THESIS PROTOCOL SUBMISISON FORM

A. GENERAL INFORMATION

1. Name (in full) :NATARAJ YALIGAR .P

2. Father’s/Husband’s Name :PANCHAXARI

3. Correspondence Address :

4. Permanent Address:

S/O P.S. YALIGAR

YALIGAR ONI .SHIGGAON -581205. Dist- HAVERI

………………………………………………………………………………………………………………

Telephone No…………………………………………..Mobile -9611720414

………………………………………………..

E-mail- natarajyaligar@gmail.com

DNB TRAINING DETAILS

5. Registration Details

a) Reg.No. AWAITED

b) Date of Registration AWAITED

c) Scheduled Date of Completion of DNB training-16-03-2019

1

Subject--- GENERAL MEDICINE

Institute/ University- CSI HOLDSWORTH MEMORIAL HOSPITAL .MYSORE

State- KARNATAKA

Period of Training-3 YEARS

d) Information about Thesis Protocol

Title -LONG TERM EFFECT OF DISSEMINATED INTRAVASCULAR

COAGULATION ON PITUITARY FUNCTIONS- A PROSPECTIVE STUDY

Area of Specialty- GENERAL MEDICINE

(Medicine, surgery

etc)

Thesis Guide - DR MOHAN KUMAR G MBBS, IDCCM,EDIC

Place of practice- MYSORE

Co-guides- DR MOHIYUDDIN MBBS MD

2

LONG TERM EFFECT OF DISSEMINATED INTRAVASCULAR COAGULATION ON PITUITARY FUNCTIONS - A PROSPECTIVE STUDY

Introduction/Background

Hypopituitarism is defined as deficiency of one or more hormones of the pituitary gland which can result from diseases of the pituitary gland or from diseases of the hypothalamus causing diminished secretion of hypothalamic releasing hormones, thereby reducing secretion of the corresponding pituitary hormones. When one hormone is deficient, it is usually called isolated deficiency, e.g. Isolated GH deficiency or isolated ACTH deficiency. Deficiency of a single pituitary hormone occurs less commonly than deficiency of more than one hormone. The deficiency of all anterior pituitary hormones is termed panhypopituitarism, and deficiency of one or more pituitary hormones called as partial hypopituitarism. The hypothalamus regulates pituitary secretion by the production of releasing hormones and posterior pituitary hormones, and hence its dysfunction can also lead to hypopituitarism1.

Clinical manifestations depend on the extent of hormone deficiency and may be non-specific and thus the diagnosis is often missed. The progressive loss of pituitary hormone secretion is usually a slow process, which can occur over a period of months or years. Generally, growth hormone (GH) is lost first, and then luteinizing hormone (LH) deficiency follows. The loss of follicle-stimulating hormone (FSH), thyroid stimulating hormone (TSH), adrenocorticotropin (ACTH) hormones and prolactin typically follow much later1.

Estimated total prevalence of pituitary disorder in India was about 4 million in the year 2000 2

;but the actual prevalence is likely to much higher because of poor recognition of clinical signs and symptoms1.

The etiology of hypopituitarism is different in tropical countries as compared to the West. Awareness of the various etiologies of pituitary dysfunction, as well as recognition of their subtle clinical features, is necessary for optimal management of the patient3.

Etiology of hypopituitarism in India results from numerous causes, ranging from pituitary tumours, Sheehan’s syndrome, familial hypopituitarism, idiopathic hypopituitarism, hypophysitis, empty sella syndrome, snake bite, viral hemorrhagic fever to mechanical ventilation4.

Some of the above mentioned etiologies of hypopituitarism like snake bite, sheehan’s syndrome ,virla haemorrhagic fever are directly or indirectly related to disseminated intravascular coagulation (DIC). DIC manifest as spectrum from mild thrombocytopenia to multiple organ failure and death.

A widely accepted definition put forward by the subcommittee on DIC on the scientific and standardization committee of the international society on thrombosis and hemostasis (ISTH) is as follows: DIC is an acquired syndrome characterized by the intravascular activation of coagulation pathway with a loss of localization arising from different causes. It can originate

3

from and cause damage to the microvasculature, which if sufficiently severe, can produce organ dysfunction. However, DIC should not be considered as a distinct disease entity but rather a sign of another disease. It has been associated with almost all life threatening diseases5.

It has been clearly established that sepsis is associated with neuroendocrine disorder affecting all axes. During the acute stage of sepsis, the secretions of hypophyseal hormones are increased and the expression of their peripheral receptors is down regulated. Prolonged sepsis is characterize by a decreased in pituitary hormone release, but residual pituitary dysfunction following sepsis is not extensively studied6.

Prevalence of Sheehan’s syndrome in India is 2.7%-3.9% among parous women older than 20 years. This is in sharp contrast to the prevalence studies from developed countries where it is 0.005%. The poor obstetrical care and poor access to health care are the underlying cause of Sheehan’s syndrome in India7.

Snake bite is one of the most neglected public health issues in poor rural communities living in the tropics. Because of serious misreporting, the true worldwide burden of snake bite is not known. An accurate measure of the global burden of snakebite envenoming remains elusive despite several attempts to estimate it and, apart from a few countries, reliable figures on incidence, morbidity, and mortality are scarce. South Asia is by far the most affected region. India has the highest number of deaths due to snake bites in the world with 35,000–50,000 people dying per year according to World Health Organization (WHO) direst estimates. However, existing epidemiological data remain fragmented and the true impact of snake bites is very likely to be underestimated8.

