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Subsequent bilateral inferior petrosal sinus sample (BIPSS) was performed for the localization diagnosis [Figure 1]d, which demonstrated adrenocorticotrophic hormone (ACTH) level of inferior petrosal sinus and femoral vein at 0 min were 691.4 ng/L and 162.9 ng/L, at 5 min were 952.2 ng/L and 172.3 ng/L, respectively; GH level of inferior petrosal sinus and femoral vein at 0 min were 6.34 ng/ml and 3.88 ng/ml, at 5 min were 3.7 ng/ml and 2.38 ng/ml, respectively.
Serum cortisol, adrenocorticotrophic hormone, free thyroxine (T4), thyroid stimulating hormone, testosterone, and prolactin levels were normal as well.
Cytokines increase levels of corticotropin-releasing hormone and adrenocorticotrophic hormone, leading to a higher-than-normal cortisol concentration in depressed patients.(8)
Pituitary hormone studies were compatible with a status of primary pituitary insufficiency: Adrenocorticotrophic Hormone (ACTH) 4.2.00 pg/mL (N 0-46); cortisol <1 [micro]g/100mL (N 10-25); after a Synacthen stimulation test, cortisol was 3 [micro]g/100mL; Thyroid Stimulating Hormone (TSH) 0.28 MU/mL (N 0.4-4); free triiodothyronine (FT3), 1.2 pg/mL (N 1.8-4.8); free thyroxine(FT4), 1.36 ng/dL (N 0.8-1.9); Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH), <0.1 mIU/mL (N 0.4-11 mIU/ml, 0.08-7 mIU/ml respectively); estradiol 8.5 pg/mL (N 40-100); prolactin (PRL), 3.8 ng/mL (N 3.5-30); GH 0.05 ng/mL (N0.1-10), Insulin-like growth Factor 1 (IgF1) 62ng/mL (N 120-450).
The reason for the increased pigmentation is thought to be due to increased melanocyte stimulation by melanocyte stimulating hormone and stimulation of melanocytes by adrenocorticotrophic hormone.8 In our patient the flagellate pigmentation started appearing after the second cycle.
Noga et al (10) report that in cases representing metastatic spread to hormonally functional pituitary adenomas, 60% secrete prolactin, 20% growth hormone, and 20% adrenocorticotrophic hormone. Our patient presented with visual field deficits and no evidence of a hormonally active tumor.
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