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Asada T, Takenoshita S, Senda M, Yamamoto K, Sasaki R, Otsuka F, Terada S, Yamada N. Secondary autoimmune hypothalamitis with severe memory impairment 7 years after the onset of diabetes insipidus due to lymphocytic hypophysitis: a case report. BMC Neurol 2022; 22:371. [PMID: 36175850 PMCID: PMC9520890 DOI: 10.1186/s12883-022-02891-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 09/14/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Autoimmune hypothalamitis is a very rare neuroendocrine disorder that causes central diabetes insipidus, headache, visual impairment, and sometimes cognitive impairment. Autoimmune hypothalamitis may occur in association with autoimmune hypophysitis, including lymphocytic hypophysitis, or in isolation. It is not known whether autoimmune hypothalamitis and autoimmune hypophysitis are consecutive diseases. CASE PRESENTATION A 52-year-old woman developed autoimmune hypothalamitis 7 years after developing central diabetes insipidus due to lymphocytic hypophysitis, resulting in severe memory impairment. High-dose intravenous methylprednisolone therapy improved her cognitive function and decreased the size of the lesion. CONCLUSION This case presented a unique clinical course, with a long period of time between the onset of autoimmune hypopituitaritis and the development of autoimmune hypothalamitis.
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Affiliation(s)
- Takahiro Asada
- Department of Neuropsychiatry, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Shintaro Takenoshita
- Department of Neuropsychiatry, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan.
| | - Mayuko Senda
- Department of Neuropsychiatry, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Koichiro Yamamoto
- Department of General Medicine, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Ryo Sasaki
- Department of Neurology, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Fumio Otsuka
- Department of General Medicine, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Seishi Terada
- Department of Neuropsychiatry, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Norihito Yamada
- Department of Neuropsychiatry, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
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Barnabei A, Corsello A, Paragliola RM, Iannantuono GM, Falzone L, Corsello SM, Torino F. Immune Checkpoint Inhibitors as a Threat to the Hypothalamus-Pituitary Axis: A Completed Puzzle. Cancers (Basel) 2022; 14:cancers14041057. [PMID: 35205804 PMCID: PMC8870574 DOI: 10.3390/cancers14041057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/11/2022] [Accepted: 02/16/2022] [Indexed: 02/06/2023] Open
Abstract
Immune checkpoint inhibitors (ICI) prolong the survival in an increasing number of patients affected by several malignancies, but at the cost of new toxicities related to their mechanisms of action, autoimmunity. Endocrine toxicity frequently occurs in patients on ICI, but endocrine dysfunctions differ based on the ICI-subclass, as follows: agents targeting the CTLA4-receptor often induce hypophysitis and rarely thyroid dysfunction, which is the opposite for agents targeting the PD-1/PD-L1 axis. Recently, few cases of central diabetes insipidus have been reported as an adverse event induced by both ICI-subclasses, either in the context of anterior hypophysitis or as selective damage to the posterior pituitary or in the context of hypothalamitis. These new occurrences demonstrate, for the first time, that ICI-induced autoimmunity may involve any tract of the hypothalamic-pituitary axis. However, the related pathogenic mechanisms remain to be fully elucidated. Similarly, the data explaining the endocrine system susceptibility to primary and ICI-induced autoimmunity are still scarce. Since ICI clinical indications are expected to expand in the near future, ICI-induced autoimmunity to the hypothalamic-pituitary axis presents as a unique in vivo model that could help to clarify the pathogenic mechanisms underlying both the dysfunction induced by ICI to the hypothalamus-pituitary axis and primary autoimmune diseases affecting the same axis.
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Affiliation(s)
- Agnese Barnabei
- Endocrinology Unit, P.O.—S. Spirito in Sassia, ASL Roma 1, Lungotevere in Sassia 1, I-00193 Rome, Italy;
| | - Andrea Corsello
- Unit of Endocrinology, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore-Fondazione Policlinico “Gemelli” IRCCS, Largo Gemelli 8, I-00168 Rome, Italy; (A.C.); (R.M.P.); (S.M.C.)
| | - Rosa Maria Paragliola
- Unit of Endocrinology, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore-Fondazione Policlinico “Gemelli” IRCCS, Largo Gemelli 8, I-00168 Rome, Italy; (A.C.); (R.M.P.); (S.M.C.)
| | - Giovanni Maria Iannantuono
- Medical Oncology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier 1, I-00133 Rome, Italy;
| | - Luca Falzone
- Epidemiology Unit, IRCCS Istituto Nazionale Tumori ‘Fondazione G. Pascale’, I-80131 Naples, Italy;
| | - Salvatore Maria Corsello
- Unit of Endocrinology, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore-Fondazione Policlinico “Gemelli” IRCCS, Largo Gemelli 8, I-00168 Rome, Italy; (A.C.); (R.M.P.); (S.M.C.)
