How does Hypopituitarism present in an aging population?

S K Bajwa (SpR), H. Williamson (GP), I Odaudu (SpR), G Towersey (SHO), C Aldrich (F1), S Bowden (F1), P Rihal (CNS), R Kaushal (Consultant), K Ahmed (Consultant),

West Middlesex University Hospital.


Abstract: In an aging population, endocrine conditions may present with atypical manifestations. We describe the case of a 68 year old man presenting to A&E with gradual fatigue, blurry vision, recent onset of poor memory and recurrent falls. On direct questioning he denied headaches, dizziness and urinary frequency. He had seen his GP several years previously with erectile dysfunction but had no other significant medical history. On examination his systolic blood pressure ranged from 79-90mmHg with no postural drop. He had good facial hair and no gynaecomastia. His visual fields were full to confrontation with normal visual acuity and eye movements. 

Investigations: Na 113 mmol/L, K 3.2 mmol/L serum osmolality 241mOsmol/kg (275-295), urine osmolality 644 mOsmol/kg (50-1200) urine sodium 26 mmol/L, 9am cortisol 48 nmol/L (185-624), GH 0.17 ug/L, IGF-1 4.6 nmol/L (6-36) FT4 9.2 pmol/L (8.4-19.1), FT3 2.8 pmol/L (2.4-4.8),TSH 1.2 mu/L (0.3-4.8), Prolactin 69 mu/L (males 56-278), FSH 1.9 IU/L (1.3-9.3), LH 1.3 IU/L (1.2-8.6), Testosterone 1 nmol/L (6.1-27.1). Short synacthen test: ACTH <5.0 ng/L, cortisol at 0mins 72 nmol/L, 30mins 274 nmol/L 60mins 324 nmol/L. CXR was unremarkable. MRI pituitary demonstrated a 20mm well-defined, homogenous lesion of CSF intensity within the pituitary fossa with posterior displacement of the infundibulum and mass effect on the optic chiasm.

The differential included a cystic pituitary adenoma, Rathke’s cleft cyst, arachnoid cyst and craniopharyngioma. The patient was commenced on hydrocortisone and testosterone replacement with complete resolution of symptoms and is awaiting neurosurgical outpatient review.

The exact incidence of cystic pituitary masses (CPM) is unclear. CPM can be asymptomatic or can cause ophthalmological deficits, neurological deficits, endocrine dysfunction and psychiatric manifestations. CPM can be difficult to distinguish preoperatively. Accurate diagnosis is vital to determine the type of treatment required and to predict prognostic outcome.

This gentleman presented with a gradual decline despite having profound hypopituitarism, which is not entirely unusual. We, like many units, have observed a recent increase in patients presenting over the age of 65 years. We would recommend a national retrospective data review of cystic pituitary masses in the elderly population.