scholarly journals Hypothyroidism presenting with development delay, failure to thrive, and pituitary adenoma

2017 ◽  
Vol 4 (5) ◽  
pp. 1906
Author(s):  
Jatinder Singh ◽  
Vaneeta Bhardwar ◽  
Daaman Mittal
Keyword(s):  
Pituitary Adenoma ◽  
Hormone Replacement ◽  
Pituitary Tumors ◽  
Failure To Thrive ◽  
Primary Hypothyroidism ◽  
Pituitary Hyperplasia ◽  
Development Delay ◽  
Pituitary Enlargement ◽  
Ct And Mri

Pituitary enlargement secondary to primary hypothyroidism (PH) is a known but uncommon occurrence, and is also difficult to distinguish on CT and MRI from primary pituitary tumors. Following adequate hormone replacement with L-thyroxine, both symptoms and pituitary hyperplasia are reported to regress within a few months. It is important to recognize this condition so as to avoid unnecessary surgery.

scholarly journals Pituitary Hyperplasia: To Operate or Not to Operate, That Is the Question

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A599-A599
Author(s):  
Aakash Rajwani ◽  
Luma Ghalib
Keyword(s):  
Imaging Techniques ◽  
Post Partum ◽  
Hormone Replacement ◽  
Mass Effect ◽  
Primary Hypothyroidism ◽  
Absolute Increase ◽  
Pituitary Hyperplasia ◽  
Imaging Results ◽  
History Of ◽  
Pituitary Enlargement

Abstract Pituitary hyperplasia is defined as an absolute increase in the number of one or more adenohypophyseal cell subtypes, manifesting radiologically as pituitary enlargement beyond what is considered normal. It has been noted in certain physiological conditions like pregnancy however can also be seen in pathological conditions with end organ insufficiency like severe hypothyroidism. 21- year old female with a past medical history of Primary Hypothyroidism secondary to Hashimoto’s thyroiditis presented initially for evaluation of worsening headache and blurry vision. She was diagnosed with hypothyroidism at 10 years of age and had an extensive family history of hypothyroidism. At the time of presentation, she was 11 months post- partum and had been on and off her levothyroxine supplementation, having stopped it completely for a few months after delivery. MRI brain showed an 18 mm homogeneously enhancing intrasellar mass with suprasellar extension. She was referred to Neurosurgery for further evaluation. Workup revealed a TSH >100 (0.27 - 4.2 mIU/L) and FT4 <0.4 (0.8 - 2 ng/dL). In the context of severe untreated hypothyroidism and MRI findings consistent with pituitary hyperplasia with abutment but no mass effect on the optic apparatus, initial plan was to treat the hypothyroidism medically and observe closely. Patient was started on levothyroxine supplementation. Her TSH improved to 3.367 (0.550 - 4.780 uIU/mL) and FT4 to 2.00 (0.89 - 1.76 ng/dL), ηοωεϖερ she continued to have worsening of visual symptoms. Surgery was considered to decompress the optic nerve, but pre-operative MRI showed a significant decrease in size of the pituitary gland with decreased suprasellar bulging and no mass effect on the optic chiasm. Surgery was subsequently cancelled. Prolonged primary hypothyroidism leads to pituitary hyperplasia due to loss of negative feedback from lack of circulating T4 and T3, leading to excessive TRH secretion from the hypothalamus. The high TRH can lead to thyrotroph as well as lactotroph hyperplasia. Subsequently patients can present with headache, vision changes along with signs and symptoms of hypothyroidism and increased prolactin secretion. It is important to differentiate hyperplasia from other sellar lesions like pituitary macroadenoma or hypophysitis. Patients with hypothyroidism, who have pituitary enlargement diagnosed on brain imaging, should be promptly diagnosed and treated with thyroid hormone replacement. With a higher frequency and improved quality of imaging techniques, we are increasingly coming across scenarios of abnormal findings on imaging. Correlation of radiographic imaging results with a thorough history and biochemical testing is essential prior to proceeding with surgical intervention.

scholarly journals Pituitary hyperplasia: an uncommon presentation of a common disease

2015 ◽  
Vol 2015 ◽  
Author(s):  
C P Neves ◽  
E T Massolt ◽  
R P Peeters ◽  
S J Neggers ◽  
W W de Herder
Keyword(s):  
Differential Diagnosis ◽  
Thyroid Function ◽  
Hormone Replacement ◽  
Primary Hypothyroidism ◽  
Common Disease ◽  
Pituitary Hormone ◽  
List Type ◽  
Pituitary Mass ◽  
Pituitary Hyperplasia ◽  
Pituitary Enlargement

