FIGURE3 Show well defined lesion involving the pituitary fossa, mostly represented pituitary macroadenoma.
5-TREATMENT AND FOLLOW UP
About the treatment patient received On the 1st day the patient received blood, potassium, and calcium.
On the 2nd day, the patient developed atrial fibrillation his blood pressure was normal, and no signs of heart failure, and received bisoprolol. TSH was 2.69.
In the 3rd day LFT showed AST = 21, ALT = 15, ALP = 159. At the end of the 3rd day, the patient complained of abdominal pain and absolute constipation since admission, on examination, there was mild abdominal distention with a resonant percussion note, and the patient then was examined by surgical department doctors and there was no fecal impaction on rectal examination, and serum electrolytes and abdominal x-ray (erect and supine) was requested, and patient puted in fasting and IV fluids and potassium.
On the 4th day, serum electrolytes were repeated and showed: Serum Na+ = 134.4 mEq/L, Serum K+= 6.02 mEq/L. Abdominal X-ray showed distended large bowel with an air-fluid level.
On the fifth-day serum electrolytes were repeated and serum K+ =2.84 and serum Na+ = 129.9.
At the end of the fifth day, the patient passed stool. On the 8th day, the patient was discharged in good clinical condition with no symptoms and normal Hb and serum electrolytes.
3 days after admission on 7/feb/2022 the patient returned presenting massive black diarrhea.On examination, he was pale and tachycardic.The patient was stabilized and prepared for an endoscopy the next day.Endoscopy was done and show mild erosion in the stomach and duodenum. The day after, the patient was prepared and a colonoscopy was done which showed multiple erosive and skip lesions, and biopsy was taken and the result showed lymphocytic infiltration
6- DISCUSSION
A typical endocrine disorder is hypogonadism. A man is considered to have hypogonadism according to the Endocrine Society if he exhibits symptoms and physical manifestations of a low level of free or total testosterone in his blood as well as clear-cut, consistent low serum levels of these substances. The 2018 definition of hypogonadism by the American Urological Association, on the other hand, combines symptoms or indicators of hypogonadism with a blood total testosterone level below 300 ng/dL. In order to distinguish between main and secondary (testicular) and Utilizing serum luteinizing hormone and follicle-stimulating hormone concentrations, one can identify secondary (pituitary-hypothalamic or central) hypogonadisms. In light of this, one must take the hypothalamus-pituitary axis into account if gonadotropin levels are low or abnormally normal. Serum prolactin as well as iron levels have to be assessed in such situations. Other pituitary hormone tests including magnetic resonance imaging (MRI) of the pituitary may be required when clinically needed. If a pituitary adenoma is suspected as a result of substantial pituitary hormone abnormalities, such as high serum pro-lectin or MRI (1). An MRI of the brain was performed in our instance and revealed a pituitary mega adenoma, confirming the patient’s hypogonadism. Hormonal study was performed, and the findings indicated hallmarks of hypogonadism based on low levels of LH, FSH, and testosterone in the lab.IBD, which has a consistently rising prevalence, has been an issue in healthcare across the world. It comes in two main varieties: ulcerative colitis (UC) and Crohn’s disease (CD), which are separate inflammatory chronic bowel diseases that relapse often. Any area of the digestive system can be affected by CD, which can produce transmural inflammation. The perianal region or terminal ileum are the most often affected areas. In contrast to UC, CD frequently results in problems such abscesses, fistulas, and strictures. While UC is confined to the colon and is characterized by mucosal inflammation(2). Bloody diarrhea was the first symptom that our patient had experienced, and he had previously experienced it three times.and colonoscopies were performed repeatedly due to persistent diarrhea since 2010. In the stomach and duodenum, the most recent endoscopic revealed little erosion. A biopsy was performed after the most recent colonoscopy, which revealed several erosive and skip lesions. The biopsy’s results revealed lymphocytic infiltration.
Among the subtypes of hemolytic anemia, known as microangiopathic hemolytic anemia (MAHA), there is fragmentation andhemolysis brought on by erythrocyte destruction in the tiny blood vessels (3). The patient was responding well to immunosuppressive medications (steroids) and hydroxychloroquine when we started them, and the patient showed a dramatic improvement in the hemoglobin level and no more hemolysis. Since starting treatment, there has been no history of blood transfusion. The patient had electrolyte disturbance, subacute intestinal obstruction brought on by paralytic ileus, therapy for hypokalemia, and correction of the patient’s hypocalcemia all led to a worsening of the case’s circumstances.
Because the patient’s most recent episodes of hypokalemia and sepsis did not improve with therapy, the patient’s decline and reason of death remained unknown. There have never been any records of cases like the one in our case presentation. We hypothesize that the reason may be because recognizing this sickness may be challenging in low-resource countries like Sudan. The availability of complex investigation modalities outside of big cities can be a significant hurdle when it comes to detecting people with suspected hypogonadism caused by macroadenoma and hemolytic anemia with inflammatory bowel disease..
7- Conclusion
Even though it’s an uncommon occurrence, a patient from Sudan who is 22 years old and has hemolytic anemia, inflammatory bowel disease, and hypogonadism as a result of a pituitary macroadenoma should be remembered. Regarding his prior medical history, the patient had a lengthy (more than 10 years) history of recurrent hospital admissions due to recurrent attacks of anemia at a frequency of one admission every two months, and every time was receiving blood. The patient also had a history of bloody diarrhea three times before, and recurrent diarrhea since 2010, particularly when the patient presented with the headache associated with neck pain, cough vomiting, and diarrhea.Investigations have supported the patient’s previous medical history that macroadenoma causes hypogonadism. When the patient was last admitted, they had severe black diarrhea. An endoscopic revealed minor erosion in the stomach and duodenum. Multiple erosive and skip lesions were seen during a colonoscopy, and when a biopsy was performed, the finding of lymphocytic infiltration proved the presence of Crohn’s disease.
When the patient first presented, he often had low hemoglobin levels and clinical signs of thalassemia, which led us to suspect hemolytic anemia. The patient was given hydroxychloroquine and steroids, and he responded well. Hemoglobin electrophoresis was used to rule out sickle cell anemia and thalassemia, which excludes them. Instead, we advised microangiopathic hemolytic anemia.
The patient, however, got therapy and was closely monitored when this diagnosis was determined after a protracted investigation and flow up. Sadly, the patient’s condition worsened until he passed away from sepsis, hypokalemia, and sequences of hypokalemia that did not respond to therapy.
ACKNOWLEDGMENT
Not applicable
CONFLICTS OF INTEREST
The authors report no conflict of interest
AUTHOR CONTRIBUTIONS
All authors participated in planning the study. FMT and FMM collected data and did investigations and examinations, and wrote the first draft. DAH, MAY, and MMA supervised the process of study and revised the draft. All authors participated significantly in writing the draft.
ETHICAL APPROVAL
Ethics approval was obtained from the Ethical committee at the University of ALgazera and informed consent was taken from the patient for purposes of publication.
CONSENT
Written informed consent was obtained from the patient
for publication of this case report and accompanying
images.
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available
with the corresponding author upon reasonable .
REFERENCES
1. Levy S, Arguello M, Macki M, Rao SD. Pituitary Dysfunction Among Men Presenting with Hypogonadism. 2019;
2. Zhang Y, Li Y. Inflammatory bowel disease : Pathogenesis. 2014;20(1):91–9.
3. Thomas MR, Scully M. How I treat microangiopathic hemolytic anemia in patients with cancer. 2021;137(10):1310–7.