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Koide H, Shiga A, Komai E, Yamato A, Fujimoto M, Tamura A, Kono T, Nakayama A, Takiguchi T, Higuchi S, Sakuma I, Nagano H, Hashimoto N, Suzuki S, Takeda Y, Shibuya M, Nishioka H, Yamada S, Inoshita N, Ishiwatari N, Horiguchi K, Yokote K, Tanaka T. Prednisolone-responsive Postpartum IgG4-related Hypophysitis. Intern Med 2018; 57:367-375. [PMID: 29093382 PMCID: PMC5827318 DOI: 10.2169/internalmedicine.8446-16] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
We herein report the case of a 25-year-old woman who presented with severe headache and visual field defects after childbirth. Magnetic resonance imaging revealed marked swelling of the pituitary gland, and an endocrinological examination revealed panhypopituitarism and diabetes insipidus. An immunohistological analysis of a transsphenoidal biopsy sample of the pituitary gland showed the significant accumulation of an immunogloblin G4 (IgG4)-positive population, leading to the diagnosis of IgG4-related hypophysitis. The patient was treated with prednisolone, which markedly reduced the swelling of the pituitary gland, in association with recovery of the pituitary function. This is a rare case of biopsy-proven IgG4-related hypophysitis with a postpartum onset.
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Affiliation(s)
- Hisashi Koide
- Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Japan
- Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Japan
| | - Akina Shiga
- Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Japan
- Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Japan
| | - Eri Komai
- Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Japan
- Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Japan
| | - Azusa Yamato
- Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Japan
- Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Japan
| | - Masanori Fujimoto
- Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Japan
- Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Japan
| | - Ai Tamura
- Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Japan
- Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Japan
| | - Takashi Kono
- Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Japan
- Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Japan
| | - Akitoshi Nakayama
- Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Japan
| | - Tomoko Takiguchi
- Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Japan
- Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Japan
| | - Seiichiro Higuchi
- Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Japan
- Department of Molecular Diagnosis, Chiba University Graduate School of Medicine, Japan
| | - Ikki Sakuma
- Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Japan
- Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Japan
| | - Hidekazu Nagano
- Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Japan
- Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Japan
| | - Naoko Hashimoto
- Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Japan
- Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Japan
| | - Sawako Suzuki
- Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Japan
- Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Japan
| | - Yasuaki Takeda
- Department of Neurosurgery, Tokyo Yamate Medical Center, Japan
| | - Makoto Shibuya
- Central Laboratory, Hachioji Medical Center, Tokyo Medical University, Japan
| | - Hiroshi Nishioka
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Japan
| | - Shozo Yamada
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Japan
| | | | - Norio Ishiwatari
- Department of Neurological Surgery, Chiba University Hospital, Japan
| | - Kentaro Horiguchi
- Department of Neurological Surgery, Chiba University Hospital, Japan
| | - Koutaro Yokote
- Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Japan
- Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Japan
| | - Tomoaki Tanaka
- Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Japan
- Department of Molecular Diagnosis, Chiba University Graduate School of Medicine, Japan
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Murphy AN, Hannon AM, Brett FM, Agha A, Javadpour M, Looby S. IgG4 hypophysitis - a rare and underdiagnosed cause of pituitary gland and stalk mass-like thickening. Br J Neurosurg 2018; 34:91-93. [PMID: 29291640 DOI: 10.1080/02688697.2017.1416061] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Our aim is to present a typical case of IgG4-related hypophysitis, which will offer insight into the aetiology and pathogenesis of this relatively newly described disease. IgG4 Related Disease is a protean systemic condition that mimics inflammatory, infectious, and malignant processes. Biopsy of affected organs will show a typical histopathological pattern.
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Affiliation(s)
- Alexandra N Murphy
- Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | | | | | - Amar Agha
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | | | - Seamus Looby
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
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Liu Y, Wang L, Zhang W, Pan H, Yang H, Deng K, Lu L, Yao Y, Chen S, Chai X, Feng F, You H, Jin Z, Zhu H. Hypophyseal Involvement in Immunoglobulin G4-Related Disease: A Retrospective Study from a Single Tertiary Center. Int J Endocrinol 2018; 2018:7637435. [PMID: 29755523 PMCID: PMC5883929 DOI: 10.1155/2018/7637435] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 10/08/2017] [Accepted: 10/18/2017] [Indexed: 12/20/2022] Open
Abstract
This study aims to outline the clinical features and outcomes of IgG4-related hypophysitis (IgG4-RH) patients in a tertiary medical center. We reviewed clinical manifestations and imaging and pituitary function tests at baseline, as well as during follow-up. Ten patients were included. The mean age at diagnosis of IgG4-RH was 48.4 (16.0-64.0) years. An average of 3 (0-9) extrapituitary organs were involved. Five patients had panhypopituitarism, three had only posterior hypopituitarism, one had only anterior hypopituitarism, and one had a normal pituitary function. One patient in our study had pituitary mass biopsy, lacking IgG4-positive cells despite lymphocyte infiltration forming an inflammatory pseudotumor. Five patients with a clinical course of IgG4-RH less than nine months and a whole course of IgG4-RD less than two years were managed with glucocorticoids, while three patients with a longer history were administered glucocorticoids plus immunosuppressive agents. One patient went through surgical excision, and one patient was lost to follow-up. All patients showed a prompt response clinically, but only three patients had normalized serum IgG4 levels. Two patients who took medications for less than six months relapsed. Conclusions. IgG4-RD is a broad disease, and all physicians involved have to be aware of the possibility of pituitary dysfunction. Younger patients should be expected. The histopathological feature of pituitary gland biopsy could be atypical. For patients with a longer history, the combination of GC and immunosuppressive agents is favorable. Early and adequate courses of treatment are crucial for the management of IgG4-RH. With GC and/or immunosuppressant treatment, however, pituitary function or diabetes insipidus did not improve considerably.
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Affiliation(s)
- Yang Liu
- Department of Neurosurgery, Peking Union Medical College, Beijing 100730, China
| | - Linjie Wang
- Key Laboratory of Endocrinology of National Health and Family Planning Commission, Department of Endocrinology, Peking Union Medical College, Beijing 100730, China
| | - Wen Zhang
- Department of Rheumatology, Peking Union Medical College, Beijing 100730, China
| | - Hui Pan
- Key Laboratory of Endocrinology of National Health and Family Planning Commission, Department of Endocrinology, Peking Union Medical College, Beijing 100730, China
| | - Hongbo Yang
- Key Laboratory of Endocrinology of National Health and Family Planning Commission, Department of Endocrinology, Peking Union Medical College, Beijing 100730, China
| | - Kan Deng
- Department of Neurosurgery, Peking Union Medical College, Beijing 100730, China
| | - Lin Lu
- Key Laboratory of Endocrinology of National Health and Family Planning Commission, Department of Endocrinology, Peking Union Medical College, Beijing 100730, China
| | - Yong Yao
- Department of Neurosurgery, Peking Union Medical College, Beijing 100730, China
| | - Shi Chen
- Key Laboratory of Endocrinology of National Health and Family Planning Commission, Department of Endocrinology, Peking Union Medical College, Beijing 100730, China
| | - Xiaofeng Chai
- Key Laboratory of Endocrinology of National Health and Family Planning Commission, Department of Endocrinology, Peking Union Medical College, Beijing 100730, China
| | - Feng Feng
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Hui You
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Zimeng Jin
- Key Laboratory of Endocrinology of National Health and Family Planning Commission, Department of Endocrinology, Peking Union Medical College, Beijing 100730, China
| | - Huijuan Zhu
- Key Laboratory of Endocrinology of National Health and Family Planning Commission, Department of Endocrinology, Peking Union Medical College, Beijing 100730, China
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Hadjigeorgiou GF, Lund EL, Poulsgaard L, Feldt-Rasmussen U, Rasmussen ÅK, Wegener M, Fugleholm K. Intrachiasmatic abscess caused by IgG4-related hypophysitis. Acta Neurochir (Wien) 2017; 159:2229-2233. [PMID: 28799078 DOI: 10.1007/s00701-017-3288-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 07/26/2017] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Autoimmune hypophysitis is a rare disease of the pituitary, which may affect vision by inflammation and compression of the optic chiasm. However, intrachiasmatic abscess formation has not been previously reported. METHODS In this study, we report a case of a 29-year-old female with bitemporal hemianopia due to a cystic intrasellar tumor. The patient underwent surgical decompression of the lesion, which was found to be an intrachiasmatic abscess. RESULTS The histologic findings were consistent with IgG4 hypophysitis. CONCLUSION This rare clinical presentation suggests that in case of a disproportionate degree of visual impairment in relation to the size of the lesion, suspicion should lead to an intrachiasmatic lesion.
