A case of hypothalamic sarcoidosis with hypopituitarism and prolonged remission of hypogonadism

Central diabetes insipidus due to sarcoidosis

We describe a case of a 40-year old Caucasian male who presented with bihilar enlargement. Additional investigation revealed sarcoidosis. During hospitalization patient developed hypernatremia due to central diabetes insipidus. Central diabetes insipidus was caused by neurosarcoidosis. MRI-scan did not show abnormalities of the pituitary gland, but additional investigation showed hypopituitarism. He was treated with prednisolone, minrin and testosterone. Sodium- and testosterone levels normalised but suppletion is still required. (Sarcoidosis Vasc Diffuse Lung Dis 2017; 34: 191-193).

Partial improvement of anterior pituitary deficiency following steroid treatment in a patient with neurosarcoidosis accompanied by central diabetes insipidus

A 58-year-old woman was admitted due to visual field abnormalities, thirst, polydipsia, polyuria and fever. T1-weighted magnetic resonance imaging revealed an absence of the usual bright signal in the posterior lobe of the pituitary gland, and an enlarged pituitary gland with a thickened stalk was enhanced by the gadolinium contrast medium. Computed tomography revealed tumor lesions in the left maxillary sinus and right retroperitoneum and axillary and subclavian lymph node swelling. An endocrinological provocation test demonstrated that her pituitary endocrine function was disturbed, although her ACTH and TSH secretion was normal. The patient was histologically diagnosed with neurosarcoidosis accompanied by hypopituitarism and central diabetes insipidus upon an examination of a subclavian lymph node specimen. Six months of prednisolone treatment resulted in the disappearance of any morphological abnormalities in the pituitary gland and stalk as well as a partial improvement in her LH, FSH and GH secretions. Pituitary endocrine functions can be rescued if steroid treatment is performed under conditions that maintain several hormonal axes.

A successful conception by a shift from human menopausal gonadotropin therapy to therapy with recombinant human follicular-stimulating hormone for the treatment of male hypogonadotropic hypogonadism

Stimulatory therapy with gonadotropins effectively induces spermatogenesis and increases the chances of successful reproduction. However, the optimal treatment modality and schedule, and required duration of treatment have not been determined. A 27-year-old man presented with erectile and ejaculatory disorder. Endocrinological examinations revealed isolated luteinizing hormone-releasing hormone (LHRH) deficiency of the hypothalamus, resulting in hypogonadotropic hypogonadism. No causative abnormality was detected in imaging studies. Having a diagnosis of adult-onset hypogonadotropic hypogonadism, the patient received pulsatile subcutaneous human chorionic gonadotropin (hCG) and human menopausal gonadotropin (hMG). Hypogonadism did not improve with hCG/hMG combination therapy. He was successfully treated with the replacement therapy from hMG into recombinant human follicular-stimulating hormone (rhFSH) for induction of spermatogenesis, along with pregnancy in the female partner.

An elderly patient with sarcoidosis manifesting panhypopituitarism with central diabetes insipidus

We here report a 77-year-old Japanese male who suffered general fatigue with progressive thirst and polyuria. Central diabetes insipidus was diagnosed by depletion of vasopressin secretion in response to increases in serum osmolality. Secretory responses of anterior pituitary hormones including adrenocorticotropin, thyrotropin, gonadotropins and growth hormone were severely impaired. Diffuse swelling of the infundibulum as well as lack of T1-hyperintense signal in the posterior lobe was noted by pituitary magnetic resonance imaging. The presence of bilateral hilar lymphadenopathy and increased CD4/CD8 ratio in bronchoalveolar lavage fluid was diagnostic for lung sarcoidosis. Physiological doses of corticosteroid and thyroid hormone were administered in addition to desmopressin supplementation. Complete regression of the neurohypophysial swelling was notable two years after corticosteroid replacement. Diffuse damage of anterior pituitary combined with hypothalamic involvement leading to central diabetes insipidus is a rare manifestation in such elderly patients with neurosarcoidosis.

Transient hypopituitarism

Spontaneous recovery of pituitary function in patients with hypopituitarism is rare. We report the case of a 30-year-old man in whom hypopituitarism and sudden onset of bilateral hearing loss developed after a viral infection. No evidence of a mass lesion was detected on computed tomography or magnetic resonance imaging of the pituitary gland. The patient received a 3-week course of treatment with a high dose of glucocorticoids; in a period of 6 weeks, he felt clinically well, and biochemical tests showed spontaneous return of normal anterior pituitary function. We speculate that an immune response triggered by the viral infection initiated an inflammatory process that involved the hypothalamus or pituitary gland and caused the hypopituitarism. The treatment with high-dose glucocorticoids could have prompted the resolution of the hypothalamic-pituitary inflammatory process and facilitated spontaneous recovery of pituitary function. This case shows that hypopituitarism may be transient an outcome that should be considered in patients with idiopathic hypopituitarism.