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Baral B, Sharma M, Khadka R, Naveed O, Bekele A. Postpartum Hypophysitis: A Case Report and a Literature Review. Cureus 2024; 16:e59396. [PMID: 38817522 PMCID: PMC11139491 DOI: 10.7759/cureus.59396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 06/01/2024] Open
Abstract
Hypophysitis is a rare pituitary gland disease primarily seen in females of reproductive age. Patients can present with various non-specific symptoms, which makes diagnosis challenging. Appropriate endocrine workup supplemented with magnetic resonance imaging (MRI) helps establish a diagnosis. We present a case of a 22-year-old postpartum female who came with nausea, vomiting, and abdominal pain. Global endocrine insufficiency was seen in the laboratory workup, and an MRI confirmed the diagnosis of hypophysitis. She was treated with steroid and thyroid hormone supplementation.
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Affiliation(s)
| | - Monica Sharma
- Internal Medicine, Saint Agnes Hospital, Baltimore, USA
| | - Ranjan Khadka
- Internal Medicine, Saint Agnes Hospital, Baltimore, USA
| | - Ossama Naveed
- Internal Medicine, Ross University School of Medicine, New Jersey, USA
| | - Ammer Bekele
- Internal Medicine, Saint Agnes Hospital, Baltimore, USA
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Катамадзе НН, Цкаева АА, Пигарова ЕА, Дзеранова ЛК, Тарбаева НВ. [Differential diagnosis and tactics of managing a patient with primary hypophysitis on the example of a clinical case]. PROBLEMY ENDOKRINOLOGII 2024; 69:54-62. [PMID: 38311995 PMCID: PMC10851037 DOI: 10.14341/probl13311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/26/2023] [Accepted: 06/29/2023] [Indexed: 02/06/2024]
Abstract
In recent years, there has been a significant increase in the prevalence of autoimmune endocrinopathies, which are known to affect various levels of the endocrine system, including the pituitary gland. Hypophysitis is a general term used to describe any form of sellar and suprasellar inflammation that leads to structural changes in the hypothalamic-pituitary region and manifests itself in varying degrees of hormonal deficiency of the anterior and posterior pituitary glands. To date, there is a primary form of hypophysitis, which occurs as a result of an autoimmune lesion directly to the pituitary gland, and a secondary form of hypophysitis, which occurs as a result of the presence of a systemic autoimmune disease. Regardless of the etiology, patients with hypophysitis show various signs and symptoms caused by an inflammatory process in the pituitary gland, which can lead to the development of hypopituitarism, compression of the sellar and parasellar structures. MRI is currently the best non-invasive diagnostic tool for diagnosing hypopituitarism, however, the diagnosis can be made with certainty only by histological examination of the pituitary tissue, which requires an invasive approach, which greatly reduces the feasibility of this procedure. In this article, we present a patient with MRI showing signs of hypophysitis in the absence of clear clinical symptoms.
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Affiliation(s)
- Н. Н. Катамадзе
- Национальный медицинский исследовательский центр эндокринологии
| | - А. А. Цкаева
- Национальный медицинский исследовательский центр эндокринологии
| | - Е. А. Пигарова
- Национальный медицинский исследовательский центр эндокринологии
| | - Л. К. Дзеранова
- Национальный медицинский исследовательский центр эндокринологии
| | - Н. В. Тарбаева
- Национальный медицинский исследовательский центр эндокринологии
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Galligan A, Iravani A, Lasocki A, Wallace R, Weppler AM, Sachithanandan N, Chiang C, Colman PG, Wentworth J, Spain L, Au-Yeung G, Lee B, Kay TWH, Hicks RJ, Sandhu S, Krishnamurthy B. Imaging for assessment of cancer treatment response to immune checkpoint inhibitors can be complementary in identifying hypophysitis. Front Endocrinol (Lausanne) 2023; 14:1295865. [PMID: 38093958 PMCID: PMC10716424 DOI: 10.3389/fendo.2023.1295865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 11/06/2023] [Indexed: 12/18/2023] Open
Abstract
Introduction Hypophysitis is reported in 8.5%-14% of patients receiving combination immune checkpoint inhibition (cICI) but can be a diagnostic challenge. This study aimed to assess the role of routine diagnostic imaging performed during therapeutic monitoring of combination anti-CTLA-4/anti-PD-1 treatment in the identification of hypophysitis and the relationship of imaging findings to clinical diagnostic criteria. Methods This retrospective cohort study identified patients treated with cICI between January 2016 and January 2019 at a quaternary melanoma service. Medical records were reviewed to identify patients with a documented diagnosis of hypophysitis based on clinical criteria. Available structural brain imaging with magnetic resonance imaging (MRI) or computed tomography (CT) of the brain and 2-deoxy-2-[18F]fluoro-D-glucose positron emission tomography with computed tomography (FDG-PET/CT) were assessed retrospectively. The main radiological outcome measures were a relative change in pituitary size or FDG uptake temporally attributed to cICI. Results There were 162 patients (median age 60 years, 30% female) included. A total of 100 and 134 had serial CT/MRI of the brain and FDG-PET/CT, respectively. There were 31 patients who had a documented diagnosis of hypophysitis and an additional 20 who had isolated pituitary imaging findings. The pituitary gland enlargement was mild, and the largest absolute gland size was 13 mm, with a relative increase of 7 mm from baseline. There were no cases of optic chiasm compression. Pituitary enlargement and increased FDG uptake were universally transient. High-dose glucocorticoid treatment for concurrent irAEs prevented assessment of the pituitary-adrenal axis in 90% of patients with isolated imaging findings. Conclusion Careful review of changes in pituitary characteristics on imaging performed for assessment of therapeutic response to iICI may lead to increased identification and more prompt management of cICI-induced hypophysitis.