Summary A 21-year-old woman presented with amenorrhea, bilateral galactorrhea and fatigue. Visual acuity and visual fields were normal. Laboratory examination demonstrated hyperprolactinemia. Magnetic resonance imaging (MRI) of the pituitary showed a 19×17×12-mm sellar mass with supra- and parasellar extension, causing compression of the pituitary stalk and optic chiasm. Further examinations confirmed mild hyperprolactinemia, strongly elevated TSH (>500 mU/l), low free thyroxine (FT4), hypogonadotropic hypogonadism and secondary adrenal insufficiency. Hydrocortisone and l-T4 replacement therapy was started. Three months later, the galactorrhea had disappeared, thyroid function was normalized and MRI revealed regression of the pituitary enlargement, confirming the diagnosis of pituitary hyperplasia (PH) due to primary hypothyroidism. Subsequently, the menstrual cycle returned and the hypocortisolism normalized. This case demonstrates that severe primary hypothyroidism may have an unusual presentation and should be considered in the differential diagnosis of pituitary enlargement associated with moderate hyperprolactinemia. Learning points One should always try to find one etiology as the common cause of all the clinical findings in a pathologic process. Amenorrhea, galactorrhea and fatigue may be the only presenting clinical manifestations of primary hypothyroidism. Not every patient with galactorrhea, hyperprolactinemia and a pituitary mass has a prolactinoma. Primary hypothyroidism should always be considered in the differential diagnosis of hyperprolactinemia associated with pituitary enlargement and pituitary hormone(s) deficiency(ies). When PH due to primary hypothyroidism is suspected, thyroid hormone replacement should be started and only regression of pituitary enlargement on MRI follow-up can confirm the diagnosis. Examination of thyroid function in patients with a pituitary mass may avoid unnecessary surgery.

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) >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 Dome-Shaped Pituitary Enlargement in Primary Hypothyroidism: Avoiding Neurosurgical Interventions

2020 ◽  
Vol 35 (2) ◽  
pp. 238-243
Author(s):  
Satyam Chakraborty ◽  
◽  
Mona Tiwari ◽  
Rajan Palui ◽  
Kajari Bhattacharya ◽  
...  
Keyword(s):  
Case Reports ◽  
Pituitary Surgery ◽  
Primary Hypothyroidism ◽  
Hormone Deficiency ◽  
Homogeneity Analysis ◽  
Imaging Characteristic ◽  
Pituitary Hyperplasia ◽  
Pituitary Enlargement ◽  
Levothyroxine Treatment ◽  
Thyrotroph Hyperplasia

We describe three cases of primary hypothyroidism which presented initially to neurosurgery department with pituitary hyperplasia. We have found a novel pattern of ‘dome shaped’ enlargement of pituitary in MRI of these patients. Out of these 3 patients, in two of them, the planned surgery was deferred when endocrinologists were consulted and the pituitary hyperplasia completely resolved with levothyroxine treatment. In the third case, pituitary surgery was already performed before endocrinology consultation and histopathology revealed thyrotroph hyperplasia. The hyperplastic lesions described typically have a homogenous symmetrical ‘dome’ shaped architecture unlike the non-functioning pituitary adenoma (NFPA), which usually might often be of varying shapes and homogeneity. Analysis of pituitary images from similar case reports published in literature, also showed this typical ‘dome’ shaped pituitary enlargement. This imaging characteristic can be a clue to look for underlying hormone deficiency, especially in primary hypothyroidism. Therefore, a thorough endocrine evaluation especially looking for primary hypothyroidism in such dome shaped pituitary lesions are mandatory to prevent unwarranted neuro-surgical intervention as treatment of primary hypothyroidism may result in resolution of the abnormal enlargement.

scholarly journals P.055 Epidemiologic features of pituitary adenoma patients requiring surgical treatment: large North American patient population based study

2018 ◽  
Vol 45 (s2) ◽  
pp. S30-S30
Author(s):  
F Alkherayf ◽  
F Banaz ◽  
A Lasso ◽  
S Mohajeri ◽  
P Masoudian ◽  
...  
Keyword(s):  
Surgical Treatment ◽  
Pituitary Adenoma ◽  
North American ◽  
Patient Population ◽  
Hormone Replacement ◽  
Tumor Resection ◽  
Pituitary Tumors ◽  
Tumor Type ◽  
Complete Excision ◽  
American Patient

