Endocrine Abstracts

Introduction: Weakness is one of the most common complaints among the patients. Clinical manifestations of a hypopituitarism depend on the extent of hormone deficiency and may be non-specific and thus the diagnosis is often missed. The progressive loss of pituitary hormone secretion is usually a slow process, which can occur over a period of months or years.

Clinical case: A 62 years old women who complained of mild weakness mostly in the evenings in the past 3 months was referred to an endocrinologist in Vilnius University hospital Santaros clinics. Her accompanying documentation reported a background of hypothyroidism, biochemical blood test showed low level of thyroid stimulating hormone (TSH) 0.05 mU/l (normal 0.4–4.1 mU/l), FT4 – 11.90 pmol/l (normal 9.0–19.0 pmol/l). Patient was treated with 75 μg of levothyroxine at least 15 years. Patients medical history revealed primary hypertension, menopauses from age of 30 years old, short period of breastfeeding due to insufficient lactation. Her list of regular medications comprised of valsartan and hydrochlorothiazide. Patient denied any headaches or visual disturbance. She also denied dizziness on standing, but her blood pressures revealed a significant postural drop (110/70 mm Hg lying, 88/64 mm Hg standing).

Management and Outcome: Further pituitary function testing also revealed a low level of prolactin – 31.9 mU/l (108.7–557.1 mU/l), low insulin- like growth factor-1 – 18.8 μg/l (normal 43–220 μg/l), low luteinizing hormone – 0.09 U/l (normal 5.16–61.99 U/l) and low follicle- stimulating hormone – 0.3 U/l (normal 26.72–13.41 U/l). A synacthen stimulation test was arranged which demonstrated an inadequate cortisol response (basal: 139 nmol/l, 30 minutes: 338 nmol/l, 60 minutes: 416 nmol/l) and a baseline ACTH level within the normal range. These results were suggestive of pan- anterior hypopituitarism, and a subsequent MRI pituitary confirmed an almost empty sella with a small area of residual pituitary tissue visible. Finally, we prescribed her hydrocortisone 20 mg and levothyroxine 0.1 mg daily. In subsequent follow-up the patient’s symptoms resolved and her life status had improved.

Conclusion: High index of suspicion is required to seek hypopituitarism in patients with non-specific symptoms such as mild weakness. In our case, the diagnosis and treatment of his hypothyroidism and adrenal insufficiency were delayed, potentially early diagnosis would have a significant effect on her quality of life.