Pituitary case example 1

A previously healthy 50-year-old male presents to your office with several new complaints. About three months earlier he had been given the diagnosis of Raynaud's phenomenon due to cold intolerance particularly affecting his hands. Over the past month, he has been fatigued and has generalized cramping and achiness. On further questioning, he also thinks he has lost some hair on his hands, has been having difficulty concentrating and has had some loss of libido. He has no constipation, abdominal discomfort, orthostasis, headaches or visual problems. He has been told that many of his symptoms are consistent with depression possibly related to the stress of being diagnosed with Raynaud's phenomenon as well as problems at work. His physical exam is unremarkable (weight is 100 kg). His CBC, metabolic panel, and sedimentation rate are all normal but his free T4 is low at 0.48 (nl 0.8 - 1.8) with a normal TSH of 1.58 (nl 0.38 - 4.70).

What Would Your Next Step Be?

  Assure the patient that the normal TSH confirms his thyroid function is adequate and that some normal people have lower than "normal" free T4 levels due to population variance.

  Start the patient on thyroid hormone replacement and refer him for the next available endocrinology appointment for evaluation of possible central hypothyroidism.

  Start the patient on thyroid hormone replacement (175 mcg qd based on his weight) and hydrocortisone (20 mg q a.m.). You repeat the TSH and free T4 and order the other labs as described in The Basic Pituitary Disease/Pituitary Tumor Work-up including a head MRI (with and without gadolinium). Refer the patient to a neuroendocrinologist to set up further endocrine testing and management.