Anaemia leading to diagnosis of pan-hypopituitarism in an elderly gentleman
Preethi Rao, Srikanth Mada, Ravi Erukulapathi & S Jones
Introduction: Pituitary hormones play a vital role in the development of various organs since birth. Testosterone is essential not only for the development of primary and secondary sexual characteristics but also influences erythropoiesis. We describe a clinically challenging case of hypopituitarism presented as normochromic normocytic anaemia at the age of 74 years.
Case: A 74 years gentleman with a background of previous Myocardial Infarction was referred to gastroenterology team for investigation of normochromic normocytic anaemia (Hb: 9.0 gm/dl MCV: 84.0 fl). His upper and lower endoscopies were normal; He had normal renal function, liver function, bone profile, ESR, and serum electrophoresis. His B12, folate and ferritin were normal. The endoscopist noticed absence of development of primary and secondary sexual characters and referred to endocrinology team.
His clinical assessment suggested deficiency of anterior pituitary hormones.
His endocrine profile showed: TSH2.31 mIU/l (0.274.2) T4 7.3 pmol/l (1223) T33.4 pmol/l (4.78), GH 0.1 mIU/l Somatomedin <3 nmol/l (630), prolactin 486 mU/l (53360), testosterone 0.1 nmol/l (1030), FSH0.4 IU/l (1.611), LH <0.01 IU/l (1.38.3), random cortisol 84, SST 0 min: 84, 30 min: 511, 60 min: 630.
Radiological investigations (MRI pituitary) showed small amount of pituitary tissue and DEXA scan showed osteoporosis.
Management: He was started on replacement doses of thyroxine and corticosteroid.
He was also started on testosterone (oral) for anaemia and osteoporosis.
Discussion: Testosterone has a key role in pubertal changes. We know that testosterone influences erythropoiesis. Replacing testosterone (dose and route) posed a clinical challenge in view of its psycho-sexual effect in elderly gentleman who has not gone through pubertal changes. This case highlights the clinical challenges in the management of hypopituitarism and testosterone replacement in the elderly who have not attained puberty.