- UniCamillus, Saint Camillus International University of Health Sciences, Via di Sant’Alessandro, 8, I-00131 Rome, Italy
| | - Francesco Torino
- Medical Oncology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier 1, I-00133 Rome, Italy;
- Correspondence: ; Tel.: +39-062-090-8190
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Goglin S, Cho TA. Clinical approach to neuro-rheumatology. J Neurol Sci 2021; 431:120048. [PMID: 34768134 DOI: 10.1016/j.jns.2021.120048] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 10/19/2021] [Accepted: 11/01/2021] [Indexed: 01/13/2023]
Abstract
Recognizing the neurologic manifestations of systemic rheumatologic diseases and certain isolated autoimmune neurologic diseases poses challenges to the clinician. Using a systematic approach allows the clinician to diagnose these conditions more readily and to initiate treatment more rapidly. Specific neurological syndromes frequently associated with rheumatologic or specific autoimmune conditions can suggest the diagnosis. A targeted history and examination can identify neurological and systemic clues that help to identify an underlying rheumatologic condition. Judicious use of laboratory and radiographic studies can help confirm suspected diagnoses. This article will review some of the neurological syndromes typical of rheumatologic disease and outline an approach to evaluating for unknown rheumatologic disease in this context.
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Affiliation(s)
- Sarah Goglin
- Division of Rheumatology, Department of Medicine, University of California, 1001 Potrero Ave, San Francisco, CA 94110, USA.
| | - Tracey A Cho
- Neuroimmunology Division, Department of Neurology, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA.
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Frasca F, Piticchio T, Le Moli R, Malaguarnera R, Campennì A, Cannavò S, Ruggeri RM. Recent insights into the pathogenesis of autoimmune hypophysitis. Expert Rev Clin Immunol 2021; 17:1175-1185. [PMID: 34464545 DOI: 10.1080/1744666x.2021.1974297] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Hypophysitis is an inflammation of the pituitary gland and a rare case of hypopituitarism. Despite the expanding spectrum of histological variants and causative agents, its pathogenesis is far to be fully understood. The present review is focused on recent evidence concerning the pathogenesis of autoimmune hypophysitis by searching through online databases like MEDLINE and Scopus up to May 2021. AREAS COVERED Hypophysitis frequently develops in the context of a strong autoimmune background, including a wide spectrum of subtypes ranging from the commonest form of lymphocytic hypophysitis to the newly described and less common IgG4-, anti-PIT-1, and ICI-induced forms. A peculiar combination of genetic predisposition, pituitary damage and immunological setting represents the pathogenetic basis of autoimmune hypophysitis, which is characterized by diffuse infiltration of the gland by lymphocytes and variable degrees of fibrosis followed by pituitary cell destruction. Anti-pituitary antibodies (APA) have been described in sera from patients suffering from autoimmune hypophysitis, though their pathophysiological significance remains largely unknown and their diagnostic value limited. EXPERT OPINION In recent years hypophysitis has gained interest due to the increased number of new diagnoses and the recognition of novel subtypes. Further studies could lead to improvements in biochemical/immunological diagnosis and targeted treatments.
