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Confusion in an elderly patient: an uncommon diagnosis for such a common event
  1. D Piettea,
  2. P Selvaisb,
  3. D Vanpeea,
  4. C Swinea
  1. aUniversité Catholique de Louvain, Mont-Godinne Hospital, Yvoir, Belgium: Division of Geriatric Medicine, bDivision of Endocrinology
  1. Professor Christian Swine, Department of Geriatric Medicine, University Hospital of Mont-Godinne, B-5530 Yvoir, Belgiumswine{at}intr.ucl.ac.be

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Answers on p 542.

A 90 year old woman was admitted to the emergency department with delirium and falls. She had a recent history of cognitive impairment, insomnia, drowsiness, and progressive disability. Three months before admission, in the course of a medical check-up, an isolated increased plasma thyroid stimulating hormone (TSH 8 mIU/l, normal values 0.5–2.9) was discovered, leading to a levothyroxine therapy (50 μg daily). This patient was previously alert and able to live almost independently. Physical examination was unremarkable, except for fidgeting and restlessness. Other biochemical investigations were normal. A cranial tomographic study was obtained and revealed no intracranial haematoma but unexpectedly showed a pituitary macroadenoma, subsequently confirmed by magnetic resonance imaging (fig1).

Figure 1

Magnetic resonance imaging of the brain shows a large pituitary adenoma (arrow).

Questions

(1)
What is the initial diagnosis?
(2)
In view of the results, which diagnosis should be considered and which parameters shall be measured?

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