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Vol. 92 Suppl. HPT July 2016
Na CPK 1
NaCPK
63 116 1 Na CPKNa 117 mEq/lCPK 1883 IU/l ACTH 2.9 pg/ml 14 μg/dl
NaNa11 mEq/l Na Figure 1-A 8 Na JCS 300 Na CPK Na 107 mEq/lCPK 4463 IU/l 3 Na MRI ACTH 3.8 pg/ml 3.8 μg/dl HC Figure 1-B
1-A 1-B
Figure 1. History of Present Illness 1-A: Clinical course before and after the 1st hospitalization. 1-B: Clinical course in the 2nd hospitalization.
F: Cortisol F: Cortisol
26 Proceeding
400 mg 100 mg 0.25 mg 3CPK 0.2 mg 5 mg
30
10 / 168.7 cm56.9 kgBMI 20 kg/
m2 36.3 120/74 mmHg 67/SpO2 97 +/+
// / /
Na 110 mg/dl HC 10.6 μg/dl ACTH 1.9 pg/mlPRL 0.5 ng/mlFT4TSH IGF-1 Table 1MRI Figure 2-A B
Figure 2. T1-weighted coronal (2-A) and sagittal (2-B) gadolinium- enhanced MRI scan.
2-A 2-B
Table 1. Laboratory data on hospital transfer (after administration of hydrocortisone started)
Blood Cell Count Biochemistry Endocrinology Urinalysis WBC 7800 /μl TP 5.2 g/dl ACTH <2.0 pg/ml SG 1.013 Neu 7.40 % Alb 2.9 g/dl Cortisol 10.6 μg/dl pH 7.0 Lym 17.0 % T-bil 0.37 mg/dl TSH 3.90 μIU/ml Pro (-) Other 9.0 % AST 81 U/I Free T4 0.45 ng/dl Glu (-)
ALT 35 U/I GH 0.09 ng/ml Ket (-) Hb 11.3 g/dl LDH 235 U/I IGF-1 27 ng/ml Bil (-) Hct 32.3 % ALP 330 U/I PRL 0.5 ng/ml U-Osm 371mOsm/kg Plt 180000 /μl γGTP 51 U/I FSH 1.1 mIU/ml U-Cr 64.1 mg/dl
CPK 462 U/I LH 0.7 mIU/ml U-Na 46 mg/dl BUN 9.1 mg/dl ADH 0.8 pg/ml U-K 27 mg/dl Cr 0.51 mg/dl HbA1c 5.3 % UA 1.4 mg/dl Na 137 mEq/l K 3.4 mEq/l Cl 101 mEq/l Ca 9.4 mg/dl P 2.2 mg/dl Glu 110 mg/dl
32 26 Proceeding
Vol. 92 Suppl. HPT July 2016
HC 15 mg/L-T450 μg/ 26 Figure 3-A GHPRLACTHFSHLHTSH αSUSSTR2 SSTR5 MIB-1 index7.7Figure 3-B 3CRHTRHGnRHGHRP-2 GH1.91 ng/ml HCL-T4 40
1 Na 1 Na Na
2 Na 2 CPK2 1 2 Na Na Na Na-Ca CaCa 12 Na Na 3 CPK 4 Na
Figure 3. Histopathological view of the resected pituitary tumor. 3-A: Photomicrograph of the surgical specimen stained with hematoxylin and eosin (original magnification×400). 3-B: Photomicrograph of the surgical specimen stained with anti-Ki67 antibody (original magnification×400). MIB-1 index : 7.7
3-A 3-B
26 Proceeding
MIB-1 index 7.7 MIB-1 index 5 3 6 MIB-1 index
Na CPK
1Singhal PC, Abramovici M, Venkatesan J. Rhabdomy-
olysis in the hyperosmolal state. Am J Med. 1990; 88: 9–12.
2Rizzieri DA. Rhabdomyolysis after correction of hy- ponatremia due to psychogenic polydipsia. Mayo Clin Proc. 1995; 70: 473–6.
