[Diabetes insipidus revealing primary malignant non-Hodgkin's lymphoma of bone]

Burkitt's lymphoma presenting with hypopituitarism: a case report and review of literature

Hypopituitarism is a rare presentation of Burkitt's lymphoma (BL). The purpose of this report is to present a case of BL presenting with panhypopituitarism and to review other case reports of lymphoma presenting with pituitary dysfunction to highlight the distinguishing features of these cases from other benign aetiologies of pituitary dysfunction such as non-functioning pituitary adenomas. We reviewed a total of 11 cases of lymphoma presenting with pituitary dysfunction published from 1998 to 2013 including the present case. The demographics, clinical presentations, laboratory features, radiological findings, histological diagnosis, treatment administered and outcomes were described. Of the total number of patients, 45.5% of the cases had diffuse large B-cell lymphoma while 27.3% had BL. Anterior pituitary dysfunction was more common than posterior pituitary dysfunction at presentation. The other common associated presenting symptoms were painful ophthalmoplegia, cranial nerve palsies and constitutional symptoms. Hypothalamic–pituitary abnormalities were often demonstrated radiologically to be associated with cavernous sinus and/or stalk involvement. All patients who completed immunochemotherapy responded haematologically. Pituitary dysfunction also improved in most cases although the recovery tended to be partial. In conclusion, a high index of suspicion of underlying malignancy, such as lymphoma, should be present in patients presenting with acute pituitary dysfunction associated with painful ophthalmoplegia, rapidly evolving neurological features, radiological features atypical of a pituitary adenoma and constitutional symptoms. An early diagnosis is essential as prompt initiation of definitive therapy will induce disease remission and recovery of pituitary dysfunction.

Clinical features of patients with non-Hodgkin's lymphoma metastasizing to the pituitary glands

It is rare for systemic non-Hodgkin’s lymphoma (NHL) to metastasize to the hypothalamus and pituitary glands. The present study describes two patients with NHL and diabetes insipidus (DI) and 17 patients from the literature in order to analyze the clinical features of patients with NHL metastasizing to the pituitary glands. Diffuse large B cell lymphoma (DLBCL) was observed to be the most common type of NHL involving the hypothalamus-pituitary axis. A total of 11 patients (57.9%) had been diagnosed with DI (post-pituitary involvement), five (26.3%) with anterior hypopituitarism and three (15.8%) with posterior and anterior hypopituitarism. Only two cases exhibited simultaneous endocrine and lymphoma manifestations; the majority of cases (68.4%) exhibited lymphoma manifestations first. To make an etiological diagnosis of NHL with metastases to the pituitary glands, it is necessary to find that NHL exists in other regions of patient’s body. Biopsy of the sellar may have significant meaning, but this examination may difficult to perform. Chemotherapy for NHL relieves pituitary impairment symptoms and improves the overall examination results. Additionally, magnetic resonance imaging (MRI) of the pituitary gland has a certain differential diagnostic value as the T1- and T2-weighted imaging (WI) signals from patients with systemic NHL with pituitary involvement are low.

Panhypopituitarism as an initial manifestation of primary central nervous system non-Hodgkin's lymphoma

OBJECTIVE

To report an unusual case of primary central nervous system non-Hodgkin's lymphoma in which the initial manifestation was panhypopituitarism.

METHODS

We present a retrospective case review and discuss similar cases from the literature.

RESULTS

A 64-year-old woman with nausea, vomiting, diarrhea, and peripheral and periorbital edema was found to have panhypopituitarism. Magnetic resonance imaging showed minimal enlargement of the pituitary, and a transsphenoidal biopsy of the pituitary was nondiagnostic. Months later, abnormalities of extraocular movements developed. Repeated imaging and a second transsphe-noidal biopsy did not reveal the ultimate diagnosis. When further neurologic signs and symptoms subsequently developed, a right temporal open craniotomy was performed. It was not until this procedure, the patient's third biopsy, that the cause of her illness was discovered to be diffuse large cell lymphoma.

CONCLUSION

Although idiopathic panhypopituitarism is a relatively common clinical entity, it remains a diagnosis of exclusion. The development of associated neurologic signs should prompt the clinician to initiate a new search for an underlying cause. This case underscores the protean manifestations of central nervous system lymphoma, both endocrine and neurologic, and the difficulties that may be encountered in attempts to establish a diagnosis.