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Balen AH, Tamblyn J, Skorupskaite K, Munro MG. A comprehensive review of the new FIGO classification of ovulatory disorders. Hum Reprod Update 2024; 30:355-382. [PMID: 38412452 DOI: 10.1093/humupd/dmae003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 01/23/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND The World Health Organization (WHO) system for the classification of disorders of ovulation was produced 50 years ago and, by international consensus, has been updated by the International Federation of Gynecology and Obstetrics (FIGO). OBJECTIVE AND RATIONALE This review outlines in detail each component of the FIGO HyPO-P (hypothalamic, pituitary, ovarian, PCOS) classification with a concise description of each cause, and thereby provides a systematic method for diagnosis and management. SEARCH METHODS We searched the published articles in the PubMed database in the English-language literature until October 2022, containing the keywords ovulatory disorders; ovulatory dysfunction; anovulation, and each subheading in the FIGO HyPO-P classification. We did not include abstracts or conference proceedings because the data are usually difficult to assess. OUTCOMES We present the most comprehensive review of all disorders of ovulation, published systematically according to the logical FIGO classification. WIDER IMPLICATIONS Improving the diagnosis of an individual's ovulatory dysfunction will significantly impact clinical practice by enabling healthcare practitioners to make a precise diagnosis and plan appropriate management.
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Affiliation(s)
- Adam H Balen
- Leeds Centre for Reproductive Medicine, The University of Leeds, Leeds, UK
| | - Jennifer Tamblyn
- Leeds Centre for Reproductive Medicine, The University of Leeds, Leeds, UK
| | | | - Malcolm G Munro
- Department of Obstetrics and Gynecology, The University of California, Los Angeles, Los Angeles, CA, USA
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Pagoada-Torres JD, Villalobos-Díaz R, Pineda-Centeno LM, Pesci-Eguia L, Gomez-Villegas T, Rivera-Montes H, Portocarrero-Ortiz LA. Bilateral Sixth Nerve Palsy: A Rare Presentation of Primary Hypophysitis. Cureus 2024; 16:e58850. [PMID: 38784347 PMCID: PMC11115475 DOI: 10.7759/cureus.58850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2024] [Indexed: 05/25/2024] Open
Abstract
Cranial nerve palsy is common in pituitary disease and depends on the extension of the lesion into the cavernous sinuses. Bilateral cranial nerve palsy was described in pituitary adenomas with apoplexy and in only one case in hypophysitis. We present a case of a 32-year-old female manifesting with headache, diplopia, bilateral sixth nerve palsy, and hypopituitarism. Magnetic resonance imaging (MRI) revealed symmetric expansion of the pituitary gland, with bilateral cavernous sinus invasion and thickening of the pituitary stalk. Hypophysitis was suspected, and after treatment with IV methylprednisolone boluses, a decrease in the pituitary lesion was observed, with complete remission of sixth nerve palsy in the right eye and partial improvement in the left eye. In this case, we report an infrequent form of presentation of hypophysitis, and highlight that steroids are the first line of treatment.
