HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds
description
Transcript of HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds
![Page 1: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/1.jpg)
HONEY, I BLEW UP THE KID!
A SUPER Sized Medical Grand Rounds
Presentor: Suzette Grace R. Kho, M.D.
Resource Persons:
Eric Flores, M.D. (Neurosurgery)
Paolo Villanueva, M.D (Pathology)
Gerardo Beltran, M.D. (Radiology)
Teresa Sy-Ortin, M.D. (Radio-oncology)
Moderator: Thelma Crisostomo, M.D.
![Page 2: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/2.jpg)
To present a case of a 17 year old female with unusually tall stature
To discuss differential diagnosis, & work-up for patients presenting with pituitary mass
to discuss pathophysiology & treatment options for patients presenting with pituitary tumors
![Page 3: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/3.jpg)
F.O. 17 Female Filipino Cagayan de Oro
Chief Complaint:
Evaluation of Tall Stature
![Page 4: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/4.jpg)
121 cm
154 cm
168 cm
185 cm
191cm
198 cm
> 95th %
![Page 5: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/5.jpg)
3 mos PTA (+) “dimming” of her peripheral vision.
(+) difficulty guarding her opponents, & would sometimes miss catching a pass.
no consult was done until an annual school PE› Tall stature› Delayed development of
secondary sexual characteristcs
› Visual field abnormalitiesCONSULT
![Page 6: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/6.jpg)
(-) rashes, (-) skin pigmentation (-) nocturia, (-) polyuria, (-) polydipsia (-) palpitations, (-) tremors, (-) heat/ cold
intolerance, (-)weight gain/ weight loss (-) chest pain , (-)no difficulty of breathing,
(-) lactation (-) easy fatigability, (-) body weakness,
(-) tetany, (-) muscle cramps (-) hirsutism
![Page 7: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/7.jpg)
Delivered term via NSD to a 24 y/o G2P1 Birth weight: 6 lbs. Birth length: claims to be within normal No delivery complications
unremarkable
unremarkable
![Page 8: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/8.jpg)
Father- 5’4” (162.54 cm) Mother- 5’3” (160 cm), menarche at age 12
*midparental height: 154.77cm 1 Sibling: Brother- 5’9” (175.26 cm) tall relatives >182 cm ( 6’): mother side
-8 uncles-: 6’ to 6’2” -1 male cousin: 6’1”
(+) thyroid disease- aunt (+) HPN- father, uncle (+) asthma- father and brother (+) CVA- grandfather (-) DM, (-) colon cancer
![Page 9: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/9.jpg)
Conscious, coherent, ambulatory, oriented to 3 spheres
Vital Signs: BP 110/70 mmHg HR 84 bpmRR 20 cpm T 36.3°C
![Page 10: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/10.jpg)
Anthropometricswt: 95.5kg ht: 198cmBMI:
24.1(overweight)
upper segment: 84.84 cm
lower segment: 113cm
U/L segment: 0.76
6’6”
![Page 11: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/11.jpg)
Anthropometrics
Arm span - 205.74 cm
ht: 198cm
![Page 12: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/12.jpg)
Physical Examination
(+) depressed anterior (5.5 cm x 3.5cm) &
posterior (1.5cm x1.0cm) fontanelles
no coarsening of features (+) slightly thickened &
widened nose and lips (+) gap between incisors,
with slight prominence of jaw
![Page 13: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/13.jpg)
Lipomastia with no distinct glandular tissues
External genitalia: female pubic hair, with no clitoral
enlargement, bright pink vaginal mucosa, no
milky secretions noted.
