Hypopituitarism differential diagnosis: Difference between revisions

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* Rare
* Rare
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===Differentiating Hypogonadism from other Diseases===
Hypogonadism must be differentiated from [[diseases]] that cause [[delayed puberty]] or [[infertility]]. These diseases include [[Congenital disease|congenital diseases]] as [[Klinefelter syndrome]], [[Kallmann syndrome]] and [[cryptorchidism]]. The diseases also include [[testicular torsion]] and [[orchitis]] in males, [[polycystic ovary syndrome]], [[pelvic inflammatory disease]], and [[endometriosis]] in females.
{| class="wikitable"
! colspan="2" |Diseases
!Clinical findings
!Diagnosis
!Manangement
|-
| rowspan="3" |Congenital diseases
|[[Klinefelter syndrome]]
|Clinical features of [[Klinefelter syndrome]] are as the following:<ref name="fertstert2004">{{Citation|last = Denschlag|first = Dominik, MD|last2 = Clemens|first2 = Tempfer, MD|last3 = Kunze|first3 = Myriam, MD|last4 = Wolff|first4 = Gerhard, MD|last5 = Keck|first5 = Christoph, MD|title = Assisted reproductive techniques in patients with Klinefelter syndrome: A critical review|journal = Fertility and Sterility|volume = 82|issue = 4|pages = 775–779|date = October 2004|year = 2004|doi = 10.1016/j.fertnstert.2003.09.085}}</ref>
* Language learning impairment.
* [[Neuropsychological]] testing often reveals deficits in [[executive functions]].
* Delays in motor development.
|
* [[Karyotype|Karyotyping]]
* [[Semen]] count
* [[Serum]] [[estradiol]] levels (a type of [[estrogen]])
* [[Serum]] [[follicle stimulating hormone]]
* [[Serum]] [[luteinizing hormone]]
* [[Serum]] [[testosterone]]
|
* [[Testosterone]] [[therapy]] may be indicated to treat the symptoms of the disease
|-
|[[Kallmann syndrome]]
|Clinical features of Kallmann syndrome include:
* Hypogonadism
* [[Anosmia]]
|
* [[Serum]] [[follicle stimulating hormone]]
* [[Serum]] [[luteinizing hormone]]
* [[Serum]] [[testosterone]]
* [[Gonadotropins|Gonadotropin hormones]]
|
* [[Testosterone|Testosterone replacement therapy]]
* [[Estrogen]] replacement therapy (in females)
|-
|[[Cryptorchidism]]
|Clinical features of cryptorchidism include:<ref name="pmid17462053">{{cite journal| author=Virtanen HE, Bjerknes R, Cortes D, Jørgensen N, Rajpert-De Meyts E, Thorsson AV et al.| title=Cryptorchidism: classification, prevalence and long-term consequences. | journal=Acta Paediatr | year= 2007 | volume= 96 | issue= 5 | pages= 611-6 | pmid=17462053 | doi=10.1111/j.1651-2227.2007.00241.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17462053  }}</ref>
* [[Empty scrotum]]
* [[Inguinal]] fullness
|
* [[Ultrasonography]] may be indicated to locate the [[gonads]]
|
* Treatment of cryptorchidism is mainly surgical in order to reduce the risk of malignancy
* [[Orchiopexy]] surgery is recommended in order to reposition the undecsended testes.
|-
| rowspan="2" |Male diseases
|[[Testicular torsion]]
|Patients of testicular torsion usually present with following:<ref name="pmid19679025">{{cite journal| author=Schmitz D, Safranek S| title=Clinical inquiries. How useful is a physical exam in diagnosing testicular torsion? | journal=J Fam Pract | year= 2009 | volume= 58 | issue= 8 | pages= 433-4 | pmid=19679025 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19679025  }}</ref>
* Sudden onset of severe [[pain]] in one [[testicle]], with or without a previous predisposing event
* [[Swelling]] within one side of the [[scrotum]] (scrotal swelling)
* [[Nausea]] or [[vomiting]]
* [[Lightheadedness]]
* Bell clapper deformity of [[testes]] on examination
|
* Scrotal [[ultrasound]]
* [[Urinalysis]] to exclude [[bacterial infection]]
|Management is mainly surgical through detorsion and fixation of the affected [[testes]].
|-
|[[Orchitis]]
|Clincial features of orchitis include the following:<ref name="pmid19378875">{{cite journal |vauthors=Trojian TH, Lishnak TS, Heiman D |title=Epididymitis and orchitis: an overview |journal=Am Fam Physician |volume=79 |issue=7 |pages=583–7 |year=2009 |pmid=19378875 |doi= |url=}}</ref><ref name="pmid21490048">{{cite journal |vauthors=Stewart A, Ubee SS, Davies H |title=Epididymo-orchitis |journal=BMJ |volume=342 |issue= |pages=d1543 |year=2011 |pmid=21490048 |doi= |url=}}</ref>
* [[Scrotum|Scrotal]] [[swelling]]
