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Inoue E, Kesumayadi I, Fujio S, Makino R, Hanada T, Masuda K, Higa N, Kawade S, Niihara Y, Takagi H, Kitazono I, Takahashi Y, Hanaya R. Secondary hypophysitis associated with Rathke's cleft cyst resembling a pituitary abscess. Surg Neurol Int 2024; 15:69. [PMID: 38468645 PMCID: PMC10927231 DOI: 10.25259/sni_947_2023] [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: 11/26/2023] [Accepted: 02/06/2024] [Indexed: 03/13/2024] Open
Abstract
Background Although rare, cases of hypophysitis resembling a pituitary abscess (PA) have been reported. Differential diagnosis between hypophysitis and PA is crucial as the two diseases require different treatments. Case Description A 38-year-old woman with headaches underwent head magnetic resonance imaging (MRI), which revealed an 11-mm mass lesion in the sella turcica. Due to breastfeeding, contrast-enhanced MRI was avoided. Pituitary adenomas and Rathke's cleft cyst (RCC) were suspected, and she was initially treated conservatively. Five months later, she acquired syndrome coronavirus two infections, and while the fever subsided with acetaminophen, the headache persisted. One month later, the headache worsened, followed by fever and diabetes insipidus. MRI revealed a pituitary cystic mass with ring-shaped contrast enhancement on T1-weighted MRI and increased signal intensity on diffusion-weighted imaging (DWI). PA was suspected, and emergency endoscopic transsphenoidal surgery was performed. The microbiological examination of the yellowish-brown content drained from the cystic mass was negative. Microscopically, the cystic lesion was covered with ciliated columnar epithelium and stratified squamous epithelium, with a dense inflammatory cell infiltrate consisting mainly of lymphocytes and plasma cells observed around the cyst. This supported the diagnosis of secondary hypophysitis associated with RCC without PA. Conclusion We report a case of hypophysitis secondary to RCC resembling PA with ring-shaped contrast enhancement on MRI and increased signal intensity on DWI. This case emphasizes the need for cautious diagnosis of secondary hypophysitis due to RCC in individuals with MRIs and clinical manifestations resembling an abscess.
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Affiliation(s)
- Eri Inoue
- Department of Neurosurgery, Kagoshima University, Kagoshima, Japan
| | - Irfan Kesumayadi
- Department of Neurosurgery, Kagoshima University, Kagoshima, Japan
- Department of Neurosurgery, Diponegoro University, Tembalang, Semarang, Indonesia
| | - Shingo Fujio
- Department of Neurosurgery, Kagoshima University, Kagoshima, Japan
- Pituitary Disorders Center, Kagoshima University Hospital, Kagoshima, Japan
| | - Ryutaro Makino
- Department of Neurosurgery, Kagoshima University, Kagoshima, Japan
- Pituitary Disorders Center, Kagoshima University Hospital, Kagoshima, Japan
| | - Tomoko Hanada
- Department of Neurosurgery, Kagoshima University, Kagoshima, Japan
- Pituitary Disorders Center, Kagoshima University Hospital, Kagoshima, Japan
| | - Keisuke Masuda
- Department of Neurosurgery, Kagoshima University, Kagoshima, Japan
| | - Nayuta Higa
- Department of Neurosurgery, Kagoshima University, Kagoshima, Japan
| | - Shigeru Kawade
- Pituitary Disorders Center, Kagoshima University Hospital, Kagoshima, Japan
- Department of Diabetes and Endocrine Medicine, Kagoshima University, Kagoshima, Japan
| | - Yuichiro Niihara
- Pituitary Disorders Center, Kagoshima University Hospital, Kagoshima, Japan
- Department of Obstetrics and Gynecology, Kagoshima University, Kagoshima, Japan
| | - Hirosuke Takagi
- Department of Hematology and Rheumatology, Kagoshima University, Kagoshima, Japan
| | - Ikumi Kitazono
- Department of Pathology, Kagoshima University, Kagoshima, Japan
| | - Yutaka Takahashi
- Department of Diabetes and Endocrinology, Nara Medical University, Kashihara, Nara, Japan
| | - Ryosuke Hanaya
- Department of Neurosurgery, Kagoshima University, Kagoshima, Japan
