Preoperative diagnosis of lymphocytic hypophysitis (adenohypophysitis) unresponsive to short course dexamethasone: case report

Pregnancy-related hypophysitis revisited

OBJECTIVE

The aim of the study is to assess the distinguishing features of pregnancy-related hypophysitis (PR-Hy) compared to non-pregnancy autoimmune hypophysitis and to evaluate the changing therapeutic approaches and outcomes in PR-Hy over time.

DESIGN

Retrospective analysis of all published cases with PR-Hy and 6 own cases.

METHODS

A PubMed search was performed and abstracts screened for publications with information on cases with PR-Hy from which full-text review was performed. Clinical features, diagnostic findings, and outcome in relation to treatment modalities in PR-Hy were assessed.

RESULTS

One hundred and forty-eight cases with PR-Hy were identified. PR-Hy was significantly delimited from non-PR-Hy by the frequent occurrence of the chiasmal syndrome (50% vs 13%, P < .0001), higher rate of intrasellar origin (94% vs 74%, P = .0005), lower rate of pituitary stalk involvement (39% vs 86%, P < .0001), and low rate of diabetes insipidus (12% vs 54%, P < .0001). The role of surgery in PR-Hy decreased over time while noninvasive treatment modalities increased. The recurrence rate after high-dose glucocorticoid therapy (33%) was high and exceeded that of surgery (2%) and conservative management (2%). In contrast to initial reports on PR-Hy, recent literature regarding outcome of mother's and child's health was positive. The frequency of spontaneous preterm delivery was not increased. Recurrent PR-Hy in a subsequent pregnancy was reported in only two females.

CONCLUSION

PR-Hy has distinct features that delineate the disorder from non-PR-Hy. With increasing experience in diagnosis, availability of adequate replacement therapy, and improved treatment modalities, PR-Hy has lost its threat and the outcome is encouraging.

Central Diabetes Insipidus Due to IgG4-related Hypophysitis That Required over One Year to Reach the Final Diagnosis Due to Symptoms Being Masked by Sialadenitis

Pituitary inflammation due to IgG4-related disease is a rare condition and is sometimes accompanied by central diabetes insipidus. Central diabetes insipidus produces a strong thirst sensation, which may be difficult to distinguish when complicated by salivary insufficiency. A 45-year-old man was admitted to our department for a thorough examination of his thirst and polyuria. He had suddenly developed these symptoms more than one year earlier and visited an oral surgeon. Swelling of the left submandibular gland, right parotid gland, and cervical lymph nodes had been observed. Since his IgG4 level was relatively high at 792 mg/dL and a lip biopsy showed high plasmacytoid infiltration around the gland ducts, he had been diagnosed with IgG4-related disease. He had started taking 0.4 mg/kg/day of prednisolone, and his chief complaint temporarily improved. However, since the symptom recurred, he was referred to our institution. After admission, to examine the cause of his thirst and polyuria, we performed a water restriction test, vasopressin loading test, hypertonic saline loading test and pituitary magnetic resonance imaging. Based on the findings, we diagnosed him with central diabetes insipidus due to IgG4-related hypophysitis. We increased the dose of prednisolone to 0.6 mg/kg/day and started 10 μg/day of intranasal desmopressin. His symptoms were subsequently alleviated, and his serum IgG4 level finally normalized. We should remember that IgG4-related disease can be accompanied by hypophysitis and that central diabetes insipidus is brought about by IgG4-related hypophysitis. This case report should remind physicians of the fact that pituitary inflammation due to IgG4-related disease is very rare and can be masked by symptoms due to salivary gland inflammation, which can lead to pitfalls in the diagnosis in clinical practice.

Other Pituitary Conditions and Pregnancy

Diagnosis of lymphocytic hypophysitis occurring in the peripartum period is based on clinical and neuroradiological data and does not require a biopsy. Its course is generally spontaneously favorable in terms of mass effect but may require the administration of corticosteroids or even transsphenoidal resection. The course of pituitary deficiencies is highly variable; some cases recover over time, whereas others persist indefinitely. Sheehan syndrome is very rare in developed countries. Because agalactia and amenorrhea are often neglected, the diagnosis is generally delayed. Diabetes insipidus occurring in late pregnancy is caused by the increased placental production of vasopressinase and disappears after delivery.