Background: The surgical treatment of pituitary adenoma has evolved greatly over the decades. In order to better understand the patient population and their surgical treatment, we conducted an institutional review for pituitary adenoma surgery using the endoscopic endonasal trans-sphenoidal (EETS) approach. Methods: A retrospective review of all EETS cases for pituitary tumor resection was performed between November 2009 and June 2016. Patient characteristics, tumor type, endocrine data, operation characteristics were extracted from medical records. Preoperative MRI images were reviewed. The SIPAP classification was applied to the pituitary tumors. Postoperative patient data were extracted for the available follow-up period. Results: 232 cases were identified. Functional tumors were present in 29% of the cohort. Complete excision was most common for functioning tumors (49%) compared to nonfunctioning tumors (26%). There were no major vascular injuries. Hormone replacement with cortisol was required transiently in 70% of patients, with thyroid hormone replacement occurring in 40% of the cohort. Conclusions: From this large North American cohort nearly 30% of operated pituitary tumors were functioning. More commonly, these tumors were completely resected compared to the nonfunctioning group. The most commonly replaced hormone following EETS surgery was cortisol and this was largely transient.

scholarly journals Pituitary hyperplasia: case series and literature review of an under-recognised and heterogeneous condition

2015 ◽  
Vol 2015 ◽  
Author(s):  
Sunita M C De Sousa ◽  
Peter Earls ◽  
Ann I McCormack
Keyword(s):  
Polycystic Ovary ◽  
Case Series ◽  
Primary Hypothyroidism ◽  
List Type ◽  
Close Monitoring ◽  
Gnrh Analogues ◽  
Pituitary Hyperplasia ◽  
Pituitary Enlargement ◽  
And Gender ◽  
Trophic Hormone

Summary Pituitary hyperplasia (PH) occurs in heterogeneous settings and remains under-recognised. Increased awareness of this condition and its natural history should circumvent unnecessary trans-sphenoidal surgery. We performed an observational case series of patients referred to a single endocrinologist over a 3-year period. Four young women were identified with PH manifesting as diffuse, symmetrical pituitary enlargement near or touching the optic apparatus on MRI. The first woman presented with primary hypothyroidism and likely had thyrotroph hyperplasia given prompt resolution with thyroxine. The second and third women were diagnosed with pathological gonadotroph hyperplasia due to primary gonadal insufficiency, with histopathological confirmation including gonadal-deficiency cells in the third case where surgery could have been avoided. The fourth woman likely had idiopathic PH, though she had concomitant polycystic ovary syndrome which is a debated cause of PH. Patients suspected of PH should undergo comprehensive hormonal, radiological and sometimes ophthalmological evaluation. This is best conducted by a specialised multidisciplinary team with preference for treatment of underlying conditions and close monitoring over surgical intervention. Learning points Normal pituitary dimensions are influenced by age and gender with the greatest pituitary heights seen in young adults and perimenopausal women. Pituitary enlargement may be seen in the settings of pregnancy, end-organ insufficiency with loss of negative feedback, and excess trophic hormone from the hypothalamus or neuroendocrine tumours. PH may be caused or exacerbated by medications including oestrogen, GNRH analogues and antipsychotics. Management involves identification of cases of idiopathic PH suitable for simple surveillance and reversal of pathological or iatrogenic causes where they exist. Surgery should be avoided in PH as it rarely progresses.

MICROSURGICAL ANATOMY OF THE DIAPHRAGMA SELLAE AND ITS ROLE IN DIRECTING THE PATTERN OF GROWTH OF PITUITARY ADENOMAS

Neurosurgery ◽  
2008 ◽  
Vol 62 (3) ◽  
pp. 717-723 ◽  
Author(s):  
Alvaro Campero ◽  
Carolina Martins ◽  
Alexandre Yasuda ◽  
Albert L. Rhoton
Keyword(s):  
Pituitary Adenoma ◽  
Cavernous Sinus ◽  
Dura Mater ◽  
Pituitary Adenomas ◽  
Potential Role ◽  
Pituitary Tumors ◽  
Microsurgical Anatomy ◽  
Suprasellar Region ◽  
Lateral Distance ◽  
Diaphragma Sellae

