Hypopituitary coma

Think of decompensated chronic hypophyseal failure whenever hypothermia, refractory hypotension ± septic signs without fever occur with short stature or loss of axillary/pubic hair ± gonadal atrophy. Waiting for lab confirmation may be fatal.

It usually develops gradually in a person with known hypopituitarism. If rapid onset due to pituitary infarction (e.g. postpartum, Sheehan’s), subarachnoid hemorrhage is often misdiagnosed as symptoms include headache and meningism.

Investigations

• Cortisol
• T4, TSH
• ACTH
• Glucose
• Pituitary fossa CT/MRI

Treatment

1. Hydrocortisone, e.g. 100mg IV/6h.
2. Only after hydrocortisone begun: liothyronine (L-tri-iodothyronine sodium), e.g. 10mcg/12h oral or by slow IV: 5–20mcg/12h (4-hourly may be needed).
3. Prompt surgery is needed if the cause is pituitary apoplexy.