Medical and Surgical Treatments 🧠🔪👃
A 42-year-old male presents with bitemporal hemianopsia and a 2.5 cm sellar mass. This first-line surgical approach, which traverses the nasal cavity and the sphenoid bone, is indicated to achieve rapid decompression of the optic chiasm.
What is Transsphenoidal Surgical Resection?
In the classic HPT axis, the hypothalamus releases TRH, which stimulates the anterior pituitary to release TSH. TSH then binds to G-protein coupled receptors on thyroid follicular cells to stimulate the release of these two primary hormones.
What are T4 (Thyroxine) and T3 (Triiodothyronine)?
Following a transsphenoidal resection of a non-functioning macroadenoma, this class of medication is often administered empirically or in "stress doses" to prevent life-threatening hypotension and vascular collapse.
What are Glucocorticoids (e.g., Hydrocortisone or Dexamethasone)?
Beyond the classic physical signs, upwards of 80% of patients with Cushing’s Syndrome present with this category of psychiatric symptoms, which frequently leads to an initial misdiagnosis of a primary "Mood Disorder."
What are Depressive symptoms (or Anxiety/Emotional Lability)?
A 35-year-old female with persistent Cushing’s disease after a failed resection is started on Pasireotide. This medication's therapeutic effect is mediated by its high affinity for this somatostatin receptor subtype, which is most prevalent on corticotroph adenoma cells.
What is SSTR5?
A 30-year-old female with Hashimoto thyroiditis is started on L-thyroxine. This synthetic hormone acts as a pro-hormone that is converted in peripheral tissues by deiodinase enzymes into this more physiologically active form.
What is T3?
To assess the integrity of the Hypothalamic-Pituitary-Adrenal (HPA) axis on postoperative day 1, clinicians typically measure this specific serum value at 8:00 AM; a result below 3 ug/dL is highly suggestive of secondary adrenal insufficiency.
What is Serum Cortisol?
Emotional management must address the psychological impact of these three distinct cutaneous and structural changes, which often lead to social withdrawal and body dysmorphic distress in Cushing's patients.
Answer: What are Purple striae, Moon facies, and the Supraclavicular fat pad (Buffalo hump)?
Following a transsphenoidal resection, a patient experiences a sudden increase in thirst and produces 6 liters of dilute urine in 24 hours. This postoperative complication results from the manipulation of the posterior pituitary, leading to a deficiency in this hormone.
What is Antidiuretic Hormone (ADH) (or Vasopressin)?
When titrating L-thyroxine, a physician must wait 6 to 8 weeks before re-checking a patient's TSH level. This delay is necessary because it takes approximately five of these for the drug to reach a steady-state concentration.
What is a Half-life (T4 has a half-life of ~7 days)?
When educating a post-op patient on the "consistency of cortisone," a clinician must emphasize that during periods of physiological stress (such as a high fever or subsequent surgery), the patient must perform this specific adjustment to their dose to prevent an adrenal crisis.
What is "Stress Dosing" (or doubling/tripling the dose)?
Clinicians must counsel patients that while surgery may "cure" the hypercortisolemia, this specific phenomenon—characterized by joint pain, lethargy, and low mood—often occurs post-operatively, making the patient feel "worse" despite biochemical success.
What is Glucocorticoid Withdrawal Syndrome?
A patient with acromegaly is switched from Octreotide to Pasireotide due to uncontrolled IGF-1 levels. Unlike first-generation analogs, Pasireotide significantly increases the risk of hyperglycemia because it inhibits the secretion of this pancreatic hormone while also suppressing GLP-1 and GIP.
What is Insulin?
A patient on a stable dose of L-thyroxine is diagnosed with osteoporosis and starts taking calcium carbonate and ferrous sulfate. The physician must advise the patient to take these at least 4 hours apart from her thyroid medication to prevent this specific pharmacokinetic effect.
What is Decreased Absorption (or Chelated Malabsorption)?
A patient who underwent resection for a GH-secreting adenoma shows a borderline morning cortisol of 10 ug/dL. Before deciding to discontinue steroid therapy, this "gold standard" provocative test may be used to determine if the adrenal glands can respond to signaling.
What is the ACTH Stimulation Test (or Cosyntropin Test)?
During both the peak of the disease and the tapering phase of recovery, patients are at a significantly increased risk for this specific psychiatric emergency, necessitating routine screening and a "safety plan" involving family members.
What is Suicidal Ideation (or Suicidality)?
In comparing medical vs. surgical outcomes for a prolactinoma, surgery is often bypassed for medical therapy. However, for Cushing’s Disease, surgery is the preferred "cure." Medical therapy with Pasireotide is typically reserved for this specific patient population who cannot undergo or have failed surgery.
Who are refractory patients or those with high surgical/anesthetic risk?
A 38-year-old woman, gravida 2, para 2, is brought to the emergency department by her husband after an episode of unconsciousness. She delivered a healthy infant two weeks ago and the postpartum course was complicated by severe vaginal bleeding, for which she required 4 units of packed red blood cells. Since the blood transfusion, she has had decreased milk production and has felt fatigued. Her pulse is 118/min and blood pressure is 104/63 mm Hg. Her finger-stick glucose concentration is 34 mg/dL. Serum thyroid-stimulating hormone and thyroxine levels are low and the serum sodium level is 132 mEq/L. Which of the following is the most likely cause of this patient's condition, AND What is the name of the syndrome?
A) Postpartum thyroiditis
B) Lactotrophic adenoma
C) Adrenal hemorrhage
D) Hypothalamic infarction
E) Pituitary Ischemia
E) Pituitary Ischemia, Sheehan Syndrome
Patients undergoing transsphenoidal surgery for this specific condition are at the highest risk for prolonged, profound postoperative adrenal insufficiency because their healthy pituitary tissue has been chronically suppressed by high cortisol levels for years.
What is Cushing’s Disease (or ACTH-secreting pituitary adenoma)?
A patient 4 weeks post-transsphenoidal resection for Cushing’s Disease is currently on a physiological tapering dose of hydrocortisone (15 mg AM / 5 mg PM). They present with acute, treatment-resistant anhedonia, severe emotional lability, and "mental paralysis." Despite the patient’s biochemically "normal" replacement levels, this specific pharmacological intervention—rather than the initiation of an SSRI—is often the next best step to stabilize the patient’s acute psychological crisis during the "glucocorticoid washout" phase
What is a Temporary Increase (or "Rescue Dose") of Glucocorticoids?