Pituitary damage an unexpected war wound
Months after Chuck Spires came home from Iraq, he began having dizzy spells and radical mood swings and had lost all interest in sex.
Army doctors diagnosed him with multiple brain injuries — he had endured several head-rattling bomb blasts — along with depression and post-traumatic stress disorder.
But it was another symptom, the sudden gain of 50 pounds, that led to deeper investigation.
Tests revealed damage to Spires’ pituitary gland. It was a rare finding in the military, but that may be because few doctors have been looking for it.
Emerging evidence suggests that pituitary problems may be going undiagnosed in victims of blast-related brain injuries, the defining wounds of the recent wars.
The symptoms often overlap, perhaps explaining why some patients do not fully recover and offering hope that hormone replacement therapy might help in some cases.
Trying to get a handle on the problem, the Pentagon last year issued guidelines to its doctors to screen for hormone irregularities when symptoms persist after concussions — the mildest and most common form of traumatic brain injury, or TBI.
The pea-sized pituitary gland secretes nine hormones that help regulate metabolism, sexual function, blood pressure and other vital processes. Housed in a bony pocket in the skull, it hangs from the base of the brain by a strand of neurons and blood vessels.
Experts long have known that serious head trauma can disrupt the blood supply and nerve connections. Over the last decade, the same damage has been documented in people who suffered concussions in car crashes and sports accidents. Only in the last few years did scientists begin to look specifically at the risk from blasts.
The first study, published last year, looked at concussions. Researchers at the VA Puget Sound Health Care System and the University of Washington found evidence of pituitary damage in 42% of the cases they examined. In another study, to be published later this year, researchers in England found pituitary problems in 32% of soldiers with TBIs classified as moderate or severe.
The scientists say their studies were far too small to determine the true rate.
That may become known as more military doctors start to look for the problem and more studies are completed. The Department of Veterans Affairs gave the Washington researchers $932,000 to expand their work.
Over the last decade, more than 200,000 U.S. service members are thought to have withstood explosions from roadside bombs and other artillery. Many TBIs are believed to have gone unreported, especially in the early years of the wars in Afghanistan and Iraq.
Bomb blasts were so common that “getting blown up” — as troops came to call it — became part of the job. Some have reported enduring dozens of close-range explosions.
In more serious TBIs, rehabilitation can take months or years, often with incomplete results. Most patients with concussions get better in a few days. For reasons that largely remain a mystery, up to 15% do not or develop new symptoms later.
In studies of accident victims, the rates of hormone abnormalities have varied from 5% to 90%, a range that reflects the small size of the studies, the fact that participants were not chosen at random and differences in diagnosis criteria.
The British study suggested that explosions were more likely than other kinds of head trauma to cause hormone problems. While six of 19 soldiers with blast-related TBIs had pituitary damage, there was just one case in a control group of 39 patients who suffered TBIs from accidents and assaults.
“A blast wave is different than hitting your head,” said the study’s lead author, Dr. Tony Goldstone, an endocrinologist at Imperial College in London.
The VA researchers did not examine patients directly. Instead, the team analyzed blood samples stored in a repository used to study various neurological conditions. The samples came from 26 male veterans who had seen combat in the wars and suffered at least one concussion from a blast.
Eleven of them had evidence of pituitary problems, according to the study.
Five of the men had a growth hormone deficiency, which has been linked to depression, sleep disorders, irritability and cognitive problems. Three had testosterone shortages. Four lacked oxytocin, which influences social interaction. And four had abnormal levels of vasopressin, which regulates blood pressure and water in the body.
“Some of these people had three different abnormalities,” said Charles Wilkinson, who led the research.
In a control group of seven veterans who had been deployed to the wars but not suffered concussions, the researchers did not find any sign of hormone problems.
“This got me so excited,” said Wilkinson, who spent a long career studying hormones and behavior. “It was something that was far more important than anything I’ve ever done before.”
Outside experts were more measured about the results.
Dr. Richard Auchus, an endocrinologist at the University of Michigan, said that the data are open to interpretation and that he would have classified only six of the veterans as having pituitary problems.
The defense department’s guidelines advise doctors to screen for endocrine problems in patients who suffer concussions and still have symptoms after three months or develop new symptoms up to three years later. It is unclear how often such tests are ordered.
Dr. Andrew Hoffman, chief endocrinologist at the VA hospital in Palo Alto, said few TBI cases, mild or severe, are ever sent to him or other hormone specialists because the research has not been widely disseminated.
In combat veterans, the situation is especially complicated because they frequently also suffer from post-traumatic stress, chronic pain and a variety of conditions that themselves can disrupt the endocrine system.
Four of the soldiers in Goldstone’s study are being treated with regular injections of growth hormone, cortisol or testosterone. All have improved, he said, while noting that without more careful study he cannot rule out a placebo effect.
Spires, who is now 45 and lives in Michigan, has not been as fortunate.
Since his diagnosis in 2010, he has regularly received testosterone injections as well as a synthetic thyroid hormone. He also takes a variety of psychiatric medications.
His wife, Debbie, said his mood has improved but not much else.
“I’d like to have my husband back,” she said.