Physical Examination
![Page 14: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/14.jpg)
Physical Examination
(+) prominent hands and feet, with thickening of the soles of the foot
Full & equal pulse
![Page 15: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/15.jpg)
Neurologic Examination Awake, alert, oriented to 3 spheres Pupils 3-4mm ERTL, EOM full and equal, (+)
ROR, (+) visual field cuts Can smile, frown, clench teeth, tongue midline
on protrusion Can shrug shoulders MMT: 5/5 on all extremities Sensory: 100% intact No dysmetria, no dysdiadokinesia (-) Brudzinski’s (-) Kernig’s (-) Babinski DTR: ++
![Page 16: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/16.jpg)
17 year old female
Tall stature Delayed puberty Headaches Visual field defect
Depressed fontanelles slightly thickened &
widened nose and lips upper tooth gap with
slight prominence of jaw
Prepubertal Tanner stage 1 breasts
Tanner stage 3 pubic hair
Prominent hands and feet
Salient Features
![Page 17: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/17.jpg)
DifferentialsTall Stature Pubertal
DelayHeadache &
Visual Changes
Familial Pituitary MassChromosomal Abnormalities
PhysiologicPathologicPituitary MassChromosomal Abnormalities
AstigmatismMigraineIntracranial Tumor
![Page 18: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/18.jpg)
Initial Impression
Gigantism probably secondary to Growth hormone secreting pituitary adenoma with Hypogonadotrophic Hypogonadism
![Page 19: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/19.jpg)
Work UpClinical Features of
Gigantism/ Acromegaly
IGF-1 Level
Normal for Age & Gender Elevated
Measure OGTT & GH levels
Adequate GH suppression
Inadeguate / no GH
suppression
Pituitary MRI
Dx excluded
Piuitary Mass
Assess likelihood of surgical success
Surgery
Medical
(Clinical features figure from Minkowski O. Ueber einen Fall von Akromegalie. Berliner Klinische Wochenschrift 1887;21:371-374; from Melmed S. Medical progress: acromegaly. N Engl J Med 2006;355:2558-2573. Erratum in N Engl J Med 2007;356:879).
![Page 20: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/20.jpg)
75g Oral Glucose Tolerance Test TIME (mins)
Growth Hormone(n.v. 0-7)
FBS IGF-1 (193-731 ng/ml)
0 203.229
90.98 1244
60 mins 208.948
109.17
120 mins
199.466
67.32
Work up
NONSUPPRESSION
![Page 21: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/21.jpg)
MRI of Brain (+)pituitary mass Referred to a neurosurgeon
› Transsphenoidal Surgery
![Page 22: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/22.jpg)
GENETIC STUDY AUTOMATED PERIMETRY
VISUAL FIELD TEST
LEFT EYE RIGHT EYETEMPORAL TEMPORAL HEMIANOPSIA HEMIANOPSIA
WITH CENTRAL SPARING
![Page 23: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/23.jpg)
Hormones
9/09
F- Prolactin (3.6-18.9 ng/ml)
255.49
F- FSH (3.3-8.8 mlU/ml) 0.366
F- LH (0.6-6.2 mlU/ml) 0.001
F- Testosterone 27.346 (normal)
F- Estradiol 19.845 (premenarcheal)
10/16/09 F-DHEAS (0.94-11.67 umol/L) 8.484
![Page 24: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/24.jpg)
10/19/09Cortisol 8am (138-690 nmol/L) 420.960 9am 279.550
10/16/09ACTH (<50 pg/ml) 15.231
9/12/09TSH IRMA (0.27- 3.75) 0.621FT4 (8.8- 33) 23.413
![Page 25: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/25.jpg)
Pelvic Ultrasound
Infantile uterus, with thin endometrium (3mm)
Small left ovary, right ovary not visualized
infantile uterus, with thin endometrium (3mm), small left ovary, and right ovary not visualized. infantile uterus, with thin endometrium (3mm), small left ovary, and right ovary not visualized.
![Page 26: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/26.jpg)
Skeletal Survey
![Page 27: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/27.jpg)
Bone Aging
![Page 28: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/28.jpg)
Bone Mineral Density
SPINESPINE FEMORAL NECKFEMORAL NECK
NORMALNORMAL
![Page 29: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/29.jpg)
2 D Echocardiogram
Ultrasound of the Neck and Thyroid Gland
![Page 30: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/30.jpg)
Dec. 2, 2010: transnasal transphenoidal resection of the pituitary mass
Post op:› (+) mild transient DI, treated with small doses Desmopressin
100 mcg/tablet› Hydrocortisone 100mg/IV was maintained and tapered in 4
days. Transient sugar elevations noted, given insulin injections.
› 7th HD: discharged, on Prednisone 7.5mg/tab (5mg- 0-2.5mg).
