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Thyrotropin-Induced Hyperthyroidism Caused by Selective Pituitary Resistance to Thyroid Hormone

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Thyrotropin-Induced Hyperthyroidism Caused by Selective Pituitary Resistance to Thyroid Hormone Thyrotropin-induced hyperthyroidism caused by selective pituitary resistance to thyroid hormone. A new syndrome of "inappropriate secretion of TSH". M C Gershengorn, B D Weintraub J Clin Invest. 1975;56(3):633-642. https://doi.org/10.1172/JCI108133. Research Article An 18-yr-old woman with clinical and laboratory features of hyperthyroidism had persistently elevated serum levels of immunoreative thyrotropin (TSH). During 11 yr of follow-up there had been no evidence of a pituitary tumor. After thyrotropin-releasing hormone (TRH), there was a marked increase in TSH and secondarily in triiodothyronine (T3), the latter observation confirming the biologic activity of the TSH. Exogenous T3 raised serum T3 and several measurements of peripheral thyroid hormone effect, while decreasing serum TSH, thyroxine (T4), and thyroidal radioiodine uptake. After T3, the TRH-stimulated TSH response was decreased but was still inappropriate for the elevated serum T3 levels. Dexamethasone reduced serum TSH but did not inhibit TRH stimulation of TSH. Propylthiouracil reduced serum T4 and T3 and raised TSH. This patient represents a new syndrome of TSH-induced hyperthyroidism, differing from previous reports in the absence of an obvious pituitary tumor and in the responsiveness of the TSH to TRH stimulation and thyroid hormone suppression. This syndrome appears to be caused by a selective, partial resistance of the pituitary to the action of thyroid hormone. This case is also compared with previous reports in the literature of patients with elevated serum levels of immunoreactive TSH in the presence of elevated total and free thyroid hormones. A classification of these cases, termed "inappropriate secretion of TSH," is proposed. Find the latest version: https://jci.me/108133/pdf Thyrotropin-Induced Hyperthyroidism Caused by Selective Pituitary Resistance to Thyroid Hormone A NEW SYNDROME OF "INAPPROPRIATE SECRETION OF TSH" MARvIN C. GERSHENGORN and BRUCE D. WENRAUB From the Clinical Endocrinology Branch, National Institute of Arthritis, Metabolism, and Digestive Diseases, National Institutes of Health, Bethesda, Maryland 20014 A B S T R A C T An 18-yr-old woman with clinical and INTRODUCTION laboratory features of hyperthyroidism had persistently Serum thyrotropin (TSH)1 is usually suppressed in elevated serum levels of immunoreactive thyrotropin clinical disorders associated with the hypersecretion of (TSH). During 11 yr of follow-up there had been no thyroid hormones, thyroxine (T4), and triiodothyronine evidence of a pituitary tumor. After thyrotropin-releas- (T3) (1-4). However, recently the combination of ele- ing hormone (TRH), there was a marked increase in vated serum TSH and thyroid hormones has been de- TSH and secondarily in triiodothyronine (T3), the scribed in a few patients. Even this small group appears latter observation confirming the biologic activity of heterogeneous, since clinical features of the patients and the TSH. Exogenous T3 raised serum Ts and several proposed pathogenesis of the TSH hypersecretion differ. measurements of peripheral thyroid hormone effect, while Hamilton, Adams, and Maloof (5), Faglia et al. (6), decreasing serum TSH, thyroxine (T4), and thyroidal O'Donnell, Hadden, Weaver, and Montgomery (7), and radioiodine uptake. After T3, the TRH-stimulated TSH Mornex et al. (8) studied patients with pituitary tu- response was decreased but was still inappropriate for mors, hypersecretion of TSH and hyperthyroidism, the elevated serum Ta levels. Dexamethasone reduced while Hamilton and Maloof (9) described a similar serum TSH but did not inhibit TRH stimulation of patient who also had acromegaly.' Refetoff, DeGroot, TSH. Propylthiouracil reduced serum T4 and Ts and Benard, and DeWind (10, 11), Bode, Danon, Wein- raised TSH. This patient represents a new syndrome of traub, Maloof, and Crawford (12), and Lamberg (13) TSH-induced hyperthyroidism, differing from previ- have described clinically euthyroid patients with ele- ous reports in the absence of an obvious pituitary tu- vated serum thyroid hormones and TSH who appear mor and in the responsiveness of the TSH to TRH to have varying degrees of tissue resistance to the ac- stimulation and thyroid hormone suppression. This syn- tion of thyroid hormones and elevated serum TSH. drome appears to be caused by a selective, partial re- More recently, Emerson and Utiger (14) reported a of the to the action of sistance pituitary thyroid with and elevated serum TSH hormone. patient hyperthyroidism This case is also compared with previous reports in but without evidence of a pituitary tumor. In their case the literature of patients with elevated serum levels of immunoreactive TSH in the presence of elevated total 1Abbreziations used in this paper: PBI, protein-bound iodine; Ts, triiodothyronine; T4, thyroxine; TRH, thyro- and