Endocrine Abstracts

A 45-year-old man was found wandering in the streets by the Ambulance Service. He complained of productive cough with haemoptysis. On examination he was cachectic with clubbing, and he was confused (abbreviated mental test score 1/10). Chest XR showed left hilar and perihilar air space shadowing. He was treated for a community acquired pneumonia. A CT scan of the head showed a mass lesion in the pituitary fossa, confirmed on an MRI scan.

Assessment of his anterior pituitary function showed 0900 h Cortisol 12 nmol/l, TSH 0.78 mU/l, FT₄ 6.6 pmol/l, IGF1 6.9 nmol/l, Testosterone <0.01 nmol/l, LH 0.1 U/l, and FSH 0.5 U/l. He was started on corticosteroid replacement with hydrocortisone, followed by levothyroxine and i.m. testosterone undecanoate. Interestingly he did not have diabetes insipidus. On thoracic and abdominal CT scanning a left proximal upper lobe lung mass was identified with liver metastasis. The biopsy of the lung mass was consistent with a squamous cell carcinoma. The diagnosis was therefore made of a secondary metastasis to the pituitary.

On hormone replacement, his mental state improved (AMT 8/10). He was given advice regarding his steroid replacement, an emergency hydrocortisone pack to use parenterally should he become unwell, a steroid card and a Dossette box for his medicines. Unfortunately, two months later he was readmitted with Addisonian crisis due to non-compliance with the glucocorticoid replacement. The hydrocortisone was changed to the longer acting dexamethasone once a day. Daily district nursing support was arranged to ensure compliance and safe discharge.

Pituitary metastases occur in between 1 and 3.6% of patients with malignant tumours. This case illustrates a vulnerable adult with multiple anterior pituitary hormone deficiencies secondary to metastasis from lung cancer and emphasises the importance of individualised management.