title: Plurihormone secreting pituitary macroadenoma masquerading as thyrotoxicosis: Clinical presentation and diagnostic challenges.
abstract: Thyroid stimulating hormone (TSH) secreting adenomas are the rarest type of pituitary adenomas (1:1000000 in the population; 0.2- 2.8% of adenomas). Plurihormonal thyrotropic adenomas are even rarer usually having cosecretion of growth hormone (GH) and prolactin. We report perhaps for the first time, TSH, GH, adrenocorticotrophic hormone (ACTH) and gonadotropins secreting pituitary macroadenoma diagnosed in a 40 year lady presenting with features of thyrotoxicosis for 5 months, amenorrhea for 3 months and newly diagnosed diabetes and hypertension for 2 months along with headache, nausea, and vomiting, who had acromegaloid habitus, grade-II goitre, increased uptake on Technitium-99 pertechnate thyroid scan (4.1%; normal: 0.24-3.34%), with increased T3 (5.98 pg/ ml; 1.5-4.1), increased T4 (2.34 ng/dl; 0.9-1.8), inappropriately high TSH (2.32 μIU/ml; 0.4-4.2), insulin like growth factor-1 (711 ng/ ml; 109-264), non-suppressed post-glucose GH (15.9 ng/ml; <1 ng/ml), normal estradiol (52 pg/ml; 21-251), inappropriately high luteinizing hormone (53.5 mIU/ml; 1.1-11.6), inappropriately high follicle stimulating hormone (59 mIU/ml; 3-14.4), non-suppressed overnight dexamethasone cortisol (5.8 mcg/dl; <2), elevated ACTH (58 pg/ml 5-15), withdrawal bleed on progestrogen challenge, bitemporal hemianopia on automated perimetry and pituitary macroadenoma on MRI imaging of sella. Thyroid hormone resistance was ruled out by documenting normal sex hormone binding globulin and ferritin levels. Her clinical and biochemical phenotype was not suggestive of multiple hormone resistance seen in pseudohypoparathyroidism. This report intends to highlight the challenges in the diagnosis of plurihormonal thyrotropic adenoma.
authors.affiliation: Department of Endocrinology & Metabolism, IPGMER & SSKM Hospital, Kolkata, India.
authors.forename: Indira
authors.initials: I
authors.lastname: Maisnam
authors.forename: Deep
authors.initials: D
authors.lastname: Dutta
authors.forename: Rajesh
authors.initials: R
authors.lastname: Jain
authors.forename: Sujoy
authors.initials: S
authors.lastname: Ghosh
authors.forename: Satinath
authors.initials: S
authors.lastname: Mukhopadhyay
authors.forename: Subhankar
authors.initials: S
authors.lastname: Chowdhury
keywords: Gonadotropins; growth hormone; pituitary adenoma; plurihormonal; thyroid stimulating hormone
references.citation: J Pediatr Endocrinol Metab. 2006 May;19 Suppl 2:663-70
references.pmid: 16789632
references.citation: Eur J Endocrinol. 1999 Jun;140(6):519-27
references.pmid: 10366408
references.citation: Thyroid. 1994 Summer;4(2):225-32
references.pmid: 7920008
references.citation: Cancer. 2002 Jul 15;95(2):258-66
references.pmid: 12124824
references.citation: Eur J Endocrinol. 2003 Apr;148(4):433-42
references.pmid: 12656664