11/14/17 Intern Morning Report – Headache, Fatigue, Blurry Vision, Irregular Menses, Pituitary Macroadenoma, Central Adrenal Insufficiency

CC: Headache x 3 days

HPI: The patient is a 48 year-old Hispanic female with history of DM and hypothyroidism who presented to LAC-USC ED with a 3 day history of headache. She states that starting 2 months ago, she began to have symptoms of generalized weakness. By the end of the day, patient felt very fatigued though she is still able to complete her daily tasks. Starting three days prior to presentation, patient experienced sudden onset, severe headache.  It is difficult to say what makes it worse or better however the patient has tried over the counter medications of Tylenol with no improvement. The patient denies fevers, chills, neck stiffness, photophobia or phonophobia, but endorses blurry vision. Of note, patient gives a history of irregular menses for the last year as well.  On exam, patient has poor visual acuity bilaterally with right temporal vision loss.  Otherwise the exam is normal.  Labs are significant for Na 130, Serum Osm 275, Urine Osm 376, and Urine Na 147 that in the patient’s euvolemic state is consistent with SIADH versus cortisol deficiency.  Further endocrine labs and CT Head ordered are written below.

 

Endocrine Labs:

Prolactin 87.4

AM Cortisol: 0.5

ACTH: 5 (Normal 6-50)

TSH 6.14 (H)

Free T4 0.97

Anti-TPO: 355.7 (H)

IGF-I: 45 (normal 52-358)

Luteinizing Hormone: 0.3

FSH: 151.0 (Post-menopausal range 25.8-135)

 

CT Head:  Large bulky sella, supra-sellar, para-sellar mass with involvement of the bilateral cavernous sinuses and sphenoid sinuses with imaging features suggestive of a pituitary macroadenoma

 

Labs are significant for elevated prolactin likely from the mass causing stalk effect.  The elevated FSH, decreased ACTH and random cortisol, indicates likely FSH-secreting tumor with adrenal insufficiency from pituitary compression. Though FSH is difficult to interpret in peri-menopausal state, LH should also be elevated peri-menopausally which is not seen in this case. Patient was started on Hydrocortisone 20mg AM, 10mg PM with significant improvement in energy levels. Sodium did dip to 128 as an inpatient but improved with glucocorticoid replacement. Neurosurgery plans to follow her as an outpatient for tumor removal.

 


Morning Report Pearls: 

Let’s review the work up of hyponatremia which is an important work up in this patient.

Whenever considering SIADH as the etiology, exclude thyroid and adrenal causes which can have similar appearance.

 

Taking a look at the hypothalamic pituitary axis issue, remember that the first step with a pituitary tumor is identifying size and whether it is functional or non-functional.

  • Determining if this is a macroadenoma versus microadenoma will give you an idea if it could potentially be causing compression leading to a panhypopituitary state.

Figuring out if it is a functional tumor versus non-functional is important because management changes.

  • The most common functional tumor is a prolactinoma which can be medically managed initially, even if causing neurologic defects. This is unlike the other functional and non-functional tumors where surgery is usually your only option when neurologic defects are present.
  • This patient’s prolactin elevation is not very high so unlikely to present a prolactinoma.  Usually when a macroadenoma is prolactin producing, the PRL are at least >100 and usually closer to 200.  The elevation in this patient is due to stalk compression leading to a blockade of the dopamine inhibitory pathway.

Another interesting part of the case is interpreting the FSH level.  This becomes slightly more complicated given the patient’s perimenopausal state, as this is a time when an elevated FSH level is expected.  However, the tumor may be FSH producing instead of related to a perimenopausal state as the LH is actually low which is not typical for someone going through menopause. In addition, all other pituitary hormone levels are low or inappropriately normal which confirms that this patient is having pituitary dysfunction from tumor compression.

 

 

 

 

11/7/17 Intern Morning Report – Lower Extremity Edema, Periorbital Swelling, Weight Gain, Nephrotic Syndrome, Diabetic Nephropathy

CC: Lower extremity swelling for 2 months

HPI: 32 year-old male with no known past medical history who presents with a chief complaint of lower extremity swelling for 2 months. Patient reports that he noticed swelling in his feet approximately 2 months prior to admission that has gradually worsened in severity. He now reports swelling extending to mid thighs that interferes with ability to ambulate comfortably, prompting him to present for evaluation. The swelling is not painful and without overlying skin discoloration and is symmetric bilaterally; he also states that his swelling is not firm but pits with digital pressure. He notes mild periorbital swelling over the past 3 weeks though he reports no visual disturbances.  On exam, patient has periorbital edema and pitting lower extremity edema to mid thigh but otherwise no other signficant findings.  Labs are significant for renal injury, non-gap acidosis, hyperkalemia, normocytic anemia, and UA>300 protein.  The urine protein/creatinine ratio is 13.84, high above the cut off for nephrotic range proteinuria.  Urine anion gap is positive. For work up of nephrotic syndrome, tests of ANA, SPEP/UPEP, Hepatitis panel, HIV, RPR, C3/C4, and HgbA1c were sent.  The only pertinent finding was a HgbA1c of 10.1.  A renal biopsy was pursued after ultrasound showed kidneys to be around 12cm in length with no other specific findings.  Biopsy demonstrated patient to have Kimmelstiel Wilson nodules which is consistent with Diabetic Nephropathy.