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Affiliation(s)
- Anna Galligan
- Immunology and Diabetes Unit, St Vincent’s Institute of Medical Research, Melbourne, VIC, Australia
- Department of Endocrinology and Diabetes, St Vincent’s Hospital, Melbourne, VIC, Australia
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Amir Iravani
- Department of Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia
- Department of Radiology, University of Washington, Seattle, WA, United States
| | - Arian Lasocki
- Department of Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia
| | - Roslyn Wallace
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Alison M. Weppler
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Nirupa Sachithanandan
- Department of Endocrinology and Diabetes, St Vincent’s Hospital, Melbourne, VIC, Australia
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
- Department of Internal Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Cherie Chiang
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
- Department of Internal Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Diabetes and Endocrinology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Peter G. Colman
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
- Department of Diabetes and Endocrinology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - John Wentworth
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
- Department of Diabetes and Endocrinology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Lavinia Spain
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - George Au-Yeung
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Belinda Lee
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Thomas W. H. Kay
- Immunology and Diabetes Unit, St Vincent’s Institute of Medical Research, Melbourne, VIC, Australia
- Department of Endocrinology and Diabetes, St Vincent’s Hospital, Melbourne, VIC, Australia
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Rodney J. Hicks
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Shahneen Sandhu
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Balasubramanian Krishnamurthy
- Immunology and Diabetes Unit, St Vincent’s Institute of Medical Research, Melbourne, VIC, Australia
- Department of Endocrinology and Diabetes, St Vincent’s Hospital, Melbourne, VIC, Australia
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
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Wright K, Kim H, Hill T, Lee M, Orillac C, Mogar N, Pacione D, Agrawal N. Preoperative differentiation of hypophysitis and pituitary adenomas using a novel clinicoradiologic scoring system. Pituitary 2022; 25:602-614. [PMID: 35622211 DOI: 10.1007/s11102-022-01232-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2022] [Indexed: 01/29/2023]
Abstract
PURPOSE Hypophysitis can clinically and radiologically mimic other nonfunctioning masses of the sella turcica, complicating preoperative diagnosis. While sellar masses may be treated surgically, hypophysitis is often treated medically, so differentiating between them facilitates optimal management. The objective of our study was to develop a scoring system for the preoperative diagnosis of hypophysitis. METHODS A thorough literature review identified published hypophysitis cases, which were compared to a retrospective group of non-functioning pituitary adenomas (NFA) from our institution. A preoperative hypophysitis scoring system was developed and internally validated. RESULTS Fifty-six pathologically confirmed hypophysitis cases were identified in the literature. After excluding individual cases with missing values, 18 hypophysitis cases were compared to an age- and sex-matched control group of 56 NFAs. Diabetes insipidus (DI) (p < 0.001), infundibular thickening (p < 0.001), absence of cavernous sinus invasion (CSI) (p < 0.001), relation to pregnancy (p = 0.002), and absence of visual symptoms (p = 0.007) were significantly associated with hypophysitis. Stepwise logistic regression identified DI and infundibular thickening as positive predictors of hypophysitis. CSI and visual symptoms were negative predictors. A 6-point hypophysitis-risk scoring system was derived: + 2 for DI, + 2 for absence of CSI, + 1 for infundibular thickening, + 1 for absence of visual symptoms. Scores ≥ 3 supported a diagnosis of hypophysitis (AUC 0.96, sensitivity 100%, specificity 75%). The scoring system identified 100% of hypophysitis cases at our institution with an estimated 24.7% false-positive rate. CONCLUSIONS The proposed scoring system may aid preoperative diagnosis of hypophysitis, preventing unnecessary surgery in these patients.