Pituitary disorders in pregnancy

The pituitary gland is significantly affected during gestation in terms of both size and function. Due to this physiologic adaptation, endocrine evaluation and interpretation of imaging is far more complex than in the non-pregnant state. Pituitary disorders are rare in pregnancy, as they are usually associated with gonadal dysfunction, thereby posing difficulties with fertility. This review will focus on pituitary adenomas (prolactinomas, GH-secreting and ACTH-secreting), their diagnostic handicaps and the recommendations for treatment. We will also discuss the two pituitary disorders encountered in pregnancy, Sheehan's syndrome and lymphocytic hypophysitis.

Update on hypophysitis and TTF-1 expressing sellar region masses

This article reviews recent literature on sellar region masses that most closely mimic nonsecretory pituitary adenomas: hypophysitis, pituicytoma, spindle cell oncocytoma, and granular cell tumor of neurohypophysis. Even today, these four entities often cannot be confidently distinguished from each other clinically or by preoperative neuroimaging features. Thus, they often come to biopsy/surgical resection and require tissue confirmation of diagnosis. Causes of secondary and primary hypophysitis will be discussed, including two newly described types, IgG4 plasma cell hypophysitis and hypophysitis caused by anti-cytotoxic T-lymphocyte antigen 4 antibody therapy for cancer. For the neoplastic conditions, emphasis will be placed on literature that has emerged since these entities were first codified in the 2007 World Health Organization fascicle. The finding that immunohistochemical staining for thyroid transcription factor-1 is shared by pituicytoma, spindle cell oncocytoma, and granular cell tumor of neurohypophysis suggests common lineage and explains why histological overlap can be encountered. We incorporate our own experiences over the last 30 years from two referral institutions with specialty practices in pituitary region masses.

Lymphocytic hypophysitis in a patient presenting with sequential episodes of optic neuritis

A 41-year-old man presented with left optic neuritis (ON) without evidence of other autoimmune disease or hormonal imbalance. MRI showed enlargement of the left optic nerve but no sellar lesion. The patient recovered after steroid therapy but later developed right ON and required treatment again. Follow-up MRI revealed an ill-defined, enlarging sellar lesion with enhancement extending into the right cavernous sinus, and the patient developed symptoms of fatigue and loss of libido. Hormonal studies revealed hypogonadism and hypocortisolism. All laboratory investigation for autoimmune and infectious diseases remained negative. A transsphenoidal biopsy of the lesion revealed lymphocytic hypophysitis. The concomitant development of lymphocytic hypophysitis and optic neuritis suggests a common and likely autoimmune etiology. Visual loss in patients with LYH can sometimes be due to ON rather than compression of the optic apparatus, with significant implications for treatment strategies.

Long-term clinical course of IgG4-related systemic disease accompanied by hypophysitis

A 70-year old man with a 14 year history of Sjögren syndrome, interstitial pneumonia, and autoimmune hepatitis (AIH) was admitted to our hospital due to hyponatremia with a one month history of fatigue, thirst, and nausea. Laboratory tests on admission revealed that this patient had a central adrenal insufficiency. Pituitary magnetic resonance imaging (MRI) further showed swelling of the stalk and posterior lobe of his pituitary, suggesting infundibulo-hypophysitis. Based on his past history of autoimmune disease, his serum IgG4 levels were measured and found to be remarkably high (924 mg/ dL). Previous biopsy specimens from his liver, lung, and parotid gland were immunostained for IgG4, which revealed a marked infiltration of IgG4-positive plasma cells. As a result of our tests, we made a diagnosis of IgG4-related systemic disease. Interestingly, a subsequent MRI scan at three weeks after the patient commenced glucocorticoid replacement therapy for adrenal insufficiency showed that the swelling of his pituitary stalk was reduced. This finding suggested that IgG4-related hypophysitis may improve either as a result of a supplemental dose of glucocorticoid or possibly spontaneously. Although six cases of IgG4-related hypophysitis have been reported in the scientific literature published in English, our current case is the first in which IgG4-related hypophysitis likely occurred as a result of a long-term history of IgG4-related systemic disease. We report this case herein and review the relevant literature.

