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LETTER
Year : 2014  |  Volume : 60  |  Issue : 4  |  Page : 422-424

Hand-grenade splinter-induced hypopituitarism


Department of Medicine, Sher-I-Kashmir Institute of Medical Sciences Medical College and Hospital, Srinagar, Jammu and Kashmir, India

Date of Web Publication5-Nov-2014

Correspondence Address:
Dr. Naik Muzafar
Department of Medicine, Sher-I-Kashmir Institute of Medical Sciences Medical College and Hospital, Srinagar, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0022-3859.144001

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How to cite this article:
Muzafar N, Tariq B, Irfan Y, Mehmood Q, Imran H. Hand-grenade splinter-induced hypopituitarism. J Postgrad Med 2014;60:422-4

How to cite this URL:
Muzafar N, Tariq B, Irfan Y, Mehmood Q, Imran H. Hand-grenade splinter-induced hypopituitarism. J Postgrad Med [serial online] 2014 [cited 2019 Nov 17];60:422-4. Available from: http://www.jpgmonline.com/text.asp?2014/60/4/422/144001


Sir,

The orbital cavity serves as a vulnerable access to the cranial cavity and can be injured by penetrating injuries. The ability of a foreign body to penetrate the orbital wall and reach the cranial cavity depends upon three factors; the nature of the foreign body (metallic or nonmetallic), the shape of foreign body, and the velocity of impaction. Metallic splinters retained following grenade explosions are usually inert and most of these metallic splinters remain asymptomatic for years. However, delayed complications of these metallic splinters are well known. [1],[2],[3],[4],[5] Metallic splinters leading to brain injury through the transorbital route has been reported earlier. [6],[7] An unusual case of hypopituitarism due to a metallic splinter in the suprasellar area following a penetrating eye injury is reported here.

A 27-year-old male presented to our Outpatient Department (OPD) with symptoms of lethargy, generalized aches and pain, dizziness, cold intolerance, increased sleep, and constipation, of a 14-year duration. In the past he had lost his eyesight on the right side following an eye injury, caused by a grenade explosion. The records revealed that he had an impacted foreign body (metallic splinter) in the right eye and the suprasellar area and he was managed conservatively. He also had cold intolerance and dizziness a month after the incident., The symptoms worsened over the years with the development of pedal edema and puffiness of the hands and feet over the last four months. On examination, he was conscious and oriented, with puffiness of the face, hands, and feet. There was phthisis of the right eye, with an impacted metallic splinter in it. He also had mild non-pitting edema of the lower limbs. The pulse was 74 beats/min and blood pressure was 80/60 mm Hg. He had delayed relaxation of the ankle jerk. The rest of the systemic examination was normal.

Investigations revealed the following: Hemoglobin (Hb) 11.2 g/dL; total leukocyte count (TLC) 7.2 × 10 9 /L; differential leukocyte count (DLC): N 72%, L 26%, M 2%; platelet 214 × 10 9 /L; erythrocyte sedimentation rate (ESR) 10/first hour; urea 40 mg/dL; creatinine 1.14 mg/dL; bilirubin 0.9 mg/dl; aspartate transaminase (AST) 42 U/L; alanine transaminase (ALT) 36 U/L; alkaline phosphate (ALP) 210 U/L; total protein 8.2 gm/dL; albumin 4.4 gm/dL; blood sugar (random) 86 mg/dL; creatinine phosphokinase (CPK) 196 U/dL; uric acid 6.5 mg/dL; serum calcium 9.6 mg/dL; serum phosphorus 3.2 mg/dL; thyroxine (T 4 ) <1 μg/dL (4.0-13.0); thyroid stimulating hormone (TSH) 2.52 μIU/ML (0.5-6.5); serum cortisol (collection time 8 a.m.) 6.75 μg/dL (10-25); Human growth hormone (hGH) <0.25 NG/ML (not detectable-07); luteinizing hormone (LH) 3.69 IU/L (0.5-10); follicle stimulating hormone (FSH) 6.51 IU/L (1.6-11.6); testosterone 508 ng/dL (250-1500); and prolactin (PRL) <1 ng/ml (1-20).

Radiograph of the skull [Figure 1] showed a metallic splinter in the suprasellar area, right orbit, and right temporal area. A CT scan of the head [Figure 2] confirmed the presence of a metallic splinter in the right eye, right temporal area, and suprasellar area. The patient was diagnosed as having panhypopituitarism and was put on replacement with steroids and levothyroxine. He demonstrated significant improvement in his symptoms subsequently.
Figure 1: X-ray skull showing splinter in the pituitary fossa

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Figure 2: CT showing grenade splinter in the suprasellar area

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Hypopituitarism could be due to a developmental, [8] vascular, [9] inflammatory, [10] infectious, [11] parasitic [12] or a neoplastic [13] cause. In the case of hypopituitarism of vascular origin, postpartum hemorrhage (Sheehan's syndrome) and traumatic brain injury (TBI) are the common causes. Traumatic brain injury leading to posttraumatic hypopituitarism (PTHP) is an important medical condition in survivors of head trauma. The mechanism of hypopituitarism in TBI is due to the mechanical disruption of brain tissue at the time of injury or due to edema, hypoxia or circulatory disturbances, secondary to brain injury. The impact of a head trauma in such cases is usually very severe and gives rise to hemodynamic compromise. However, without obvious head trauma the pituitary can still be damaged by penetrating injuries of the orbit as they are in anatomical approximation.

