Endocrine Abstracts

Hypopituitarism as a consequence of snake bite is rare. However, there are a few case reports from India and adjacent South-East Asian countries. We present a case of hypopituitarism secondary to snake bite where the diagnosis was significantly delayed. A 42-year-old gentleman presented as out-patient with a 10 years history of generalized weakness, lethargy, coarse facial features, reduced libido, reduced socialization and depression. He had an acute illness following a snake bite 15 years ago. He was also diagnosed with hypothyroidism 11 years ago. The snake bite was associated with altered sensorium and acute renal failure requiring dialysis for several days. He was managed by general physicians who diagnosed hypothyroidism and commenced levothyroxine. His symptoms persisted, for which his levothyroxine dosage was reorganized many times and multivitamins prescribed. Review of the original TFTs were consistent with secondary hypothyroidism, which had been overlooked by his treating physicians. Further investigations revealed fT₄ 8.6 (9.0–20.0) pmol/l, TT₃ 1.32 (0.6–1.80) ng/ml, TSH 0.00 (0.35–5.5) μIU/ml, 8am cortisol 0.00 (4.30–22.40) mg/dl, ACTH 6.10 (7.2–63.3) pg/ml, LH <0.10 (1.1–7.0) mIU/ml, FSH <0.10 (1.7–12) mIU/ml, GH <0.05 (0.00–4.00) ng/ml, IGF1 <25 (101.00–267.00) ng/ml, IGFBP3 1.01 (3.30–6.60) μg/ml, and testosterone <0.10 (3.0–10.6) ng/ml. Pituitary MRI Scan revealed an ‘Empty Sella’. Hypopituitarism was diagnosed and he was immediately commenced on Hydrocortisone 10-5-5 mgs. He was subsequently started on Testosterone gel, later changing to testosterone depot injections 10 weekly. His symptoms improved significantly over a few weeks.

Discussion: The type of snake bitten determines the symptoms and signs of envenomation. Viper bites are venomous and cause altered sensorium, coagulopathy, internal bleeding, hypotension, tachycardia, renal and respiratory failure. Our patient’s symptoms were consistent with a viper bite. His hypopituitarism and secondary hypothyroidism remained undiagnosed leading to physical and mental suffering for more than 10 years. We suspect that the patient developed pituitary apoplexy and chronic hypopituitarism resulting from the snake bite. Endocrinologists should be aware of the possibility of hypopituitarism in patients who suffer a snake bite.