1. Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Case Presentation 내분비내과 R3 최하나 / 진상욱교수님

2. Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Patient information Chief Complaint Known thyrotoxicosis onset) 3 개월 전 Present Illness 57 세 여자환자 HTN, Atrial fibrillation with RVR 로 본원 순환기 내과 f/u 중이었 으며 Brain epidermoid cyst removal (2012.5 본원 신경외과 ), CSF leakage 로 Endoscopic repair of sphenoid sinus CSF leakage 2 차례 시행 (2012.7), Hydrocephalus 로 VP shunt 시행 (2012.8) 한 병력 있는 자로 신경외과 입원 당시 시행한 갑상선 기능검사상 Thyrotoxicosis 소견 보여 내분비 내과에 진료 의뢰 되 었고 Methimazole 10 mg bid 복용한 상태로 내분비 내과 외래 방문함. 12276944 박 O 혜 (F/57) 내분비내과 외래 방문 : 2012.09.17

3. Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Past Medical History DM/ HTN/ hepatitis/ Tbc (-/+/-/-) HTN : 2008 년, bevantolol 50 mg 1T qd Atrial fibrillation with RVR : no medication Thyrotoxocosis: methimazole 10 mg bid Op Hx(+) : Brain epidermoid cyst removal (2012.5.25) Endoscopic repair of CSF leakage (2012.7.10, 2012.7.27) V-P shunt (2012.8.24) Personal History Smoking (-) Alcohol (-) Family History (-)

4. Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Review of System GeneralFever (-) Chills (-) Weakness (-) Weight change(-) SkinRash (-) Itching (-) Pigmentation (-) sweating(-) HE/ENT Headache (-) Visual disturbance (-) Rhinorrhea (-) Sore throat (-) Hoarseness (-) RespiratoryCough (-) Sputum (-) Dyspnea (-) Hemoptysis (-) Cardiac Chest pain (-) Palpitation (-) Syncope (-) GI A/N/V/D/C (-/-/-/-) Abdominal pain (-) Hematochezia (-) Melena (-) Hematemesis(-) GU Oliguria (-) Hematuria (-) Discharge(-)

5. Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Physical Examination Vital sign125/86 mmHg – 95 /min – 20 /min - 36.5 °C Ht : 154 cm Wt : 68 kg BMI : 28.7 General Alert consciousness Not-so-ill looking appearance HE/ENTCervical LN enlargement (-) goiter (+) ThoraxSymmetrical chest expansion Clear breathing sound without rale Regular heart beat without murmur AbdomenSoft and flat abdomen Normoactive bowel sound

6. Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Initial Lab Findings CBC/DC 4,980/mm² - 12.4 g/dl – 38.2% - 224K (Seg. 62.0%) Chemistry Prot/Alb8.0/4.4 g/dLBUN/Cr 18/0.7 mg/dL TB/DB0.81/0.48 mg/dL Na/K/Cl 140/4.3/104 mEq/L AST/ALT40/33 IU/LCa/P/Mg 9.2/4.4/1.9 mg/L ALP/γGT81/40 IU/L Glucose 145 mg/dL HbA1C 6.0% U/A Occult blood - Protein - Glucose - Ketone - RBC 2-4/HFPWBC 0-1/HPF

7. Towards Global Eminence K Y U N G H E E U N I V E R S I T Y 2012-062012-08 free T4 (0.77-1.94 ng/dl) 4.466.92 TSH (0.30-4.00 μU/mL) 0.120.01 TPO Ab (0-8 U/mL) 54 TBII (0-10 %) 0.1 Thyroid Function Test (NS 입원 기간 중 )

8. Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Thyroid sono (2012-08-06) Rt. thyroid 2.73 x 1.81 x 3.83 cm sized well defined mixed echoic nodule

9. Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Thyroid sono (2012-08-06) Lt. thyroid Thyroid, right, isthmus, left : Benign Consistent with a benign follicular nodule (includes adenomatoid nodule, colloid nodule, etc.)

10. Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Initial Problem List #1. Thyrotoxicosis d/t r/o Graves’ disease d/t r/o toxic nodular hyperthyroidism d/t r/o toxic adenoma #2. Brain epidermoid cyst s/p removal #3. Sphenoid sinus CSF leakage s/p endoscopic repair #4. HTN #5. Atrial fibrillation with RVR

11. Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Initial Assessment and Plan #1. Thyrotoxicosis d/t r/o Graves’ disease d/t r/o toxic nodular hyperthyroidism d/t r/o toxic adenoma  Diagnostic plan Thyroid function test f/u, thyroid scan  Therapeutic plan Methimazole 10 mg bid

12. Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Initial Assessment and Plan #2. Brain epidermoid cyst s/p removal #3. Sphenoid sinus CSF leakage s/p endoscopic repair  Therapeutic plan Observation #4. HTN #5. Atrial fibrillation with RVR  Therapeutic plan bevantolol 50mg qd

13. Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Thyroid Function Test 2012-062012-082012-112013-012013-032013-05 free T4 (0.77-1.94 ng/dl) 4.466.924.14.244.193.21 TSH (0.30-4.00 μU/mL) 0.120.012.154.3816.47>84.5 Methimazole 10 mg bid

14. Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Thyrotoxicosis evaluation category

15. Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Assessment and Plan #1. Elevation of fT4,TSH d/t r/o TSH-producing pituitary adenoma d/t r/o Thyroid hormone resistance syndrome  Diagnostic plan TRH stimulation test Sella MRI Free a-subunit α-GSU/TSH molar ratio

16. Towards Global Eminence K Y U N G H E E U N I V E R S I T Y -30 min0 min30 min60 min90 min120 min TSH (μU/mL) >84.5 TRH Stimulation Test (2013-07-09) Free a-subunit : 2.31 mIU/mL (normal range: < 0.9 mIU/mL) α-GSU/TSH molar ratio : 1.40

17. Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Sella MRI (2013-07-09)

18. Towards Global Eminence K Y U N G H E E U N I V E R S I T Y E2 6 pg/mL Progesterone 0.5 ng/mL Testosterone 0.23 ng/mL IGF-I 144 ng/mL Weight: 68 kg RI: 6 IU Pituitary Function Test -30 min0 min30 min60 min90 min120 min Glucose (mg/dL) 7537544567 GH (ng/mL) 0.71.2 2.312.47.3 ACTH (pg/mL) 64.138.851.890.186.565.3 Cortisol (µg/dL) 20.915.715.119.020.421.0 FSH (mIU/mL) 25.933.634.835.236.5 LH (mIU/mL) 14.316.536.924.523.9 PRL (ng/mL) 9.674.556.532.523.8 TSH (μU/mL) >84.5

19. Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Pre-operative diagnosis Impression TSH-producing pituitary adenoma Plan Total mass removal via Trans-sphenoidal approach

20. Towards Global Eminence K Y U N G H E E U N I V E R S I T Y

21. Towards Global Eminence K Y U N G H E E U N I V E R S I T Y ACTH(-) FSH(-) GH(-) PRL(-)

22. Towards Global Eminence K Y U N G H E E U N I V E R S I T Y 채취장기 ( 부위 ) : Pituitary gland Gross Description : Specimen received in formalin is clusters of brown tissue, measuring 0.5 x 0.5 x 0.3 cm in aggregating. Totally embedded in 1. Diagnosis : Brain, pituitary gland, excision: Adenoma Immunohistochemical finding (S-13-16049, 1): GH (-), FSH (-), LH (-), ACTH (-) Prolactin (-), TSH (+) Immunohistochemistry TSH(+)

23. Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Final Diagnosis #1. TSH-producing pituitary adenoma s/p total mass removal via TSA #2. Brain epidermoid cyst s/p removal #3. Sphenoid sinus CSF leakage s/p endoscopic repair #4. HTN #5. Atrial fibrillation with RVR

24. Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Thyroid Function Test 2012-112013-012013-032013-052013-072013-092013-102013-112014-1 free T4 (0.77-1.94 ng/dl) 4.14.244.193.212.081.832.211.941.73 TSH (0.30-4.00 μU/mL) 2.154.3816.47>84.5 50.6347.0359.8380.47 Methimazole 10mg bid 10mg qd TSH (uU/mL) FT4 (ng/dl) 10/5mg 5mg qd