Endocrine Abstracts

Sarcoidosis is a very rare inflammatory disease and UK prevalence was 8% between 2008 to 2012 of which only 15 % developed neurosarcoidosis. Our patient is a 83 year old gentleman who presented with symptoms of lethargy, low blood pressure and confusion over 2 weeks . He had multiple comorbidities including heart failure, chronic kidney disease, permanent pacemaker, hypertension. His bloods showed normocytic anaemia and raised inflammatory markers, with eosinophilia and he was started on broad spectrum antibiotic but his condition continued to deteriorate . There was no evidence of infection. He had mild postural hypotension probably due to his comorbidities. His free thyroxine was low with inappropriately low normal TSH. He was commenced on thyroxine and his conscious levels dropped. Therefore cortisol level were checked, which were low therefore followed by full pituitary profile, and short synacthen test . Pituitary profile revealed low FSH, LH, IGF-1, testosterone in keeping with panhypopituitarism.Results of short synacthen test were inadequate suggesting a central cause. He also had CT scan of brain which was unremarkable. He later had CT pituitary as MRI was not compatible due to pacemaker but no significant abnormality was found . His autoimmune screen for vasculitis showed weakly positive p-ANCA. He was reviewed by neurology team and lumbar puncture was done which did not show any CNS infection but raised CSF-protein and CSF-ACE level . He also had high normal serum ACE level, raised calcium and peripheral eosinophilia . He was started on intravenous hydrocortisone 100 mg QDS and patient’s conscious level and general condition improved remarkably. His hydrocortisone was changed to oral prednisolone 30 mg daily and confusion settled and mobility improved slowly over the next 2 weeks. The steroids were slowly weaned down to maintenance dose of 5 mg. The low dose levothyroxine was continued and he remains well on 5 mg prednisolone and 75 microgram of levothyroxine . Pan-hypopituitarism secondary to neurosarcoidosis is a rare manifestation and was considered in this patient but he was not suitable for tissue diagnosis due to comorbidities. We were unable to get MRI to see infiltration but clinical improvement with steroids and investigations-higher end of normal serum ACE levels, raised CSF-ACE levels, eosinophilia and raised calcium are all in keeping with clinical diagnosis of neurosarcoidosis . Neurosarcoidosis can also present without pulmonary involvement and prompt diagnosis and treatment is life saving.