scholarly journals Emergence of a latent TSHoma pituitary macroadenoma on a background of primary autoimmune hypothyroidism

2018 ◽  
Vol 2018 ◽  
Author(s):  
Yew Wen Yap ◽  
Steve Ball ◽  
Zubair Qureshi
Keyword(s):  
Anterior Pituitary ◽  
Primary Hypothyroidism ◽  
Alpha Subunit ◽  
Serum Prolactin ◽  
List Type ◽  
Pituitary Macroadenoma ◽  
Free T4 ◽  
Autoimmune Hypothyroidism ◽  
Levothyroxine Treatment ◽  
Tsh Levels

Summary The coexistence of primary hypothyroidism and thyroid-stimulating hormone (TSH)-stimulating pituitary macroadenoma can be a rare occurrence and can make diagnosis very challenging. We describe a case of a 44-year-old female with a history of fatigue, poor concentration, weight gain and amenorrhoea together with biochemical evidence of primary autoimmune hypothyroidism. Her initial TSH levels were elevated with low normal free thyroxine (T4) levels. Levothyroxine treatment was initiated and the dose was gradually titrated to supraphysiologic doses. This led to the normalisation of her TSH levels but her free T4 and triiodothyronine (T3) levels remained persistently elevated. This prompted a serum prolactin check which returned elevated at 2495 µ/L, leading onto pituitary imaging. A MRI of the pituitary gland revealed a pituitary macroadenoma measuring 2.4 × 2 × 1.6 cm. Despite starting her on cabergoline therapy with a reduction in her prolactin levels, her TSH levels began to rise even further. Additional thyroid assays revealed that she had an abnormally elevated alpha subunit at 3.95 (age-related reference range <3.00). This corresponded to a thyroid-secreting hormone pituitary macroadenoma. She went on to have a transphenoidal hypophysectomy. Histology revealed tissues staining for TSH, confirming this to be a TSH-secreting pituitary macroadenoma. This case highlighted the importance of further investigations with thyroid assay interferences, heterophile antibodies, alpha subunit testing and anterior pituitary profile in cases of resistant and non-resolving primary hypothyroidism. Learning points: Levothyroxine treatment in primary hypothyroidism can potentially unmask the presence of a latent TSH-secreting pituitary macroadenoma, which can make diagnosis very challenging. A high index of suspicion should prompt clinicians to further investigate cases of primary hypothyroidism which despite increasing doses of levothyroxine treatment with normalisation of TSH, the free T4 and T3 levels remain persistently elevated. Clinicians should consider investigating for adherence to levothyroxine, thyroid assay interference, heterophile antibodies, TSH dilution studies, alpha subunit and anterior pituitary profile testing to further clarity the diagnosis in these patients. Although coexistent cases of TSHoma with primary hypothyroidism are rare, it should always be in the list of differential diagnoses in cases of unresolving primary hypothyroidism.

scholarly journals Assessment of thyroid and prolactin levels among the women with abnormal uterine bleeding

2017 ◽  
Vol 6 (6) ◽  
pp. 2547
Author(s):  
Jovita Deepthy John ◽  
Vimala Damodaran ◽  
Shankar Radhakrishnan
Keyword(s):  
Abnormal Uterine Bleeding ◽  
Cross Sectional Study ◽  
High Serum ◽  
Uterine Bleeding ◽  
Serum Prolactin ◽  
Age Group ◽  
Free T4 ◽  
Cross Sectional ◽  
The Mean ◽  
Tsh Levels