Chronic ill-health in those who apparently recover from Snake bite, obstetrical syndromes and sepsis should always raise the possibility of panhypopituitarism. Our study focused on prospective evaluation of pituitary dysfunction following above mentioned disease conditions.

Review of Literature

Anatomy and its importance in pituitary disorderThe pituitary gland weighs less than 10g and is roughly 10mm in length. The gland is located in the sella turcica and hypophyseal fossa at the skull base. The optic chiasma is anterosuperior to the pituitary gland and lateral to the cavernous sinuses surrounding the gland, inferiorly, the venous structures are located between the sphenoid fossa and pituitary gland.

The pituitary gland is connected to the hypothalamus by pituitary stalk, the infundibulum. The pituitary gland can be divided into two anatomical and functionally different parts, both of which are of ectoderm origin; the anterior pituitary gland (adenohypophysis) and the posterior pituitary gland (neurohypophysis). The anterior pituitary gland comprises approximately 75% of the total weight of the pituitary gland and consists of pars anterior, pars intermedia, and the pars tuberalis.

4

The anterior portion contains different cell types: somatotrophs, thyrotrophs, gonadotrophs, lactotrophs and corticotrophs. Blood is supplied to the anterior pituitary gland by a complex portal system. Hypophyseal arteries originate from the internal carotid artery and posterior communicating artery from the primary plexus of the hypophyseal portal system. This primary portal plexus is connected by hypophyseal portal veins to a secondary portal plexus at the adenohypophysis and drains into anterior hypophyseal veins.

The anterior lobe of the pituitary gland receives only 10-20% of its blood supply from superior and inferior hypophyseal arteries while the remaining 80-90% is provided by hypophyseal venous portal circulation. Because of the complex anatomical location of the pituitary and the portal vessels, the pituitary gland is thought to be especially vulnerable to trauma and other acute intracranial pathology9.

Posterior pituitary is neural tissue and consists only of distal axons of the hypothalamic magnocellular neurons that make up the neurohypophysis. The cell bodies of thee axons are located in the paired paraventricular nuclei (PVN) and supraoptic nuclei(SON) of the hypothalamus. The blood supply for the posterior pituitary directly from the inferior hypohyseal arteries, which are branches of the posterior communicating and internal carotid arteries. the hormones of posterior pituitary , oxytocin and vasopressin , are for the most part synthesized in individual hormone s[pecific magnocellular neurons.

Science direct posterior pituitary alan G , ROBINSON ,JOSEPH G ,VERBALIS. WILLIAMS TEXT BOOK OF ENDOCRINOLOGY ,2016

5

6

CAUSES OF HYPOPTUITARISM

7

Clinical features

The underlying pathology, speed of onset and the severity of hypopituitarism have significant impact on the clinical features. In particular, if hyopopituitarism is caused by space -occupying lesions, apoplexy or hypophysectomy then clinical expression typically occurs immediately or may be evident within few hours or after several days. However , most patients exhibit a slow and progressive loss of pituitary function with relatively mild and vague or nonspecific clinical symptoms . in fact ,in many cases , these patients are not diagnosed with hypopituitarism for prolonged time.

Following table shows pituitary hormones and its deficiency manifestations.

8

DIC

Definition and backgroundDisseminated intravascular coagulation (DIC) is a syndrome characterized by the systemic activation of blood coagulation, which generates intravascular thrombin and fibrin, resulting in the thrombosis of small- to medium-sized vessels and ultimately organ dysfunction and severe bleeding .DIC may result as a complication of infection, solid cancers, hematological malignancies, obstetric diseases, trauma, aneurysms, and liver diseases, etc., each of which presents characteristic features related to the underlying disorder10. 

A widely accepted definition put forward by the subcommittee on DIC on the scientific and standardization committee of the international society on thrombosis and hemostasis (ISTH) in 2001,is as follows: DIC is an acquired syndrome characterized by the intravascular activation of coagulation pathway with a loss of localization arising from different causes. It can originate from and cause damage to the microvasculature, which if sufficiently severe, can produce organ dysfunction. However, DIC should not be considered as a distinct disease entity but rather a sign of another disease. It has been associated with almost all life threatening diseases05.

In the older literature, DIC was also known as defibrination syndrome, acquired afibrinogenemia, consumptive coagulopathy, and thrombohemorrhagic disorder.1

Maladies resulting in both thrombosis and hemorrhage have been recognized for centuries, the foremost of which were the “black plague” of the Middle Ages with symptoms of gangrene of the fingers as well as generalized hemorrhage in organs. It remains controversial as to whether the cause of this plague was from Yersinia pestis, spread by the bites of the rat flea, or from an Ebola-like hemorrhagic virus.8

DIC was first experimentally induced by M. Dupuy in 1834 when he intravenously injected brain tissue into animals, resulting in clots seen throughout the vasculature. In 1873, B. Naunyn intravenously injected dissolved RBCs and observed disseminated thrombosis. A. Trousseau in 1865 described in patients with advanced malignancy, the multiple thromboses, and tendency of blood to clot. In 1961, Lasch et al introduced the concept of consumption coagulopathy as the mechanism leading to hemorrhage in DIC.1

DIC is relatively uncommon in the general hospitalized patient but accounts for 9% to 19% of ICU admissions and has a high mortality rate of 45% to 78%.9

9

Pathophysiology

DIC is a consumption coagulopathy state where excess thrombin is generated to such a high degree that it overcomes the large amounts of natural anticoagulants normally present in the plasma.10 Acute DIC is usually triggered by large amounts of tissue factor released into the intravascular space, leading to generalized deposition of fibrin thrombi in the microvasculature contributing to multiorgan dysfunction.10,11 MODS most frequently involves the lungs and kidneys followed by brain, heart, liver, spleen, adrenals, pancreas, and the gastrointestinal (GI) tract.10

