Hypopituitarism differential diagnosis: Difference between revisions

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=== </small> Differentiating hypopituitarism from hypothyroidism that present as a single hormonal deficiency:<ref name="pmid19949140" /><ref name="pmid18177256" /><ref name="pmid18415684" /> ===
===Differentiating hypopituitarism from hypothyroidism that present as a single hormonal deficiency===
ABC <ref name="pmid19949140" /><ref name="pmid18177256" /><ref name="pmid18415684" />  
 
 
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! colspan="2" rowspan="2" align="center" style="background: #4479BA; color: #FFFFFF; " |Disease
! colspan="2" rowspan="2" align="center" style="background: #4479BA; color: #FFFFFF; " |Disease

Revision as of 20:36, 18 September 2017

Hypopituitarism Microchapters

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Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Hypopituitarism from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X Ray

CT

MRI

Ultrasound

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Iqra Qamar M.D.[2], Ahmed Elsaiey, MBBCH [3]

Overview

Hypopituitarism must be differentiated from Sheehan's syndrome, lymphocytic hypophysitispituitary apoplexyhypothyroidismAddison's disease, empty sella syndromehypogonadotropic hypogonadismSimmonds' disease, hypoprolactinemia, and menopause.

Differentiating Hypopituitarism from other Diseases

  • For the differential of hypopituitarism on the basis of thyroid hormone deficiency, click here.
  • For the differential of hypopituitarism on the basis of panhypopituitarism, click here.
  • For the differential of hypopituitarism on the basis of Gonadotropins (FSH/LH) deficiency, click here.
  • For the differential of hypopituitarism on the basis of panhypopituitarism, click here.

Differentiating various causes of Panhypopituitarism

Hypopituitarism should be differentiated from other diseases like Sheehan's syndrome, lymphocytic hypophysitispituitary apoplexyhypothyroidismAddison's disease, empty sella syndromehypogonadotropic hypogonadismSimmonds' disease, hypoprolactinemia, and menopause.[1][2][3][4][5][6][7]

Diseases Onset Manifestations Diagnosis
History and Symptoms Physical examination Laboratory findings Gold standard Imaging Other investigation findings
Trumatic delivery Lactation failure Menstrual irregularities Other features
Panhypopituitarism Chronic - + Oligo/amenorrhea
  • All pituitary hormones decreased
Sheehan's syndrome Acute ++ ++ Oligo/amenorrhea
  • Dx is clinical
  • Most sensitive test: low baseline prolactin levels w/o response to TRH
CT/MRI:
  • Sequential changes of pituitary enlargement followed by
  • Shrinkage and necrosis leading to decreased sellar volume or empty sella
Lymphocytic hypophysitis Acute +/- + Oligo/amenorrhea
  • Retro-orbital or Bitemporal pain
  • Diffuse and homogeneous contrast enhancement
Assays for:
  • Anti-TPO
  • Anti-Tg Ab
Pituitary apoplexy Acute +/- ++ Oligo/amenorrhea Severe headache
  • Decreased levels of anterior pituitary hormones in blood.
  • CT scan without contrast: Hemorrhage on CT presents as a hyperdense lesion

Blood tests may be done to check:

Empty sella syndrome Chronic - + Oligo/amenorrhea
  • Decreased levels of pituitary hormones in blood.
Simmond's disease/Pituitary cachexia Chronic +/- + Oligo/amenorrhea
  • Loss of body hair
  • Decreased levels of anterior pituitary hormones in blood.

Differentiating hypopituitarism from hypothyroidism that present as a single hormonal deficiency

ABC [8][9][10]


Disease History and symptoms Laboratory findings Additional findings
Fever Goiter Pain TSH Free T4 T3 T3RU Thyroglobin TRH TPOAb
Primary hypothyroidism Autoimmune + +/-

Diffuse

- N/ Normal N/ Normal
Thyroiditis + +/- + Normal Normal N/ Normal Normal
Others - +/- - Normal Normal N/ Normal Normal
Transient hypothyroidism +/- - +/- Normal Normal Normal Normal
Subclinical hypothyroidism - - - Normal Normal Normal Normal N/
  • Asymptomatic
Central Hypothyroidism Pituitary + - - N/ N/ N/ Normal Normal Normal
Hypothalamus + - - Normal Normal
Resistance to TSH/TRH - - - N/ N/ Normal Normal / Normal
  • Rare

