Hypopituitarism from Hyderabad.
Tanday R, Falinska A, Woods D, Ling Y, Vakilgilani T, Todd JF
Imperial College Healthcare NHS Trust
A 33 year old woman was referred to our service for investigation of secondary amenorrhea. She is from India and moved to the UK eight years ago. She has two children aged seven and four years. She has a history of TB adenitis treated in 2007 with quadruple anti TB medication for six months. She was told she had no pulmonary involvement and was clear after treatment. She is currently on no medication. During 2012 she noticed her menstrual cycles were lengthening with amenorrhoea since January 2013. She also complained of weight loss, abdominal pains and general malaise for several months. She denied significant post-partum haemorrhage.
Examination revealed BMI of 26. Cardiorespiratory and GI examination was normal apart from a blood pressure of 99/55. She had no postural drop.
Baseline bloods showed prolactin 74 mU/L, TSH 3.31 mU/L, fT3 < 3.31 pmol/L, fT4 < 5.2 pmol/L, ACTH 9.7 ng/L, cortisol 20 nmol/L, DHEAS < 0.4 umol/L, LH 1 IU/L, FSH 4.5 IU/L, oestradiol < 70 pmol/L, IGF1 6.6 nmol/L.
She was brought back the same evening and commenced on hydrocortisone 10mg, 5mg, 5mg. Steroid rules were explained. At the next visit she reported feeling stronger with more energy. Thyroxine 25mcg was added. It was explained that we will replace other hormones in time. A DEXA scan, USS pelvis, urgent MRI and ITT have been arranged.
The MRI showed an empty sella of normal size with no pituitary tissue, no pituitary mass, normal infundibulum and no cerebral abnormality.
In summary our patient has panhypopituitarism with MRI appearances of an empty sella. We propose the following causes:
1 Pituitary infarction due to undiagnosed / delayed Sheehan’s
2 Previous hypophysitis
3 TB infection
4 Idiopathic empty sella