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Tahara S, Osamura RY, Hattori Y, Ishisaka E, Inomoto C, Sugihara H, Teramoto A, Morita A. Concurrent IgG4-related hypophysitis and clinically nonfunctioning gonadotroph pituitary neuroendocrine tumor. BMC Endocr Disord 2023; 23:96. [PMID: 37143052 PMCID: PMC10158217 DOI: 10.1186/s12902-023-01353-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 04/25/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Some patients develop immunoglobulin G4 (IgG4)-related hypophysitis associated with systemic diseases. More than 30 cases of IgG4-related hypophysitis have been reported. However, biopsy has rarely been performed in these patients, and none have had an associated pituitary neuroendocrine tumor (PitNET). We present a case of concurrent IgG4-related hypophysitis and PitNET. CASE PRESENTATION A 56-year-old Japanese man arrived at the hospital with visual impairment, bitemporal hemianopia, and right abducens nerve palsy. Magnetic resonance imaging revealed pituitary body and stalk swelling as well as a small poorly enhanced right anterior lobe mass. Laboratory and loading test results suggested hypopituitarism. Because IgG4 level was elevated, a systemic examination was performed; multiple nodules were found in both lung fields. The diagnosis was based on an endoscopic transnasal biopsy of the pituitary gland. A histopathological examination revealed a marked infiltration of plasma cells into the pituitary gland, which was strongly positive for IgG4. The histological features of the resected tumor were consistent with those of gonadotroph PitNET, which was immunohistochemically positive for follicle-stimulating hormone-β and steroidogenic factor-1, and no plasma cell infiltration was observed. Based on the histopathological examination results, steroid therapy was initiated, which reduced pituitary gland size and serum IgG4 levels. DISCUSSION AND CONCLUSIONS This is the first reported case of IgG4-related hypophysitis with PitNET. Although no pathological findings indicating a relationship between the two conditions were found, we were able to preoperatively differentiate multiple lesions via detailed diagnostic imaging.
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Affiliation(s)
- Shigeyuki Tahara
- Department of Neurological Surgery, Graduate School of Medicine, Nippon Medical School, 1-1-5Bunkyo-Ku, SendagiTokyo, 113-8603, Japan.
| | | | - Yujiro Hattori
- Department of Neurological Surgery, Graduate School of Medicine, Nippon Medical School, 1-1-5Bunkyo-Ku, SendagiTokyo, 113-8603, Japan
- Department of Anatomy and Neurobiology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Eitaro Ishisaka
- Department of Neurological Surgery, Graduate School of Medicine, Nippon Medical School, 1-1-5Bunkyo-Ku, SendagiTokyo, 113-8603, Japan
| | - Chie Inomoto
- Department of Pathology, Tokai University School of Medicine, Kanagawa, Japan
| | - Hitoshi Sugihara
- Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, Nippon Medical School, Tokyo, Japan
| | | | - Akio Morita
- Department of Neurological Surgery, Graduate School of Medicine, Nippon Medical School, 1-1-5Bunkyo-Ku, SendagiTokyo, 113-8603, Japan
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3
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Chen K, Yao Y, Mao X, You H, Wang L, Duan L, Deng K, Zhang W, Lian X, Zhu H. Sellar germinoma mimicking IgG4-related hypophysitis: a case report. BMC Endocr Disord 2022; 22:23. [PMID: 35033046 PMCID: PMC8760830 DOI: 10.1186/s12902-021-00930-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 12/30/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The differential diagnosis of IgG4-related hypophysitis and other inflammatory diseases or tumors involving sellar region is challenging even after sellar biopsy. Sellar germinoma is usually infiltrated by lymphocytes or plasma cells, and may be confused with hypophysitis. CASE PRESENTATION A 36-year-old man with diabetes insipidus, elevated serum IgG4 level (336 mg/dl), and sellar mass was suspected to have IgG4-related hypophysitis, and no other lesion of IgG4-related disease was detected. After treated by prednisone and mycophenolate mofetil, the serum IgG4 decreased to 214 mg/dl. However, after withdrawal of the drugs, the IgG4 level increased to 308 mg/dl. Endocrine assessments revealed panhypopituitarism, and the sellar mass enlarged. Transsphenoidal sellar exploration and biopsy was conducted. Pathological examination showed that the lesion was germinoma with lymphocytes and plasma cells infiltration, and IgG4-staining was positive (70/HPF, IgG4/IgG ratio = 10%). The patient was then treated by cisplatin and etoposide. After four cycles of chemotherapy, the serum IgG4 was 201 mg/dl, and the sellar mass was invisible. CONCLUSION Sellar germinoma can mimic the clinical characteristics of IgG4-related hypophysitis. Poor response to glucocorticoids can be used as an exclusion criterion in the clinical diagnosis of IgG4-related hypophysitis.