Empty sella may be the final outcome in lymphocytic hypophysitis

INTRODUCTION

Lymphocytic hypophysitis (LH) is an autoimmune disorder associated with the infiltration of the pituitary gland by lymphocytes leading to different degrees of hypopituitarism. Females are affected more frequently than males and the disease is usually associated with pregnancy or postpartum period.

CASE

We present a case of LH who was first diagnosed with diabetes insipidus and hyperprolactinemia. In the follow-up, the patient developed growth hormone, gonadotropin, and thyroid stimulating hormone deficiency. The typical appearance of increased stalk thickness and diffuse homogenous contrast enhancement of pituitary on magnetic resonance imaging resulted in empty sella by time.

CONCLUSION

The present case demonstrates the natural course of LH over a 13-year period in which the empty sella was the final outcome.

Lymphocytic hypophysitis

BACKGROUND

Lymphocytic hypophysitis is a disorder of the pituitary gland that presents as a sellar mass lesion and/or hypopituitarism. It causes pituicyte destruction and hypopituitarism and is speculated to have an autoimmune basis.

DIAGNOSIS

Lymphocytic hypophysitis should be considered in the differential diagnosis of pituitary masses and/or hypopituitarism in females who are pregnant or in the early postpartum period, especially in cases associated with other autoimmune diseases or unusual patterns of hormone deficiencies. A definitive diagnosis requires tissue biopsy. A presumptive clinical diagnosis can be made based on a history of gestational or postpartum hypopituitarism, a contrast-enhancing sellar mass with imaging features characteristic of lymphocytic hypophysitis, a pattern of pituitary hormone deficiency with early loss of adrenocorticotrophic hormone and thyroid-stimulating hormone unlike that typically found with macroadenomas, relatively rapid development of hypopituitarism and a degree of pituitary failure disproportionate to the size of the mass. Symptoms resulting from partial or panhypopituitarism occur in approximately 80% of cases and multiple deficiencies are found in approximately 75% of cases.

MANAGEMENT

Appropriate management remains controversial. Corticosteroid therapy has been advocated as a means of attenuating inflammation, but given the uncertainty of its efficacy and the known adverse effects, such therapy does not seem justified for most patients. The optimal surgical strategy involves partial resection of the mass to decompress the surrounding structures. All patients with lymphocytic hypophysitis require appropriate replacement therapy for deficient hormones. Long-term follow-up is mandatory to monitor for the development of other hormonal deficits.

A case of lymphocytic panhypophysitis (LPH) during pregnancy

A 37-year-old pregnant woman developed continuous headache in the 10th week of pregnancy, followed by bilateral visual field defect and general malaise in the 24th week. The brain magnetic resonance imaging showed a pituitary mass. In laboratory examination, plasma concentration of free thyroxine, thyroid stimulating hormone (TSH), cortisol, and adrenocorticotropic hormone (ACTH) was low. General malaise vanished shortly after the replacement therapy of glucocorticoid and thyroid hormone, but partial central diabetes insipidus (CDI) appeared, which could be treated with desmopressin acetate (DDAVP). The visual field defect having enlarged, transsphenoidal surgery was performed in the 31st week of pregnancy. Adenohypophysis could be resected, and it showed infiltration of mature lymphocytes. After the surgery, the visual defect had improved, but hormone replacement was still necessary. She delivered a baby in the 38th week without any trouble. Provocative tests after delivery revealed a low response in TSH, prolactin (PRL), and follicle stimulating hormone (FSH). Hormone replacement and DDAVP administration was necessary in the same doses after delivery. The diagnosis was lymphocytic panhypophysitis (LPH). In the case of pregnant woman, LPH should be included in the differential diagnosis of pituitary mass for the fetomaternal safety.

Hypophysitis

Hypophysitis is an uncommon inflammatory condition that may affect the pituitary gland and stalk. Patients often present with varying degrees of hypopituitarism. The diagnosis is often made presumptively based on clinical history and biochemical data but may also be supported by magnetic resonance imaging. Therapy is generally supportive in nature but may require surgery for pathological diagnosis and treatment of mass effect.

