Response: Russell’s viper envenomation: acute hypopituitarism or acute primary adrenal insufficiency

We read with interest the points raised by Dr Krishnamurthy and Dr Vishnu about the distinction between acute hypopituitarism (AHP) and adrenal insufficiency related to Russell's viper envenomation (RVE). We strongly encourage them to read the supplementary materialsupplementary material provided with our manuscript.¹ Firstly, autopsy was performed on two of the four patients that died and it showed pituitary necrosis in both (Supplementary Table 2Supplementary Table 2). In the survivors (2, 3, 5), there was demonstrable hyposecretion of at least one other pituitary hormone apart from TSH and low cortisol in the acute setting (Supplementary Table 2Supplementary Table 2). In all the survivors, including the two cases without acute hormonal results (Cases 8 and 9) follow up showed persisting low cortisol, Thyroid-stimulating hormone (TSH) and Prolactin or testosterone at 3 months. Prednisolone and thyroxine replacement has been continued in all, including GH replacement for Case 9. Secondly, abnormalities in imaging are neither needed nor enough to support a diagnosis of AHP; pituitary imaging has been described to be normal in published cases of RVE-HP.² Thirdly, we do not agree with the statement that the combination of hypotension and hypoglycemia in the setting of RVE occurs with isolated capillary leak, major bleeding, renal or hepatic dysfunction; these are probably cases of AHP that are being missed by the authors. Fourthly, the aim of our manuscript was to describe a series of well-characterized patients of RVE-AHP so that a diagnosis of AHP is suspected prospectively in this setting thereby triggering steroidal replacement therapy. As we have pointed out in our manuscript, several cases of de-novo chronic HP related to RVE continue to be reported suggesting significant under-recognition of AHP with associated mortality. We believe, and it is our practice, to make the final diagnosis of AHP retrospectively with repeat biochemical testing at follow-up after withdrawing replacement under supervision. Finally, we agree that availability of ACTH results in the acute setting could have made our manuscript more robust but funding for this test was unavailable at the time of writing this manuscript and results are usually unavailable for weeks in our institution.

from # All Medicine by Alexandros G. Sfakianakis via alkiviadis.1961 on Inoreader http://ift.tt/2uRZlpi