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Affiliation(s)
- Kang Chen
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Centre, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No.1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, 100730, China
| | - Yong Yao
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xinxin Mao
- Department of Pathology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Hui You
- Department of Radiology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Linjie Wang
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Centre, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No.1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, 100730, China
| | - Lian Duan
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Centre, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No.1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, 100730, China
| | - Kan Deng
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Wen Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xin Lian
- Department of Radiation Oncology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Huijuan Zhu
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Centre, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No.1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, 100730, China.
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Saitakis G, Chwalisz BK. The neurology of IGG4-related disease. J Neurol Sci 2021; 424:117420. [PMID: 33845982 DOI: 10.1016/j.jns.2021.117420] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 10/29/2020] [Accepted: 03/24/2021] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW IgG4-related disease (IgG4-RD) is emerging as a fibro-inflammatory entity affecting multiple organs, including manifold neurologic manifestations. This review discusses general characteristics of IgG4-RD neurologic disease including epidemiology, histology, clinical picture and treatment approaches. RECENT FINDINGS IgG4-RD is increasingly recognized as an important underlying pathophysiology in multiple disorders of neurologic interest, including orbital inflammation, infundibulo-hypophysitis, hypertrophic pachymeningitis, and even in rare cases CNS parenchymal disease and cranial vascular involvement. These were previously considered idiopathic and unrelated to any systemic disease but now known to share a common histopathology. New knowledge regarding the pathogenesis, clinical features and epidemiology of IgG4 is emerging, and new neurological manifestations continue to be described. Diagnostic progress includes CT-PET imaging, the use of flow cytometry for plasmablast quantification, and the use of reverse passive latex agglutination aiming to overcome the prozone phenomenon. Histopathologic confirmation of IgG4-RD remains the gold standard method of diagnosis but new diagnostic criteria for systemic and organ-specific disease are being proposed. Though glucorticoids remain the mainstay of therapy, relapses and incomplete recovery are frequent. Rituximab is a promising treatment in IgG4-RD that is severe, refractory or glucocorticoid dependent. Initiation of immunosuppression at an early stage of disease should be considered in order to avoid development of refractory fibrosis. SUMMARY The current review emphasizes the neurologic manifestations of IgG4-RD.
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Affiliation(s)
- G Saitakis
- Division of Neuro-Ophthalmology, Department of Ophthalmology, Massachusetts Eye & Ear Infirmary/Harvard Medical School, Boston, MA, USA
| | - B K Chwalisz
- Division of Neuro-Ophthalmology, Department of Ophthalmology, Massachusetts Eye & Ear Infirmary/Harvard Medical School, Boston, MA, USA; Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA.
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5
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Imai T, Shibata S, Shinohara K, Sakurai K, Horiuchi M, Sakai K, Asai S, Hasegawa Y. IgG4-related hypophysitis diagnosed by retroperitoneal mass biopsy in a patient presenting with abducens nerve palsy: A case report (CARE-compliant article). Medicine (Baltimore) 2020; 99:e22484. [PMID: 33019443 PMCID: PMC7535663 DOI: 10.1097/md.0000000000022484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
RATIONALE Immunoglobulin G4 (IgG4)-related hypophysitis is a rare disorder which often requires invasive pituitary gland biopsy to confirm its diagnosis. We present a case whereby peripheral organ lesion biopsy and imaging findings were sufficient for the diagnosis. PATIENT CONCERNS A 77-year-old man with diplopia was referred to our department by an opthomologist who had diagnosed the patient with right abducens nerve palsy. DIAGNOSES Head magnetic resonance imaging revealed enlargement of the pituitary gland and pituitary stalk, while hormonal analysis revealed panhypopituitarism, thereby indicating a diagnosis of hypophysitis. Abdominal computed tomography imaging revealed a solid mass that encompassed the left kidney ureter. Although the patient did not have an increase in serum IgG4, a biopsy of the periureteral mass revealed infiltrating plasma cells that were positive when stained for IgG4. INTERVENTIONS The patient was given corticosteroid pulse therapy (methylprednisolone: 1 g × 3 days), followed by oral corticosteroids (prednisolone, 0.5 mg/kg/d). OUTCOMES The right abducens nerve palsy improved and the pituitary lesion shrank after the initiation of corticosteroid treatment. CONCLUSION Based on the diagnosis of IgG4-related disease in the retroperitoneal organ and response to corticosteroid treatment, this patient was diagnosed with IgG4-related hypophysitis. This hypophysitis caused enlargement of the pituitary gland with resulting nerve compression, causing abducens nerve palsy. When IgG4-related hypophysitis is suspected, a thorough examination of other organ lesions and biopsy should be considered.