Background: Thyroid disorders are 10 times more common in women than men.1 Menstrual disturbances usually accompany clinical alterations in thyroid function and every clinician would have encountered altered menstrual pattern among women suffering from either hypo or hyper thyroidism. A high serum prolactin level can distrurb the follicular maturation and corpus luteum function, and leads to inhibition of normal pulsatile secretion of gonadotrophin-releasing hormone in hypothalamus resulting in anovulation. The aim of the study was to assess the thyroid and the prolactin levels among the women with abnormal uterine bleeding and to evaluate the association between them by comparing with normal females.Methods: A cross sectional study was conducted for a period of one year between Jan 2016 and December 2016 in our institution at the gynaecology OPD. Patients in the age group of 15 to 45 with the complaints of abnormal uterine bleeding and with the ultrasound findings showing normal uterus and ovary were included in the study. Hundred age and sex matched controls without any complaints of abnormal uterine bleeding in the age group of 15 – 45 years were also included in the study. Free T3, Free T4, TSH and prolactin estimation was done by chemiluminescent immunoassay for both the patients and the controls.Results: The mean TSH levels among the cases were much higher than that of the controls and the difference in the levels found to be statistically significant. Similarly, hyperprolactinemia was found in 18 cases when compared to 2 cases in controls and the mean prolactin levels were higher in cases. The serum prolactin levels and the serum TSH levels showed a perfect positive correlation which indicates that as the TSH level increases prolactin levels also increases with the R value >0.5.Conclusions: Early detection of hypothyroidism in such subjects saves the patient from recurrent curettage and at times hysterectomy. The financial implications of screening for prolactin/thyroid hormone abnormalities will have to be evaluated before a general recommendation can be made.

scholarly journals SUN-281 Pituitary Hyperplasia Secondary to Uncontrolled Primary Hypothyroidism

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Jessica Lee Betancourt
Keyword(s):  
Pituitary Gland ◽  
Early Recognition ◽  
Hormone Replacement ◽  
Primary Hypothyroidism ◽  
Laboratory Evaluation ◽  
Complete Regression ◽  
Pituitary Macroadenoma ◽  
Free T4 ◽  
Pituitary Hyperplasia ◽  
Patient Reported

Abstract Background: There are several recognized causes of hyperplasia of the pituitary gland. These may present as sellar masses and be misdiagnosed as pituitary adenomas. Pituitary hyperplasia can occur in the presence of long standing primary hypothyroidism due to the loss of negative feedback caused by decreased secretion of thyroxine (T4) and triiodothyronine (T3) by the thyroid gland, leading to excessive thyrotropin releasing hormone (TRH) production by the hypothalamus causing Thyrotroph pituitary hyperplasia Clinical case: 51 y/o female with a past medical history that includes anxiety & depression, obesity, pre-diabetes and uncontrolled hypothyroidism due to Hashimoto’s, presented to the Endocrinology clinic for recent diagnosis of pituitary macroadenoma. Patient reported tiredness, decrease energy, myalgias, weight gain, abnormal menstrual periods and frontal headaches. On physical exam, she had a body mass index of 37.39kg/m2, blood pressure of 130/85mmHg, heart rate of 91 bpm. There was no thyromegaly noted on exam. No abdominal striae was noted. Overall, exam was unremarkable. Her neurological exam was normal and there were no obvious visual field deficits. Initial laboratory tests revealed a thyroid stimulating hormone (TSH) &gt;150 uIU/mL (0.46–4.7 uIU/mL), free T4 0.3 ng/dL (0.7–1.3 ng/dL) and positive TPO antibodies. Other endocrine work up including ACTH, cortisol, prolactin, FSH, LH and IGF-1, were normal. An MRI of the pituitary revealed a heterogeneous enhancing mass replacing the pituitary gland in the sella that measured 16 x 17 x 11 mm. She was evaluated by Neurosurgery, for presumed diagnosis of pituitary macroadenoma. However, prompt recognition of uncontrolled primary hypothyroidism causing pituitary hyperplasia lead to medical management, first. She was started on weight based (1.6mcg/kg/day) levothyroxine at 175 mcg per day. Six weeks after thyroid replacement therapy laboratory evaluation showed improvement in thyroid function test with a TSH of 0.8mIU/mL, free T4 2.8ng/dL and total T3 307ng/dL. A repeat MRI of the pituitary showed decrease in size of the pituitary gland measuring 15 x 4 x 10 mm. Conclusion: This case illustrates the importance of early recognition of uncontrolled primary hypothyroidism during the evaluation of a pituitary mass. Complete regression of this pituitary gland abnormality can be achieved with thyroid hormone replacement avoiding the irreversible consequences of inappropriate pituitary surgery.

scholarly journals Two patients with atypical low triiodothyronine syndrome: primary deiodinase abnormalities?