* [[Scrotal pain]]
* [[Lower urinary tract infections|urinary tract infections]]
* [[Nausea]], [[vomiting]] and [[chills]]
* [[Prehn's sign]] positive
* [[Costovertebral]] angle [[tenderness]] 
* [[Fever]]
|
* [[Urethral]] [[Gram stain]]
* [[Urinalysis]]
* [[Urine culture]]
* [[PCR]] to detect the presence of ''[[Neisseria gonorrheae]]'' and ''[[Chlamydia trachomatis]]''
* Scrotal [[ultrasound]] is the diagnostic [[imaging]] of choice in cases of acute scrotum.
|
* [[Bed rest]] and limitation of [[physical activity]]
* Use of cold packs
* [[Analgesia]]
* [[Non-steroidal anti-inflammatory drugs]] ([[NSAIDs]])
* [[Levofloxacin]] in [[bacterial infeciton]].
|-
| rowspan="3" |Female diseases
|[[Polycystic ovarian syndrome]] (PCOS) 
|Possible clinical findings in cases of PCOS:<ref name="AMN">{{cite web | author = Christine Cortet-Rudelli, Didier Dewailly | title =Diagnosis of Hyperandrogenism in Female Adolescents| work =Hyperandrogenism in Adolescent Girls | url=http://www.health.am/gyneco/more/diagnosis-of-hyperandrogenism-in-female/ | year = 2006 | month= Sep 21 | publisher=Armenian Health Network, Health.am}}</ref>
* [[Amenorrhea]]
* [[Oligoamenorrhea]]
* [[Ovarian cysts]]
* [[Pelvic pain]]
* [[Dysparuenia]]
* [[Acne]]
* [[Hirsutism]]
* [[Anxiety]] and [[depression]]
* [[Sleep apnea]]
|
* Blood [[testosterone]] level
* [[LH]] and [[FSH]] levels
* Pelvic ultrasound
|
* [[Clomiphene citrate]] and [[metformin]] to manage infertility.<ref>{{cite journal |author=Legro RS, Barnhart HX, Schlaff WD |title=Clomiphene, Metformin, or Both for Infertility in the Polycystic Ovary Syndrome|journal=N Engl J Med|volume=356 |issue=6 |pages=551-566 |year=2007 |pmid=17287476 |doi=}}</ref>
* [[Cyproterone acetate]] for the treatment of acne and hirsutism.
* [[Spironolactone]] 
|-
|[[Pelvic inflammatory disease]]
|Patients usually present with the following:<ref name="pmid25992748">{{cite journal |vauthors=Brunham RC, Gottlieb SL, Paavonen J |title=Pelvic inflammatory disease |journal=N. Engl. J. Med. |volume=372 |issue=21 |pages=2039–48 |year=2015 |pmid=25992748 |doi=10.1056/NEJMra1411426 |url=}}</ref><ref name="pmid27107781">{{cite journal |vauthors=Ford GW, Decker CF |title=Pelvic inflammatory disease |journal=Dis Mon |volume=62 |issue=8 |pages=301–5 |year=2016 |pmid=27107781 |doi=10.1016/j.disamonth.2016.03.015 |url=}}</ref>
* Bilateral [[abdominal pain]]
* [[Abnormal uterine bleeding]]
* [[Urinary frequency]]
* Abnormal [[vaginal discharge]]
* [[Fever]]
* Decreased [[bowel sounds]]
|
* [[Nucleic acid amplification technique|Nucleic acid amplification tests]] is the best laboratory test for [[PID]].
* [[Transvaginal ultrasound|Transvaginal utrasonography]]
|
* Broad spectrum [[antibiotics]]
* [[Hospitalization]]
|-
|[[Endometriosis]]
|Clinical features of endometriosis include the following:<ref name="pmid11949938">{{cite journal| author=Murphy AA| title=Clinical aspects of endometriosis. | journal=Ann N Y Acad Sci | year= 2002 | volume= 955 | issue=  | pages= 1-10; discussion 34-6, 396-406 | pmid=11949938 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11949938  }}</ref>
* [[Dyspareunia]]
* [[Nausea and vomiting|Nausea]] and vomiting
* Intermenstrual spotting
* Prolonged [[menstrual bleeding]] and increased amount of [[bleeding]] ([[menorrhagia]])
* [[Acute abdomen]]
|
* Features of [[iron deficiency anemia]] may be present such as:
** Low [[MCV]],
** Low [[Mean cell haemoglobin|MCHC]]
** Elevated RBC distribution width
* Elevated levels of [[CA-125|serum cancer antigen-125]] in some cases.<sup>[[Endometriosis laboratory findings#cite note-pmid12521524-1|[1]]]</sup>
* Increased levels of [[interleukin 1]], chemoattractant protein-1 and [[Interferon-gamma|interferon gamma]] may be present in patients with [[endometriosis]]. These are useful markers to monitor the disease activity and progression.<sup>[[Endometriosis laboratory findings#cite note-pmid28189296-2|[2]]]</sup>
|Medical therapy:
* [[Gonadotropin-releasing hormone agonist|Gonadotrophin releasing hormone agonists]]
* [[Oral contraceptive|Oral contraceptive pills]]
* [[Aromatase inhibitor|Aromatase inhibitors]]
Surgery:
* Conservative removal of the [[endometrial]] tissues by laser or electrocautry
* Definitive surgery[[hysterectomy]] with [[Salpingo-oophorectomy|bilateral salpingo-oophorectomy]].
|}
|}


