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Graves disease
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Hashimoto thyroiditis
Pituitary adenoma
Toxic adenoma
Toxic multinodular goiter
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This patient presents with palpitations, heat intolerance, headache, irregular tachycardia, and a diffusely-enlarged thyroid in the setting of an elevated TSH, which are indicative of hyperthyroidism secondary to a functional pituitary adenoma ("central hyperthyroidism"). The anterior pituitary gland consists of thyrotropes, corticotropes, gonadotropes, somatotropes, and lactotropes. Functional adenomas can involve any of these cell types, resulting in overproduction of their respective hormones. Functional thyrotroph adenomas overproduce TSH, resulting in thyroid gland enlargement due to inappropriate stimulation and hyperthyroidism. In addition to symptoms of hyperthyroidism which include palpitations, heat intolerance, unintentional weight loss, and anxiety, pituitary thyrotroph adenomas cause a goiter. Other symptoms due to mass effect in the sella can include headache. Diagnostic workup includes measurement of serum T3, T4, and TSH concentrations; brain magnetic resonance imaging (MRI) showing the adenoma is confirmatory. Treatment is initially with somatostatin analogs to restore euthyroidism prior to surgical resection of the adenoma. Amlashi and Tritos review the diagnosis and management of TSH-secreting pituitary adenomas. They highlight the central role of transsphenoidal resection in management, although novel radiation therapies have seen increased use. Incorrect Answers: Answer 1: Graves disease presents with moderate to severe hyperthyroidism symptoms including palpitations, heat intolerance, weight loss, and a goiter but also includes ophthalmopathy and elevation of thyrotropin receptor antibodies (TRAbs), not TSH. TRAbs act as agonists at the thyrotropin receptor to cause hyperthyroidism, which results in inhibition of TSH release by the pituitary. Answer 2: Hashimoto thyroiditis is caused by an inflammatory process resulting in release of preformed thyroid hormones into the circulation. It has a hyperthyroid phase that presents with symptoms of hyperthyroidism such as palpitations and heat intolerance, but TSH would be suppressed due to negative feedback by increased thyroid hormone levels. Answer 4: Toxic adenoma is caused by autonomous secretion of thyroid hormone by an adenoma within the thyroid gland. This presents with symptoms of hyperthyroidism such as palpitations and heat intolerance with focal uptake on radioiodine scan. However, TSH is suppressed due to feedback inhibition. Answer 5: Toxic multinodular goiter is caused by autonomous secretion of thyroid hormone by multiple regions of the thyroid gland. This presents with symptoms of hyperthyroidism such as palpitations and heat intolerance with multiple areas of uptake on radioiodine scan. However, TSH is suppressed due to feedback inhibition. Bullet Summary: A functional pituitary adenoma is a cause of hyperthyroidism that presents with an elevated thyroid-stimulating hormone level.
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