2014 ◽  
Vol 2014 ◽  
Author(s):  
Gerald J M Tevaarwerk
Keyword(s):  
Reference Range ◽  
Primary Hypothyroidism ◽  
Response To Treatment ◽  
List Type ◽  
Deiodinase Activity ◽  
Encoding Genes ◽  
Learning Points ◽  
Tsh Levels ◽  
Secondary Causes ◽  
Biochemical Abnormalities

Summary Low triiodothyronine (T3) concentrations in the presence of normal thyroxine (T4) and TSH levels, referred to as the low T3 syndrome (LT3S), are common. LT3S may be caused by starvation, various non-thyroidal illnesses (NTIs) and some medications. Reverse T3 (rT3) concentrations are elevated in the more severely ill, and they characteristically fail to respond to exogenous levothyroxine (l-T4) therapy. The biochemical abnormalities have been explained on the basis of altered peripheral deiodinase activities. Herein, we report on two patients with hypothyroid symptoms who on testing were found to have LT3S. They were atypical clinically in not having LT3S due to any of the usual causes, had no increased rT3 concentrations, and had a normal negative TSH feedback response to l-T4. One (patient 1) had previously been diagnosed with Hashimoto's autoimmune primary hypothyroidism and was on l-T4 therapy. Both had T4 concentrations in the reference range. TSH levels were elevated in patient 1 and in the reference range in patient 2. Starting or increasing l-T4 doses resulted in no clinical improvement and no increase in T3 levels in spite of a marked increase in T4 levels. It is suggested that in the absence of the usual causes, lack of elevated rT3 levels, response to treatment and intact negative TSH feedback these two patients differ from the usual secondary causes of decreases in deiodinase activity. It is speculated that they may represent primary alterations in deiodinase enzymes possibly due to genetic variations in the deiodinase-encoding genes. Learning points LT3S is commonly found secondary to starvation, NTIs and use of some medications. Low T3 levels are the result of alterations in the activity of deiodinase enzymes. LT3S without the usual causes may represent a primary disturbance in deiodinase activity.

Autoimmune Hypothyroidism Coexisting with a Pituitary Adenoma Secreting Thyroid-Stimulating Hormone, Prolactin and α-Subunit

2001 ◽  
Vol 38 (5) ◽  
pp. 566-571 ◽  
Author(s):  
Jyothi M Idiculla ◽  
Geoff Beckett ◽  
Patrick F X Statham ◽  
James W Ironside ◽  
Stephen L Atkin ◽  
...  
Keyword(s):  
Anterior Pituitary ◽  
Elevated Serum ◽  
Pituitary Tumour ◽  
Thyroid Stimulating Hormone ◽  
Serum Prolactin ◽  
Residual Tumour ◽  
Mri Scan ◽  
Α Subunit ◽  
Autoimmune Hypothyroidism ◽  
Stimulating Hormone

A 44-year-old woman presented to her GP with excessive tiredness. She had positive thyroid microsomal and thyroglobulin autoantibodies and was found to have an elevated serum thyroid-stimulating hormone (TSH) concentration of 8.37 (normal = 0·15–3·5) mU/L and a low normal total thyroxine (T4) of 86 (reference range 60–145) nmol/L. She was rendered symptom free on a dose of 150μg of thyroxine per day. However, her TSH failed to return to normal, and following a further increase in her thyroxine dose she was referred to the endocrine clinic for further assessment. Her TSH at this stage was 14mU/L, free T4 (fT4) 28 (normal = 10–27) pmol/L and free T3 (fT3) 10 (normal = 4·3–7·6) pmol/L. She denied any problems with adherence to her medication. Her serum prolactin was elevated at 861 (normal = 60–390) mU/L. A pituitary tumour was suspected and an MRI scan showed a macroadenoma of the right lobe of the pituitary, extending into the suprasellar cistern. The tumour was resected trans-sphenoidally. Electron microscopy showed a dual population of neoplastic cells compatible with a thyrotroph cell and prolactin-secreting adenoma. Immunocytochemistry and cell culture studies confirmed the secretion of TSH, prolactin and α-subunit. Postoperative combined anterior pituitary function tests did not demonstrate any deficiency of anterior pituitary hormones. A repeat MRI scan showed no significant residual tumour; however, her serum TSH and prolactin levels remained high and she was given a course of pituitary irradiation. This case illustrates the difficulty of diagnosing a TSHoma when it coexists with autoimmune hypothyroidism. We believe the combination of pathologies reported here is unique.

