An Unusual Case of Hypopituitarism in a 68 Year Old Man With a Normal Appearing Pituitary Gland and a Remote History of Severe Headache Attributed to Possible Apoplexy

A 66-year-old previously healthy man was admitted to the hospital with severe hypotension and gastroenteritis symptoms, which were attributed to food poisoning. No one else who ate with him got sick. Random morning cortisol was found to be 0.6, which was followed by the Cortrosyn stimulation test. Baseline cortisol was 0.9, which went up to 2.0 mcg/dL in 30 minutes after Cortrosyn stimulation and 2.9 mcg per dl after an hour. He was treated with high dose steroids during his inpatient stay and sent home on physiologic steroid doses. He followed up in the Endocrinology clinic after hospital discharge. A review of old records showed he was prescribed testosterone about ten years prior for symptoms of hypogonadism, but he never took it. Detailed workup revealed hypopituitarism. Serum prolactin, growth hormone, IGF-1, LH, FSH, Testosterone, TSH, and free T4 were all decreased. Brain/pituitary MRI, however, showed no pituitary abnormalities. All pituitary hormones were checked multiple times and were found to be consistently low. He was given hormone replacement therapy with levothyroxine and testosterone in addition to continuing steroids resulting in marked improvement. He gave a remote history of the worst headache of his life about twenty years ago. He stayed awake all night but never went to the hospital for an evaluation. A possible pituitary apoplexy several years ago was suspected in this case. We have not found any such case in the medical literature with hypopituitarism with a completely normal-appearing pituitary gland. This case illustrates the importance of detailed history, physical examination, hormonal testing, and appropriate hormone replacement in patients where an obvious acute cause may not be ascertained.