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Affiliation(s)
- Kyla Wright
- NYU Grossman School of Medicine, NYU Langone Health, 1st Ave, New York, NY, 10016, USA
| | - Hyon Kim
- Division of Endocrinology, Metabolism and Nutrition, Rutgers-Robert Wood Johnson Medical School, 125 Paterson St, New Brunswick, NJ, 0890, USA
| | - Travis Hill
- Department of Neurosurgery, NYU Grossman School of Medicine, 550 1st Avenue, New York, NY, 10016, USA
| | - Matthew Lee
- Department of Radiology, NYU Grossman School of Medicine, 550 1st Avenue, New York, NY, 10016, USA
| | - Cordelia Orillac
- Department of Neurosurgery, NYU Grossman School of Medicine, 550 1st Avenue, New York, NY, 10016, USA
| | - Nikita Mogar
- Department of Medicine, NYU Grossman School of Medicine, 550 1st Avenue, New York, NY, 10016, USA
| | - Donato Pacione
- Department of Neurosurgery, NYU Langone Medical Center, 530 1st Ave Skirball Suite 8R, New York, NY, 10016, USA
| | - Nidhi Agrawal
- Division of Endocrinology, Diabetes and Metabolism, NYU Langone Medical Center, 550 1st Avenue, New York, NY, 10016, USA.
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Abstract
OBJECTIVE Hypophysitis is considered a rare inflammatory disease of the pituitary gland. For a long time, primary autoimmune hypophysitis has stood out as the most relevant type of hypophysitis. However, with the advent of immunotherapy for the treatment of malignancies and identification of hypophysitis as an immune-related adverse event, hypophysitis has garnered increasing interest and recognition. Therefore, awareness, early recognition, and appropriate management are becoming important as the indication for immunomodulatory therapies broaden. METHODS In this review, we discuss the epidemiology, diagnosis, and treatment of hypophysitis with a focus on recent data and highlight subtypes of particular interest while recognizing the gaps in knowledge that remain. RESULTS Regardless of cause, symptoms and signs of hypophysitis may be related to mass effect (headache and visual disturbance) and hormonal disruption that warrant prompt evaluation. In the vast majority of cases, a diagnosis of hypophysitis can be made presumptively in the appropriate clinical context with radiologic findings consistent with hypophysitis and after the exclusion of other causes. CONCLUSION Although subtle differences currently exist in management and outcome expectations between primary and secondary causes of hypophysitis, universally, treatment is aimed at symptom management and hormonal replacement therapy.
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Chiloiro S, Capoluongo ED, Angelini F, Mariotti F, Grande G, Stigliano E, Vincenzoni F, Bianchi A, Giampietro A, Milardi D, Tartaglione T, Urbani A, Pontecorvi A, De Marinis L, Di Zenzo G. Autoantibody reactivity profile of primary autoimmune hypophysitis patients: preliminary results. Endocrine 2022; 76:224-227. [PMID: 34797510 DOI: 10.1007/s12020-021-02937-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 10/31/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Sabrina Chiloiro
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, Italy.
- Endocrinology and Diabetology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.
| | - Ettore Domenico Capoluongo
- Department of Molecular Medicine and Medical Biotechnology, Università Federico II-CEINGE, Advanced Biotechnology, Naples, Italy
| | - Flavia Angelini
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, Italy
| | | | - Giuseppe Grande
- International Scientific Institute "Paul VI", ISI, Fondazione Policlinico 'A. Gemelli' IRCCS, 00100, Rome, Italy
| | - Egidio Stigliano
- Department di Pathology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Federica Vincenzoni
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, 00168, Roma, Italy
- Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Roma, Italy
| | - Antonio Bianchi
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, Italy
- Endocrinology and Diabetology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Antonella Giampietro
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, Italy
- Endocrinology and Diabetology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Domenico Milardi
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, Italy
- Endocrinology and Diabetology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Tommaso Tartaglione
- Department of Radiological and Haematological Sciences, Università Cattolica del Sacro Cuore, Roma, Italy
- Department of Radiology and Diagnostic Imaging, IDI-IRCCS, Istituto Dermopatico dell'Immacolata, Roma, Italy
| | - Andrea Urbani
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, 00168, Roma, Italy
- Dipartimento di Scienze Laboratoristiche ed Infettivologiche, UOC Chimica, Biochimica e Biologia Molecolare Clinica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Alfredo Pontecorvi
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, Italy
- Endocrinology and Diabetology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Laura De Marinis
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, Italy
- Endocrinology and Diabetology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