scholarly journals MON-058 Precocious Puberty and Hypothyroidism in a Pediatric Case

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Jessica L Sea ◽  
Michael J Head ◽  
Harvey Kenn Chiu
Keyword(s):  
Precocious Puberty ◽  
Mass Effect ◽  
Optic Chiasm ◽  
Large Mass ◽  
Primary Hypothyroidism ◽  
Serum Prolactin ◽  
Free T4 ◽  
Pituitary Hyperplasia ◽  
Suprasellar Extension

Abstract Background: Hypothyroidism with secondary sellar/suprasellar mass is rarely associated with precocious puberty. Here we describe a rare case of pediatric hyperprolactinemia and precocious puberty secondary to hypothyroidism, marked TSH elevation, and pituitary hyperplasia. Clinical Case: A 9-year-old female, with onset of thelarche and menses occurring at age 7 and 8 respectively, presented with primary hypothyroidism (Free T4 &lt;0.11; n=4.9-11.4mcg/mL), elevated TSH (1620.0mU/mL; n=0.3-4.7mU/mL), hyperprolactinemia (108.6ng/mL; n=3.0-23.1ng/mL), and elevated serum estradiol (37.6pg/mL; n=10pg/mL). The patient had coarse scaly skin, diminished energy, and poor growth lasting 1 year. There were no associated gastrointestinal issues, temperature intolerance, nor visual impairments noted during this time. Magnetic resonance imaging revealed a large mass (1.48cm) with suprasellar extension and a mass effect on the optic chiasm. The patient was then started on Levothyroxine and Cabergoline, to reduce serum prolactin levels. However, upon follow-up two months later, the patient had hypoprolactinemia (2.0ng/mL; n=3.0-23.1ng/mL). The patient was referred to neurosurgery for resection of the sellar mass. Endocrinology was also consulted, at which point Cabergoline was discontinued and Levothyroxine was gradually increased. Follow up 4 months later showed prolactin levels had normalized to 11.4ng/mL (3.0-23.1ng/mL). Serum LH and FSH were within normal ranges (1.2mIU/mL and 4.2mIU/mL, respectively). TSH, though still elevated (47.35mU/mL; n=0.3-4.7mU/mL), was significantly reduced compared to the prior measurement (1620mU/mL). Serum levels of Free T4 increased to 1.06mcg/mL (n=4.9-11.4mcg/mL). Levothyroxine was titrated up and a repeated pituitary MRI demonstrated a significant decrease in the size of the mass with resolution of the suprasellar extension and mass effect on the optic chiasm. Further, the patient’s menses ceased and thelarche resolved upon correction of T4 and regression of the pituitary mass. Conclusions: While rare, primary hypothyroidism and TSH-driven pituitary hyperplasia can result in a large mass effect with suprasellar extension, causing secondary hyperprolactinemia by a mass effect and central precocious puberty. This case highlights the benefits for evaluating underlying hypothyroidism as a cause for hyperprolactinemia and sellar/suprasellar mass.

scholarly journals Effect of once weekly oral levothyroxine therapy

2021 ◽  
Vol 2021 ◽  
Author(s):  
Andrea del Toro-Diez ◽  
Ernesto Solá-Sánchez ◽  
Michelle Mangual-García
Keyword(s):  
Case Series ◽  
Cost Effective ◽  
Primary Hypothyroidism ◽  
Endocrine Disorders ◽  
List Type ◽  
Common Cause ◽  
Cost Effective Approach ◽  
Alternative Approach ◽  
Learning Points ◽  
Tsh Levels

Summary Primary hypothyroidism is one of the most common endocrine disorders with widely available treatment. A minority of patients remain with uncontrolled hypothyroidism despite therapy. The objective of this case series was to demonstrate that medication non-adherence, rather than malabsorption, should be sought as the most common cause of unsuppressed TSH levels in patients receiving treatment for this condition. Non-adherence is often considered as a diagnosis of exclusion. Nonetheless, a diagnosis of malabsorption requires a more extensive workup, including imaging and invasive procedures, which increase healthcare costs and burden to the patient. The findings of this study allow for a cost-effective approach to uncontrolled hypothyroidism. Learning points Medication non-adherence is a common cause of insuppressible TSH levels. Once weekly levothyroxine is an alternative approach to non-compliant patients. Assessing compliance is more cost-effective and less burdensome than testing for malabsorption.