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Affiliation(s)
- Francesco Frasca
- Endocrinology Section, Department of Clinical and Experimental Medicine, Garibaldi Nesima Hospital, University of Catania, Catania, Italy
| | - Tommaso Piticchio
- Endocrinology Section, Department of Clinical and Experimental Medicine, Garibaldi Nesima Hospital, University of Catania, Catania, Italy
| | - Rosario Le Moli
- Endocrinology Section, Department of Clinical and Experimental Medicine, Garibaldi Nesima Hospital, University of Catania, Catania, Italy
| | | | - Alfredo Campennì
- Unit of Nuclear Medicine, Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University of Messina, Messina, Italy
| | - Salvatore Cannavò
- Unit of Endocrinology, University Hospital of Messina, Messina, Italy.,Department of Human Pathology DETEV, University of Messina, Messina, Italy
| | - Rosaria Maddalena Ruggeri
- Unit of Endocrinology, University Hospital of Messina, Messina, Italy.,Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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Niri T, Horie I, Kawahara H, Ando T, Fukuhara N, Nishioka H, Inoshita N, Fujisawa H, Suzuki A, Sugimura Y, Abiru N, Kawakami A. A case of isolated hypothalamitis with a literature review and a comparison with autoimmune hypophysitis. Endocr J 2021; 68:119-127. [PMID: 32963149 DOI: 10.1507/endocrj.ej20-0300] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Idiopathic hypothalamitis is a rare condition that can cause anterior pituitary dysfunction and central diabetes insipidus (CDI), occasionally accompanied by a disturbance of autonomic regulation known as hypothalamic syndrome. This condition has been described as a subtype of autoimmune (lymphocytic) hypophysitis; however, some cases of isolated hypothalamic involvement with no inflammatory lesions in either the pituitary gland or infundibulum have been reported. The detailed epidemiology and pathophysiology of isolated hypothalamitis have not been clarified. We herein report a case of a solitary hypothalamic lesion in a young woman who showed spontaneous development of CDI and panhypopituitarism accompanied by hyperphagia. The hypothalamic lesion increased from 11 × 7 to 17 × 7 mm over 16 months based on the sagittal slices of magnetic resonance imaging examinations. The negative results for anti-pituitary antibodies and anti-Rabphilin-3A antibodies suggested that upward extension of lymphocytic adenohypophysitis or infundibulo-neurohypophysitis was unlikely. Infectious disease, granulomatosis, Langerhans cell histiocytosis, vasculitis, and systemic neoplastic diseases were excluded by the findings of a laboratory investigation, cerebrospinal fluid examination, and imaging studies. To make a definitive diagnosis, we performed a ventriculoscopic biopsy of the hypothalamic lesion. Histology revealed an infiltration of nonspecific lymphoplasmacytes with no evidence of neoplasm, which was consistent with a diagnosis of idiopathic hypothalamitis. Subsequently, the patient was treated with methylprednisolone pulse therapy followed by oral prednisolone. The hypothalamic lesion improved and remained undetectable after withdrawal of the prednisolone, suggesting that the glucocorticoid treatment was effective for isolated hypothalamitis while the patient remains dependent on the replacement of multiple hormones.
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Affiliation(s)
- Tetsuro Niri
- Department of Endocrinology and Metabolism, Nagasaki University Hospital, Nagasaki, Japan
| | - Ichiro Horie
- Department of Endocrinology and Metabolism, Nagasaki University Hospital, Nagasaki, Japan
| | - Hiromi Kawahara
- Department of Endocrinology and Metabolism, Nagasaki University Hospital, Nagasaki, Japan
| | - Takao Ando
- Department of Endocrinology and Metabolism, Nagasaki University Hospital, Nagasaki, Japan
| | - Noriaki Fukuhara
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Tokyo, Japan
| | - Hiroshi Nishioka
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Tokyo, Japan
| | - Naoko Inoshita
- Department of Pathology, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Tokyo, Japan
| | - Haruki Fujisawa
- Department of Endocrinology and Metabolism, Fujita Health University, Toyoake, Japan
| | - Atsushi Suzuki
- Department of Endocrinology and Metabolism, Fujita Health University, Toyoake, Japan
| | - Yoshihisa Sugimura
- Department of Endocrinology and Metabolism, Fujita Health University, Toyoake, Japan
| | - Norio Abiru
- Department of Endocrinology and Metabolism, Nagasaki University Hospital, Nagasaki, Japan
| | - Atsushi Kawakami
- Department of Endocrinology and Metabolism, Nagasaki University Hospital, Nagasaki, Japan
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Türe U, De Bellis A, Harput MV, Bellastella G, Topcuoglu M, Yaltirik CK, Cirillo P, Yola RN, Sav A, Kelestimur F. Hypothalamitis: A Novel Autoimmune Endocrine Disease. A Literature Review and Case Report. J Clin Endocrinol Metab 2021; 106:e415-e429. [PMID: 33104773 DOI: 10.1210/clinem/dgaa771] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Indexed: 12/18/2022]
Abstract
CONTEXT The relationship between the endocrine system and autoimmunity has been recognized for a long time and one of the best examples of autoimmune endocrine disease is autoimmune hypophysitis. A better understanding of autoimmune mechanisms and radiological, biochemical, and immunological developments has given rise to the definition of new autoimmune disorders including autoimmunity-related hypothalamic-pituitary disorders. However, whether hypothalamitis may occur as a distinct entity is still a matter of debate. EVIDENCE ACQUISITION Here we describe a 35-year-old woman with growing suprasellar mass, partial empty sella, central diabetes insipidus, hypopituitarism, and hyperprolactinemia. EVIDENCE SYNTHESIS Histopathologic examination of surgically removed suprasellar mass revealed lymphocytic infiltrate suggestive of an autoimmune disease with hypothalamic involvement. The presence of antihypothalamus antibodies to arginine vasopressin (AVP)-secreting cells (AVPcAb) at high titers and the absence of antipituitary antibodies suggested the diagnosis of isolated hypothalamitis. Some similar conditions have sometimes been reported in the literature but the simultaneous double finding of lymphocytic infiltrate and the presence of AVPcAb so far has never been reported. CONCLUSIONS We think that the hypothalamitis can be considered a new isolated autoimmune disease affecting the hypothalamus while the lymphocytic infundibuloneurohypophysitis can be a consequence of hypothalamitis with subsequent autoimmune involvement of the pituitary. To our knowledge this is the first observation of autoimmune hypothalamic involvement with central diabetes insipidus, partial empty sella, antihypothalamic antibodies and hypopituitarism.
