Sequential pituitary MR imaging in Sheehan syndrome: report of 2 cases.

We present the evolution of pituitary changes in the cases of 2 patients with Sheehan syndrome as assessed by MR imaging. Both patients had severe postpartum hemorrhage, symptoms of pituitary gland apoplexy, and hypopituitarism. Sequential MR imaging demonstrated evidence of ischemic infarct in the pituitary gland with enlargement followed by gradual shrinkage during several months, to pituitary atrophy.

High prevalence of adrenal suppression during acute illness in hospitalized patients receiving megestrol acetate.

INTRODUCTION: Megestrol acetate (MA) is a progestational agent used for palliation of breast and endometrial cancer. The drug promotes weight gain via appetite stimulation. This property has led to widespread use in patients with wasting illnesses. Increasing numbers of reports suggest glucocorticoid activity. OBJECTIVE: Unrecognized adrenal suppression may result from MA use. This is the first study to examine the prevalence of adrenal suppression in hospitalized patients treated with MA. SUBJECTS AND DESIGN: This is a cross-sectional study of hospitalized patients receiving MA compared to control subjects. Morning cortisol levels, endocrine signs and symptoms, and duration of MA therapy were evaluated in 28 hospitalized medical patients treated with MA, and 21 control patients admitted to the same hospital service during the study period. RESULTS: Median cortisol levels were significantly lower in patients using MA vs controls (160 vs 386 nmol/l, p=0.003). Forty-three percent of subjects on MA demonstrated morning cortisol levels below the normal range (138-690 nmol/l), compared with 10% of controls (p=0.013). Ninety-three percent of subjects taking MA had morning cortisol levels below the level that excludes adrenal insufficiency in hospitalized patients (497 nmol/l) vs 71% of controls (p=0.06). CONCLUSIONS: MA use is associated with significant adrenal suppression in acutely ill individuals. This should alert physicians to the possibility of adrenal insufficiency and the need to assess for signs or symptoms of adrenal insufficiency, and mandates a low threshold for testing adrenal function in hospitalized patients taking MA.

Radiation therapy of metastatic pheochromocytoma: case report and review of the literature.

Malignant pheochromocytomas are rare tumors, which are considered radioresistant on the basis of little information. We report a patient, with cranial nerve deficits from a pheochromocytoma metastatic to the parasellar region, who promptly responded to radiation therapy (2,500 cGy) with reversal of neurologic deficit. The disease recurred 2 years later and again promptly responded upon treatment to 2,000 cGy. Hepatic metastases were controlled for over 1 year with 3,240 cGy. The radiotherapy of pheochromocytoma and chemodectoma is reviewed, and the similarities between the two kinds of tumor are discussed. We speculate that a higher initial radiation dose might have resulted in a more sustained remission in our patient and recommend doses of 4,000-5,000 cGy if they can be safely administered, in 4-5 weeks for pheochromocytomas.

Diabetic ketoacidosis.

Diabetic ketoacidosis is characterized by insulin deficiency, which permits the release of massive amounts of fatty acids from the fat cell, and by glucagon excess, which orchestrates the conversion of fatty acids into ketoacids in the liver. Low insulin and high glucagon also lead to increased hepatic glucose production. Therapy is directed towards the developing indications of systemic acidosis, hyperglycemia, osmotic diuresis, and dehydration by administration of fluid, electrolytes, and insulin; the precipitating cause of each episode must be sought and treated simultaneously.

Empty sella of normal size in Sheehan's syndrome.

This report describes the findings of computed tomography of the sella turcica region in 13 women in whom postpartum hypopituitarism developed in the absence of a pituitary tumor. Seven patients had the typical history of severe postpartum hemorrhage (Sheehan's syndrome). Computed tomographic scanning in these patients revealed absence (in six patients) or marked reduction (in one patient) of the amount of demonstrable pituitary tissue. The pituitary fossa was occupied by material with the density of cerebrospinal fluid, resulting in the appearance of an "empty sella." Sella size was within the normal range in six of the seven patients and enlarged in one. The six remaining patients lacked a characteristic history of vascular collapse, although several did have postpartum complications. The radiologic findings in four of these patients were similar to those seen in the patients with typical Sheehan's syndrome: one patient had a partially empty sella and another had normal results of computed tomographic scanning. Thus, 11 of 13 women with postpartum hypopituitarism were noted to have an empty or partially empty sella of normal size. This report represents the first radiologic documentation of Sheehan's syndrome as a cause of the secondary empty sella, with the characteristic finding being an empty sella of normal size.