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Affiliation(s)
- Georgios F Hadjigeorgiou
- Department of Neurosurgery, Academic Hospital Munich-Bogenhausen, Technical University of Munich, Munich, Germany.
| | - Eva Løbner Lund
- Department of Pathology, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Lars Poulsgaard
- Department of Neurosurgery, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Ulla Feldt-Rasmussen
- Department of Endocrinology, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Åse Krogh Rasmussen
- Department of Endocrinology, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Marianne Wegener
- Department of Neuro-opthalmology, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Kåre Fugleholm
- Department of Neurosurgery, University Hospital of Copenhagen, Copenhagen, Denmark
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AbdelRazek M, Stone JH. Neurologic Features of Immunoglobulin G4–Related Disease. Rheum Dis Clin North Am 2017; 43:621-631. [DOI: 10.1016/j.rdc.2017.06.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Abstract
Central hypothyroidism is a rare and heterogeneous disorder that is characterized by a defect in thyroid hormone secretion in an otherwise normal thyroid gland due to insufficient stimulation by TSH. The disease results from the abnormal function of the pituitary gland, the hypothalamus, or both. Moreover, central hypothyroidism can be isolated or combined with other pituitary hormone deficiencies, which are mostly acquired and are rarely congenital. The clinical manifestations of central hypothyroidism are usually milder than those observed in primary hypothyroidism. Obtaining a positive diagnosis for central hypothyroidism can be difficult from both a clinical and a biochemical perspective. The diagnosis of central hypothyroidism is based on low circulating levels of free T4 in the presence of low to normal TSH concentrations. The correct diagnosis of both acquired (also termed sporadic) and congenital (also termed genetic) central hypothyroidism can be hindered by methodological interference in free T4 or TSH measurements; routine utilization of total T4 or T3 measurements; concurrent systemic illness that is characterized by low levels of free T4 and normal TSH concentrations; the use of the sole TSH-reflex strategy, which is the measurement of the sole level of TSH, without free T4, if levels of TSH are in the normal range; and the diagnosis of congenital hypothyroidism based on TSH analysis without the concomitant measurement of serum levels of T4. In this Review, we discuss current knowledge of the causes of central hypothyroidism, emphasizing possible pitfalls in the diagnosis and treatment of this disorder.
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Affiliation(s)
| | - Giulia Rodari
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Endocrinology and Metabolic Diseases Unit, Via Francesco Sforza 35, Milan 20122, Italy
| | - Claudia Giavoli
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Endocrinology and Metabolic Diseases Unit, Via Francesco Sforza 35, Milan 20122, Italy
| | - Andrea Lania
- Department of Biomedical Sciences, Humanitas University and Endocrinology Unit, Humanitas Research Hospital, Via Manzoni 56, Rozzano 20086, Italy
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Jolobe OMP. IgG4-related disease as the differential diagnosis of hypophysitis. Br J Hosp Med (Lond) 2017; 78:536. [DOI: 10.12968/hmed.2017.78.9.536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Oscar MP Jolobe
- Retired Geriatrician, Manchester Medical Society, Manchester M13 9PL
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58
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Roberts L, Alner S. Documentation standards and clinical coding. Br J Hosp Med (Lond) 2017; 78:536. [DOI: 10.12968/hmed.2017.78.9.536a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Luke Roberts
- Clinical Coding Improvement Manager, Evelina London Children's Hospital, St Thomas's Hospital, London SE1 7EH
| | - Samuel Alner
- Service Improvement Team Project Coordinator, Evelina London Children's Hospital, St Thomas's Hospital, London
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Iwata N, Iwama S, Sugimura Y, Yasuda Y, Nakashima K, Takeuchi S, Hagiwara D, Ito Y, Suga H, Goto M, Banno R, Caturegli P, Koike T, Oshida Y, Arima H. Anti-pituitary antibodies against corticotrophs in IgG4-related hypophysitis. Pituitary 2017; 20:301-310. [PMID: 27896569 DOI: 10.1007/s11102-016-0780-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE IgG4-related disease is a systemic inflammatory disease characterized by infiltration of IgG4-positive plasma cells into multiple organs, including the pituitary gland. Autoimmunity is thought to be involved in the pathogenesis of IgG4-related disease. The diagnosis of IgG4-related hypophysitis (IgG4-RH) is difficult because its clinical features, such as pituitary swelling and hypopituitarism, are similar to those of other pituitary diseases, including lymphocytic hypophysitis and sellar/suprasellar tumors. The presence and significance of anti-pituitary antibodies (APA) in IgG4-RH is unclear. METHODS In this case-control study, we used single indirect immunofluorescence on human pituitary substrates to assess the prevalence of serum APA in 17 patients with IgG4-RH, 8 control patients with other pituitary diseases (lymphocytic infundibulo-neurohypophysitis, 3; craniopharyngioma, 2; germinoma, 3), and 9 healthy subjects. We further analyzed the endocrine cells targeted by the antibodies using double indirect immunofluorescence. RESULTS APA were found in 5 of 17 patients with IgG4-RH (29%), and in none of the pituitary controls or healthy subjects. The endocrine cells targeted by the antibodies in the 5 IgG4-RH cases were exclusively corticotrophs. Antibodies were of the IgG1 subclass, rather than IgG4, in all 5 cases, suggesting that IgG4 is not directly involved in the pathogenesis. Finally, antibodies recognized pro-opiomelanocortin in 2 of the cases. CONCLUSIONS Our study suggests that autoimmunity is involved in the pathogenesis of IgG4-RH and that corticotrophs are the main antigenic target, highlighting a possible new diagnostic marker for this condition.
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Affiliation(s)
- Naoko Iwata
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - Shintaro Iwama
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan.
