complaints of poor linear...

A 13-year-old girl visited her primary care physician with complaints of poor linear growth and delayed puberty. She had no linear growth for six years of age. In addition, she complained of cold intolerance, dry skin and was easily fatigued with physical activity. Upon examination, she had no breast development or galactorrhoea. Her karyotype was normal. A brain MRI scan indicated a possibility of pituitary macroadenoma as shown in the figure.

The patient was then reported to have elevated TSH with an undetectable free T4 level, suggesting hypothyroidism. Insulin-like growth factor 1 levels were low for her age, consistent with the phenomenon of decreased growth hormone secretion. Multiple biochemical abnormalities were also present.