8186 Hypoglycemia as an Unusual Presentation of Panhypopituitarism

Abstract

Abstract Disclosure: P. Chalasani: None. M. Asfaw: None. M. Mansour: None. M. Hammoud: None. T. Altaweel: None. H. Ilyas: None. L. Lawrence: None. Introduction: Hypopituitarism refers to the diminished or complete absence of anterior pituitary function, which may arise from acquired or congenital factors. The symptoms depend on the patient’s age and the hormones affected. We report a case where hypoglycemia led to a new diagnosis of panhypopituitarism in an adult patient. Clinical Case:A 53-year-old female with a past medical history of hypertension was brought to the emergency department after syncope. Patient experienced diaphoresis and loss of consciousness associated with urinary incontinence. She did not have confusion, tongue biting, or muscular weakness after the episode. On presentation, the patient was hypoglycemic with blood glucose of 39 mg/dl and received IV dextrose. No focal neurologic deficits were noted on physical examination. She was mildly hypotensive with blood pressure 98/66 mmHg, and received hydrocortisone 100 mg IV once, and started on IV dextrose infusion. Hypoglycemia workup revealed elevated insulin 16.6 uIU/mL and C-peptide 4.8 ng/mL (1.1-4.4) levels for a blood glucose level of 132 mg/dl, with normal beta-hydroxybutyrate of 0.14 mmol/L (0.02-0.27). Sulfonylurea screen was negative. CT abdomen revealed no pancreatic lesions or abnormalities. Hyperinsulinemia was attributed to insulin resistance in this patient with a BMI of 34 kg/m2. CT head revealed a heterogeneous low-density expansile mass in the sella/suprasellar region measuring approximately 2.5 x 2.3 x 2 cm. MRI brain confirmed a heterogeneous sellar mass with suprasellar extension measuring 3.4 x 2.3 x 2.1 cm abuting the optic chiasm without displacement. Biochemical workup revealed panhypopituitarism with secondary adrenal insufficiency ACTH < 1.5 pg/mL (7.2-63.3) and cortisol 3.63 ug/dL (3.70-19.40); secondary hypothyroidism TSH 0.84 mIU/mL (0.27-4.20) and FT4 < 0.50 ng/dL (0.70-14.8); growth hormone deficiency with low IGF-1 23 ng/mL (65-216); secondary hypogonadism FSH < 1 mIU/mL (46-177), LH < 1 mIU/mL (7.7-59) and estrone < 6 pg/mL (0-125); with normal prolactin 14.1 ng/mL (4.8-23.3). Patient revealed she had been amenorrheic since 23 years old and conceived one child prior. Patient was transitioned to oral hydrocortisone 20 mg AM and 10 mg PM, and started on levothyroxine 50 mcg PO daily. No neurosurgical intervention was recommended. Subsequently, patient requested a second opinion and was transferred to a tertiary center. Conclusion: The link between hypoglycemia and hypopituitarism, may be attributed to hypocortisolism and growth hormone / IGF-1 deficiency. Intriguingly, this patient's initial clinical presentation centered around hypoglycemia, and further evaluation led to the identification of a sellar mass and new diagnosis of panhypopituitarism. This case demonstrates the need to include hypopituitarism in the differential when evaluating hypoglycemic patients. Presentation: 6/2/2024