Endocrine Abstracts

A 45 year old female was referred to the Endocrinology department with complains of severe fatigue and weakness from basic daily activities, also irregular menstrual circle during last five years. Twelve years back she had twin pregnancy, premature delivery on 29th week, and absence of lactation. Afterwards she gradually lost 6 kg of her body weight and her menstrual circle become sparse and disappeared five years back. 1.5 years ago type 1 diabetes was diagnosed (C-peptide below range, anti-insulin antibodies elevated), and patient immediately started intensified insulin therapy scheme. Despite of adequate diabetes education she regularly experienced hypoglycemic episodes even from very low insulin doses (2–3 IU of long acting insulin, 1–2 IU of short acting insulin) and was repeatedly hospitalized with hypoglycemic coma. Due fear of hypoglycemia patient rather preferred to skip injections and her last HbA1c was elevated (75 mmol/mol, 9%). Endocrine function tests revealed disturbed pituitary function: plasma TSH was within the normal range (2.5 uIU/ml) despite of markedly decreased FT4 (0.4 ng/ml) and elevated TPO antibodies; her morning plasma cortisol was decreased (0.54 mg/dl), yet ACTH was relatively low (6.84 pg/ml); plasma LH, FSH, estradiol, progesterone, testosterone levels were decreased. MRI scan revealed pituitary gland to be thinned out to less then 1 mm in size. Substitution therapy was immediately started with levothyroxine and hydrocortisone, which led to complete disappearance of hypoglycemic episodes. Within half a year patient regained 6 kg, her BMI become optimal. Her mental and bodily strength returned and she started to menstruate again.

Discussion: We demonstrate the case of female patient having hypopituitarism due to empty sella syndrome, coexisting with autoimmune thyroiditis and type 1. diabetes mellitus. However, it was difficult to determine the primary cause of hypopituitarism. Differential diagnosis in this case is between Sheehan syndrome, lymphocytic hypophysitis or combination of both. In conclusion, our case report is showing importance of testing of pituitary function within the endocrinology setting for unclear severe hypoglycemia in diabetic patients complaining of increasing fatigue and weight loss.