Picture quiz: Headache, visual blurring, and gynaecomastia
A 54 year old man presented with a six month history of severe headaches and visual blurring. He also noted decreased libido and progressive impotence. And he complained of general fatigue, intolerance to cold, and decreased appetite.
On physical examination, blood pressure was 105/60 mm Hg (with postural hypotension) and his pulse rate was 60 beats/min. In addition there was pallor and bilateral gynaecomastia without Cushingoid or acromegalic features. Visual field testing showed bitemporal hemianopia.
Notable laboratory test results were testosterone 180 (normal range 300-1100) ng/dl, T4 4 (4-12) µg/dl, thyroid stimulating hormone 0.5 (0.5-5.0) mIU/ml, and prolactin 48 (<10) ng/ml. An adrenocorticotropic hormone stimulation test showed a peak cortisol concentration of 10 (>20) µg/dl. In view of the panhypopituitarism and visual field defects magnetic resonance imaging of the brain was ordered (figure).
The presentation of pituitary tumours can be divided into two groups-mass effect and endocrine effect. Mass effects