Diagnosis and Treatment > Medication

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Fernando Gomez-Peralta Endocrinology and Nutrition Unit, Hospital General de Segovia, Segovia, Spain

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Pablo Velasco-Martínez Department of Internal Medicine, Hospital General de Segovia, Segovia, Spain

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Cristina Abreu Endocrinology and Nutrition Unit, Hospital General de Segovia, Segovia, Spain

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María Cepeda Department of Internal Medicine, Hospital General de Segovia, Segovia, Spain

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Marta Fernández-Puente Department of Internal Medicine, Hospital General de Segovia, Segovia, Spain

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Summary

Methimazole (MMI) and propylthiouracil (PTU) are widely used antithyroid drugs (ATD) that have been approved for the treatment of hyperthyroidism. Hepatotoxicity may be induced by these drugs, though they exert dissimilar incidence rates of hepatotoxicity and, possibly, with different underlying pathogenic mechanisms. We report the case of a 55-year-old woman with no relevant medical history diagnosed with hyperthyroidism due to Graves’ disease, who developed two episodes of acute hepatitis concurrent with the consecutive administration of two different ATDs, first MMI and then PTU. Given the impossibility of administering ATDs, it was decided to perform a total thyroidectomy because the patient was found to be euthyroid at that point. Pathological anatomy showed diffuse hyperplasia and a papillary thyroid microcarcinoma of 2 mm in diameter. Subsequent clinical check-ups were normal. This case suggests the importance of regular monitoring of liver function for hyperthyroid patients. Due to the potential severity of this side effect, it is recommended to determine baseline liver function prior to initiation of treatment.

Learning points:

  • We present a rare case of two acute hepatitis episodes concurrent with two different consecutive ATD therapies.

  • Our results highlight the relevance of a liver function monitoring during the treatment with MMI or PTU.

  • A baseline assessment of the liver function before starting an ATD treatment should be recommendable.

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K Majumdar University College London Hospitals NHS Foundation Trust, Diabetes and Endocrinology, 250 Euston Road, London NW1 2PG, UK

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M Barnard Whittington Hospital, London, UK

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S Ramachandra Whittington Hospital, London, UK

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M Berovic Whittington Hospital, London, UK

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M Powell National Hospital for Neurology and Neurosurgery, Neurosurgery, London, UK

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Summary

Tuberculosis (TB) is an important cause of mortality and morbidity across the world. In 2–5% of all cases of systemic TB, the C is affected, with lesions reported in the meninges, cortex and ventricles. Intrasellar tuberculomas, however, are extremely rare. We report the interesting case of a young female patient who presented with secondary hypothyroidism and hyperprolactinaemia. She was treated successfully for pituitary TB. We also highlight and discuss some interesting (and hitherto unreported) endocrine issues. Radiological and histological features and treatment of pituitary TB are discussed using this case as an example.

Learning points

  • Intrasellar TB continues to be a rare presentation, but incidence and prevalence are expected to grow with increasing numbers of multidrug-resistant TB and shrinking geographical boundaries across the world.

  • Pituitary TB can present with features of a typical adenoma, but has certain radiological and histological features that help to differentiate from an adenoma.

  • Patients can present with a variety of endocrine abnormalities at different times.

  • The presence of an intrasellar mass in individuals at a high risk of developing TB, or with a previous history of systemic TB, should prompt the diagnosis of pituitary TB. In such individuals, it may be worth considering a trial of anti-tuberculous therapy, before considering surgery.

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