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Hypothyroidism masquerading as ovarian malignancy

A 9 years and 1-month-old girl was referred to us for evaluation of precocious puberty because of suspected ovarian malignancy. She had presented with progressive enlargement of bilateral breasts and per vaginal bleeding for last three months along with evidence of large cystic ovaries and raised cancer antigen 125 (CA-125) level of 54 IU/mL (normal <35 IU/mL). There was no family history of thyroid disorders or precocious puberty. Clinical evaluation showed short stature (height-117 cm, < 5th percentile), normal weight (26 kg, 75th percentile), Tanner stage 3 breast development without axillary or pubic hair growth. She had pallor and mild facial puffiness, but no goitre. Radiological evaluation showed a bone age of 6 years. Ultrasonography showed presence of a pubertal uterus and large multicystic ovaries (Fig. 1a,b). Biochemical evaluation showed pre pubertal luteinizing hormone (LH) level (0.12 mIU/mL, normal: 0.02–0.6 mIU/mL) elevated follicle-stimulating hormone (FSH) level (7.31 mIU/mL, normal: 0.5–4.5 mIU/mL) and elevated prolactin level (43.37 ng/mL: normal 5–25 ng/ mL). Thyroid function tests showed a low serum free triiodothyronine (FT3) of 1.04 pg/mL (normal range: 2.02–4.43 pg/ mL), low serum free thyroxine (FT4) of 0.45 ng/dL (normal range: 0.93–1.71 ng/dL), coupled with high thyroid-stimulating hormone (TSH) level of >500 mIU/mL (normal: 0.35–5.5 mIU/ mL). Anti-thyroid peroxidise antibody (305.2 IU/mL, normal 0–35 IU/mL) was positive. The presence of enlarged cystic ovaries with sexual precocity and raised tumour marker level points to the possibility of oestrogen secreting ovarian tumour. However presence of gross hypothyroidism, a delayed bone age, FSH predominant response and absence of pubic and axillary hair pointed towards