3Lau SY, Yong TY. Rhabdomyolysis in acute primary adrenal insufficiency complicated by severe hyponatre- mia. Intern Med. 2012; 51: 2371–4.
4Capatina C, Inder W, Karavitaki N, Wass JA. Manage- ment of endocrine disease: pituitary tumour apoplexy. Eur J Endocrinol. 2015; 172: R179–90.
5Pizarro CB, Oliveira MC, Coutinho LB, Ferreira NP. Measurement of Ki-67 antigen in 159 pituitary adeno- mas using the MIB-1 monoclonal antibody. Braz J Med Biol Res. 2004; 37: 235–43.
6Ogawa Y, Ikeda H, Tominaga T. Clinicopathological study of prognostic factors in patients with pituitary adenomas and Ki-67 labeling index of more than 3%. J Endocrinol Invest. 2009; 32: 581–4.
34 26 Proceeding
Vol. 92 Suppl. HPT July 2016
1
34 4MRI 27 6 TSH 0.14 0.45–4.90 μU/mlfT3 2.37 2.55–4.84pg/mlfT4 0.51 1.07–1.99ng/dl 110.1 6.1–30.5ng/ mlGH 2.19ng/mlACTH 5.7 7.2–63.3pg/ml 6.8 4.5–21.1μg/dl MRI1
1MRI T1T1T2T1 ←
T1 multidetector CT 2 fT40.50ng/dl CRH +TRH ACTH CRH 9.4 53.6pg/ml13.1 μg/dl 1 9.7μg/dl 2 TRH 69.9 30 227.5ng/ml TSHGH 3ng/ml IGF-1 264ng/ml+1.2 SD GH GH
35
26 Proceeding
1CRH
0 15 30 60 90 120 ACTH 9.4 53.6 53.1 37.4 24.8 17.6 pg/ml
Cortisol 3.8 6.3 9.8 13.1 11.5 9.1 μg/dl
2Insulin+TRH
0 15 30 60 90 120 ACTH 9.4 53.6 53.1 37.4 24.8 17.6 pg/ml
Cortisol 3.8 6.3 9.8 13.1 11.5 9.1 μg/dl
GH 3.87 4.06 4.59 4.19 4.15 4.17 ng/ml
PRL 69.9 210.7 227.5 180.8 133.9 125.2 ng/ml
TSH <0.02 0.07 0.14 0.17 0.18 0.17 μU/ml
66 35 42 66 59 mg/dl
2 CTmultidetector-CT
30mg/body0.5mg/kg/110mg/ 10mg/ 15mg/ 2 8 MRI 3 38 6 1MRI 4 1MRI
12 34
56 78 9 spindle cell oncocytoma 10 11 Catregli 379 3 130 12 1314 Gutenberg 15
36 26 Proceeding
Vol. 92 Suppl. HPT July 2016
−5 −13 +2 +4 −2 +8 −4 FDA 16 Europian Society of Urogenital RadiologyESUR 17
Mutidetector-CTMass macroadenoma
3 8MRI T1T2T1
4 7MRI T1GdT1Gd
37
26 Proceeding
1Molitch ME. Pituitary disease in pregnancy. Semin
Perinatol 1998; 22(6): 457–470. 2Sharma JB, Roy KK, Mohanraj P, Kumar S, Karma-
kar D, Barua J. Pregnancy outcome in pituitary tumors. Arch Gynecol Obstet 2009; 280(3): 401–404.
3Nishio S, Morioka T, Suzuki S, Takeshita I, Ikezaki K, Fukui M, Nakano H. Primary brain tumours manifest- ing during pregnancy: presentation of six cases and a review of the literature. J Clin Neuroscience 1996; 3(4): 334–337.
4Masding MG, Lees PD, Gawne-Cain ML, Sandeman DD. Visual field compression by a non-secreting pitu- itary tumour during pregnancy. J R Soc Med 2003; 96: 27–28.
5Semple PL, Jane JA, Laws ER. Clinical relevance of precipitating factors in pituitary apoplexy. Neurosur- gery 2007; 61(5): 956–962.