- Research Center of Health, Physical Fitness and Sports, Nagoya University, Furo-cho, Chikusa-ku, Nagoya, 464-8601, Japan.
| | - Yoshihisa Sugimura
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - Yoshinori Yasuda
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - Kohtaro Nakashima
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - Seiji Takeuchi
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - Daisuke Hagiwara
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - Yoshihiro Ito
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - Hidetaka Suga
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - Motomitsu Goto
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - Ryoichi Banno
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - Patrizio Caturegli
- Department of Pathology, Johns Hopkins University, Baltimore, MD, 21205, USA
- Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA
| | - Teruhiko Koike
- Research Center of Health, Physical Fitness and Sports, Nagoya University, Furo-cho, Chikusa-ku, Nagoya, 464-8601, Japan
| | - Yoshiharu Oshida
- Research Center of Health, Physical Fitness and Sports, Nagoya University, Furo-cho, Chikusa-ku, Nagoya, 464-8601, Japan
| | - Hiroshi Arima
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
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Gu WJ, Zhang Q, Zhu J, Li J, Wei SH, Mu YM. Rituximab was used to treat recurrent IgG4-related hypophysitis with ophthalmopathy as the initial presentation: A case report and literature review. Medicine (Baltimore) 2017; 96:e6934. [PMID: 28614220 PMCID: PMC5478305 DOI: 10.1097/md.0000000000006934] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
RATIONALE Immunoglobulin G4 (IgG4)-related hypophysitis is a type of IgG4-related disease (IgG4-RD), which is characterized by plasma cells infiltration in the pituitary causing functional changes and (or) space-occupying effect in the pituitary. IgG4-related hypophysitis is sensitive to hormone therapy in most patients, but recurrence is very likely. PATIENT CONCERNS Here, we report a 57-year-old male patient with bilateral eye redness as the initial presentation. He later presented with pituitary hypofunction that involved multiple organs, including eyes, lacrimal gland, pituitary, lung, gall bladder, and intestine. There was an elevation of C-reactive protein and blood sedimentation, but the IgG and IgG4 levels of the serum and the cerebrospinal fluid did not increase obviously following irregular glucocorticoid therapy. Magnetic resonance imaging revealed enlarged pituitary and obviously thickened pituitary stalk. IgG4-related hypophysitis was confirmed by biopsy of the pituitary. DIAGNOSES The patient was diagnosis of IgG4-related hypophysitis with ophthalmopathy by pathological and molecular tests. INTERVENTIONS The patient responded to methylprednisolone pulse therapy but relapsed during the maintenance therapy using small-dose hormones combined with azathioprine. Methylprednisolone pulse therapy was given for 3 days followed by rituximab injection for 4 weeks. OUTCOMES After use methylprednisolone pulse therapy with rituximab the patient achieved complete remission. LESSONS Rituximab achieved good effect for recurrent IgG4-related hypophysitis after glucocorticoid therapy combined with immunosuppressant in this case. Moreover, comparative analysis was carried out with other reported cases of IgG4-related hypophysitis in terms of clinical features, treatment, and follow-up.
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Affiliation(s)
- Wei-Jun Gu
- Department of Endocrinology, Chinese PLA General Hospital
| | - Qian Zhang
- Department of Endocrinology, Chinese PLA General Hospital
- Department of Endocrinology, PLA Army General Hospital, Nanmencang
| | | | | | - Shi-Hui Wei
- Department of Ophthalmology, Chinese PLA General Hospital, Beijing, China
| | - Yi-Ming Mu
- Department of Endocrinology, Chinese PLA General Hospital
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Matsuda K, Saito A, Takeuchi Y, Fukami H, Sato H, Nagasawa T. IgG4-Related Disease Manifesting as Interstitial Nephritis Accompanied by Hypophysitis. AMERICAN JOURNAL OF CASE REPORTS 2017; 18:593-598. [PMID: 28552902 PMCID: PMC5459220 DOI: 10.12659/ajcr.902187] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Patient: Male, 85 Final Diagnosis: IgG4-related disease Symptoms: Renal failure Medication: — Clinical Procedure: — Specialty: Nephrology
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Affiliation(s)
- Ken Matsuda
- Department of Nephrology, Japanese Red Cross Ishinomaki Hospital, Ishinomaki, Miyagi, Japan
| | - Ayako Saito
- Department of Nephrology, Japanese Red Cross Ishinomaki Hospital, Ishinomaki, Miyagi, Japan
| | - Yoichi Takeuchi
- Department of Nephrology, Japanese Red Cross Ishinomaki Hospital, Ishinomaki, Miyagi, Japan
| | - Hirotaka Fukami
- Department of Nephrology, Japanese Red Cross Ishinomaki Hospital, Ishinomaki, Miyagi, Japan
| | - Hiroyuki Sato
- Department of Nephrology, Japanese Red Cross Ishinomaki Hospital, Ishinomaki, Miyagi, Japan
| | - Tasuku Nagasawa
- Department of Nephrology, Japanese Red Cross Ishinomaki Hospital, Ishinomaki, Miyagi, Japan
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Anno T, Kawasaki F, Takai M, Shigemoto R, Kan Y, Kaneto H, Mune T, Kaku K, Okimoto N. Clinical course of pituitary function and image in IgG4-related hypophysitis. Endocrinol Diabetes Metab Case Rep 2017; 2017:EDM160148. [PMID: 28469927 PMCID: PMC5409939 DOI: 10.1530/edm-16-0148] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 03/31/2017] [Indexed: 12/11/2022] Open
Abstract
A 76-year-old man had a hypopituitarism including adrenal insufficiency, hypogonadism and hypothyroidism. Based on various findings including the swelling of the pituitary gland, increase of serum IgG4 level and abundant IgG4-positive plasma cell infiltration in immunostaining of the pituitary gland, we diagnosed this subject as IgG4-related hypophysitis. In general, a high-dose glucocorticoid treatment is effective for IgG4-related disease. His clinical symptom, laboratory data and adrenal insufficiency were almost improved without any therapy. The serum IgG4 level was decreased and pituitary size was normalized with hydrocortisone as physiological replacement. This case report provides the possibility that IgG4 level is decreased spontaneously or with physiological dose of glucocorticoid therapy. LEARNING POINTS We performed the pituitary gland biopsy and histochemical examination glucocorticoid therapy in a subject with IgG4-related hypophysitis.This case report provides the possibility that IgG4 level is decreased spontaneously or with a physiological dose of glucocorticoid therapy. We reported the clinical course of IgG4-related hypophysitis without a high-dose glucocorticoid treatment, although there were a few reports about the retrospective examination.Although the patient had still higher IgG4 level compared to normal range, his clinical symptom disappeared and his laboratory data were improved.We should keep in mind the possibility of IgG4-related hypophysitis when we examine one of the uncertain causes of a hypopituitarism including adrenal insufficiency, hypogonadism and hypothyroidism.
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Affiliation(s)
- Takatoshi Anno
- Department of General Internal Medicine 1, Kawasaki Medical School, OkayamaJapan
| | - Fumiko Kawasaki
- Department of General Internal Medicine 1, Kawasaki Medical School, OkayamaJapan
| | - Maiko Takai
- Department of General Internal Medicine 1, Kawasaki Medical School, OkayamaJapan
| | - Ryo Shigemoto
- Department of General Internal Medicine 1, Kawasaki Medical School, OkayamaJapan
| | - Yuki Kan
- Department of General Internal Medicine 1, Kawasaki Medical School, OkayamaJapan
| | - Hideaki Kaneto
- Department of Diabetes, Metabolism and Endocrinology, Kawasaki Medical School, KurashikiJapan
| | - Tomoatsu Mune
- Department of Diabetes, Metabolism and Endocrinology, Kawasaki Medical School, KurashikiJapan
| | - Kohei Kaku
- Department of General Internal Medicine 1, Kawasaki Medical School, OkayamaJapan
| | - Niro Okimoto
- Department of General Internal Medicine 1, Kawasaki Medical School, OkayamaJapan
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Baptista B, Casian A, Gunawardena H, D'Cruz D, Rice CM. Neurological Manifestations of IgG4-Related Disease. Curr Treat Options Neurol 2017; 19:14. [PMID: 28374231 PMCID: PMC5378735 DOI: 10.1007/s11940-017-0450-9] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OPINION STATEMENT IgG4-related disease (IgG4-RD) is a multisystem inflammatory disorder. Early recognition of IgG4-RD is important to avoid permanent organ dysfunction and disability. Neurological involvement by IgG4-RD is relatively uncommon, but well recognised-hypertrophic pachymeningitis and hypophysitis are the most frequent manifestations. Although the nervous system may be involved in isolation, this more frequently occurs in conjunction with involvement of other systems. Elevated circulating levels of IgG4 are suggestive of the condition, but these are not pathognomonic and exclusion of other inflammatory disorders including vasculitis is required. Wherever possible, a tissue diagnosis should be established. The characteristic histopathological changes include a lymphoplasmacytoid infiltrate, storiform fibrosis and obliterative phlebitis. IgG4-RD typically responds well to treatment with glucocorticoids, although relapse is relatively common and treatment with a steroid-sparing agent or rituximab may be required. Improved understanding of the pathogenesis of IgG4-RD is likely to lead to the development of more specific disease treatments in the future.
