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Amirbaigloo A, Esfahanian F, Mouodi M, Rakhshani N, Zeinalizadeh M. IgG4-related hypophysitis. Endocrine 2021; 73:270-291. [PMID: 33837927 DOI: 10.1007/s12020-021-02714-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 03/23/2021] [Indexed: 12/13/2022]
Abstract
Hypophysitis is a rare pituitary inflammatory disorder classified in different ways. Immunoglobulin G4-related disease (IgG4-RD), also a rare disease is a systemic fibro-inflammatory condition characterized by infiltration of tissue with IgG4-positive plasma cells; however prevalence of both of them probably is underestimated. In this paper, we present an Iranian patient with biopsy-proven IgG4-related hypophysitis and then review the clinical characteristics, laboratory, imaging, pathologic findings and therapeutic management as well as prognosis of 115 published cases of hypophysitis secondary to IgG4-related disease.
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Affiliation(s)
| | - Fatemeh Esfahanian
- Department of Endocrinology and Metabolism, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran.
| | - Marjan Mouodi
- Department of Endocrinology and Metabolism, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Nasser Rakhshani
- Department of Pathology, Firoozgar Hospital, Iran University of medical sciences, Tehran, Iran
| | - Mehdi Zeinalizadeh
- Department of Neurological Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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2
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Comai G, Cuna V, Fabbrizio B, Sabattini E, Leone O, Tondolo F, Angeletti A, Cappuccilli M, Liguori R, La Manna G. A case report of IgG4-related disease: an insidious path to the diagnosis through kidney, heart and brain. BMC Nephrol 2019; 20:418. [PMID: 31752722 PMCID: PMC6868811 DOI: 10.1186/s12882-019-1587-4] [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: 03/27/2019] [Accepted: 10/13/2019] [Indexed: 11/22/2022] Open
Abstract
Background IgG4-related disease, described around the years 2000 as a form of autoimmune pancreatitis, is now increasingly accepted as a systemic syndrome. The diagnosis is based on both comprehensive and organ-specific criteria. For the kidney, Mayo clinic classification and the guidelines of the Japanese Nephrology Society are used. Ultimately, together with parameters that characterize every organ or apparatus involved, the key element is the confirmation of growing levels of IgG4 in blood or in tissues. Case presentation We describe a male patient with chronic renal failure associated to hypertension without proteinuria. IgG4-related disease was diagnosed through renal biopsy. After an initial positive response to steroids, he presented tinnitus, and histological assessment showed cerebral and subsequently cardiac damage, both IgG4-related. This case appears unique for the type of histologically documented cardiac and neurological parenchymal involvement, and at the same time, exemplifies the subtle and pernicious course of the disease. Frequently, blurred and non-specific signs prevail. Here, kidney damage was associated with minimal urinary findings, slowly progressive renal dysfunction and other factors that can be equivocated in the differential diagnosis. Neurological involvement was represented by tinnitus alone, while cardiac alterations were completely asymptomatic. Conclusions This report is representative of the neurological and cardiac changes described in the literature for IgG4-related disease, which may be correlated or not with the renal form and highlights the need, in some cases, of targeted therapeutic approaches. In addition to glucocorticoids, as in this case, rituximab may be necessary.
