Endocrine Abstracts

A 39 years old pacient presented for the first time in may 2023 with altered vision, dizziness, tachycardia and palpitations with paraclinical investigations suggestive for inappropiate TSH secretion: TSH=5.31 μUI/ml (NR: 0.27-0.42), fT4=56.8 pmol/l (NR: 11.9-21.6), fT3=17.4 ng/dl (NR: 3.1-6.8), ATPO <9 UI/ml, ATG=12.7 UI/ml (NR: 0-115). He has been treated with antithyroid drugs (Thiamazole 10 mg per day). The thyroid ultrasound and ophthalmological exam were normal. Additional laboratory testing showed elevated level of prolactin=919 μUI/ml (NR: 86-324) and SHBG=141 nmol/l (NR: 18.3-54.1), IGF-1=126.5 ng/ml (NR: 83-238). We repeated the thyroid function which revealed: TSH=4.71 μUI/ml (NR: 0.35-4.94), fT4=24.69 pmol/l (NR: 9-19), T3=208.26 ng/dl (NR: 35-193). He never experienced galactorrhea or symptoms of low libido. The MRI exam revealed a sellar gadolinophilic tumor with suprasellar extension, having contact with the optic chiasm and the left optic nerve, extended at the level of the right cavernous sinus measuring approximately 20/28.1/24 mm (AP/lL/CC) concordant with clinical manifestations and laboratory results. The tumor ablation was performed through transsphenoidal approach endoscopic assisted. The histophatological and immunohistochemistry results proved that it was a plurihormonal macroadenoma prolactin and GH secreting but with negative staining for TSH (repeated twice), ACTH, LH, and FSH. Given all the information, we could not exclude an immature adenoma of PIT1 line which requires additional genetic testing. After surgery, at 3 months apart, the pacient presents central hypothyroidism, central adrenal insufficiency, confirmed with the insulin tolerance test (basal cortisol=0.62 μg/dl, maximum cortisol=8.79 μg/dl) and somatotroph insufficiency (maximum GH=0.16 ng/ml) but with normal pituitary-gonadic axis and prolactin slightly above the upper limit of normal. We substituted the thyroid and the adrenal function. At 5 months post-surgery we obtained optimal thyroid and adrenal substitution, and partial stimulation after 1 μg of Synachten i.v with the highest cortisol level=17.58 μg/dl with normal somatotroph and gonadal axis (we considered optimal stimulation if cortisol >18 μg/dl, partial response 12-18 μg/dl and diagnostic for insufficiency <12 μg/dl). In conclusion, particularity of the case is the initial clinical and biochemical setting of the patient which is in contrast with the histopathological exam of the macroadenoma and also the partial recovery of the adrenal axis, especially after pituitary surgery.