30 An unexpected endocrine cause of a presumed eating disorder and postnatal depression
Kool, R.O., Berk, G.E.L. van den, Dam, P.S. van
Locatie(s): Auditorium 2
Categorie(ën): Parallelsessie
Introduction: Discrimination between a severe primary eating disorder and hypocortisolism may be difficult because of the large clinical similarity. The classical symptoms of the ‘Unforgiving master of non-specificity and disguise’ as described by Thomas Addison are not always present and can even be misleading. We present an impressive and instructive case of diagnostic errors and delays in a woman during three years after delivery of her twins.
Case: A 43-year old woman was hospitalised and treated for a collapse as a consequence of spontaneous hypoglycaemia and hypotension. Her history revealed that she had lost 40 kilogram after giving birth to twins three years earlier. In the mean time, she had been supported and treated for anorexia and depression. Because of these conditions she had lost custody of her twins. After delivery, breast feeding had been impossible, and a year later she had become amenorrheic. At presentation, we saw a confused Creolic woman with a BMI of 18 kg/m2, a body temperature of 35 ºC and a blood pressure of 110/65 mmHg. Hypoglycemia and hypotension had already been corrected. Palmar or buccal hyperpigmentation was absent. Blood tests showed low levels of potassium (2,6 mmol/L), magnesium (0,47 mmol/L), phosphate (0,64 mmol/L), albumin (23 g/L) and pancytopenia. Because of her psychiatric history, she was admitted to our medical-psychiatric unit. On the next day, plasma cortisol was undetectable. Additional laboratory tests were consistent with panhypopituitarism. MRI of the pituary gland showed an empty sella.
Discussion: Severe loss of weight by anorexia with a late first presentation of a presumed eating or mood disorder should raise the suspicion of a endocrine cause by any treating physician. The present case demonstrates that diagnosing secondary hypocortisolism may be less straightforward than primary hypocortisolism (Addison’s disease). Central hypocortisolism is less characterised by hyperkaliaemia and hypovolemic shock since aldosteron production remains undisturbed. Hypoglycaemia can be a diagnostic clue and can be explained by the absence of growth hormone-induced gluconeogenesis. Addison’s disease may also be diagnosed earlier because of hyperpigmentation. A serious endocrine disease was considered to be a psychiatric disorder for a long time, while the real cause was hypopituitarism as a consequence of an empty sella, possibly due to pituitary infarction during pregnancy or delivery.