Thrombin has the following general procoagulant actions12 (see Figure 1):

1. Converts fibrinogen to fibrin2. Activates factors V, VIII, and XI to stimulate further thrombin formation3. Activates factor XIII to stimulate fibrin cross-linking4. Causes platelet aggregation, which induces the coagulation cascade system to

generate even more thrombin

These actions of thrombin cause more activation of coagulation factors, resulting in the production of more thrombin and therefore more fibrin clot. This ultimately leads to fibrinolysis, in which fibrin thrombi are broken down by plasmin with the subsequent release of fibrin degradation products (FDPs). When intravascular, these FDPs can inhibit fibrin polymerization as well as platelet aggregation by interfering with the GPIIbIIIa fibrinogen receptor.7These FDPs, in concert with the consumption of platelets, fibrinogen, and coagulation factors, contribute to the most common symptom seen in acute DIC: bleeding.

Other thrombin-induced situations enhance clot formation activities in DIC. Thrombin proteolytically cleaves a class of extracellular G-protein-coupled receptors on the platelet called protease-activated receptors (PARS), which then converts the stimulus into intracellular signaling events that include release of interleukins (ILs): IL-1 and IL-6. This leads to proinflammatory activity with an increase in platelet activation and leukocyte adhesion.13 Thrombin causes release of PAI-1 from endothelial cells and activates thrombin-activatable fibrinolysis inhibitor (TAFI) in the plasma, both of which impair plasminogen activation, thereby reducing clot dissolution from plasmin. In addition, DIC causes the consumption of AT and the downregulation of the PrC system, diminishing the ability of the body to turn thrombin off. AT production can be diminished as a consequence of hepatic MODS and can be degraded by enzymes released from neutrophils. TFPI may also be reduced in DIC.

10

Shock often occurs in DIC and can lead to impaired clearance of tissue factor, activated coagulation factors, and FDP by the reticuloendothelial system macrophages of the spleen and liver, thereby perpetuating the DIC.7 Shock could be caused by the excessive stimulation of the contact system (factor XII, HMWK, and PK), resulting in large amounts of bradykinin production, which cannot be inhibited by the presence of normal concentrations of angiotensin-converting enzyme. Shock is probably responsible for the hyperfibrinolysis syndrome by endothelial cell release of TPA from and the amplification of the PrC system when there is hypoperfusion of endothelial cells.

Laboratory features

Acute DIC results in rapid consumption of platelets and coagulation factors so that at the time of diagnosis, the platelet count may be less than 50,000/μL (10%-15% of cases), the PT and aPTT may be extremely prolonged, and the D-dimers are high.10,15 However, it is important to keep in mind that the aPTT and, less often, the PT may be minimally prolonged. The platelet-poor plasma tests, PT and aPTT, both reflect the level of factors in the common pathway of coagulation: factors X, V, and II (prothrombin) and fibrinogen (see Figure 1). This is the pathway “common” to both the extrinsic and intrinsic systems that result in the activation of thrombin and conversion of fibrinogen to fibrin. In addition, the PT reflects the level of factor VII in

11

the extrinsic pathway. In this pathway, factor VII is activated by tissue factor, which then proceeds through the common pathway, leading to activation of thrombin and fibrin clot formation. In addition, the aPTT measures the intrinsic pathway, which includes factors XII, XI, IX, and VIII. In this pathway, factor XII is activated by collagen or polyphosphate, which eventually leads to the activation of the common pathway and fibrin clot formation. The PT and aPTT are both prolonged in DIC because they contain coagulation factors that have been consumed: factor V, factor VIII, and fibrinogen.

D-dimers are a specific type of fibrin degradation product consisting of polymerized fibrin monomers that have been cross-linked by activated factor XIII and subsequently cleaved by plasmin.15 Hence, D-dimers are only produced when three enzymes are functioning: thrombin, factor XIIIa, and plasmin. D-dimers are therefore created after intravascular coagulation and clot formation have recently occurred. D-dimers are increased in a number of conditions in which clot formation occurs, including arterial or venous thrombosis, preeclampsia, eclampsia, and DIC. However, D-dimers may also be produced during extravascular coagulation and clot formation and are commonly elevated in hospitalized patients without overt intravascular thrombosis. Such scenarios include trauma, surgery, healing, and inflammation. Elevated levels of D-dimers may also be seen in severe liver disease due to decreased clearance of the D-dimers. The absence of D-dimers is especially useful as a negative predictive tool to exclude a diagnosis of DIC. Elevated levels are useful in helping confirm an already suspected diagnosis of DIC.

Manifestation of DIC.

Acute DIC is initially a hypercoagulable state where fibrin thrombi are formed in arterioles and capillaries, often resulting in ischemia and multiorgan failure. As RBCs are pushed through these compromised tiny vessels in the microvasculature, they become fragmented to form schistocytes (broken RBCs; Image 1), resulting in microangiopathic hemolytic anemia (MAHA). Acute DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyte formation. The free hemoglobin released in this hemolytic process enhances the hypercoagulable state by combining with nitric oxide (endothelial relaxing factor). The removal of intravascular nitric oxide by free hemoglobin can cause vasospasm and platelet activation. Other abnormal tests in acute DIC are related to hemolysis and include increased serum LDH and hyperbilirubinemia.

12

Causes of DIC.

