Effects of chronic alcoholic disease on magnocellular and parvocellular hypothalamic neurons in men

Although numerous data showing severe morphological impairment of magnocellular and parvocellular hypothalamic neurons due to chronic alcoholic consumption have been gathered from animal experiments, only one study (Harding et al., 1996) was performed on POST MORTEM human brain. This study showed a reduction in the number of vasopressin (VP)-immunoreactive neurons in the supraoptic (SON) and paraventricular (PVN) nuclei, but did not provide any data regarding the effect of chronic alcohol intake on human parvocellular neurons. In order to assess whether the changes observed in the animal model also occur in humans and provide a structural basis for the results of clinical tests, we performed immunohistochemical and morphometric analysis of magnocellular (VP and oxytocin, OT) and parvocellular (corticotropin-releasing hormone, CRH) neurons in post-mortem brains of patients afflicted with chronic alcoholic disease. We analyzed 26-male alcoholics and 22 age-matched controls divided into two age groups--"young" (< 40 yr) and "old" (> 40 yr). Hypothalamic sections were stained for OT, VP, and CRH. The analysis revealed: 1) decrease in VP-immunoreactivity in the SON and PVN as well as OT-immunoreactivity in the SON in alcoholic patients; 2) increase in OT-immunoreactivity in the PVN; 3) increase in CRH-immunoreactivity in parvocellular neurons in the PVN. Furthermore, the proportion of cells containing CRH and VP was increased in alcoholics. These findings indicate that chronic alcohol consumption does indeed impair the morphology of magnocellular neurons. The enhancement of CRH-immunoreactivity and increased co-production of CRH and VP in parvocellular neurons may be due to a decline in glucocorticoid production, implied by the hypoplasic impairment of adrenal cortex we observed in alcoholics during the course of this study.

Isolated Langerhans cell histiocytosis of the infundibulum presenting with fulminant diabetes insipidus

INTRODUCTION

Langerhans cell histiocytosis (histiocytosis X) is a rare disorder that can manifest with solitary bony lesions or disseminated disease in various tissues. A common manifestation of the disease is diabetes insipidus even in the absence of neural involvement. Disseminated disease often involves the central nervous system, but only six isolated lesions in the infundibulum have been reported.

CASE REPORT

An 18-year-old male had failed to develop secondary sexual characteristics. He also had diabetes insipidus for more than 1 year. Magnetic resonance imaging (MRI) of the brain showed a 1-cm homogeneously enhancing mass in the region of the infundibulum. No other lesions were found in other organ systems. The patient underwent an orbitozygomatic osteotomy and pterional craniotomy. The lesion, which was adherent to the infundibulum, was partially resected. Microscopic analysis showed multiple lymphocytes and eosinophils with Langerhans cells that stained positive for S-100. Langerhans cell histiocytosis was diagnosed, and the patient was discharged on postoperative day 6 with no neurological deficits. His diabetes insipidus persisted, and he underwent intensity-modulated radiation therapy to the sellar region.

CONCLUSIONS

Isolated Langerhans cell histiocytosis of the infundibulum is rare. The usual presentation is hypothalamic-pituitary axis dysfunction and diabetes insipidus. Patients with diabetes insipidus of unknown origin should undergo MRI of the sellar region to rule out infundibular abnormalities.

Central diabetes insipidus in a patient with malaria tropica

Up to 21% of severe cases of malaria tropica are associated with polyuria and are life-threatening. We describe a 39-yr-old man with malaria tropica who developed disseminated intravascular coagulation, polyuria, and a pituitary lesion. Empiric treatment with vasopressin improved the polyuria. This is the first case of malaria tropica in which central diabetes insipidus has been documented.

Intracranial retrograde dissemination in filum terminale myxopapillary ependymomas

Myxopapillary ependymomas (ME) are considered benign tumours (WHO grade I) of the central nervous system with long term survival rates and a tendency to local recurrence. However an aggressive course has occasionally been described, leading to CSF dissemination and even systemic metastases. We describe the case of a 23-year-old man diagnosed with intracranial subarachnoid dissemination of a filum terminale ME three years after the initial diagnosis. We have performed a careful review of the literature on CSF dissemination in ME and finally propose treatment of these cases.