Revision as of 16:33, 6 September 2017

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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 hypophysitis, pituitary apoplexy, hypothyroidism, Addison's disease, empty sella syndrome, hypogonadotropic hypogonadism, Simmonds' disease, hypoprolactinemia, and menopause.

Differentiating hypopituitarism from other Diseases

Hypopituitarism should be differentiated from other diseases like Sheehan's syndrome, lymphocytic hypophysitis, pituitary apoplexy, hypothyroidism, Addison's disease, empty sella syndrome, hypogonadotropic hypogonadism, Simmonds' 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
Sheehan's syndrome Acute ++ ++ Oligo/amenorrhea
  • Dx is clinical
  • Most senitive 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.
Primary hypothyroidism Chronic +/- - Oligomenorrhea/menorrhagia
  • Dry skin
  • Hair loss
  • Rest of pituitary hormone levels WNL
  • Done to rule out any pituitary cause
  • Assays for anti-TPO and anti-Tg Ab
  • FNA biopsy
Primary Hypogonadotropic hypogonadism Chronic - - Oligo/amenorrhea
  • Energy and mood changes
  • Done to rule out any pituitary cause
Hypoprolactinemia Chronic - + -
  • Puerperal agalactogenesis
  • No workup is necessary
  • Done to rule out any pituitary cause
Panhypopituitarism Chronic - + Oligo/amenorrhea
  • All pituitary hormones decreased
Primary adrenal insufficiency/Addison's disease Chronic - - -
  • Abdominal CT
  • Abdominal CT
  • Anti-adrenal Ab testing
Menopause Chronic - +/- Oligo/amenorrhea

Differentiating different causes of hypothyroidism

Various kinds of hypothyroidism can be differentiated from each other on the basis of history and symptoms and laboratory findings:[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 Hypogonadism from other Diseases

Hypogonadism must be differentiated from diseases that cause delayed puberty or infertility. These diseases include congenital diseases as Klinefelter syndrome, Kallmann syndrome and cryptorchidism. The diseases also include testicular torsion and orchitis in males, polycystic ovary syndrome, pelvic inflammatory disease, and endometriosis in females.

