Cushing's syndrome from Klack's solution.

OBJECTIVE: To report, for the first time, a case of Cushing's syndrome from the use of Klack's solution, a multipurpose remedy composed of various pharmaceutical agents with a glucocorticoid as one of the active ingredients. METHODS: A case report of Cushing's syndrome is presented, and the different components of Klack's solution are compared. RESULTS: In a 36-year-old man with the development of Cushing's syndrome, the use of Klack's solution for the treatment of oral lichen planus was incriminated. For the evaluation of Cushing's syndrome, all potential sources and doses of corticosteroids, as well as the patient's compliance with dosing instructions, must be examined. In this case, the Klack's solution, which can be prepared in multiple versions and strengths at the discretion of the prescriber, had a high content of corticosteroid. CONCLUSION: Health-care providers should be reminded of the potency and potential harm of corticosteroids by this unusual case of Cushing's syndrome attributable to Klack's solution.

Severe hypoglycemia in diabetic pregnancy.

Our results are presented to reemphasize that strict glucose control in pregnant Type I diabetic patients carries not only significant benefits but risk as well. Despite careful attention, self glucose monitoring, multi-shot/pump insulin, diabetic team management and obstetrical expertise, pregnant Type I diabetic patients are at increased risk for hypoglycemic episodes.

A cyproheptadine-reversible defect in ACTH control persisting after removal of the pituitary tumor in Cushing's disease.

We studied two phases of cortisol feedback suppression of ACTH in nine patients who had had adrenalectomy for Cushing's disease. Four had been treated by adrenalectomy alone and presumably had ACTH-secreting pituitary tumors. Five others were studied two or more years after transsphenoidal removal of an ACTH-secreting microadenoma. In both groups, cortisol-ACTH feedback during the first 30 minutes of cortisol infusion was abnormal; plasma ACTH fell only 2.7 +/- 2.6 per cent (mean +/- S.E.), as compared with 28.0 +/0 10.1 per cent in five hypoadrenal controls (p less than 0.01). The fall in ACTH during the second phase of cortisol infusion was similar in the patients and the controls. Cyproheptadine corrected the feedback abnormality occurring during the first phase in both groups of patients with Cushing's disease; ACTH fell by 24.4 +/- 4.8 per cent (P less than 0.005). Persistence of a cortisol-ACTH feedback abnormally after removal of the pituitary tumor in Cushing's disease, as well as the correction by cyproheptadine, suggests that higher centers have a role in the pathophysiology of Cushing's disease.

Effects of thyrotropin-releasing hormone and metoclopramide in patients with phenothiazine-induced hyperprolactinemia.

TRH and metoclopramide tests were performed in 10 female patients with presumed phenothiazine-induced hyperprolactinemia to define the serum PRL response to these agents. Our results show that the serum PRL response to metoclopramide is blunted in most patients with phenothiazine-induced hyperprolactinemia, and the serum PRL response to TRH is exaggerated in most patients during and 3 weeks after stopping phenothiazines.

Galactorrhea-amenorrhea syndrome: follow-up of forty-five patients after pituitary tumor removal.

Forty-five patients with galactorrhea-amenorrhea were followed during a period of 1 to 8 years (mean 3.1) after transsphenoidal prolactinoma removal. The ratios of patients who appear to be cured to the total numbers treated were 20 patients of 27 with grade I tumors; six of 10 with grade II; two of five with grade III; and none with grade IV tumors. Six patients with normal prolactin levels one week postoperatively had relapse later, as did three with normal prolactin levels 2 months postoperatively. A normal prolactin level 6 months postoperatively predicted ultimate cure. The 19 pregnancies that occurred in 15 patients, four with high prolactin levels, were uneventful. Prolactin rose normally with pregnancy and returned to prepregnancy level in all but one patient. Prolactin responses to stimulation tests were blunted for 6 months after successful tumor removal. By 1 year, responses to thyrotropin releasing hormone and metoclopramide tests were returning to normal, although responses to chlorpromazine and hypoglycemia remained blunted. The postoperative inhibition of normal lactotropes for 6 months is suggested. Ultimate cure cannot be determined before 6 months and conception should be deferred until then.

Persistent defect in regulation of prolactin secretion after successful pituitary tumor removal in women with the galactorrhea-amenorrhea syndrome.

TRH, metoclopramide (MCP), chlorpromazine (CPZ), and insulin (ITT) stimulation tests of PRL secretion were carried out in age-matched controls and before and after successful removal of pituitary prolactinomas in women with the galactorrhea-amenorrhea syndrome. In preoperative patients there was a blunted or absent PRL response to TRH in 87%, to MCP in 100%, to CPZ in 100%, and to ITT in 93%. Two to 6 months after successful tumor removal, serum PRL rose 2-fold (the usual criterion for a normal response) in 73% after TRH, in 100% after MCP, but in only 13% after CPZ and in only 14% on ITT. However, the PRL increment with all four tests was significantly lower than that in normal controls. One to 8 yr after successful surgery, the PRL increments after TRH and MCP were returning to normal, but the PRL responses to CPZ and ITT remained blunted. GH, ACTH, and TSH reserves were intact in all patients. The diminished PRL response to all stimulation tests observed up to 6 months postoperatively might be explained by the persistence of a negative feedback effect from high PRL levels associated with the tumor. The more persistent impairment of the PRL response to CPZ and ITT is unexplained but suggests a hypothalamic defect.

Cardiopulmonary dynamics in a severe case of Rocky Mountain spotted fever.

A 19-year-old man had multisystem organ failure secondary to Rocky Mountain spotted fever. In addition to renal, cerebral, liver, and gastrointestinal tract involvement he manifested noncardiogenic pulmonary edema and, later, myocardial dysfunction. Aggressive surgical, medical, and monitoring procedures led to recovery. Previously suggested myocardial dysfunction was documented for the first time.