Background: Most cases of hypopituitarism are due to pituitary tumours or their treatment. Surgery is the treatment of choice in cases of pituitary adenomas which account for 90% of sellar and parsellar lesions. We present an unusual case of a non-adenomatous pituitary mass presenting with panhypopituitarism.
Case: A 56-year-old male with background of sickle cell trait and hypertension presented with syncope, lethargy and nausea. He had an 18-month history of headache and recurrent episodes of sinusitis.Clinical examination revealed proximal myopathy and normal visual fields. Pituitary function tests demonstrated an IGF1 of 27.1 nmol/l and partial hypopituitarism fT3 2.9 pmol/l, fT4 8.9 pmol/l, TSH <0.03, LH <0.5 IU/l, FSH <1 IU/l, and testosterone 3.4 nmol/l. He was also found to be in acute kidney injury with unremarkable renal ultrasound and negative urinary protein: creatinine ratio with no casts or red blood cells. Autoimmune profile revealed anti-MPO Abs 7.9 U/ml and anti-PR3 Abs 2.4 U/ml. ESR was elevated at 73 mm/hr. Pituitary MRI demonstrated a 16×10 mm pituitary mass with supra-sellar extension. 18F-FDG whole body PETCT was performed to investigate a possible underlying vasculitis or granulomatous process, this revealed FDG avid biapical lung nodules and right cervical lymphadenopathy.
Conclusion: The biochemical and imaging findings coupled with the patients longstanding history of sinusitis point to a granulomatous/vasculitic cause for his pituitary mass. PETCT has provided a target for extraneural biopsy, which is less risky and may be of higher diagnostic yield than neural biopsy. On confirmation of the underlying diagnosis we aim to initiate medical treatment of the underlying cause which might enable reduction/resolution of his pituitary mass without the risks of surgery.