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 undecsended 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:

References

  1. ↑ Sato N, Sze G, Endo K (1998). "Hypophysitis: endocrinologic and dynamic MR findings". AJNR Am J Neuroradiol. 19 (3): 439–44. PMID 9541295.
  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.
  3. ↑ Honegger J, Schlaffer S, Menzel C, Droste M, Werner S, Elbelt U, Strasburger C, Störmann S, Küppers A, Streetz-van der Werf C, Deutschbein T, Stieg M, Rotermund R, Milian M, Petersenn S (2015). "Diagnosis of Primary Hypophysitis in Germany". J. Clin. Endocrinol. Metab. 100 (10): 3841–9. doi:10.1210/jc.2015-2152. PMID 26262437.
  4. ↑ Thodou E, Asa SL, Kontogeorgos G, Kovacs K, Horvath E, Ezzat S (1995). "Clinical case seminar: lymphocytic hypophysitis: clinicopathological findings". J. Clin. Endocrinol. Metab. 80 (8): 2302–11. doi:10.1210/jcem.80.8.7629223. PMID 7629223.
  5. ↑ Imura H, Nakao K, Shimatsu A, Ogawa Y, Sando T, Fujisawa I, Yamabe H (1993). "Lymphocytic infundibuloneurohypophysitis as a cause of central diabetes insipidus". N. Engl. J. Med. 329 (10): 683–9. doi:10.1056/NEJM199309023291002. PMID 8345854.
  6. ↑ Hsieh CY, Liu BY, Yang YN, Yin WH, Young MS (2011). "Massive pericardial effusion with diastolic right ventricular compression secondary to hypothyroidism in a 73-year-old woman". Emerg Med Australas. 23 (3): 372–5. doi:10.1111/j.1742-6723.2011.01425.x. PMID 21668725.
  7. ↑ Dejager S, Gerber S, Foubert L, Turpin G (1998). "Sheehan's syndrome: differential diagnosis in the acute phase". J. Intern. Med. 244 (3): 261–6. PMID 9747750.
  8. ↑ Invalid <ref> tag; no text was provided for refs named pmid19949140
  9. ↑ Invalid <ref> tag; no text was provided for refs named pmid18177256
  10. ↑ Invalid <ref> tag; no text was provided for refs named pmid18415684
  11. ↑ Denschlag, Dominik, MD; Clemens, Tempfer, MD; Kunze, Myriam, MD; Wolff, Gerhard, MD; Keck, Christoph, MD (October 2004), "Assisted reproductive techniques in patients with Klinefelter syndrome: A critical review", Fertility and Sterility, 82 (4): 775–779, doi:10.1016/j.fertnstert.2003.09.085
  12. ↑ Virtanen HE, Bjerknes R, Cortes D, Jørgensen N, Rajpert-De Meyts E, Thorsson AV; et al. (2007). "Cryptorchidism: classification, prevalence and long-term consequences". Acta Paediatr. 96 (5): 611–6. doi:10.1111/j.1651-2227.2007.00241.x. PMID 17462053.
  13. ↑ Schmitz D, Safranek S (2009). "Clinical inquiries. How useful is a physical exam in diagnosing testicular torsion?". J Fam Pract. 58 (8): 433–4. PMID 19679025.
  14. ↑ Trojian TH, Lishnak TS, Heiman D (2009). "Epididymitis and orchitis: an overview". Am Fam Physician. 79 (7): 583–7. PMID 19378875.
  15. ↑ Stewart A, Ubee SS, Davies H (2011). "Epididymo-orchitis". BMJ. 342: d1543. PMID 21490048.
  16. ↑ Christine Cortet-Rudelli, Didier Dewailly (2006). "Diagnosis of Hyperandrogenism in Female Adolescents". Hyperandrogenism in Adolescent Girls. Armenian Health Network, Health.am. Unknown parameter |month= ignored (help)
  17. ↑ Legro RS, Barnhart HX, Schlaff WD (2007). "Clomiphene, Metformin, or Both for Infertility in the Polycystic Ovary Syndrome". N Engl J Med. 356 (6): 551–566. PMID 17287476.
  18. ↑ Brunham RC, Gottlieb SL, Paavonen J (2015). "Pelvic inflammatory disease". N. Engl. J. Med. 372 (21): 2039–48. doi:10.1056/NEJMra1411426. PMID 25992748.
  19. ↑ Ford GW, Decker CF (2016). "Pelvic inflammatory disease". Dis Mon. 62 (8): 301–5. doi:10.1016/j.disamonth.2016.03.015. PMID 27107781.
  20. ↑ Murphy AA (2002). "Clinical aspects of endometriosis". Ann N Y Acad Sci. 955: 1–10, discussion 34-6, 396–406. PMID 11949938.

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