We present an unusual cause for symptomatic hypopituatism presenting due to a metastatic deposit. A 77 year old smoker and ex-miner was admitted with a 3 week history of breathlessness, malaise and weight loss. He had clinical evidence of a severe pneumonia but also had clubbing, was hypotensive, hypothermic and hypoglycaemic. He had no clinical features of Addisons disease, no neurological symptoms or signs and a normal breast examination. Chest X-ray suggested extensive interstitial fibrosis. Laboratory findings showed hypoglycaemia (1.8 mmol), hyponatremia (128 mmol, normal 130145) and raised inflammatory markers. Initial suspicion of underlying hypoadrenalism was confirmed with a random cortisol of 78 nmol/l. He was also found to have a FT4 of 5.7 pmol/l (0.34.3), a FT3 of 2.2 pmol/l (2.87.1) with normal liver biochemistry.
MRI Pituitary showed a lesion related to the pituitary fossa in keeping with a metastatic deposit. Further investigation to identify the primary tumour included a HRCT scan of his chest which was reported as showing no evidence of malignancy.
After initial management of his adrenal crisis, hypothyroidism and chest infection he improved dramatically and was discharged on oral steroid and thyroid replacement therapy while awaiting results of further investigations. He was admitted a month later with a malignant left sided pleural effusion. Pleural aspirate revealed adenocarcinoma. Unfortunately he died on that admission and limited post-mortem examination revealed extensive adenocarcinoma of the lung.
This demonstrates a classical presentation of adrenal crisis precipitated by intercurrent illness. It also show an unusual cause of symptomatic hypopituatism presenting due to a metastatic deposit as well as highlighting the importance of post mortem examination as a useful audit tool demonstrating the fallibility of what are considered highly sensitive tests (HRCT).
06 - 07 Nov 2006
Society for Endocrinology