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Affiliation(s)
- Josue D Pagoada-Torres
- Endocrinology, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez", Mexico City, MEX
| | - Rodolfo Villalobos-Díaz
- Neurosurgery, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez", Mexico City, MEX
| | - Luz M Pineda-Centeno
- Neurology, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez", Mexico City, MEX
| | - Luis Pesci-Eguia
- Ophthalmology, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez", Mexico City, MEX
| | - Thamar Gomez-Villegas
- Ophthalmology, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez", Mexico City, MEX
| | - Hector Rivera-Montes
- Endocrinology, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez", Mexico City, MEX
| | - Lesly A Portocarrero-Ortiz
- Neuroendocrinology, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez", Mexico City, MEX
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Wang L, Chen X, Liu X, Miao H, Gong F, Yang H, Duan L, Zhu H, Sun W. Cerebrospinal Fluid Metabolomic Pattern of Different Pituitary Stalk Lesions. J Clin Endocrinol Metab 2024; 109:802-814. [PMID: 37769631 DOI: 10.1210/clinem/dgad559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 09/11/2023] [Accepted: 09/19/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE To describe the cerebrospinal fluid (CSF) metabolomic pattern of pituitary stalk lesions. METHODS CSF was collected from patients with different pituitary stalk lesions treated at Peking Union Medical College Hospital: germ cell tumor (GCT, n = 27); hypophysitis (n = 10); and Langerhans cell histiocytosis (LCH) or Erdheim-Chester disease (ECD) (LCH + ECD, n = 10). The CSF metabolome profiles were characterized by liquid chromatography-mass spectrometry (LC-MS). RESULTS There were 44 metabolites that significantly differed between patients with GCT and those with hypophysitis (P < .05). Between patients with GCT with CSF level of beta subunit of human chorionic gonadotrophin (β-hCG) < 5 mIU/mL and those with hypophysitis, there were 15 differential metabolites (P < .05, fold change > 1.5 or < 1/1.5). All of the metabolites had an area under the curve (AUC) above 0.7. There were 9 metabolites that significantly differed between patients with GCT and those with LCH + ECD (P < .05) and 7 metabolites had significant differences between GCT (CSF β-hCG < 5 mIU/mL) and LCH + ECD (P < .05, fold change > 1.5 or < 1/1.5). We found 6 metabolites that were significantly different between patients with hypophysitis and those with LCH + ECD (P < .05) and 5 of these had fold change more than 1.5 or less than 1/1.5. Three metabolites, 5-deoxydiplosporin, cloversaponin I, and phytosphingosine, showed excellent capabilities to differentiate the 3 disease categories. Furthermore, we identified 67 metabolites associated with clinical test results (ρ > 0.2, P < .05) and 29 metabolites showed strong correlation (ρ > 0.4, P < .05). CONCLUSION Our study is the first to systematically investigate the metabolomics of CSF in different pituitary stalk lesions. CSF metabolomics is a useful strategy for biomarker discovery.
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Affiliation(s)
- Linjie Wang
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health and Family Planning Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Xiaoxue Chen
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health and Family Planning Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
- Eight-Year Program of Clinical Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Xiaoyan Liu
- Proteomics Research Center, Core Facility of Instruments, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, 100730, China
| | - Hui Miao
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health and Family Planning Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Fengying Gong
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health and Family Planning Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Hongbo Yang
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health and Family Planning Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Lian Duan
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health and Family Planning Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Huijuan Zhu
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health and Family Planning Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Wei Sun
- Proteomics Research Center, Core Facility of Instruments, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, 100730, China
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Shen K, Cadang C, Phillips D, Babu V. Unique case of lymphocytic hypophysitis with normal pituitary hormone serology mimicking a non-functioning pituitary adenoma. BMC Endocr Disord 2024; 24:20. [PMID: 38326790 PMCID: PMC10851602 DOI: 10.1186/s12902-024-01546-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 01/23/2024] [Indexed: 02/09/2024] Open
Abstract
BACKGROUND Lymphocytic hypophysitis is a rare autoimmune condition that usually presents during pregnancy and causes inflammation of the pituitary gland. Although the pathophysiology is not well understood, it often presents with headaches, visual disturbances, and symptoms of hypopituitarism. However, not all cases may present with hypopituitarism which can make this rare disease with an incidence of ~ 1 in 9 million much more difficult to diagnose. CASE PRESENTATION We present a 35-year-old G4P4 woman with progressive vision loss and intermittent frontal headaches during her first trimester through 2 months postpartum. She presented with no symptoms of hypopituitarism and her hormone panel only showed elevated prolactin, possibly due to her breastfeeding. She was treated with a right pterional craniotomy with decompression of both optic nerves, partial resection of the suprasellar mass, and glucocorticoid therapy for headaches and visual disturbances. CONCLUSION This case is notable for a presentation of lymphocytic hypophysitis without symptoms of hypopituitarism. This is important for outpatient providers to be aware of, especially those that care for pregnant patients so that unfavorable outcomes can be avoided.
