Moffitt Morning Report Pearls 7/24: Hypopituitarism (Endocrine Report!)

PEARLS

  • If searching for hyperpigmentation in primary adrenal insufficiency, look in buccal mucosa and palmar creases
  • If suspicious of primary AI, think autoimmune (in the US) and a clue may be vitiligo as a skin finding
  • When thinking about hypopituitarism, must check fT4 and TSH, not just TSH alone
  • Acute hypopituitarism -> image the head and call neurosurgery. Worried about hemorrhage and potential damage to the optic chiasm

Hypopituitarism (see attached review articles for detailed discussion)

Causes

  • Pituitary disease
    • Mass
      • Pituitary tumor
      • Parasellar tumor
      • Metastatic tumor
    • Radiation
    • Postsurgical
    • Infiltrative disease (hemochromatosis, sarcoid, lymphocytic hypophysitis)
    • Infections (TB, syphilis, mycoses)
    • Pituitary infarction (Sheehan’s syndrome)
    • Pituitary apoplexy (hemorrhage)
    • Misc: empty sella, trauma, internal carotid aneurysm
    • Genetic diseases
  • Hypothalamic disease
    • Mass
    • Radiation
    • Infiltrative
    • Infection

Treatment: replace the missing hormones!

  • TSH: levothyroxine
  • ACTH: steroids
  • Growth hormone: replacement with recombinant GH is controversial (indicated in kids for growth), data less clear for adults
  • Gonadotropin: testosterone, estrogen as needed based on symptoms

Further reading

  • Recent review from the BMJ’s Postgrad Med Journal: PMID 16597813
  • Older review from the NEJM (1994) but with great graphics: PMID 8043090

Empty sella syndrome: sella turcica that appears empty and devoid of any pituitary tissue!

  • Primary: herniation of the subarachnoid space into the sella turcica, flattening the pituitary (squashed by CSF)
  • Secondary: usually from pituitary adenoma that is treated and shrinks (surgery, radiotherapy, drugs, spontaneous) and leaves the sella empty
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