examination, she was noted to have high blood pressure. Subsequent investigations revealed a phaeochromocytoma. Her polyuria and hypertension resolved immediately after the surgery. We did not have the facilities to arrange for genetic tests; however, the patient and the family members are under follow-up for other associated conditions. Learning points Polyuria and polydipsia are rare symptoms of phaeochromocytoma. Complete physical examination prevented unnecessary investigations for polyuria and led to a correct diagnosis. Classic features are not always necessary for diagnostic evaluation of rare diseases.

scholarly journals Late presentation of acromegaly in medically controlled prolactinoma patients

2016 ◽  
Vol 2016 ◽  
Author(s):  
Ekaterina Manuylova ◽  
Laura M Calvi ◽  
Catherine Hastings ◽  
G Edward Vates ◽  
Mahlon D Johnson ◽  
...  
Keyword(s):  
Growth Hormone ◽  
Dopamine Agonists ◽  
Late Presentation ◽  
List Type ◽  
Biochemical Control ◽  
Current Recommendation ◽  
Long Term Follow Up ◽  
Learning Points

Summary Co-secretion of growth hormone (GH) and prolactin (PRL) from a single pituitary adenoma is common. In fact, up to 25% of patients with acromegaly may have PRL co-secretion. The prevalence of acromegaly among patients with a newly diagnosed prolactinoma is unknown. Given the possibility of mixed GH and PRL co-secretion, the current recommendation is to obtain an insulin-like growth factor-1 (IGF-1) in patients with prolactinoma at the initial diagnosis. Long-term follow-up of IGF-1 is not routinely done. Here, we report two cases of well-controlled prolactinoma on dopamine agonists with the development of acromegaly 10–20 years after the initial diagnoses. In both patients, a mixed PRL/GH-cosecreting adenoma was confirmed on the pathology examination after transsphenoidal surgery (TSS). Therefore, periodic routine measurements of IGF-1 should be considered regardless of the duration and biochemical control of prolactinoma. Learning points: Acromegaly can develop in patients with well-controlled prolactinoma on dopamine agonists. The interval between prolactinoma and acromegaly diagnoses can be several decades. Periodic screening of patients with prolactinoma for growth hormone excess should be considered and can 
lead to an early diagnosis of acromegaly before the development of complications.

scholarly journals Hypertension due to a deoxycorticosterone-secreting adrenal tumour diagnosed during pregnancy

2019 ◽  
Vol 2019 ◽  
Author(s):  
Pedro Marques ◽  
Nicola Tufton ◽  
Satya Bhattacharya ◽  
Mark Caulfield ◽  
Scott A Akker
Keyword(s):  
Adrenal Mass ◽  
List Type ◽  
Third Trimester ◽  
Adrenal Tumours ◽  
Adrenocortical Tumours ◽  
Apparent Mineralocorticoid Excess ◽  
Increased Activity ◽  
Reduced Activity ◽  
Learning Points

Summary Mineralocorticoid hypertension is most often caused by autonomous overproduction of aldosterone, but excess of other mineralocorticoid precursors can lead to a similar presentation. 11-Deoxycorticosterone (DOC) excess, which can occur in 11-β hydroxylase or 17-α hydroxylase deficiencies, in DOC-producing adrenocortical tumours or in patients taking 11-β hydroxylase inhibitors, may cause mineralocorticoid hypertension. We report a 35-year-old woman who in the third trimester of pregnancy was found to have a large adrenal mass on routine obstetric ultrasound. On referral to our unit, persistent hypertension and long-standing hypokalaemia was noted, despite good compliance with multiple antihypertensives. Ten years earlier, she had hypertension noted in pregnancy which had persisted after delivery. A MRI scan confirmed the presence of a 12 cm adrenal mass and biochemistry revealed high levels of DOC and low/normal renin, aldosterone and dehydroepiandrosterone, with normal catecholamine levels. The patient was treated with antihypertensives until obstetric delivery, following which she underwent an adrenalectomy. Histology confirmed a large adrenal cortical neoplasm of uncertain malignant potential. Postoperatively, blood pressure and serum potassium normalised, and the antihypertensive medication was stopped. Over 10 years of follow-up, she remains asymptomatic with normal DOC measurements. This case should alert clinicians to the possibility of a diagnosis of a DOC-producing adrenal tumours in patients with adrenal nodules and apparent mineralocorticoid hypertension in the presence of low or normal levels of aldosterone. The associated diagnostic and management challenges are discussed. Learning points: Hypermineralocorticoidism is characterised by hypertension, volume expansion and hypokalaemic alkalosis and is most commonly due to overproduction of aldosterone. However, excess of other mineralocorticoid products, such as DOC, lead to the same syndrome but with normal or low aldosterone levels. The differential diagnosis of resistant hypertension with low renin and low/normal aldosterone includes congenital adrenal hyperplasia, syndrome of apparent mineralocorticoid excess, Cushing’s syndrome, Liddle’s syndrome and 11-deoxycorticosterone-producing tumours. DOC is one intermediate product in the mineralocorticoid synthesis with weaker activity than aldosterone. However, marked DOC excess seen in 11-β hydroxylase or 17-α hydroxylase deficiencies in DOC-producing adrenocortical tumours or in patients taking 11-β hydroxylase inhibitors, may cause mineralocorticoid hypertension. Excessive production of DOC in adrenocortical tumours has been attributed to reduced activity of the enzymes 11-β hydroxylase and 17-α hydroxylase and increased activity of 21-α hydroxylase. The diagnosis of DOC-producing adrenal tumours is challenging because of its rarity and poor availability of DOC laboratory assays.