Pituitary apoplexy as a consequence of lymphocytic adenohypophysitis in a pregnant woman: a case report

OBJECTIVE AND IMPORTANCE

A patient with pituitary apoplexy resulting from lymphocytic adenohypophysitis, which caused visual disturbance during pregnancy, is described. This is the first report of such case.

CLINICAL PRESENTATION

A 23-year-old primigravida in her 25th week of gestation experienced headache and bitemporal hemianopsia of sudden onset. Magnetic resonance imaging (MRI) revealed a large pituitary mass with intratumoral hemorrhage. Although conservative treatment with intravenous glycerol improved the symptoms partially, the visual symptoms worsened again 6 weeks later. After delivering a girl by scheduled caesarean section her visual symptoms improved. Despite the symptomatic improvement, MRI showed the chiasmatic compression by the enlarged pituitary gland had not changed. Therefore, trans-sphenoidal surgery to decompress the chiasm was performed. Necrotic tissue was seen exuding behind the enlarged pituitary gland and adenohypophysitis with bleeding (apoplexy) was diagnosed histologically. After follow-up for 40 months, she was doing well without any visual or neurological deficits.

CONCLUSION

Although relatively rare, pituitary apoplexy as a consequence of lymphocytic adenohypophysitis should be borne in mind when a pregnant woman presents with headache and visual disturbance of sudden onset.

Delayed lymphocytic infundibuloneurohypophysitis following successful transsphenoidal treatment of Cushing’s disease

Lymphocytic infundibuloneurohypophysitis is a rare disorder in which neurohypophyseal function is impaired by an autoimmune process. Although several etiologies for this rare entity have been suggested, its occurrence following transsphenoidal adenomectomy has not been reported. A 20-year-old man presented with diabetes insipidus - seven years after successful transsphenoidal microadenomectomy for Cushing's disease, first diagnosed at the age of 13. Seven years later, he developed fairly rapid onset of polydipsia and polyuria. Magnetic resonance imaging demonstrated swelling of the posterior pituitary gland with thickening of the pituitary stalk. Endocrinological evaluation revealed neurohypophyseal dysfunction without the adenohypophysis being affected. On the basis of these findings, a diagnosis of lymphocytic infundibuloneurohypophysitis was made. The mass lesion of the posterior pituitary resolved after the administration of corticosteroids for two months and no operation was required. Lymphocytic infundibuloneurohypophysitis should be considered in the differential diagnosis of pituitary mass lesions following transsphenoidal surgery, especially when the mass is confined to the posterior pituitary gland with neurohypophyseal function being compromised.

Primary hypophysitis: a single-center experience in 16 cases

Object. The authors review their experience in the treatment of 16 patients with primary hypophysitis.

Methods. A retrospective study was undertaken to review cases of primary hypophysitis. The mean age of the patients was 47 years and there was an equal distribution of sexes. Recent pregnancy and underlying autoimmunity were noted in 50% of the patients. Two patients had undergone previous transsphenoidal operations at other centers, one for prolactinoma and another for hypophysitis. Headache, anterior pituitary deficiency, and suprasellar mass lesions were the most common presenting features. The initial presumptive diagnosis was pituitary adenoma in six patients (37.5%) and inflammatory hypophysitis in 10 (62.5%). Five patients received initial medical therapy for hypophysitis; although three (60%) responded satisfactorily, two (40%) did not and later underwent surgery.

Altogether 13 patients (81.2%) underwent transsphenoidal surgery. The histological diagnoses were lymphocytic hypophysitis in 10 (76.9%) and granulomatous hypophysitis in three (23.1%) of the surgically treated patients. A coexistent Rathke cleft cyst was noted in one patient. There was no death in this series. One patient experienced postoperative cerebrospinal fluid leakage and meningitis. One patient had bilateral internal carotid artery occlusion secondary to inflammatory involvement of the cavernous sinuses and arteritis. This patient recovered and is capable of independent functional activities.

Conclusions. All surgical patients experienced improvement in their headache and/or visual field defects and none had visual deterioration. None of the patients experienced any improvement in endocrine function and all required long-term hormone replacement. Transsphenoidal surgery was a safe and effective treatment especially for visual and pressure symptoms. A postoperative recurrence developed in two patients (15.4%) and the treatment modalities included steroid therapy, repeated surgery, and radiosurgery.