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Affiliation(s)
- Uğur Türe
- Department of Neurosurgery, Yeditepe University School of Medicine, Istanbul, Turkey
| | - Annamaria De Bellis
- Unit of Endocrinology and Metabolic Diseases, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Mehmet Volkan Harput
- Department of Neurosurgery, Yeditepe University School of Medicine, Istanbul, Turkey
| | - Giuseppe Bellastella
- Unit of Endocrinology and Metabolic Diseases, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Melih Topcuoglu
- Department of Radiology, Yeditepe University School of Medicine, Istanbul, Turkey
| | - Cumhur Kaan Yaltirik
- Department of Neurosurgery, Yeditepe University School of Medicine, Istanbul, Turkey
| | - Paolo Cirillo
- Unit of Endocrinology and Metabolic Diseases, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Rima Nur Yola
- Medical Student, Yeditepe University School of Medicine, Istanbul, Turkey
| | - Aydın Sav
- Department of Pathology, Yeditepe University School of Medicine, Istanbul, Turkey
| | - Fahrettin Kelestimur
- Department of Endocrinology, Yeditepe University School of Medicine, Istanbul, Turkey
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Chiloiro S, Tartaglione T, Giampietro A, Bianchi A. Hypothalamitis and pituitary atrophy. HANDBOOK OF CLINICAL NEUROLOGY 2021; 181:149-159. [PMID: 34238454 DOI: 10.1016/b978-0-12-820683-6.00011-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Hypothalamitis is a rare inflammatory disorder involving the hypothalamus and classified as primary, or isolated, and secondary hypothalamitis. Secondary hypothalamitis although very rare is more common than the primary one and may occur in patients affected by autoimmune diseases such as autoimmune hypophysitis, systemic autoimmune diseases, infective diseases in patients affected by immune-deficit, paraneoplastic encephalitis, or in patients treated with immune checkpoint inhibitors. In accordance with the rarity of this disease, diagnosis and management of hypothalamitis prove to be challenging. The diagnosis requires a high index of clinical suspicion. The main symptoms may be: various degrees of hypopituitarism, neuropsychiatric and behavioral disorders, and disturbances of autonomic and metabolic regulation. Magnetic resonance images play a crucial role in the diagnosis of hypothalamitis and in the exclusion of a neoplastic lesion. Therapeutic management should be oriented according to the disease etiology. In most cases, after ruling out infective hypothalamitis, the mainstay of therapy consists of immunosuppressive treatment. Great attention should be paid to hormonal replacement therapy, if partial or total hypopituitarism is present, in particular in patients affected by diabetes insipidus, central hypoadrenalism and hypothyroidism. According to the complexity of this disease, a multidisciplinary approach is strongly advocated to reach an early diagnosis and an integrated therapy.