6Hayes AR, O’Sullivan AJ, Davies MA. A case of pi- tuitary apoplexy in pregnancy. Endocrinol Diabetes Metab Case Rep 2014; 2014: 140043. PMD: 25031837.
7Maniker AH, Krieger AJ. Rapid recurrence cranio- pharyngioma during pregnancy with recovery of vi- sion: a case report. Surg Neurol 1996; 45(4): 324–327.
8Aydin Y, Can SM, Gulkilik A, Turkmenoglu O, Alatli C, Ziyal I. Rapid enlargement and recurrence of a pre- existing intrasellar craniopharyngioma during the course of two pregnancies: case report. J Neurosurg 1999; 91(2): 322–324.
9Ebner FH, Bornemann A, Wilhelm H, Ernemann U, Honegger J. Tuberculum sellae meningioma symptom- atic during pregnancy: pathophysiological consider- ations. Acta Neurochir(Wien) 2008; 150(2): 189–193.
10Zygourakis CC, Rolston JD, Lee HS, Partow C, Kun- war S, Aghi MK. Pituicytomas and spindle cell oncocy- tomas: modern case series from the University of Cal- fornia San Francisco. Pituitary 2015; 18(1): 150–158.
11 monostotic fibrous dysplasia 1 1988; 40(8): 727–732.
12Caturegli P, Newschaffer C, Olivi A, Pomper MG, Burger PC, Rose NR. Autoimmune hypophysitis. En- docrine Rev 2005; 26(5): 599–614.
13Alexiadou-Rudorf C, Hildebrandt G, Schroeder R, Ernestus R-I. Lymphocytic adenohypophysitis mim- icking a pituitary macroadenoma. Neurosurg Rev 2000; 23(2): 112–116.
14 MRI 1No Shinkei Geka 2005; 33(10): 971–977.
15Guttenberg A, Larsen J, Lupi I, Rohde V, Caturegli P. A radiologic score to distinguish autoimmune hypoph- ysitis from nonsecreting pituitary adenoma preopera- tively. AJNR 2009; 30(9): 1766–1772.
16FDAhttp://www.okusu ri110.com/kinki/ninpkin/ninpkin_03-02.htr
17ESUR Guidelines. http://www.esur.org/esur-guidelines 18Nishioka H, Ito H, Fukushima C. Recurrent lym-
phocytic hypophysitis: case report. Neurosurgery 1997; 41(3): 684–687.
19Ishihara T, Hino M, Kurahachi H, Kobayashi H, Kaji- kawa M, Moridera K, Ikekubo K, Hattori N. Long-term clinical course of two cases of lymphocytic adenohy- pophysitis. Endocrine J 1996; 43(4): 433–440.
20Gagneja H, Arafah B, Taylor HC. Histologically proven lymphocytic hypophysitis: spontaneous resolu- sion and subsequent pregnancy. Mayo Clin Proc 1999; 74: 150–154.
21Siddique H, Baskar V, Chakrabarty A, Clayton RN, Hanna FW. Spontaneous pregnancy after trans-sphe- noidal surgery in a patient with lymphocytic hypophy- sitis. Crin Endocrinol 2007; 66: 454–455.
38 26 Proceeding
Vol. 92 Suppl. HPT July 2016
10
20 9 DI 20 DI 60 10
Na 1 Na 2 Na
Na
10 X 9 10 9 8 MRI9 10 CT
ADH 9 11
ADH 9 4 6 10 5 1 ADH 3 2 1 1–2 ADH 1 2 7 ADH ADH1 3 ADH 1 2–4 in-out 1Na 1 125ml/m2/h 1 CT
WBC
RBC
Hb
Hct
Plt
PT
INR
APTT
6700
396
11.3
32.4
37.0
134.3
0.88
26.1
g/dl
26 Proceeding
2Na in over NaNa
10
1 Neurol Med Chir 1983; 23: 797–801.
2John C. Ausiello, Jeffrey N. Bruce, Pamela U. Freda. Postoperative assessment of the patient after transsphe- noidal pituitary surgery. Pituitary, 2008; 11: 391–401.
