Journal of Surgery Current Trends & Innovations Category: Clinical Type: Review Article
The Effect of Diabetes Type 1 on Pituitary Apoplexy in Pediatric Patients
- Dennis Adjepong, MD, MBA1*, Dennis Brako Sarpong, MD2, Naa Oyoo Shidaa, MD2, Kwaku Amoateng3
- 1 Department Of Neurological Surgery, California Institute Of Behavioral Neurosciences & Psychology, Fairfield, United States
- 2 Washington Adventist University, Takoma Park, United States
- 3 University Of Medicine & Pharmacy Of Targus Mures, Transylvania, Romania
*Corresponding Author:Dennis Adjepong, MD, MBA
Department Of Neurological Surgery, California Institute Of Behavioral Neurosciences & Psychology, Fairfield, United States
Received Date: Jul 14, 2020 Accepted Date: Aug 08, 2020 Published Date: Aug 14, 2020
Pituitary Apoplexy (PA) often arises as a result of a bleeding tumor in the pituitary gland. Diabetes type 1 is among the significant risk factors of PA in children, young adults, and teens. The analysis proves that given the rare cases of symptoms accompanying pituitary apoplexy, it is usually challenging to diagnose it. However, it is characterized by severe sudden symptoms of altered mental status and headaches that raise intracranial pressure, whereby subsequent imaging proves the diagnosis. This review investigates the effect of diabetes type 1 on pituitary apoplexy in pediatric patients, identifying how the PA symptoms manifest, genetic factors, and the clinical presentation of the condition.
Diabetes type 1; Pituitary apoplexy
Pituitary apoplexy is considered a life-threatening condition, given the acute infarctions by pituitary glands . Its major characteristics include nausea, headaches, vomiting, hypopituitarism, altered mental status, and visual impairment . On the other hand, diabetes type I is associated with ketoacidosis, which is also an acute complication among patients with itself having its associated characteristics . Clinicians consider pituitary apoplexy to be an endocrine emergency originating from poorly controlled glucose, with its causative factors unknown . Type 1 diabetes has been considered to predispose PA due to its degenerative changes in the microvasculature glands . Patients with type 1 diabetes may develop a complication referred to as Diabetes Ketoacidosis (DKA), which can be fatal if untreated . DKA is associated with similar symptoms presented in patients with PA. For instance, a patient may exhibit alterations in the biochemical and mental status. Physicians may suggest DKA, but after diagnosis, the patient may be identified with PA . PA may display intracranial disorders making it hard for diagnosis. PA is associated with low frequency and acute and dramatic presentations accompanied by non-specific symptoms making it hard for diagnosis .
The research study reviewed multiple clinical features, biochemistry, predisposing factors, and clinical outcomes of patients across the United States presenting clinical diagnosis of type I diabetes and pituitary apoplexy between the years 2000 and 2020. Most of the studies had their patients presented with diabetes and sudden onset of visual disturbances, headache, and altered consciousness, including characteristics of subclinical pituitary apoplexy. Patients without diabetes were excluded from the study. All others included had pituitary hemorrhages on MRI, with historical evidence of necrosis or hemorrhage in their pituitary glands. The study also evaluated the diagnosis process of DKA with type I diabetes. After 24 hours, their metabolisms abnormalities were also recorded, with many patients having severe symptoms of headache and higher RBC counts.
This study proved that in severe cases, PA patients experience vasospasm whereby their growth exceeds the arterial supply hence compressing the vascular structures, among other intrinsic factors including local inflammations. It is always worth mentioning prolactinomas and non-functioning adenomas, given their higher association with apoplexy compared to different types of tumors [9,10]. Over the years, diabetes has also been known to be a significant cause of pituitary apoplexy, given the degenerative changes in the microvasculature glands among patients diagnosed with pituitary apoplexy [11,12]. Regardless, research argues that diabetes ketoacidosis often precipitates with apoplectic episodes. The conditions are life-threatening, given its association with insulin resistance and the uncontrollable type I diabetes.
