Multiple Fractures in Patient with Graves' Disease Accompanied by Isolated Hypogonadotropic Hypogonadism

Abstract

Isolated hypogonadotropic hypogonadism (IHH) is known to decrease bone mineral density due to deficiency of sex steroid hormone. Graves' disease is also an important cause of secondary osteoporosis. However, IHH does not preclude the development of primary hyperthyroidism caused by Graves' disease, leading to more severe osteoporosis rapidly. Here, we describe the first case of 35-year-old Asian female patient with IHH accompanied by Graves' disease and osteoporosis-induced multiple fractures. Endocrine laboratory findings revealed preserved anterior pituitary functions except for secretion of gonadotropins and showed primary hyperthyroidism with positive autoantibodies. Sella magnetic resonance imaging showed slightly small sized pituitary gland without mass lesion. Dual energy X-ray absorptiometry revealed severe osteoporosis in lumbar spine and femur neck of the patient. Plain film radiography of the pelvis and shoulder revealed a displaced and nondisplaced fracture, respectively. After surgical fixation with screws for the femoral fracture, the patient was treated with antithyroid medication, calcium, and vitamin D until now and has been recovering fairly well. We report a patient of IHH with Graves' disease and multiple fractures that is a first case in Korea.

Keywords: Graves disease; Hypogonadism; Osteoporosis.

Fig. 1. Image findings of the patient. (A) Mid-sagittal T2-weighted image showing thinning of the lower half of the pituitary stalk (arrow). (B) Technetium-99m pertechnetate scintigraphy for thyroid gland. Radioactive thyroid uptake was 8.9% (range, 1.7 to 4.0%). (C) Thyroid ultrasonography with color doppler method (upper panel, right thyroid; lower panel, left thyroid). (D) Antero-posterior X-ray of the pelvis demonstrating a fracture of the left femoral neck (arrow head). (E) Antero-posterior radiograph of the left shoulder showing nondisplaced fracture of proximal humerus (arrow head).