Abstract OBJECTIVE To evaluate the anatomic aspects of the diaphragma sellae and its potential role in directing the growth of a pituitary adenoma. METHODS Twenty cadaveric heads were dissected and measurements were taken at the level of the diaphragma sellae. RESULTS The diaphragma sellae is composed of two layers of dura mater. There is a remarkable variation in the morphology of the diaphragm opening. The average anteroposterior distance of the opening was 7.26 mm (range, 3.4–10.7 mm) and the average lateral-to-lateral distance was 7.33 mm (range, 2.8–14.1 mm). CONCLUSION The variability in the diameter of the opening of the diaphragma sellae could explain the growth of pituitary tumors toward the cavernous sinus or toward the suprasellar region.

scholarly journals Marked Response of a Hypermutated ACTH-Secreting Pituitary Carcinoma to Ipilimumab and Nivolumab

2018 ◽  
Vol 103 (10) ◽  
pp. 3925-3930 ◽  
Author(s):  
Andrew L Lin ◽  
Philip Jonsson ◽  
Viviane Tabar ◽  
T Jonathan Yang ◽  
John Cuaron ◽  
...  
Keyword(s):  
Pituitary Adenoma ◽  
Liver Metastasis ◽  
Effective Treatment ◽  
Somatic Hypermutation ◽  
Treatment Options ◽  
Pituitary Tumors ◽  
Pituitary Carcinoma ◽  
Tumor Resistance ◽  
Clinical Sequencing ◽  
Acth Secreting

Abstract Context Pituitary carcinoma is a rare and aggressive malignancy with a poor prognosis and few effective treatment options. Case A 35-year-old woman presented with an aggressive ACTH-secreting pituitary adenoma that initially responded to concurrent temozolomide and capecitabine prior to metastasizing to the liver. Following treatment with ipilimumab and nivolumab, the tumor volume of the dominant liver metastasis reduced by 92%, and the recurrent intracranial disease regressed by 59%. Simultaneously, her plasma ACTH level decreased from 45,550 pg/mL to 66 pg/mL. Molecular Evaluation Both prospective clinical sequencing with Memorial Sloan Kettering–Integrated Mutation Profiling of Actionable Cancer Targets and retrospective whole-exome sequencing were performed to characterize the molecular alterations in the chemotherapy-naive pituitary adenoma and the temozolomide-resistant liver metastasis. The liver metastasis harbored a somatic mutational burden consistent with alkylator-induced hypermutation that was absent from the treatment-naive tumor. Resistance to temozolomide treatment, acquisition of new oncogenic drivers, and subsequent sensitivity to immunotherapy may be attributed to hypermutation. Conclusion Combination treatment with ipilimumab and nivolumab may be an effective treatment in pituitary carcinoma. Clinical sequencing of pituitary tumors that have relapsed following treatment with conventional chemotherapy may identify the development of therapy-induced somatic hypermutation, which may be associated with treatment response to immunotherapy.

Twice-Weekly Dosing for Thyroxine Replacement in Elderly Patients with Primary Hypothyroidism

1994 ◽  
Vol 22 (5) ◽  
pp. 273-277 ◽  
Author(s):  
J Taylor ◽  
B O Williams ◽  
J Frater ◽  
D J Stott ◽  
J Connell
Keyword(s):  
Thyroid Hormone ◽  
Elderly Patients ◽  
Hormone Replacement ◽  
Systolic Time Intervals ◽  
Serum Levels ◽  
Primary Hypothyroidism ◽  
Time Intervals ◽  
Thyroxine Therapy ◽  
Total Triiodothyronine ◽  
Systolic Time

Seven female patients (mean age 86 years) with proven biochemical primary hypothyroidism were enrolled in a single-blind randomized crossover study, of standard daily versus twice-weekly thyroxine therapy, with each phase of one month's duration. The median daily dose of thyroxine was 100 μg (range 75 – 100 μg). Serum levels of thyroid hormones and thyrotrophin were very similar during twice-weekly thyroxine therapy to those during daily therapy and there were no statistically significant differences between trough and peak serum total triiodothyronine, free thyroxine, or thyrotrophin levels or systolic time intervals during twice-weekly thyroxine. Administration of thyroxine twice-weekly to elderly patients with primary hypothyroidism gives effective biochemical thyroid hormone replacement, with no evidence from the systolic time intervals of tissue thyrotoxicosis at expected peak thyroid hormone concentrations. Supervised twice-weekly thyroxine should be considered in patients with primary hypothyroidism who comply poorly with daily dosing.

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