![Page 31: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/31.jpg)
PATIENT: F.O. 17/FSPECIMEN NO.: 10-SR-0282
![Page 32: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/32.jpg)
IMMUNOHISTOCHEMICAL STAIN: GROWTH HORMONE, POSITIVE (>90%)
![Page 33: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/33.jpg)
IMMUNOHISTOCHEMICAL STAIN PROLACTIN, POSITIVE (<5%)
![Page 34: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/34.jpg)
75g Oral Glucose Tolerance Test9/15/09(Pre-op)
1/15/10(Post-op)
TIME Growth Hormone (n.v. 0-7)
FBS Growth Hormone (n.v. 0-7)
FBS
0 203.229 90.98 378.709 93.19
60 mins
208.948 109.17
415.996 109.17
120 mins
199.466 67.32 419.659 83.7
Follow Up
NONSUPPRESSIONNONSUPPRESSION
![Page 35: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/35.jpg)
IGF-1(193-731 ng/ml)
9/11/09Pre-op
1/15/10Post-op
0 1244 1075
![Page 36: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/36.jpg)
Sex Hormones 9/16/09Pre-op
1/20/10Post -op
F-Prol (3.6- 18.9 ng/mL)
255.499 383.588
F-FSH (3.3-8.8 mIU/mL)
0.366 0.001
F-LH (0.6-6.2 mlU/ml) 0.001 0.018
9/17/09Pre-op
1/21/10Post- op
Estradiol pg/ml 19.845 (premenarcheal)
19.496 (premenarcheal)
![Page 37: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/37.jpg)
Follow Up Repeat MRI 3 mos. after surgery: mass
slightly decreased but appears unchanged
April 29, 2010: Repeat transsphenoidal surgery
![Page 38: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/38.jpg)
9/16/09(Baseline)
1/20/101st Post -op
5/19/102nd Post -op
F-Prol (3.6-18.9 ng/ml)
255.499 383.588
F-FSH (3.3-8.8 mlU/ml))
0.366 0.001 0.76
F-LH (0.6-6.2 mlU/ml)
0.001 0.018 0.26
Updates
![Page 39: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/39.jpg)
75g Oral Glucose Tolerance Test 9/15/09 BASELINE
1/15/10 1st Post-op
6/4/10 2nd Post-op
Growth Hormone (0-7)
FBS Growth Hormone (0-7)
FBS Growth Hormone (0-7)
0 203.229 90.98 378.709 93.19
60 mins 208.948 109.17
415.996 109.17
120 mins
199.466 67.32 419.659 83.7 256.873
Updates
NONSUPPRESSION NONSUPPRESSION NONSUPPRESSION
![Page 40: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/40.jpg)
Insulin Growth Like Factor 1
9/11/091st Preop(193-731)
1/15/101st Postop
4/15/102nd Preop
5/19/102nd Postop(1mo)
7/16/102nd
PostOp
(3 mos)
0 1244 1,075 1437 >1600 1429
Updates
![Page 41: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/41.jpg)
17 year old female› Tall stature› Prominently enlarged
hands and feet› Slightly widened and
thickened nose and lips› Widened upper tooth gap
Delayed pubertyTanner stage 1 breaststanner stage 3 pubic hair
Bitemporal Hemianopsia
MRI of the brain: (+) pituitary mass
Histopathological & Immunohistochemical Findings: GH & Prolactin Macroadenoma
Elevated GH levels IgF-1 level Prolactin level
Prepubertal Estradiol FSH and LH level
Infantile uterus
Normal Karyotype- 46 XX
CASE SUMMARY
![Page 42: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/42.jpg)
Final Diagnosis
Gigantism secondary to Growth Hormone and Prolactin Co- Secreting Pituitary Macroadenoma with stalk compression resulting in hypogonadotrophic hypogonadism, s/p Transnasal Transphenoidal Surgery (12/2/09 & 4/29/10)
![Page 43: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/43.jpg)
The Pituitary Gland & Mass Effects of Pituitary Tumor
BITEMPORAL HEMIANOPSIA
HEADACHES
COMPRESSION OF PITUITARY STALK
HYPERPROLACTINEMIA HYPOPITUITARISM
![Page 44: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/44.jpg)
Hypothalamic Pituitary AxisHypothalamus
Pituitary
Trophic H.
Target Organ
![Page 45: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/45.jpg)
In our patient..HORMONE HYPERSECRETION
Growth Hormone Secreting Adenoma (>90%)
Prolactin Co-Secreting Adenoma (<5%)
(Mammasomatotrophs)
GIGANTISM
Lafferty, A.R & Chrousos, G.P., Pituitary tumors in Children & Adolescents. J. Clin. Endccinol. Metab. 1999.84:4317-4323.