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Affiliation(s)
- Kyle Shen
- UCSF, School of Medicine, San Francisco, California, USA.
| | - Catherine Cadang
- UCSF Fresno, Department of Internal Medicine, Fresno, California, USA
| | | | - Varsha Babu
- UCSF Fresno, Division of Endocrinology, Department of Internal Medicine, Fresno, California, USA
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Kara Z, Eşkazan T, Şahin S, Durcan E, Sulu C, Demir AN, Uysal S, Özkaya HM, Yılmaz E, Hatemi Aİ, Bolayırlı İM, Kadıoğlu P. Is There A Connection Between Primary Hypophysitis and Celiac Disease? Exp Clin Endocrinol Diabetes 2024; 132:33-38. [PMID: 37977557 DOI: 10.1055/a-2213-4375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
AIM To investigate the autoimmune and genetic relationship between primary hypophysitis (PH) and celiac disease (CD). METHODS The study was retrospective and patients with PH followed in our clinic between 2007 and 2022 were evaluated. Clinical, endocrinologic, pathologic, and radiologic findings and treatment modalities were assessed. Patients diagnosed with CD in the Gastroenterology outpatient clinic in 2020-2022 were included in the study as a control group. Information such as sociodemographic data, year of diagnosis, human leukocyte antigen (HLA) DQ2/8 information, CD-specific antibody levels, pathologic results of duodenal biopsy, treatment received, follow-up status, additional diseases, hormone use, and surgical history was obtained from patient records at PH.In patients diagnosed with PH, a duodenal biopsy was obtained, and the tissue was examined for CD by experienced pathologists. Anti-pituitary antibody (APA) and anti-arginine-vasopressin (AAVP) antibody levels of individuals with PH and CD were measured. RESULTS The study included 19 patients with lymphocytic hypophysitis, 30 celiac patients, and 30 healthy controls. When patients diagnosed with lymphocytic hypophysitis were examined by duodenal biopsy, no evidence of CD was found in the pathologic findings. The detection rate of HLA-DQ2/8 was 80% in celiac patients and 42% in PH (p=0.044). (APA and AAVP antibodies associated with PH were tested in two separate groups of patients and in the control group. APA and anti-arginine vasopressin (AAVP) levels in PH, CD and healthy controls, respectively M [IQR]: 542 [178-607];164 [125-243]; 82 [74-107] ng/dL (p=0.001), 174 [52-218]; 60 [47-82]; 59 [48-76] ng/dL (p=0.008) were detected. The presence of an HLA-DQ2/8 haplotype correlates with posterior hypophysitis and panhypophysitis (r=0.598, p=0.04 and r=0.657, p=0.02, respectively). CONCLUSION Although patients with PH were found to have significant levels of HLA-DQ2/8, no CD was found in the tissue. Higher levels of pituitary antibodies were detected in celiac patients compared with healthy controls, but no hypophysitis clinic was observed at follow-up. Although these findings suggest that the two diseases may share a common genetic and autoimmune basis, the development of the disease may be partially explained by exposure to environmental factors.
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Affiliation(s)
- Zehra Kara
- Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Department of Endocrinology, Metabolism, and Diabetes, Istanbul, Turkey
| | - Tuğçe Eşkazan
- Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Department of Gastroenterology and Hepatology, Istanbul, Turkey
| | - Serdar Şahin
- Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Department of Endocrinology, Metabolism, and Diabetes, Istanbul, Turkey
| | - Emre Durcan
- Bağcılar Training and Research Hospital, Department of Endocrinology, Metabolism, and Diabetes, Istanbul, Turkey
| | - Cem Sulu
- Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Department of Endocrinology, Metabolism, and Diabetes, Istanbul, Turkey
| | - Ahmet Numan Demir
- Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Department of Endocrinology, Metabolism, and Diabetes, Istanbul, Turkey
| | - Serhat Uysal
- Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Department of Endocrinology, Metabolism, and Diabetes, Istanbul, Turkey
| | - Hande Mefkure Özkaya
- Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Department of Endocrinology, Metabolism, and Diabetes, Istanbul, Turkey
| | - Erkan Yılmaz
- Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Department of Organ Transplantation, HLA Laboratory, Istanbul, Turkey