Morning Report Pearls:

Once you have nephrotic range proteinuria, remember the types of nephrotic syndromes. This will help organize how to evaluate for underlying etiologies. Some of these syndromes can be idiopathic but most have secondary causes.

  1. Membranous – Associated with Hepatitis B, Hepatitis C, Malaria, Syphilis, SLE, Medications, Malignancies (solid tumor and lymphoma), RA, and Sjogren’s
  2. Minimal Change – Associated with medications like NSAIDs, Malignancies (Hodgkin’s Lymphoma)
  3. FSGS – HIV, Obesity, Reflux Nephropathy, Sickle Cell, HTN, DM
  4. Amyloidosis
  5. Multiple Myeloma (Membranoproliferative possible finding)
  6. Diabetic
  7. IgA Nephropathy

Some basic screenings should be done based off this information: HIV, HgbA1c, ANA, C3/C4, Hepatitis B/C, SPEP/UPEP with Light chains

 

Be on the look out for complications related to Nephrotic Syndrome secondary to loss of albumin (drop in oncotic pressure) and other proteins:

  • Hyperlipidemia due to increase hepatic production of apolipoproteins due to loss of oncotic pressure and decrease lipoprotein lipase
  • Hypercoaguablility due to loss of Protein C, Antithrombin II and increase production of coagulation factors from decrease oncotic pressure. Note that renal vein thrombosis is most common in Membranous Nephropathy
  • Higher risk of infection due to loss of Immunoglobulins
  • Due to loss of carrier proteins some patients can become Vitamin D deficiency, Thyroid hormone deficient, Iron deficient

This patient had a non gap acidosis for which the differential is narrow:

  1. GI loss
  2. Renal Acidosis – RTA versus CKD
  3. Drug Induced

Given the hyperkalemia in the setting of lack of oliguria or insults with CKD, it was thought that patient had Type IV RTA. Here is a breakdown of the RTAs:

December 6, 2017

Our annual Internal Medicine Residency Program Holiday Party will be on December 12, 2018.  Please check your emails for the location and time – we hope to see you all there!

Congratulations to all of our residents who matched into fellowship this year!

Cardiology
Kristen Burton – USC
Brian Butera – Henry Ford Hospital
Samuel Cho – University of Hawaii
Jonathan Lerner – Harbor-UCLA Medical Center
Jonathan Nattiv – USC
Newton Phuong – University of Vermont Medical Center
Megan Sattler – University of North Carolina Hospitals
Lindsay Short – UC Riverside School of Medicine
Peter Xu – USC
Omid Yousefian – University of Arizona College of Medicine at Tucson

Gastroenterology
Piyanka Chandra – CA Pacific Med Center
Ray Dong – Icahn School of Medicine Beth Israel
Jay Guan – Loma Linda University
David Herman – USC
Christopher Ko – USC
Evan Mosier – Loma Linda University
Bing Zhang – UC San Francisco

Pulmonary Critical Care
Tamana Ahmadi – UC Irvine Med Center
Mishala Bateman – USC
Praveen Belur – CA Pacific Med Center
Christopher Chang – Oregon Health & Science University
Mark Slootsky – Rhode Island Hospital/Brown University

Infectious Diseases
Pam Lee – Harbor-UCLA Medical Center
Navid Pour-Ghasemi – USC
Christina Yen – Beth Israel Deaconess Medical Center

Endocrinology
Sandra Arie Chung – USC

Hematology Oncology
Kevin Do – Tufts Medical Center
Mindy Hsiao – USC
Pete Pow-anpongkul- Harbor-UCLA Medical Center
Katherine Roth – Harbor-UCLA Medical Center
Mihee Park – USC

Rheumatology
Sky Wang – USC

 

Happy Birthday to all of our December residents!!

Alice Lee – December 2
Kathan Chintamaneni – December 2
James Zhang – December 7
Gieric Laput – December 10
Ronak Patel – December 11
Helen Shen – December 17
Nikhil Singh – December 18
Ian Roy – December 23
Nikhil Gupta – December 25
Patrick Chan – December 27
Edward Chau – December 30
Analiese DiConti-Gibbs – December 30