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Krishnappa B, Shah R, Sarathi V, Lila AR, Sehemby MK, Patil VA, Sankhe S, Shah N, Bandgar T. Early Pulse Glucocorticoid Therapy and Improved Hormonal Outcomes in Primary Hypophysitis. Neuroendocrinology 2022; 112:186-195. [PMID: 33744880 DOI: 10.1159/000516006] [Citation(s) in RCA: 2] [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] [Received: 12/10/2020] [Accepted: 03/19/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The role of glucocorticoids in primary autoimmune hypophysitis (PAH) has been fraught with variability in regimens, leading to inconsistent outcomes in terms of anterior pituitary (AP) hormonal recovery. Hence, we aimed to compare the clinical, hormonal, and radiological outcomes of a standardized high-dose glucocorticoid therapy group (GTG) in PAH with a matched clinical observation group (COG). METHODS Thirty-nine retrospective patients with PAH evaluated and treated at a single center in western India from 1999 to 2019 with a median follow-up duration of 48 months were subdivided into the GTG (n = 18) and COG (n = 21) and compared for the outcomes. RESULTS Baseline demographic, hormonal, and radiological features matched between the groups, except pituitary height, which was significantly higher in GTG. Cortisol, thyroid, and gonadal axes were affected in 25 (64%), 22 (56%), and 21 (54%) patients, respectively, and central diabetes insipidus was seen in 7 (18%) patients. Panhypophysitis (PH) was the most common radiological subtype (n = 33, 84.6%). Resolution of mass effects was similar in both groups. Overall and complete AP hormonal recovery was significantly higher in the GTG than in the COG (12/14 [85.7%) vs. 6/14 [42.8%], p = 0.02; 10/14 [71.4%] vs. 1/14 [7.7%], p = 0.0007, respectively). Proportion of cases with empty sella were significantly higher in the COG (9/20 [45%] vs 1/17 [5.9%], p = 0.001). Among PH patients in the GTG (n = 17), we found duration from symptoms onset to treatment as the predictor of recovery. CONCLUSION In a PH subtype-predominant PAH cohort, a standardized high-dose glucocorticoid regimen resulted in higher overall and complete AP hormonal recovery than that in the COG. Initiation of glucocorticoids in the early disease course may have been contributory.
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Affiliation(s)
- Brijesh Krishnappa
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Ravikumar Shah
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Vijaya Sarathi
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research center, Bengaluru, India
| | - Anurag Ranjan Lila
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Manjeet Kaur Sehemby
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Virendra A Patil
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Shilpa Sankhe
- Department of Radiology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Nalini Shah
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Tushar Bandgar
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, India
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de Vries F, van Furth WR, Biermasz NR, Pereira AM. Hypophysitis: A comprehensive overview. Presse Med 2021; 50:104076. [PMID: 34687912 DOI: 10.1016/j.lpm.2021.104076] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/27/2021] [Accepted: 10/12/2021] [Indexed: 10/20/2022] Open
Abstract
Hypophysitis is defined as inflammation of the pituitary gland. It is a heterogeneous condition as it can originate from different parts of the pituitary gland, can be caused by different pathophysiological processes, and can be isolated or the manifestation of a underlying systemic disease. Hypophysitis usually presents with endocrine deficiencies, including diabetes insipidus, with varying patterns. A subset of patients presents with mass effects. The last decades major progress has been made in the understanding of this disease. New forms are now recognized, new diagnostics are being developed, and specific treatments are proposed. This review provides an overview of the current knowledge on hypophysitis using an aetiology-based approach and provides the clinician with a stepwise approach to the patient with (suspected) hypophysitis.
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Affiliation(s)
- F de Vries
- Department of Neurosurgery and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands; Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands
| | - W R van Furth
- Department of Neurosurgery and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands
| | - N R Biermasz
- Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands
| | - A M Pereira
- Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands
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Chiloiro S, Russo F, Tartaglione T, Capoluongo ED. Molecular and Genetic Immune Biomarkers of Primary and Immune-Therapy Induced Hypophysitis: From Laboratories to the Clinical Practice. J Pers Med 2021; 11:1026. [PMID: 34683167 PMCID: PMC8537090 DOI: 10.3390/jpm11101026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 09/15/2021] [Accepted: 10/12/2021] [Indexed: 12/12/2022] Open
Abstract
Hypophysitis is a rare and potentially life-threatening disease, characterized by an elevated risk of complications, such as the occurrence of acute central hypoadrenalism, persistent hypopituitarism, or the extension of the inflammatory process to the neighboring neurological structures. In recent years, a large number of cases has been described. The diagnosis of hypophysitis is complex because it is based on clinical and radiological criteria. Due to this, the integration of molecular and genetic biomarkers can help physicians in the diagnosis of hypophysitis and play a role in predicting disease outcome. In this paper, we review current knowledge about molecular and genetic biomarkers of hypophysitis with the aim of suggesting a possible integration of these biomarkers in clinical practice.