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Affiliation(s)
- Giorgia Comai
- Unit of Nephrology, Dialysis and Transplantation, Department of Experimental Diagnostic and Specialty Medicine, University of Bologna, S. Orsola Malpighi Hospital, Via G. Massarenti 9 (Pad. 15), 40138, Bologna, Italy
| | - Vania Cuna
- Unit of Nephrology, Dialysis and Transplantation, Department of Experimental Diagnostic and Specialty Medicine, University of Bologna, S. Orsola Malpighi Hospital, Via G. Massarenti 9 (Pad. 15), 40138, Bologna, Italy
| | - Benedetta Fabbrizio
- Unit of Oncology and Transplant Pathology, Department of Experimental Diagnostic and Specialty Medicine, University of Bologna, S. Orsola Malpighi Hospital, Via G. Massarenti 9 (Pad. 18), 40138, Bologna, Italy
| | - Elena Sabattini
- Unit of Hemolymphopathology, Department of Hematology & Oncology, University of Bologna, S. Orsola Malpighi Hospital, Via G. Massarenti 9 (Pad. 8), 40138, Bologna, Italy
| | - Ornella Leone
- Unit of Oncology and Transplant Pathology, Department of Experimental Diagnostic and Specialty Medicine, University of Bologna, S. Orsola Malpighi Hospital, Via G. Massarenti 9 (Pad. 18), 40138, Bologna, Italy
| | - Francesco Tondolo
- Unit of Nephrology, Dialysis and Transplantation, Department of Experimental Diagnostic and Specialty Medicine, University of Bologna, S. Orsola Malpighi Hospital, Via G. Massarenti 9 (Pad. 15), 40138, Bologna, Italy
| | - Andrea Angeletti
- Unit of Nephrology, Dialysis and Transplantation, Department of Experimental Diagnostic and Specialty Medicine, University of Bologna, S. Orsola Malpighi Hospital, Via G. Massarenti 9 (Pad. 15), 40138, Bologna, Italy
| | - Maria Cappuccilli
- Unit of Nephrology, Dialysis and Transplantation, Department of Experimental Diagnostic and Specialty Medicine, University of Bologna, S. Orsola Malpighi Hospital, Via G. Massarenti 9 (Pad. 15), 40138, Bologna, Italy
| | - Rocco Liguori
- IRCCS Institute of Neurological Sciences of Bologna and Department of Biomedical and Neuromotor Sciences, University of Bologna, Via Altura 3, 40139, Bologna, Italy
| | - Gaetano La Manna
- Unit of Nephrology, Dialysis and Transplantation, Department of Experimental Diagnostic and Specialty Medicine, University of Bologna, S. Orsola Malpighi Hospital, Via G. Massarenti 9 (Pad. 15), 40138, Bologna, Italy.
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Cossu G, Brouland JP, La Rosa S, Camponovo C, Viaroli E, Daniel RT, Messerer M. Comprehensive Evaluation of Rare Pituitary Lesions: A Single Tertiary Care Pituitary Center Experience and Review of the Literature. Endocr Pathol 2019; 30:219-236. [PMID: 31209729 DOI: 10.1007/s12022-019-09581-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The 2017 World Health Organization classification of central nervous system and endocrine tumors have introduced significant changes in the diagnostic criteria for pituitary lesions. The aim of our paper is to describe the epidemiological, clinico-pathological, and radiological features of a single consecutive institutional surgical series of rare pituitary lesions, using these new criteria. Of the 316 endoscopic endonasal trans-sphenoidal approaches performed for pituitary lesions between 2010 and 2018, 15 rare lesions were encountered. These included metastases, pituitary carcinomas, pituicytomas, granular cell tumor, primary pituitary lymphomas, germinoma, mixed gangliocytoma-adenoma, hypophysitis, and pituitary hyperplasia. Their clinical, radiological, and pathological features are herewith presented along with a literature review that enabled us to propose an algorithm to facilitate a diagnosis for rare pituitary lesions.
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Affiliation(s)
- Giulia Cossu
- Department of Neurosurgery, Lausanne University Hospital, Rue du Bugnon 44, 1005, Lausanne, Switzerland
| | - Jean-Philippe Brouland
- Department of Clinical Pathology, Institute of Pathology, Lausanne University Hospital, Lausanne, Switzerland
- University of Lausanne, Lausanne, Switzerland
| | - Stefano La Rosa
- Department of Clinical Pathology, Institute of Pathology, Lausanne University Hospital, Lausanne, Switzerland
- University of Lausanne, Lausanne, Switzerland
| | - Chiara Camponovo
- Department of Endocrinology, University Hospital of Lausanne, Lausanne, Switzerland
| | - Edoardo Viaroli
- Department of Neurosurgery, Lausanne University Hospital, Rue du Bugnon 44, 1005, Lausanne, Switzerland
| | - Roy Thomas Daniel
- Department of Neurosurgery, Lausanne University Hospital, Rue du Bugnon 44, 1005, Lausanne, Switzerland
- University of Lausanne, Lausanne, Switzerland
| | - Mahmoud Messerer
- Department of Neurosurgery, Lausanne University Hospital, Rue du Bugnon 44, 1005, Lausanne, Switzerland.
- University of Lausanne, Lausanne, Switzerland.