Pathophysiology of disease
Pituitary Apoplexy (PA) is a fatal disease caused by hemorrhage or acute ischemic infarction of the pituitary gland. PA is associated with type 1 diabetes. Type 1 diabetes is a rare condition and can occur at any stage [13-15]. However, it is mostly diagnosed in children, teenagers, and young adults. When one has this condition, the body has complications in producing insulin. This is a result of the stopping of the pancreas cells responsible for producing insulin. Type 1 diabetes may lead to kidney problems such as kidney failure. Diabetes Type 1 is rare in patients with Pituitary Apoplexy on the onset. Studies show that less than 5% of these patients display symptoms of Diabetes Type 1 [16-18]. However, PA may be masked by the secondary failure of the adrenaline, a condition referred to as hypothyroidism. Diabetes Type 1 may be fatal to pediatric patients with PA.
Biochemistry of disease
Most of the biochemical characteristics of the disease were in line with type I diabetes, including the altered mental status of individuals that had been completely resolved during metabolic treatments. Diagnosis of pituitary apoplexy is considered not valid until headaches prompted additional testing [19,20]. Again, aligned symptoms with the diseases included visual abnormalities, persistent headaches, vomiting, and nausea. Serum cortisol was evident in the quarter of the population [21,22]. Gonadotrophin deficiency was apparent in almost half of patients, with thyrotropin deficiency and low serum prolactin in the above quarters of the people.
Genetics of disease
Diabetes type 1 is considered highly inheritable and susceptible. In this case, patients are more likely to suffer from the disease if they have a family member with type 1 diabetes. In either case, parents and siblings who have developed cases of type 1 diabetes have higher chances of hereditary affecting other individuals in the family. Only in rare instances does genetics affect pituitary apoplexy . However, with diabetes, individuals whose either parent or sibling present with such diagnoses make them at higher risk of PA.
Diabetes Type 1 causes an increase in the levels of glucose in the blood. An increase in the glucose levels causes the growth of larger pituitary tumors, referred to as macro-adenomas. Diabetes Type 1 happens when the pituitary gland and the hypothalamus, fail to produce enough vasopressin or the Anti-Diuretic Hormone (ADH). This hormone is responsible for maintaining the water balance in the body. If one has type 1 diabetes, the body may fail to balance the fluid levels [24,25]. Constant thirst is the most common symptom when these glands fail to produce vasopressin. Damage to the hypothalamus and pituitary gland from a tumor or surgery or illness may increase the chances of type 1 diabetes. This may, in turn, affect the usual production, storage, and release of ADH . If the kidneys fail to hold water, the body may get thirsty, triggering one to be thirsty. Clinical presentation of PA is accompanied by severe headache, diplopia, visual impairment, and vomiting. However, subclinical tumor bleeding may be identified by imaging exams . Almost 50% of patients with PA had previously been diagnosed with pituitary adenoma. An adenoma may lead to apoplexy due to compression of vascular structures as a result of resistance of arterial blood supply. However, prolactinomas and non-functioning adenomas may also increase the risk of apoplexy. This condition may, therefore, stimulate numerous neurological complications and diseases.
The clinical analysis of the disease
The typical clinical features of PA are the occurrence of headache in the retro-orbital location. The headaches are severe, and sudden can lead to the emergence of other symptoms. The potential factors leading to the problem is due to Dura-mater compression, meningeal irritation, or sellar walls enlargement . Clinically, PA also results in endocrine dysfunction, with most patients presenting with adrenocorticotrophic hormone deficiency and hypo-secretion. Clinical research shows that there is a high occurrence of pediatric invasive PA is high. Research shows that the use of MRI and CT is crucial in diagnosing PA. The primary intervention on patients with hemodynamic instability is the administration of hydrocortisone and intravenous fluid [29-31]. Due to the increase in cases of children and adolescents at the risk of pituitary apoplexy, clinicians must show awareness while treating pituitary adenomas.