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Affiliation(s)
- Takeshi Imai
- Department of Neurology
- Tama Medical Practice Center
| | | | | | | | | | - Kensuke Sakai
- Department of Metabolism and Endocrinology, Kawasaki Municipal Tama Hospital, Kawasaki, Kanagawa, Japan
| | - Shiko Asai
- Department of Metabolism and Endocrinology, Kawasaki Municipal Tama Hospital, Kawasaki, Kanagawa, Japan
| | - Yasuhiro Hasegawa
- Department of Internal Medicine, Division of Neurology, St Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
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6
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Takagi H, Iwama S, Sugimura Y, Takahashi Y, Oki Y, Akamizu T, Arima H. Diagnosis and treatment of autoimmune and IgG4-related hypophysitis: clinical guidelines of the Japan Endocrine Society. Endocr J 2020; 67:373-378. [PMID: 32037390 DOI: 10.1507/endocrj.ej19-0569] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [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
Hypophysitis, which is often accompanied by pituitary dysfunction, is classified into several subtypes based on the cause, histology, and the location of inflammation in the pituitary gland. A definitive diagnosis requires pituitary biopsy, which is invasive, and the process is limited to specialized clinical settings. In this opinion paper, we review the literature associated with hypophysitis, and provide the guidelines of the Japan Endocrine Society for the diagnosis and treatment of autoimmune and IgG4-related hypophysitis.
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Affiliation(s)
- Hiroshi Takagi
- 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
| | - Yoshihisa Sugimura
- Department of Endocrinology and Metabolism, Fujita Health University School of Medicine, Toyoake 470-1192, Japan
| | - Yutaka Takahashi
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
| | - Yutaka Oki
- Department of Family and Community Medicine, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
| | - Takashi Akamizu
- The First Department of Medicine, Wakayama Medical University, Wakayama 641-8509, Japan
| | - Hiroshi Arima
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
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7
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Rzepecka A, Babińska A, Sworczak K. IgG4-related disease in endocrine practice. Arch Med Sci 2019; 15:55-64. [PMID: 30697253 PMCID: PMC6348348 DOI: 10.5114/aoms.2017.70889] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 09/28/2017] [Indexed: 12/24/2022] Open
Abstract
IgG4-related disease is a set of symptoms resulting from a chronic, usually multiple organ inflammatory condition which affects various organs. It consists of lymphoplasmacytic infiltrations with attendant fibrosis and deep vein thrombosis. Frequently observed tissue lesions are accompanied by elevated IgG4 levels in serum. The etiopathogenesis of the lesions is of multifactor character and the clinical manifestation of the disease is highly diverse. The diagnostic process is based on the patient's medical history, clinical examination and additional tests, including a histopathological examination of the infected organ's tissues. Almost forty different locations of the disease have been reported, including disorders of the endocrine system. IgG4-related endocrinopathies are quite rare. However, it is likely that the diagnosis is under-reported due to lack of awareness of this clinical entity. Despite increasing interest in the subject, there are not enough reliable studies evaluating the link between IgG4-RD and endocrine disorders.
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Affiliation(s)
- Agata Rzepecka
- Department of Endocrinology and Internal Medicine, Medical University of Gdansk, Gdansk, Poland
| | - Anna Babińska
- Department of Endocrinology and Internal Medicine, Medical University of Gdansk, Gdansk, Poland
| | - Krzysztof Sworczak
- Department of Endocrinology and Internal Medicine, Medical University of Gdansk, Gdansk, Poland
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8
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Marked effectiveness of low-dose oral methotrexate for steroid-resistant idiopathic hypertrophic pachymeningitis: Case report. Clin Neurol Neurosurg 2018; 168:30-33. [DOI: 10.1016/j.clineuro.2018.02.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 02/14/2018] [Accepted: 02/20/2018] [Indexed: 11/22/2022]
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9
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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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10
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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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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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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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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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Ohkubo Y, Sekido T, Takeshige K, Ishi H, Takei M, Nishio SI, Yamazaki M, Komatsu M, Kawa S, Suzuki S. Occurrence of IgG4-related hypophysitis lacking IgG4-bearing plasma cell infiltration during steroid therapy. Intern Med 2014; 53:753-7. [PMID: 24694491 DOI: 10.2169/internalmedicine.53.0714] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Eight years after an episode of multiple IgG4-related disease, a pituitary mass with panhypopituitarism and a visual disturbance developed in a 70-year-old man under low-dose steroid therapy. A pituitary biopsy revealed findings of lymphocytic hypophysitis with the absence of IgG4-positive plasma cell infiltration. The serum IgG4 level was unremarkable. Although performing a pituitary biopsy and measuring the serum IgG4 level is crucial for making a diagnosis of IgG4-related hypophysitis, it is occasionally difficult to diagnose the disease in patients treated with steroid therapy, as observed in the present case. Based on a review of the diagnosis, conducting a careful assessment is required, especially in men and elderly patients thought to have solitary hypophysitis.