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Affiliation(s)
| | - Alina Casian
- Louise Coote Unit, Guy's and St Thomas NHS Foundation Trust, London, UK
| | - Harsha Gunawardena
- Department of Rheumatology, Brunel Building, Southmead Hospital, Bristol, UK
- Musculoskeletal Research Unit, Learning and Research Building, University of Bristol, Southmead Hospital, Bristol, BS10 5NB, UK
| | - David D'Cruz
- Louise Coote Unit, Guy's and St Thomas NHS Foundation Trust, London, UK
- Division of Immunology, Infection and Inflammatory Diseases, King's College London, New Hunt's House, Guy's Campus, Great Maze Pond, London, SE1 1UL, UK
| | - Claire M Rice
- School of Clinical Sciences, Level 1, Learning and Research Building, University of Bristol, Southmead Hospital, Bristol, BS10 5NB, UK.
- Department of Neurology, Brunel Building, Southmead Hospital, Bristol, UK.
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Abstract
PURPOSE IgG4-related hypophysitis is a rare disease, with only 34 cases published in English (2015). Available short reviews may not present complete details of IgG4-related hypophysitis. We aimed to survey case reports of IgG4-related hypophysitis, including abstracts of scientific meetings, in English and Japanese. METHODS We searched for information about IgG4-related hypophysitis in PubMed and Igakuchuozasshi (Japan Medical Abstracts Society). Among 104 case reports found, we reviewed 84 fulfilling Leporati's diagnostic criteria. RESULTS The mean ± SD age of onset was 64.2 ± 13.9, 67.5 ± 9.8, and 56.4 ± 18.6 years for all subjects, men, and women, respectively. Men:women was 2.4:1. On magnetic resonance imaging, pituitary, stalk, and pituitary-stalk mass were observed at frequencies of 14.3, 21.4, and 64.3%, respectively. Manifestations were anterior hypopituitarism in 26.2% (22 cases), central diabetes insipidus in 17.9% (15 cases), and panhypopituitarism in 52.4% (44 cases). The median level of serum IgG4 was 264.5 mg/dL for all subjects, 405 mg/dL for men, and 226 mg/dL for women. The mean number of IgG4-related systemic diseases was 2.7 ± 1.5 in all subjects, 3.0 ± 1.5 in men, and 1.8 ± 1.1 in women. Among the IgG4-related diseases, retroperitoneal fibrosis was the most frequent (26.2%), followed by salivary gland diseases (25%). Glucocorticoid therapy was generally effective, except for two cases that received replacement doses. There were significant differences between sexes in terms of age, serum IgG4 levels, and number of IgG4-related diseases. CONCLUSION IgG4-related hypophysitis may have different clinical characteristics between genders. This survey may lack some information because the Japanese abstracts did not contain certain details.
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Affiliation(s)
- Junpei Shikuma
- Department of Diabetology, Metabolism, and Endocrinology, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Kenshi Kan
- Department of Diabetology, Metabolism, and Endocrinology, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Rokuro Ito
- Department of Diabetology, Metabolism, and Endocrinology, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Kazuo Hara
- Department of Diabetology, Metabolism, and Endocrinology, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Hiroyuki Sakai
- Department of Diabetology, Metabolism, and Endocrinology, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Takashi Miwa
- Department of Diabetology, Metabolism, and Endocrinology, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Akira Kanazawa
- Department of Diabetology, Metabolism, and Endocrinology, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Masato Odawara
- Department of Diabetology, Metabolism, and Endocrinology, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
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Bernreuther C, Illies C, Flitsch J, Buchfelder M, Buslei R, Glatzel M, Saeger W. IgG4-related hypophysitis is highly prevalent among cases of histologically confirmed hypophysitis. Brain Pathol 2017; 27:839-845. [PMID: 27864854 DOI: 10.1111/bpa.12459] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 11/17/2016] [Indexed: 12/24/2022] Open
Abstract
IgG4-related disease is an immune-mediated disease with manifestations in most organ systems among them the pituitary gland. To date, few cases of histologically confirmed cases of IgG-related hypophysitis have been reported. The aim of this study was to retrospectively determine the prevalence of IgG4-related hypophysitis among cases previously diagnosed as primary hypophysitis (lymphocytic hypophysitis, granulomatous hypophysitis and hypophysitis not otherwise specified). Histological and immunohistochemical analysis revealed that 12 of 29 cases (41.4%) previously diagnosed as primary hypophysitis fulfilled the criteria for IgG4-related disease and, thus, IgG4-related hypophysitis should always be considered in the differential diagnosis of primary hypophysitis. All cases of IgG4-related hypophysitis showed a dense lymphoplasmacytic infiltrate with more than 10 IgG4-positive cells per high power field and a ratio of IgG4/IgG-positive cells of more than 40%, whereas storiform fibrosis was an inconsistent histological feature and was also seen in few cases of non-IgG-related hypophysitis, thus lacking sensitivity and specificity. Obliterative phlebitis was not seen in any case. Thus, histological criteria defined for IgG4-related disease in other organs should be modified for IgG4-related hypophysitis, accordingly.
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Affiliation(s)
- Christian Bernreuther
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christopher Illies
- Department of Pathology, Karolinska Institute and University Hospital, Stockholm, Sweden
| | - Jörg Flitsch
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Buchfelder
- Department of Neurosurgery, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Rolf Buslei
- Institute of Neuropathology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Markus Glatzel
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Saeger
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Sasaki Yatabe M, Watanabe K, Hayashi Y, Yatabe J, Morimoto S, Ichihara A, Nakayama M, Watanabe T. Overlap of Post-obstructive Diuresis and Unmasked Diabetes Insipidus in a Case of IgG4-related Retroperitoneal Fibrosis and Tuberoinfundibular Hypophysitis: A Case Report and Review of the Literature. Intern Med 2017; 56:47-53. [PMID: 28049999 PMCID: PMC5313424 DOI: 10.2169/internalmedicine.56.6648] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The clinical picture of IgG4-related disease (IgG4-RD) is diverse because various organs can be affected. We describe the case of a 56-year-old man with acute renal failure and tuberoinfundibular hypophysitis due to IgG4-RD. Steroid therapy lowered the serum IgG4 level and ameliorated renal dysfunction, bilateral hydronephrosis and retroperitoneal fibrosis. However, polyuria from post-obstructive diuresis and unmasked central diabetes insipidus ensued. The patient's polyuria continued despite the administration of a therapeutic dose of glucocorticoid; the patient's pituitary swelling and anterior pituitary dysfunction were partially ameliorated. The pituitary swelling recurred seven months later. In patients with IgG4-RD, the manifestation of polyuria after steroid therapy should prompt suspicion of post-obstructive diuresis and the unmasking of central diabetes insipidus.
