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A case of cocaine-induced panhypopituitarism with human neutrophil elastase-specific anti-neutrophil cytoplasmic antibodies

Department of Internal Medicine, VU University Medical Center, PO Box 7075, 1007 MB Amsterdam, The Netherlands

(Correspondence should be addressed to P W B Nanayakkara; Email: p.nanayakkara{at}vumc.nl)

Abstract

Objective: To describe a patient with cocaine-induced panhypopituitarism associated with human neutrophil elastase-anti-neutrophil cytoplasmic antibodies (HNE-ANCA).

Case: A 41-year-old man presented with extreme fatigue, cold intolerance and anorexia with 20 kg weight loss in the last 6 months. His medical history was unremarkable. He snorted cocaine twice a week during the last 6 years. On examination, we saw a pale and skinny man, with a normal blood pressure. Because of the severity of symptoms central hypothyroidism was suspected and very low values of TSH, free thyroxine and free triiodothyronine were measured. His FSH, LH, ACTH, cortisol, prolactin and testosterone levels were also low.

Magnetic resonance imaging and computed tomography scan showed a normal-sized pituitary gland entirely embedded in a dense, oedematous, contrast-enhancing mass, and a total destruction of the nasal septum with the absence of conchae and severely impaired sinus walls. A transnasal biopsy showed an acute necrotising, non-specific and non-granulomatous inflammation. Although cocaine-induced panhypopituitarism was suspected, Wegener's granulomatosis could not be excluded. Serology on ANCA showed a strongly positive C-ANCA titre (320 U/l) with specificity for HNE. A cocaine-induced HNE-ANCA-associated panhypopituitarism was diagnosed.

Our patient was advised to quit using cocaine immediately and was initially treated with glucocorticoids and testosterone, followed by thyroxine. This led to a dramatic clinical response with an increase of appetite, weight gain and regained energy. After 2 years, the patient is well and his ANCA titre is no longer positive.

Conclusion: We describe the first documented case of cocaine-induced panhypopituitarism associated with HNE-specific ANCA.