Adrenal crisis after missed diagnosis of pituitary sarcoidosis: a case report

Marwa Salah

doi:10.1530/endoabs.110.EP1197

JOINT1922

Sarcoidosis is a disease characterized histologically by multiple non-caseating granulomata without a clear infectious or toxic trigger, with an unclear aetiology. The prevalence of sarcoidosis in the Middle East population is not well known. The clinical features of patients with sarcoidosis in the Middle East appear to be like that reported in the world with female predominance than males. In many cases, the diagnosis of sarcoidosis was made based on intrathoracic biopsy. Neurosarcoidosis (NS) is a rare form of sarcoidosis, with hypothalamic-pituitary involvement being uncommon. We report a 27-year-old man presenting with nausea, vomiting, diarrhoea, abdominal pain, weight loss, bilateral neck swellings and generalized fatigue. The patient was admitted to the hospital for suspected acute gastroenteritis. He further developed mental confusion, arterial hypotension (90/60 mmHg), and hypokalaemia (2.6 mmol/L). Initial assessment revealed adrenal crisis, and the patient received parenteral hydrocortisone. Further hormonal evaluation revealed hypopituitarism with secondary hypothyroidism, adrenal insufficiency and diabetes insipidus Table 1. Magnetic resonance imaging demonstrated pituitary stalk thickening, initially suggestive of hypophysitis. CT chest reported enlarged bilateral hilar lymph nodes with noted bilateral lower lung lobes few sub-pleural consolidative patches suggestive of sarcoidosis. Biopsy was performed from the suspected cervical lesions showed granuloma confirming the diagnosis sarcoidosis. The patient started prednisolone 60 mg daily, tapered to 7.5 mg daily and he was maintained on replacement therapy with levothyroxine and desmopressin. The condition of the patient improved during follow up.

Table 1. Results of the basal laboratory investigations of the patient.
Variables (units)	Results	Normal range
Thyroid stimulating hormone, TSH (µIU/ml)	0.42	0.27–4.2
Serum free thyroxine, fT4 (ng/dl)	0.76	0.89-1.76
Serum free T3(pg/ml)	1.9	2.3-4.2
Serum cortisol 8:00 am (ug/dl)	0.5	3-25
Adrenocorticotroph hormone, ACTH (pmol/L)	1.4	1.5-14.7
Prolactin (ng/ml)	14	3.8-23
Potassium (mmol/L)	2.6	3.5-5
Sodium (mmol/L)	143	136-145
Calcium (mg/dl)	10	8-11
Phosphorus (mg/dl)	2.9	2.5-4.9
Albumin (g/dl)	4.2	3.4-5
Total Bilirubin (mg/dl)	0.59	Up to 1
Protein (g/dl)	6.5	5.7-8.2
ALT (U/L)	26	10-49
Creatinine (mg/dl)	0.9	0.5-1.3
BUN (mg/dl)	9	9-23
Blood Urea (mg/dl)	19	15-45
Uric acid (mg/dl)	4.6	3.5-7.2

Conclusion: We report a case of undiagnosed hypopituitarism initially presenting as a case of adrenal crisis with hypotension and gastrointestinal symptoms. The patient also displayed clinical diagnosis of pulmonary and pituitary sarcoidosis with secondary hypothyroidism and diabetes insipidus. The case highlights the importance of endocrine sequelae of sarcoidosis.

Endocrine Abstracts

EP1197