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Affiliation(s)
- Midori Sasaki Yatabe
- Department of Nephrology, Hypertension, Diabetology, Crinology and Metabolism, Fukushima Medical University School of Medicine, Japan
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Kottahachchi D, Topliss DJ. Immunoglobulin G4-Related Thyroid Diseases. Eur Thyroid J 2016; 5:231-239. [PMID: 28101487 PMCID: PMC5216195 DOI: 10.1159/000452623] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 10/14/2016] [Indexed: 12/24/2022] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a new disease category involving many organ systems, including the endocrine system in general and the thyroid in particular. Since an initial association was made between hypothyroidism and autoimmune (IgG4-related) pancreatitis, more forms of IgG4-related thyroid disease (IgG4-RTD) have been recognized. Four subcategories of IgG4-RTD have so far been identified: Riedel thyroiditis (RT), fibrosing variant of Hashimoto thyroiditis (FVHT), IgG4-related Hashimoto thyroiditis, and Graves disease with elevated IgG4 levels. Although a male predominance is seen for IgG4-RD in general, RT and FVHT have a female preponderance. The pathogenesis of IgG4-RD is not completely understood; however, genetic factors, antigen-antibody reactions, and an allergic phenomenon have been described. Diagnosis of IgG4-RD requires a combination of clinical features, serological evidence, and histological features. Histology is the mainstay of diagnosis, with IgG4 immunostaining. Although serum IgG4 levels are usually elevated in IgG4-RD, raised serum IgG4 is neither necessary nor adequate for diagnosis. Imaging supports the diagnosis and is a useful tool in disease monitoring. Management of IgG4-RTD is both medical and surgical. Steroids are the first-line treatment and may produce a swift response. Tamoxifen and rituximab are second-line agents used in steroid-resistant patients. Surgical debulking is carried out in RT solely as a procedure to relieve obstruction. Other endocrine associations described with IgG4-RD are hypophysitis and Hashimoto encephalopathy. IgG4-RTD is an uncommon disease entity, and prompt diagnosis and treatment can improve outcomes.
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Affiliation(s)
- Dulani Kottahachchi
- Department of Endocrinology and Diabetes, The Alfred Hospital, Monash University, Melbourne, VIC, Australia
| | - Duncan J. Topliss
- Department of Endocrinology and Diabetes, The Alfred Hospital, Monash University, Melbourne, VIC, Australia
- Department of Medicine, Monash University, Melbourne, VIC, Australia
- *Duncan J. Topliss, Department of Endocrinology and Diabetes, The Alfred, PO Box 315, Prahran, VIC 3181 (Australia), E-Mail
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Okano Y, Satoh T, Horiguchi K, Toyoda M, Osaki A, Matsumoto S, Tomaru T, Nakajima Y, Ishii S, Ozawa A, Shibusawa N, Shimada T, Higuchi T, Chikamatsu K, Yamada M. Nivolumab-induced hypophysitis in a patient with advanced malignant melanoma. Endocr J 2016; 63:905-912. [PMID: 27440480 DOI: 10.1507/endocrj.ej16-0161] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The anti-programmed cell death-1 monoclonal antibody (mab), nivolumab has recently been approved for the treatment of unresectable or metastatic malignant melanoma and non-small-cell lung cancers in Japan. Ipilimumab, an anti-cytotoxic T lymphocyte antigen-4 mab for malignant melanoma that was approved earlier than nivolumab in Western countries, is known to frequently cause endocrine immune-related adverse events such as hypophysitis and thyroid dysfunction. We herein report a patient with advanced melanoma who appeared to develop hypophysitis as a consequence of the inhibition of PD-1 by nivolumab. One week after the 6th administration of nivolumab, the patient developed progressive fatigue and appetite loss. Laboratory data on admission for the 7th administration of nivolumab showed eosinophilia and hyponatremia. Since ACTH and cortisol levels were low, nivolumab was discontinued and a large dose of hydrocortisone (100 mg/d) was promptly administered intravenously. A magnetic resonance imaging scan revealed the mild enlargement of the anterior pituitary gland and thickening of the stalk with homogenous contrast. A detailed assessment of anterior pituitary functions with hypothalamic hormone challenges showed that hormonal secretions other than ACTH and TSH were normal. With a replacement dose of hydrocortisone (20 mg/d), the 7th administration of nivolumab was completed without exacerbating the patient's general condition. The present report provides the first detailed endocrinological presentation of nivolumab-induced hypophysitis showing the enlargement of the pituitary gland and stalk in a malignant melanoma patient in Japan. Oncologists and endocrinologists need to be familiar with potentially life-threatening hypophysitis induced by immune-checkpoint inhibitors.
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Affiliation(s)
- Yudai Okano
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi 371-8511, Japan
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Lasolle H, Borson-Chazot F. Actualités autour de la prise en charge des diabètes insipides centraux. ANNALES D'ENDOCRINOLOGIE 2016. [DOI: 10.1016/s0003-4266(17)30073-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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70
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Abstract
Hypophysitis is the acute or chronic inflammation of the pituitary gland. The spectrum of hypophysitis has expanded in recent years with the addition of two histologic subtypes and recognition as a complication of treatment with immune checkpoint inhibitors. Despite the increased number of published cases, the pathogenesis of hypophysitis is poorly understood, and treatment strategies are diverse and controversial. The diagnosis of hypophysitis generally requires histopathologic confirmation. The presentation and clinical course of hypophysitis varies. Hypophysitis can resolve spontaneously, relapse may occur, and some cases can be refractory to treatment.
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Affiliation(s)
- Alexander Faje
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114 USA
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71
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Huang CJ, Chang FP, Chang LH, Won JGS. A study of primary hypophysitis, i.e., two cases of lymphocytic hypophysitis and one IgG4-related variant: The importance of measuring serum IgG4 levels to allow early diagnosis and prompt treatment for the IgG4-related variant. J Formos Med Assoc 2016; 116:207-209. [PMID: 27375049 DOI: 10.1016/j.jfma.2016.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 04/18/2016] [Accepted: 04/19/2016] [Indexed: 11/26/2022] Open
Affiliation(s)
- Chun-Jui Huang
- Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Fu-Pang Chang
- Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Li-Hsin Chang
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan; Division of Endocrinology and Metabolism, Department of Medicine, Taoyuan Branch of Taipei Veterans General Hospital, Taoyuan, Taiwan
| | - Justin Ging-Shing Won
- Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
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73
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Masdeu JC, Gadhia R, Faridar A. Brain CT and MRI: differential diagnosis of imaging findings. HANDBOOK OF CLINICAL NEUROLOGY 2016; 136:1037-54. [PMID: 27430457 DOI: 10.1016/b978-0-444-53486-6.00054-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Following a traditional approach, in Chapters 5 and 14-29 in the previous volume, diverse brain diseases are listed and their imaging findings described in detail. In this chapter the approach is from the imaging finding to the disease: for instance, what list of diseases can give rise to a contrast-enhancing mass in the cerebellopontine angle? Imaging findings that are reviewed in succession include the location of the lesion, its multiplicity and symmetry, its volume, ranging from atrophy to mass effect, its homogeneity, its density, measurable by computed tomography (CT), its appearance on T1, T2, and diffusion magnetic resonance imaging (MRI), and, finally, its characteristics after the infusion of intravenous contrast. A differential diagnosis for each finding is provided. While the approach adopted in this chapter is unconventional, we hope that it will be most helpful to anyone reading images. Furthermore, it could serve as the basis to create or complete image databases to guide in the interpretation of brain CT and MRI.
