HYPONATREMIA SECONDARY TO PANHYPOPITUITARISM IN A PATIENT WITH A HISTORY OF SIADH M. Bilalis; T. Joshi; D. Matrana; S. Sanne Department of Internal Medicine, LSU Health Sciences Center - New Orleans Introduction: Non-pituitary intrasellar neoplasms, though less common than pituitary adenomas, can cause hypopituitarism via mass effect and compression of neighboring structures. Mass effect can also lead to panhypopituitarism. Hyponatremia secondary to panhypopituitarism mimics SIADH, but the hyponatremia is typically corrected after administering thyroxine and corticosteroids. We present a rare case of hyponatremia in a patient with a history of SIADH where a recurrent meningioma was the true culprit. Case: A 51 year old woman presented to the emergency department for tinnitus associated with her chronic headaches. She was found to have a Na of 116 and due to concern for hypovolemic hyponatremia was given 1 L of NS. Her Na decreased from 116 to 113 and she was admitted to the MICU. She had a PMH of SIADH with NA levels recorded in the 130’s, hypothyroidism, and meningioma resection. Head CT without contrast showed possible recurrence of meningioma. Patient was then given salt tablets, free water restricted, and started on her home dose of levothyroxine. She remained stable and was transferred to the floor. But, she was readmitted to the MICU the next day due to decreased level of consciousness, hypotension, increased somnolence. She was started on 3% hypertonic saline bolus, and her blood pressure increased. Considering differentials such as SIADH, hypothyroidism, adrenal insufficiency, or hypopituitarism, stress dose steroids were administered. Sodium initially dropped, but then started trending up. The dosage was decreased to 20mg AM/10mg PM once her sodium was around 120. The patient was found to have a high TSH, low free T4, FSH, IGF-1, and morning cortisol consistent with hypopituitarism. Brain MRI with contrast revealed invasion of sella and mass effect on pituitary gland as well as encasement of left cavernous internal carotid artery. Imaging and labs suggested panhypopituitarism as the
A CRYPTOGENIC CASE OF PNEUMONIA
cause for the patient’s hyponatremia.
Discussion: Hyponatremia secondary to a neoplasm is typically a diagnosis of exclusion. Initial symptoms of mass effect on the pituitary gland include irregular menstrual periods, infertility, decreased libido, and erectile dysfunction. As the tumor causes more compression, the more severe consequences include the effects of hypothyroidism and low cortisol (low blood pressure, confusion, nausea, vomiting, and fever) some visualizedwithout patient. Early detection via process of elimination taking all differentials into account is the key to ensuring a positive outcome.
E. Lee; J. Coe; K. Vaishnani; K. Curry; N. Sells Department of Internal Medicine, LSU Health Sciences Center - Lafayette Introduction: Pneumonia is one of the most common presentations in both the inpatient and outpatient settings. We present here a very interesting case of pneumonia caused by both Cryptococcus and Strep gordonii . Case: A 43 year old African-American woman with no significant past medical history presents with SOB, cough, and left-sided chest pain for 10 days. She presented to the ER 7 days prior to admission with bronchitis. She returned 5 days later with similar symptoms. CXR revealed left lower lobe pneumonia and she was discharged with oral Levaquin. She continued to endorse worsening of symptoms, which prompted her to return to the hospital. CT Chest revealed left basilar consolidation, moderate left pleural effusion, and fluid along the left fissureconcerning for possibledeveloping empyema. Pulmonology was consulted and recommended chest tube placement and obtaining cultures. IR placed a chest tube and sent pleural fluid samples for studies. She was treated empirically with Vancomycin, Pip-tazo, and Azithromycin. Blood and respiratory cultures were negative. Pleural fluid studies showed 30,836 WBC with 93% neutrophils and LDH of 2,227. Cytology showed reactive fluid with abundant acute inflammation but no evidence of malignancy. HIV was negative. Patient did well clinically throughout the hospitalization and eventually was discharged home with Linezolid. Pleural fluid later grew rare Strep gordonii and Cryptococcus . CSF was negative for meningitis. Cryptococcal antigen in the CSF and blood were both negative. Patient is currently being treated with fluconazole with a close outpatient follow-up. Discussion: We have a case of pneumonia with positive pleural cultures of two unusual causes of pneumonia. Strep gordonii is bacteria that resides primarily in oral flora in humans but is known to spread outside the oral cavity rarely. Cryptococcus is a yeast that usually
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