Primary hypothyroidism presenting as growth delay and pituitary enlargement

Pituitary Macroadenoma Secondary to Congenital Hypothyroidism With Growth Failure and Developmental Delay: A Rare Presentation

Reactive pituitary hyperplasia can develop as a pituitary (pseudo) macroadenoma in the case of primary hypothyroidism. Hypothyroidism-induced pituitary hyperplasia (PHPH) can be managed medically. Surgery should not be performed if this condition is misdiagnosed as an adenoma. Primary hypothyroidism is a well-known cause of children's slow linear growth. Anterior pituitary enlargement is a rare symptom of severe or long-term illness (pituitary pseudotumor). Thyroid-stimulating hormone-secreting adenomas (TSHomas) are the rarest type of pituitary adenomas, with most endocrinologists seeing just a few cases throughout their lives. In most situations, the diagnosis is difficult, and patients may be referred after presenting with a condition of excessive thyroid-stimulating hormone secretion or a pituitary tumor. In this case study, we describe a 3.5-year-old girl who was referred to our hospital for a surgical assessment of a suspected pituitary neoplastic lesion. It was later determined that the suspected lesion was really pituitary hyperplasia brought on by primary hypothyroidism. Levothyroxine was started, and the dose was increased. The patient was advised to follow up to see if pituitary macroadenoma had responded to levothyroxine supplementation. Pituitary enlargement (pseudotumor of the pituitary gland) is a rare complication of primary hypothyroidism. Early diagnosis and treatment are critical for children with severe primary hypothyroidism to maintain their final height, as late diagnosis nearly always leads to a decline in adult stature. Pituitary macroadenoma secondary to severe hypothyroidism does not need risky and expensive surgical intervention. Because PHPH is rare in children, more credible information is needed to have a better knowledge of how the disease progresses and to develop scientific diagnostic criteria.

Pituitary hyperplasia in childhood primary hypothyroidism: a review

INTRODUCTION

Pituitary hyperplasia following primary hypothyroidism in pediatric age group population is considered rare with reports of unnecessary neurosurgical intervention for this medically treatable condition. Given the paucity of information on this topic, it is timely to provide clinicians with a comprehensive summary of available research.

METHODS

A search of published studies in Pubmed, PsychInfo and Cochrane Database with the terms "pituitary hyperplasia" or "pituitary hypertrophy" and "hypothyroidism" was performed and the results filtered for English language, pediatric (0-18 years) population and CT or MRI confirmed findings. 55 studies met the inclusion criteria. Data for a total of 110 patients with pituitary hyperplasia following primary hypothyroidism were extracted. The study population included 29 males and 81 females (M: F= 0.35:1). Patient age varied from 3 weeks to 18 years with a mean age of 10.22 years.

RESULTS

The most common clinical presentations included growth retardation, constipation and features of myxedema which were present in 78, 36 and 18 percent of children included in our review. Neuroimaging showed the mean (SD) pituitary height being 13.48 mm (4.72 mm). All of the patients achieved resolution of their pituitary mass and clinical as well as biochemical abnormalities 1 to 26 months after initiation of thyroid hormone replacement therapy, with an average time interval of 7.22 months. Our review has tried to delve in the pathophysiology as well as clinical, biochemical and radiological aspects of pediatric pituitary hyperplasia secondary to primary hypothyroidism and provide recommendations for treatment and follow-up. This may help anyone concerned gain a substantial knowledge on this topic.

Headache in recent onset hypothyroidism: Prevalence, characteristics and outcome after treatment with levothyroxine

Objective

The objective of this article is to analyze the features of headache attributed to hypothyroidism (HAH), evaluate the differences between groups with and without HAH, between “overt” and “subclinical” hypothyroidism groups, and evaluate outcomes after levothyroxine treatment.

Methods

Patients with hypothyroidism were selected in a cross-sectional study, followed prospectively for 12 months, and classified as subclinical or overt hypothyroidism. The patients were divided into two groups: with and without HAH.

Results

HAH was reported by 73/213 (34%) patients, involving the following areas: fronto-orbital (49%), temporal (37%), and posterior part of the head (15%). The HAH features were as follows: pulsatile (63%), four to 72 hours’ duration (78%), unilateral (47%), nausea/vomiting (60%), and moderate-severe intensity (72%). Hypothyroidism symptomatology was similar in both groups, except for a greater frequency of hoarseness in the group with HAH. Migraine history was more frequent in the patients with HAH (53% vs 38%, p < 0.05). The frequency of HAH was similar both in overt and subclinical hypothyroidism. After levothyroxine treatment 78% reported a decrease in HAH frequency. Subclinical and overt hypothyroid patients reported a similar alleviation of their headaches.

Conclusion

Patients with HAH may present with unilateral, pulsatile, episodic pattern, and nausea/vomiting, which is at odds with the criteria for HAH established by ICHD 3 beta. Not all individuals responded to levothyroxine, and patients with the subclinical form of hypothyroidism benefit from this treatment.

Primary hypothyroidism with growth failure and pituitary pseudotumor in a 13-year-old female: a case report

Introduction

Primary hypothyroidism is a well-known cause of poor linear growth in children. A rare finding with profound or long-standing disease is anterior pituitary enlargement (pituitary pseudotumor). This case highlights this uncommon finding, discusses clinical situations in which gradual dose escalation of levothyroxine may be advisable and reviews adjuvant therapies that have been previously attempted to improve final height in the setting of profound hypothyroidism.

Case presentation

We report the case of a 13-year-old Hispanic girl initially evaluated for poor linear growth and delayed puberty, and found to have pituitary enlargement secondary to profound primary hypothyroidism. Treatment with progressive doses of levothyroxine normalized her symptoms and led to complete resolution of her pituitary findings, but she then rapidly progressed through puberty, achieving an adult height of only 142cm, significantly below her calculated mid-parental height.

Conclusions

In cases of severe primary hypothyroidism with prolonged elevation of thyroid-stimulating hormone and pituitary pseudotumor, gradual replacement of thyroid hormone with slowly escalating doses of levothyroxine may be beneficial to prevent complications of therapy. Early recognition and treatment of hypothyroidism during childhood is essential for normal growth, as final height is invariably compromised in children with prolonged disease. Additional study is needed to determine the potential beneficial effects of gonadotropin-releasing hormone agonist and recombinant human growth hormone treatment in this setting.

Pituitary enlargement due to lingual thyroid gland and primary hypothyroidism

Pituitary enlargement can occur as a result of primary hypothyroidism. We present a newborn with pituitary enlargement and congenital hypothyroidism secondary to a lingual thyroid gland. Thyroid hormone therapy caused a regression of pituitary enlargement.