Untreated hypopituitarism due to absence of the pituitary stalk with normal adult height: report of two cases

Patients with congenital multiple pituitary hormones deficiency (MPHD) occasionally present with pituitary stalk interruption and ectopic posterior lobe on magnetic resonance imaging (MRI). Very rarely normal adult height despite growth hormone deficiency (GHD) has been described in these patients. We report two patients with evidence of congenital MPHD, who remained untreated until adulthood. They both failed to develop spontaneous puberty, and they demonstrated very low growth velocity until adulthood when they continued to grow, with a final height of 176 and 169 cm when they sought medical attention in our department at the age of 45 and 33 yr, respectively. At that time a hypoplastic pituitary, absence of pituitary stalk, and ectopic posterior pituitary lobe were found on MRI, and the laboratory investigations, including dynamic tests for pituitary hormone reserve, revealed MPHD with severe GHD. In conclusion, these cases illustrate that very rarely patients with untreated MPHD can reach normal adult height. Some postulations about the pathophysiology of this phenomenon are discussed.

A comprehensive description of the transcriptome of the hypothalamoneurohypophyseal system in euhydrated and dehydrated rats

The hypothalamoneurohypophyseal system (HNS) consists of the large peptidergic magnocellular neurons of the supraoptic hypo thalamic nucleus (SON) and the paraventricular hypothalamic nucleus (PVN), the axons of which course through the internal zone of the median eminence and terminate at blood capillaries of the posterior lobe of the pituitary gland. The HNS is a specialized brain neurosecretory apparatus responsible for the production of the antidiuretic peptide hormone vasopressin (VP). VP maintains water balance by promoting water conservation at the level of the kidney. Dehydration evokes a massive increase in the regulated release of VP from magnocellular neuron axon terminals in the posterior pituitary, which is accompanied by a plethora of changes in the morphology, electrophysiological properties, and biosynthetic and secretory activity of the HNS. We wish to understand this functional plasticity in terms of the differential expression of genes. We have therefore used microarrays to comprehensively catalog the genes expressed in the PVN, the SON and the neurointermediate lobe of the pituitary gland of control and dehydrated rats. Comparison of these gene lists has enabled us to identify transcripts that are regulated as a consequence of dehydration as well as RNAs that are enriched in the PVN or the SON. We suggest that these differentially expressed genes represent candidate regulators and effectors of HNS activity and remodeling.

Crush cytology of pituicytoma

The crush cytology of a pituicytoma is reported. The lesion was resected from a 54-yr-old man with a 7-mo history of headache. The intraoperative crush smears revealed plump spindle cells with elongated, nonwavy nuclei, and moderate, finely granular cytoplasm with distinct cytoplasmic borders. These cells were arranged in cohesive fascicles exhibiting a storiform pattern focally. Cytologically, this lesion can be differentiated from pituitary adenoma, astrocytoma, meningioma, and schwannoma.

Pituicytoma incidentally found at autopsy

Pituicytoma is a rare benign neoplasm, occurring in the sellar and suprasellar regions. Reported herein is a case of asymptomatic pituicytoma, discovered at autopsy, in a 54-year-old Japanese woman. This is the first case report of pituicytoma, found incidentally at autopsy (incidentaloma), in which whole-mounted sections are available for histological and immunohistochemical studies. Grossly, the bisected pituitary gland revealed a round, white to light tan, 7 mm-diameter nodule. Microscopically, whole-mounted sections revealed a well-circumscribed nodule with no fibrous capsule, located mainly in the neurohypophysis and partially compressing the adenohypophysis. The tumor was composed primarily of bipolar, occasionally unipolar, cells with syncytial fibrillary cytoplasm, arranged in short curvilinear fascicles and/or storiform patterns. Unusual histological features were seen, which included a few groups of large pleomorphic tumor cells with abundant, glassy, eosinophilic cytoplasm, occasionally associated with multinucleated giant tumor cells, and scattered Herring bodies within the tumor. Immunohistochemically, the tumor showed diffuse strong expression of glial fibrillary acidic protein, S-100 protein, and vimentin. Epithelial membrane antigen immunoreactivity was focally observed, mainly in the large tumor cells. Distinction from other intrasellar tumors (granular cell tumor and pilocytic astrocytoma) is important. Because the immunohistochemical profiles of these tumors are similar, histological findings are crucial for distinction.

