A 12 year old boy sustained a severe head injury by a passing car whilst crossing the road. Injuries were confined to massive basal skull fracture, right sided blindness, acute onset diabetes insipidus, extradural and subdural bleeding requiring surgical decompression. Pre-operative physical examination revealed a healthy looking boy, height 60th centile for age, Tanner stage III puberty, 10 ml testes bilaterally. MR head demonstrated apparent pituitary stalk transection and right optic nerve transection, confirmed during surgical exploration. Pituitary function testing 1, 6, 16 days post-surgery. Hydrocortisone, thyroxine and DDAVP replacement were commenced immediately post-operative. Over 12 months, linear growth failure and pubertal arrest occurred. Glucagon stimulation confirmed GH deficiency. rGH was commenced, with improved growth parameters. As bone age was advanced (14 years at 12), consistent with pubertal status at admission, testosterone replacement was delayed to age 14, then commenced, achieving final height of 165 cm, appropriate for MPH. GH was ceased at end of linear growth. Over 7 years, to age 21, he received thyroxine, hydrocortisone, testosterone and vasopressin. At age 21 he stopped taking thyroxine. Thyroid hormone levels remained normal. Attempted reduction in hydrocortisone resulted in severe tiredness. Testosterone supplementation was ceased at age 23. Testosterone remained normal at 22 nmol/l. Hydrocortisone was gradually withdrawn between ages 2325, cortisols 200252 nmol/l. Due to excessive lethargy, formal GH testing with ITT was performed max GH 5 μ/l, cortisols 200250 nmol/l but no stress response to hypoglycaemia. GH replacement at 2.5 mg/m2 per week was given, with restoration of good health. Diabetes insipidus is persistent and advice given for steroid cover for stress. Due to excessive lethargy, formal GH testing with ITT was performed max GH 5 mu/l, cortisols 200250 nmol/l but no stress response to hypoglycaemia. GH replacement at 2.5 mg/m2 per week was given, with restoration of good health. Diabetes insipidus is persistent and advice given for steroid cover for stress.
|fT4 pmol/l (1024)||TSH mU/l (0.54)||IGF1 nmol/l (2595)||Cortisol nmol/l (240400)||FSH U/l (0.76)||LH U/l (0.96)||Testosterone nmol/l (310+ pubertal)|
|Day 6||11||<0.01||Treated||1.0 nmol/l|
|Day 16||9.6||<0.01||<1 nmol/l||0.4||<0.1||<0.3|
10 - 12 Sep 2016
European Society for Paediatric Endocrinology