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Affiliation(s)
- Sabrina Chiloiro
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
- UOC Endocrinology and Diabetology, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy
| | - Filippo Russo
- Department of Molecular Medicine and Medical Biotechnology, Federico II University-CEINGE, 80126 Naples, Italy;
| | - Tommaso Tartaglione
- Department of Radiological and Haematological Sciences, Università Cattolica del Sacro Cuore, 00168 Roma, Italy;
- Department of Radiology and Diagnostic Imaging, Istituto Dermopatico dell’Immacolata, IDI-IRCCS, 00167 Roma, Italy
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Chiloiro S, Giampietro A, Angelini F, Arena V, Stigliano E, Tartaglione T, Mattogno PP, D'Alessandris QG, Lauretti L, Pontecorvi A, De Marinis L, Bianchi A. Markers of humoral and cell-mediated immune response in primary autoimmune hypophysitis: a pilot study. Endocrine 2021; 73:308-315. [PMID: 33484410 PMCID: PMC8263439 DOI: 10.1007/s12020-021-02612-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 01/05/2021] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Primary autoimmune hypophysitis (PAHs) is a rare inflammatory disease of the pituitary gland. Although largely investigated, the pathogenesis of PAH is not completely clarified. We aimed to investigate the immune response in PAHs. MATERIAL AND METHODS Serum anti-pituitary and anti-hypothalamus antibodies (respectively APAs and AHAs) were investigated though an indirect immunofluorescence on monkey hypophysis and hypothalamus slides, serum cytokines though an array membrane and cell-mediated immunity though the white blood cells count. RESULTS Nineteen PAH cases entered the study. APA or AHA were identified in all cases. APA were detected in 13 patients (68.4%) and AHA in 13 patients (68.4%). Ten patients (52.6%) were simultaneously positive for both APA and AHA. The prevalence of APAs and AHAs was higher as compared to those observed in 50 health controls (respectively 14% p < 0.001 and 24% p = 0.004) and in 100 not-secreting pituitary adenoma (NFPAs) (respectively 22% p = 0.002 and 8% p < 0.001). Similarly, the prevalence of simultaneous positivity for APA and AHA (52.9%) was higher as compared to the those detected in patients affected by NFPAs (0%; p < 0.001) and in health controls (16% p = 0.002). No differences were identified between PAHs and controls at qualitative and quantitative analysis of serum cytokines and white blood cells count. CONCLUSIONS This study suggest that APA and AHA may be detected in an high percentage of PAH cases and that their simultaneous identification may be useful for the differential diagnosis between PAH and NFPAs, in an appropriate clinical context.
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Affiliation(s)
- Sabrina Chiloiro
- Pituitary Unit, Department of Endocrinology and Diabetes, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Dipartimento di Medicina e Chirurgia traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonella Giampietro
- Pituitary Unit, Department of Endocrinology and Diabetes, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Dipartimento di Medicina e Chirurgia traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Flavia Angelini
- Laboratory of Vascular Biology and Genetics, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vincenzo Arena
- Department di Pathology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Istitute of Pathology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Egidio Stigliano
- Department di Pathology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Istitute of Pathology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Tommaso Tartaglione
- Radiology Unit, Istituto Dermopatico dell'Immacolata-IRCCS-FLMM, Rome, Italy
| | - Pier Paolo Mattogno
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Quintino Giorgio D'Alessandris
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Liverana Lauretti
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alfredo Pontecorvi
- Pituitary Unit, Department of Endocrinology and Diabetes, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Dipartimento di Medicina e Chirurgia traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Laura De Marinis
- Pituitary Unit, Department of Endocrinology and Diabetes, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy.