| | - Ali İbrahim Hatemi
- Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Department of Gastroenterology and Hepatology, Istanbul, Turkey
| | - İbrahim Murat Bolayırlı
- Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Department of Biochemistry, Istanbul, Turkey
| | - Pınar Kadıoğlu
- Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Department of Endocrinology, Metabolism, and Diabetes, Istanbul, Turkey
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Uccella S, Dottermusch M, Erickson L, Warmbier J, Montone K, Saeger W. Inflammatory and Infectious Disorders in Endocrine Pathology. Endocr Pathol 2023; 34:406-436. [PMID: 37209390 PMCID: PMC10199304 DOI: 10.1007/s12022-023-09771-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2023] [Indexed: 05/22/2023]
Abstract
A variety of inflammatory conditions may directly involve the endocrine glands, leading to endocrine dysfunction that can cause severe consequences on patients' health, if left untreated. Inflammation of the endocrine system may be caused by either infectious agents or other mechanisms, including autoimmune and other immune-mediated processes. Not infrequently, inflammatory and infectious diseases may appear as tumor-like lesions of endocrine organs and simulate neoplastic processes. These diseases may be clinically under-recognized and not infrequently the diagnosis is suggested on pathological samples. Thus, the pathologist should be aware of the basic principles of their pathogenesis, as well as of their morphological features, clinicopathological correlates, and differential diagnosis. Interestingly, several systemic inflammatory conditions show a peculiar tropism to the endocrine system as a whole. In turn, organ-specific inflammatory disorders are observed in endocrine glands. This review will focus on the morphological aspects and clinicopathological features of infectious diseases, autoimmune disorders, drug-induced inflammatory reactions, IgG4-related disease, and other inflammatory disorders involving the endocrine system. A mixed entity-based and organ-based approach will be used, with the aim to provide the practicing pathologist with a comprehensive and practical guide to the diagnosis of infectious and inflammatory disorders of the endocrine system.
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Affiliation(s)
- Silvia Uccella
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanule, Milan, Italy
- Pathology Service IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Matthias Dottermusch
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lori Erickson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN USA
| | - Julia Warmbier
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kathleen Montone
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA USA
| | - Wolfgang Saeger
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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7
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Kurokawa R, Kurokawa M, Baba A, Nakaya M, Kato S, Bapuraj J, Nakata Y, Ota Y, Srinivasan A, Abe O, Moritani T. Neuroimaging of hypophysitis: etiologies and imaging mimics. Jpn J Radiol 2023; 41:911-927. [PMID: 37010787 PMCID: PMC10468747 DOI: 10.1007/s11604-023-01417-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 03/24/2023] [Indexed: 04/04/2023]
Abstract
Hypophysitis is an inflammatory disease affecting the pituitary gland. Hypophysitis can be classified into multiple types depending on the mechanisms (primary or secondary), histology (lymphocytic, granulomatous, xanthomatous, plasmacytic/IgG4 related, necrotizing, or mixed), and anatomy (adenohypophysitis, infundibulo-neurohypophysitis, or panhypophysitis). An appropriate diagnosis is vital for managing these potentially life-threatening conditions. However, physiological morphological alterations, remnants, and neoplastic and non-neoplastic lesions may masquerade as hypophysitis, both clinically and radiologically. Neuroimaging, as well as imaging findings of other sites of the body, plays a pivotal role in diagnosis. In this article, we will review the types of hypophysitis and summarize clinical and imaging features of both hypophysitis and its mimickers.
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Affiliation(s)
- Ryo Kurokawa
- Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA.
