Don’t be careless when people’s appearance becomes ugly. When your original long and thin face becomes big and garden, and your ears and nose are also much bigger, you often need to consider the possibility of intracranial pituitary tumor. 27-year-old young girl, Xiao Liu, didn’t know when her face became big and round, her skin was rough, pigmentation appeared, and her weight grew a lot. At first, she thought she was fat and had an endocrine disorder. Until one day she met a friend she hadn’t seen for several years and was surprised that her looks had changed a lot. After returning home, Ms. Liu took out a few years of photos to compare, and found that she really changed, then went to the local hospital, and soon found the culprit. Checking blood cortisol 1024nmol/L (reference value 171-536), blood pressure elevated up to 170/120mmHg, pituitary MRI plain + enhancement: pituitary nodules (diameter about 7mm), consider pituitary tumor; patient for further surgical treatment our department to consult.
The diagnosis was.
1, pituitary tumor ;
2, Cushing’s disease;
3, hypertensive disease. On examination, we found a typical full-moon face and buffalo back with thin skin, scattered acne on the abdomen, back and outer thighs, and purple lines visible on the inner thigh skin.
Pituitary adenomas are now the second most common tumor of the nervous system. There are mainly prolactin, growth hormone, and ACTH (adrenocorticotropic hormone) pituitary adenomas. Prolactin adenomas are mainly associated with increased prolactin leading to abnormal menstruation and poor sexual function, which can affect reproductive function. Growth hormone adenoma can occur in adolescence when the height is too high, such as some basketball players suffer from this disease; in adulthood, the onset is acromegaly, and the appearance gradually becomes ugly, with enlarged hands and feet, a wider chin, and higher cheekbones.
This patient has ACTH-secreting pituitary adenoma, an endogenous hypercorticosteronism caused by excessive secretion of ACTH. ACTH-secreting adenomas account for 10-12% of pituitary adenomas. They are nine times more common in women than in men. More than half of patients with Cushing’s disease have suspicious findings of pituitary tumors <5 mm in diameter at the onset of symptoms, which are difficult to detect on CT or mri films. Only about 10% of tumors are large enough to cause an occupational effect that can result in enlargement of the pterygoid saddle, visual field defects, cerebral nerve involvement, and/or hypopituitarism.
I. The clinical manifestations of Cushin’s disease include.
1. Weight gain.
(1) Present in approximately 50% of patients ;
(2) 50% are centripetal fat deposits: typically “buffalo back”, “full moon face” and long thin limbs.
(2) Hypertension.
3) Petechiae and purple lines, especially in the lateral abdomen, chest and lower abdomen.
4.Menstrual disorders and amenorrhea in women, impotence and reduced libido in men.
5, Excessive skin and mucous membrane pigmentation.
6, Skin atrophy, thin paper-like changes, easy bruising, poor wound healing.
7.Osteoporosis.
8.Elevated other adrenal hormones: androgens can cause hirsutism and acne.
9. Severe sepsis may occur.
II. Laboratory tests for Cushing’s disease.
1, elevated blood sugar.
2. Hypokalemic alkalosis.
3, loss of cortisol levels day to day.
4, normal or elevated ACTH levels.
5.Small dose (1mg) dexamethasone suppression test fails to suppress cortisol.
6, 24h urinary free cortisol was elevated.
Soon after admission, Xiao Liu was scheduled for surgery, which went very smoothly. The 7mm pituitary tumor hidden in Xiao Liu’s brain was removed intact through precise localization.
Pre-operative pituitary MRI
Post-operative pituitary MRI
Surgical resection is the treatment of choice for ACTH pituitary adenomas. Surgery is performed mainly in early adenoma cases and can achieve the dual objectives of tumor removal, biological eradication and preservation of the pituitary gland. In those with successful radical surgery, postoperative temporary hypofunction of the pituitary-adrenal axis is indicative of successful surgery. This is mainly because the hypothalamic-pituitary-adrenal axis enters an inert response phase to the removal of ACTH pituitary adenoma after a long-lasting hypercortisolism, which takes one year to gradually recover, and of course, further postoperative visits to the endocrinology department can be chosen to adjust hormone levels. Therefore, postoperative cortisol decline is the best sign of surgical cure of ACTH pituitary adenoma. In this patient, postoperative recheck: cortisol(16:00):35.90↓nmol/L,cortisol(8:00):57.90↓nmol/L.
When you read this article and find a friend around you with the above condition, it is best to suggest them to seek early neurosurgical consultation to identify the cause and treat it as early as possible.