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Affiliation(s)
- Yohsuke Ohkubo
- Division of Diabetes, Endocrinology and Metabolism, Department of Internal Medicine, Shinshu University School of Medicine, Japan
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Kanoke A, Ogawa Y, Watanabe M, Kumabe T, Tominaga T. Autoimmune hypophysitis presenting with intracranial multi-organ involvement: three case reports and review of the literature. BMC Res Notes 2013; 6:560. [PMID: 24373428 PMCID: PMC3877864 DOI: 10.1186/1756-0500-6-560] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 12/16/2013] [Indexed: 11/23/2022] Open
Abstract
Background Autoimmune hypophysitis very rarely spreads to nearby organs outside the pituitary tissue, for unknown reasons, with only 5 reported cases of hypophysitis spreading over the cavernous sinus. Case presentation Three patients presented with cases of non-infectious hypophysitis spreading outside the pituitary tissue over the cavernous sinus. All three cases were diagnosed with histological confirmation by transsphenoidal surgery, and the patients showed remarkable improvement with postoperative pulse dose steroid therapy, including disappearance of abnormal signal intensities in the bilateral hypothalami on magnetic resonance imaging, resolution of severe stenosis of the internal carotid artery, and normalization of swollen pituitary tissues. Two of 3 cases fulfilled the histological criteria of immunoglobulin G4-related disease, although none of the patients had high serum immunoglobulin G4 level. Conclusion The true implications of such unusual spreading of hypophysitis to nearby organs are not fully understood, but the mechanism of occurrence might vary according to the timing of inflammation in this unusual mode of spreading. Pulse dose steroid therapy achieved remarkably good outcomes even in the patient with progressive severe stenosis of the internal carotid artery and rapid visual deterioration.
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Affiliation(s)
| | - Yoshikazu Ogawa
- Department of Neurosurgery, Kohnan Hospital, 4-20-1 Nagamachiminami, Taihaku-ku, Sendai 982-8523, Miyagi, Japan.
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Tomio R, Ohira T, Wenlin D, Yoshida K. Immunoglobulin G4-related intracranial inflammatory pseudotumours along both the oculomotor nerves. BMJ Case Rep 2013; 2013:bcr-2012-007320. [PMID: 23314876 DOI: 10.1136/bcr-2012-007320] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report the first documented case of IgG4-related inflammatory pseudotumours (IPTs) along the bilateral oculomotor nerves. A man in his 60s complained of decreased vision. He exhibited bilateral optic nerve atrophy without any extraocular movement deficits. MRI revealed enhanced masses that reached from the bilateral cavernous sinus to within the bilateral orbits. The tumours extended along the lines of the bilateral oculomotor nerves. The patient's serum level of IgG4 was high, 147 mg/dl. A biopsy specimen showed inflammatory cell-rich lesions against a collagenous stroma. Immunostaining revealed infiltration of CD138-positive plasma cells, which were mainly IgG and IgG4 positive. The IgG4/IgG ratio was greater than 0.4. These factors led us to a diagnosis of IgG4-related IPTs. Oral administration of prednisolone (30 mg/day) was started 3 months after the operation and continued for 6 months with gradual tapering. The tumour was significantly reduced by prednisolone.
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Affiliation(s)
- Ryosuke Tomio
- Department of Neurosurgery, Keio University School of Medicine, Shinjuku, Japan.