Symptomatic metastases to the pituitary infundibulum resulting from primary breast cancer

Metastatic spread into the brain is not infrequently seen in association with epithelial neoplasms such as lung and breast cancer, among others. In the majority of cases such spread entails a poor prognosis. Metastasic spread to the pituitary gland, specifically to the area of the infundibulum is, however, a more rare presentation. Most reported cases of metastatic disease to the pituitary are confined to the posterior lobe, probably related to the richer blood supply as compared to the anterior counterpart. The detection of pituitary metastasis is further complicated by the lack of specific associated symptomatology or definite radiologic diagnostic findings. We here describe the different clinical presentations of two patients with symptomatic pituitary stalk metastasis resulting from primary breast cancer; we also provide a systematic review of the literature.

Posterior pituitary astrocytoma: a rare tumor of the neurohypophysis: a case report

Astrocytoma, or pituicytoma, of the posterior pituitary is a relatively rare entity consisting of poorly characterized glial tumor cells. We report two cases of posterior pituitary astrocytomas in middle-aged women presenting as focal lesions of the neurohypophysis. A review of the literature reveals only a few reports of this tumor, and there has been scanty discussion of the imaging findings of posterior pituitary astrocytomas compared with lesions of the anterior pituitary gland. This report reviews the clinical characteristics and imaging findings and discusses the differential diagnosis of these two cases.

Novel mutations within the POU1F1 gene associated with variable combined pituitary hormone deficiency

CONTEXT

Mutations within the gene encoding the pituitary-specific transcription factor POU1F1 are associated with combined pituitary hormone deficiency (CPHD). Most of the affected individuals manifest GH, prolactin, and TSH deficiency.

OBJECTIVE

We have now screened 129 individuals with CPHD and isolated GH deficiency for mutations within POU1F1.

RESULTS

Causative mutations were identified in 10 of 129 individuals (7.8%). Of these, five patients harbored the dominant negative R271W mutation, which is a well-recognized mutational hot spot. We have also identified a second frequently occurring mutation, E230K, which appears to be common in Maltese patients. Additionally, we describe two novel mutations within POU1F1, an insertion of a single base pair (ins778A) and a missense mutation (R172Q). Functional studies have revealed that POU1F1 (E230K) is associated with a reduction in transactivation, although DNA-binding affinity is similar to the wild-type protein. On the other hand, POU1F1 (R172Q) is associated with a reduction in DNA binding and transactivation, whereas POU1F1 (ins778A) is associated with loss of DNA binding and a reduction in transactivation.

CONCLUSIONS

Our data suggest that the phenotype associated with POU1F1 mutations may be more variable, with the occasional preservation of TSH secretion. Additionally, our data revealed POU1F1 mutations in three patients who were diagnosed as having ACTH deficiency but who, on further evaluation, were found to have normal cortisol secretion. Hence, elucidation of the genotype led to further evaluation of the phenotype, with the cessation of cortisol replacement that had been commenced unnecessarily. These data reflect the importance of mutational analysis in patients with CPHD.

Ectopic posterior pituitary high signal in preoperative and postoperative macroadenomas: dynamic MR imaging

BACKGROUND AND PURPOSE

In patients with macroadenoma, posterior pituitary high signal (PPHS) on T1-weighted magnetic resonance (MR) imaging is sometimes observed in an ectopic location. The present study compared incidences of ectopic PPHS before and after macroadenoma surgery using MR imaging, including dynamic MR imaging to ascertain whether this ectopic change is irreversible.

MATERIALS AND METHODS

MR imaging was performed preoperatively in 111 cases of macroadenoma, and then repeated more than 1-year postoperatively in 47 patients. Enhancement of PPHS was assessed using dynamic MR imaging. Areas of enhanced hyperintensity were considered true PPHS, and the relationship between presence and location of true PPHS and adenoma volume was analyzed. Moreover, changes in the presence and location of true PPHS were ascertained among the patients who underwent postoperative follow-up MR imaging.

