Endocrine Abstracts

A 28-year-old female presented to the optician with visual disturbance, lethargy and headaches, which were initially attributed to long hours of IT work. Despite a trial of eye exercises she experienced worsening colour vision and acuity in the right eye, hence a further consultation with an optometrist. Examination did not reveal a visual field defect. Visual acuity was 6/6 with 9/17 ishihara plates in the right eye and 5/6 with 17/17 ishihara plates in the left. A further referral to the ophthalmologist elicited a history of hearing changes in the right ear. MRI brain revealed a 20 × 28 × 33 mm pituitary mass, requiring an urgent referral to the endocrine team. On review in the endocrine clinic she denied any breast tenderness or galactorrhoea. As part of a general examination (including the neck), deep seated thyroid lobes (clinically not enlarged) with palpable nodules were noted. Pituitary profile showed prolactin 2229 mU/l [normal range (NR) 90–520 mU/l], TSH 0.945 mU/l (NR 0.47–4.68), freeT4 7.1 pmol/l (NR 10.1–30.2) and 9am cortisol < 100 nmol/l. She was commenced initially on cabergoline 0.5milligrams twice weekly and up-titrated to 1.5milligrams twice weekly alongside levothyroxine 100micrograms once daily and hydrocortisone 25 mg daily in divided doses. Repeat prolactin a month later on cabergoline therapy was < 10 mU/l, however pituitary MRI showed no interval change. On further assessment by the neurosurgical team and discussion with the patient, in view of ongoing visual symptoms combined with no reduction in size of pituitary mass, she underwent trans-sphenoidal surgery. Histology confirmed benign adenoma. She subsequently reported resolution of her headaches and improvement of her colour vision. Thyroid ultrasound (USS) identified a 5.4 mm × 2.7 mm U3 nodule in the right lobe and a 4.2 mm × 2.5 mm U2 nodule in the left lobe. Cytology following USS-guided fine needle aspiration of the right U3 nodule concluded papillary thyroid carcinoma (THY5). A formal referral was made to endocrine surgeon for the management of her papillary thyroid carcinoma. She made an uneventful recovery following thyroid and pituitary surgeries with acceptable thyroid function tests of TSH 0.26 mU/l, freeT4 19.6 pmol/l, freeT3 5.1 pmol/l, normal gonadotropins and prolactin 9 mU/l. She continued on levothyroxine 100 micrograms and hydrocortisone 25 mg in divided doses with cessation of cabergoline.

Conclusion: This case highlights the need for a full and thorough examination, which is the most basic but fundamental code of clinical practice and may well lead to the finding of other coexisting pathology in patients, despite singular presentation.