Endocrine Abstracts

Case History-A 74 year old female patient presented to the emergency department following a witnessed seizure and profound hypoglycaemia (BM 1.1 mmol/l) with an initial GCS of 7/15. Collateral history described 4 days’ feeling unwell with reduced oral intake and multiple recent ‘vacant episodes’. An urgent CT head was unremarkable. Past medical history included hypothyroidism of several years’ duration on T4 50 mcg [3 months’ prior to admission, TSH was 2.25 mIU/l]. Observations demonstrated a temperature of 38.9 degrees, tachycardic and hypotensive. On examination of the chest, crepitations were heard on the left; Chest X-Ray showed opacity of the left lower zone. Blood tests revealed hyponatraemia [128 nmol/l] and raised CRP. The patient was treated for a community-acquired pneumonia, commencing with intravenous [i/v] fluids and antibiotics. The seizures were initially thought to be precipitated by severe hypoglycaemia due to systemic illness. Endocrine consultation however suggested the possibility of hypocortisolaemia and i/v hydrocortisone was initiated, with prompt clinical improvement. Pituitary blood tests were requested with the following results; LH 5.6 u/l [16–75 u/l], FSH 19.9 u/l [21–140 u/l], Prolactin 487 [59–619 mU/l] and IGF-1 15 [6–36 nmol/l]. A short synacthen test response was highly insufficient, with 60′ cortisol of 143 nmol/l [>550 nmol/l] and an unrecordable ACTH of <5 ng/l. An MRI scan of the pituitary provided clear evidence of an Empty Sella. Testing for adrenal cortex antibodies was negative. The patient has been maintained on hydrocortisone and thyroxine replacement therapy and is now well. Case Discussion-Hypoglycaemic seizures are an acute, uncommon, presenting feature of Empty Sella Syndrome [ESS]. This case highlights the diagnostic challenges and difficulties in managing such patients. It emphasises that in all patients presenting with severe hypoglycaemia who are not taking any hypoglycaemic-inducing agents, that ESS is a key differential diagnosis to be considered.