- Dipartimento di Medicina e Chirurgia traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Antonio Bianchi
- Pituitary Unit, Department of Endocrinology and Diabetes, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Dipartimento di Medicina e Chirurgia traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
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11
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Angelousi A, Mytareli C, Xekouki P, Kassi E, Barkas K, Grossman A, Kaltsas G. Diabetes insipidus secondary to sellar/parasellar lesions. J Neuroendocrinol 2021; 33:e12954. [PMID: 33769630 DOI: 10.1111/jne.12954] [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] [Received: 12/27/2020] [Revised: 01/24/2021] [Accepted: 02/09/2021] [Indexed: 12/25/2022]
Abstract
Diabetes insipidus (DI) is a well-recognised transient or permanent complication following transsphenoidal surgery for pituitary adenomas or other sellar/parasellar lesions. However, data regarding the prevalence of pre-operative DI in sellar/parasellar lesions other than pituitary adenomas are scarce. We systematically reviewed the existing data for defining the prevalence of DI before any treatment in adult patients with sellar/parasellar lesions, excluding pituitary adenomas and metastatic lesions. In total, 646 patients with sellar/parasellar lesions presenting with DI at diagnosis were identified. The most common pathologies of sellar/parasellar lesions presenting with DI at diagnosis were lymphocytic hypophysitis (26.5%), craniopharyngiomas (23.4%), Langerhans's cell histiocytosis (18.9%) and Rathke's cleft cyst (12.7%), accounting for the vast majority (more than 80%) of these lesions. Overall, DI at diagnosis was found in 23.4% of all patients with sellar/parasellar lesions, albeit with a wide range from 10.6% to 76.7%, depending on the nature of the pathology. The highest prevalence of DI was found in less commonly encountered lesions namely germ-cell tumours (76.7%), abscesses (55.4%) and neurosarcoidosis (54.5%), each accounting for less than 3% of all sellar/parasellar lesions. Most DI cases (68.8%) were associated with anterior pituitary hormonal deficiencies, in contrast to pituitary adenomas that rarely present with DI. The enlargement and enhancement of the pituitary stalk were the most common findings on magnetic resonance imaging besides the loss of the high signal of the posterior pituitary on T1-weighted images. Resolution of DI spontaneously or following systemic and surgical management occurred in 22.4% of cases. Post-operative DI, not evident before surgery, was found in 27.8% of non-adenomatous sellar/parasellar lesions, and was transient in 11.6% of them. Besides distinctive imaging features and symptoms, early recognition of DI in such lesions is important because it directs the diagnosis towards a non-adenomatous sellar/parasellar tumour and the early initiation of appropriate treatment.
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Affiliation(s)
- Anna Angelousi
- 1st Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Chrysoula Mytareli
- 1st Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Paraskevi Xekouki
- Endocrinology and Diabetes Clinic, University General Hospital of Heraklion, Heraklion, Greece
| | - Eva Kassi
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, Athens, Greece
- 1st Department of Propaedeutic and Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Barkas
- Department of Neurosurgery, General Hospital of Nikaia-Pireas, Agios Panteleimon, Athens, Greece
| | - Ashley Grossman
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
- Centre for Endocrinology, Barts and the London School of Medicine, London, UK
| | - Gregory Kaltsas
- 1st Department of Propaedeutic and Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
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12
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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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13
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Caranci F, Leone G, Ponsiglione A, Muto M, Tortora F, Muto M, Cirillo S, Brunese L, Cerase A. Imaging findings in hypophysitis: a review. Radiol Med 2019; 125:319-328. [PMID: 31863360 DOI: 10.1007/s11547-019-01120-x] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 11/28/2019] [Indexed: 12/24/2022]
Abstract
Hypophysitis (HP) is a rare acute or chronic inflammatory condition of the pituitary gland. The greatest challenge in the management of HP is establishing a diagnosis through clinical criteria and non-invasive methods and predicting the patients' clinical outcome. The aim of this review is to describe the neuroradiological findings of this rare disease, providing some information regarding the possible differential diagnosis in order to avoid unnecessary surgery. Gadolinium-enhanced pituitary magnetic resonance imaging (MRI) is considered the neuroradiological investigation of choice. The features suggestive for HP include an enlarged triangular- or dumbbell-shaped gland with a thickened and not obviously deviated stalk, further supported by the absence of posterior pituitary bright spot on T1weighted images, particularly in patients presenting with diabetes insipidus. Contrast enhancement pattern is quite variable; dural enhancement has been reported in some cases after intravenous contrast administration. The characterization of the unusual sellar mass is not straightforward and generally results in a wide differential. HP should be primarily differentiated from pituitary adenomas (including pituitary apoplexy), from pituitary metastases, and from other sellar and parasellar tumors, e.g., craniopharyngiomas, germinomas, gliomas, lymphomas, meningiomas, pituicytomas, chordomas, teratomas, dermoids and epidermoids, Rathke's cleft cysts, and abscesses. In patients suspected for secondary forms related to systemic pathology, additional imaging is helpful in identifying other involved sites. Neuroradiologists need to know MRI appearance of this rare disease, as well as its typical symptoms and serological markers. A strict collaboration with endocrinologists and neurosurgeons is mandatory in order to reach a definitive diagnosis, allowing to promptly initiating an appropriate treatment.
