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Hypopituitarism

Category: Illness or disabilities

Type

Involuntary

Introduction and description

 

Hypopituitarism is the decreased (hypo) secretion of one or more of the eight hormones normally produced by the pituitary gland at the base of the brain.  It is thus a Pituitary gland disease.  If there is decreased secretion of most pituitary hormones, the term panhypopituitarism (pan meaning "all") is used.

A subset of this disease is called Sheehan syndrome, which is the shrinking and killing of the cells of the Pituitary gland caused by blood loss or lowering of the blood pressure during childbirth.

The first description of the condition was made in 1914 by the physician Dr Morris Simmonds.

Symptoms

The signs and symptoms of hypopituitarism vary, depending on which hormones are undersecreted and on the underlying cause of the abnormality. The hormones of the pituitary have different actions over the whole body in a complex cycle that involves the entire endocrine system

 

 Diagnosis

The diagnosis of hypopituitarism is made by blood tests, but often specific scans and other investigations are needed to find the underlying cause.

Causes

 

Blood circulatory problems

Cutting off the blood supply to the gland, whatever the ultimate cause, will cause the death of cells.  Brain injury is one cause of this. 

Whenever brain injury is described, it tends to be associated with trauma, but surgery, including plastic surgery can have the same effects.

Blood loss can cause a loss in blood pressure, which can in turn can cause the cells in the pituitary gland to die [necrosis]Furthermore any drop in blood pressure can have the same effect as a restricted supply due to atherosclerosis. 

Childbirth may result in blood loss and fall in blood pressure, but then so can car accidents, various forms of physical trauma and shock, if it is prolonged. So essentially the cells die when they have been starved of oxygen, for various reasons.

Traumatic brain injury (TBI) is recognized as a risk factor for hypopituitarism, most frequently presenting with isolated growth hormone deficiency (GHD). Data analysis shows that about 15% of patients with TBI have some degree of hypopituitarism which if not recognized may be mistakenly ascribed to persistent neurologic injury and cognitive impairment. Identification of predictors for hypopituitarism after TBI is important, one of them being the severity of TBI. The mechanisms involve lesions in the hypothalamic-pituitary axis and inflammatory changes in the central nervous system (CNS). With time, hypopituitarism after TBI may progress or reverse. PMID: 25248593

Finally tumours or lesions in the rest of the brain can cut off the blood supply.

A 64-year-old woman with nausea, vomiting, diarrhea, and peripheral and periorbital edema was found to have panhypopituitarism. Magnetic resonance imaging showed minimal enlargement of the pituitary, and a transsphenoidal biopsy of the pituitary was nondiagnostic. Months later, abnormalities of extraocular movements developed. Repeated imaging and a second transsphe-noidal biopsy did not reveal the ultimate diagnosis. When further neurologic signs and symptoms subsequently developed, a right temporal open craniotomy was performed. It was not until this procedure, the patient's third biopsy, that the cause of her illness was discovered to be diffuse large cell lymphoma.  PMID:  14561574

Which themselves have a cause……

Pathogens

Bacteria can kill off cells, so can viruses, fungi, parasites and toxins such as heavy metals.  For example:

Hypopituitarism is a condition characterized by dysfunction of the pituitary gland hormone production. The insults of the perinatal period, which includes the late infection by Group B Streptococcus, consists in a rare etiology of this condition. We present the case of a 39-days-old infant with meningitis caused by Streptococcus Group B, which showed, among other consequences, hypopituitarism.  PMID: 26161231

And

Nephropathia epidemica (NE) is a haemorrhagic fever with renal syndrome (HFRS) caused by Puumala hantavirus (PUUV). Pituitary haemorrhage and hypopituitarism may complicate recovery from acute NE.  PMID:  26202013

And

Despite numerous case reports, the incidence of hypothalamic-pituitary dysfunction following infectious diseases of the CNS has been underestimated. Hypopituitarism usually relates to the severity of the disease, type of causative agent (bacterial, TBC, fungal, or viral) and primary localization of the infection. Unrecognized hypopituitarism may be misdiagnosed as postencephalitic syndrome, while the presence of a sellar mass with suprasellar extension may be misdiagnosed as pituitary macroadenoma in a patient with pituitary abscess which is potentially a life-threatening disease. PMID: 25248593