scholarly journals A rare ophthalmic condition associated with primary hyperparathyroidism (PHPT): sclerochoroidal calcification (SC)

2019 ◽  
Vol 2019 ◽  
Author(s):  
Mona Abouzaid ◽  
Ahmed Al-Sharefi ◽  
Satish Artham ◽  
Ibrahim Masri ◽  
Ajay Kotagiri ◽  
...  
Keyword(s):  
Primary Hyperparathyroidism ◽  
Observational Studies ◽  
Systemic Disease ◽  
List Type ◽  
Long Term Follow Up ◽  
Eye Examination ◽  
Learning Points ◽  
True Association

Summary An 82-year-old male with a proven diagnosis of primary hyperparathyroidism (PHPT) was found to have bilateral changes in the fundi during a routine eye examination which were consistent with SC. In this report, we discuss the link between SC and PHPT and question the need for prospective observational studies to establish the true association between these conditions. Though screening PHPT patients for SC might not be justified/warranted given the benign course of the latter, patients with SC need to be assessed for PHPT, as the former may be the first clue to an underlying treatable systemic disease. Learning points: Sclerochoroidal calcifications (SCs), though rare and harmless, could be associated with an underlying systemic disease, such as primary hyperparathyroidism (PHPT). Biochemical screening for hypercalcaemia is a simple, cheap and widely available tool that could facilitate an identification of undiagnosed PHPT in patients with SC. A joint care by endocrinologists and ophthalmologists is warranted for those patients, as thorough investigations and long-term follow-up plans are crucial.

scholarly journals Neurofibromatosis-related phaeochromocytoma: two cases with large tumours and elevated plasma methoxytyramine

2015 ◽  
Vol 2015 ◽  
Author(s):  
Stephanie Teasdale ◽  
Elham Reda
Keyword(s):  
Neurofibromatosis Type ◽  
List Type ◽  
Elevated Plasma ◽  
Previous Diagnosis ◽  
Clinical Presentations ◽  
Work Up ◽  
Learning Points ◽  
Large Primary

Summary We present two cases of adrenal phaeochromocytoma in patients with a previous diagnosis of neurofibromatosis type 1 (NF1). One had an adrenergic phenotype. The other had a more noradrenergic phenotype. Both had large primary tumours, which increases the likelihood of malignancy. Both also had elevated plasma-free methoxytyramine, which has been linked with malignancy even in non-SDHB phaeochromocytomas. Learning points Phaeochromocytoma can have varied clinical presentations. Methoxytyramine can be useful in the biochemical work-up of both SDHB-positive and SDHB-negative phaeochromocytoma. The utility of methoxytyramine as a marker of malignancy in NF1-related phaeochromocytoma is unclear, and cases with elevated titres warrant longer follow-up.

scholarly journals Hypokalemia associated with mifepristone use in the treatment of Cushing’s syndrome

2019 ◽  
Vol 2019 ◽  
Author(s):  
Katta Sai ◽  
Amos Lal ◽  
Jhansi Lakshmi Maradana ◽  
Pruthvi Raj Velamala ◽  
Trivedi Nitin
Keyword(s):  
Adrenocorticotropic Hormone ◽  
Glucocorticoid Receptors ◽  
Biochemical Parameter ◽  
List Type ◽  
Care Level ◽  
Unilateral Adrenalectomy ◽  
Dosage Escalation ◽  
Potent Antagonist ◽  
Learning Points

