Case History/ Examination:
A 22-year-old female with no significant medical history presented with a three-year history of headaches and three months of vomiting. She also reported five months of amenorrhea, with a negative pregnancy test and stable weight, though she experienced generalized body aches during this period. She had no galactorrhea, changes in hand or foot size, or hirsutism. She had no medical or surgical history and wore glasses for reduced visual acuity. Her physical examination was unremarkable.
Her blood work revealed an elevated thyroid-stimulating hormone (TSH) level and a local doctor started her on thyroxine 50 mcg daily. A complete pituitary profile was conducted, as shown in Table 4 , which confirmed significantly elevated TSH levels while the rest of her pituitary profile was within normal limits.
MRI brain was performed to investigate the underlying cause of her symptoms, which included prolonged headaches, vomiting, and amenorrhea. These symptoms, coupled with her elevated TSH levels and pituitary profile findings, raised suspicion of a possible pituitary or central hormonal disorder. Imaging revealed a bulky pituitary gland with a mild upward convexity and a slight deviation of the pituitary stalk to the left. There was no compression of the optic chiasm. A small, hypo- to non-enhancing lesion measuring approximately 7 x 6 x 5 mm was identified in the anterior part of the pituitary gland on the right side of the midline. The rest of the pituitary gland showed homogeneous enhancement, with no invasion into the cavernous sinus (Figure 5 and 6).
Her thyroxine increased to 150mcg daily. She was kept on follow-up as per a multidisciplinary meeting in which neurosurgeons and endocrinologists decided to follow her repeat thyroid profile and brain imaging.
A follow-up MRI performed six months later showed that the pituitary gland remained persistently bulky with mild upward convexity, with the pituitary stalk now in the midline. There was no compression of the optic chiasm. The small, hypo- to non-enhancing lesion was re-demonstrated in the anterior part of the pituitary gland on the right side of the midline, measuring approximately 6.5 x 4.7 x 4.5 mm. The remainder of the pituitary gland showed homogeneous enhancement, with no cavernous sinus invasion, consistent with a stable pituitary microadenoma on the right side of the midline (Figure 7 and 8).
Approximately eight months after her symptoms began, the patient started experiencing brief episodes of loss of consciousness, followed by spontaneous recovery, often accompanied by headaches. A neurologist diagnosed her with epilepsy and initiated treatment with levetiracetam. The orofacial team managed her headaches. Specialists determined that these symptoms were unrelated to her pituitary lesions, as the pituitary mass was too small to cause such issues. However, she had been non-compliant with her thyroxine medication, resulting in persistently elevated TSH levels and the continued presence of the pituitary adenoma. Her thyroid tests at that time are shown in Table 5.
Her thyroxine dose was subsequently increased to 200 mcg for six days per week and 150 mcg on one day, emphasizing reinforcing medication compliance. Her lab results at the two-year follow-up are shown in