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We describe a year-old female that has presented an AVN with Cushing's syndrome. Biochemical investigations confirmed HC. Magnetic resonance imaging MRI showed a pituitary adenoma that was resected transsphenoidally. The postoperative failure directed to radiosurgery treatment. Then, the patient then expressed a significant clinical improvement while developing adrenocorticotropic deficiency; hence, steroids were indicated. During the discovery of Cushing disease, the patient presented also limping and progressive pain in right hip.
The patient underwent a total replacement of the right hip sine presenting an extensive AVN. This case elucidates that AVN could be an early manifestation of Cushing's disease. Most corticosteroid cases are inducing osteonecrosis that is caused by exogenous doses of corticosteroid. A few case reports have described avascular osteonecrosis of the femoral head associated with endogenous hypercortisolism HC.
This article presents a case of avascular osteonecrosis caused by Cushing's disease in a young woman and discusses the clinical features of literature review. The patient was admitted in our department for Cushing's syndrome CS. The patient had never been treated with oral, inhaled, or locally applied corticosteroids. The patient reported weight gain and secondary amenorrhea.
Once the initiating insult has been stabilized, electrolyte and fluid management often continues to occupy a central component of therapy, and is usually directed at trying to re-establish physiologically appropriate interstitial and vascular compartment volumes. Despite 30 years of research, basic questions are still debated concerning the type of fluid to administer blood products, artificial colloids, or crystalloids , the amount of fluid to administer the choice and measurement of appropriate physiological indices , and the clinical scenario wherein fluids should be administered acute trauma, head injury, sepsis, major surgery, or heart- renal- or hepatic failure, etc.
By extension, proper fluid and electrolyte management is better than inappropriate management. While the answer may be unsatisfying to residents, they can be re-assured that the answer s becomes clearer after they gain a thorough understanding of the physiology of fluid and electrolytes and once they acquire several years of experience.
In their paper in the current issue of the Journal, Stelfox et al. The answer as to why acutely ill patients develop changes in fluid and electrolyte status is partly a function of: 1 the effects of the initial insult on control mechanisms; 2 the unavoidable consequences of therapy in patients whose normal regulatory abilities are attenuated; and 3 perhaps a certain lack of appreciation of the complexity of the physiology of sodium and compartment regulation. A case in point is the use of normal saline as a maintenance solution in the stable yet critically ill patient.
It is common knowledge that it is lethal to drink sea water because it is too salty and results in hypernatremia, hyperosmolality, dehydration, and, ultimately, renal failure and death. It often comes as a surprise for residents to learn that this concentration is 0. A healthy person loses water at a greater rate than salt loss through respiratory, cutaneous, gastrointestinal, and urinary routes. Therefore, maintenance solutions require significantly more free water, e. A brief review of the underlying physics of compartment physiology illustrates the complexity of salt and volume regulation.
The simplest two-compartment system is exemplified by the Donnan equilibrium established by the movement of water and salts between two compartments separated by a semi-permeable membrane, and one of the compartments contains a non-transfusable charged colloid as in an erythrocyte. Electrochemical gradients described by the Nernst equation determine the distribution of a given electrolyte on either side of the membrane.
While correct, the Nernst equation is only a partial description of this system. Unpublished lecture notes by Stewart described in Wilkes , 8 demonstrate that a complete description of electrolyte distribution in a simple Donnan system requires the simultaneous solution of 11 equations with three independent variables.
The physics becomes more complicated when the system is defined by a capillary bed. As is well known, the Starling equation describes the interplay between hydrostatic and oncotic pressures. While the equation itself would seem straightforward, there is an underlying layer of complexity that is not inherently obvious. Understanding normal physiology is not easy; thus, it is not surprising that treatment of pathophysiology is even more challenging.
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