Here are some stories taken from published medical case histories.

A - a car crash and a fall

Study in Endocrine Abstracts (2007)

'Greg' aged 21, was hit by a car going at 50 mph. While he was in intensive care he was producing too much urine. This can be a sign that the pituitary gland has been damaged, so the doctors tested his other hormones too, and found that he was very low in sex, growth, thyroid and stress hormones.

His urinating problem has cleared up now but he still suffers from persistent hypopituitarism and needs regular hormone treatment.

'Brett' aged 34 fractured his skull falling from a 20 foot high bridge. He too was found to be producing too much urine and was found to be low in thyroid stimulating hormone and sex hormones.

"These two patients illustrate the potential of head injuries to cause Pituitary insufficiencies. In creased awareness and a high index of suspicion will help in identifying problems early enough."

B - playing soccer

Study in Journal of Athletic Training (2007)

"Gary" was a promising junior soccer player who was the youngest in his team and spent his weekends travelling to inter-school matches. But between ages 14 to 16 he stopped growing, remaining at 5ft 6in. This was strange because his father was nearly 6 feet and both his grandfathers were over 6ft tall. He wasn't getting erections as boys of his age too, and he often felt tired. The doctors were puzzled because he didn't smoke or drink or do drugs. The only possible cause seemed to be 4 mild head injuries he'd had when he was 14.

The first was when he ran his head into the shoulder of another soccer player and sat out of the game because he "didn't feel right." The second happened when he was tandem-tubing behind a speedboat going at 15-20 mph and his face whiplashed into the head of the person in front of him. He couldn't remember much about this - only 'waking up in the water.'

The third and fourth times were ten minutes apart. He was hit hard on the head by a soccer ball, but played on even though he was dazed. Then in the same game he fell and hit the back of his head on the ground, possibly losing consciousness. Afterwards he slept more than usual and found that going upstairs gave him a headache.

The doctors thought his pituitary gland must have been damaged by these four bangs on the head and they tested his hormone levels, and sure enough, they were low.

Now he's on growth hormone, cortisol and replacement thyroid hormone and he is doing fine. He grew 4 inches in a year, and his stamina is back to normal. He has to wear a medical bracelet and will always need hormone checks, but otherwise he can lead a normal life.

C - falling off a bed

Study in Endocrine 2007

"Vera", aged 26 went to the doctors complaining of severe weight gain, swollen ankles, weakness, mild headache and high blood pressure, and was given a thorough hormone check.

She'd had a history of problems. At the age of seven she had been diagnosed with diabetes insipidus (a condition that means passing urine too often and being continuously thirsty), and when she was 12 she was unusually short for her age. She was diagnosed with growth hormone deficiency but not given any replacement hormone, and still, surprisingly, managed to reach adult height. However at the age of 18 her periods had still not started. She was given sex hormones, but that made her put on weight.

After this most recent visit at the age of 26 the doctors discovered that she was still lacking in growth and sex hormones. They questioned her parents in more depth and discovered that when she was seven, before she was diagnosed with diabetes insipidus, she had fallen off a bed on to her head and been mildly concussed. The doctors decided that this minor, long ago head injury had been the cause of all her problems.

D - violent assault

I had three head injuries between 1972 and 2003: an accident when I was driving a truck in 1972, a violent assault in 1985 when I had a basal skull fracture, and the third head injury in 2003. After this I began to suffer from right neck pain from spondylosis, dizziness when I turned my head, attacks of acute vertigo with vomiting (though these subsided), and aches and pains. To these symptoms were added tinnitus and deafness in my right ear, and headaches. In 2004 I was referred to a dizzy clinic, but with no improvement in my health. By 2006 I was still suffering all my previous symptoms, with the addition of pains in my face, and tingling and numbness in both hands. I was diagnosed with Menieres symptoms. My GP found hypothyroidism, which he diagnosed as primary, and prescribed thyroxin. At this point I started to wonder if my problems might stem from my pituitary gland. I had a private BUPA test that showed my TSH levels were borderline low. However, a short synacthen test that year showed no abnormalities.

In 2007, desperate that I was feeling no better, and now suffering from atrial fibrillation, chest discomfort, chronic fatigue and sleep problems, I approached an eminent endocrinologist privately, but neither he nor the endocrinology department at Manchester Royal Infirmary discovered what was wrong with me. In 2008, in fact, I was discharged from that hospital with a diagnosis of chronic fatigue syndrome and a letter that said “We have explained to Mr Barker that there are no signs of an underlying endocrinological problem to explain his many symptoms . . . there may well be an element of psychosomatic or depressive problems . . I am concerned that he may go on to undergo further investigation and medicalisation of his symptoms,” and suggested cognitive behavioural therapy.

Now at the end of my tether after four years of dizziness, I changed my GP in order to be referred privately to Dr Tara Kearney, consultant endocrinologist at Salford Royal Hospital. How I wish I could have been treated by her from the beginning. Here at last, in 2008, I made two discoveries. One was that around a third of head injuries cause pituitary problems [1], and the symptoms can include dizziness, tingling and numbness, headaches and chronic fatigue. The other was that the short synacthen test is not a reliable way to diagnose ACTH or growth hormone deficiency, as it misses about 40% of cases [2]. At last I was given the right tests – the glucagon stimulation test and the arginine test – which together showed that I was suffering from growth hormone deficiency and ACTH deficiency. Dr Kearney said of me, “he has certainly had conflicting opinions from several endocrinologists, however I have checked several insulin stress tests and glucagon tests and I am certain that Mr Barker has evidence of pituitary dysfunction.” At long last I began the appropriate treatment.

