Adrenal incidentaloma

SIR--Non-functional pituitary adenoma is the most common cause of pan-hypopituitarism, but it is not often diagnosed in old age. Perhaps many adenomas do not cause hypophysial hypofunction, or their manifestations, if they arise, may be underestimated. We describe two older patients with chronic general malaise which was initially attributed to depression and which was found to be caused by hypophysial insufficiency resulting from a non-functioning adenoma. Both cases were characterized both by delay in diagnosis and treatment and by a gratifying response to hormone replacement.

Hypopituitarism is uncommon in elderly people and is rarely mentioned in standard texts of geriatric medicine [1]. Its clinical presentations may be non-specific and there are physiological endocrinological changes associated with age which may confound the interpretation of analytical data. This may lead to a delay in diagnosis and treatment.

Case 1: a 76-year-old man presented with a long history of fatigue, anorexia, drowsiness and slowed intellectual and motor activity. This combination of symptoms had been treated as a depressive syndrome but no improvement had taken place. Eventually, after an acute behavioural disturbance, the patient was admitted. The hormonal study showed hypopituitarism (Table 1). The plain skull radiographs revealed an enlarged pituitary fossa with erosion of posterior clinoid caused by a non-functional hypophysial adenoma of 28 mm diameter. We instituted a conservative treatment with 30 mg hydrocortisone and 253 [micro]g levothyroxine per 24 h, increasing the levothyroxine to 150 [micro]g per 24 h. The clinical response to hormone therapy was spectacular.

HGH, human growth hormone; TSH, thyroid stimulating hormone; ACTH, adrenocorticotrophic hormone; PRL, prolactin; LH, leutinizing hormone; FSH, follicle stimulating hormone; T3, triiodothyronine; T4, thyroxine.

Case 2: a 72-year-old man with a depressive syndrome for over 2 years was admitted with a decrease in the level of consciousness. No motor deficiency was observed, but there was left homonymous hemianopia. On computerized axial tomography, multiple non-acute ischaemic infarcts were observed, together with a hypophysial adenoma with infra- and suprasellar growth which was destroying the posterior clinoid. After intravenous therapy his general condition improved and he was discharged pending the results of tine functional studies. No hormonal treatment was prescribed. He was readmitted 30 days later to the internal medicine department due to a further drop in level of consciousness. The results of the functional studies (Table 1) confirmed hypopituitarism. Replacement treatment was initiated with hydro-cortisone and levothyroxine with a good response. Following initiation of therapy a spontaneous decrease in tumour size was observed.

Non-functioning pituitary adenoma is the most common cause of hypophysial insufficiency in the elderly patient [2, 4]. In one autopsy series, pituitary adenomas were found in 10-20% of autopsies of subjects not suspected of having pituitary disease, although only 0.28% were greater than 10 mm in diameter [5]. This suggests that many adenomas do not cause hypophysial hypofunction, or that any manifestations that do arise are overlooked in subjects of over 65. In younger subjects, symptoms of thyroid, adrenal or gonadal insufficiency or visual field defects are usual [61, while in elderly subjects malaise, confusion or falls predominate and may be.' attributed to other diseases [2, 7].

In the assessment of hormonal assays, one must consider the somatic and biological changes that may accompany old age and illness, and drugs that may interfere with the interpretation [8, 9].

To detect hypophysial insufficiency, some authors consider it essential to determine the serum sodium and thyroxine concentrations [7], while others only consider it necessary to measure the thyroid stimulating hormone [1]. The insulin-induced hypoglycaemia test is not recommended for elderly patients with cardiac diseases.

Although trans-sphenoidal hypophysectomy is recommended when there are visual deficiencies or evidence of tumour growth [5, 6], our second patient had a spontaneous reduction in tumour size (as did three of the 12 macro-adenomas in another series [10]). In both cases, hormone replacement treatment was followed by a dramatic improvement in symptoms and quality of life.

Fernando Jose Ruiz Laiglesia Fermin Reclusa Poyo Carmen Torrubia Perez Department of Internal Medicine, Hospital Clinico Universitario `Lozano Blesa' Zaragoza, Spain (Address correspondence to F. J. Ruiz Laiglesia, C/Duquesa Villahermosa 159, 1 [degrees] B, Zaragoza 50009, Spain)

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