Endocrine Abstracts

A 60-year-old Caucasian male was referred to our Endocrine unit with symptoms suggestive of adrenal failure (malaise and fatigue).

A Synachten test confirmed the diagnosis (baseline cortisol <5 nmol/l, post Synachten 74 nmol/l) and indicated secondary adrenal failure (baseline ACTH undetectable). Further hormonal tests showed secondary hypothyroidism (TSH 0.43 mU/ml, FT4 7.1 pmol/l) and hypogonadism (testosterone <0.7 nmol/l, LH 0.6 U/l). Prolactin was undetectable but IGF1 levels were normal. A pituitary MRI scan showed only a slight enlargement of the hypophysis and the stalk. Our patient was started on triple hormone replacement therapy. A repeated pituitary MRI scan (ten months after the original) showed a comparative improvement with reduction in the size of the pituitary and the stalk.

We reviewed the patient’s previous records in order to find a possible explanation for his panhypopituitarism. He had been recently assessed for recurrent episodes of myalgia associated with an evanescent skin rash and he had been found to have high titre of ANCA with a perinuclear pattern. We then considered a diagnosis of Wegener’s disease with pituitary involvement. Our patient denied symptoms suggestive of respiratory or ENT pathology. His urine dipstick and serum creatinine were consistently normal. Chest XR and a high-resolution CT scan were both normal. CT guided biopsy of the maxillary sinuses showed inflammation of the capillaries but no granulomas.

Conclusions.

Although our patient did not meet the criteria for Wegener’s disease, the reason for his hypopituitarism and the high titre ANCA levels remains unclear. The final diagnosis remains open and include possible atypical early Wegener’s disease, non-specific ANCA-related vasculitis with pituitary involvement or lymphocytic hypophysitis.