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Disease heterogeneity in IgG4-related hypophysitis: report of two histopathologically proven cases and review of the literature. Virchows Arch 2019; 475:373-381. [PMID: 30911814 DOI: 10.1007/s00428-019-02564-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 03/14/2019] [Accepted: 03/17/2019] [Indexed: 12/20/2022]
Abstract
IgG4-related hypophysitis (IgG4-RH) is a rare disease, which can occur singularly or as manifestation of a systemic IgG4-related disease (IgG4-RD). Less than one hundred cases have been reported in the literature, very few of which were histopathologically documented. We analyzed the clinical, radiological, and histopathological features of two cases of IgG4-RH, the former observed in a 66-year-old man in the context of an IgG4-RD, and the latter affecting a 21-year-old woman, as an isolated lesion. In addition, we performed a comprehensive review of the previously published histopathologically documented cases of IgG4-RH. Pituitary samples from both patients showed dense lymphoplasmacytic infiltration, interstitial and storiform fibrosis, and high numbers of IgG4-positive plasma cells, consistent with IgG4-RH. From the literature review, we retrieved 18 papers reporting a total of 22 cases of histopathologically documented IgG4-RH. The revision of these cases, also including the two reported herein, showed an equal distribution of IgG4-RH in the two sexes, albeit significant clinico-pathological variation was found between cases arisen in female and male patients, respectively. In detail, IgG4-RH females were affected in their second-third decade of life, with a solitary pituitary lesion, low IgG4 serum level, and frequent association with autoimmune disorders. By contrast, IgG4-RH in men was a disease of the elderly, often in the context of a systemic IgG4-RD, with high IgG4 serum levels. Our study shows that IgG4-RH, as currently defined, is a clinically heterogenous disease, with different features in the two sexes. Indeed, cases diagnosed in young women, as our case 2, mostly do not present other evidence of IgG4-RD and might be better classified as lymphocytic hypophysitis with abundant IgG4+ plasma cells. For this reason, the histopathological examination of the pituitary lesion, particularly in female patients, may still be useful for a correct differential diagnosis with other variants of primary hypophysitis.
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Li Y, Gao H, Li Z, Zhang X, Ding Y, Li F. Clinical Characteristics of 76 Patients with IgG4-Related Hypophysitis: A Systematic Literature Review. Int J Endocrinol 2019; 2019:5382640. [PMID: 31929792 PMCID: PMC6935800 DOI: 10.1155/2019/5382640] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/20/2019] [Accepted: 11/19/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND IgG4-related hypophysitis (IgG4-RH) is a rare disease, and its prevalence remains unclear. In recent years, an increasing number of cases have been reported because of the increasing recognition of this disease. We aimed to summarize case reports of IgG4-RH and outline the clinical features and outcomes. METHODS We performed PubMed search of articles using the search terms "hypophysitis [AND] IgG4." Consequently, only 54 English articles (76 cases) met Leporati's diagnostic criteria. RESULTS Of the 76 cases, the ratio of men to women was 1.5 : 1, and the age at diagnosis was 54.1 ± 17.8 years. The median IgG4 concentration was 405.0 mg/dl. Anterior hypopituitarism, isolated central diabetes insipidus, and panhypopituitarism were observed in 14 (18.4%), 12 (15.8%), and 44 (57.9%) cases, respectively. The sequence of anterior hormone deficiency was as follows: gonadotropin (68.4%), ACTH (63.2%), TSH (59.2%), GH (48.7%), and prolactin (42.1%). The median number of involved organs was 1.5, and the lung (18.4%), retroperitoneum (17.1%), kidney (15.8%), submandibular glands (14.5%), and pancreas (13.2%) were the common involved organs. Elevated IgG4 concentration and normal IgG4 level were in 42 (76.4%) and 13 (23.6%) cases, respectively. Patients with elevated serum IgG4 concentration were older (60.9 ± 14.3 vs 45.6 ± 17.4, p=0.001) and male-prone (78.6% vs 40.4%, p=0.003) and had a susceptibility of multiple organ involvement (78.6% vs 35.0%, p=0.001) compared to those with normal serum IgG4 levels. Males were older at disease onset (61.5 ± 12.6 vs 42.9 ± 18.8, p < 0.001) and had a higher IgG4 concentration (425.0 vs 152.5, p=0.029) and a greater number of involved organs (2.0 vs 0.0, p=0.001), while isolated hypophysitis was more prominent in female (63.3% vs 26.1%, p=0.001). CONCLUSION In this review, we found that there were different characteristics between different genders. Patients with elevated serum IgG4 level in terms of some clinical features were also different from those with normal serum IgG4 level. However, the data in this review were limited by bias and confounding. Further clinical studies with larger sample sizes are warranted.
