Endocrine Abstracts

A 60-year-old gentleman known to suffer from atrial fibrillation (on warfarin therapy), hypertension and beta-thalassemia trait presented to the endocrine clinic for follow-up of hypothyroidism for which he was started on levothyroxine by his general practitioner about 2 years before. Serial thyroid function tests revealed a progressive reduction in thyroid stimulating hormone (TSH) levels in the setting of a decline in free thyroxine (fT4) levels. The patient denied any history of headaches, visual disturbances or symptoms suggestive of any relevant hormone deficiency, other than a long-standing history of easy fatiguability and mild weight loss. There was no past surgical history. He was married with three children and was an ex-smoker. On examination, the parameters were stable with no postural hypotension. He had very sparse body hair. However, systemic examination was otherwise unremarkable. A full pituitary hormone profile confirmed panhypopituitarism as outlined below:

TSH 0.645 mIU/L (0.3–3) ↓

fT4 10.3 pmol/L (11–18) ↓

10 am cortisol 21 nmol/L (119–618) ↓

FSH 2.4 U/L (0.7–11.1)

LH 1.1 U/L (0.8–7.6)

Prolactin 339 mU/L (53–360)

Oestradiol 79.7 pmol/L (0–206)

Testosterone < 0.69 nmol/L (4.47–29.57) ↓

GH <0.05 ug/L (0–3)

IGF-1 20 ng/Ml (41–189) ↓

ACTH 20 pg/mL (10–48)

Serum osmolality 297 mOsmol/kg

Urine osmolality 502 mOsmol/kg

An MR of the pituitary showed a large pituitary macroadenoma containing large areas of haemorrhage. The adenoma itself had a craniocaudal diameter of 2.8 cm, an anteroposterior diameter of 2.4 cm and a transverse diameter of 2.3 cm. The haemorrhage within the adenoma measured 2 cm × 1.7 cm × 1.7 cm. Superiorly, the adenoma was compressing the optic chiasm, also invading the left cavernous sinus in close proximity to the left internal carotid artery. Formal Goldmann perimetry showed a relative temporal visual field defect. He was commenced on lifelong hydrocortisone replacement therapy at 10mg-5mg-5mg. A hydrocortisone emergency pack was given together with a steroid card. The patient was re-assessed within a few days from the MRI. He denied any headaches, other than few hours of mild to moderate headaches (severity scaled 6 out of 10) occurring a few days after his MRI had been carried out. There was no diplopia or extraocular muscle weakness. Warfarin therapy was immediately stopped. He underwent transsphenoidal resection of the pituitary adenoma. There were no perioperative or postoperative complications. On follow-up, he remained clinically well and his visual fields improved.