Challenges in the functional diagnosis of thyroid nodules before surgery for TSH-producing pituitary adenoma

Summary A 50-year-old woman with thyroid-stimulating hormone (TSH)-producing pituitary adenoma (TSHoma) was diagnosed due to symptoms of thyrotoxicosis. Preoperatively, she showed thyrotoxicosis with the syndrome of inappropriate secretion of TSH (SITSH) and had a 5 cm nodule in her thyroid gland. Octreotide was administered preoperatively, which helped lower her serum TSH level but not her thyroid hormone level. These findings were atypical for a patient with TSHoma. The TSHoma was completely resected, and the TSH level dropped below the sensitivity limit shortly after surgery. Interestingly, however, thyroid hormone levels remained high. A clear clue to the aetiology was provided by consecutive thyroid scintigraphy. Although preoperative thyroid scintigraphy did not show a hot nodule and the mass was thought to be a non-functional thyroid nodule, the nodule was found to be hot in the postoperative phase of TSH suppression. By focusing on the atypical postoperative course of the TSHoma, we were able to conclude that this was a case of TSHoma combined with an autonomously functioning thyroid nodule (AFTN). Learning points The diagnosis of autonomously functioning thyroid nodules (AFTNs) depends on suppressed serum TSH levels. If thyroid hormones are resistant to somatostatin analogue therapy or surgery for TSHoma, complications of AFTN as well as destructive thyroiditis need to be considered. It is important to revisit the basics when facing diagnostic difficulties and not to give up on understanding the pathology.

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TSH-secreting pituitary adenoma: benefits of pre-operative octreotide

Endocrinology Diabetes and Metabolism Case Reports ◽

10.1530/edm-15-0007 ◽

2015 ◽

Vol 2015 ◽

Cited By ~ 1

Author(s):

I R Wallace ◽

E Healy ◽

R S Cooke ◽

P K Ellis ◽

R Harper ◽

...

Keyword(s):

Pituitary Adenoma ◽

Thyroid Hormone ◽

Tumour Size ◽

Diagnostic Testing ◽

Somatostatin Analogue ◽

List Type ◽

Hormone Resistance ◽

Thyroid Hormone Resistance ◽

Tsh Secretion ◽

Inappropriate Tsh Secretion

Summary TSH-secreting pituitary adenomas are rare and the optimal investigation and management is uncertain. We describe a case of a 43 year-old woman with a TSH-secreting pituitary adenoma, highlighting diagnostic testing and our use, pre-operatively of somatostatin analogue therapy, which induced biochemical euthyroidism and a reduction in tumour size. Learning points The differential diagnosis of the syndrome of inappropriate TSH secretion is non-thyroidal illness, medications, assay interference due to heterophilic antibodies, thyroid hormone resistance and TSH-secreting pituitary adenoma. TRH stimulation test and triiodothyronine suppression test assist in differentiating thyroid hormone resistance and TSH-secreting pituitary adenoma. Somatostatin analogue therapy can induce biochemical euthyroidism and reduce tumour size.

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Multiple Hürthle cell adenomas in a patient with thyroid hormone resistance

Endocrinology Diabetes and Metabolism Case Reports ◽

10.1530/edm-13-0032 ◽

2013 ◽

Vol 2013 ◽

Author(s):

Gemma Xifra ◽

Silvia Mauri ◽

Jordi Gironès ◽

José Ignacio Rodríguez Hermosa ◽

Josep Oriola ◽

...

Keyword(s):