RESULTS

Preoperatively, PPHS was seen only in the normal location in 29 patients (Group A: 26.1%). High signal was detected only in an ectopic location in 58 patients, and early enhancement of this ectopic high signal was confirmed by dynamic MR imaging in 56 patients (Group B: 50.5%). No PPHS was observed in 24 patients (Group C: 21.6%). Adenoma volume was significantly greater for Group B than for Group A (p<0.001). Among the Group B patients who underwent MR imaging postoperatively (n=31), the location of PPHS was not changed, except for two patients in whom PPHS was absent. Postoperatively, PPHS was not observed in the normal location in any patient in the Group B.

CONCLUSIONS

Greater volume of adenoma is associated with a higher incidence of ectopic PPHS, and the ectopic change is irreversible.

Diabetes insipidus presentation before renal and pulmonary features in a patient with Wegener’s granulomatosis

We report a case of a 47-year-old woman with Wegener's granulomatosis complicated by central diabetes insipidus. The patient had initially seronegative polyarthritis which mostly responded well to methotrexate and steroid therapy. Eight months later the patient suffered from polyuria and polydipsia. There were no abnormalities of the anterior pituitary hormones. MR images showed only loss of brightness of the posterior pituitary. Extensive evaluation of the patient revealed the presence of ANCA, in c-ANCA pattern and also PR3 positivity. Three months later findings of glomerulonephritis, as suggested by an active urine sediment and gradual proteinuria, and, finally, asymptomatic pulmonary nodules completed the clinical picture of Wegener's disease within 1 year. Renal biopsy showed crescent formation in two glomeruli, consistent with ANCA-related glomerulonephritis which showed pauci-immün depositions by direct immunofluorescence. Diabetes insipidus symptoms mostly regressed; renal and pulmonary findings completely disappeared with glucocorticoid and pulse cyclophosphamide treatment. These findings show that diabetes insipidus may rarely develop early in the disease process and ANCA positivity was directly indicative of Wegener's granulomatosis before the classic clinical signs of the disease.

Delayed lymphocytic infundibuloneurohypophysitis following successful transsphenoidal treatment of Cushing’s disease

Lymphocytic infundibuloneurohypophysitis is a rare disorder in which neurohypophyseal function is impaired by an autoimmune process. Although several etiologies for this rare entity have been suggested, its occurrence following transsphenoidal adenomectomy has not been reported. A 20-year-old man presented with diabetes insipidus - seven years after successful transsphenoidal microadenomectomy for Cushing's disease, first diagnosed at the age of 13. Seven years later, he developed fairly rapid onset of polydipsia and polyuria. Magnetic resonance imaging demonstrated swelling of the posterior pituitary gland with thickening of the pituitary stalk. Endocrinological evaluation revealed neurohypophyseal dysfunction without the adenohypophysis being affected. On the basis of these findings, a diagnosis of lymphocytic infundibuloneurohypophysitis was made. The mass lesion of the posterior pituitary resolved after the administration of corticosteroids for two months and no operation was required. Lymphocytic infundibuloneurohypophysitis should be considered in the differential diagnosis of pituitary mass lesions following transsphenoidal surgery, especially when the mass is confined to the posterior pituitary gland with neurohypophyseal function being compromised.

Do all patients with childhood-onset growth hormone deficiency (GHD) and ectopic neurohypophysis have persistent GHD in adulthood?

