Key Clinical Message:In cases of pituitary lesions with elevated TSH, a comprehensive diagnostic approach that includes biochemical, clinical, and radiological assessment is essential. Not all pituitary masses are adenomas. Pituitary hyperplasia secondary to primary hypothyroidism can mimic adenomas, particularly prolactinomas, due to associated hyperprolactinemia. Thyroxine replacement therapy often reduces pituitary hyperplasia, making hormonal profiling essential to avoid unnecessary surgical interventions. Patient compliance with hormone therapy is also a key factor, as non-compliance can lead to persistent symptoms and impact outcomes. Early specialist involvement and a multidisciplinary approach are beneficial in these complex cases to ensure accurate diagnosis and timely intervention.Introduction :The pituitary gland, often called the ”master gland” of the body, regulates numerous essential functions by releasing various hormones. Structurally, the gland is divided into an anterior and a posterior lobe. The anterior lobe produces several vital hormones, including human growth hormone (HGH or GH), thyroid-stimulating hormone (TSH), adrenocorticotropic hormone (ACTH), follicle-stimulating hormone (FSH), luteinizing hormone (LH), and prolactin. The posterior lobe produces oxytocin and antidiuretic hormone (ADH). The hypothalamus controls all these hormones, which regulate their release through specific signaling chemicals.Pituitary adenomas, or benign tumors of the pituitary gland, can be classified by size—macroadenomas are more significant than 10 mm, while microadenomas are smaller. They are also categorized as either secreting or non-secreting, depending on whether they actively release hormones. The most common secreting adenoma is prolactinoma, which overproduces prolactin (1). Pituitary hyperplasia, on the other hand, involves the overgrowth of pituitary cells and may affect either specific hormone-producing cells or the entire gland. Both adenomas and hyperplasia can present as a pituitary mass on imaging, which can complicate diagnosis.In primary hypothyroidism, inadequate thyroid hormone production can result in elevated TSH levels and pituitary hyperplasia due to loss of negative feedback in the hypothalamic-pituitary-thyroid axis. Studies indicate that 25-81% of hypothyroid patients present with pituitary hyperplasia (2). Additionally, thyroid-stimulating hormone (TSH)-secreting adenomas, or TSHomas, are rare, accounting for only 0.5% to 3% of all pituitary tumors (3). These tumors are typically characterized by elevated levels of free thyroid hormones (FT4 and FT3) in the presence of non-suppressed TSH, often presenting clinically with symptoms of hyperthyroidism (4). Differentiating between TSHomas, thyroid hormone resistance, and other causes of elevated TSH can be challenging.This case series presents three patients with elevated TSH and pituitary lesions, each with a unique clinical outcome and treatment pathway. Although their initial symptoms were similar varying diagnoses led to distinct management strategies. This series highlights the diverse presentations of pituitary lesions with elevated TSH and underscores the importance of systematic evaluation to avoid misdiagnosis and unnecessary surgical interventions.

Introduction:Felty syndrome, also known as Chauffard-Still-Felty syndrome, was first described by Augustus Felty. It is a rare condition diagnosed in patients with longstanding seropositive rheumatoid arthritis (RA) characterized by an enlarged spleen and neutropenia (1). Neutropenia, defined as absolute neutrophil count <1500/mm, is Felty syndrome’s hallmark feature. In RA, the patient usually presents initially with arthritis, and the felty syndrome commonly develops after many years. However, in highly uncommon instances, felty syndrome can manifest before or without any signs of arthritis. Only a few case reports have been published highlighting this unusual presentation of the Felty syndrome (Table 2). We present a similar case of a young female who initially presented with felty syndrome without arthritis. This case report emphasizes the clinical and diagnostic approach to rule out alternate causes of neutropenia with splenomegaly and timely recognition of the atypical presentation of Felty syndrome.

Background: Multiple myeloma (MM) has different complications, including renal failure, anemia, infections, metabolic complications, and skeletal problems. Hypercalcemia is the most common metabolic complication, and the presence of hypercalcemia indicates worse outcomes. Aims: The study aims to examine outcomes such as hospitalization costs, length of stay, survival rates, and the incidence of complications of hypercalcemia in multiple myeloma patients admitted in the United States from 2017 to 2020. Methods: We performed a retrospective analysis using the National Inpatient Sample database to determine the incidence of hypercalcemia in patients admitted to United States hospitals from 2017 to 2020. Univariate and multivariate logistic regression were used to calculate the odds ratio. We used STATA software 17 to perform the analysis. Results: We found that the total number of patients with MM was 437799, out of which 8.6% had hypercalcemia. The mean age of the patients was 69 years, and hypercalcemia was found to be more common in males (55%) than females (45%). The presence of hypercalcemia was also associated with increased mortality (adjusted odds ratio 1.3, p-value 0.00). It was also seen that MM patients who had hypercalcemia had a higher risk of complications, including acute kidney injury (OR 3, p<0.05), hyperkalemia (OR 1.8, p-value <0.05), metabolic acidosis (1.4, p-value <0.05), spinal cord compression (OR 0.9, p-value >0.05), increased length of stay (OR 3, p-value <0.05), and higher cost of hospitalizations (p-value <0.05). Conclusion: The data is also limited to the demographic characteristics, impact, and outcomes of hypercalcemia on patients with MM. This study contributes valuable insights into the clinical implications of hypercalcemia in patients with multiple myeloma (MM). It fills existing gaps in the literature by utilizing a large population-based dataset.