Thyroid Hormone ◽

Thyroid Nodules ◽

List Type ◽

Hormone Resistance ◽

Subsequent Growth ◽

Thyroid Hormone Resistance ◽

Hürthle Cell ◽

First Case ◽

Increased Risk ◽

Tsh Levels

Summary Background: Thyroid hormone resistance (RTH) is a rare cause of thyroid dysfunction. High TSH levels, as described in RTH syndrome, are known to be associated with an increased risk of developing thyroid nodules with subsequent growth and malignancy. Patient findings: In 2006, a 29-year-old Caucasian man presented with a palpable mass in the neck. Increased free thyroxine and triiodothyronine levels were found in the context of unsuppressed TSH levels, despite no signs or symptoms of hyperthyroidism. Ultrasonography revealed a multinodular and enlarged goitre, and fine-needle aspiration cytology revealed suspicious features of malignancy. After excluding pituitary tumour and levothyroxine (l-T4) treatment, the patient was diagnosed with generalized RTH. Screening for all the known mutations in thyroid hormone receptor-β (TR β (THRB)) was negative. Thyroidectomy disclosed five Hürthle adenomas and three hyperplasic nodules. Euthyroidism was achieved after surgery with 6.1 μg/kg per day of l-T4. Conclusion: RTH may be a risk factor that predisposes to the development of multiple Hürthle cell adenomas. To our knowledge, this is the first case of multiple Hürthle cell adenomas in a patient with RTH. Learning points High TSH levels, as described in RTH syndrome, are known to be associated with an increased risk of developing thyroid nodules, with subsequent growth and malignancy. The exact role of TR β mutants in thyroid carcinogenesis is still undefined. We report the first case of multiple Hürthle cell adenomas associated with RTH.

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Giant plurihormonal pituitary adenoma in a child – case study

Journal of Pediatric Endocrinology and Metabolism ◽

10.1515/jpem-2021-0094 ◽

2021 ◽

Vol 0 (0) ◽

Author(s):

Elżbieta Moszczyńska ◽

Wiesława Grajkowska ◽

Maria Maksymowicz ◽

Joanna Malicka ◽

Mieczysław Szalecki ◽

...

Keyword(s):

Pituitary Adenoma ◽

Middle Cranial Fossa ◽

Thyroid Stimulating Hormone ◽

Somatostatin Analogue ◽

Tall Stature ◽

Pituitary Macroadenoma ◽

Hand Tremor ◽

Cranial Fossa ◽

Magnetic Resonance Imaging Mri ◽

Plurihormonal Pituitary Adenoma

Abstract Objectives To describe the case of a 12-year-old girl with a rare plurihormonal pituitary macroadenoma secreting prolactin (PRL), growth hormone (GH), thyroid-stimulating hormone (TSH), and alpha subunit (α-SU). Case presentation The patient experienced recurrent headaches and progressing loss of vision in one eye. During the examination, abnormalities such as tall stature, coarse facial features, enlarged feet and hands, tachycardia, hand tremor, hyperhidrosis, galactorrhea, and goiter were observed. Head magnetic resonance imaging (MRI) revealed a solid tumor in the anterior and middle cranial fossa, measuring 80 × 50 × 55 mm. A stereotactic biopsy revealed plurihormonal Pit-1 positive pituitary adenoma secreting PRL, GH, and TSH. A pituitary hyperfunction with PRL, GH, TSH, and α-SU excess was diagnosed. The patient was successfully treated pharmacologically with dopamine agonists and somatostatin analogue, and a decrease of tumor volume (30%) was achieved. Conclusions When neurosurgery is not possible, long-term pharmacological treatment of plurihormonal pituitary macroadenoma can be a safe and relatively effective alternative.

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Iodide Metabolism and Effects

Diagnosing and Managing Hashimoto’s Disease - Advances in Medical Diagnosis, Treatment, and Care ◽

10.4018/978-1-5225-9655-4.ch004 ◽

2020 ◽

pp. 25-33

Keyword(s):

Thyroid Hormone ◽

Thyroid Gland ◽

Thyroid Hormones ◽

Dietary Supplement ◽

Thyroid Function ◽

Thyroid Stimulating Hormone ◽

Hormone Synthesis ◽

Serum Tsh ◽

Tsh Stimulation ◽

Sensitive Marker

Iodine (I2) is essential in the synthesis of thyroid hormones T4 and T3 and functioning of the thyroid gland. Both T3 and T4 are metabolically active, but T3 is four times more potent than T4. Our body contains 20-30 mg of I2, which is mainly stored in the thyroid gland. Iodine is naturally present in some foods, added to others, and available as a dietary supplement. Serum thyroid stimulating hormone (TSH) level is a sensitive marker of thyroid function. Serum TSH is increased in hypothyroidism as in Hashimoto's thyroiditis. In addition to regulation of thyroid function, TSH promotes thyroid growth. If thyroid hormone synthesis is chronically impaired, TSH stimulation eventually may lead to the development of a goiter. This chapter explores the iodide metabolism and effects of Hashimoto's disease.