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Affiliation(s)
- Joseph C Masdeu
- Department of Neurology, Houston Methodist Hospital, Houston, TX, USA.
| | - Rajan Gadhia
- Department of Neurology, Houston Methodist Hospital, Houston, TX, USA
| | - Alireza Faridar
- Department of Neurology, Houston Methodist Hospital, Houston, TX, USA
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González-Moreno J, Losada López I, Ortego Centeno N. [IgG4-related disease]. Med Clin (Barc) 2015; 145:539-44. [PMID: 25726306 DOI: 10.1016/j.medcli.2014.12.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 12/17/2014] [Accepted: 12/19/2014] [Indexed: 02/08/2023]
Abstract
IgG4-related disease is a recently described clinicopathological entity showing a wide spectrum of clinical manifestations that share a common pathology. Its most characteristic feature is the formation of inflammatory tumors in different organs, which makes differentiation mainly with neoplastic diseases fundamental. The inflammatory process is typically comprised of IgG4 lymphoplasmacytic cells. The pathophysiological role of the immunoglobulin is not clear. The treatment of choice is corticosteroids. This article aims to summarize the main features of the disease.
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Affiliation(s)
| | - Inés Losada López
- Servicio de Medicina Interna, Hospital Son Llàtzer, Palma de Mallorca, España
| | - Norberto Ortego Centeno
- Unidad de Enfermedades Autoinmunes Sistémicas, Hospital Clínico San Cecilio, Granada, España
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Ngaosuwan K, Trongwongsa T, Shuangshoti S. Clinical course of IgG4-related hypophysitis presenting with focal seizure and relapsing lymphocytic hypophysitis. BMC Endocr Disord 2015; 15:64. [PMID: 26510826 PMCID: PMC4625849 DOI: 10.1186/s12902-015-0062-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 10/23/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND This is the first case report of focal seizure as a manifestation of Immunoglobulin G4 (IgG4)-related hypophysitis. IgG4-related hypophysitis is a novel category of hypophysitis. The clinical presentations, imaging studies and initial pathology studies can mimic lymphocytic hypophysitis. Here we report additional clinical clues in differentiating these two conditions. CASE PRESENTATION A 43-year-old Thai male presented with focal seizure, headache, and anterior pituitary hypofunction. His MRI study showed typical hypophysitis lesion with abnormal cerebral parenchymal signal intensity at right frontal lobe. The pituitary biopsied was obtained and the patient was initially diagnosed with lymphocytic hypophysitis. Following initial low-dose steroid therapy, his seizure and headache resolved but his anterior pituitary hormones remained deficient. However, during steroid tapering, he developed new onset acute visual loss. Upon rigorous pathologic review, his diagnosis of IgG4-related hypophysitis with suspected CNS involvement was established. He was subsequently treated with high-dose steroid and rapidly regained his sight. CONCLUSION This case report highlights the important distinguishing features of IgG4-related hypophysitis from lymphocytic hypophysitis. These include the relapsing clinical course of hypophysitis after steroid decrement and concomitant pachymeningitis particularly in middle-aged to elderly Asian male who presented with hypophysitis. With appropriate dosage of steroids, medical treatment is usually sufficient to control the disease and surgical interventions are usually not required.
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Affiliation(s)
- Kanchana Ngaosuwan
- Department of Internal Medicine, Faculty of Medicine, Srinakharinwirot University, Ongkarak, Nakhon Nayok, Thailand.
| | - Therdkiat Trongwongsa
- Department of Pathology, Faculty of Medicine, Srinakharinwirot University, Ongkarak, Nakhon Nayok, Thailand.
| | - Shanop Shuangshoti
- Department of Pathology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
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76
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Allix I, Rohmer V. Hypophysitis in 2014. ANNALES D'ENDOCRINOLOGIE 2015; 76:585-94. [DOI: 10.1016/j.ando.2015.08.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 07/07/2015] [Accepted: 08/04/2015] [Indexed: 12/24/2022]
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Abstract
PURPOSE The authors review their treatment experience and summarize clinical outcomes for patients with hypophysitis over the past 15 years. METHODS A retrospective analysis was conducted on patients with lymphocytic, granulomatous or IgG4-related hypophysitis treated from 1997 to 2014 at a single academic center. Patients' medical records were reviewed and binary logistic regression analysis was used to assess whether various clinical parameters were associated with improved outcomes including endocrine function, radiographic appearance and disease recurrence. RESULTS Twenty-one patients (13 women and 8 men) were identified with a median diagnosis age of 37.4 years. All but two patients (90%) were diagnosed histopathologically and the remaining two were diagnosed clinically with lymphocytic hypophysitis. 16 patients (76%) had lymphocytic hypophysitis, 3 (14%) had granulomatous hypophysitis, 1 (5%) had IgG4-related hypophysitis and 1 (5%) had mixed lymphocytic-granulomatous. Patients presented with various symptoms of expanding sellar mass with most common signs including headache (57%), polyuria/polydipsia (52%), vision changes (52%) and amenorrhea or decreased libido (48%). Pre-treatment endocrine evaluation revealed that 12 (57%) patients had complete anterior hypopituitarism, 11 patients (52%) had diabetes insipidus, ten patients (48%) had mild hyperprolactinemia and three patients (14%) had isolated endocrine axis deficiencies with partial gland function. We observed a broad diversity in pre-treatment imaging with common findings including uniform contrast enhancement (62%), thickened infundibulum (57%) and loss of hypophysis bright spot on T1 imaging (43%). Patients were treated with steroids and hormone supplementation as needed. 16 patients (76%) had recorded post-treatment MRI scans which revealed that half had radiographic improvement and half had stable or worsened post-treatment imaging. Only female gender was found to significantly predict improved odds of post-steroid radiographic improvement. For post-treatment endocrine evaluation, six patients (29%) did not have an evaluation on record, four patients (19%) had some improvement in at least one axis, seven patients (33%) had stable but non-worsened endocrine function and four patients (19%) had worsened endocrine function post-steroids. CONCLUSIONS Hypophysitis is an increasingly recognized diagnosis that can present with a broad array of radiographic and clinical features. Surgical biopsy can be helpful to make definitive diagnosis and may guide treatment decision-making.