Lymphocytic hypophysitis mimicking pituitary macroadenoma

Lymphocytic hypophysitis is an uncommon disease with a variable presentation and unclear pathophysiology. We present the case of a 30 year old woman who presented with features typical of a pituitary macroadenoma. She underwent a transphenoidal resection of the mass and histopathological examination revealed lymphocytic hypophysitis. This case illustrates the difficulty in differentiating pituitary macroadenoma and lymphocytic hypophysitis and the variable presentations of lymphocytic hypophysitis.

Autoimmune polyglandular endocrinopathy and anterior hypophysitis in a 14 year-old girl presenting with delayed puberty

We report a 14 year-old peripubertal girl who presented at our clinic with the primary complaint of delayed puberty. She was asymptomatic except for vague complaints of fatigue. Physical examination was significant for mucosal hyperpigmentation and lack of secondary sexual characteristics. Laboratory evaluation revealed a morning cortisol concentration of <0.1 microg/dl (normal range [n.r.]: 4.3-22.4 microg/dl) and a simultaneous ACTH concentration of 2 pg/ml (n.r. 25-62 pg/ml); FSH 66.8 IU/l (n.r. for age: 1-12.8 IU/l); LH 41.1 IU/l (n.r. for age: 1-12 IU/l); E2 38 pg/ml (n.r. for age: 7-60 pg/ml). She had a flat cortisol response to an ACTH stimulation test. MRI of the pituitary gland failed to reveal a lesion. Plasma renin activity, thyroid function tests, parathyroid hormone, prolactin, IGF-I, IGFBP-3 concentrations and serum electrolytes were normal. However, her urinary sodium concentration was high. She was diagnosed with autoimmune polyglandular endocrinopathy including ovarian failure, adrenal failure and autoimmune anterior hypophysitis presenting as isolated ACTH deficiency. We emphasize that autoimmune etiology should be considered in the differential diagnosis of delayed puberty and ovarian failure and that the presence of other endocrinopathies should be searched for even in asymptomatic patients.

The spectrum and significance of primary hypophysitis

Hypophysitis can present clinically as a mass lesion of the sella turcica. Secondary hypophysitis occurs in cases where a definite etiologic agent or process inciting the inflammatory reaction can be identified. In contrast, primary hypophysitis refers to inflammation confined to the pituitary gland with no identifiable etiologic associations. We report three cases of primary hypophysitis to illustrate the spectrum of three clinicopathological entities that encompass this disease: lymphocytic hypophysitis, granulomatous hypophysitis, and xanthomatous hypophysitis. Our three patients underwent surgery, with variable response. However, conservative, supportive treatment with or without surgical decompression is generally favored over aggressive and extensive surgical resection that results in hypopituitarism. We conclude that the optimal management of patients with hyophysitis requires a high index of suspicion before extensive surgical resection. Histological confirmation of the diagnosis of hypophysitis can be obtained by performing a biopsy or by requesting an intraoperative frozen section consultation.

Pathological correlates of pituitary adenomas presenting with apoplexy

Pituitary adenomas presenting de novo with apoplectic symptoms are uncommon. Several series on pituitary adenomas with apoplexy have been reported but have emphasized clinical aspects, incidence, or radiographic appearance by computed tomography (CT) scan. We reviewed our 13 years' experience, focusing on pathological appearance. We identified 15 patients with pituitary adenomas whose first presentation to our institution was with apoplexy. By combining histological and intraoperative findings with more sensitive magnetic resonance imaging (MRI) scans, we were able to attribute 5 of 15 cases to bland infarction, five cases to hemorrhagic infarction, four cases to pure clot, and one to a remote hemorrhagic infarction leaving extensive residual fibrosis and hemosiderin. Despite extensive tumor necrosis, reticulin staining still allowed identification of specimens as adenomas. Immunohistochemical staining was informative in 13 of 15 cases and endocrine-inactive, weak gonadotroph and null cell adenomas predominated. Cases with the greatest interval between symptom onset and surgery showed peripheral rim enhancement by MRI. Pathologically, this corresponded to granulation tissue, T cell lymphocytic infiltration, and atrophic pituicytes at the edge of the infarction or hemorrhage. Occasionally this reaction overshadowed the necrotic adenoma and contributed to diagnostic confusion. Our finding of lymphocytic inflammation in pituitary adenomas that have undergone an apoplectic event may suggest at least a modest immune-mediated response to damaged anterior pituitary tissue.

