Diagnosis and Treatment > Signs and Symptoms
Search for other papers by Ehtasham Ahmad in
Google Scholar
PubMed
Search for other papers by Kashif Hafeez in
Google Scholar
PubMed
Search for other papers by Muhammad Fahad Arshad in
Google Scholar
PubMed
Search for other papers by Jimboy Isuga in
Google Scholar
PubMed
Search for other papers by Apostolos Vrettos in
Google Scholar
PubMed
Summary
Primary hypothyroidism is a common endocrine condition, most commonly caused by autoimmune thyroiditis (Hashimoto’s disease) while Graves’ disease is the most common cause of hyperthyroidism. Hypothyroidism is usually a permanent condition in most patients requiring lifelong levothyroxine treatment. Transformation from Hashimoto’s disease to Graves’ disease is considered rare but recently been increasingly recognised. We describe a case of a 61-year-old lady who was diagnosed with hypothyroidism approximately three decades ago and treated with levothyroxine replacement therapy. Approximately 27 years after the initial diagnosis of hypothyroidism, she started to become biochemically and clinically hyperthyroid. This was initially managed with gradual reduction in the dose of levothyroxine, followed by complete cessation of the medication, but she remained hyperthyroid, ultimately requiring anti-thyroid treatment with Carbimazole. This case highlights that there should be a high index of suspicion for a possible conversion of hypothyroidism to hyperthyroidism, even many years after the initial diagnosis of hypothyroidism. To our knowledge, this case illustrates the longest reported time interval between the diagnosis of hypothyroidism until the conversion to hyperthyroidism.
Learning points:
-
Occurrence of Graves’ disease after primary hypothyroidism is uncommon but possible.
-
In this case, there was a time-lapse of almost 28 years and therefore this entity may not be as rare as previously thought.
-
Diagnosis requires careful clinical and biochemical assessment. Otherwise, the case can be easily confused for over-replacement of levothyroxine.
-
We suggest measuring both anti-thyroid peroxidase (TPO) antibodies and TSH receptor antibodies (TRAB) in suspected cases.
-
The underlying aetiology for the conversion is not exactly known but probably involves autoimmune switch by an external stimulus in genetically susceptible individuals.
Search for other papers by Niki Margari in
Google Scholar
PubMed
Search for other papers by Jonathan Pollock in
Google Scholar
PubMed
Search for other papers by Nemanja Stojanovic in
Google Scholar
PubMed
Summary
Prolactinomas constitute the largest subsection of all secretory pituitary adenomas. Most are microprolactinomas and are satisfactorily treated by medical management alone. Giant prolactinomas, measuring more than 4 cm in diameter, are rare and usually occur more commonly in men. Macroprolatinomas tend to present with symptoms of mass effect rather than those of hyperprolactinaemia. Dopamine agonists (DA) are the treatment of choice for all prolactinomas. Surgery is usually reserved for DA resistance or if vision is threatened by the mass effects of the tumour. We describe the case of a 52 year-old woman with a giant invasive prolactinoma who required multiple surgical procedures as well as medical management with DA. One of the surgical interventions required a posterior approach via the trans cranial sub occipital transtentorial approach, a surgical technique that has not been previously described in the medical literature for this indication. The giant prolactinoma was reduced significantly with the above approach and patient symptoms from the compressing effects of the tumour were resolved. This case highlights the importance of a multidisciplinary approach to the management of such patients who present with florid neurological sequelae secondary to pressure effects. Although this presentation is uncommon, surgery via a sub occipital transtentorial approach may be considered the treatment of choice in suitable patients with giant invasive prolactinomas compressing the brainstem.
Learning points
-
Giant prolactinomas present with symptoms of mass effect or those of hyperprolactinaemia.
-
Interpretation of the pituitary profile is crucial to guide further investigations and management.
-
Treatment of giant invasive prolactinomas may involve a combination of medical management and multiple surgical interventions.
-
Treatment with DA may cause pituitary haemorrhage or infarction in patients with these tumours.
-
A sub occipital transtetorial approach may be considered the treatment of choice in invasive prolactinomas compressing the brainstem.
-
Multidisciplinary approach of such patients is fundamental for a better outcome.