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A 90 year old woman was admitted to the emergency department with delirium and falls. She had a recent history of cognitive impairment, insomnia, drowsiness, and progressive disability. Three months before admission, in the course of a medical check-up, an isolated increased plasma thyroid stimulating hormone (TSH 8 mIU/l, normal values 0.5–2.9) was discovered, leading to a levothyroxine therapy (50 μg daily). This patient was previously alert and able to live almost independently. Physical examination was unremarkable, except for fidgeting and restlessness. Other biochemical investigations were normal. A cranial tomographic study was obtained and revealed no intracranial haematoma but unexpectedly showed a pituitary macroadenoma, subsequently confirmed by magnetic resonance imaging (fig1).