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The association of thyroid hormones and blood pressure in euthyroid preadolescents

Journal of Pediatric Endocrinology and Metabolism ◽

10.1515/jpem-2015-0084 ◽

2016 ◽

Vol 29 (4) ◽

Author(s):

Bo Hyun Park ◽

Sun Jung Baik ◽

Hye Ah Lee ◽

Young Sun Hong ◽

Hae Soon Kim ◽

...

Keyword(s):

Blood Pressure ◽

Thyroid Hormone ◽

Thyroid Hormones ◽

Diastolic Blood Pressure ◽

Pressure Control ◽

Thyroid Stimulating Hormone ◽

University Hospital ◽

Hypertension Status ◽

Childhood Hypertension ◽

Serum Tsh

AbstractHypertension is the leading cause of cardiovascular disease worldwide, and both high and low blood pressures are associated with various chronic diseases. Thyroid hormones have profound effects on cardiovascular function, including on blood pressure. Recent studies have shown that childhood hypertension can lead to adult hypertension. Therefore, adequate blood pressure control is important from early life. Employing a life-course approach, we aimed to investigate the association between thyroid hormones and blood pressure in children.A total of 290 children from the Ewha Woman’s University Hospital birth cohort participated in a preadolescent check-up program. We assessed the levels of serum thyroid-stimulating hormone (TSH) and free thyroxine (FT4) and the blood pressure status in these children. Thyroid hormone concentrations were measured using an electro-chemiluminescence immunoassay (ECLIA), and hypertension was defined according to the guideline of the Korea Centers for Disease Control and Prevention.The sex-, age-, and height-adjusted prevalence of hypertension was 27.0% in the present study. On regression analysis, serum FT4 showed significantly negative association with diastolic blood pressure (DBP; β=–8.24, 95% CI: –14.19–2.28, p=0.007). However, these relationships were not significant after adjustment for sex, age, and current body mass index. The levels of serum TSH showed no relationship with mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) after adjustment. No significant differences in serum TSH and FT4 levels according to hypertension status were found.These findings suggest that thyroid hormone is not independently associated with increased blood pressure in euthyroid preadolescents.

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A rare mutation of thyroid hormone receptor beta gene in thyroid hormone resistance syndrome

Endocrinology Diabetes and Metabolism Case Reports ◽

10.1530/edm-21-0023 ◽

2021 ◽

Vol 2021 ◽

Author(s):

Michela Del Prete ◽

Fabrizio Muratori ◽

Irene Campi ◽

Gianleone Di Sacco ◽

Federico Vignati ◽

...

Keyword(s):

Thyroid Hormone ◽

Thyroid Hormones ◽

Genetic Test ◽

List Type ◽

Thyroid Function Tests ◽

Resistance To Thyroid Hormone ◽

Hereditary Syndrome ◽

Serum Tsh ◽

Receptor Beta ◽

Tsh Levels

Summary Resistance to thyroid hormone (RTH) is a rare hereditary syndrome with impaired sensitivity to thyroid hormones (TH) and reduced intracellular action of triiodothyronine (T3) caused by genetic variants of TH receptor beta (TRB) or alpha (TRA). RTH type beta (RTHβ) due to dominant negative variants in the TRB gene usually occurs with persistent elevation of circulating free TH, non-suppressed serum TSH levels responding to a thyrotropin-releasing hormone (TRH) test, an absence of typical symptoms of hyperthyroidism and goiter. Here, we present a rare variant in the TRB gene reported for the first time in an Italian patient with generalized RTHβ syndrome. The patient showed elevated TH, with non-suppressed TSH levels and underwent thyroid surgery two different times for multinodular goiter. The genetic test showed a heterozygous mutation in exon 9 of the TRB gene resulting in the replacement of threonine (ACG) with methionine (ATG) at codon 310 (p.M310T). RTHβ syndrome should be considered in patients with elevated TH, non-suppressed TSH levels and goiter. Learning points Resistance to thyroid hormone (RTH) is a rare autosomal dominant hereditary syndrome with impaired tissue responsiveness to thyroid hormones (TH). Diagnosis of RTH is usually based on the clinical finding of discrepant thyroid function tests and confirmed by a genetic test. RTH is a rare condition that must be considered for the management of patients with goiter, elevation of TH and non-suppressed serum TSH levels in order to avoid unnecessary treatments.

