Endocrine Abstracts

A 34-year-old African woman presented with a 4-month history of profound lethargy, weight loss and a 3-day history of vomiting, fever, confusion, and drowsiness. She had given birth to her third child 6 months previously. Her pregnancy and delivery were uncomplicated and she had breastfed for 5 months prior to discontinuing due to exhaustion.

Investigations showed severe hypercalcaemia (4.94 mmol/l) and undetectable PTH. Hypercalcaemia was unresponsive to intense fluid rehydration, calcitonin and i.v. pamidronate. Emergency haemodialysis was required to reduce serum calcium to a safe level.

Further investigations showed severe cortisol deficiency (34 nmol/l) with undetectable ACTH and mild T₃ thyrotoxicosis, (fT₃ 7.5 pmol/l, normal fT₄ and suppressed TSH). Pituitary MRI showed no pituitary mass or significant radiological abnormality. Insulin stress test performed 2 months after discharge confirmed profound hypocortisolaemia (cortisol <30 nmol/l at all test points with normal growth hormone response (peak of 10.80 μg/l).

The patient was treated with hydrocortisone, initially i.v. and then converted to orally (10 mg twice a day). Her symptoms dramatically improved following cortisol replacement and normalisation of serum calcium.

The patient subsequently developed hypocalcaemia, with serum calcium falling to a nadir of 1.79 mmol/l. This was treated and corrected with alfacalcidol and calcium supplementation.

Discussion: This case demonstrates the emergency management of severe hypercalcaemia including the use of dialysis. The etiology of the hypercalcaemia is a combination of thyroiditis and cortisol deficiency, both of which are known to cause this. Cortisol deficiency is, in turn, due to ACTH deficiency in the presence of an apparently structurally normal pituitary gland. The presumed underlying cause is combined postpartum hypophysitis and postpartum thyroiditis. This combined presentation with hypercalcaemia is extremely rare.

The treatment given led to a subsequent hypocalcaemic phase which can be regarded as a form of hungry bone syndrome.