Diagnostic criteria for DIC(ISTH)

13

Snake bite

Snake bite is an important occupational and rural hazard in developing countries in the tropical region.(1)It is one of the most neglected public health issues in Asia. There has been significant underreporting of the snake bite cases and the mortality associated with it. Hence the world wide burden of snake bite is not known.(2) There is significant morbidity, mortality and economic burden associated with snake bite

Epidemiology of snake bite

The global snake bite initiative has reported that approximately 4,21,000 envenomations and 20,000 deaths occur every year due to snake bites. The actual figures may be as high as 18,41,000 envenomations and 94,000 deaths. (3)

In the rural India, only 7.23% of the snake bite deaths were officially reported. There is wide geographical variation in proportion seeking medical care ranging between 22-75%. The highest burden of snake bites occurs in the tropical countries of the South Asia, South East Asia

14

and Sub Saharan Africa. The large population in rural areas who work outdoors are more prone to snake bites. Men are twice as prone to snake bite as women and the age group commonly affected is between 15-45 years. Agricultural labourers and construction workers are prone to snake bite. Snake bite is a seasonal disease increasing in prevalence during the rainy season between June to September in India.(1)

SNAKE BITE AND PITUITARY DYSFUNCTION

Snake bite has been known to cause pituitary failure during the acute stage or after months to years. Russell's viper, Vipera russelli (Shaw), is a leading cause of fatal snake bite in Pakistan, India, Bangladesh, Sri Lanka, Burma, and Thailand4.

Hypopituitarism following Russell’s viper bite was first reported in 1976 by Eapen et al in 3 adults from Kerala, southern India11.

Earlier it was believed that snake bites led to haemorrhagic necrosis of the pituitary. But later studies have also favoured damage by intravascular coagulation which was further supported by fibrin deposition and micro-haemorrhages at autopsy12.

A systematic study of patients in Burma by Tun-Pe et al. has clearly demonstrated that Russell’s viper bite can lead to acute and chronic hypopituitarism4.

The pathophysiology as described in their study. Russell’s viper venom is known to contain many toxins, including several different biologically active pro coagulant enzymes activating factors V, X and other steps in the blood clotting cascade. This results in the formation of cross-linked fibrin in the blood stream, most of which is immediately broken down by the body’s own fibrinolytic system. Eventually, and occasionally within 30 min, the levels of clotting factors become so depleted by disseminated intravascular coagulation (DIC) that consumption coagulopathy develops. Russell’s viper venom also contains a metalloproteinase ‘haemorrhagin’ which damages vascular endothelium and toxins that impair platelet function. These venom-induced disturbances lead to the thromboses and spontaneous haemorrhages seen in victims of Russell’s viper bite envenoming. Focal haemorrhage and micro vascular thrombin deposition in the pituitary may be responsible for the pathological finding of haemorrhagic infarction of the anterior pituitary and functional consequences of acute and chronic pan-hypopituitarism 3. Than-Than et al. have reported autopsy findings in the pituitaries of three patients who died following Russell’s viper bite envenoming in Burma. They noticed focal haemorrhages and small fibrin thrombi. They also showed micro-thrombi and histological evidence suggestive of acute tubular necrosis in the kidneys. This suggests that DIC plays a part in acute renal injury in these patients along with other causes of pre-renal renal failure such as shock. Than-Than et al. have also reported adrenal haemorrhage but this is less common than pituitary haemorrhage 13.

Unlike Russell’s viper, venoms of other snakes can produce similar intravascular coagulation but not pituitary damage 5.The mechanism by which haemorrhagic necrosis of the pituitary takes place in snake envenomation differs from that seen in postpartum pituitary necrosis. Heat and

15

trypsin stable components of the viper venom release GH, ACTH and TSH from cultured rat pituitary cells which could not be suppressed by somatostatin, indicating tachyphylaxis.

In

Sheehan’s syndrome, pituitary necrosis results

since the enlarged pituitary is more susceptible

to ischaemia either by hypovolemic shock

or haemorrhage. On the contrary, excessive

pituitary stimulation by certain toxins in the

venom makes the pituitary more vulnerable to

destruction. In postpartum necrosis there is an

enlarged pituitary with intrapitutary haemorrhage

due to ischaemia, whereas in the case of

snake bite, there is haemorrhage into a normal

sized pituitary because of hyperstimulation by

certain components of the venom 5. Most of the

patients surviving Russell’s viper bite present

months to years later with signs of panhypopituitarism.

A mild form of the disease may

remain undetected and many do not receive

treatment for many years. A study by Proby

et Al disclosed deficits in pituitary hormone secretion

in 11 out of 12 survivors of Russell’s viper

16

bite 6,9. An empty sella was the finding on

MRI with notable suppression of anterior and

posterior pituitary hormones biochemically 7.

Thus Russell’s viper envenoming may produce

a disorder resembling Sheehan’s syndrome 8.

Snake bite should be considered in the differential

diagnosis of the causes of hypopituitarism

and a history of snake bite should be

elicited from patients especially those living in

rural areas.

Conclusion

Pituitary necrosis after snake bite is a relative

rare entity confined to certain regions of

the world . Diagnosis of hypopituitarism can

be confirmed by biochemical findings but imaging

of the pituitary has seldom been done in

such cases. We described a case of pituitary

insufficiency caused by envenomation of Russell’s

viper, with empty sella on MRI imaging

supported with biochemical studies. Early diagnosis

and appropriate treatment are important

to reduce the morbidity and mortality of

the patients with hypopituitarism.