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Affiliation(s)
- Sabrina Chiloiro
- Pituitary Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Tommaso Tartaglione
- Department of Radiology and Diagnostic Imaging, Istituto Dermatopatico dell'Immacolata IRCCS, Rome, Italy; Institute of Radiology, Catholic University of the Sacred Heart, Rome, Italy
| | - Antonella Giampietro
- Pituitary Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Bianchi
- Pituitary Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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Wei Q, Yang G, Lue Z, Dou J, Zang L, Li Y, Du J, Gu W, Mu Y. Clinical aspects of autoimmune hypothalamitis, a variant of autoimmune hypophysitis: Experience from one center. J Int Med Res 2019; 48:300060519887832. [PMID: 31779500 PMCID: PMC8371234 DOI: 10.1177/0300060519887832] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Objective Autoimmune hypothalamitis (AHT) is a rare inflammatory disorder that involves
the hypothalamus. It remains unclear whether autoimmune hypophysitis (AH)
and AHT represent different diseases or different aspects of the same
disease. Thus, further investigation of AHT is required. Methods A retrospective review of medical and pathological records of AHT patients
from the Chinese PLA General Hospital were examined from January 1, 2005 to
May 1, 2017. Clinical data, treatments, and outcomes were investigated. Results Five female patients were identified (median age, 42.6 years). Symptoms
included central diabetes insipidus, hypopituitarism, hyperprolactinemia,
headache, and hypothalamic syndrome. The following hormonal deficits were
noted: follicle-stimulating hormone, luteinizing hormone,
adrenocorticotropic hormone, thyroid stimulating hormone, and growth
hormone. One patient underwent high-dose methylprednisolone pulse treatment
(HDMPT) and azathioprine plus intensity modulated radiation therapy (IMRT),
and two patients underwent HDMPT and two rounds of replacement therapy.
During follow-up, one patient died because of non-compliance with therapy
and the others were in remission or they recovered. Conclusions AHT had similar MRI results, pathology, and treatment compared with AH. Thus,
it may be a subtype of AH, and AHT patients may also show hypothalamic
syndrome.
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Affiliation(s)
- Qian Wei
- Department of Endocrinology, The First Medical Center of the Chinese PLA General Hospital, Beijing, China
| | - Guoqing Yang
- Department of Endocrinology, The First Medical Center of the Chinese PLA General Hospital, Beijing, China
| | - Zhaohui Lue
- Department of Endocrinology, The First Medical Center of the Chinese PLA General Hospital, Beijing, China
| | - Jingtao Dou
- Department of Endocrinology, The First Medical Center of the Chinese PLA General Hospital, Beijing, China
| | - Li Zang
- Department of Endocrinology, The First Medical Center of the Chinese PLA General Hospital, Beijing, China
| | - Yijun Li
- Department of Endocrinology, The First Medical Center of the Chinese PLA General Hospital, Beijing, China
| | - Jin Du
- Department of Endocrinology, The First Medical Center of the Chinese PLA General Hospital, Beijing, China
| | - Weijun Gu
- Department of Endocrinology, The First Medical Center of the Chinese PLA General Hospital, Beijing, China
| | - Yiming Mu
- Department of Endocrinology, The First Medical Center of the Chinese PLA General Hospital, Beijing, China
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Bustos M, Berger H, Hannoush ZC, Ayala A, Freire R, Kargi AY. Anti-Ma-1 and Anti-Ma-2 Antibodies in Isolated Fatal Hypothalamitis. J Endocr Soc 2018; 2:106-111. [PMID: 29379898 PMCID: PMC5783447 DOI: 10.1210/js.2017-00354] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 12/28/2017] [Indexed: 11/19/2022] Open
Abstract
Lymphocytic hypothalamitis (LHT) is a rare disease characterized by pituitary dysfunction, autonomic instability, metabolic disturbances, and neuropsychiatric disorders. We report the case of a 30-year-old man found to have LHT that progressed despite treatment with methylprednisolone and intravenous immunoglobulin (IVIG). A literature review was conducted to identify prior studies pertaining to LHT. Our patient presented with several weeks of fatigue, cold intolerance, weight loss, confusion, and headache. Laboratory tests were consistent with panhypopituitarism. Brain magnetic resonance imaging revealed an infiltrative enhancing mass in the area of the hypothalamus, and stereotactic biopsy findings showed reactive inflammatory changes. A course of hormone replacement (levothyroxine), methylprednisolone, and IVIG was initiated. The patient’s course was complicated by a fatal tonsillar herniation. Autopsy revealed LHT. The diagnosis and management of autoimmune LHT are challenging. The entity should be considered in the setting of panhypopituitarism with a hypothalamic mass. Differentiating paraneoplastic and nonparaneoplastic hypothalamitis should be established for management and prognosis. Definitive treatment remains unclear; treatment with corticosteroids should be attempted, followed by consideration of other immunosuppressive agents, such as rituximab. If a paraneoplastic syndrome is suspected, management should also be directed toward the primary tumor.
