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  • Development of Diabetic Ketoacidosis in a Patient with a Growth Hormone Secreting Macro-Adenoma and Suspected Pituitary Apoplexy

    Final Number:

    Roberto Perez-Roman MD; Adisson Nostradamous Fortunel; Iahn Cajigas MD, PhD; Ricardo Jorge Komotar MD, FACS

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2018 Annual Meeting

    Introduction: While acromegaly is the most common clinical sign of a growth hormone (GH) secreting pituitary adenoma, these tumors can be accompanied by multiple important metabolic changes. Acromegalic patients can develop varying levels of insulin resistance via the downstream effects of growth hormone on the insulin receptor and about 10% develop diabetes mellitus (DM). Rarely, the relative insulin deficiency in these patients can lead to diabetic ketoacidosis (DKA) characterized by hyperglycemia and metabolic acidosis. Although rapid deterioration in a patient with a known pituitary macro-adenoma (PMA) should lead to exclusion of more common etiologies such as pituitary apoplexy, DKA should also be considered in the appropriate context.

    Methods: Case review of a 32-year-old previously healthy female patient with a newly diagnosed PMA after development of progressive vision loss who presented with acute clinical changes suspicious for pituitary apoplexy but was instead found to be in DKA.

    Results: The patient presented one day prior to elective surgical intervention with sudden onset fatigue, nausea, vomiting, polydipsia and polyuria. CT scan of the brain showed a hyperdensity around the mass concerning for pituitary apoplexy. Laboratory studies were remarkable for elevated serum GH and IGF-1 with an otherwise normal pituitary panel, high anion gap metabolic acidosis, and elevated glucose. A diagnosis of DKA was made and treatment initiated with intravenous hydration, potassium, and insulin administration. MRI of the brain did not revealed any intracranial blood and pituitary apoplexy was eliminated from the differential diagnosis. The patient’s condition improved with subsequent closure of the anionic gap.

    Conclusions: In rare cases, DKA may be the initial presentation for a GH secreting macro-adenoma. Recognition, appropriate management, and differentiation of DKA from pituitary apoplexy requires prompt evaluation to achieve good outcomes.

    Patient Care: This case illustrates the importance of recognizing DKA as the initial presentation for a GH secreting macro-adenoma as prompt evaluation and treatment are paramount to achieving good outcomes. This association is important to describe as pituitary apoplexy may present in a similar fashion and requires a different treatment approach.

    Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe different metabolic changes seen by over production of Growth Hormone. 2) Recognize that DKA can be seen in rare cases with GH secreting macro-adenomas and can be seen even in the absence of diabetes mellitus. 3) Understand that the DKA and Pituitary apoplexy are included in the differential diagnosis of rapid deterioration in patients with GH secreting macro-adenoma.

    References: • Jiang HJ, Hung WW, Hsiao PJ (2013). A case of acromegaly complicated with diabetic ketoacidosis, pituitary apoplexy, and lymphoma. Kaohsiung J Med Sci. 29: 687–90. • Turgut, M., Özsunar, Y., Basak, S. et al. Pituitary apoplexy: an overview of 186 cases published during the last century. Acta Neurochir (2010) 152: 749. • Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN (2009). Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 32: 1335–1343. • Nyenwe EA, Kitabchi AE. The Evolution of Diabetic Ketoacidosis: An Update of its Etiology, Pathogenesis and management, Metabolism (2015) Volume 65 , Issue 4 , 507 – 521 • Katz JR, Edwards R, Khan M, et al. Acromegaly presenting with diabetic ketoacidosis. Postgrad Med J 1996;72:682–3. • Chen YL, Wei CP, Lee CC, Chang TC. Diabetic Ketoacidosis in a Patient with Acromegaly. Journal of the Formosan Medical Association (2007), Volume 106 , Issue 9 , 788 - 791 • Yoshida N, Goto H, Suzuki H, et al. Ketoacidosis as the initial clinical condition in nine patients with acromegaly: a review of 860 cases at a single institute. Eur J Endocrinol 2013; 169 127-132. • Xiao D, Wang S, Huang Y, Zhao L, Wei L, Ding C. Clinical analysis of infarction in pituitary adenoma. International Journal of Clinical and Experimental Medicine. 2015;8(5):7477-7486. • Singh TD, Valizadeh N, et al. Management and outcomes of pituitary apoplexy. J Neurosurg 122:1450–1457, 2015. Published online April 10, 2015; DOI: 10.3171/2014.10.JNS141204 • Biousse V, Newman NJ, Oyesiku NM (2001). Precipitating factors in pituitary apoplexy. J Neurol Neurosurg Psychiatry. 71: 542–5 • Turner HE, Nagy Z, Gatter KC, Esiri MM, Harris AL, Wass JA. Angiogenesis in pituitary adenomas and the normal pituitary gland. J Clin Endocrinol Metab. 2000;85: 1159–1162. • Oldfield EH, Merrill MJ. Apoplexy of pituitary adenomas: the perfect storm. J Neurosurg. 2015;122:1444–1449. • Gorczyca W, Hardy J. Microadenomas of the human pituitary and their vascularization. Neurosurgery. 1988;22: 1–6. • Hirano A, Tomiyasu U, Zimmerman HM. The fine structure of blood vessels in chromophobe adenoma. Acta Neuropathol. 1972;22:200–207. • Briet C, Salenave S, Chanson P. Pituitary Apoplexy. Endocr Rev 2015; 36 (6): 622-645. • Wang XL, et al. Spontaneous remission of acromegaly or gigantism due to subclinical apoplexy of pituitary growth hormone adenoma.Chin Med J 2011;124:3820-3823 • Gurling KJ. Diabetic Coma and Pituitary Necrosis in an Acromegalic Patient: A Case Report. Diabetes Mar 1955, 4 (2) 138-14 • Kuzuya T, Matsuda A, Sakemoto Y, Yamamoto K, Saito T, Yoshida S. A case of pituitary gigantism who had two episodes of diabetic ketoacidosis followed by complete recovery of diabetes. Endocrinol Jpn 1983;30:323–334 • Camara-Lemarroy CR, Infante-Valenzuela A. Pituitary apoplexy presenting as diabetic ketoacidosis: a great simulator? Neuroendocrinol Lett 2016; 37(1):101–103. • Stentz FB, Umpierrez GE, Cuervo R, Kitabchi AE. Proinflammatory cytokines, markers of cardiovascular risks, oxidative stress, and lipid peroxidation in patients with hyperglycemic crises. Diabetes 2004; 53:2079–2086

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