17

DIC in obstetrical Syndrome andThe complications of pregnancy that have associated with DIC include : 1) acute peripartum hemorrhage ;2) placental abruption ; 3) pre-eclampsia/eclampsia and HELLP syndrome;4) retained stillbirth; 5) septic abortion and intrauterine infection; 6) amniotic fluid embolism;

Some authors compare the pituitary lesion in survivors snake bites to classical Sheehan’s syndrome13, 14

Sheehan's syndrome (SS), which was first described by HL Sheehan, classically refers to postpartum hypopituitarism due to pituitary occurring during severe hypotension or shock secondary to massive bleeding at or just after the delivery.1 But, before Sheehan, Glinski and Simmonds had already published autopsy of patients who had died after severe postpartum bleeding. It was named as Simmonds disease until 1939 when Sheehan stated that Simmonds disease was due to necrosis of the anterior pituitary following postpartum haemorrhage.1 Thus, the condition was named after Sheehan.

The pituitary is one of the highly vascularized tissues in the body. Its volume increases two-folds during pregnancy; mostly due to the massive hyperplasia of lactotrophs as a result of elevated estrogensecretion. Enlarged pituitary gland is vulnerable to ischemia and does not have the ability to regenerate. Scar tissue substitutes the necrotic cells. The presence of 50% of pituitary gland is sufficient for the maintenance of normal functions. Partial or total hypopituitarism develops with necrosis of 70% - 90% of the gland. Growth hormone (GH) and prolactin (PRL) involvement is seen in 90%-100% of the patients; whereas, involvement of gonadotrophs, thyrotrophs and corticotrophs may be seen in 50%-100% of the patients. GH deficiency is very common in Sheehan’s Syndrome as somatotrophs, located in the lower and lateral regions of the pituitary, are most likely to be damaged by ischemic necrosis of pituitary7.

Sheehan, in his original article entitled ‘post-partum necrosis of the anterior pituitary’ published in 1937, had studied the macroscopic and microscopic appearances of the pituitary glands of 59 women who died during the puerperium. There were changes in the pituitary in 12 of them. Eleven women had died soon after delivery. Nine had postpartum haemorrhage(PPH), with retained placenta in five, and two had bronchopneumonia. All 11 showed coagulative- necrosis of the anterior pituitary. This affected the antero-inferior part of the anterior lobe of the pituitary in the mid line and spread out to involve most of the rest of the lobe. The part that usually escaped was the postero-superior angle beneath and in front of the stalk and a very thin layer on the surface. Histologically, there was fibrin meshwork laid down along the walls of the sinuses interpreted by the author as in situ thrombosis. The 12th woman survived an episode of PPH and developed symptoms suggestive of hypopituitarism but died 18 months later following delivery at her subsequent pregnancy. Sheehan’s conclusion was that thrombosis had occurred soon after delivery during the women’s collapse usually following severe haemorrhage and often as a result of retained placenta. If the patients survived this episode, the lesion healed to a mass of condensed stroma. He did not describe any haemorrhage in the pituitary15.

18

Pathophysiology of sheehan’s syndrome.

19

DIC in SepsisInfectious disease is the most common clinical condition associated with DIC .It is mediated by several pro- inflammatory cytokines results in dysregulation of the physiologic anticoagulation pathway and fibrinolytic defect. The effect of above process causes microcirculation failure culminating in DIC and multi organ failure10.

Patients with DIC may present with manifest thrombo-embolic disease or with clinically less apparent microvascular thrombosis, which predominantly exhibits as multiple organ dysfunction. The systemic microthrombo-emboli will affect pituitary cause an acute dysfunction which is well known and well reported2, but long term effects on pituitary need to be studied.

Assessment of sepsis severity.

Sequential Organ Failure Assessment

The SOFA was developed in 1994 during a consensus conference. Six organ systems (respiratory, cardiovascular, renal, hepatic, central nervous, coagulation) were selected based on a review of the literature, and the function of each is scored from 0 (normal function) to 4 (most abnormal), giving a possible score of 0 to 24. For the SOFA score, the worst value on each day is recorded. The SOFA score uses a treatment-related variable (dose of vasopressor agents). This is not ideal, as treatment protocols vary among institutions, among patients and over time, but it is difficult to avoid, especially for the cardiovascular system20.

The SOFA was initially validated in a mixed, medical-surgical ICU population and has since been validated and applied in various patient groups. In a prospective analysis of 1,449 patients, a maximum total SOFA score greater than 15 correlated with a mortality rate of 90%. Changes in SOFA score over time are also useful in predicting outcome. In a prospective study of 352 ICU patients, an increase in SOFA score during the first 48 hours in the ICU, independent of the initial score, predicted a mortality rate of at least 50%, while a decrease was associated with an ICU mortality rate of just 27%21 . In a prospective observational study of 1,340 patients with multiple organ dysfunction syndrome, Cabrè and colleagues reported 100% mortality for patients with age over 60 years, a total maximum SOFA greater than 13 on any of the first 5 days of ICU admission, minimum SOFA greater than 10 at all times, and a positive or unchanged SOFA trend over the first 5 days of ICU admission22.

20

Assessment of pituitary function.The evaluation of pituitary function is often based on clinical assessment, amalgamated with relevant laboratory and radiologic investigations. Testing should assess the target organ and radiologic investigations.

Basal pituitary blood tests are usually the first line investigations. They should be taken with the patient resting, because of circadian variation, these investigations ideally performed between 7 a.m and 9 a.m.

Labarotary testing for basal hormones.

1.Adrenocortical axis: serum cortisol

2. Thyroid axis : TSH and free T4 levels.

3. Gonadal axis : men- testosterone ,SHBG, LH, FSH.

Women- oestradiol, LH, FSH, progesterone(day21 if menstruating)

4. Prolactin.

5.Insulin like growth factors-1.