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Affiliation(s)
- Mario Bustos
- University of Miami Miller School of Medicine at Holy Cross Hospital, Fort Lauderdale, Florida 33308
| | - Hara Berger
- Division of Endocrinology, Diabetes and Metabolism, University of Miami Miller School of Medicine, Miami, Florida 33136
| | - Zeina Carolina Hannoush
- Division of Endocrinology, Diabetes and Metabolism, University of Miami Miller School of Medicine, Miami, Florida 33136
| | - Alejandro Ayala
- Division of Endocrinology, Diabetes and Metabolism, University of Miami Miller School of Medicine, Miami, Florida 33136
| | - Rochelle Freire
- Department of Pathology, University of Miami Miller School of Medicine, Miami, Florida 33136
| | - Atil Yilmaz Kargi
- Division of Endocrinology, Diabetes and Metabolism, University of Miami Miller School of Medicine, Miami, Florida 33136
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10
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Long-Standing Isolated Autoimmune Hypothalamitis Diagnosed with Endoscopic Transventricular Biopsy. World Neurosurg 2017. [DOI: 10.1016/j.wneu.2017.06.055] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Polledo L, Oliveira M, Adamany J, Graham P, Baiker K. Hypophysitis, Panhypopituitarism, and Hypothalamitis in a Scottish Terrier Dog. J Vet Intern Med 2017; 31:1527-1532. [PMID: 28745808 PMCID: PMC5598883 DOI: 10.1111/jvim.14790] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 05/18/2017] [Accepted: 06/22/2017] [Indexed: 12/27/2022] Open
Abstract
A 6‐year old male neutered Scottish Terrier was referred with a 1 week history of progressive lethargy and anorexia. Neurological examination localized a lesion to the forebrain and hormonal testing showed panhypopituitarism. Magnetic resonance imaging (MRI) of the brain revealed a rounded, well‐defined, suprasellar central mass. The mass was slightly hyperintense to the cortical grey matter on T2‐weighted (T2W), hypointense on T1‐weighted (T1W) images and without T2* signal void. There was a central fusiform enhancement of the mass after contrast administration which raised the suspicion of a pituitary neoplasm. Rapid deterioration of the dog prevented further clinical investigations. Histopathologic examination revealed a lymphocytic panhypophysitis of unknown origin suspected autoimmune involving the hypothalamus (hypothalamitis). This is a unique case report of a dog presenting with inflammatory hypophysitis and hypothalamitis of suspected autoimmune origin with detailed clinical, MRI, histology and immunohistochemistry findings.
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Affiliation(s)
- L Polledo
- Pathology Department, Veterinary Medicine and Science, University of Nottingham, Nottingham, UK
| | | | | | - P Graham
- Pathology Department, Veterinary Medicine and Science, University of Nottingham, Nottingham, UK
| | - K Baiker
- Pathology Department, Veterinary Medicine and Science, University of Nottingham, Nottingham, UK
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Xu C, Ricciuti A, Caturegli P, Keene CD, Kargi AY. Autoimmune lymphocytic hypophysitis in association with autoimmune eye disease and sequential treatment with infliximab and rituximab. Pituitary 2015; 18:441-7. [PMID: 25224140 DOI: 10.1007/s11102-014-0592-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Autoimmune lymphocytic hypophysitis associates predominantly with other autoimmune endocrinopathies and is most commonly treated with glucocorticoids and/or decompressive pituitary surgery. Here we report a new association and treatment modality for lymphocytic hypophysitis. METHODS A 52-year-old woman presented with scleritis, uveitis, facial palsy, and central diabetes insipidus, accompanied by thickened pituitary stalk and enlarged pituitary on cranial MRI. Neurosarcoidosis was suspected and treatment with glucocorticoids and methotrexate initiated. Since symptoms persisted, infliximab (a monoclonal antibody that antagonizes tumor necrosis factor alpha) was added to her regimen. The patient initially improved but after 6 months developed recurrent pituitary enlargement, bilateral optic neuritis, and panhypopituitarism. To ascertain the nature of the pituitary lesion, she underwent transsphenoidal biopsy, which revealed lymphocytic hypophysitis with numerous CD20 positive B lymphocytes. The pathological finding suggested to us that administration of rituximab (a monoclonal antibody that lyzes B cells expressing CD20) could be useful. Following two courses of rituximab, the pituitary mass resolved and the corticotroph axis partially recovered. The patient has remained in remission during 3 years of follow up. CONCLUSION This is the first report of hypophysitis occurring with the triad of scleritis, uveitis, and optic neuritis, as well as the first immunotherapy based on the sequential use of infliximab and rituximab.
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Affiliation(s)
- Chengyu Xu
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA,
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