Panhypopituitarism with empty sella a sequel of pituitary hyperplasia due to chronic primary hypothyroidism
A 27-year-old man, born of non-consanguineous marriage, with normal perinatal history and milestones, complained of recurrent episodes of vomiting with headache since 6 years of age along with generalized weakness, fatigue ability, malaise and swelling of the body. There was history of cold intolerance, constipation and proximal weakness. However, he did not seek formal medical advice at that time due to lack of awareness and poverty. Evaluation for the persisting headache at 11 years of age (1995) lead to a Computerized tomography (CT) brain, which showed a homogenously enhancing midline mass in the pituitary fossa suggestive of pituitary hyperplasia []. However, he did not come back for further evaluation and treatment.\nHe presented to us for the first time 6 years back (in 2005, 21 years age) with persistence of the previous complaints. Examination at that time was significant for Grade-2 soft goitre, depressed nasal bridge, absent axillary and pubic hair, and bilateral testicular volume of 8 ml each. Biochemical evaluation revealed severe primary hypothyroidism, a diagnosis which was likely missed all these years []. Levothyroxine replacement was started at 50 mcg/day. Patient responded dramatically to treatment, with rapid resolution of all symptoms within months along with a height gain of 28 cm in 6 years (from 105 cm to 133 cm) [].\nHe now complained of progressively worsening nausea, vomiting and fatigue for the last 1 year, along with weight loss. Examination was significant for severe short stature (height-133 cm; standard deviation score-7.36), normal blood pressure (90/60 mm Hg), lack of facial hair and signs of masculinization, normal phallus, Tanner-II stage public hair and bilateral testicular volume of 8 ml []. Hormonal evaluation this time was significant for secondary hypocortisolism, low IGF-1 and hypogonadotropic hypogonadism []. T1 Weighted (T1W) MRI brain (after 6 years of levothyroxine therapy) revealed an ES with intact posterior pituitary signal [].\nHydrocortisone supplementation was started at 15 mg per day. Levothyroxine replacement was continued. Testosterone propionate 20 mg, testosterone phenlypropionate 40 mg and testosterone isocaprote 40 mg injection (Sustanon-100, Organon, India) was started every 3 weekly. He could not afford growth hormone replacement.