Category: Pituitary Disorders/Neuroendocrinology
Plurihormonal Pituitary adenoma is defined as an adenoma that expresses more than one hormone on immunohistochemistry. The most common combination in these adenomas includes growth hormone (GH) and prolactin (PRL).
We describe an interesting case of plurihormonal pituitary adenoma with triple hormonal staining for ACTH, GH and prolactin in a patient who presented with Cushing disease due to a large pituitary macroadenoma.
A 65-year-old woman known to have known to have type 2 diabetes, hypertension, and class-III obesity, presented with intractable headache and blurring vision. She also had significant worsening of her diabetes control recently despite being on insulin. CT brain and later Magnetic resonance imaging (MRI) pituitary showed a large sellar mass which measured 2.9 cm x 1.5 cm, compressing the neurophysis and the optic chiasm. Her initial investigations showed elevated corticotrophin (ACTH) level 33.6 pmol/L (1.03 - 10.7), prolactin level was high at 66.3 ng/ml (5.18 - 26.53ng/ml) and the rest of anterior pituitary hormones and IGF-1 were normal apart from primary hypothyroidism. She didn’t particularly look cushingoid, apart from rounded face and central obesity. Cushing’s disease was confirmed on failure of cortisol to suppress to 1mg dexamethasone (serum cortisol 783 nmol/L) and high 24-hour urinary free Cortisol at 391 ug/24 (6-123. She underwent transsphenoidal surgery (TSS) for decompression of the optic chiasm which was successful to normalize the visual fields, however, a residual tumor was still present on follow up MRI after 3 months. Interestingly, immunohistochemistry showed staining for ACTH, GH and prolactin, Ki67 was less than 2%. Follow up evaluation showed normal response to 1 mg suppression test and normal 24-hour urinary free cortisol.
Discussion : Plurihormonal adenomas of the pituitary, represent approximately 10% to 15% of all adenomas, Here we report here a rare case Plurihormonal with of a very unusual immunoreactivity for GH, ACTH, PRL.This triple immunostaining combination is very rare and only reported in the literature in 6 cases . In contrast to the other cases our patient was diagnosed in post-menopausal woman who suffered chronic subtle clinical for hypercortisolism. Also, she never experienced any hormonal symptoms of acromegaly or hyperprolactinemia
Conclusion : We present a very interesting case of plurihormonal pituitary adenoma with triple immunohistochemical stating for ACTH, GH and Prolactin, which is a very rare entitiy but deserve attention.
KING FAHAD MEDICAL CITY
Riyadh, Ar Riyad, Saudi Arabia
Currently second-year endocrinology fellow. Started Saudi adult endocrinology in March 2017
-Arab board in internal medicine 2015
-Finished Saudi board in internal medicine 2009
-Graduated from Umm Al-Qura University Faculty of medicine MBBS 2004
King Fahad Medical City, Ar Riyad, Saudi Arabia
• Director, Endocrinology Fellowship Training Program, King Fahad Medical City, Riyadh, Saudi Arabia. Jan 2015 to present.
• Endocrinology /Pituitary disorder Consultant at King Fahad Medical City, Riyadh, Saudi Arabia. April 2012 to present.
• Assistant Professor of Medicine at King Saud bin Abdul-Aziz University for health science. April 2012 to present.