Endocrine Abstracts

Case history: An 80-year-old female presented with progressive leg and facial swelling, postural dizziness, generalised lethargy and reduced mobility. She suffered with chronic kidney disease (stage 3), rheumatoid arthritis and hypertension and had undergone partial thyroidectomy. Examination revealed marked bilateral leg oedema to the sacrum, facial oedema, an ejection systolic murmur, normal JVP and a clear chest.

Investigations and results: Investigations showed serum sodium 124 mmol/l (133–146), creatinine 70 umol/l (55–110), albumin 32 g/l (35–50), BNP 44.7 ng/l (<266), and normal liver function and glucose. Urinalysis showed trace proteinuria; urine protein:creatinine ratio 79 mg/mmol (<20). Echocardiography showed mild aortic stenosis, preserved ejection fraction and no evidence of diastolic dysfunction. Heart failure, nephrotic syndrome and hypoalbuminaemia were thus excluded. Computed tomography showed no masses. Mild, but not adequate, rise in serum sodium was achieved with intravenous diuresis. Endocrine tests showed fT4 8.0 pmol/l (9–23), TSH 2.28 milliunit/l (0.3–4.2), Oestradiol <70 pmol/l, LH <0.5 IU/l, FSH 0.5 IU/l, Prolactin 1,473 milliunit/l (100–500). Short synacthen test showed baseline cortisol 269 nmol/l, ACTH <5.0 ng/l and peak cortisol 450 nmol/l, inadequate in the presence of intercurrent urinary tract infection. MRI of the pituitary showed an expanded pituitary fossa containing homogenously enhancing preserved pituitary tissue within the floor and lateral margins of the sella, raising the possibility of a previous haemorrhagic nodular adenoma or intrasellar craniopharingioma.

Treatment: A diagnosis of panhypopituitarism with partial loss of the HPA axis was made. She was started on hormone replacement with Levothyroxine after acute hydrocortisone replacement on the ward. Serum sodium normalised to 134 mmol/l. Hydrocortisone is to be taken only in the context of any acute illness in the future.

Discussion: Oedema is a rare sign of panhypopituitarism. Several case reports have reported non-specific symptoms of central (and peripheral) cortisol deficiency in the elderly, but review of the literature found no cases where oedema was the sole presenting symptom. The diagnosis should be considered in cases of unexplained oedema, which ensues in the context of inability to excrete free water due to hypocortisolaemia.