Summary Mifepristone is a promising option for the management of hypercortisolism associated with hyperglycemia. However, its use may result in serious electrolyte imbalances, especially during dose escalation. In our patient with adrenocorticotropic hormone-independent macro-nodular adrenal hyperplasia, unilateral adrenalectomy resulted in biochemical and clinical improvement, but subclinical hypercortisolism persisted following adrenalectomy. She was started on mifepristone. Unfortunately, she missed her follow-up appointments following dosage escalation and required hospitalization at an intensive care level for severe refractory hypokalemia. Learning points: Mifepristone, a potent antagonist of glucocorticoid receptors, has a high risk of adrenal insufficiency, despite high cortisol levels. Mifepristone is associated with hypokalemia due to spill-over effect of cortisol on unopposed mineralocorticoid receptors. Given the lack of a biochemical parameter to assess improvement, the dosing of mifepristone is based on clinical progress. Patients on mifepristone require anticipation of toxicity, especially when the dose is escalated. The half-life of mifepristone is 85 h, requiring prolonged monitoring for toxicity, even after the medication is held.

scholarly journals DICER1 mutation and pituitary prolactinoma

2018 ◽  
Vol 2018 ◽  
Author(s):  
Ellena Cotton ◽  
David Ray
Keyword(s):  
Case Reports ◽  
Early Death ◽  
Suppressor Gene ◽  
Tumour Suppressor Gene ◽  
List Type ◽  
Non Coding Rna ◽  
Increased Risk ◽  
Non Coding Rnas ◽  
Learning Points

Summary A young woman carrying germline DICER1 mutation was discovered to have a pituitary microprolactinoma when she became amenorrhoic. The mutation was identified as a result of family screening following the early death of the patient’s daughter with ovarian cancer. The patient was in follow-up screening for thyroid disease, and investigations were initiated when she became amenorrhoic. MR scan revealed a 6 mm diameter pituitary microadenoma and raised prolactin. The prolactin was efficiently suppressed with low-dose cabergoline, and her menstrual cycles resumed. Dicer is an RNase enzyme, which is essential for processing small non-coding RNAs. These molecules play pleiotropic roles in regulating gene expression, by targeting mRNA sequences for degradation. DICER1 plays different roles depending on cell context, but is thought to be a functional tumour suppressor gene. Accordingly, germline mutation in one DICER1 allele is insufficient for oncogenesis, and a second hit on the other allele is required, as a result of postnatal somatic mutation. Loss of DICER1 is linked to multiple tumours, with prominent endocrine representation. Multinodular goitre is frequent, with increased risk of differentiated thyroid cancer. Rare, developmental pituitary tumours are reported, including pituitary blastoma, but not reports of functional pituitary adenomas. As DICER1 mutations are rare, case reports are the only means to identify new manifestations and to inform appropriate screening protocols. Learning points: DICER1 mutations lead to endocrine tumours. DICER1 is required for small non-coding RNA expression. DICER1 carriage and microprolactinoma are both rare, but here are reported in the same individual, suggesting association. Endocrine follow-up of patients carrying DICER1 mutations should consider pituitary disease.

Major Depression with Psychotic Features Associated with Acyclovir Therapy

1988 ◽  
Vol 22 (4) ◽  
pp. 306-308 ◽  
Author(s):  
Pinkhas Sirota ◽  
Moshe Stoler ◽  
Betty Meshulam
Keyword(s):  
Herpes Simplex ◽  
Medical Literature ◽  
Lymphocytic Leukemia ◽  
Acyclovir Treatment ◽  
Simplex Infection ◽  
Intravenous Acyclovir ◽  
Acyclovir Therapy ◽  
Psychiatric Side Effects ◽  
Psychotic Features

Psychiatric side-effects associated with acyclovir therapy are very rare in the medical literature. We present a case of depression with paranoid delusions in a patient with chronic lymphocytic leukemia that appeared after intravenous acyclovir treatment for herpes simplex infection. The clinical picture resolved following discontinuation of acyclovir and treatment with haloperidol and maprotiline. The patient's status was intact at an eight-month follow-up check. The few reports of psychiatric disorders due to acyclovir are reviewed and discussed.

scholarly journals Spironolactone Improves the All-Cause Mortality and Re-Hospitalization Rates in Acute Myocardial Infarction with Chronic Kidney Disease Patients

2021 ◽  
Vol 12 ◽  
Author(s):  
Xiang Qu ◽  
Hui Yao ◽  
Changxi Chen ◽  
Shuting Kong ◽  
Lingyue Sun ◽  
...  
Keyword(s):  
Treatment Group ◽  
Dose Group ◽  
Low Dose ◽  
Standard Treatment ◽  
High Dose Group ◽  
High Dose ◽  
Single Center ◽  
All Cause Mortality ◽  
Standard Treatment Group

