Letter to the Editor
Hypoglycemia as an onset form of hypophysial infiltration by lymphoma
Hipoglucemia como forma de presentación de infiltración hipofisaria por un linfoma
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Thickening of the infundibular stalk and the pituitary gland with heterogeneous uptake and focal bone involvement of the sellar bone structure with destruction of the posterior central portion of the sella turcica with soft tissues affecting the posterior dorsum of the sphenoidal sinus.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Panhypopituitarism secondary to metastasis of the pituitary gland is an uncommon entity mainly produced by solid tumours, with breast and lung cancer being the most common primary tumors.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Haematological metastases constitute less than 0.5% and are almost exclusively limited to the posterior pituitary gland, often with diabetes insipidus as the first manifestation.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> We report the case of a male patient diagnosed with diffuse large B-cell lymphoma (DLBCL) with hypopituitarism secondary to pituitary infiltration who presented with hypoglycaemia in the postoperative period following a hip fracture.</p><p id="par0010" class="elsevierStylePara elsevierViewall">This is a 69-year-old diabetic male patient under treatment with metformin and previously diagnosed with high-grade DLBCL, stage IV-B, who after a casual fall and due to pain and functional deficit in the hip, was diagnosed with a subcapital fracture of the femur, so a total hip replacement prosthesis was decided. Symptoms prior to the fall included asthenia. Physical examination only revealed preauricular, cervical and axillary lymphadenopathy. Laboratory tests showed hypercalcaemia on admission (calcium 10.9 mg/dL).</p><p id="par0015" class="elsevierStylePara elsevierViewall">During the immediate postoperative period, the patient was hemodynamically stable, with preserved blood glucose levels and no dyselectrolytemia. Calcium concentrations remained high (11 mg/dL) and the patient continued under serum therapy. From the fourth postoperative day onwards the patient experienced asymptomatic morning hypoglycaemia (< 40 mg/dL) which resolved with oral intake. No other abnormalities were found in the complete blood count or in the routine analysis. A baseline endocrine evaluation revealed corticotropic, thyrotropic and gonadotropic deficiencies. A contrast cranial tomography (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) showed heterogeneous uptake and thickening of the infundibular stalk and pituitary gland, with destruction of a portion of the sella turcica, as well as lateral cervical signs of lymphoma progression. With the diagnostic approach of panhypopituitarism secondary to pituitary infiltration, hormone replacement therapy with glucocorticoids was initiated, followed by levothyroxine; but the patient's general condition deteriorated rapidly in the following days, secondary to his underlying condition, and he died five days after diagnosis.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The differential diagnosis of hypoglycaemia in the diabetic patient is broad. First, a pharmacological cause must be ruled out, as it is the most common reason, as well as endogenous hyperinsulinism. In the specific case of this patient, he had not received any oral hypoglycaemic agent during hospitalisation that could be the causative factor and the concentrations of C-peptide extracted during hypoglycaemia were decreased, so the next diagnostic suspicion was primary or secondary adrenal failure. A possible tumour infiltration of the adrenal gland was considered in this patient. However, a recent PET/CT showed no signs of adrenal infiltration. It was known that the patient had received corticosteroids during previous chemotherapy, so at some point the probability of adrenal failure secondary to steroid treatment was raised. However, laboratory findings showed inhibition of all pituitary axes, so a differential diagnosis of panhypopituitarism secondary to the underlying haematological disease was suggested, which was confirmed by imaging.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Pituitary tumour infiltration is an unusual cause of panhypopituitarism. Yang et al. recognize that lymphoma-associated sellar involvement constitutes less than 0.5% of all metastases in the pituitary gland.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Diagnosis is difficult in the absence of known neoplastic disease because of clinical nonspecificity and the absence of characteristic radiological findings to differentiate it from other benign sellar lesions such as granulomas, hypophysitis, stroke or infection.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The involvement of the anterior part of the pituitary gland and the manifestations secondary to endocrine deficiencies are generally preceded by the involvement of the neurohypophysis and its onset as diabetes insipidus in up to 100% of the series.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">We report this exceptional case of panhypopituitarism whose form of presentation was hypoglycaemia on the fourth day and not as adrenal failure. After a stressor such as a fracture and surgery, you would expect an acute condition characterized by fever, confusion, hypotension, metabolic acidosis, and dyselectrolytemia.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Thus, when dealing with a patient with hypoglycaemia and a progressive neoplastic disease, we consider it important to rule out adrenal and pituitary involvement.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Vega-Cano S, Cordero-Vázquez E, Mestre-Torres J. Hipoglucemia como forma de presentación de infiltración hipofisaria por un linfoma. Med Clin (Barc). 2021;156:362–363.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 602 "Ancho" => 1500 "Tamanyo" => 87324 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Post-contrast brain CT. Thickening of the infundibular stalk and the pituitary gland with heterogeneous uptake and focal bone involvement of the sellar bone structure with destruction of the posterior central portion of the sella turcica with soft tissues affecting the posterior dorsum of the sphenoidal sinus.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tumors metastatic to the pitituary gland: case report and literature review" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J. Kominos" 1 => "V. Vlassopoulou" 2 => "D. 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Rochwerg" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/CCM.0000000000002737" "Revista" => array:5 [ "tituloSerie" => "Crit Care Med" "fecha" => "2017" "volumen" => "45" "paginaInicial" => "2078" "paginaFinal" => "2088" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015600000007/v1_202104020834/S2387020621000942/v1_202104020834/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015600000007/v1_202104020834/S2387020621000942/v1_202104020834/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020621000942?idApp=UINPBA00004N" ]
