Melissa Carabrese, Kira Piccone, Sophia Wang, Erika Sakkestad

Group 4

(Melissa Carabrese, Kira Piccone, Sophia Wang, Erika Sakkestad)

Anatomy & Physiology II

Professor Kollmeier

27 February 2014

Mary’s Aching Head – Final Report

Mary Keeper is a 41-year-old, female patient who has been complaining of re-occurring headaches for the past month and trouble sleeping has been a recent outcome. She has seen her physician, Dr. Nee, for a total of three times ever since her symptoms had started surfacing. During the first visit, Dr. Nee performed a physical examination and ordered Mary to have a blood chemistry, thyroid, and endocrine test prior to her next follow-up visit in order to review the blood lab results. The week after, Mary returned to the doctor’s office to discuss her results in hopes to gain more insight on her symptoms. Throughout Mary’s results, there are concerns with her T3 and T4 values, indicating that Mary may be suffering from an endocrine dysfunction. Additional blood work was done to help with a final diagnosis. In terms of Mary’s diagnosis, she has a benign, anterior pituitary adenoma which has lead to Grave’s disease linked with hyperthyroidism.

During the initial physical examination, issues specifically arose in the head and neck area. Mary shows symptoms of lid lag where the upper eye lid is delayed when instructed to look downward. This is an example of an ophthalmic manifestation called hypermetabolic which is linked to hyperthyroidism from Grave’s Disease in this instance. Excess thyroid hormone causes the upper eyelids to retract (Trobe 2009). A study was done with 120 patients with thyroid disease and 43% had lid lag. In addition to lid lag, she experiences bitemporal hemianopsia which is a very common result from pituitary tumors. Mary portrays blindness in her lateral visual fields. An expanding mass on the pituitary is strong evidence for her re-occurring headaches in which they tend to be worse when first awakened (Willacy and Tidy 2010). Dilation of the left pupil is also noticeable. If the nerves around the tumor on the pituitary are affected, it is an explanation for the pupil enlargement. In addition to that, the oculomotor (III) nerve can be affected by a tumor and cause her lateral deviation of the left eye (Thomas 2012).

Mary’s blood chemistry results showed that her calcium as well as her parathyroid hormone values were above the normal limits meaning that she is a strong candidate for primary hyperparathyroidism. A benign tumor on her parathyroid gland can explain the above normal results (Collip 1924). The increased calcium level was the only test that brought concern in the areas of cholesterol, osmolality and urea nitrogen. When focusing on osmolality, it measures the concentration of all chemical particles found in the plasma of blood. Mary’s levels came back within range at 280 mOsm/kg/water. Osmolality evaluates water balance within the body and concentration amongst urine and stool. If levels get too high, the body releases an antidiuretic hormone and sends a message to the kidneys to reabsorb water, allow the blood to become more diluted and return to normal (Dugdale 2010).

Dr. John Krusz, an expert in the fields of headache and pain management, was interviewed by Teri Robert and suggested that patients with headache or migraine issues should have blood work to check thyroid, cortisol, and other endocrine levels. He also recommends that free T3 and T4 should be checked since the TSH test might not reveal all problems (Robert 2006). From that information, it is reassuring to see that Mary’s tests covered those areas. Her blood thyroid results said that her T3-total, T4-free, and T4-total values were all above normal limits. Since Mary’s T3 values were above normal limits, there are multiple thyroid issues that Mary may have. These thyroid issues include: Graves’ Disease, hyperthyroidism, and toxic nodular goiter. Hyperthyroidism is when the thyroid gland produces excess hormone because it is overactive. Grave’s Disease is the most common cause of hyperthyroidism. This disease is when the body’s immune system creates antibodies that attach to the thyroid gland, which then causes the thyroid to make excess of that hormone. Symptoms of hyperthyroidism include hand tremors, sleeping problems, losing weight, fatigue, eye problems, and thyroid gland swelling (Topiwala 2014). Toxic nodular goiter is when lumps develop in the thyroid gland, which contain abnormal thyroid tissue causing excess hormone to be made (Kenny and Knott). T4-free is the thyroxine that is unbound to protein and free to circulate in blood. When elevated, some indications include hyperthyroidism, thyroiditis (an inflammation of the thyroid gland), toxic nodular goiter, and high levels of protein (Holm). Usually, a T4 test is ordered to check thyroid function, specifically the effects of TSH and T3. They are also ordered if a doctor sees signs of thyroid disorder, including hyperthyroidism, thyrotoxic periodic paralysis, and thyroid nodules. T4-total measures the unbound and bound T4. High levels of T4-total is seen in patients who are on estrogen medication as well as during pregnancy (Topiwala 2014). Because medications, pregnancy, and high levels of iodine affect levels of T4-total, it is important that results from other tests are looked at. Her TBG value is also above normal limits and her TSH was undetectable. High levels of TBG could be caused by high levels of T3 and T4 because TBG is a carrier protein that binds T3 and T4 together in the bloodstream. High levels of TBG indicate a possible overactive thyroid gland (Ticchio 2008). Undetectable levels of TSH could also result in hyperthyroidism (Spencer et al 1987). Studies show that patients who suffer from hyperthyroidism also suffer from chronic headaches (Iwasaki 1991).