Differentiating hypopituitarism on the basis of Gonadotropins (FSH/LH) deficiency

Diseases Clinical findings Diagnosis Manangement
Congenital diseases Klinefelter syndrome Clinical features of Klinefelter syndrome are as the following:[11]
  • Language learning impairment.
Kallmann syndrome Clinical features of Kallmann syndrome include:
Cryptorchidism Clinical features of cryptorchidism include:[12]
  • Treatment of cryptorchidism is mainly surgical in order to reduce the risk of malignancy
  • Orchiopexy surgery is recommended in order to reposition the undescended testes.
Male diseases Testicular torsion Patients of testicular torsion usually present with following:[13] Management is mainly surgical through detorsion and fixation of the affected testes.
Orchitis Clincial features of orchitis include the following:[14][15]
Female diseases Polycystic ovarian syndrome (PCOS) Possible clinical findings in cases of PCOS:[16]
Pelvic inflammatory disease Patients usually present with the following:[18][19]
Endometriosis Clinical features of endometriosis include the following:[20] Medical therapy:

Surgery:

Differentiating hypopituitarism on the basis of ACTH Deficiency

Disease Differentiating symptoms Differentiating laboratory findings Gold standard test
Hypotension Abdominal pain Anorexia/

weight loss

Muscle weakness Hypoglycemia Skin pigmentation Other symptoms Hyponatremia Cortisol levels Other labs
Addison's disease + + + + + + + Low ACTH stimulation test
Myopathies

(polymyositis,

hereditary myopathies)

- - - + - Heliotrope rash and

Gottron's sign

- Normal - Muscle biopsy
Celiac disease - + + - - Dermatitis herpetiformis  - Normal - Abnormal small bowel biopsy
Syndrome of inappropriate anti-diuretic hormone

(SIADH)

- - - - - - - + Normal Water deprivation test
Neurofibromatosis - - + + - Axillary- and inguinal-area freckling - - - Biopsy of skin tissue
Peutz-Jeghers syndrome + + - Normal Colonic imaging showing the small intestinal polyps
Porphyria cutanea tarda - + - - - Blisters on sun-exposed sites - Normal or elevated High level of porphyrins in the urine
Salt-depletion nephritis + Flank pain - - - - + Elevated <15:1 BUN:CR
Bronchogenic carcinoma - - + - - + - Elevated Increased ACTH and

Hypokalemia

Cytological or histological evidence of lung cancer in sputum, pleural fluid, or tissue
Anorexia nervosa + - + + + - - Elevated - Psychiatric condition

Differentiating hypopituitarism on the basis of High prolactin level

Disease Clinical Findings Laboratory findings Management
Somatotroph adenoma:

Acromegaly

Clinical features of acromegaly are due to high level of human growth hormone (hGH):
Corticotroph adenoma: Cushing's syndrome Clinical features of Cushing's syndrome are due to increased levels of cortisol:
Hypothyroidism Clinical features of hypothyroidism are due to deficiency of thyroxine:
  • Fullness in the throat and neck
Levothyroxine
Chronic renal failure There are no pathognomonic symptoms associated with chronic renal failure. Common non-specific symptoms of chronic renal failure include: Urinalysis:

Fluid and electrolyte disturbances:

Endocrine and metabolic disturbances:

Hematologic abnormalities:

Liver disease: Cirrhosis The clinical features of liver cirrhosis are very nonspecific. These include:
Seizure disorder The clinical features of seizure disorder may include:
  • Change in alertness, orientation and time perception
  • Mood changes, such as unexplainable fear, panic, joy, or laughter
  • Changes in sensation of the skin, usually spreading over the arm, leg, or trunk
  • Vision changes, including seeing flashing lights
  • Rarely, hallucinations (seeing things that aren't there)
  • Falling, loss of muscle control, occurs very suddenly
  • Muscle twitching that may spread up or down an arm or leg
  • Muscle tension or tightening that causes twisting of the body, head, arms, or legs
  • Shaking of the entire body
  • Tasting a bitter or metallic flavor
Electroencephalogram
Medication-induced Clinical features of hyperprolactinemia after a specific period of regular medication ingestion Discontinuation of the medication for 3 days and remeasurement of prolactin levels[21] Change to alternate medication

