Abstract
“DOME SIGN” in Thyrotroph Hyperplasia
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Undiagnosed or inappropriately treated primary hypothyroidism has symptoms and signs which can overlap with a pituitary Adenoma more so in adolescent females where they commonly present with stunting of growth and primary amenorrhea, symptoms which are also seen in non-functional pituitary adenoma. The aforementioned clinical situation might invite a radiological evaluation before a hormonal work-up in patients commonly presenting to primary care physicians, who might miss a Thyrotroph Hyperplasia for a Pituitary Macroadenoma. The patients are thereafter referred to neurosurgeons for operative intervention.
We present a case-series of two Adolescent females who were mistaken to have Pituitary Macroadenoma based on MR findings in the presence of Untreated Hypothyroidism and were successfully treated with appropriate doses of Levothyroxine leading to total disappearance of the Pseudo-tumorous Pituitary Enlargement which actually was Thyrotroph Hyperplasia. Our third case was a young female who underwent Neuro-Surgical referral prior to Endocrinological evaluation but fortunately did not bear the brunt of permanent Multiple Pituitary Deficiencies except a transient Diabetes Insipidus.
In the process we reviewed the literature to discover that all the Thyrotroph Hyperplasia described in the Literature were symmetrical in shape and had a symmetrical homogenous “DOME” shaped configuration. The anatomical location of the Thyrotrophs in the midline has been depicted by Ben -Shlomo et al. (http://dx.doi.org/10.1016/B978-0-12-804169-7.00002-7) which makes it imperative that any hyperplasia in the aforementioned region will cause similar “dome-shaped” architecture. We proposed “DOME” sign on MR imaging to describe Thyrotroph Hyperplasia in untreated Hypothyroidism which will guide Primary care Physicians to exercise caution before a Neuro-surgical Referral.
Our work addresses the unmet need to radiologically characterize a Thyrotroph Hyperplasia in cases where Biochemical evaluation of a Pituitary Macroadenoma is not done. Our efforts to prevent unnecessary Neuro-Surgical interventions have been refuted by Roux et al. (https://doi.org/10.3390/biomedicines12061368) where they found 11 cases out of 93 cases of Thyrotroph hyperplasia, unfortunately operated.
Pituitary tumors are usually asymmetrical in shape unlike Thyrotroph Hyperplasia. The “Dome Sign” in MR imaging proposed by our team might remain the radiological cornerstone to prevent Neuro-Surgical Intervention in Thyrotroph Hyperplasia due to untreated or inappropriately treated Primary Hypothyroidism.
Keywords: Primary hypothyroidism, Thyrotroph hyperplasia, Pituitary macroadenoma, Radiological evaluation, Diabetes insipidus
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