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Affiliation(s)
- Yujuan Li
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, Tianjin, China
| | - Hua Gao
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, Tianjin, China
| | - Zhen Li
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, Tianjin, China
| | - Xinxin Zhang
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, Tianjin, China
| | - Yizhi Ding
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, Tianjin, China
| | - Fengao Li
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, Tianjin, China
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Abstract
The increasing recognition of pituitary disorders and their impact on quality of life and longevity has made understanding of this small gland a subject of paramount importance. Pituitary pathology has seen many significant studies that indicate progress in identification and classification of pituitary lesions, as well as improved management strategies for patients. In this review, we outline six major areas of advances: (i) changes in terminology from 'adenoma' to 'pituitary neuroendocrine tumour'; (ii) reclassification of hormone-negative tumours based on transcription factor expression that defines lineage; (iii) updates in new pathogenetic mechanisms, including those that underlie rare lesions such as X-LAG and pituitary blastoma; (iv) clarification of hypophysitis due to immunotherapy, xanthomatous hypophysitis due to rupture of a Rathke's cleft cyst and IgG4 disease as the cause of inflammatory pseudotumour; (v) the consolidation of pituicytoma variants, including spindle cell oncocytoma and granular cell tumour based on thyroid transcription factor-1 (TTF-1) reactivity; and (vi) the pathogenetic mechanisms that distinguish papillary from adamantinomatous craniopharyngioma. The remaining challenge is clarification of the pathogenetic mechanisms underlying the development of many of these disorders.
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Affiliation(s)
- Sylvia L Asa
- Department of Pathology, Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Ozgur Mete
- Department of Pathology, Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
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Yuen KCJ, Moloney KJ, Mercado JU, Rostad S, McCullough BJ, Litvack ZN, Delashaw JB, Mayberg MR. A case series of atypical features of patients with biopsy-proven isolated IgG4-related hypophysitis and normal serum IgG4 levels. Pituitary 2018; 21:238-246. [PMID: 29248982 DOI: 10.1007/s11102-017-0852-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND IgG4-related hypophysitis is a rare clinical entity that forms part of an emerging group of multi-organ IgG4-related fibrosclerotic systemic diseases. The rare prevalence of the disease, presenting features that overlap with other sellar pathologies, and variable imaging features can make preoperative identification challenging. PURPOSE AND METHODS We report three cases of isolated IgG4-related hypophysitis with atypical clinical and imaging features that mimicked those of pituitary apoplexy and other sellar lesions. Additionally, we review the literature of IgG4-related hypophysitis to provide context for individual patient data described herein. RESULTS All patients presented with symptoms that mimicked those of pituitary apoplexy and visual disturbance, and MRI findings suggestive of pituitary macroadenoma, Rathke's cleft cyst and craniopharyngioma. The clinical presentation warranted surgical decompression, resulting in rapid symptomatic improvement. Preoperative high-dose followed by postoperative low-dose glucocorticoid replacement therapy was administered in all cases. Histopathology showed dense infiltrate of IgG4 cells. Post-operative follow-up monitoring for 12-26 months revealed normal serum IgG4 levels with no other organ involvement, while endocrinological testing revealed persistent pituitary hormone deficiencies. CONCLUSIONS Our cases highlight the importance of considering IgG4-related hypophysitis in the differential diagnosis of solid and cystic sellar lesions presenting acutely with pituitary apoplexy symptoms. Existing diagnostic criteria may not be sufficiently precise to permit rapid and reliable identification, or avoidance of surgery in the acute setting. In contrast to other reports of the natural history of this condition, despite the severity of presenting features, the disease in our cases was pituitary-restricted with normal serum IgG4 levels.
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Affiliation(s)
- Kevin C J Yuen
- Swedish Pituitary Center, Department of Neuroendocrinology, Swedish Neuroscience Institute, Seattle, WA, 98122, USA.
- Barrow Pituitary Center, Departments of Neuroendocrinology and Neurosurgery, Barrow Neurological Institute, University of Arizona College of Medicine, Phoenix, AZ, 85013, USA.
| | - Kelley J Moloney
- Swedish Pituitary Center, Department of Neuroendocrinology, Swedish Neuroscience Institute, Seattle, WA, 98122, USA
| | - Jennifer U Mercado
- Swedish Pituitary Center, Department of Neuroendocrinology, Swedish Neuroscience Institute, Seattle, WA, 98122, USA
| | | | - Brendan J McCullough
- Department of Neuroradiology, Swedish Neuroscience Institute, Seattle, WA, 98122, USA
- Radia, Inc., 19020 33rd Avenue West, Suite 210, Lynnwood, WA, 98036, USA
| | - Zachary N Litvack
- Department of Neurosurgery, Swedish Neuroscience Institute, Seattle, WA, 98122, USA
| | - Johnny B Delashaw
- Department of Neurosurgery, Swedish Neuroscience Institute, Seattle, WA, 98122, USA
| | - Marc R Mayberg
- Department of Neurosurgery, Swedish Neuroscience Institute, Seattle, WA, 98122, USA
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