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A case of a co-secreting TSH and growth hormone pituitary adenoma presenting with a thyroid nodule

Endocrinology Diabetes and Metabolism Case Reports ◽

10.1530/edm-18-0067 ◽

2018 ◽

Vol 2018 ◽

Cited By ~ 1

Author(s):

Laura Hamilton Adams ◽

Derick Adams

Keyword(s):

Growth Hormone ◽

Pituitary Adenoma ◽

Complete Remission ◽

Pituitary Adenomas ◽

Thyroid Nodules ◽

Pituitary Hormones ◽

Pituitary Hormone ◽

List Type ◽

Learning Points ◽

Pituitary Macroadenomas

Summary Co-secreting TSH and growth hormone pituitary adenomas are rare. We present a case of a 55-year-old woman who presented with symptoms of neck fullness. Ultrasound revealed multiple thyroid nodules and examination revealed several clinical features of acromegaly. She was found to have a co-secreting TSH and growth hormone pituitary macroadenoma. She underwent surgical resection followed by gamma knife radiation, which resulted in complete remission of her TSH and GH-secreting adenoma. Learning points: TSH-secreting pituitary adenomas are rare and about one-third co-secrete other hormones. Thyroid nodules are common in acromegaly and can be the presenting sign of a growth hormone-secreting pituitary adenoma. In the workup of acromegaly, assessment of other pituitary hormones is essential, even in the absence of symptoms of other pituitary hormone dysfunction. Complete remission of co-secreting GH and TSH pituitary macroadenomas is possible with surgery and radiation alone.

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Familial Partial Peripheral and Pituitary Resistance to Thyroid Hormone: A Frequently Missed Diagnosis?

PEDIATRICS ◽

10.1542/peds.78.6.1114 ◽

1986 ◽

Vol 78 (6) ◽

pp. 1114-1122

Author(s):

Nancy J. Hopwood ◽

Sue Ellyn Sauder ◽

Brahm Shapiro ◽

James C. Sisson

Keyword(s):

Thyroid Hormone ◽

Family Members ◽

Elevated Serum ◽

Thyroid Stimulating Hormone ◽

Thyrotropin Releasing Hormone ◽

Resistance To Thyroid Hormone ◽

Releasing Hormone ◽

Thyroxine Therapy ◽

Missed Diagnosis ◽

Serum Tsh

The diagnosis of partial peripheral and pituitary resistance to thyroid hormone was ultimately made in two boys, 7 and 9 years of age, and a 10-year-old girl who had goiters and hyperthyroxinemia. The boys were treated with propythiouracil and/or thyroidectomy or iodine 131 for suspected thyrotoxicosis but had poorly suppressible serum thyroid-stimulating hormone (TSH) post treatment in spite of the usual L-thyroxine replacement. The girl had increasing goiter size while receiving propylthiouracil, 100 mg every eight hours. These findings led to reevaluation of thyroid hormone dynamics in these children and their families. Twelve additional family members, 3 to 38 years of age, compatible with an autosomal dominant inheritance, were also found to have peripheral and pituitary resistance to thyroid hormone. All affected individuals had elevated serum thyroxine and triiodothyronine levels, normal to slightly elevated triiodothyronine resin uptakes, and a nonsuppressed serum TSH. The five individuals who were given thyrotropin-releasing hormone showed exaggerated TSH responses, which normalized on L-thyroxine therapy. Misdiagnosis in six of 15 family members led to significant morbidity (hypothyroidism, delayed growth, and therapy risk). A nonsuppressed serum TSH in a patient with suspected thyrotoxicosis should lead to suspicion of this disorder. Appropriate management for this condition includes L-thyroxine therapy to decrease goiter size and normalize TSH responses to thyrotropin-releasing hormone.