2 Na
Na CPK 1
NaCPK
63 116 1 Na CPKNa 117 mEq/lCPK 1883 IU/l ACTH 2.9 pg/ml 14 μg/dl
NaNa11 mEq/l Na Figure 1-A 8 Na JCS 300 Na CPK Na 107 mEq/lCPK 4463 IU/l 3 Na MRI ACTH 3.8 pg/ml 3.8 μg/dl HC Figure 1-B
1-A 1-B
Figure 1. History of Present Illness 1-A: Clinical course before and after the 1st hospitalization. 1-B: Clinical course in the 2nd hospitalization.
F: Cortisol F: Cortisol
26 Proceeding
400 mg 100 mg 0.25 mg 3CPK 0.2 mg 5 mg
30
10 / 168.7 cm56.9 kgBMI 20 kg/
m2 36.3 120/74 mmHg 67/SpO2 97 +/+
// / /
Na 110 mg/dl HC 10.6 μg/dl ACTH 1.9 pg/mlPRL 0.5 ng/mlFT4TSH IGF-1 Table 1MRI Figure 2-A B
Figure 2. T1-weighted coronal (2-A) and sagittal (2-B) gadolinium- enhanced MRI scan.
2-A 2-B
Table 1. Laboratory data on hospital transfer (after administration of hydrocortisone started)
Blood Cell Count Biochemistry Endocrinology Urinalysis WBC 7800 /μl TP 5.2 g/dl ACTH <2.0 pg/ml SG 1.013 Neu 7.40 % Alb 2.9 g/dl Cortisol 10.6 μg/dl pH 7.0 Lym 17.0 % T-bil 0.37 mg/dl TSH 3.90 μIU/ml Pro (-) Other 9.0 % AST 81 U/I Free T4 0.45 ng/dl Glu (-)
ALT 35 U/I GH 0.09 ng/ml Ket (-) Hb 11.3 g/dl LDH 235 U/I IGF-1 27 ng/ml Bil (-) Hct 32.3 % ALP 330 U/I PRL 0.5 ng/ml U-Osm 371mOsm/kg Plt 180000 /μl γGTP 51 U/I FSH 1.1 mIU/ml U-Cr 64.1 mg/dl
CPK 462 U/I LH 0.7 mIU/ml U-Na 46 mg/dl BUN 9.1 mg/dl ADH 0.8 pg/ml U-K 27 mg/dl Cr 0.51 mg/dl HbA1c 5.3 % UA 1.4 mg/dl Na 137 mEq/l K 3.4 mEq/l Cl 101 mEq/l Ca 9.4 mg/dl P 2.2 mg/dl Glu 110 mg/dl
32 26 Proceeding
Vol. 92 Suppl. HPT July 2016
HC 15 mg/L-T450 μg/ 26 Figure 3-A GHPRLACTHFSHLHTSH αSUSSTR2 SSTR5 MIB-1 index7.7Figure 3-B 3CRHTRHGnRHGHRP-2 GH1.91 ng/ml HCL-T4 40
1 Na 1 Na Na
2 Na 2 CPK2 1 2 Na Na Na Na-Ca CaCa 12 Na Na 3 CPK 4 Na
Figure 3. Histopathological view of the resected pituitary tumor. 3-A: Photomicrograph of the surgical specimen stained with hematoxylin and eosin (original magnification×400). 3-B: Photomicrograph of the surgical specimen stained with anti-Ki67 antibody (original magnification×400). MIB-1 index : 7.7
3-A 3-B
26 Proceeding
MIB-1 index 7.7 MIB-1 index 5 3 6 MIB-1 index
Na CPK
1Singhal PC, Abramovici M, Venkatesan J. Rhabdomy-
olysis in the hyperosmolal state. Am J Med. 1990; 88: 9–12.
2Rizzieri DA. Rhabdomyolysis after correction of hy- ponatremia due to psychogenic polydipsia. Mayo Clin Proc. 1995; 70: 473–6.