THE UNANSWERED QUESTIONS
Further research is needed to investigate the precise physiopathology of pituitary apoplexy. Researchers should also focus on confirming how systemic hypertension, which results in increased blood flow, is associated with both PA and diabetes type 1.
This research shows that pituitary apoplexy is a rare disease that is associated with diabetes type 1 in pediatric patients. Increased blood flow and imbalance stimulation of the pituitary gland impacts the pituitary adenoma level, which, as a result, increases complications among PA pediatric patients. PA is commonly caused when the benign tumor of the pituitary bleeds. These tumors are rarely diagnosed. When these tumors enlarge, the pituitary may be damaged. Enlargement of these tumors may either flow into the pituitary or block the supply of blood. Diabetes may increase the chance of occurrence of PA in individuals without an enlarged cyst. However, the study indicates that although PA can occur spontaneously with type 1 diabetes, there are various underlying risk factors linked to the condition.
- Camara-Lemarroy CR, Infante-Valenzuela A, Rodriguez-Velver K, Rodriguez-Gutierrez R, Villareal-Velazquez HJ (2016) Pituitary apoplexy presenting as diabetic ketoacidosis: A great simulator? Neuro Endocrinol Lett 37: 9-11.
- Merwitz BJ, Zamparini JM, Raal FJ (2016) Pituitary apoplexy masquerading as meningitis. Journal of Endocrinology, Metabolism, and Diabetes of South Africa 21: 38-39.
- Thomas N, Simon R, Chacko G, Chacko A, Chandy MJ, et al. (1999) Regression of acromegaly following pituitary apoplexy. Neurology India 47: 161-162.
- Jiang HJ, Hung WW, Hsiao PJ (2013) A case of acromegaly complicated with diabetic ketoacidosis, pituitary apoplexy, and lymphoma. Kaohsiung J Med Sci 29: 687-690.
- Cinar N, Metin Y, Dagdelen S, Ziyal MI, Soylemezoglu F, et al. (2013) Spontaneous remission of acromegaly after infarctive apoplexy with a possible relation to MRI and diabetes mellitus. Neuro Endocrinol Lett 34: 339-342.
- Salehi N, Firek A, Munir I (2018) Pituitary Apoplexy Presenting as Ophthalmoplegia and Altered Level of Consciousness without Headache. Case Rep Endocrinol 2018: 7124364.
- Paz-Ibarra J, Siura G, Quinto F, Ticona C (2019) Diabetic ketoacidosis post surgery of an insulinoma. Endocrine Practice 25: 235-236.
- Mittal A, Mishra S, Yadav K, Rajput R (2019) Uncontrolled diabetes as a rare presenting cause of pituitary apoplexy. BMJ Case Rep 12:
- Matfin G, Evans K, Dhatariya K (2018) Emergency Perioperative Diabetes and Endocrine Management. Endocrine and Metabolic Medical Emergencies: A Clinician's Guide 2: 129.
- Abunimer AM, Abou-Al-Shaar H, Azab MA, Karsy M, Guan J, et al. (2019) Transsphenoidal Approaches for Microsurgical Resection of Pituitary Adenomas in Pediatric Patients. World neurosurg 123: 186-193.
- Zilker H, Schagen S, Wit JM, Biermasz N, van Furth W, et al. (2017) Pituitary Adenoma Apoplexy in an Adolescent: A Case Report and Review of the Literature. J Clin Res Pediatr Endocrinol 9: 265-273.
- Ferdous HS, Afsana F, Qureshi N, Rouf RS, Parvez AA, et al. (2016) Recent Advancement on Current Trend in the Management of Endocrine Emergency in Critically Ill Patient. Journal of Medicine 17: 100-108.
- Mehrazin M (2007) Pituitary tumors in children: clinical analysis of 21 cases. Child's Nervous System 23: 391-398.
- Voss LD, Kirkby J, Metcalf BS, Jeffery AN, O'Riordan C, et al. (2003) Preventable factors in childhood that lead to insulin resistance, diabetes mellitus and the metabolic syndrome: the EarlyBird diabetes study 1. J Pediatr Endocrinol Metab 16: 1211-1124.