6.Paired plasma and urine osmolality.

In many circumstances, dynamic testing is necessary to diagnose (or equally to exclude) underlying pituitary hypo function. As a general rule, if the diagnostic suspicion is of underlying hormone insufficiency, then the tests will aim to stimulate production of the particular hormone, and for hormone excess, to inhibit their secretion23.

Brar et al. have done pituitary hormone evaluation according to availability of facilities and in step wise manner. Initially screened for free FT4,TSH, basal cortisol and prolactin levels and if they are deranged confirmed the diagnosis of hypopituitarism or if the above tests values normal and clinical suspicion is high, then blood sample should be sent for post-ACTH cortisol , LH, FSH, estradiol (women) and testosterone (males). If these hormonal levels are abnormal confirms the diagnosis1.

In our study ,we assessed for serum cortisol,FSH,LH,FT4 and TSH.

21

No Test Sample/method Normal range

1 Serum cortisol Serum/CLIA 8am 3.7-19.4ug/dl

2 TSH Serum/CLIA 0.35-5.5Miu/ml

3 FT4 Serum/CLIA 0.89-1.78ng/dl

4 FSH Serum/CLIA Male 1.4-18.1miu/ml

Postmenopausal 23-116.3

Follicular phase 2.5-10.2

Luteal phase1.5-9.1

Midcycle peak3.4-33.4

5 LH Serum/CLIA Male Adult-0.7-7.4,pre puberty 0.0—6.0miu/ml

Female pre puberty 0.0-15.0

Postmenopausal 23-116.3

Follicular phase 2.5-10.2

Luteal phase1.5-9.1

Ovulatory peak3.4-33.4

Lacunae in the literature- Patients with sepsis may present with manifest thrombo-embolic disease or with clinically less apparent micro-vascular thrombosis, which predominantly exhibits as multiple organ dysfunction. But long term outcomes from sepsis are poorly understood, and sepsis in patients may have different long term effects on mortality and quality of life. The systemic micro thromboemboli will affect the pituitary gland and causes acute dysfunction which is well studied and reported. So far, a long term effect of sepsis on pituitary function is not extensively studied.

22

Another common cause of pituitary dysfunction in the developing countries is Sheehans syndrome. There are only few case series have been reported in India, no prospective studies have been done7.

It has been estimated that 2, 00,000 people bitten by venomous snake bites in India every year. But we came across only few case studies on hypopituitarism following snake bite8.

There are no specific guidelines for screening for hypopituitarism following snake bite and sepsis.

23

Research question

Does DIC damage pituitary gland to cause residual dysfunction?

Aims and objectives

Aims:

- To study the effect of Disseminated Intravascular Coagulation on the pituitary functions six months after their recovery from the critical illness.

- To recommend pituitary function tests in patients who have recovered from DIC/ multiorgan dysfunction.

Objectives:

- Identify critically ill patients who have disseminated intravascular coagulation and select patients with snake bite, obstetric complications and septic patients for follow-up.

- Evaluate the functions of the anterior pituitary gland in those patients who have recovered from the critical illness with DIC after a period of six months.

MATERIAL AND METHODS

1] Study site

The study will be carried out on patients admitted in ICU under Department of Medicine at CSI HMH KARNATAKA between 6/2016 to 12/2017.

2] Study population The patients admitted to the ICU of CSI Holds worth Memorial Hospital, Mysore , in defined study period with history of snake bite, obstetrical complications and sepsis.

3] Study Design – A prospective study, observational study.

4] Sample Size with justification.

The main objective of the present study is to study the effect of DIC on Pituitary function, hence

by taking percentage of patients who have Lactational Failure among Sheehans Syndrome was

24

76%. (Ref: Sunil et al, “Sheehan's syndrome: a single centre experience” J ClinSci Res

2013;2:16-21)and by taking 12% absolute precision, with 95% Confidence limits, sample size

was calculated using the formula

Sample Size = Z 2 *p*q

L2

Z is the Standard NormalVariate for 95% of Confidence Interval.

p = 76%

q = 100-p = 24%

     

L= absolute Precision or Maximum Allowable Error = 12%

   

Accordingly, sample size calculated was 48.64. Hence 50cases will be taken for the study.

5] Time frame to the address the study–from to 6/2016 to 12/2017

6] Inclusion and Exclusion criteria

Inclusion criteria –

• Patients age -Adults (18 -65 years)

• Gender- Male and female

• Patients with prolonged PT ( >4 seconds) and low platelets

25

(<150000) with underlying snake bite/ peripartum state/ sepsis and recovered.

Exclusion criteria –

• Patients with known pituitary dysfunction/ disease/ tumour.

• Patients receiving treatment for or treated for hypopituitarism.

• Patients on hormone replacement therapy.

• Patients with traumatic brain injury.

7] Methodology

Patient admitted to ICU in defined study duration with history of snake bite, sepsis, obstetrical syndromes will be considered for the study and evaluated in 2 steps.

A] at admission.

B]after 6 months.

A] at admission – Each patient will be evaluated with complete clinical examination and laboratory investigations(proforma A). Later patients will be selected according to inclusion and exclusion criteria, and are considered for the follow up after 6 months.

B]after 6 months- each patients will be followed up and evaluated clinically with symptoms and signs of hypopituitarism. Hormonal evaluation done for all patients .We considered only few pituitary hormones because of limited resources and complexity. Next step will be dynamic tests for hormone deficiency, these test are considered only if base line hormone levels are abnormal. Analysis of our study yield effect of Disseminated Intravascular Coagulation on the pituitary functions six months after their recovery from the critical illness, it helps clinicians to recommend pituitary function tests in patients who have recovered from DIC/ multiorgan dysfunction.