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Hirano H, Yoshioka T, Yunoue S, Fujio S, Yonezawa H, Niiro T, Habu M, Oyoshi T, Sugata S, Kamezawa T, Arimura H, Hanaya R, Tokimura H, Tokudome M, Arita K. TLR4, IL-6, IL-18, MyD88 and HMGB1 are highly expressed in intracranial inflammatory lesions and the IgG4/IgG ratio correlates with TLR4 and IL-6. Neuropathology 2012; 32:628-37. [PMID: 22414145 DOI: 10.1111/j.1440-1789.2012.01310.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We determined distribution of plasma cells and IgG4/IgG index and factors associated with the index in intracranial inflammatory lesions. Specimens of nine patients were analyzed immunohistochemically using antibodies against CD45, CD68, CD3, CD4, CD8, CD20, CD138, lambda chain, kappa chain, IgG, IgG4, IL-1α, IL-6, IL-18, toll-like receptor (TLR) 2, TLR4, high-mobility group box 1 (HMGB1), tumor necrosis factor-alpha (TNF-α), myeloid differentiation factor 88 (MyD88), and anaplastic lymphoma kinase (ALK). The relationship between all the factors was assessed using Spearman's rank correlation coefficient (ρ). Negative ALK staining was observed in all the patients. Plasma cells were detected in eight patients with varying degrees. The highest number of neutrophils, but no plasma cells, was observed in a patient with the shortest history of inflammation. IgG4/IgG index was independent of the number of plasma cells. The index was relatively highly correlated with IL-6 (ρ = 0.7271) and TLR4 expression (ρ = 0.7246). IL-6 expression was highly correlated with TLR4 expression (ρ = 0.8042). IL-18 was maximally expressed in all the patients. TLR4 expression was strong, but TRL2 expression was weak. Positive HMGB1 staining was observed in all the patients, predominantly in the nuclei, but also in the cytoplasm in four patients. The cytoplasmic expression strongly correlated with IL-1α expression (ρ = 0.9583). The cytoplasmic colocalization of HMGB1 and IL-1α was histologically confirmed in cells with collapsing nuclei by the double-staining method. The IgG4/IgG indexes varied case by case. IL-6 and TLR4 expressions may influence IgG4/IgG index. The nuclei of cells with both IL-1α and HMGB1 expressions in the cytoplasm collapse in the cell death stage. The cooperative high expression of TLR4, IL-6, IL-18, MyD88 and HMGB1 suggest their critical roles in the inflammation circuit.
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Affiliation(s)
- Hirofumi Hirano
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan.
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Yamashita H, Takahashi Y, Ishiura H, Kano T, Kaneko H, Mimori A. Hypertrophic pachymeningitis and tracheobronchial stenosis in IgG4-related disease: case presentation and literature review. Intern Med 2012; 51:935-41. [PMID: 22504255 DOI: 10.2169/internalmedicine.51.6604] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Immunoglobulin G4 (IgG4)-related disease is a distinctive mass-forming disorder with frequent systemic involvement, most commonly in the pancreas, salivary glands and lacrimal glands. A few cases of dural involvement and one case of central airway stenosis have also been described. We report here a rare case of IgG4-related disease with intracranial hypertrophic pachymeningitis and irregular tracheobronchial stenosis. We review four previously reported cases of IgG4-related pachymeningitis. We currently lack international standards for the diagnosis of extrapancreatic IgG4-related disease. Based on the findings of the present case and those reported previously, we discuss the distinctive features of IgG4-related pachymeningitis.
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Affiliation(s)
- Hiroyuki Yamashita
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, Japan.
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Kim EH, Kim SH, Cho JM, Ahn JY, Chang JH. Immunoglobulin G4–related hypertrophic pachymeningitis involving cerebral parenchyma. J Neurosurg 2011; 115:1242-7. [DOI: 10.3171/2011.7.jns1166] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors report a case of IgG4-related hypertrophic pachymeningitis that involved cerebral parenchyma. The mass was removed surgically. Histopathological studies showed diffuse infiltration of lymphoplasmacytic cells without evidence of Langerhans histiocytes or meningothelial cells. Immunoglobulin G4 was strongly positive on immunohistochemical staining. The Gd-enhanced lesion deep inside brain parenchyma was completely resolved after 3 months of oral corticosteroid medication. A nodular type of hypertrophic pachymeningitis that mimics a meningioma is rare. Nevertheless, preoperative presumption is very important, and immunohistochemical studies for IgG4 may be helpful in the differential diagnosis.
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Affiliation(s)
- Eui Hyun Kim
- 1Departments of Neurosurgery and
- 3Neuro-Oncology Clinic, and
| | - Se Hoon Kim
- 2Pathology,
- 3Neuro-Oncology Clinic, and
- 4Brain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Mo Cho
- 1Departments of Neurosurgery and
- 3Neuro-Oncology Clinic, and
| | | | - Jong Hee Chang
- 1Departments of Neurosurgery and
- 3Neuro-Oncology Clinic, and
- 4Brain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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