A 30 year old gentleman was admitted to our department with symptoms of tiredness and weight loss over the past 3 weeks. He also gave a history of erectile dysfunction for several years. His only significant past history was asthma well controlled on inhalers. On examination he appeared tanned. There was no buccal or skin crease pigmentation. Smell sensation was normal and he had normal external genitalia and secondary sexual characteristics.
Initial investigations revealed low sodium of 106 mmol/L with a potassium of 5.6 mmol/L, associated with a random cortisol of 96 nmol/L. Synacthen test at 0 and 30 minutes showed readings of 96 and 102 nmol/L respectively. Further results demonstrated testosterone of 7.9 nmol/l[10-40] with FSH of 0.9 U/L and LH of 3.1 U/L. His IGF-1, Prolactin and thyroid function tests were normal. His ACTH levels were elevated at 866 ng/L(10-50) and his anti-adrenal antibodies were positive. His MRI-Pituitary was normal. His response to LHRH and TRH administration were normal. Ferritin and Iron saturation was normal.
The association of hypogonadism and hypoadrenalism would normally prompt evaluation of the hypothalamic-pituitary axis. In this case we were surprised to find low gonadotrophins associated with low testosterone levels indicating secondary hypogonadism. Hypogonadotrophic hypogonadism can be associated with anosmia (Kallmans syndrome) or haemochromatosis, but neither was present in this patient. We assume therefore that he had long standing idiopathic hypogonadotrophic hypogonadism.
In males with autoimmune endocrinopathies, primary gonadal failure has been well recognized. However here we present a unique case of hypogonadotrophic hypogonadism in a male with Addisons disease.