3Lau SY, Yong TY. Rhabdomyolysis in acute primary adrenal insufficiency complicated by severe hyponatre- mia. Intern Med. 2012; 51: 2371–4.
4Capatina C, Inder W, Karavitaki N, Wass JA. Manage- ment of endocrine disease: pituitary tumour apoplexy. Eur J Endocrinol. 2015; 172: R179–90.
5Pizarro CB, Oliveira MC, Coutinho LB, Ferreira NP. Measurement of Ki-67 antigen in 159 pituitary adeno- mas using the MIB-1 monoclonal antibody. Braz J Med Biol Res. 2004; 37: 235–43.
6Ogawa Y, Ikeda H, Tominaga T. Clinicopathological study of prognostic factors in patients with pituitary adenomas and Ki-67 labeling index of more than 3%. J Endocrinol Invest. 2009; 32: 581–4.
34 26 Proceeding
Vol. 92 Suppl. HPT July 2016
1
34 4MRI 27 6 TSH 0.14 0.45–4.90 μU/mlfT3 2.37 2.55–4.84pg/mlfT4 0.51 1.07–1.99ng/dl 110.1 6.1–30.5ng/ mlGH 2.19ng/mlACTH 5.7 7.2–63.3pg/ml 6.8 4.5–21.1μg/dl MRI1
1MRI T1T1T2T1 ←
T1 multidetector CT 2 fT40.50ng/dl CRH +TRH ACTH CRH 9.4 53.6pg/ml13.1 μg/dl 1 9.7μg/dl 2 TRH 69.9 30 227.5ng/ml TSHGH 3ng/ml IGF-1 264ng/ml+1.2 SD GH GH
35
26 Proceeding
1CRH
0 15 30 60 90 120 ACTH 9.4 53.6 53.1 37.4 24.8 17.6 pg/ml
Cortisol 3.8 6.3 9.8 13.1 11.5 9.1 μg/dl
2Insulin+TRH
0 15 30 60 90 120 ACTH 9.4 53.6 53.1 37.4 24.8 17.6 pg/ml
Cortisol 3.8 6.3 9.8 13.1 11.5 9.1 μg/dl
GH 3.87 4.06 4.59 4.19 4.15 4.17 ng/ml
PRL 69.9 210.7 227.5 180.8 133.9 125.2 ng/ml
TSH <0.02 0.07 0.14 0.17 0.18 0.17 μU/ml
66 35 42 66 59 mg/dl
2 CTmultidetector-CT
30mg/body0.5mg/kg/110mg/ 10mg/ 15mg/ 2 8 MRI 3 38 6 1MRI 4 1MRI
12 34
56 78 9 spindle cell oncocytoma 10 11 Catregli 379 3 130 12 1314 Gutenberg 15
36 26 Proceeding
Vol. 92 Suppl. HPT July 2016
−5 −13 +2 +4 −2 +8 −4 FDA 16 Europian Society of Urogenital RadiologyESUR 17
Mutidetector-CTMass macroadenoma
3 8MRI T1T2T1
4 7MRI T1GdT1Gd
37
26 Proceeding
1Molitch ME. Pituitary disease in pregnancy. Semin
Perinatol 1998; 22(6): 457–470. 2Sharma JB, Roy KK, Mohanraj P, Kumar S, Karma-
kar D, Barua J. Pregnancy outcome in pituitary tumors. Arch Gynecol Obstet 2009; 280(3): 401–404.
3Nishio S, Morioka T, Suzuki S, Takeshita I, Ikezaki K, Fukui M, Nakano H. Primary brain tumours manifest- ing during pregnancy: presentation of six cases and a review of the literature. J Clin Neuroscience 1996; 3(4): 334–337.
4Masding MG, Lees PD, Gawne-Cain ML, Sandeman DD. Visual field compression by a non-secreting pitu- itary tumour during pregnancy. J R Soc Med 2003; 96: 27–28.
5Semple PL, Jane JA, Laws ER. Clinical relevance of precipitating factors in pituitary apoplexy. Neurosur- gery 2007; 61(5): 956–962.
