Susana D'Amico, MD, Luis Lopez-Penabad, MD, A. Kevin Raymond, MD, Donna Coffey, MD, Rena Vassilopoulou-Sellin, MD Series Editor: Ashok Balasubramanyam, MD

September 12, 2002

Case Presentation

A 33-year-old Hispanic man presented with a history of generalized fatigue for the past 4 months. He was also experiencing difficulty concentrating, emotional lability, decreased libido, and erectile dysfunction. He had noticed a tender "swelling" in the scalp for the past 3 weeks.

Fifteen months prior to this presentation, he had sustained minor head trauma without loss of consciousness. Three weeks after that episode, he developed polyuria, polydipsia, and nocturia. A diagnosis of central diabetes insipidus (DI) was confirmed 2 months later with a water deprivation test. MRI of the brain at that time showed thickening of the pituitary stalk.

The past medical history was significant for hypertension of 7 years' duration and dyspepsia of uncertain cause. He had had reconstructive surgery of the left knee 6 years previously. Both parents suffered from type 2 diabetes and hypertension, and 2 sisters (aged 29 and 31) had been diagnosed with papillary thyroid cancer. The patient had 1 healthy 7-year-old daughter.

The patient denied alcohol, tobacco, or illicit drug use. He was taking the following medications: desmopressin (DDAVP) 0.1 mg by mouth in the morning and at noon, and 0.2 mg by mouth at bedtime; fosinopril 15 mg daily; and omeprazole 20 mg daily.

The physical examination showed temperature 36.6º C (97.9º F), blood pressure 100/60 mm Hg (without orthostatic changes), heart rate 85/min, respirations 16/min. The patient weighed 122 kg, and his body mass index (BMI) was 39 kg/m2.

There was no papilledema or optic disk atrophy. The visual fields were intact by the confrontation test. A tender, soft mass of about 5 cm in diameter was palpable in the right parieto-occipital area of the scalp. Examination of the neck showed no jugular venous distension, a normal thyroid gland, and no abnormal lymph nodes. The chest and heart were normal. The abdomen was soft, with no masses or organomegaly. The extremities were unremarkable. The patient was normally virilized, with 3.5-cm testes of normal texture. All aspects of the neurologic examination were normal.

The patients' laboratory test results are displayed in Table 1 .

The above results indicated that the patient had hypogonadotropic hypogonadism, growth hormone deficiency, and primary hypothyroidism. The hypothalamic-pituitary-adrenocortical axis appeared to be functioning adequately.


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