- Jankowski PP, Crawford JR, Khanna P, Malicki DM, Ciacci JD, et al. (2015) Pituitary tumor apoplexy in adolescents. World neurosurgery 83: 644-651.
- Rahman SH, Chittibonia P, Quezado M, Patronas N, Stratakis CA, et al. (2016) Delayed diagnosis of Cushing's disease in a pediatric patient due to apparent remission from spontaneous apoplexy. Journal of Clinical and Translational Endocrinology: Case Reports 2: 30-34.
- Romano A, Rigante D, Cipolla C (2019) Autoimmune phenomena involving the pituitary gland in children: New developing data about diagnosis and treatment. Autoimmunity Rev 8: 102363.
- Jemel M, Alaya W, Boubaker F, Berrich O, Zantour B (2018) Pituitary Apoplexy. InPituitary Diseases IntechOpen. London, UK.
- Sweeney AT, Blake MA, Adelman LS, Habeebulla S, Nachtigall LB, et al. (2004) Pituitary apoplexy precipitating diabetes insipidus. Endocrine Pract 10: 135-138.
- Glezer A, Bronstein MD (2015) Pituitary apoplexy: pathophysiology, diagnosis and management. Arch Endocrinol Metab 59: 259-264.
- Briet C, Salenave S, Bonneville JF, Laws ER, Chanson P (2015) Pituitary apoplexy. Endocrine reviews 36: 622-645.
- Rutkowski MJ, Kunwar S, Blevins L, Aghi MK (2017) Surgical intervention for pituitary apoplexy: an analysis of functional outcomes. Journal of neurosurgery 129: 417-424.
- Small J, Noujaim D, Ginat D, Kelly H, Schaefer P (2018) Neuroradiology: Spectrum and Evolution of Disease (1st edn). Elsevier, Amsterdam, Netherlands.
- Rajasekaran S, Vanderpump M, Baldeweg S, Drake W, Reddy N, et al. (2011) UK guidelines for the management of pituitary apoplexy. Clinical endocrinol 74: 9-20.
- Pal A, Capatina C, Tenreiro AP, Guardiola PD, Byrne JV, et al. (2011) Pituitary apoplexy in non-functioning pituitary adenomas: long term follow up is important because of significant numbers of tumour recurrences. Clinical endocrinol 75: 501-504.
- Gondim JA, de Albuquerque LA, Almeida JP, Bulcao T, Gomes E, et al. (2017) Endoscopic endonasal surgery for treatment of pituitary apoplexy: 16 years of experience in a specialized pituitary center. World neurosurg 108: 137-142.
- Lubbe DE, Mankahla N, Carrara H, Semple P (2019) Surgical intervention for binocular blindness in pituitary apoplexy. Interdisciplinary Neurosurgery 18: 100490.
- Nieman LK, Lacroix A, Martin K (2018) Clinical manifestations of adrenal insufficiency in adults. UpToDate, Massachusetts, USA.
- Kelly PD, Fernando SJ, Malenke JA, Chandra RK, Turner JH, et al. (2020) The Effect of Timing of Surgery in Pituitary Apoplexy on Continuously Valued Visual Acuity. X-Mol, Beijing, China.
- Tu M, Lu Q, Zhu P, Zheng W (2016) Surgical versus non-surgical treatment for pituitary apoplexy: A systematic review and meta-analysis. Journal of the neurological sciences 370: 258-262.
- Pangal DJ, Chesney K, Memel Z, Bonney PA, Strickland BA, et al. (2020) Pituitary Apoplexy Case Series: Outcomes After Endoscopic Endonasal Transsphenoidal Surgery at a Single Tertiary Center. World Neurosurgery 137: 366-372.
Citation: Adjepong D, Sarpong DB, Shidaa NO, Amoateng K (2020) The Effect of Diabetes Type 1 on Pituitary Apoplexy in Pediatric Patients. J Surg Curr Trend Innov 4: 043.
Copyright: © 2020 Dennis Adjepong, MD, MBA, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.