Central hypothyroidism in a patient with pituitary autoimmunity: Evidence for TSH-independent thyroid hormone synthesis

Context: Acquired central hypothyroidism is rare, especially when isolated, and is typically associated with detectable, although biologically inactive, serum TSH. Objective: We describe a 56-yr-old woman with profound central hypothyroidism and partial central hypoadrenalism, in the absence of other endocrine abnormalities. In contrast to most cases of central hypothyroidism, serum TSH remained undetectable for 9 months before the initiation of thyroid hormone and hydrocortisone treatment. A test for pituitary autoantibody was moderately positive. Serum free T₄, serum T₃, and neck radioiodine uptake were low but detectable. The thyroid and pituitary glands appeared morphologically normal on neck ultrasound and head magnetic resonance imaging, respectively. Settings: The study was conducted in a tertiary academic medical center. Conclusions: This case illustrates the variable clinical presentation of pituitary autoimmunity. The persistence of low but detectable thyroid hormone levels and radioiodine neck uptake in the absence of TSH suggests that significant TSH-independent thyroid hormone synthesis may occur in the normal thyroid.