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Affiliation(s)
- Brandon S Imber
- Department of Neurological Surgery, University of California at San Francisco, 505 Parnassus Ave. Room M779, San Francisco, CA, 94143, USA
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Honegger J, Schlaffer S, Menzel C, Droste M, Werner S, Elbelt U, Strasburger C, Störmann S, Küppers A, Streetz-van der Werf C, Deutschbein T, Stieg M, Rotermund R, Milian M, Petersenn S. Diagnosis of Primary Hypophysitis in Germany. J Clin Endocrinol Metab 2015; 100:3841-9. [PMID: 26262437 DOI: 10.1210/jc.2015-2152] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
CONTEXT Representative data on diagnostic findings in primary hypophysitis (PrHy) are scarce. OBJECTIVE The objective of the study was to collate consistent data on clinical features in a large series of patients with PrHy. Another objective was to gain information on current practice in a diagnostic work-up. DESIGN The Pituitary Working Group of the German Society of Endocrinology conducted a nationwide retrospective cross-sectional cohort study in Germany. PATIENTS Seventy-six patients with PrHy were identified. MAIN OUTCOME MEASURES Clinical and endocrinological features were assessed. RESULTS Headache (50%) and increase in body mass (18%) were the most frequent nonendocrine symptoms. Hypophysitis was associated with pregnancy in only 11% of the female patients. Diabetes insipidus was found in 54% of the patients at presentation. Hypogonadotropic hypogonadism was the most frequent endocrine failure (62%), whereas GH deficiency was the least frequent (37%). With 86%, thickening of the pituitary stalk was the prevailing neuroradiological sign. Compared with surgical cases, the cases without histological confirmation presented more often with suprasellar lesions and had less severe nonendocrine symptoms. Granulomatous hypophysitis was associated with more severe clinical symptoms than lymphocytic hypophysitis. Examination of cerebrospinal fluid was predominantly performed in participating neurosurgical centers, whereas thyroid antibodies were almost exclusively assessed in endocrinological centers. CONCLUSION In contrast to the literature, hypogonadism was found to be the most frequent endocrine failure in PrHy. Weight gain was identified as a clinical sign of PrHy. In the majority of patients, PrHy can be reliably identified by characteristic clinical signs and symptoms, obviating histological confirmation. The diagnostic approach should be standardized in PrHy.
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Affiliation(s)
- Jürgen Honegger
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Sven Schlaffer
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Christa Menzel
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Michael Droste
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Sandy Werner
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Ulf Elbelt
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Christian Strasburger
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Sylvère Störmann
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Anna Küppers
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Christine Streetz-van der Werf
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Timo Deutschbein
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Mareike Stieg
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Roman Rotermund
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Monika Milian
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Stephan Petersenn
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
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Bando H, Iguchi G, Fukuoka H, Taniguchi M, Kawano S, Saitoh M, Yoshida K, Matsumoto R, Suda K, Nishizawa H, Takahashi M, Morinobu A, Kohmura E, Ogawa W, Takahashi Y. A diagnostic pitfall in IgG4-related hypophysitis: infiltration of IgG4-positive cells in the pituitary of granulomatosis with polyangiitis. Pituitary 2015; 18:722-30. [PMID: 25822111 DOI: 10.1007/s11102-015-0650-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Immunoglobulin (Ig) G4-related hypophysitis is an emerging clinical entity, which is characterized by an elevated serum IgG4 concentration and infiltration of IgG4-positive plasma cells in the pituitary. Although some criteria for its diagnosis have been proposed, they have not been fully established. In particular, differential diagnosis from secondary chronic inflammation including granulomatosis with polyangiitis (GPA) is difficult in some cases. We describe central diabetes insipidus with pituitary swelling exhibiting infiltration of IgG4-positive cells. PATIENT A 43-year-old woman in the remission stage of GPA presented with sudden-onset polyuria and polydipsia. Pituitary magnetic resonance imaging revealed swelling of the anterior and posterior pituitary and stalk, with heterogeneous gadolinium enhancement and disappearance of the high signal intensity of the posterior pituitary. Evaluation of biochemical markers for GPA suggested that the disease activity was well-controlled. Endocrinological examination revealed the presence of central diabetes insipidus and growth hormone deficiency. Pituitary biopsy specimen showed IgG4-positive cells, with a 43% IgG4(+)/IgG(+) ratio, which met the criteria for IgG4-related hypophysitis. However, substantial infiltration of polymorphonuclear neutrophils with giant cells was also noted, resulting in a final diagnosis of pituitary involvement of GPA. CONCLUSION These results suggest that pituitary involvement of GPA should be taken into account for the differential diagnosis of IgG4-related hypophysitis.
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Affiliation(s)
- Hironori Bando
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
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80
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Islam AD, Selmi C, Datta-Mitra A, Sonu R, Chen M, Gershwin ME, Raychaudhuri SP. The changing faces of IgG4-related disease: Clinical manifestations and pathogenesis. Autoimmun Rev 2015; 14:914-22. [PMID: 26112170 DOI: 10.1016/j.autrev.2015.06.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 06/09/2015] [Indexed: 02/08/2023]
Abstract
Since the earliest reports in 2001, immunoglobulin G4 (IgG4)-related disease has been defined as an autoimmune systemic disease characterized by the lymphoplasmacytic infiltration of affected tissues leading to fibrosis and obliterative phlebitis along with elevated serum IgG4 levels. Prior to this unifying hypothesis, a plethora of clinical manifestations were considered as separate entities despite the similar laboratory profile. The pathology can be observed in virtually all organs and may thus be a challenging diagnosis, especially when the adequate clinical suspicion is not present or when obtaining a tissue biopsy is not feasible. Nonetheless, the most frequently involved organs are the pancreas and exocrine glands but these may be spared. Immunosuppressants lead to a prompt clinical response in virtually all cases and prevent histological sequelae and, as a consequence, an early differential diagnosis from other conditions, particularly infections and cancer, as well as an early treatment should be pursued. We describe herein two cases in which atypical disease manifestations were observed, i.e., one with recurrent neck lymph node enlargement and proptosis, and one with jaundice. Our understanding of the pathogenesis of IgG4-related disease is largely incomplete but data support a significant role for Th2 cytokines with the contribution of innate immunity factors such as Toll-like receptors, macrophages and basophils. Further, macrophages activated by IL4 overexpress B cell activating factors and contribute to chronic inflammation and the development of fibrosis. We cannot rule out the possibility that the largely variable disease phenotypes reflect different pathogenetic mechanisms and the tissue microenvironment may then contribute to the organ involvement.
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Affiliation(s)
- Arshia Duza Islam
- Department of Internal Medicine, Division of Rheumatology, Allergy and Clinical Immunology, University of California Davis, School of Medicine, Davis, CA, USA; VA Medical Center Sacramento, Mather, CA, USA
| | - Carlo Selmi
- Division of Rheumatology and Clinical Immunology, Humanitas Research Hospital, Rozzano, Italy; BIOMETRA Department, University of Milan, Italy
| | | | - Rebecca Sonu
- Department of Pathology and Laboratory Medicine, University of California Davis, School of Medicine, Davis, CA, USA
| | - Mingyi Chen
- Department of Pathology and Laboratory Medicine, University of California Davis, School of Medicine, Davis, CA, USA
| | - M Eric Gershwin
- Department of Internal Medicine, Division of Rheumatology, Allergy and Clinical Immunology, University of California Davis, School of Medicine, Davis, CA, USA
| | - Siba P Raychaudhuri
- Department of Internal Medicine, Division of Rheumatology, Allergy and Clinical Immunology, University of California Davis, School of Medicine, Davis, CA, USA; VA Medical Center Sacramento, Mather, CA, USA.
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81
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Harano Y, Honda K, Akiyama Y, Kotajima L, Arioka H. A Case of IgG4-Related Hypophysitis Presented with Hypopituitarism and Diabetes Insipidus. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2015; 8:23-6. [PMID: 25861230 PMCID: PMC4360849 DOI: 10.4137/ccrep.s15352] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 04/10/2014] [Accepted: 04/13/2014] [Indexed: 01/15/2023]
Abstract
Immunoglobulin (Ig) G4-related systemic syndrome is a recently described entity characterized by elevated serum IgG4 and tissue infiltration of IgG4-positive plasma cells. Pituitary gland can be involved as hypophysitis. We report a case of a 72-year-old man, who presented with general fatigue and weakness. Laboratory tests revealed diabetes insipidus as well as hypopituitarism including adrenal insufficiency, hypogonadism, and hypothyroidism. His serum IgG4 was elevated. MR images showed enlargement of the pituitary stalk. Multiple nodules in bilateral kidneys were pointed out in the abdominal CT. Histological examination of the nodules showed increased IgG4-positive plasma cells. We diagnosed him with IgG4-related kidney disease and hypophysitis. After treatment with hydrocortisone, his symptoms improved. The follow-up images showed that almost all renal nodules disap-peared and his pituitary stalk was shrinking. Our case appears to be very sensitive to glucocorticoid and suggests the possibility of treating IgG4-related hypophysitis successfully with a lower dose of glucocorticoid.
