e182 AACE CLINICAL CASE REPORTS Vol 3 No. 3 Summer 2017 Copyright © 2017 AACE Case Report FORTY YEARS OF UNRECOGNIZED HYPOPITUITARISM DIAGNOSED BY PHYSICAL EXAM Victoria R. Hudspeth, MD 1 ; William A. Fischer II, MD 2 ; George S. DeCherney, MD, MPH 1 Submitted for publication June 5, 2016 Accepted for publication August 21, 2016 From the 1 Department of Medicine, Division of Endocrinology and Metabolism, and 2 Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina. Address correspondence to Dr. Victoria Rollins Hudspeth, Endocrinology Fellow, Department of Medicine, Division of Endocrinology and Metabolism, University of North Carolina at Chapel Hill School of Medicine, 8025 Burnett Womack Building, Campus Box # 7172 UNC-CH, Chapel Hill, NC 27599. E-mail: [email protected] DOI: 10.4158/EP161426.CR To purchase reprints of this article, please visit: www.aace.com/reprints. Copyright © 2017 AACE. ABSTRACT Objective: To describe the diagnosis of a case of hypo- pituitarism that went undiagnosed for 40 years, having been masked by inhaled glucocorticoids. Methods: We present the clinical, laboratory, exam, and imaging findings, along with a review of the literature. Results: A 58-year-old man with a history of inter- mittent hyponatremia of unknown etiology and chronic abdominal cramps presented with worsening cramps, confusion, and serum sodium of 112 mmol/L (reference range, 135 to 145 mmol/L). His urine sodium and osmo- lality suggested the syndrome of inappropriate antidiuretic hormone (SIADH), but serum sodium did not normalize with hypertonic saline and fluid restriction. Exam revealed no axillary or pubic hair and no palpable testes. He report- ed 3 episodes of traumatic head injury around the age of 18 and an inability to have an erection since that time. Further testing found undetectable luteinizing hormone, unde- tectable testosterone, low free thyroxine, low insulin-like growth factor 1, and a failed cosyntropin stimulation test. Magnetic resonance imaging showed an empty sella. His sodium and cramping improved rapidly with hydrocorti- sone. He had not used his glucocorticoid inhaler for 3 days prior to admission. He had a similar admission after stop- ping his inhaler 4 years ago, leading us to the conclusion that the chronic inhaled glucocorticoid may have masked his hypopituitarism. Conclusion: This case highlights the common and life-threatening delay in diagnosis of adrenal insufficiency, the need to consider SIADH a diagnosis of exclusion, and the importance of a thorough physical exam and history, even in this era of digital medicine. (AACE Clinical Case Rep. 2017;3:e182-e186) Abbreviations: SIADH = syndrome of inappropriate antidiuretic hormone; T4 = thyroxine INTRODUCTION Patients with hypopituitarism often experience a delay in diagnosis. In patients diagnosed with hypopituitarism at the time of adrenal crisis, symptoms have been present on average 9.1 months (1). In patients with adrenal insuffi- ciency, 20% reported that symptoms were present greater than 5 years prior to diagnosis and 67% reported seeing at least 3 physicians before the diagnosis was made (2). We present the case of a 58-year-old man with panhypopitu- itarism that went undiagnosed for 40 years, with part of the delay thought to be due to masking of adrenal insuf- ficiency by inhaled glucocorticoids. To our knowledge, this is the first report of adrenal insufficiency masked by inhaled glucocorticoids. This is an Open Access article under the CC-BY-NC license. -ND
FORTY YEARS OF UNRECOGNIZED HYPOPITUITARISM DIAGNOSED BY PHYSICAL EXAM
Apr 27, 2023
To describe the diagnosis of a case of hypopituitarism that went undiagnosed for 40 years, having
been masked by inhaled glucocorticoids
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This case highlights the common and life-threatening delay in diagnosis of adrenal insufficiency, the need to consider SIADH a diagnosis of exclusion, and the importance of a thorough physical exam and history, even in this era of digital medicine
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