6Hayes AR, O’Sullivan AJ, Davies MA. A case of pi- tuitary apoplexy in pregnancy. Endocrinol Diabetes Metab Case Rep 2014; 2014: 140043. PMD: 25031837.
7Maniker AH, Krieger AJ. Rapid recurrence cranio- pharyngioma during pregnancy with recovery of vi- sion: a case report. Surg Neurol 1996; 45(4): 324–327.
8Aydin Y, Can SM, Gulkilik A, Turkmenoglu O, Alatli C, Ziyal I. Rapid enlargement and recurrence of a pre- existing intrasellar craniopharyngioma during the course of two pregnancies: case report. J Neurosurg 1999; 91(2): 322–324.
9Ebner FH, Bornemann A, Wilhelm H, Ernemann U, Honegger J. Tuberculum sellae meningioma symptom- atic during pregnancy: pathophysiological consider- ations. Acta Neurochir(Wien) 2008; 150(2): 189–193.
10Zygourakis CC, Rolston JD, Lee HS, Partow C, Kun- war S, Aghi MK. Pituicytomas and spindle cell oncocy- tomas: modern case series from the University of Cal- fornia San Francisco. Pituitary 2015; 18(1): 150–158.
11 monostotic fibrous dysplasia 1 1988; 40(8): 727–732.
12Caturegli P, Newschaffer C, Olivi A, Pomper MG, Burger PC, Rose NR. Autoimmune hypophysitis. En- docrine Rev 2005; 26(5): 599–614.
13Alexiadou-Rudorf C, Hildebrandt G, Schroeder R, Ernestus R-I. Lymphocytic adenohypophysitis mim- icking a pituitary macroadenoma. Neurosurg Rev 2000; 23(2): 112–116.
14 MRI 1No Shinkei Geka 2005; 33(10): 971–977.
15Guttenberg A, Larsen J, Lupi I, Rohde V, Caturegli P. A radiologic score to distinguish autoimmune hypoph- ysitis from nonsecreting pituitary adenoma preopera- tively. AJNR 2009; 30(9): 1766–1772.
16FDAhttp://www.okusu ri110.com/kinki/ninpkin/ninpkin_03-02.htr
17ESUR Guidelines. http://www.esur.org/esur-guidelines 18Nishioka H, Ito H, Fukushima C. Recurrent lym-
phocytic hypophysitis: case report. Neurosurgery 1997; 41(3): 684–687.
19Ishihara T, Hino M, Kurahachi H, Kobayashi H, Kaji- kawa M, Moridera K, Ikekubo K, Hattori N. Long-term clinical course of two cases of lymphocytic adenohy- pophysitis. Endocrine J 1996; 43(4): 433–440.
20Gagneja H, Arafah B, Taylor HC. Histologically proven lymphocytic hypophysitis: spontaneous resolu- sion and subsequent pregnancy. Mayo Clin Proc 1999; 74: 150–154.
21Siddique H, Baskar V, Chakrabarty A, Clayton RN, Hanna FW. Spontaneous pregnancy after trans-sphe- noidal surgery in a patient with lymphocytic hypophy- sitis. Crin Endocrinol 2007; 66: 454–455.
38 26 Proceeding
Vol. 92 Suppl. HPT July 2016
10
20 9 DI 20 DI 60 10
Na 1 Na 2 Na
Na
10 X 9 10 9 8 MRI9 10 CT
ADH 9 11
ADH 9 4 6 10 5 1 ADH 3 2 1 1–2 ADH 1 2 7 ADH ADH1 3 ADH 1 2–4 in-out 1Na 1 125ml/m2/h 1 CT
WBC
RBC
Hb
Hct
Plt
PT
INR
APTT
6700
396
11.3
32.4
37.0
134.3
0.88
26.1
g/dl
26 Proceeding
2Na in over NaNa
10
1 Neurol Med Chir 1983; 23: 797–801.
2John C. Ausiello, Jeffrey N. Bruce, Pamela U. Freda. Postoperative assessment of the patient after transsphe- noidal pituitary surgery. Pituitary, 2008; 11: 391–401.
2 Na
