New onset Graves' disease as a cause of an adrenal crisis inan individual with panhypopituitarism: brief report
46 year old patient was admitted as an emergency with vomiting, hypotension and serum cortisol of 0,940 g/dl (26 nmol/l) indicative of adrenal failure. Despite previous history of panhypopituitarism he was found to be hyperthyroid [free T4 6.32 ng/dl (ref.
range: 0.93-1.7), free T3 22.21 pg/ml (ref. range: 1.8-4.6)].
He was fit and well till the age of 45. Eight months prior to this hospitalisation he presented with diabetes insipidus and was found to have a large cystic tumour in the area of the pituitary gland.
Surgery was only partially successful and histologically the tumour was diagnosed as craniopharyngioma. Endocrine assessment revealed deficiency in ACTH-cortisol, growth hormone, and gonadotropin, as well as low-normal free T4.
On the day of his emergency admission he looked ill and dehydrated, though was fully conscious and cooperative. Heart rate was 120 beats/min (sinus rhythm), blood pressure 85/40 mm Hg.
There were no obvious features of infection, but there was marked tremor and thyroid bruit. He received treatment with intravenous fluids and hydrocortisone.
L-thyroxine was stopped. Administration of large dose of methimazole (60 mg/day) resulted in gradual decrease in free T4 and free T3 (to 1.76 ng/ml, and 5.92 pg/ml, respectively) over a 15-day period.
The patient was found to have increased titre of antithyroperoxidase (anti-TPO) and anti-TSH receptor (anti-TSHR) antibodies (2300 IU/l (ref. range <40) and 3.6 IU/l (ref.
range <1.0 IU/l), respectively). He was referred for radioactive iodine treatment.
Iodine uptake scan performed prior to radioiodine administration confirmed uniformly increased iodine uptake consistent with Graves' disease.
Conclusions: Our case illustrates coexistence of hypopituitarism and clinically significant autoimmune thyroid disease.
The presence of hypopituitarism does not preclude the development of autoimmune thyrotoxicosis.
Author: Krzysztof C Lewandowski, Magdalena Marcinkowska, Elzbieta Skowronska-Jozwiak, Jacek Makarewicz and Andrzej Lewinski
Credits/Source: Thyroid Research 2008, 1:7
Published on: 2008-11-19
Copyright by the authors listed above - made available via BioMedCentral (Open Access). Please
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