Recurrent lymphocytic hypophysitis: case report

OBJECTIVE AND IMPORTANCE

Lymphocytic hypophysitis is being recognized with increasing frequency, but the long-term course is not well known. Recurrence of lymphocytic hypophysitis after a long interval has never been reported.

CLINICAL PRESENTATION

A 53-year-old woman presented with central diabetes insipidus. Magnetic resonance imaging (MRI) revealed an intrasellar lesion. Transsphenoidal biopsy yielded a diagnosis of lymphocytic hypophysitis. Regression of the lesion was confirmed by follow-up MRI. The patient lived normally, with gradual improvement of diabetes insipidus, until she suddenly became aware of a visual defect, which developed into bitemporal hemianopsia 2 years after the biopsy. MRI revealed a larger sellar lesion extending to the hypothalamus. However, the adenohypophysial function remained normal and the mild diabetes insipidus continued unchanged.

INTERVENTION

Prompt corticosteroid treatment was remarkably effective. The visual defect disappeared during steroid therapy, and a significant reduction of the lesion was revealed by MRI.

CONCLUSION

It is suggested that long-term follow-up with endocrinological and radiological studies may be necessary in cases of lymphocytic hypophysitis. Recurrent cases should be promptly treated with steroids when a definitive histological diagnosis had been confirmed.

Acquired hypophysitis in adolescence

Lymphocytic and granulomatous hypophysitis are rare causes of anterior pituitary dysfunction, diabetes insipidus and hyperprolactinemia. The clinical, radiographic, and laboratory features of hypophysitis in two adolescent girls are presented along with a review of the medical literature. These subjects represent the youngest cases of autoimmune (lymphocytic) and granulomatous hypophysitis reported to date. While hypophysitis remains an unusual cause of pituitary dysfunction, it may also occur in early adolescence.

Lymphocytic and granulomatous hypophysitis: experience with nine cases

OBJECTIVE

Lymphocytic hypophysitis and granulomatous hypophysitis are rarely encountered. The aim of this study was to demonstrate their clinical peculiarities among pituitary disorders and to provide an approach for their clinical management.

METHODS

In a retrospective study, we reviewed our surgical experience with nine patients harboring hypophysitis. The series included six cases of lymphocytic hypophysitis, two cases of granulomatous hypophysitis, and one case with evidence of coexisting lymphocytic and granulomatous hypophysitis.

RESULTS

A striking similarity of clinical signs was found for our nine patients. Headache or aseptic meningitis, thickening of the sphenoid sinus mucosa, pituitary stalk enlargement, and tongue-shaped extension of the lesion along the basal hypothalamus were characteristic signs. Lymphocytic hypophysitis was not associated with pregnancy in any of the seven cases. No recurrence has been observed in six cases with total removal of the inflammatory tissue.

CONCLUSION

Lymphocytic hypophysitis and granulomatous hypophysitis represent related inflammatory disorders. Their conspicuous clinical features frequently allow preoperative diagnosis of hypophysitis. In view of their sometimes insidious clinical course, early surgical exploration is justified.

Acute loss of vision during pregnancy due to a suprasellar mass

A pregnant woman presented with headaches, bilateral decreased visual acuity, and a central scotoma with a superotemporal hemianopic defect in the right eye and a superotemporal hemianopic defect in the left eye, and bilateral temporal optic disk pallor. Neuroimaging revealed an intrasellar mass with suprasellar extension. Biopsy of the lesion revealed lymphocytic hypophysitis (LH). Treatment with steroids produced marked improvement in visual function. The clinical presentation of lymphocytic hypothysitis may mimic pituitary adenoma and the diagnosis should be suspected in any pregnant or postpartum patient with an intrasellar or suprasellar mass.

