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      Pituitary macroadenoma resulting from primary hypothyroidism; a 16-year-old girl

      case-report

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          Abstract

          Background:

          Primary hypothyroidism is a common medical condition. It can lead to pituitary adenoma which is usually asymptomatic, but it can also lead to symptomatic macroadenomas which are hard to diagnose due to different clinical presentations.

          Case presentation:

          A 16-year-old girl presented for endocrinology consultation prior to neurosurgical operation. She had galactorrhea which was accompanied by vertigo & low grade blurred vision without a headache and was diagnosed with pituitary macroadenoma and was planned for a surgery. She had TSH level of more than 100 mU/L, free thyroxine of 1.9 pmol/L. Her thyroid peroxidase (TPO) antibody level was 13.3 IU/mL, insulin growth factor-1 392 µ/l and serum prolactin level 42 ng/ml. During physical exam and with the laboratory findings, we suspected for a primary hypothyroidism as the leading cause of pituitary macroadenoma. As the result, we cancel the surgery and start levothyroxine therapy 100µg daily for her. In the follow-up it revealed that our diagnosis was correct and she went into remission with pituitary gland shrinking and decreasing TSH and prolactin levels.

          Conclusion:

          It is important to understand the different presentation of primary hypothyroidism to decrease the unnecessary risk of maltreatment in patients.

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          Most cited references10

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          Autoimmune hypophysitis.

          Craig Newschaffer, Alessandro Olivi, Karina P Bürger … (2005)
          Autoimmune (lymphocytic) hypophysitis is a rare disease that should be considered in the differential diagnosis of any nonsecreting pituitary mass, especially when occurring during pregnancy or postpartum. We have analyzed 370 articles published from January 1962 to October 2004 and identified a total of 379 patients with primary lymphocytic hypophysitis. The present review synthesizes the clinical and research data reported in this body of scientific literature.
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            Recovery of hypopituitarism after neurosurgical treatment of pituitary adenomas.

            S. Webb, M Rigla, A. WAGNER … (1999)
            Surgery is the treatment of choice for many pituitary tumors; pituitary function may suffer after operation, but relief of pressure on the normal pituitary may also favor postoperative recovery of hypopituitarism. The aim of this study was to investigate the frequency of new appearance and recovery of hypopituitarism after neurosurgery and try to identify features associated with it. Pre- and postoperative anterior pituitary functions were investigated in 234 patients with pituitary adenomas (56 nonfunctioning, 71 PRL-secreting, 66 GH-secreting, 39 ACTH-secreting, 1 LH/FSH-secreting, and 1 TSH-secreting tumors). Eighty-eight new postoperative pituitary hypofunctions appeared in 52 patients (12 NF, 14 PRL-secreting, 15 GH-secreting, 10 ACTH-secreting, and 1 LH/FSH-secreting adenomas). They corresponded to 27% ACTH deficiencies (in 29 of the 107 patients with normal preoperative ACTH in whom postoperative evaluation was complete), 14.5% (15 of 103) new GH deficiencies, 10.5% (15 of 143; P < 0.0005, significantly less than ACTH deficiency) new TSH deficiencies, 16.5% (20 of 121) new gonadotropin deficiencies, and 13% (9 of 71) new PRL deficiencies. Preoperatively, 93 were deficient in at least 1 pituitary hormone; after surgery, 45 (48%) recovered between 1 and 3 hormones. The 2 patients with LH/FSH- and TSH-secreting macroadenomas did not recover pituitary function. Factors associated with a higher probability of postoperative pituitary function recovery were: no tumor rests on postoperative pituitary imaging (P = 0.001) and no neurosurgical (P = 0.001) or pathological evidence (P = 0.049) of an invasive nature. Tumor size did not differ significantly between those who did and those who did not recover pituitary function after surgery. Even if clear hypofunction is observed at initial work-up, patients should be reassessed after surgery without substitution therapy, because practically half the preoperative pituitary hormone deficiencies recover postoperatively, eliminating the need for life-long substitution therapy.
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              Lymphocytic hypophysitis: disease spectrum and approach to diagnosis and therapy.

              Juan A. Rivera (2005)
              Lymphocytic hypophysitis (LYH) is a neuroendocrine disorder characterized by autoimmune inflammation of the pituitary gland with various degrees of pituitary dysfunction. The histopathology consists of an initial monoclonal lymphocytic infiltrate, which can heal with minimal sequela or progress to fibrosis and result in permanent hypopituitarism. Coexistence of other autoimmune conditions is reported in 25-50% of cases and pituitary autoantibodies have been detected in up to 70% of biopsy-proven cases. The clinical presentation varies depending on the pituitary segment that is more severely affected. In lymphocytic adenohypophysitis (LAH) an early destruction of the ACTH-producing cells is characteristic. Other anterior pituitary hormones can also be affected but posterior pituitary involvement is absent or minimum. Lymphocytic Infundibuloneurohypophysitis (LINH) typically presents as acute onset diabetes insipidus (DI) with intracranial mass-effect symptoms. A combination of extensive anterior pituitary involvement and DI characterizes lymphocytic Infudibulopanhypophysitis (LIPH). The diagnosis can be challenging in many cases, because distinction from pituitary adenomas and other sellar masses is not obvious. Significant efforts have been made to identify specific serum markers, but it would seem unlikely that this approach will ever have the specificity to replace histopathological examination of a surgical specimen. Diagnostic criteria have been proposed to help in the decision-making process and to avoid, whenever possible, unnecessary invasive procedures. The therapeutic approach is controversial and, although transsphenoidal surgery is often performed, a conservative medical management is justified in many cases, given the self-limited nature of the inflammatory process. This paper reviews the etiology, epidemiology, clinical and radiological findings, diagnosis and management of LYH.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Caspian J Intern Med
                Journal ID (iso-abbrev): Caspian J Intern Med
                Journal ID (publisher-id): CJIM
                Title: Caspian Journal of Internal Medicine
                Publisher: Babol University of Medical Sciences (Babol, Iran )
                ISSN (Print): 2008-6164
                ISSN (Electronic): 2008-6172
                Publication date (Print): Summer 2019
                Volume: 10
                Issue: 3
                Pages: 347-350
                Affiliations
                [1 ]Skull Base Research Center, Loghman Hakim Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
                [2 ]Department of Neurosurgery, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
                Author notes
                [* ]Correspondence: Guive Sharifi, Skull Base Research Center, Loghman Hakim Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. E-mail: rafieirana@yahoo.com , Tel: 0098 2151025582, Fax: 0098 215541630
                Article
                DOI: 10.22088/cjim.10.3.347
                PMC ID: 6729158
                SO-VID: c252ff43-9d4a-4dba-ab98-3f80e3b1f325
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License, ( http://creativecommons.org/licenses/by/3.0/) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 3 June 2018
                Date revision received : 9 December 2018
                Date accepted : 22 December 2018
                Categories
                Subject: Case Report

                Keywords: primary hypothyroidism,pituitary macro adenoma,galactorrhea
                Data availability:
                Keywords: primary hypothyroidism, pituitary macro adenoma, galactorrhea

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