Lastly, Mary’s blood endocrine results shows that her ACTH value is below the normal limits, her Beta-hCG value is normal for a non-pregnant woman, and her Prolactin value is within normal limits. Because her ACTH value is below normal limits, it is likely that the pituitary is not producing enough of this hormone and a tumor is present. The tumor can affect the pituitary gland and its ability to produce hormones. These hormones then affect how other glands function and since there is a deficiency in ACTH there may be adrenal insufficiencies. After reviewing Mary’s blood results, Dr. Nee ordered hematology tests and arranged a follow-up appointment for Mary the following week. In receiving the hematology results, the blood lab results indicated that Mary’s PTH, LH, estrogen, and FSH values are all above the normal limits, but her GH value is below the normal limits.

After thorough research of Mary’s final blood result levels, she seems to be experiencing a pituitary tumor which is triggering her hyperthyroidism. Specifically, we can diagnose her hyperthyroidism as primary hyperthyroidism especially since Grave’s disease is the most common form. A pituitary tumor causes your body to produce a very low level of hormone or too much hormone in Mary’s case. Some symptoms include unexplained weight loss, visual field loss, weakness and headaches (Mayo 2012). These specific symptoms leading to a pituitary tumor are the primary symptoms Mary has been experiencing the past few weeks. However, to get a valid confirmation of the diagnosis, Mary will have to take cortisol level tests. Cortisol tests may reveal problems with the adrenal or pituitary gland. If the pituitary gland secretes ACTH, cortisol levels will increase in response to ACTH being secreted. Most of the endocrine tests already evaluated reveal information that bring us close to a concrete diagnosis. Since Mary is experiencing a pituitary tumor that is setting off her hyperthyroidism then she can undergo radiation therapy to help shrink the tumor (Eckman). Other standard treatments are chemotherapy, surgery, or drug therapy. These treatment options depend on the type and size of the tumor among many other factors. One of the factors is whether the tumor is causing vision problems, in which it is, and another is if the tumor is spreading into the brain or spinal cord. Further tests are done to rule out if the tumor is, or is not, spreading into the central nervous system and that is done with an MRI (magnetic resonance imaging). From the MRI, the size of the pituitary can be established in which many are microadenomas; smaller than a centimeter (Pituitary Tumor Treament, 2014). Treatments for hyperthyroidism include radiation iodine and antithyroid medicine. Antithyroid medication prevents the synthesis of thyroid hormone while the radiation iodine destroys the thyroid production of cells (Krucik 2012).

Overall, Mary Keeper’s test results and symptoms led us to conclude that she is suffering from more than one dysfunction. Her diagnosis incorporates a benign, anterior pituitary adenoma which is a major source to the headaches that initially brought her to see Dr. Nee. After further evaluation, Mary has Grave’s disease linked with hyperthyroidism. Through treatments such as radiation iodine and antithyroid medication for hyperthyroidism and radiation, chemotherapy or surgery for the pituitary tumor, we expect Mary will be feeling better in time.

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