Endocrine Abstracts

Background: Hypophysitis is a rare inflammatory condition of the pituitary gland, speculated to have autoimmune aetiology. The diverse clinical presentations rely on hormonal deficiencies and the pathophysiological impact on the target organs. This condition may give rise to life-threatening complications. MRI is the best imaging modality for diagnosis and the conclusive diagnosis necessitates a biopsy of the affected tissue. The optimal management approach remains a subject of controversy. Herein, we describe a case of hypophysitis with sudden cardiac arrest.

Case Report: An 18-year-old female was admitted to the hospital due to loss of consciousness during swimming, and involuntary movements. Cardiopulmonary resuscitation was performed successfully with restoration of cardiac function. Further investigation revealed mitral valve abnormalities, systemic inflammatory syndrome, and severe metabolic acidosis. Laboratory tests showed: pH=6.5, PcO2=34, Po2=275, Hco3=2.9 mmol/l, lac=22. Cardiac catheterization ruled out significant coronary stenosis, pinpointing the cause of cardiac arrest to ventricular fibrillation. Four months prior, patient had a Covid-19 infection, and a month later she developed visual disturbances, transient blindness, hearing loss episodes, and menstrual irregularities. laboratory tests showed slightly elevated TSH, and pituitary hyperplasia on brain MRI. Medications were not prescribed. On the 3rd day of hospitalisation, patient developed polyuria and hypernatremia, plasma and urine osmolarity were normal, ACTH=9.0 0 pg/ml, Cortisol=16.320 µg/dl (5.27-22.4), TSH=0.10 µIU/ml (0.35-5.5), FT4=0.59 pg/ml (0.83-1.43), FT3=0.7 pg/ml (3-4.74). Considering the previous MRI findings, hypophysitis was suspected and the diagnosis of hypopituitarism with hypothyroidism and hypocortisolism was established. The patient was commenced on replacement therapy with hydrocortisone and levothyroxine sodium, alongside desmopressin for fluid and electrolyte balance. For cardiac rhythm disturbances, antiarrhythmic medication was started, the patient underwent an implantation of a cardioverter-defibrillator. Currently the patient on levothyroxine sodium 50 mg daily, Hydrocortisone 20mg daily, metoprolol 100mg twice weekly, levetiracetam 500 mg twice daily. Follow-up assessments demonstrated improvement in cardiac function and normalisation of hormone levels. In 6 months, the patient failed short Synacthen test and was continued on replacement.

Conclusion: Making an accurate and timely diagnosis of hypophysitis still remains a challenge. It is possible that Covid-19 was the reason of hypophysitis. Recognizing and addressing early symptoms and signs of hypopituitarism can be potentially life-saving, in particular when it is masked with cardiac disorders. Additionally, detailed history-taking may play a key role in establishing the diagnosis. Addressing hormonal deficiencies early on not only prevents potential life-threatening events but also improves the overall quality of patient care.