Endocrinol Metab.  2012 Dec;27(4):308-313. 10.3803/EnM.2012.27.4.308.

Pancytopenia Associated with Hypopituitarism in an Acromegaly Patient: A Case Report and a Review of the Literature

• Koh JH
• Lee YJ
• Kang JH
• Choi BK
• Jeon YK
• Kim SS
• Kim BH
• Kim IJ

• KMID: 1973795
• DOI: http://doi.org/10.3803/EnM.2012.27.4.308

Abstract

We present the case of a patient with acromegaly who had pancytopenia with hypopituitarism secondary to the excision of a pituitary macroadenoma and radiation therapy. A 28-year-old man presented with pancytopenia and serum electrolyte abnormalities. He was diagnosed with acromegaly and underwent surgery and gamma-knife radiotherapy for a pituitary macroadenoma at the age of 22 years. A recent brain magnetic resonance imaging showed an empty sella, and the basal hormonal profile demonstrated deficiencies of pituitary hormones except thyrotropin. As presenting pancytopenia, his bone marrow biopsy showed hypocellular marrow. The total number of hemocytes increased after hydrocortisone replacement. Hypopituitarism was a possible cause of pancytopenia, and glucocorticoids had crucial effects on converting pancytopenia to normal in this case.

Keyword

Acromegaly; Hypopituitarism; Pancytopenia

MeSH Terms

Acromegaly
Adult
Biopsy
Bone Marrow
Brain
Glucocorticoids
Hemocytes
Humans
Hydrocortisone
Hypopituitarism
Magnetic Resonance Imaging
Pancytopenia
Pituitary Hormones
Thyrotropin
Glucocorticoids
Hydrocortisone
Pituitary Hormones
Thyrotropin

Figure

• 

  Fig. 1 A T1-weighted sagittal (upper) and coronal views (lower) of a pituitary macroadenoma by magentic resonance imaging which was taken before and after surgery. (A) A 40-mm macroadenoma invading the cavernous sinus before surgery. (B) Two months after pituitary surgery, a residual mass was seen around the cavernous sinus on both sides. (C) Three years after radiotherapy, the remnant mass decreased in both cavernous sinuses and pituitary gland was enhanced on the coronal view (arrow). (D) Six years after pituitary surgery, the pituitary gland was atrophied, and the sella was empty and filled with cerebrospinal fluid.

• 

  Fig. 2 Clinical course of the patient (changes in insulin like growth factor [IGF]-1 and growth hormone [GH] levels).

• 

  Fig. 3 High-power view of a bone marrow section. Decreased hematopoiesis with hypocellurarity are noted (H&E stain, × 100).

• 

  Fig. 4 Changes in hematologic findings through hydrocortisone replacement therapy. Hb, hemoglobin; WBC, white blood cell.

Reference

1. Holdaway IM, Rajasoorya C. Epidemiology of acromegaly. Pituitary. 1999. 2:29–41.

2. Melmed S, Colao A, Barkan A, Molitch M, Grossman AB, Kleinberg D, Clemmons D, Chanson P, Laws E, Schlechte J, Vance ML, Ho K, Giustina A. Acromegaly Consensus Group. Guidelines for acromegaly management: an update. J Clin Endocrinol Metab. 2009. 94:1509–1517.

3. Segel GB, Lichtman MA. Kaushansky K, Williams WJ, editors. Aplastic anemia: acquired and inherited. Williams Hematology. 2010. 8th ed. New York: McGraw-Hill Medical;569–590.

4. Kim DY, Kim JH, Park YJ, Jung KH, Chung HS, Shin S, Yun SS, Park S, Kim BK. Case of complete recovery of pancytopenia after treatment of hypopituitarism. Ann Hematol. 2004. 83:309–312.

5. Ozdogan M, Yazicioglu G, Karadogan I, Cevikol C, Karayalcin U, Undar L. Sheehan's syndrome associated with pancytopenia due to marrow aplasia: full recovery with hormone replacement therapy. Int J Clin Pract. 2004. 58:533–535.

6. Gokmen Akoz A, Atmaca H, Ustundag Y, Ozdamar SO. An unusual case of pancytopenia associated with Sheehan's syndrome. Ann Hematol. 2007. 86:307–308.

7. Laway BA, Bhat JR, Mir SA, Khan RS, Lone MI, Zargar AH. Sheehan's syndrome with pancytopenia: complete recovery after hormone replacement (case series with review). Ann Hematol. 2010. 89:305–308.

8. Laway BA, Mir SA, Bhat JR, Lone MI, Samoon J, Zargar AH. Hematological response of pancytopenia to glucocorticoids in patients with Sheehan's syndrome. Pituitary. 2012. 15:184–187.

9. Fatma M, Mouna E, Nabila R, Mouna M, Nadia C, Mohamed A. Sheehan's syndrome with pancytopenia: a case report and review of the literature. J Med Case Rep. 2011. 5:490.

10. Holmes GI, Shepherd P, Walker JD. Panhypopituitarism secondary to a macroprolactinoma manifesting with pancytopenia: case report and literature review. Endocr Pract. 2011. 17:e32–e36.

11. Badawi MA, Salih F, Al-Humaidi AA, El Khalifa MY, Elhadd TA. Bone marrow hypoplasia responsive to testosterone therapy in a patient with panhypopituitarism: need for adherence to androgen replacement. Endocr Pract. 2008. 14:229–232.

12. Lee AC. Pancytopenia secondary to hypopituitarism may just be due to hypothyroidism alone. Ann Hematol. 2010. 89:1181.

13. Nishioka H, Haraoka J. Hypopituitarism and anemia: effect of replacement therapy with hydrocortisone and/or levothyroxine. J Endocrinol Invest. 2005. 28:528–533.

14. Laway BA, Mir SA, Bashir MI, Bhat JR, Samoon J, Zargar AH. Prevalence of hematological abnormalities in patients with Sheehan's syndrome: response to replacement of glucocorticoids and thyroxine. Pituitary. 2011. 14:39–43.

15. Moriyama Y, Fisher JW. Effects of testosterone and erythropoietin on erythroid colony formation in human bone marrow cultures. Blood. 1975. 45:665–670.

16. Dainiak N, Hoffman R, Maffei LA, Forget BG. Potentiation of human erythropoiesis in vitro by thyroid hormone. Nature. 1978. 272:260–262.

17. Merchav S, Tatarsky I, Hochberg Z. Enhancement of erythropoiesis in vitro by human growth hormone is mediated by insulin-like growth factor I. Br J Haematol. 1988. 70:267–271.

18. Sohmiya M, Kato Y. Effect of long-term administration of recombinant human growth hormone (rhGH) on plasma erythropoietin (EPO) and haemoglobin levels in anaemic patients with adult GH deficiency. Clin Endocrinol (Oxf). 2001. 55:749–754.