1. 1 Pituitary deficiencies following head injury – a patient case Sue Cox Endocrine CNS Torbay hospital

2. 2 Patient 42 year old male Married Unemployed Ex smoker Moderate alcohol

3. 3 Medical History Hayfever Crush injury right arm Asymptomatic proteinuria Familial hypercholesterolaemia (Jan 06) Assault 1994 - #skull and left frontal subdural haematoma Legionnaires 2005 DVT 2005

4. 4 Presentation Oct 04 (approx 2 weeks after head injury) Polydipsia 15-20 pints/day Polyuria Nocturia 1-10/night (avg 3-4) Tired, cold Headaches Loss of smell and taste Loss of appetite

5. 5 Investigations 24 hour urine volume Urine osmolality* Serum osmolality* Sodium FSH LH Testosterone Cortisol TSH IGF-1 MRI 5.25L 106 (0 -1400) 311 (281 – 297) 151 (132 – 144) 3.2 (0 – 10) 5.6 (0 – 10) 15.79 (8 – 29) 419 (10.00 am) 1.80 (0.35 – 5.5) 156 (90 – 360) Normal appearance of pituitary

6. 6 Conclusion Cranial Diabetes Inspidues secondary to head injury Started Desmopressin Urine volume improved – 1.5 L Drinking less Nocturia resolved However………………

7. 7 There’s more Dec 06 Limb weakness Memory problems Dizziness General fatigue Tiredness CT scan Cerebral atrophy & left frontal lobe damage Synacthen test = normal Gonadotrophins and testosterone = normal Free T4 – low 9.4 (n = 11-24 )

8. 8 Feb 07 Free T4 = 10 Start T4 50 mcg Plan for GH stimulation test GHRH/Arginine (Sept 07) Peak GH = 37 IGF-1 = 248 (9 – 40) ?? False negative Proceed to Glucagon Peak GH = 0.9 (mu/l) IGF-1 = 18.1 AGDHA score = 24/25

9. 9 Where are we now Desmopressin 200 mcg tds T4 50mcg od Cortisol = normal response during Glucagon Testosterone normal Started GH replacement March 08 IGF-1 – normalised June 08

10. 10 Any questions?