Cerebral magnetic resonance imaging findings are of great value for the diagnosis of nonacquired GH deficiency (GHD), and ectopic posterior pituitary hyperintense signal (EPPHS) is a sensitive and specific indicator of hypopituitarism. It has been suggested that patients with childhood-onset GHD and EPPHS do not require additional investigation of GH secretion and should not be retested when adult height is achieved. This recommendation has never been validated through a systematic study. This study aimed to characterize the anterior pituitary function status of patients with EPPHS treated for GHD during childhood after completion of GH therapy when adult height had been achieved. Patients (n = 18; 15 males and three females) with childhood-onset GHD associated with ectopic neurohypophysis were treated with hGH (0.20 +/- 0.05 mg/kg.wk) for 9.9 +/- 4.0 yr (from 6.8 +/- 4.7 to 17.7 +/- 1.3 yr of age) with a mean height gain of 2.6 +/- 1.4 sd score. GH secretion was reevaluated by arginine insulin (n = 15) or propanolol glucagon (n = 3) test after 0.5 +/- 0.6 yr of GH withdrawal. At reevaluation, peak GH was more than 10 mug/liter in four patients (22%; range, 11.7-19.5 microg/liter; group I), between 5 and 10 microg/liter in three patients (17%; range, 7.3-9 mug/liter; group II), and less than 5 microg/liter in 11 patients (61%; range, 0-4.7 microg/liter; group III). A positive correlation was found between serum IGF-I and peak GH levels after attainment of adult height (P = 0.007). Only one of the seven patients who showed increased GH secretion ability in adulthood (groups I and II) demonstrated other hormonal deficiencies (gonadotropin and adrenal insufficiencies). Among the 11 patients with persistent severe GHD (group III), 10 (91%) of the 11 subjects were shown to have multiple pituitary hormone deficits after attainment of adult height. The structure of the hypothalamo-pituitary axis differs among groups [i.e. patients who showed increased GH secretion ability in adulthood (groups I and II) vs. those who remained severely GHD (group III)]. The location of the EPPHS was significantly different among groups (P < 0.003). The EPPHS was found at the median eminence in all but one of group III patients and along the pituitary stalk (proximal stalk) in all but one of group I and II patients. The pituitary stalk was visible and described as normal (n = 1) or thin (n = 6) in all group I and II patients, whereas the pituitary stalk was not visible even after enhancement in seven of the 11 group III patients (P < 0.02). The prevalence of anterior pituitary hypoplasia and the mean height gain sd score were similar in each group. In conclusion, only 61% of patients with childhood-onset GHD and EPPHS remained severely GHD, and thus suitable for GH therapy, in adulthood. Although the pathogenesis of anterior pituitary dysfunction remains unclear in patients with ectopic neurohypophysis, isolated GHD, location of EPPHS along the stalk, and visibility of the pituitary stalk on magnetic resonance imaging findings clearly represent important markers to predict a less severe form of the disease.

Pituicytoma

Pituicytoma is a rare, low-grade neoplasm that originates in the neurohypophysis of the pituitary gland. We report the clinicopathologic features of a pituicytoma arising in a 52-year-old man who presented with a mass and panhypopituitarism, clinically suggestive of a pituitary adenoma. The tumor was marked by a proliferation of elongated cells arranged in bundles and interlacing fascicles. The tumor demonstrated positive staining with S-100 protein and glial fibrillary acid protein antibodies. The tumor did not stain with antibodies to cytokeratin, synaptophysin, chromogranin, anterior pituitary hormones, or p53. An MIB-1 labeling index of 1.1% was observed. The tumor was subtotally resected and recurred 11 months after the initial surgery. The literature on this rare tumor will be reviewed and differential diagnosis discussed.

Suprapineal recess: an alternate site for third ventriculostomy?

✓ This 30-year-old woman presented with clinical symptoms and signs of intracranial hypertension and Parinaud syndrome secondary to ventriculoperitoneal shunt dysfunction. Magnetic resonance (MR) imaging revealed gross triventricular hydrocephalus with a large suprapineal recess due to aqueductal stenosis. Using an endoscopic approach, a ventriculostomy was performed within the floor of the dilated suprapineal recess. Following this procedure the patient experienced alleviation of all her neurological symptoms and signs. Postoperative MR imaging and cerebrospinal fluid flow studies demonstrated a functioning ventriculostomy. The anatomy of the suprapineal recess and its suitability for endoscopic ventriculostomy are discussed.

Growing teratoma syndrome in a patient with a non-germinomatous germ cell tumor in the neurohypophysis--case report

A 16-year-old woman presented with a non-germinomatous germ cell tumor in the neurohypophysis manifesting as progressive visual disturbance, amenorrhea, hydrodipsia, and polyuria. Her serum alpha-fetoprotein and human chorionic gonadotropin levels were elevated. She experienced sudden, rapid visual deterioration and underwent emergency partial tumor removal to decompress the optic nerves. Her vision subsequently improved. Histological examination of the surgical specimens confirmed immature teratoma. She received chemotherapy (ifosphamide 900 mg/m2, cisplatin 20 mg/m2, etoposide 60 mg/m2) for 5 consecutive days. Although the tumor marker levels decreased remarkably, her vision again declined rapidly due to enlargement of the tumor after the first course of chemotherapy. A second radical operation resulted in vision improvement. The tumor specimen showed only mature teratoma elements. This phenomenon, called the growing teratoma syndrome, is very rare in intracranial non-germinomatous germ cell tumors.