Radiation

Cranial irradiation is [an] important risk factor for hypopituitarism. Deficiencies in anterior pituitary hormone secretion (partial or complete) occur following radiation damage to the hypothalamic-pituitary region, the severity and frequency of which correlate with the total radiation dose delivered to the region and the length of follow-up. These radiation-induced hormone deficiencies are irreversible and progressive. PMID: 25248593

Snake bites

The venom of a number of snakes causes hypopituitarism.  Please note that it does not follow that this venom can help with hyperpituitarism, because it depends on what caused the hyperpituitarism

Chronic hypopituitarism following Russell viper envenomation (RVE) is a rare but well-recognized syndrome. …. hypoglycemia (100%) and hypotension (66.7%) were the most common findings at presentation. AHP [associated-acute hypopituitarism] occurred after a median of 9 (range, 2-14) days after severe envenomation and was associated with multi-organ dysfunction, lower platelet counts, more bleeding and transfusions when compared to patients with RVE alone. PMID: 25630907

Treatment

It is NOT surgery:

Syndrome of inappropriate antidiuretic hormone secretion-induced hyponatremia is a common morbidity after pituitary surgery that can be profoundly symptomatic and cause costly readmissions. The authors calculated the frequency of postoperative hyponatremia after 1045 consecutive operations and determined the efficacy of interventions correcting hyponatremia…… 19% of operations leading to postoperative hyponatremia were associated with postoperative symptoms (38% involved dizziness and 29% involved nausea/vomiting) and 15% involved readmission for a mean of 5 days (range 1-20 days). …..  only preoperative hypopituitarism predicted postoperative hyponatremia.  PMID:  23971964

Most hormones controlled by the secretions of the pituitary can be replaced by tablets or injections, although it is exceptionally difficult to get the dose right unless the underlying cause is known, as there is a difference between one-off damage and ongoing damage.

In other words FIND THE CAUSE.

For more details of causes – see the section on Pituitary gland disease.

References and further reading

  • Pan Afr Med J. 2015 Mar 30;20:308. doi: 10.11604/pamj.2015.20.308.6538. eCollection 2015.  Hypopituitarism as consequence of late neonatal infection by Group B streptococcus: a case report.  Ferreira AS1, Fernandes AL2, Guaragna-Filho G3.
  • Clin Endocrinol (Oxf). 2016 Jan;84(1):85-91. doi: 10.1111/cen.12863. Epub 2015 Sep 14.  Long-term hormonal follow-up after human Puumala hantavirus infection.  Partanen T1, Koivikko M1, Leisti P1, Salmela P1, Pääkkö E2, Karttunen A2, Sintonen H3, Risteli L4, Hautala N5, Vapalahti O6, Vaheri A6, Kauma H1, Hautala T1.
  • Handb Clin Neurol. 2014;124:271-90. doi: 10.1016/B978-0-444-59602-4.00018-6.  Alternative causes of hypopituitarism: traumatic brain injury, cranial irradiation, and infections.  Pekic S1, Popovic V2. Faculty of Medicine, University of Belgrade, and Clinic of Endocrinology, Diabetes and Metabolic Diseases, University Clinical Center Belgrade, Belgrade, Serbia.
  • Endocr Pract. 2003 Jul-Aug;9(4):296-300.  Panhypopituitarism as an initial manifestation of primary central nervous system non-Hodgkin's lymphoma.  Katz BJ1, Jones RE, Digre KB, Warner JE, Moore KR.
  • Eur J Obstet Gynecol Reprod Biol. 2016 Feb;197:83-5. doi: 10.1016/j.ejogrb.2015.11.028. Epub 2015 Nov 29.  Questioning the role of pituitary oxytocin in parturition: spontaneous onset of labor in women with panhypopituitarism--a case series.  Shinar S1, Many A2, Maslovitz S2.  Lis Maternity Hospital, Obtsterics and Gynecology, Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Israel.
  • QJM. 2015 Sep;108(9):719-28. doi: 10.1093/qjmed/hcv011. Epub 2015 Jan 27.  Acute hypopituitarism complicating Russell's viper envenomation: case series and systematic review.  Rajagopala S1, Thabah MM2, Ariga KK2, Gopalakrishnan M2.

Observations

The majority of observations can be found in the section on Pituitary gland disease.

Related observations