Endocrine Abstracts

A 30-year-old male was admitted to the neurotraumatology ward after head trauma with cerebral concussion, subdural & subarachnoidal haemorrhage. The Endocrinologist was called to evaluate high urinary debits. The patient was healthy until 4 years before admission. He enrolled on variate patterns of alimentary restriction that resulted in the loss of 28 kg. Since then he had visited multiple doctors (Cardiology, Haemathology, Psychiatry, Gastroenterology, Urology, Endocrinology) and performed extensive exams. In conclusion, he had history of sinus bradycardia, normocytic normochromic anemia, bile stones, suspected obstructive incontinence, diabetes insipidus, central hypothyroidism and hypogonadism of unspecified aetiology (normal anterior and posterior pituitary on RMI). From all prescribed drugs he adhered only to levothyroxine 112 mg and testosterone. He complained of weakness, fatigue, nocturia and lack of drive. After a thorough investigation during hospitalization a pathological cause for the syncopal head trauma could not be identified and the history of skipping meals became consistent. Blood tests revealed slight pancytopenia, low testosterone, low IGF-1, normal prolactin, cortisol 12 mg/dl (21 mg/dl after Synacthen), normal FT4 and low FT3, 24 h urinary debits of 2.8–3.6 l of urine with 621 mOsm, normal natremia and blood osmolality. He was discharged weighting 68 kg (192 cm, BMI 18 kg/m²). Levothyroxine and testosterone were maintained. Control RMI showed a normal pituitary with adequate neural hyperintense sign, anti-hypophyseal Ab were negative. By exclusion and given specially the persistent low IGF-1 and FT3, it was postulated that he had hypopituitarism and possibly mild diabetes insipidus in the context of the alimentary disorder and that the syncope was due to low caloric intake. He was followed up by Nutrition, Psychology, Psychiatry, Physiotherapy and Neurology. Testosterone was weaned off progressively based on symptoms and blood tests and levothyroxine was reduced according to FT3 recovery. After 8 months, CBC was normal, FT3 improved slightly and TT was withing RR. After 12 months, there was increased frequency of shaving and body hair density, he recovered spontaneous erections and testosterone was stopped. Levothyroxine has been reduced to 88 mg.

Conclusions: Severe caloric restriction results in typical hypopituitarism with preserved ACTH-cortisol axis and less commonly accompanying mild DI. Pharmacological resistance to hormonal substitution is well known, caloric intake is the mainstay of treatment for adequate functional recovery.