Earlier, one of my GPs and a consultant did say it “was all in my head,” and this, sadly, turned out to be prophetic, though not in the way they meant.

I wish I could say that this was the end of my troubles, but I had been so long deprived of growth hormone that my abdomen had swollen and I developed divancation of the rectus sheath and below that an incisional hernia. I am still very ill. I feel that if only there had been more awareness of the considerable risk of pituitary failure after head injury, and the shortcomings of the short synacthen test, my whole story might have turned out differently. But it will be a comfort to me if my story alerts doctors and helps others to be diagnosed.

References
[1] Schneider HJ et al, Hypothalamopituitary Dysfunction Following Traumatic Brain Injury and Aneurysmal Subarachnoid Haemorrhage: A Systematic Review, 2007, JAMA http://jama.jamanetwork.com/article.aspx?articleid=208915
[2] Dorin RI, Diagnosis of Adrenal Insufficiency, 2003, Annals of Internal Medicine, https://annals.org/article.aspx?articleid=716603 The MEDLINE database was searched from 1966 to 2002 for all English-language papers related to the diagnosis of adrenal insufficiency, and it was found that for diagnosing secondary adrenal insufficiency, the sensitivity of the short synacthen test was 57-61%.

(Source BMJ website 24 April 2013)

E - saved by hormone replacement

After being badly beaten up in a street robbery six years ago and nearly losing an eye, I suffered severe depression and tried to kill myself several times.

I did not know then that a large Danish epidemiological study had found that the risk of suicide after head injury is three or four times other people’s [1], a finding confirmed by much other research [2]. I would have thought that past head injury should be one of the first things a GP should enquire about when faced with a depressed patient.

It may be of interest if I describe how my depression was cured.
I had three distinct groups of symptoms after my injury. First, the psychological effects included depression, fatigue and cognitive defects. I’d lost all my social skills.

I couldn’t perform simple tasks like dressing myself. I couldn’t work. I had lost track of life. Secondly I found two or three months after the attack I would bruise alarmingly easily, coming out with great discoloured welts after minor bumps. Thirdly, it grew apparent that I had become infertile.

For my brain fog and depression I had neuropsychological treatment – skill mapping, strategies for circumventing particular cognitive defects – and also PTSD treatment – relaxation exercises, brain training for stress and anxiety. Neither of these approaches helped me, and I was not offered any of the blood tests which would later prove vital to my diagnosis.

When my wife and I sought help at a fertility clinic my sperm was tested for number and motility, and found to be near zero. I was prescribed a regime of diet, exercise and sleep and the dropping of certain antidepressants, and at first this appeared to work, and then not to. It was a standard one-size-fits-all procedure, and nobody ever paused to wonder why a 35-year-old who had been fertile before should have problems now?

What saved me, unexpectedly, was the bruising. My GP found my fibrinogen levels were abnormal and suggested on the face of it fibromyalgia, but wasn’t convinced. He also did a thyroid test which came out low. He consequently referred me to an endocrinologist who very, very fortunately was one of the few on the look-out for the endocrine effects of head injury. Within minutes he told me he believed he knew what was wrong with me.

He told me that roughly a third of cases head injury results in damage to the pituitary gland, causing possible deficiencies in growth hormone, gonadotrophs, ACTH and TSH, and an excess of prolactin [3]. I was found to be testosterone-deficient, and received hormone treatment within a matter of days.

Whilst markedly improved on testosterone treatment unfortunately, the fatigue, cognitive fuzziness, rhinitis, headaches, sleep problems, dizziness and depression still dogged me, and twelve months later, after something of a struggle, I was given replacement growth hormone.

At this point my brain fog and suicidal moods completely disappeared and I no longer needed antidepressants. How much simpler it would have been if instead of receiving neuropsychological and PTSD treatment, I had been routinely screened for growth hormone deficiency at the beginning?

I am off benefits and back at work now, happy with my wife and new child, with a partnership in four businesses. But it was only chance that I was diagnosed and treated. There is no proper pathway for screening for endocrine damage after head injury – and this means that there must be many, many people turning up in GP surgeries today complaining of depression who could be helped by replacement hormones. Surely GPs need to know this?

[1] Teasdale TW, Engberg AW, Suicide after traumatic brain injury: a population study, J Neurol Neurosurg, Psychiatry   2001) 

http://jnnp.bmj.com/content/71/4/436.full
 

[2] Simpson G, Tate R, Suicidality in people surviving a traumatic brain injury: prevalence, risk factors and implications for clinical management, Brain Inj 2007 Dec;21(13-14):1335-51. http://www.ncbi.nlm.nih.gov/pubmed/18066936
 

[3] Schneider HJ et al, Hypothalamopituitary Dysfunction Following Traumatic Brain Injury and Aneurysmal Subarachnoid Haemorrhage: A Systematic Review, 2007, JAMA  http://jama.jamanetwork.com/article.aspx?articleid=208915

(Source: BMJ website 12 August 2013)

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