Learning objectives

• Definition of panhypopituitarism
• Management of panhypopituitarism

Definition and mechanisms

• A rare condition in which the pituitary there’s a deficiency in all of the hormones produced by the pituitary gland
• The anterior lobe of the pituitary gland produces:
  • Adrenocorticotropic hormone (ACTH or corticotropin)
  • Follicle-stimulating hormone (FSH)
  • Growth hormone (GH)
  • Luteinizing hormone (LH)
  • Prolactin (PRL)
  • Thyroid stimulation hormone (TSH)
• The posterior lobe of the pituitary gland produces:
  • Antidiuretic hormone (ADH)/vasopressin
  • Oxytocin
• Can affect anyone at any age
• It can be life-threatening, especially if significant deficiencies of ACTH are present, and affects 4 people per 100,000 people 
• Panhypopituitarism is a type of hypopituitarism
  • A deficiency or lack in one or multiple of the hormones produced by the pituitary gland
• Patients with hormonal deficiencies present with the following:
  • ACTH deficiency – adrenal insufficiency
  • TSH deficiency – hypothyroidism
  • Gonadotropin deficiency – hypogonadism
  • GH deficiency – difficult to thrive and short stature in children, adults are usually asymptomatic; however, they may feel fatigued and weak
  • ADH deficiency – diabetes insipidus presenting with polydipsia and polyuria

Signs and symptoms

• Symptoms depend on the hormones depend on which hormone is deficient
  • Growth problems (in children)
  • Obesity
  • Hair loss
  • Bradycardia
  • Hypoglycemia
  • Hypotension
  • Fatigue
  • Nausea or dizziness
  • Depression and/or anxiety
  • Frequent infections
  • Sensitivity to cold
  • Unusually dry skin
  • Unexplained weight loss or weight gain
  • Dyslipidemia
  • Tachycardia
  • Excessive thirst and urination
  • Female and male infertility
• Additional symptoms specific to infants, children, or adolescents
  • Prolonged jaundice in newborns
  • Micropenis
  • Slowed growth
  • Delayed puberty

Causes

Complications

• Adrenal crisis (acute cortisol insufficiency) which is characterized by the following symptoms:
  • Fever
  • Weakness
  • Confusion
  • Hypotension
  • Tachycardia
  • Vomiting
  • Diarrhea
  • Hypoglycemia
• Secondary diseases:
  • Obesity
  • Increased cholesterol
  • Metabolic syndrome
  • Estradiol deficiency potentially leads to osteoporosis

Diagnosis

• MRI
• CT
• Hormone level tests:
  • Blood tests
  • ACTH-stimulation test
  • Growth hormone stimulation test
  • Insulin tolerance test
  • Modern combined test

Treatment

• Hormone replacement therapy
• Pituitary surgery
• Radiation therapy
• Corticosteroids

Management

Suggested reading

• Raut MS, Kar S, Maheshwari A, Shivnani G, Dubey S. Perioperative management in a patient with panhypopituitarism – evidence based approach: a case report. Eur Heart J Case Rep. 2019;3(3):ytz145. Published 2019 Sep 18.
• Malhotra, Surender & Jangra, Kiran & Saini, Vikas. (2013). Pituitary Surgery and Anesthetic Management: An Update. World Journal of Endocrine Surgery. 5. 1-5. 10.5005/jp-journals-10002-1114.
• Menon R, Murphy PG, Lidnley AM. 2011. Anaesthesia and pituitary disease. Continuing Education in Anaesthesia Critical Care & Pain. 11;4:133-137.