Autoimmune hypophysitis

Autoimmune (lymphocytic) hypophysitis has emerged as a distinct and specific clinical and pathological disease entity. Although relatively rare compared with other autoimmune endocrine diseases, nearly a hundred cases have been described. The condition is much more common in females (9:1) and appears to have a particular predilection for the pregnant and postpartum states. The anterior pituitary, and less often the neurohypophysis, appear to be the target for inflammatory autoimmune destruction. During the evolution of the disease process, pituitary hyperfunction (usually hyperprolactinemia) has been noted. This disease should now be included in the differential diagnosis of pituitary disorders, especially in females presenting with pituitary enlargement, particularly if symptoms occur in temporal relationship to pregnancy. The disease may form part of the spectrum of the polyglandular autoimmune endocrine disorders. (Trends Endocrinol Metab 1997;8:74-80). (c) 1997, Elsevier Science Inc.

Lymphocytic infundibulohypophysitis presenting in the postpartum period: case report

BACKGROUND

Lymphocytic adenohypophysitis is a well-known autoimmune disorder affecting the anterior pituitary gland. Posterior pituitary gland function can be impaired by a similar autoimmune disorder called lymphocytic infundibulohypophysitis. Only very few cases have been reported.

CLINICAL PRESENTATION

We present a patient with central diabetes insipidus in the postpartum period. On radiologic and endocrine evidence lymphocytic involvement of the pituitary stalk and infundibulum was suspected.

INTERVENTION

A diagnostic pterional craniotomy was performed. The diagnosis of lymphocytic infundibulohypophysitis was confirmed by biopsy.

CONCLUSION

We present a case of lymphocytic infundibulohypophysitis. In view of its autoimmune pathophysiology the occurrence of this disorder in the postpartum period is not surprising, even though it has not been reported before. This rare disorder should be distinguished from the more common lymphocytic adenohypophysitis.

Hypophysitis in surgical and autoptical specimens

We present the clinical and histological findings of 11 cases of inflammatory anterior pituitary lesions, 8 of which were obtained during surgery and 3 of which were obtained from autopsies. Additionally, we extended the conventional classification of pituitary inflammatory disease by the new entity " secondary hypophysitis". Of the surgically obtained specimens 5 consisted of inflammatory extension into the pituitary gland out of the surrounding tissue. In all of these patients the inflammation originated from an additional tumor in the sellar region (4 craniopharyngiomas, 1 prolactinoma). These will be referred to as "secondary hypophysitis", an entity which has not yet been mentioned in the literature. Of the remaining 6 cases, 2 were granulomatous hypophysitis, 2 pituitary abscesses, 1 lymphocytic hypophysitis, and 1 showed extensive scarring of the anterior pituitary lobe due to preceeding lymphocytic hypophysitis. At histological examination the basic structure of the anterior pituitary was maintained in all cases. Relative counts of hormone-producing cells were normal. In secondary hypophysitis, the affected area was composed of fibrous tissue and granulation tissue. B and T lymphocytes were present in equal amounts. Granulomas were not found. Inflammatory infiltrates, granulation tissue and fibroses were seen in different proportions. Based on our results and three other cases reported in the literature so far, we think that the presently used classification of pituitary inflammatory diseases lacks an entity which describes a non-abscess-forming inflammation of the pituitary gland originating from an associated pathological process. Therefore, we introduced the term secondary hypophysitis to describe this fourth entity of pituitary inflammatory disease.

Lymphocytic Hypophysitis Presenting as a Pituitary Tumor in a 63-Year-Old Man

This report describes a case of lymphocytic hypophysitis in a 63-year-old man who presented with symptoms of a pituitary mass lesion associated with hypothyroidism and hypogonadism. Postoperative endocrinologicaI testing demonstrated gonadotropic, thyrotropic, and corticotropic hypopituitarism, and the patient was commenced on replacement therapy with hydrocortisone and levothyroxine. Histological examination of the pituitary tissue obtained by transsphenoidal surgery revealed lymphocytic hypophysitis without evidence of a pituitary adenoma. The vast majority of patients with lymphocytic hypophysitis are women particularly during pregnancy and the puerperium. Until recently only four men were reported in the literature. The pathogenesis of lymphocytic hypophysitis is uncertain but autoimmune mechanisms are possibly involved.