The structural characteristics of the orbit play an important role in the intracranial extension of the orbital injury, due to the fact that penetrating objects are directed toward the apex of the orbit and pass through the orbital wall and reach the intracranial cavity. [14],[15] The orbital walls can get easily fractured and the structures usually affected are the greater wing of sphenoid, the petrous portion of the temporal bone, and the sella turcica. As the pituitary lies within the sella turcica any damage to the latter can have an effect on the former.

Penetrating orbital injuries with a retained foreign body always pose a diagnostic and therapeutic challenge. The diagnostic method for localization of a foreign body depends upon the nature of the foreign body - magnetic resonance imaging (MRI) for organic bodies like, wooden chips, fibers, and so on, and computed tomography (CT) for inorganic bodies, such as, metallic fragments, glass pieces, and the like. Inorganic foreign bodies usually cause less of an inflammatory reaction as compared to organic foreign bodies.

Firearm injuries involving the temporal region leading to hypopituitarism have been described earlier. [16],[17] Our patient harbored a metallic splinter in the suprasellar region for more than 14 years without any significant inflammatory reaction. He had partial hypopituitarism, with deficiency of the thyroid stimulating hormone (TSH) and the adrenocorticotropic hormone (ACTH), likely secondary to the mass effect of the metallic splinter. The patient was put on replacement with levothyroxine and prednisone, and demonstrated a significant improvement in his symptoms. Itt could be stated that penetrating orbital injuries could lead to intracranial injury and injury to the pituitary gland, as its close approximation to the orbit makes it vulnerable.

 
 :: References Top

1.
Rhomberg HP, Judmair G, Bodner E. Grenade splinter causing biliary colic. Lancet 1977;1:201.  Back to cited text no. 1
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2.
Voigtlaender H. Wandering of foreign bodies. Grenate fragment in the common bile duct causing jaundice. Chirurg 1975;46:467-9.  Back to cited text no. 2
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3.
Vilits P, Hubmer G. Ureteral obstruction caused by a grenade splinter. Z Urol Nephrol 1987;80:365-8.  Back to cited text no. 3
[PUBMED]    
4.
Möller R, Schroeder U. Obstructive jaundice 64 years after a grenade splinter injury of the liver. Chirurg 1985;56:532-4.  Back to cited text no. 4
    
5.
Wegner-Kempf L, Tornow K, Schmiedek P. Intracerebral abscess 48 years after grenade splinter injury. Radiologe 1994;34:671-3.  Back to cited text no. 5
    
6.
Dunya IM, Rubin PA, Shore JW. Penetrating orbital trauma. Int Ophthalmol Clin 1995;35:25-36.  Back to cited text no. 6
    
7.
Wesley RE, Anderson SR, Weiss MR, Smith HP. Management of orbital-cranial trauma. Adv Ophthalmic Plast Reconstr Surg 1987;7:3-26.  Back to cited text no. 7
    
8.
Jain V, Kannan L, Kumar P. Congenital hypopituitarism presenting as dilated cardiomyopathy in a child. J Pediatr Endocrinol Metab 2011;24:767-9.  Back to cited text no. 8
    
9.
Bondanelli M, Ambrosio MR, Zatelli MC, De Marinis L, degli Uberti EC. Hypopituitarism after traumatic brain injury. Eur J Endocrinol 2005;152:679-91.  Back to cited text no. 9
    
10.
Yang GQ, Lu ZH, Gu WJ, Du J, Guo QH, Wang XL, et al. Recurrent autoimmune hypophysitis successfully treated with glucocorticoids plus azathioprine: A report of three cases. Endocr J 2011;58:675-83.  Back to cited text no. 10
    
11.
Sundar US, Ramteke VV, Vaidya MS, Asole DC, Moulick ND. Suprasellar tuberculoma presenting as panhypopituitarism. J Assoc Physicians India 2010;58:706-9.  Back to cited text no. 11
    
12.
Kelesidis T, Tsiodras S. Hypopituitarism caused by neurocysticercosis. Am J Med Sci 2011;341:414-6.   Back to cited text no. 12
    
13.
Wiens AL, Hagen MC, Bonnin JM, Rizzo KA. T-cell lymphoblastic lymphoma/leukemia presenting as a pituitary mass lesion: A case report and review of the literature. Neuropathology 2012;32:668-74.  Back to cited text no. 13
    
14.
Nasr AM, Haik BG, Fleming JC, Al-Hussain HM, Karcioglu ZA. Penetrating orbital injury with organic foreign bodies. Ophthalmology 1999;106:523-32.  Back to cited text no. 14
    
15.
Hansen JE, Gudeman SK, Holgate RC, Saunders RA. Penetrating intracranial wood wounds: Clinical limitations of computerized tomography. J Neurosurg 1988;68:752-6.  Back to cited text no. 15
    
16.
Trujillo-Juarez D, Culler FL, Ganelin RS, Jones KL. Traumatic hypopituitarism due to a gunshot wound. West J Med 1987;147: 591-3.  Back to cited text no. 16
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17.
Salti IS, Haddad FS, Amiri ZN, Khalil AA, Akar AA. Bullet injury to the pituitary gland: A rare cause of panhypopituitarism. J Neurol Neurosurg Psychiatry 1979;42:955-9.  Back to cited text no. 17
[PUBMED]    


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