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Hypopituitarism can be caused by either hypothalamic or pituitary dysfunction Patients with hypopituitarism may have single or multiple hormonal deficiencies (Table 26 1) When one hormonal deficiency is discovered, others must be sought Mass lesions causing hypopituitarism include pituitary adenomas, granulomas, Rathke s cleft cysts, apoplexy, metastatic carcinomas, aneurysms, and brain tumors such as craniopharyngioma, meningioma, germinoma, glioma, chondrosarcoma, and chordoma of the clivus Langerhans cell histiocytosis usually presents in youth with diabetes insipidus or hypopituitarism Osteolytic bone lesions are noted on radiographs Autoimmune hypophysitis, postpartum pituitary necrosis (Sheehan s syndrome), eclampsia preeclampsia, sickle cell disease, and African trypanosomiasis are rare causes A pituitary tumor may be part of the syndrome of multiple endocrine neoplasia type 1 (MEN 1), with tumors of the parathyroid glands and pancreatic islets Hypopituitarism without mass lesions may be genetic or idiopathic, or may be caused by trauma, cranial radiation, surgery, encephalitis, hemochromatosis, autoimmunity, or stroke It may also occur after coronary artery bypass grafting About 25 30% of survivors of moderate to severe traumatic brain injury (Glasgow coma scale 13/15) have at least one anterior pituitary hormone deficiency Following aneurysmal subarachnoid hemorrhage, at least one pituitary hormone deficiency develops in about 55% of survivors Physiologic isolated hypogonadotrophic hypogonadism is common, occurring with severe illness, malnutrition, and extreme prolonged exercise (in women) It is also commonly found among obese patients with type 2 diabetes mellitus Long-term intrathecal administration of opioids causes hypogonadotropic hypogonadism in the overwhelming majority of patients; GH deficiency and secondary adrenal insufficiency each occurs in about 15% of such patients High-dose oral methadone can also cause hypogonadotropic hypogonadism that may persist after stopping the drug Congenital combined pituitary hormone deficiency occurs in about 1:8000 births Depending on the genetic defect, it may be transmitted as an autosomal recessive, autosomal

Loss of one, all, or any combination of anterior pituitary hormones Adrenocorticotropic hormone deficiency reduces adrenal secretion of cortisol, testosterone, and epinephrine; aldosterone secretion remains intact Growth hormone (GH) deficiency in children causes decreased growth velocity and short stature; GH deficiency in adults causes asthenia, obesity, and increased cardiac mortality Prolactin deficiency inhibits postpartum lactation Thyroid-stimulating hormone deficiency causes secondary hypothyroidism Luteinizing hormone and follicle-stimulating hormone deficiency cause hypogonadism and infertility in men and women

(x == 3) || (y == 7)

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larly if they are also hypoadrenal Men may note diminished beard growth Libido is diminished Women have amenorrhea; men note decreased erections Most patients are infertile Androgen deficiency predisposes patients to osteopenia and muscle atrophy (See section on secondary amenorrhea) Thyroid-stimulating hormone (TSH) deficiency causes hypothyroidism with manifestations such as fatigue, weakness, weight change, and hyperlipidemia (See Hypothyroidism and Myxedema) Adrenocorticotropic hormone (ACTH) deficiency results in diminished cortisol secretion (see Adrenocortical Hypofunction) Symptoms may include weakness, fatigue, weight loss, and hypotension Patients with partial ACTH deficiency continue to have some cortisol secretion and may not have symptoms until stressed by illness or surgery Adrenal mineralocorticoid secretion continues, so manifestations of adrenal insufficiency in hypopituitarism are usually less striking than in bilateral adrenal gland destruction (Addison s disease); hyponatremia may occur, especially when ACTH and TSH deficiencies are both present GH deficiency in adulthood tends to cause mild to moderate central obesity, increased systolic blood pressure, and relative increases in low-density lipoprotein (LDL) cholesterol GH deficiency also results in a small heart with reduced cardiac output, asthenia, and feelings of social isolation Panhypopituitarism is the absence of all anterior pituitary hormones Combined pituitary hormone deficiency (CPHD) refers to a deficiency of several anterior pituitary hormones CPHD gradually develops in patients with PROP1 gene mutations, usually presenting with short stature and growth failure due to GH and TSH deficiency; lack of pubertal development occurs due to deficiencies in FSH and LH ACTH-cortisol deficiency gradually develops in patients with PROP1 gene mutations; these patients typically require corticosteroid replacement therapy by age 18 years In addition to the manifestations noted above, patients with long-standing hypopituitarism tend to have dry, pale, finely textured skin The face has fine wrinkles and an apathetic countenance

Unless erysipelas is promptly treated, death may result from extension of the process and systemic toxicity, particularly in the elderly

Place the patient at bed rest with the head of the bed elevated Intravenous antibiotics effective against group A -hemolytic streptococci and staphylococci are indicated for the first 48 hours in all but the mildest cases A 7-day course is completed with penicillin VK, 250 mg, dicloxacillin, 250 mg, or a first-generation cephalosporin, 250 mg, orally four times a day Alternatives in penicillin-allergic patients are clindamycin or erythromycin, the latter only if the infection is known to be due to streptococci

the entire expression evaluates true because one side (y == 7) is true. With a not operator, the statement is true if the expression is false, and vice versa. So, in the accompanying example:

Leukocytosis or at least a neutrophilia (left shift) is present from early in the course Blood cultures may be positive If a central ulceration, pustule, or abscess is present, culture may be of value Aspiration of the advancing edge has a low yield (20%) and is usually not performed Instead, if an unusual organism is suspected and there is no loculated site to culture, a full thickness skin biopsy taken before antibiotics are given can be useful Part is cultured and part processed for histologic evaluation with Gram stain This technique is particularly useful in the immunocompromised patient

The origin of the UNIX1 operating system can be traced to the time-sharing systems proposed and developed at MIT beginning in the mid-1950s.2 To provide the necessary historical perspective, I ll begin with a brief history of computing and computer operating systems from the 1950s to the inception of UNIX. Against this backdrop, a clear picture of the foundations of the Mac OS X emerges.

Erysipelas was at one time a life-threatening infection It can now usually be quickly controlled with systemic penicillin or erythromycin therapy

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