scholarly journals Thyrotropin N-glycosylation and Glycan Composition in Severe Primary Hypothyroidism

2021 ◽  
Vol 5 (4) ◽  
Author(s):  
Leif Wide ◽  
Karin Eriksson
Keyword(s):  
Sialic Acid ◽  
Half Life ◽  
Primary Hypothyroidism ◽  
Free Thyroxine ◽  
Target Cells ◽  
Serum Samples ◽  
Glycan Pattern ◽  
Levothyroxine Treatment ◽  
Tsh Levels

Abstract Context In severe primary hypothyroidism (sPH), the serum thyrotropin (TSH) levels are elevated with an increased degree of sialylation. The circulating TSH comprises 2 different TSH glycoforms: TSHdi with 2 and TSHtri with 3 N-glycans and methods have developed to determine their contents of anionic monosaccharides (AMS), that is, sialic acid (SA) and sulfonated N-acetylglactosamine (SU) residues. Objective Characterize N-glycosylation and glycan composition of circulating TSH molecules and determine the effects during levothyroxine treatment in patients with sPH. Methods Serum samples were obtained from 25 patients with sPH, from 159 euthyroid individuals, and from 12 women during treatment with levothyroxine for sPH. Degrees of N-glycosylation and concentrations of TSHdi and TSHtri as well as their contents of AMS, SA, and SU residues were determined. Results The circulating TSH molecules in sPH patients had lower degrees of N-glycosylation, higher degrees of sialylation, and lower degrees of sulfonation than in euthyroid individuals. Levothyroxin restored sialylation and sulfonation of the glycans already at low free thyroxine (FT4) levels, while degree of N-glycosylation was not restored until the FT4 levels were normal. Conclusions The majority of TSH molecules in severe primary hypothyroidism were less N- glycosylated, more sialylated, and less sulfonated compared with euthyroid individuals. This glycan pattern favors a prolonged half-life in the circulation combined with lower in vitro biopotency at the target cells. During levothyroxine treatment of sPH patients, the sialylation and sulfonation of glycans were restored already at low FT4 levels, while N-glycosylation of TSH was not restored until the FT4 levels were normal.

scholarly journals Central hypothyroidism or subclinical hyperthyroidism: can they be confused with each other?

2020 ◽  
Vol 2020 ◽  
Author(s):  
Mauro Boronat
Keyword(s):  
Thyroid Nodule ◽  
Thyroid Tissue ◽  
Tracer Uptake ◽  
Pituitary Hormone ◽  
List Type ◽  
Subclinical Hyperthyroidism ◽  
Free T4 ◽  
Central Hypothyroidism ◽  
Laboratory Findings ◽  
Tsh Levels

Summary Isolated, adult-onset central hypothyroidism is very rare, and its diagnosis can be challenging. A 42-year-old patient was referred for evaluation of a 2.8 cm thyroid nodule. She referred symptoms that could be attributed to hypothyroidism and thyroid tests showed low TSH and normal-low levels of free T4. However, evaluation of the remaining pituitary hormones and pituitary MRI were normal, yet a radionuclide scanning revealed that the thyroid nodule was ‘hot’ and the tracer uptake in the remaining thyroid tissue was suppressed. Interpretation of these studies led to a misdiagnosis of subclinical hyperthyroidism and the patient was treated with radioiodine. Soon after treatment, she developed a frank hypothyroidism without appropriate elevation of TSH and the diagnosis of central hypothyroidism was made a posteriori. Long term follow-up revealed a progressive pituitary failure, with subsequent deficiency of ACTH and GH. This case should alert to the possibility of overlooking central hypothyroidism in patients simultaneously bearing primary thyroid diseases able to cause subclinical hyperthyroidism. Learning points: Although rarely, acquired central hypothyroidism can occur in the absence of other pituitary hormone deficiencies. In these cases, diagnosis is challenging, as symptoms are unspecific and usually mild, and laboratory findings are variable, including low, normal or even slightly elevated TSH levels, along with low or low-normal concentrations of free T4. In cases with low TSH levels, the coexistence of otherwise common disorders able to cause primary thyroid hyperfunction, such as autonomous nodular disease, may lead to a misdiagnosis of subclinical hyperthyroidism.

