A 67 year old man with 1 month history of malaise was referred when his thyroid profile suggested secondary hypothyroidism with a fT4 of 4.9 picomoles per litre, fT3 3.4 picomoles per litre and TSH 0.03 milli units per litre. Physical signs were unremarkable. Investigations:- cortisol (random) 294 nanomols per litre, prolactin 960 micro units per millilitre, testosterone < 0.04 nanomols per litre, FSH 5.2 units per litre, LH 0.07 units per litre and IGF-1 17.7 nanomols per litre. Depot Synacthen test (cortisol levels) 0 hours (09:00) 219, 1 hour 413, 2 hours 430, 4 hours 485, 8 hours 529 and 24 hours 453 nanomols per litre. MRI pituitary showed changes suggestive of an inflammatory process. A presumptive diagnosis of lymphocytic hypophysitis was made and treatment with hydrocortisone and thyroxine commenced.
4 months later he was well and repeat investigations off treatment confirmed eupituitarism:- FT4 of 14.8 picomoles per litre, TSH 0.7 milli units per litre, prolactin 398 micro units per millilitre, testosterone 10.4 nanomols per litre, FSH 7.6 units per litre and LH 6.5 units per litre. Short synacthen test (cortisol levels) 0 minutes (09:00) 470 and 60 minutes 512 nanomols per litre. A repeat pituitary MRI scan was normal. It was observed that his longstanding hypertension had resolved and anti hypertensive treatment withdrawn.
1 month later he developed non-specific abdominal pain and an ultrasound scan suggested the possibility of enlarged adrenal glands. This was confirmed by CT scanning.
At review 3 months later he was unwell with obvious signs of weight loss. Repeat CT scanning demonstrated extensive abdominal and pelvic lymphadenopathy plus the enlarged adrenal glands. Lymph node biopsy confirmed a diagnosis of large B-cell lymphoma.
The development of two very rare conditions in the same patient suggests they are related. The mechanisms of this possible relationship remain speculative.
22 - 24 Mar 2004
British Endocrine Societies