Objective: We present a case of a 45-year-old woman with history of Graves disease treated with thyroidectomy who developed panhypopituitarism due to granulomatous hypophysitis.Methods: The details of the case presentation, evaluation, diagnosis, and treatment are reviewed. On routine follow-up visits for thyroid condition, the patient complained of symptoms of hyperthyroidism, despite being on a previously adequate dose of levothyroxine. Work-up led to the diagnosis of hypophysitis.Results: The patient responded to corticosteroid therapy, but 5 months later, magnetic resonance imaging of the brain showed recurrence of the disease. Eventually, the patient underwent partial transsphenoidal hypophysectomy, later developed recurrence of disease, and had total hypophysectomy. The postoperative pathology report was consistent of granulomatous hypophysitis.Conclusion: Granulomatous hypophysitis is an uncommon inflammatory disease affecting the pituitary. It is commonly misdiagnosed as a macroadenoma because of its clinical presentation. (AACE Clinical Case Rep. 2018;4:e329-e333) Abbreviations: FT4 = free thyroxine; GH = granulomatous hypophysitis; LH = lymphocytic hypophysitis; MRI = magnetic resonance imaging; TSH = thyroid-stimulating hormone CASE REPORTHypophysitis is a rare inflammatory process of the pituitary gland that mimics pituitary macroadenomas. It can be idiopathic or manifest as a part of a systemic autoimmune disease. Granulomatous hypophysitis (GH) and lymphocytic hypophysitis (LH) are the most common subtypes reported in literature (1-3). We present a case of a 45-year-old female with past medical history of hypothyroidism after total thyroidectomy for Graves disease and surgical history of hysterectomy. On presentation, she complained of hyperthyroid symptoms (e.g., fatigue, excess sweating, hot flashes, presyncope, weight loss, and headaches), despite being on a previously adequate levothyroxine dose. Two months prior, her thyroid-stimulating hormone (TSH) and free thyroxine (FT4) were normal. Her physical exam was unremarkable except for a surgically absent thyroid. Laboratory evaluation revealed TSH <0.006 mU/L (normal range, 0.34 to 5.6 mU/L) and FT4 of 1.1 ng/dL (normal range, 0.58 to 1.64 ng/dL); thus, her levothyroxine dose was decreased. Despite this, she continued to have symptoms and low TSH. Secondary hypothyroidism was suspected, as TSH was undetectable and FT4 0.47 ng/dL off levothyroxine. Severe headache, insomnia, and worsening fatigue developed, so imaging was done and magnetic resonance imaging (MRI) revealed a large bilobed enhancing pituitary mass with suprasellar extension and thickening of the pituitary stalk (Fig. 1). Laboratory results showed low am cortisol, estrogen, follicle-stimulating hormone (FSH), insulin-like growth factor See accompanying article, p. e350.
This study addresses teachers’ activity when working with digital technologies (DT) in their classrooms. We build upon a model that considers teaching as managing open dynamic situations . Within the model, teachers’ activity is viewed as diagnosing students’ mathematical activity, managing uncertainties due to the characteristics of the situation and decision-making about didactic interventions. The study extends our earlier work and focuses on teachers’ interventions in DT-based lessons, as they manage disturbances caused by unexpected difficulties. Our first observation is that there is a substantial change in how teachers diagnose these difficulties compared to paper-and-pencil environments. Notably, they need to make more inferences about the pedagogical support that is provided. Second, we show that in such conditions, rather than facing the single dynamicity of the class as a whole, the teacher has to deal with multiple, open dynamic situations (small groups named mini-classes), which are themselves intertwined in the dynamics of students’ interactions with technology. Moreover, even if teachers are able to make reliable inferences concerning an individual student’s current difficulties, they must also be able to make inferences about the scope of such difficulties within the class as a whole. We present four case studies that illustrate the diverse approaches that teachers take when managing such open dynamic situations and use them to illustrate the concepts and analytical tools that are introduced.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
customersupport@researchsolutions.com
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.