free thyroid hormones. A classification of these tropin-releasing hormone; TSH, thyrotropin. cases, termed "inappropriate secretion of TSH," is 'In this paper the designation "TSH" is restricted to proposed. hormone measured by specific radioimmunoassay. Before the availability of radioimmunoassay, TSH was measured This work was presented in part at the 1975 Annual by relatively nonspecific bioassays, which did not always Meeting of the American Federation for Clinical Research, differentiate among various thyroid-stimulating substances. Atlantic City, N. J. Several older reports that showed an association of pitui- Received for publication 12 March 1975 and in revised tary tumor, hyperthyroidism, and increased serum thyroid- form 8 May 1975. stimulating activity are not considered in this paper. The Journal of Clinical Investigation Volume 56 September 1975a633-642 633 the relatively autonomous TSH hypersecretion was Postoperatively, while receiving no medication, she thought to result from excessive pituitary stimulation appeared euthyroid, her PBI was 8.0 /Ag/dl, and her T4 by an endogenous releasing factor, possibly thyro- was 8.1 Ag/dl. However, within 10 mo, the patient re- tropin-releasing hormone (TRH). developed mild symptoms of hyperthyroidism, and the In the patient described herein, hyperthyroidism ap- thyroid gland enlarged to approximately four times pears to be caused by excessive thyroidal stimulation by normal. At that time PBI was 13.8 ug/dl, and T4 was TSH, which remains partially responsive to both nor- 15.1 Ag/dl. Propylthiouracil therapy was reinstituted mal stimulatory and inhibitory factors. The principal in July 1970 and continued through September 1971, abnormality appears to be a selective resistance of the when she was lost to follow-up. She was next seen in pituitary to suppression by thyroid hormones. August 1972, and although she volunteered no specific CASE REPORT complaints, a goiter was present and her serum hor- mone levels were in the hyperthyroid range: T4 was 15.9 S. F. (NIH 053533), a 7-yr-old white girl, was referred ytg/dl and free T4 was 3.5 ig/dl (normal 1.0-2.1). Pro- to the National Institutes of Health in December 1963, pylthiouracil, 100 mg/day, was reinstituted, and within because of hyperkinesia, decreased attention span, and 3 mo the serum hormone levels returned to normal (T4 excessive sweating. She was the product of a normal was 7.0 Ag/dl). In January 1974, while taking 50 mg/day gestation, weighed 5 lbs, 8 oz., and appeared entirely propylthiouracil, she was entirely asymptomatic and normal at birth, and attained her developmental mile- appeared clinically euthyroid. However, her thyroid stones normally. Upon entering kindergarten she was gland had enlarged. Serum hormone levels at that time found to have a learning disability, subsequently diag- were as follows: T4 was 10.4 /g/dl, free T4 was 2.3 nosed as a specific dyslexia. Before her initial evaluation ng/dl, T3 by radioimmunoassay was 275 ng/dl (nor- at the NIH, her only medical illness had been rubeola. mals 90-160), and TSH was 26 jU/ml (normals < 0.5- There was no family history of thyroid disease. She 3.5). Because of the enlarging thyroid gland, propyl- was mildly hyperactive with a resting pulse rate of 110/ thiouracil was stopped, and 2 mo later serum thyroid min, and her height was 117 cm (just over the 10th hormone levels had increased: T4 was 19.1, free T4 was percentile). She weighed 17.6 kg (just below the 3rd 3.5, T3 was 355, and TSH had decreased to 9.2. percentile). She had widened fissures but no palpebral The patient was admitted to the NIH in August proptosis or lid lag. Her palms were warm and moist, 1974 at age 18 for further study. She volunteered no and the deep tendon reflexes were The hyperactive. thy- complaints. She had undergone roid gland was soft, symmetric, and mini- menarche at age 13 nontender, and had normal menstrual cycles. mally enlarged. Protein-bound iodine (PBI) was 14.4 Her weight was 43.4 kg (just below the 3rd percentile), and her height was pg/dl (normals 4.0-8.0), T4 was 19.7 Ag/dl (normals 4.6-10.7), thyroxine-binding globulin binding capacity 150 cm (just below the 3rd percentile). Pulse was was 18.5 isg T4/dl (normals 15-25), and radioiodine 85-95/min. Her skin was warm and dry. There were no signs of Graves' uptake was 55% at 24 h (normals 10-35). ophthalmopathy, no acropachy, and no pretibial myxedema. The Treatment with methimazole, 60 mg/day, was begun, thyroid gland was multi- nodular and enlarged, the right lobe measuring 4.0 X 4.5 and the patient became euthyroid within 2 mo. 4 mo later her thyroid gland enlarged, and thyroid studies cm and the left lobe measuring 3.0 X 4.0 cm. Her deep tendon reflexes revealed a PBI of 3.4 /g/dl and a T4 of 2.6 Ag/dl. were hyperactive. Routine laboratory studies were within Methimazole was continued at the same dose, and T3, normal limits. Her visual fields were 50 was added. For the next 3k yr she was fol- full, and tomographic study of the sella turcica showed IAg/day, no lowed regularly in the outpatient department.
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