Endocrine Abstracts

Case history: 66 year old male referred with a thyrotoxic biochemistry. History was in favour of a subacute thyroiditis with a painful neck and short-term elevation of fT3 and fT4 which have improved to lower limits of normal without any treatment at the time of first clinic visit. He was monitored for thyroiditis and the biochemistry gradually changed and patient started to complain of tiredness.

Investigations and treatment: Morning Pituitary profile in June 2021

Levothyroxine commenced and dose gradually up titrated.

SST Sep 2021:

Cortisol 279 ->567

MRI pituitary: Very little tissue is seen within the pituitary fossa. This measures 3 mm in height and enhances. Suggestive of partial empty sella. Hypogonadism persisted on bloods and Testosterone replacement commenced.

DEXA:

Lumbar spine t score -0.1

Mean right NOF -2.5

Mean left NOF -2.4

Ensured Levothyroxine adequately replaced prior to ITT. (fT4 16.1)

ITT Jan 2022:

Diagnosis of hypopituitarism confirmed and patient commenced on Prednisolone 4 mg OD.

Conclusion and points for discussion: Empty sella syndrome is a condition in which the pituitary gland is shrunk or flattened on MRI. If some of the pituitary gland is still visible on MRI it is called a partial empty sella syndrome. In majority of patients and empty sella is an incidental finding and does not need treatment. However, some may present with hypopituitarism requiring hormonal replacement. He showed an adequate response on SST even though he failed the ITT. Therefore, is SST a good alternative to look for secondary hypoadrenalism due to pituitary hypofunction? Hypothyroidism must be adequately replaced with Levothyroxine prior to ITT as this can impair the growth hormone and cortisol response.