Autoimmune hypophysitis: Anesthetic implications

• DOI: 10.4103/0970-9185.101951
• Publication Date: 2012-10-04T05:55:29Z
• Authors: RochanaG Bakhshi; SheetalR Jagtap
• Keywords: Pituitary stalk; Hypophysitis; Prednisolone

Sir, Autoimmune disease of the pituitary is rare and poorly understood as a pathologic entity.[1] The purpose reporting this case rarity disease, especially in males, scarce literature on such patients presenting for other than transphenoid surgery autoimmune hypophysitis (AH). An 80 kg, 60-year-old man was scheduled fractured tibia surgery. One year ago, patient had presented with headache, vomiting, delirium, incoherent speech diagnosed to have AH central hypothyroidism hypocortisolism. MRI brain revealed an intrasellar enhancing lesion thick nontapering stalk enhancement adjacent dura suggestive [Figure 1]. Patient responded high doses steroids (prednisolone 20 mg three times day) 2]. Presently, he prednisolone 2.5 once day thyroxine 100 mcg. Preoperative biochemical investigations including thyroid function tests, electrocardiogram, X-ray chest, 2D echocardiography were within normal limits.Figure 1: (a) coronal section showing or macroadenoma. (b) sagittal macroadenomaFigure 2: post-treatment shrunken flattened anterior giving empty sella appearancePatient received his morning dose thyroxin prednisolone. Intravenous (IV) infusion Ringer's lactate started hydrocortisone given. Routine monitors attached. Combined spinal epidural anesthesia administered by injection 3.2 ml 0.5% heavy bupivacaine 1 preservative free midazolam into subarachnoid space. Sensory loss achieved up T8 level. did not require supplementation lasted one half hours. hemodynamically stable all throughout procedure. 2 L crystalloid IV perioperatively. Postoperative analgesia using top ups tramadol. Hydrocortisone 6 hourly till oral medication restarted. Recovery uneventful discharged 8th postoperative day. lymphocytic defined below production more hormones due gland dysfunction origin. estimated incidence nine million per year[1] higher prevalence among females.[2] destruction may take 12–40 years produce symptoms. initially enlarges edematous, which results pressure structures causing visual disturbances, etc.[34] Subsequently, there atrophy gland. Adrenocorticotropin releasing hormone (ACTH) deficit usually earliest most frequent hormonal impairment. Our Surgery potent activators hypothalamic adrenal (HPA) axis. Cortisol (CRH), ACTH, cortisol levels increase significantly intact normally functioning HPA axis, during anesthesia. This response absent they can crisis intraoperatively.[5] Regional preferred group whenever possible, while ensuring adequate maintenance intravascular fluid volume prevent acute hypotensive crisis. Patients need vigilant monitoring cardiovascular instability.[5] moderate local anesthetic some extent perioperative reduction stress response. However, amide metabolism slow predisposing systemic toxicity hypothyroidism. All drugs must be carefully avoid myxedema coma.