Patients who found to have hypopituitarism will be referred to physician for appropriate intervention.

8)Statistical methods

Collected data will be entered into Microsoft excel and will be analysed using SPSS Version 23.0. Continuous variables will be reported using mean and standard deviation or median and inter-quartile range as appropriate. Categorical variables will be reported using frequency and percentage. Normality of data will be checked by using Shapiro-wilk test. Continuous variables,

26

Having more than 2 categories, which are normally distributed will be compared between groups using One way ANOVA. Otherwise Kruskal Wallis test will be used for comparison. Continuous variables having 2 categories will be analysed using Unpaired ‘t’ test.The comparison of categorical variables between groups will be done using Chi square test or Fisher's Exact test as appropriate. All the analysis will be considered statistically significant at 5% level (p value <0.05). Bar charts and pie charts will be used for the graphical presentation of data.

27

STUDY PROFORMA(A)

DEMOGRAPHIC DATA

NAME IP NO-

AGE OP NO-

SEX

PRESENTING COMPLAINTS-

PAST HISTORY-

PERSONAL HISTORY-

FAMILY HISTORY-

GENERAL PHYSICAL EXAMINATION

Pulse rate-

Blood pressure- Weight

Respiratory rate- BMI-

Temperature-

Pallor icterus clubbing cyanosis lymphadenopathy Edema

SYSTEMIC EXAMINATION

28

Central nervous system

Cardiovascular system

Respiratory system

INVESTIGATIONS-

Hb%

Total counts

Platelet count

Liver Function tests

Coagulation profile

PT INR

aPTT

Renal function tests

Creatinine

Na+/K+/Cl

ECG

OTHER RELEVANT INVESTIGATIONS-

FOR SEPSIS PATIENTS

SOFA SCORE-

Variables 1 2 3 4

Neurological-

Coma score: Glasgow

13-14 10-12 6-9 <6

Pulmonary-

PaO2(mmHg)/Fio2

<400 <300 <200

With respiratory

<100

With respiratory

29

support support

Cardiovascular-

Mean blood pressure/ systemic blood pressure(mmHg)

<70 Dopamine<5

Or

Dobutamine

(whatever dose)

Dopamine>5

Or

Adrenaline<0.1

Or

Noradrenalin<0.1

Dopamine>15

Or

Adrenaline>0.1

Or

Noradrenalin>0.1

Renal

Blood creatinine(mg/dl)

Or dieresis ml/day.

1.2-1.9 2.0-3.4 3.5-4.9 >5

Haematological

Platelets per cubic mm.

<150 <100 <50 <20

Serum bilirubin(mg/dl)

1.2-1.9 2.0-5.9 6.0-11.9 >12

TOTAL SCORE-

score 0-6 7-9 10-12 13-14 15 15-24

percentage <10 15-20 15-20 50-60 >80 >90

*Respiratory support is defined as any form of invasive or noninvasive ventilation including mask CPAP or CPAP delivered through a tracheostomy/tracheotomy or endotracheal tube.

30

PROFORMA(B)

NAME IP NO-

AGE OP NO-

SEX

Clinical evaluation

Hormone Deficiency Symptoms and Signs Yes No

Growth Hormone Baldness (in men)Decrease in sexual function and interestDecreased muscle mass and strengthDifficult to concentration and lack of memoryDry, thin skinFatigue and/or tirednessLower tolerance to exerciseSensitivity to heat and coldVery low energy levelsWeight gain, especially around the waist

Gonadotropins In men –

Poor libido/Impotence

Infertility

Small soft testis

Reduced facial/body hair

In women-

Amenorrhoea/Oligomenorrhea dyspareunia

Infertility

Breast atrophy

31

Thyroid- stimulating hormone

Weight gain

Constipation

Sensitivity to cold

Dry skin

Adrenocorticotropic hormone

Weakness

Tiredness

Dizziness on standing

Pallor

Hypoglycemia

Prolactin Failure of lactation

Anti-diuretic hormone Polyuria

Polydipsia

Nocturia

Hypotension

HORMONE EVALUATION Test results Normal range

BASELINE INVESTIGATION-

TSH 0.3 - 5.0 U/mL

FT4 0.8 -2.8 ng/dL

SERUM CORTISOL 10 to 20 (ug/dl)

If the above tests are normal and clinical suspicion is high, then blood sample will be sent for dynamic tests like post-ACTH cortisol, estradiol(women) and testosterone (males). To confirm diagnosis.

32

REFERENCES-

33

1. Brar KS, Garg MK, Suryanarayana KM. Adult hypopituitarism: Are we missing or is it clinical lethargy?. Indian Journal of Endocrinology and Metabolism. 2011;15(3):170-174.

2. Gundgurthi A, Garg MK, Bhardwaj R, Brar KS, Kharb S, Pandit A. Clinical spectrum of hypopituitarism in India: A single center experience. Indian Journal of Endocrinology and Metabolism. 2012;16(5):803-808.

3.Kalra S, Dhanwal D, Khadilkar V. Hypopituitarism in the tropics. Indian Journal of Endocrinology and Metabolism. 2011;15(Suppl3):S151-S153. doi:10.4103/2230-8210.84845.

4. Tun-Pe, Phillips RE, Warrell DA, Moore RA, Tin-Nu-Swe, Myint-Lwin, et al. Acute and chronic pituitary failure resembling Sheehan's syndrome following bites by Russell's viper in Burma. Lancet. 1987;2:763–7.