Differentiating hypopituitarism on the basis of GH Deficiency

Diseases History and symptoms Physical Examination Laboratory findings
Puberty development Height velocity Parents height Characteristic facies Bone age Genetic analysis GH level
Growth hormone deficiency[22] Delayed Decreased Normal
  • Doll-like fat distribution pattern
  • Immature face with under developed nasal bridge
  • Infantile voice
Dlayed
  • POU1F1 gene mutations 
  • GH1 gene mutations
Low
Achondroplasia[23] Normal Decreased Decreased
  • Large heads
  • Prominent forehead
  • Midface hypoplasia
Delayed

FGFR3 gene mutations

Normal
Familial short stature[24]
  • A normal variant with normal signs, investigations
  • Positive family history
Normal Decreased Decreased Normal Normal Heterozygous IGF1 Splicing mutation Normal
Constitutional growth delay[25]
  • Family history of delayed growth and puberty
  • Childhood short stature but relatively normal adult height
  • Normal size at birth
  • A delayed growth rate begins at three to six months of age
  • A family history of delayed growth and puberty in one or both parents
Delayed Normal Normal Normal Normal Mutations in Variation in FGFR1GNRHR, TAC3, and TACR3 genes Normal
Growth Hormone Resistance[26] Delayed Decreased Normal
  • Small face in relation to head circumference
  • Delayed dentition
Delayed Normal
Pediatric Hypothyroidism[27] Delayed Decreased Normal
  • Puffy facies
Delayed

Mutations in:

  • Thyroid Transcription factor-2 (TTF2
  • Transcription factors NK2
Normal
Turner Syndrome[28] Absent Decreased Decreased Normal 45 X0 Normal
Silver-Russell Syndrome[29] Delayed Decreased Decreased
  • Prominent forehead
  • Triangular face
  • Downturned corners of the mouth
  • Small jaw
  • Pointed chin
Normal Methylation involving the H19 and IGF2 genes  Normal
Noonan Syndrome[30] Delayed Decreased Decreased Minor facial dysmorphism Normal PTPN11 and SOS1 genes abnormality Normal
Psychosocial Short Stature[31]
  • A disorder of short stature or growth that is observed in association with emotional deprivation
  • A disturbed relationship between child and caregiver is usually noted.
  • A history of abuse or neglect and emotional deprivation
  • The relationship between the caregiver and the child appears to be abnormal.
Delayed Decreased Normal Normal Normal May be low
Short stature accompanying systemic disease[32] Delayed Decreased Normal Failure to thrive Delayed Normal Normal
Idiopathic short stature[33] A height below 2 standard deviations (SD) of the mean for age, in the absence of any endocrine, metabolic, or other diagnosis Normal Decreased Normal Normal Delayed SHOX gene mutations[34] Normal

Differentiating hypopituitarism on the basis of ADH deficiency

Type of DI Subclass Disease Defining signs and symptoms Lab/Imaging findings
Central Acquired Histiocytosis
  • CD1a and CD45 +
  • Interleukin-17 (ILITA)
Craniopharyngioma
Sarcoidosis
Congenital Hydrocephalus Dilated ventricles on CT and MRI
Wolfram Syndrome (DIDMOAD)
Nephrogenic Acquired Drug-induced (demeclocycline, lithium)
Hypercalcemia
  • Ca levels greater than 11 meq/L
Hypokalemia
  • K levels less than 3meq/L on CBC
Multiple myeloma
Sickle cell disease
Primary polydipsia Psychogenic
Gestational diabetes insipidus
Diabetes mellitus
  • Elevated blood sugar levels >126
  • Elevated HbA1c > 6.5

References

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  2. Powrie JK, Powell M, Ayers AB, Lowy C, Sönksen PH (1995). "Lymphocytic adenohypophysitis: magnetic resonance imaging features of two new cases and a review of the literature". Clin. Endocrinol. (Oxf). 42 (3): 315–22. PMID 7758238.
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