scholarly journals Treating primary hypothyroidism with weekly doses of levothyroxine: a randomized, single-blind, crossover study

2012 ◽  
Vol 56 (4) ◽  
pp. 250-258 ◽  
Author(s):  
Andressa Bornschein ◽  
Gilberto Paz-Filho ◽  
Hans Graf ◽  
Gisah A. de Carvalho
Keyword(s):  
Crossover Study ◽  
Primary Hypothyroidism ◽  
Weekly Dose ◽  
Safe Alternative ◽  
Cardiac Symptoms ◽  
Daily Schedule ◽  
Single Blind ◽  
Levothyroxine Treatment ◽  
Randomized Crossover Study ◽  
Blind Crossover Study

OBJECTIVE: Compliance to levothyroxine treatment in hypothyroidism is compromised by daily schedule, and a weekly dose may be an alternative. SUBJECTS AND METHODS: This was a randomized, crossover study. Fourteen females were assigned to daily or weekly doses of LT4. After six weeks, they switched regimens. Thyroid parameters were measured at baseline, and after 42 and 84 days. Echocardiogram and hyperthyroidism symptoms were evaluated before and four hours after LT4 intake. RESULTS: In the weekly dose treatment, fT4 levels were higher after taking LT4, and lower seven days after the last dose; by the 6th week there was a small decrease in T3 levels. TSH remained unchanged and there were no hyperthyroidism symptoms or echocardiographic manifestations. CONCLUSION: Weekly dose leads to transient increases in fT4, without hyperthyroidism or cardiac symptoms. That approach seems to be a safe alternative for the treatment of hypothyroidism.

scholarly journals Long-Term Cardiovascular Effects of Levothyroxine Therapy in Young Adults with Congenital Hypothyroidism

2008 ◽  
Vol 93 (7) ◽  
pp. 2486-2491 ◽  
Author(s):  
Mariacarolina Salerno ◽  
Ugo Oliviero ◽  
Teresa Lettiero ◽  
Vincenzo Guardasole ◽  
Dario Maria Mattiacci ◽  
...  
Keyword(s):  
Young Adults ◽  
Replacement Therapy ◽  
Exercise Capacity ◽  
Congenital Hypothyroidism ◽  
Intima Media Thickness ◽  
Normal Range ◽  
Levothyroxine Replacement ◽  
Levothyroxine Treatment ◽  
Tsh Levels

Abstract Context: Congenital hypothyroidism (CH) is the most prevalent endocrine disorder in the newborn and is routinely treated with life-long levothyroxine replacement therapy. Although several studies have demonstrated that such therapy may impact on the cardiovascular system, little is known with regard to the effects of long-term levothyroxine administration in patients with CH. Objective: The aim of the current study was to evaluate whether long-term levothyroxine replacement therapy in young adults with CH is associated with cardiovascular abnormalities. Patients and Methods: Thirty young adults with CH aged 18.1 ± 0.2 yr and 30 age- and sex-matched controls underwent cardiac and carotid Doppler ultrasound and symptom-limited cardiopulmonary exercise testing. Hypothyroidism was diagnosed by neonatal screening, and levothyroxine treatment was initiated within the first month of life and carefully adjusted to maintain TSH levels in the normal range and free T4 in the high-normal range. Results: Compared with controls, hypothyroid patients exhibited left ventricular diastolic dysfunction, impaired exercise capacity, and increased intima-media thickness. At multiple regression analysis, the number of episodes of plasma TSH levels less than 0.5 mU/liter and greater than 4.0 mU/liter from the age of 1 yr onward, and mean TSH plasma levels during puberty were independent predictors of diastolic filling and cardiopulmonary performance indexes (multiple r values: 0.61–0.75). Conclusions: Long-term levothyroxine treatment in young adults with congenital hypothyroidism is associated with impaired diastolic function and exercise capacity and increased intima-media thickness.

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