Lymphocytic Adenohypophysitis Associated with Rathke's Cleft Cyst

During the 8th month of her first pregnancy, a 40-year-old female suffered from visual disturbances. After treatment of pericarditis, which appeared 1 month after a normal delivery, she was referred to the neurosurgical department. She showed bitemporal hemianopsia, disturbance of visual acuity, and hypopituitarism. Initial computed tomography (CT) image showed a solid pituitary mass with suprasellar extension. However, 2 months later, the CT image changed to an enlarged partially cystic lesion. Transsphenoidal exploration of the sella demonstrated lymphocytic adenohypophysitis coexistent with Rathke's cleft cyst. To our knowledge, such an association has never been reported previously. Presurgical diagnosis of lymphocytic adenohypophysitis still remains difficult and surgical intervention is necessary for definitive diagnosis. However, special attention is needed for the histological diagnosis of this lesion, particularly in clinically atypical cases.

Pseudotumoral lymphocytic hypophysitis successfully treated by corticosteroid alone: first case report

We report the first case of pseudotumoral lymphocytic hypophysitis successfully treated by corticosteroids without surgery. A 27-year-old woman had been monitored for chronic headache 13 months after giving birth, associated with amenorrhea and galactorrhea. Cranial magnetic resonance imaging revealed a markedly enlarged pituitary gland with a suprasellar extension; the only biochemical abnormality was a mild hyperprolactinemia. Because of a putative diagnosis of prolactinoma, bromocriptine was prescribed at a dose of 5 mg daily, soon followed by the transitory appearance of menstruation. Two years later, panhypopituitarism was present and was revealed by acute adrenal insufficiency. Magnetic resonance imaging revealed that the pituitary mass was the same as previously described, but hormonal investigation showed evidence of complete hypopituitarism and no hyperprolactinemia. Nuclear antibodies were negative as well as other autoantibodies. Human leukocyte antigen serological Class II typing was DR3/DR4. Lymphocytic hypophysitis was then suspected; in the absence of visual complication and because this patient refused surgery, corticosteroids were attempted at a daily dose of 60 mg of prednisone for 3 months, progressively decreased for the next 6 months. Under this treatment, a gradual recovery of all pituitary hormones was observed and magnetic resonance imaging showed a reduction of two-thirds in pituitary mass. Five months after the end of corticoid treatment, our patient relapsed with panhypopituitarism and an increase of pituitary volume. She underwent steroid treatment, and a biopsy was performed and confirmed the diagnosis of autoimmune hypophysitis.(ABSTRACT TRUNCATED AT 250 WORDS)

A case of lymphocytic hypophysitis with massive fibrosis and the role of surgical intervention

Four weeks after a normal delivery, a 33-year-old woman was admitted to our hospital with visual disturbance, hypopituitarism, and diabetes insipidus. A homogeneously enhanced pituitary mass with suprasellar extension was observed. Presurgical steroid therapy was ineffective. A transsphenoidal approach revealed a firm white mass, which was histologically diagnosed as a lymphocytic hypophysitis with massive fibrosis. Lymphocytic hypophysitis shows a variety of clinical courses, and there are various problematic aspects concerning the histologic stage as well as the differential diagnosis. However, it is difficult to speculate concerning these without histologic studies. Cases with massive fibrosis, spontaneous resolution, or positive effects of steroids may be less likely.

The anterior pituitary lobe in patients with cystic craniopharyngiomas: three cases of associated lymphocytic hypophysitis

Specimens of the anterior pituitary lobe were investigated histologically in 28 craniopharyngioma patients operated on trans-sphenoidally. The pituitary glands in 3 patients revealed lymphocytic invasion giving a histological appearance typical of lymphocytic hypophysitis (incidence: 11%). At follow-up examination all three patients with associated lymphocytic hypophysitis had complete pituitary insufficiency, whereas only 36% of the craniopharyngioma patients without associated lymphocytic hypophysitis were in this poor postoperative endocrine state. The phenomenon of associated lymphocytic hypophysitis in craniopharyngioma patients has not been reported so far. This might be due to the fact that investigators have failed to systematically examine the anterior pituitary lobe in craniopharyngioma patients. The 60 cases of lymphocytic hypophysitis reported in the literature occurred, for the most part, in women during late pregnancy or shortly after delivery. An auto-immune origin is assumed in this type of inflammation. In contrast to this pathophysiological mechanism, we assume a local induction of inflammation resulting from the craniopharyngioma cyst in our 3 patients.