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Patient case: Hypopituitarism

Patient case: Hypopituitarism

Discussion

Presenting Complaint: A 38-year-old male presents to the clinic with complaints of unexplained weight gain, fatigue, and difficulty concentrating for the past 6 months. He also mentions that he has not been feeling sexually active, has a reduced libido, and has noticed a decrease in his ability to tolerate cold.

History: The patient reports having no significant past medical history but has been feeling progressively more fatigued. He admits to having a diminished appetite over the past several months. He also reports having frequent headaches, particularly around the eyes. There is no history of trauma, infections, or significant family history of endocrine disorders.

On further questioning, the patient reveals that he has noticed some difficulty in his vision, especially in his peripheral vision. There is no history of recent weight loss, polyuria, or polydipsia. The patient also denies any significant changes in bowel or menstrual cycles, as he is not on any hormonal treatment.

Physical Examination:

General appearance: The patient appears slightly overweight with a BMI of 30.

Head and Neck: No signs of any visible abnormalities in the thyroid or adrenal glands.

Cardiovascular: Normal heart rate and rhythm.

Neurological: Slight visual field defect is noted on the confrontation test. No other abnormalities found.

Endocrine: Decreased body hair, pale skin, and slightly dry skin. No signs of acromegaly, Cushing's, or hyperthyroidism.

Investigations:

Serum cortisol is found to be low, confirming adrenal insufficiency.

Thyroid function tests reveal low levels of T4 and TSH, indicating hypothyroidism.

The patient’s testosterone levels are low, indicating hypogonadism.

MRI of the pituitary gland shows an enlarged pituitary gland with a possible pituitary tumor.

Diagnosis: The diagnosis of hypopituitarism is made, likely secondary to a pituitary adenoma, causing the reduced function of multiple anterior pituitary hormones.

Management:

The patient is started on hydrocortisone for adrenal insufficiency, levothyroxine for hypothyroidism, and testosterone replacement therapy for hypogonadism.

Referral to an endocrinologist is made for further management and possible surgical intervention for the pituitary tumor.

Questions
1. Which of the following is the most likely cause of the patient's hypopituitarism?

A) Pituitary adenoma

B) Thyroid disease

C) Adrenal insufficiency

D) Hypothalamic dysfunction

2. What is the most likely explanation for the patient's fatigue, weight gain, and cold intolerance?

A) Primary hypothyroidism

B) Hypogonadism

C) Hypopituitarism

D) Depression

3. Which of the following laboratory findings would you expect in a patient with hypopituitarism?

A) High cortisol and low testosterone

B) Low cortisol, low T4, and low testosterone

C) Elevated TSH and low cortisol

D) Normal cortisol and high T4

4. What is the first-line treatment approach for this patient’s adrenal insufficiency, hypothyroidism, and hypogonadism?

A) Surgical resection of the pituitary adenoma

B) Hormone replacement therapy

C) Radioactive iodine therapy

D) Chemotherapy

Reveal answers

Answers

1. A) Pituitary adenoma

2. C) Hypopituitarism

3. B) Low cortisol, low T4, and low testosterone

4. B) Hormone replacement therapy