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Case records of the Massachusetts General Hospital. Case 25-2008. A 43-year-old man with fatigue and lesions in the pituitary and cerebellum.

Dr. Flavia V. Castelino (Rheumatology, Allergy, and Immunology): A 43-year-old man was seen in the neuro-oncology clinic of this hospital because of fatigue and lesions in the pituitary and cerebellum detected on radiography. He had been well until approximately 9 years earlier, when thirst, insomnia, fatigue, and arthralgias developed. On evaluation at another facility, a diagnosis of diabetes insipidus was made, and desmopressin was prescribed. The symptoms resolved; however, during the next several years, he and his wife were unable to conceive a second child. Approximately 3 years earlier, insomnia, fatigue, and joint pain recurred, associated with cold intolerance. Evaluation disclosed no evidence of sleep apnea. The results of laboratory tests are shown in Table 1. Magnetic resonance imaging (MRI) of the brain revealed a suprasellar mass with nodular enhancement involving the upper pituitary stalk and hypothalamus and an enhancing nodule in the left cerebellar hemisphere. Computed tomography (CT) of the chest, abdomen, and pelvis showed sclerotic foci in the right humeral head, several thoracic vertebral bodies, and the iliac wings, with fullness of the renal collecting systems. The results of CT were otherwise normal. Ferrous sulfate, levothyroxine, and testosterone transdermal gel were prescribed, and the symptoms abated. Two years before this evaluation, the patient was evaluated at a local hospital because of a syncopal episode; the physical examination was normal, and there was no orthostatic hypotension. CT of the head, performed without contrast material, revealed mucosal thickening in the right frontal and ethmoid sinuses and sclerotic areas within the calvaria; no abnormalities were seen in the brain. MRI of the brain showed a suprasellar lesion, approximately 4 mm by 6 mm by 9 mm, involving the upper pituitary stalk and hypothalamus; a lesion in the deep cerebellar white matter, 1.2 cm in diameter; and mild mucosal thickening of the right maxillary sinus and anterior ethmoid sinuses. On follow-up evaluation by a neurologist, an electroencephalogram and ophthalmologic examination showed no abnormalities. CT of the chest and upper abdomen, performed after the administration of contrast material, reportedly showed slight prominence of both kidneys, with bilateral perinephric stranding, and no lymphadenopathy. A small amount of fluid was noted around the aorta in the retroperitoneum and thorax, and sclerotic foci were seen in multiple vertebrae. Ultrasonography of the kidneys showed that the right and left kidneys were 12.1 cm and 10.9 cm in length, respectively, with bilateral grade Case 25-2008: A 43-Year-Old Man with Fatigue and Lesions in the Pituitary and Cerebellum