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Affiliation(s)
- Yumi Harano
- Department of General Internal Medicine, St. Luke's International Medical Center, Tokyo, Japan
| | - Kazufumi Honda
- Department of General Internal Medicine, St. Luke's International Medical Center, Tokyo, Japan
| | - Yurika Akiyama
- Department of General Internal Medicine, St. Luke's International Medical Center, Tokyo, Japan
| | - Lisa Kotajima
- Department of General Internal Medicine, St. Luke's International Medical Center, Tokyo, Japan
| | - Hiroko Arioka
- Department of General Internal Medicine, St. Luke's International Medical Center, Tokyo, Japan
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Abstract
In this article, an overview is presented of hypophysitis in terms of current clinical and experimental findings, with discussion of the anatomic and histopathologic classification of primary hypophysitis and factors associated with secondary hypophysitis. In addition, discusses the pathophysiology, clinical features, management, and prognosis associated with this disease are discussed.
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Affiliation(s)
- Hidenori Fukuoka
- Division of Diabetes and Endocrinology, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan.
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83
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Kleger A, Seufferlein T, Wagner M, Tannapfel A, Hoffmann TK, Mayerle J. IgG4-related autoimmune diseases: Polymorphous presentation complicates diagnosis and treatment. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 112:128-35. [PMID: 25759979 PMCID: PMC4361802 DOI: 10.3238/arztebl.2015.0128] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Revised: 11/11/2014] [Accepted: 11/11/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND IgG4-associated autoimmune diseases are systemic diseases affecting multiple organs of the body. Autoimmune pancreatitis, with a prevalence of 2.2 per 100,000 people, is one such disease. Because these multi-organ diseases present in highly variable ways, they were long thought just to affect individual organ systems. This only underscores the importance of familiarity with these diseases for routine clinical practice. METHODS This review is based on pertinent articles retrieved by a selective search in PubMed, and on the published conclusions of international consensus conferences. RESULTS The current scientific understanding of this group of diseases is based largely on case reports and small case series; there have not been any randomized controlled trials (RCTs) to date. Any organ system can be affected, including (for example) the biliary pathways, salivary glands, kidneys, lymph nodes, thyroid gland, and blood vessels. Macroscopically, these diseases cause diffuse organ swelling and the formation of pseudotumorous masses. Histopathologically, they are characterized by a lymphoplasmacytic infiltrate with IgG4-positive plasma cells, which leads via an autoimmune mechanism to the typical histologic findings--storiform fibrosis ("storiform" = whorled, like a straw mat) and obliterative, i.e., vessel-occluding, phlebitis. A mixed Th1 and Th2 immune response seems to play an important role in pathogenesis, while the role of IgG4 antibodies, which are not pathogenic in themselves, is still unclear. Glucocorticoid treatment leads to remission in 98% of cases and is usually continued for 12 months as maintenance therapy. Most patients undergo remission even if untreated. Steroid-resistant disease can be treated with immune modulators. CONCLUSION IgG4-associated autoimmune diseases are becoming more common, but adequate, systematically obtained data are now available only from certain Asian countries. Interdisciplinary collaboration is a prerequisite to proper diagnosis and treatment. Treatment algorithms and RCTs are needed to point the way to organ-specific treatment in the future.
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Affiliation(s)
- Alexander Kleger
- Ulm University Medical Center, Department of Internal Medicine I
| | | | - Martin Wagner
- Ulm University Medical Center, Department of Internal Medicine I
| | | | - Thomas K Hoffmann
- Department of Oto-Rhino-Laryngology Head and Neck Surgery, Ulm University Medical Center
| | - Julia Mayerle
- University Medicine Greifswald Department of Internal Medicine A
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Affiliation(s)
- Su-Jin Moon
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jun-Ki Min
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, The Catholic University of Korea, Seoul, Korea
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85
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Quoi de neuf dans les hypophysites ? Rev Med Interne 2014; 35:815-22. [DOI: 10.1016/j.revmed.2014.05.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 05/14/2014] [Accepted: 05/26/2014] [Indexed: 12/24/2022]
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Tokura Y, Yagi H, Yanaguchi H, Majima Y, Kasuya A, Ito T, Maekawa M, Hashizume H. IgG4‐related skin disease. Br J Dermatol 2014; 171:959-67. [DOI: 10.1111/bjd.13296] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2014] [Indexed: 12/15/2022]
Affiliation(s)
- Y. Tokura
- Department of Dermatology Hamamatsu University School of Medicine 1‐20‐1 Handayama Higashi‐ku Hamamatsu 431‐3192 Japan
| | - H. Yagi
- Section of Dermatology Shizuoka General Hospital 4‐27‐1 Kita‐Andou Aoi‐ku Shizuoka 420‐8527 Japan
| | - H. Yanaguchi
- Department of Dermatology Hamamatsu University School of Medicine 1‐20‐1 Handayama Higashi‐ku Hamamatsu 431‐3192 Japan
| | - Y. Majima
- Section of Dermatology Shizuoka General Hospital 4‐27‐1 Kita‐Andou Aoi‐ku Shizuoka 420‐8527 Japan
| | - A. Kasuya
- Department of Dermatology Hamamatsu University School of Medicine 1‐20‐1 Handayama Higashi‐ku Hamamatsu 431‐3192 Japan
| | - T. Ito
- Department of Dermatology Hamamatsu University School of Medicine 1‐20‐1 Handayama Higashi‐ku Hamamatsu 431‐3192 Japan
| | - M. Maekawa
- Laboratory Medicine Hamamatsu University School of Medicine 1‐20‐1 Handayama Higashi‐ku Hamamatsu 431‐3192 Japan
| | - H. Hashizume
- Section of Dermatology Shimada Municipal Hospital 1200‐5 Noda Shimada 427‐8502 Japan
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Abstract
IgG4-related disease (IgG4-RD) is an emerging immune-mediated disease with the capability of involving essentially any organ. The epidemiology of this disease has not been explored in detail. A majority of patients reported in the literature to date are from Japan, but the condition has been described all across the world and there is no strong evidence to suggest a predilection for Asian populations. The mean age at diagnosis is approximately 60 years and there is a decided male predominance for many clinical features, with an overall male:female ratio of 8:3. A cardinal feature of IgG4-RD is single or multiple organ swelling that often raises concern for malignancy. IgG4-RD should be suspected in patients presenting with unexplained enlargement or swelling of one or more organs. Presenting features vary substantially according to the specialty to which patients present first; in addition, the disease can be diagnosed unexpectedly in pathological specimens or identified incidentally on radiology studies. Involvement of major organs is common and IgG4-RD may lead to organ failure, particularly in the pancreas, liver and biliary tree, kidneys, thyroid gland, lungs, and aorta. The diagnosis of IgG4-RD relies on the coexistence of various clinical, laboratory and histopathological findings, although none is pathognomonic by itself.
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