Primary empty sella syndrome and hypopituitarism associated with primary hypothyroidism

A 63-year-old woman, married with 1 child was referred because of weight gain, cold intolerance and fatigue. Initial laboratory studies revealed decreased serum thyroxine, highly elevated TSH levels and positive-antithyroglobulin antibodies. Skull x-ray and visual fields were normal. Fasting plasma Cortisol and the response to iv ACTH were normal. Serum levels of FSH (7.4 mlU/ml) and LH (6.8 mlU/ml) were low for her age and did not rise in response to LHRH. Serum GH levels were low and did not respond to L-dopa. Following the administration of thyrotropin-releasing hormone (TRH), prolactin (PRL) response was normal. The patient was maintained on L-thyroxine (0.15 mg/day). Serum TSH levels decreased to normal levels (1.8μU/ml). Periodic examination of visual fields and x-ray of skull were normal. Three yr later x-ray of skull revealed an enlarged sella turcica. Hormonal studies revealed low basal levels of FSH and LH and absent response to LHRH. Basal PRL levels were normal but PRL response to TRH and metoclopramide was blunted, thus indicating decreased prolactin reserve. Serum TSH levels remained unchanged following TRH (1.5–2.5 μU/ml). Following insulin-induced hypoglycemia there was noGH or PRL response while Cortisol response was intact. Computerized axial tomography of the skull and sell turcica were compatible with an empty sella with no evidence of suprasellar mass or hydrocephalus. These findings suggest that this patient had primary hypothyroidism associated with empty sella syndrome and development of hypopituitarism while being euthyroid.