Combined GH and Prolactin over-secretion common inearly childhood gigantism
![Page 46: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/46.jpg)
GIGANTISM VS. ACROMEGALY
TIMING OF GH EXCESS
During period of active growth
Open epiphyseal plates
After epiphyseal closure
INCIDENCETotal cases reported only in the hundreds
3- 4 cases/million
TALL STATURE Cardinal feature 10% Cases
![Page 47: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/47.jpg)
Identical twins, 22 years old, excess GH secretion
![Page 48: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/48.jpg)
![Page 49: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/49.jpg)
49
Melmed SM, ed. Acromegaly: A Comprehensive Guide to Diagnosis and Treatment. East Hanover, NJ:Novartis; 2003.
Melmed S. Medical progress: acromegaly. N Engl J Med 2006;355:2558-2573. Erratum in N Engl J Med 2007;356:879.
>98%
![Page 50: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/50.jpg)
Clinical Features of Acromegaly
Melmed S. N Engl J Med 2006;355:2558-2573
![Page 51: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/51.jpg)
Neurosurgery: TUMOR > 2cm = REDUCED Success Rates
Medical Therapy Somatostatin Receptor
Ligands Dopamine Agonists GH Receptor Antagonist
Radiation Therapy
Treatment Guidelines
![Page 52: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/52.jpg)
Mortality in AcromegalyMortality in Acromegaly
Adapted from Rajasoorya C, et al. Clin Endocrinol. 1994; 41: 95–102.
GH Level: most impt. factor in determining
survival in patients with acromegaly
![Page 53: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/53.jpg)
Updates
June 15, 2010: 10 days loading dose 100 mcg Somatostatin SC q 8hrs was given, then somatostatin 300mg/ IM once a month started
(+) headaches and dizziness July 29, 2010: 2nd Post-op MRI showed further
decrease in the size of the pituitary mass Scheduled to go to Boston this September to
seek further treatment at Massachusetts General Hospital with pituitary expert, Dr. Anne Klibanski
![Page 54: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/54.jpg)
Summary
Pituitary tumors develop when specific types of pituitary cells proliferate and oversecrete their respective hormones.
Gigantism/ Acromegaly is a rare disorder characterized by GH hypersecretion and elevated IGF-1 levels
Almost all cases (98%), of acromegaly are caused by a somatotrope adenoma
Early diagnosis and treatment is important to prevent long term complications and mortality.
Controlling levels of GH in patients with acromegaly improves survival
![Page 55: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/55.jpg)
Thank you
and
Good Day! :)
![Page 56: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/56.jpg)
Genetically Predetermined Height
Calculate Final Height prediction (mid-parental height)› Girl
In: (Father's Ht. - 5 + Mother's Ht.) / 2 Cm: (Father's Ht. - 13 + Mother's Ht.) / 2
> F.O. In: (64- 5 + (63) = 122 /2= 61 = 5’1”
Cm:(162.54-13 +(160))= 309.54 /2 = 154.77cm
![Page 57: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/57.jpg)
1st TSS 12/2/09 12/3/09am
12/3/09 night
12/4/09 12/5/09 12/6/09 12/7/09
2nd HD 3rd HD 3rd HD 4th HD 5th HD 6th HD 7th HD
RBS 108.24 160.98 229.15 111.68 139.19 106.9
OsmolalityBlood (275-295)
296.0 309 308 302.0 302 303 297
OsmolalityUrine (250-900)
1,036 75
Na (136-145) 138 143 144 144 143 142 145BUN 11.8 10.01 8.02 7.71 5.41Calculated Osmolality
286 299 304 297 296
24 hr Intake 2580 11742 11742 5731 4520 6072 3600
24 hr Output 3350 9640 9640 8395 6990+ 1x
7195 4400
![Page 58: HONEY, I BLEW UP THE KID! A SUPER Sized Medical Grand Rounds](https://reader037.fdocuments.net/reader037/viewer/2022102719/5681443d550346895db0d726/html5/thumbnails/58.jpg)
TRANSSPHENOIDAL PITUITARY SURGERY: PRIMARY INDICATIONS
1. Intolerance to medical therapy
5. Resistance at medical therapy
2. Pituitary hemorrhage
6. Visual tract or CNS compression
3. Relief of compressive hypopituitarism
7. Tumor recurrence after surgery or radiation
4 .Personal choice 8. Desire for immediate pregnancy with macroadenoma