5. Wada H, Matsumoto T, Yamashita Y. Diagnosis and treatment of disseminated intravascular coagulation (DIC) according to four DIC guidelines.Journal of Intensive Care. 2014;2(1):15.

6. Mazeraud A, Pascal Q, Verdonk F, Heming N, Chrétien F, Sharshar T. Neuroanatomy and Physiology of Brain Dysfunction in Sepsis. Clin Chest Med. 2016 Jun;37(2):333-45.

PMID:27229649 .DOI:10.1016/j.ccm.2016.01.013.

7. Sunil E, Rajita D, Rajagopal G, Satish P, Suresh V, Laksmi P et al. Sheehan's syndrome: a single centre experience. J Clin Sci Res 2013;2:16-21.6.

8. Alirol E, Sharma SK, Bawaskar HS, Kuch U, Chappuis F. Snake Bite in South Asia: A Review. de Silva J, ed. PLoS Neglected Tropical Diseases. 2010;4(1):e603.

9. Marko et al. High risk of hypopituitarism in patients who recovered from hemorrhagic fever with renal syndrome. J Clin Endocrinol Metab. July 2008, 93(7):2722–2728.

10. Venugopal A. Disseminated intravascular coagulation. Indian Journal of Anaesthesia. 2014; 58(5):603-608.

11.Eapen CK, Chandy N, Kochuovarkey KL. Unusual complication of snake bite: hypopituitarism after viper bites. Animal, plant and microbial toxins. New York, NY: Plenum Press 1976: 2:467-473.  

12. Antonypillai CN, Wass JA, Warrell DA, Rajaratnam HN. Hypopituitarism following envenoming by Russell's vipers (Daboia siamensis and D. russelii) resembling Sheehan's syndrome:First case report from Sri Lanka, a review of the literature and recommendations for endocrine management. QJM.2011;104:97–108. 

34

13. Than-Than, Francis N, Tin-Nu-Swe, Myint-Lwin, Tun-Pe, Soe-Soe, et al. Contribution of focal haemorrhage and microvascular fibrin deposition to fatal envenoming by Russell’s viper (Vipera russelli siamensis) in Burma. Acta Trop 1989; 46:23–38.

14.Proby C, Tha-Aung, Thet-Win Hla-Mon, Burrin JM, Joplin GF. Immediate and long-term effects on hormone levels following bites by the Burmese Russell’s Viper. Q J Med 1990; 75:399–411

15. Sheehan HL. Post-partum necrosis of the anterior pituitary. J Pathol Bacteriol 1937; 45:189–214.

16. Kovacs K. Sheehan syndrome. Lancet 2003; 361:520–2.

17. Tollin SR, Seely EW. Postpartum hypopituitarism in a patient with sickle cell trait. Am J Med Sci. 1994;308:35–37. 

18 Yamauchi T, Yoshio N, Mizuguchi T, Negoro E, Kamitani N, Ueda T. Acute fatty liver of pregnancy complicated with anterior pituitary insufficiency. Intern Med .2001; 40: 1227–31.

19 .Piech JJ, Thieblot P, Haberer JP, Delatour M, Moinade S, Gaillard G. Twin pregnancy with acute hepatic steatosis followed by antehypophyseal insufficiency and diabetes insipidus . Presse Med. 1985;14:1421–1423.

20. Vincent JL, Moreno R. Clinical review: scoring systems in the critically ill.Crit. Care. 2010;14(2):207.

21.Ferreira FL,Bota DP,Bross A,Melot C,Vincent JL. Serial evaluation of the SOFA score to predict outcome in critically ill patients.JAMA.2001;286-1754-8.

22. Cabré, L,Mancebo J,Solsona, J.F. et al. Multicenter study of the multiple organ dysfunction syndrome in intensive care units: the usefulness of Sequential Organ Failure Assessment scores in decision making.Intensive Care Med.2005;31:927-33.

23. Eric Fliers, Marta Korbonits, Johannes A. Romijn. Handbook of Clinical Neurology. Volume 124. Bethesda: Elsevier;2014.2-432.

35

INFORMED CONSENT FORM Subject identification number for this trial __________________________________  Title of the Project: _____________________________________________________  _________________________________________________ Name of the Principal Investigator ____________________  Tel. No.____________  I have received the information sheet on the above study and have read and / or  understood the written information.  I have been given the chance to discuss the study and ask questions.  I consent to take part in the study and I am aware that my participation is       voluntary.  I understand that I may withdraw at any time without this affecting my future care.  I understand that the information collected about me from my participation in this research and sections of any of my medical notes may be looked at by responsible  persons (ethics committee members / regulatory authorities). I give access to these  individuals to have access to my records.  I understand I will receive a copy of the patient information sheet and the informed  consent form.       

___________________________        __________________         Signature / Thumb Impression of subject      Date of signature         

  ______________________________     

  Printed name of the subject in capitals       

___________________________                                                                __________________  Signature / Thumb Impression of legally              Date of signature  accepted representative       

[The legally acceptable representative signature should be added if the subject is a  minor or is unable to sign for themselves. The relationship between the subject and  the  legally  acceptable  representative  should  be  stated.  The  impartial  witness signature should be added if the subject / legally acceptable representative is unable  to read or write and consent should be obtained in his presence.]

36

______________________________________________________ Relationship of legally accepted representative to subject in capitals 

_______________________________                __________________  Signature of the person conducting the                                      Date of Signature  informed consent discussion    

_________________________________________ 

Printed name of the person conducting the  

Informed consent discussion in capitals 

________________________________________               __________________ 

Signature of impartial witness                                                  Date of signature 

________________________________________ 

Printed name of the impartial witness in capitals 

37