Endocrine Abstracts

Introduction: We report a case of a pituitary insufficiency apparently resistant to treatment.

Case report: A 74 year old patient was admitted through the ER in our department for a recently discovered pituitary macroadenoma. His general condition was poor in spite of the initiation of corticotherapy. Evaluation: Smoker, with no significant medical history, the BP: 100/60 mmHg, no orthostatic hypotension, disoriented, confused, with moderately altered general state and no visual deficit. Biologically: normal ionogram, TSH: 0.076 mcIU/ml, fT₄: 0.767 ng/dl, total T₃ <40 ng/dl, prolactin: 21.5 ng/dl, IGF1: 84.8 ng/ (low). He had leukocytosis, high neutrophils, but normal markers of inflammation. No causes of infection were found, but the clinical condition worsened in the next 2 days despite an i.v. with Hydrocortisone and oral Levothyroxine. Additional imaging studies showed an adenoma of 3.4/2.8/3.8 cm, with a mass effect on the optic chiasm, multiple secondary lesions in the upper and infratentorial regions at the cerebral MRI. During the neck ultrasound we found a multinodular goiter with a large nodule of 1.53/1.33 cm with multiple large pathological laterocervical adenopathies. The thoraco-abdomino-pelvic CT found a large pulmonary mass of 45/49 mm in the left lung, some osteholytic lesions in the right ribs and body of L5, a large cephalic pancreatic lesion of 35/24 mm and bilateral adrenal metastatic lesions. At that moment we thought that the pituitary macroadenoma was highly probable to be a metastatic lesion with multiple options regarding the origin of the primary neoplasia. The biopsy of an excised cervical adenopathy showed an aggressive neuroendocrine tumour as the probable cause, diagnosis which was unfortunately sustained by the lethal outcome of the patient.

Conclusion: The pituitary insufficiency in normally a benign condition which responds to treatment and has a favourable outcome; if this is not the case we must search for additional causes of poor responders.