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Affiliation(s)
- Ferdinando Caranci
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Via Francesco De Sanctis 1, 86100, Campobasso, Italy.
| | - Giuseppe Leone
- Department of Neuroradiology, A.O.R.N. Cardarelli, Naples, Italy
| | - Andrea Ponsiglione
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Massimo Muto
- Department of Neuroradiology, A.O.R.N. Cardarelli, Naples, Italy.,Department of Neuroscience and Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
| | - Fabio Tortora
- Department of Precision Medicine, School of Medicine, "Luigi Vanvitelli" University of Campania, Naples, Italy
| | - Mario Muto
- Department of Neuroradiology, A.O.R.N. Cardarelli, Naples, Italy
| | - Sossio Cirillo
- Department of Precision Medicine, School of Medicine, "Luigi Vanvitelli" University of Campania, Naples, Italy
| | - Luca Brunese
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Via Francesco De Sanctis 1, 86100, Campobasso, Italy
| | - Alfonso Cerase
- Department of Neurological and Sensorineural Sciences, Azienda ospedaliero-universitaria Senese, Policlinico "Santa Maria alle Scotte", Siena, Italy
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14
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Gubbi S, Hannah-Shmouni F, Verbalis JG, Koch CA. Hypophysitis: An update on the novel forms, diagnosis and management of disorders of pituitary inflammation. Best Pract Res Clin Endocrinol Metab 2019; 33:101371. [PMID: 31866206 PMCID: PMC7078033 DOI: 10.1016/j.beem.2019.101371] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Hypophysitis is a heterogeneous condition that leads to inflammation of the sella and/or suprasellar region, potentially resulting in hormonal deficiencies and/or mass effects. A preponderance of hypophysitis subtypes have an underlying autoimmune aetiology. The overall incidence and prevalence of hypophysitis has dramatically increased over the past decade, mainly due to increased awareness of the condition in the medical community, improvements in imaging techniques, and a rise in the occurrence of certain forms of hypophysitis such as IgG4 hypophysitis (IgG4Hy) and immune checkpoint inhibitor induced hypophysitis (ICIHy). The clinical presentation varies from an asymptomatic condition to a fatal disease often as a result of electrolyte abnormalities due to glucocorticoid deficiency in the context of adrenal crisis from central adrenal insufficiency. Milder forms of hypophysitis are treated with replacement of deficient hormones while more acute presentations with mass effects require glucocorticoid therapy, immunosuppressive therapy or surgery. Timely diagnosis and interventions are keys to prevention of the lethal complications of this disease. In this review, we provide an update on the recent advances in the field of pituitary autoimmunity, with an emphasis on autoimmune hypophysitis and novel forms of hypophysitis such as anti-PIT1 hypophysitis, IgG4Hy and ICIHy.
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Affiliation(s)
- Sriram Gubbi
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH), Bethesda, MD, 20892, USA.
| | - Fady Hannah-Shmouni
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, 20892, USA.
| | - Joseph G Verbalis
- Division of Endocrinology and Metabolism, Department of Medicine, Georgetown University Medical Center, Washington, DC, 20007, USA.
| | - Christian A Koch
- The University of Tennessee Health Science Center, Memphis, TN, 38163, USA; Fox Chase Cancer Center, Philadelphia, PA, USA.
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15
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Chiloiro S, Capoluongo ED, Tartaglione T, Giampietro A, Bianchi A, Giustina A, Pontecorvi A, De Marinis L. The Changing Clinical Spectrum of Hypophysitis. Trends Endocrinol Metab 2019; 30:590-602. [PMID: 31345630 DOI: 10.1016/j.tem.2019.06.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 06/16/2019] [Accepted: 06/21/2019] [Indexed: 12/17/2022]
Abstract
Hypophysitis is a rare and potentially life-threatening disease, characterized by an elevated risk of complications, such as occurrence of acute central hypoadrenalism, persistent hypopituitarism, or extension of the inflammatory process to the neighboring neurological structures. In recent years, a large number of patients have been described as being affected by hypophysitis, due to the increased administration of immuno-chemotherapies. At the present time, the heterogeneous nature of hypophysitis diagnostic criteria and of the treatment protocols makes the management of affected patients difficult. We review the current data and evidence on primary and secondary hypophysitis, in order to suggest a diagnostic and therapeutic protocol that should be focused on a multidisciplinary approach, for reaching a prompt diagnosis and an appropriate and safe treatment.
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Affiliation(s)
- Sabrina Chiloiro
- Pituitary Unit, Department of Endocrinology, Fondazione A Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Tommaso Tartaglione
- Department of Radiology, Istituto Dermopatico dell'Immacolata, Rome and Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonella Giampietro
- Pituitary Unit, Department of Endocrinology, Fondazione A Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Bianchi
- Pituitary Unit, Department of Endocrinology, Fondazione A Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Giustina
- Department of Endocrinology, Università Vita Salute San Raffaele, Milan, Italy
| | - Alfredo Pontecorvi
- Pituitary Unit, Department of Endocrinology, Fondazione A Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Laura De Marinis
- Pituitary Unit, Department of Endocrinology, Fondazione A Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.