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Effect of goitrogen administration on the circadian rhythm of serum thyroid stimulating hormone in the rat

Acta Endocrinologica ◽

10.1530/acta.0.0980396 ◽

1981 ◽

Vol 98 (3) ◽

pp. 396-401 ◽

Cited By ~ 6

Author(s):

B. Stringer ◽

D. Wynford-Thomas ◽

B. Jasani ◽

E. D. Williams

Keyword(s):

Circadian Rhythm ◽

Thyroid Hormone ◽

Circadian Rhythms ◽

Thyroid Function ◽

Diurnal Rhythm ◽

Thyroid Stimulating Hormone ◽

Male Rats ◽

Hormone Synthesis ◽

Serum Tsh

Abstract. Adult male rats were fed a goitrogen, aminotriazole, for 74 days at a dose known to suppress thyroid function completely. At the end of this period, these animals along with matched controls were killed in groups of seven at 3 hourly intervals throughout a 24 hour period, and serum TSH, T3, T4 and albumin assayed. No significant circadian rhythms of T3, T4 or albumin were found in either, but a highly significant rhythm of TSH was demonstrated both in controls and goitrogen treated groups, with a diminished relative amplitude in the latter. The results indicate that a significant diurnal rhythm of serum TSH persists in the rat despite long-term blockade of thyroid hormone synthesis and that the existence of this rhythm is therefore independent of the presence of circulating T3 or T4.

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New-onset thyrotoxicosis in a patient with anaplastic thyroid carcinoma: a diagnostic challenge

Endocrinology Diabetes and Metabolism Case Reports ◽

10.1530/edm-21-0053 ◽

2021 ◽

Vol 2021 ◽

Author(s):

Marcio José Concepción Zavaleta ◽

Sofia Pilar Ildefonso Najarro ◽

Esteban Alberto Plasencia Dueñas ◽

María Alejandra Quispe Flores ◽

Diego Martín Moreno Marreros ◽

...

Keyword(s):

Differential Diagnosis ◽

Thyroid Cancer ◽

Thyroid Hormone ◽

Anaplastic Thyroid Cancer ◽

Thyroid Stimulating Hormone ◽

Anaplastic Thyroid Carcinoma ◽

List Type ◽

Diagnostic Challenge ◽

Adequate Treatment ◽

The Right

Summary Anaplastic thyroid cancer (ATC) is the type of thyroid cancer that has the worst prognosis. It usually presents as a rapidly growing cervical mass that generates compressive symptoms. Its association with thyrotoxicosis is rare. A 76-year-old woman, with no contributory history, presented with a 3-month course of fast-growing cervical tumor, associated with tenderness, cough, and weight loss. Physical examination revealed goiter, localized erythema, and a painful and stone tumor dependent on the right thyroid lobe. Due to the malignant findings of the thyroid ultrasound, the patient underwent a thyroid core needle biopsy, which indicated ATC. Laboratory tests revealed leukocytosis, decreased thyroid-stimulating hormone, elevated free thyroxine (fT4), and increased thyroperoxidase (TPO) antibodies. At the beginning, we considered that the etiology of thyrotoxicosis was secondary to subacute thyroiditis (SAT) after SARS-CoV-2 infection, due to the immunochromatography result and chest tomography findings. The result of markedly elevated TPO antibodies left this etiology more remote. Therefore, we suspected Graves’ disease as an etiology; however, thyroid histopathology and ultrasound did not show compatible findings. Therefore, we suspect that the main etiology of thyrotoxicosis in the patient was the destruction of the thyroid follicles caused by a rapid invasion of malignant cells, which is responsible for the consequent release of preformed thyroid hormone. ATC is a rare endocrine neoplasm with high mortality; it may be associated with thyrotoxicosis, whose etiology can be varied; therefore, differential diagnosis is important for proper management. Learning points Anaplastic thyroid cancer is the thyroid cancer with the worst prognosis and the highest mortality. The association of anaplastic thyroid cancer with thyrotoxicosis is rare, and a differential diagnosis is necessary to provide adequate treatment. Due to the current pandemic, in patients with thyrotoxicosis, it is important to rule out SARS-CoV-2 as an etiology. Anaplastic thyroid cancer, due to its aggressive behavior and rapid growth, can destroy thyroid follicular cells, generating preformed thyroid hormone release, being responsible for thyrotoxicosis.

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