Background: Mineralocorticoid receptor antagonists (MRA) improve outcomes in chronic kidney disease (CKD) and acute myocardial infarction (AMI) patients. However, the lack of evidence regarding long-term clinical outcomes in the use of MRA, including spironolactone, in patients with AMI combined with CKD.Objectives: This study aimed to investigate whether spironolactone could significantly reduce the risk of all-cause mortality and re-admission in patients with AMI and CKD.Methods: In this single center, observational, retrospective, registry based clinical study, a total of 2,465 AMI patients were initially screened; after excluding patients with estimated glomerular filtration rate more than 60 ml/min/1.73 m2, 360 patients in the standard treatment group and 200 patients in the spironolactone group met the criteria. All enrolled patients follow-up for 30 months. The primary outcomes were all-cause mortality and re-admission. The key safety outcome was hyperkalemia rates during the 30 months follow-up period.Results: 160 (44.4%) and 41 (20.5%) patients in the standard treatment and spironolactone groups died, respectively [hazard ratio (HR): 0.389; 95% confidence interval (CI): 0.276–0.548; p < 0.001]. Re-admission occurred in 217 (60.3%) and 95 (47.5%) patients in the standard treatment and spironolactone groups, respectively (HR: 0.664; 95% CI: 0.522–0.846; p = 0.004). The spironolactone group was divided into two based on the daily dose, low dose group (no more than 40 mg) and high dose group (more than 40 mg); the differences in the mortality rate between low dose group (16.7%) and the standard treatment group (44.4%) (HR: 0.309; 95% CI: 0.228–0.418; p < 0.001) and high dose group (34.1%) (HR: 0.429; 95% CI: 0.199–0.925; p = 0.007) were significant. The differences in re-hospitalization rate between low dose group (43.6%) and the standard treatment group (60.3%) (HR: 0.583; 95% CI: 0.457–0.744; p < 0.001) and high dose group (61.4%) (HR: 0.551; 95% CI: 0.326–0.930; p = 0.007) was significant. Hyperkalemia occurred in 18 (9.0%) and 18 (5.0%) patients in the spironolactone group and standard treatment group, respectively (HR: 1.879; 95% CI: 0.954–3.700; p = 0.068). Whereas, Hyperkalemia occurred in high dose group (20.5%) significantly more often than in the standard treatment group (p < 0.001) and low dose group (5.8%) (p = 0.003).Conclusion: Using MRA, such as spironolactone, may substantially reduce the risk of both all-cause mortality and re-admission in patients with AMI and CKD; the use of low-dose spironolactone has the best efficacy and safety. However, this was a relatively small sample size, single center, observational, retrospective, registry based clinical study and further prospective evaluation in adequately powered randomized trials were needed before further use of spironolactone in AMI with CKD population.

scholarly journals Use of acetazolamide in lithium-induced nephrogenic diabetes insipidus: a case report

2018 ◽  
Vol 2018 ◽  
Author(s):  
Ricardo A Macau ◽  
Tiago Nunes da Silva ◽  
Joana Rego Silva ◽  
Ana Gonçalves Ferreira ◽  
Pedro Bravo
Keyword(s):  
Case Report ◽  
Diabetes Insipidus ◽  
Nephrogenic Diabetes Insipidus ◽  
Standard Treatment ◽  
Previous History ◽  
List Type ◽  
Severe Dehydration ◽  
History Of ◽  
Patient Series ◽  
Learning Points

Summary Lithium-induced nephrogenic diabetes insipidus (Li-NDI) is a rare and difficult-to-treat condition. A study in mice and two recent papers describe the use of acetazolamide in Li-NDI in 7 patients (a case report and a 6 patient series). We describe the case of a 63-year-old woman with bipolar disorder treated with lithium and no previous history of diabetes insipidus. She was hospitalized due to a bowel obstruction and developed severe dehydration after surgery when she was water deprived. After desmopressin administration and unsuccessful thiazide and amiloride treatment, acetazolamide was administrated to control polyuria and hydroelectrolytic disorders without significant side effects. To our knowledge, this is the third publication on acetazolamide use in Li-NDI patients. Learning points: Treatment of lithium-induced nephrogenic diabetes insipidus might be challenging. Vasopressin, amiloride and thiazide diuretics have been used in lithium-induced nephrogenic diabetes insipidus treatment. Acetazolamide might be an option to treat lithium-induced nephrogenic diabetes insipidus patients who fail to respond to standard treatment. The use of acetazolamide in lithium-induced nephrogenic diabetes insipidus must be monitored, including its effects on glomerular filtration rate.

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