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17
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Chiloiro S, Tartaglione T, Capoluongo ED, Angelini F, Arena V, Giampietro A, Bianchi A, Zoli A, Pontecorvi A, Colosimo C, De Marinis L. Hypophysitis Outcome and Factors Predicting Responsiveness to Glucocorticoid Therapy: A Prospective and Double-Arm Study. J Clin Endocrinol Metab 2018; 103:3877-3889. [PMID: 30085134 DOI: 10.1210/jc.2018-01021] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 07/27/2018] [Indexed: 02/05/2023]
Abstract
CONTEXT Primary autoimmune hypophysitis (PAH) evolves in most untreated cases in irreversible hypopituitarism. PAH outcome, instead, after immunosuppressive treatment has not been completely clarified. OBJECTIVE To evaluate hypophysitis and pituitary function outcomes. DESIGN A prospective, double-arm study with a 2-year follow-up. SETTING Referral center for pituitary disease. PATIENTS Twenty PAH cases. INTERVENTIONS Oral prednisone 50 mg/d or conservative strategy by observation. MAIN OUTCOME MEASURES Primary endpoint was the improvement/stabilization/worsening of PAH from baseline to a 2-year visit. Secondary endpoint was the improvement/stabilization/worsening of pituitary function from baseline to a 2-year visit. RESULTS Twelve patients (57.1%) were treated with a glucocorticoid-immunosuppressive therapy, and eight patients (42.9%) were observed. At the 2-year visit, PAH improvement/recovery occurred in eight immunosuppressive-treated (66.7%) patients and in two untreated patients (25%). PAH worsened in three untreated patients (37.5%) and was considered stable in four immunosuppressive-treated (33.3%) and three untreated patients (37.5%). Improvement/recovery of pituitary function occurred more frequently in immunosuppressive-treated patients (58.3%) compared with untreated ones (25%; P = 0.04). Responsiveness to immunosuppressive treatment is correlated with antipituitary antibody presence (P = 0.01), occurrence of diabetes insipidus at PAH diagnosis (P = 0.01), absence of the physiological neuropituitary "bright spot" on T1-weighed images (P = 0.01), and pituitary stalk at optical chiasm larger than 3.9 mm (area under the curve: 0.97, sensibility: 100%, specificity: 100%; P = 0.04). On the other hand, we failed to identify factors predicting the outcome, among untreated patients. CONCLUSIONS Glucocorticoid treatment of hypophysitis improves pituitary secretion and should be encouraged in accordance with the evaluation of endocrine-, immunological-, and morphological-predictive markers.
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Affiliation(s)
- Sabrina Chiloiro
- Pituitary Unit, Department of Endocrinology, Catholic University of the Sacred Heart, School of Medicine, Rome, Italy
| | - Tommaso Tartaglione
- Department of Radiology, Istituto Dermopatico dell'Immacolata, Rome, Italy
- Catholic University of the Sacred Heart, School of Medicine, Rome, Italy
| | - Ettore Domenico Capoluongo
- Department of Laboratory Medicine, Genetic and Toxicology, Istituto Dermopatico dell'Immacolata, Rome, Italy
- Institute of Biochemistry and Clinical Biochemistry, Catholic University of the Sacred Heart, School of Medicine, Rome, Italy
| | - Flavia Angelini
- Laboratory of Vascular Biology and Genetics, Department of Medicine, Catholic University of the Sacred Heart, School of Medicine, Rome, Italy
| | - Vincenzo Arena
- Department of Pathology, Catholic University of the Sacred Heart, School of Medicine, Rome, Italy
| | - Antonella Giampietro
- Pituitary Unit, Department of Endocrinology, Catholic University of the Sacred Heart, School of Medicine, Rome, Italy
| | - Antonio Bianchi
- Pituitary Unit, Department of Endocrinology, Catholic University of the Sacred Heart, School of Medicine, Rome, Italy
| | - Angelo Zoli
- Institute of Rheumatology and Affine Sciences, Division of Rheumatology, Catholic University of the Sacred Heart, School of Medicine, Rome, Italy
| | - Alfredo Pontecorvi
- Pituitary Unit, Department of Endocrinology, Catholic University of the Sacred Heart, School of Medicine, Rome, Italy
| | - Cesare Colosimo
- Department of Pathology, Catholic University of the Sacred Heart, School of Medicine, Rome, Italy
| | - Laura De Marinis
- Pituitary Unit, Department of Endocrinology, Catholic University of the Sacred Heart, School of Medicine, Rome, Italy
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