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Mariko Kurokawa
- Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Akira Baba
- Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Moto Nakaya
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Shimpei Kato
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Jayapalli Bapuraj
- Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Yasuhiro Nakata
- Department Or Neuroradiology, Tokyo Metropolitan Neurological Hospital, 2-6-1 Musashidai, Fuchu, Tokyo, 183-0042, Japan
| | - Yoshiaki Ota
- Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Ashok Srinivasan
- Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Osamu Abe
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Toshio Moritani
- Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
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Hussain A, Gudipati MK, Uy E, Piercy J, Ganti S. A Case of Central Diabetes Insipidus in a Patient With a Pineal Mass Suspected to Be a Germinoma: A Case Report. Cureus 2023; 15:e46103. [PMID: 37900440 PMCID: PMC10611980 DOI: 10.7759/cureus.46103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2023] [Indexed: 10/31/2023] Open
Abstract
Central diabetes insipidus (CDI) is a rare condition characterized by excessive urination and thirst due to vasopressin deficiency. The underlying cause of CDI remains unknown in many cases. Tumors are a leading cause of CDI in young individuals, with germinoma being the most prevalent. We present a case of a 22-year-old male diagnosed with infundibuloneurohypophysitis (INH) of unknown etiology. His pituitary stalk thickening partially responded to high-dose prednisone treatment; however, one year after initial diagnosis, a new pineal region mass was noted on imaging. Further evaluation revealed the mass to be most likely a germinoma. This case emphasizes the importance of ongoing clinical and radiologic follow-up in idiopathic cases of CDI. The patient's symptoms improved with desmopressin, but the presence of the pineal mass necessitates further comprehensive neurosurgical evaluation.
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Affiliation(s)
- Akbar Hussain
- Internal Medicine, Appalachian Regional Healthcare, Harlan, USA
| | | | - Edilfavia Uy
- Diabetes and Endocrinology, Appalachian Regional Healthcare, Harlan, USA
| | - Jonathan Piercy
- Internal Medicine, Appalachian Regional Healthcare, Harlan, USA
| | - Shyam Ganti
- Internal Medicine, Appalachian Regional Healthcare, Harlan, USA
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Vakharia JD, Muhammed M, Remba-Shapiro I, Marsiglia M, Hadaway N, Chwalisz BK, Nachtigall LB. A novel approach to hypophysitis: outcomes using non-glucocorticoid immunosuppressive therapy. Eur J Endocrinol 2023; 189:309-317. [PMID: 37602514 PMCID: PMC10473830 DOI: 10.1093/ejendo/lvad115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/08/2023] [Accepted: 07/26/2023] [Indexed: 08/22/2023]
Abstract
OBJECTIVE To determine pituitary function before and after nonglucocorticoid immunosuppressive therapy (NGIT) in subjects with hypophysitis and evaluate their clinical and radiologic outcomes. DESIGN Retrospective, longitudinal study. METHODS We reviewed a large database, selected subjects with hypophysitis treated with NGIT, and collected information on the duration of therapy, and clinical, hormonal, and radiologic outcomes. RESULTS Twelve subjects met the inclusion criteria. Five subjects had primary hypophysitis (PH), while seven had secondary hypophysitis (SH) due to an underlying systemic inflammatory disease. Mean age ± SD was 48.0 ± 15.7 years and 40.9 ± 13.0 years, for PH and SH, respectively. The majority were female (PH 60% and SH 86%). BMI ± SD at presentation was 25.2 ± 2.5 kg/m2 and 26.8 ± 6.7 kg/m2 for PH and SH, respectively. The most common symptom at presentation was fatigue (75%). All PH subjects (100%) and 2 (28.6%) SH subjects had polyuria/polydipsia. There was a significant decrease in mean pituitary stalk thickness after NGIT (P = .0051) (mean duration 16.5 ± 4.8 months). New hormone loss or recovery occurred rarely. Mycophenolate mofetil was the most used NGIT: adverse effects prompted discontinuation in 2 out of 7 subjects. CONCLUSIONS Subjects with hypophysitis receiving NGIT had stable or improved brain/pituitary magnetic resonance imaging findings with a significant decrease in pituitary stalk thickness. NGITs did not improve anterior pituitary function. Our findings suggest that NGIT may be considered as an alternative therapy for patients with hypophysitis who require immunosuppression.
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Affiliation(s)
- Janaki D Vakharia
- Neuroendocrine Unit, Division of Endocrinology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Maged Muhammed
- Neuroendocrine Unit, Division of Endocrinology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Ilan Remba-Shapiro
- Neuroendocrine Unit, Division of Endocrinology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Marcela Marsiglia
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114-2696, United States
| | - Natalia Hadaway
- Neuroendocrine Unit, Division of Endocrinology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Bart K Chwalisz
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114-2696, United States
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA 02114-2696, United States
| | - Lisa B Nachtigall
- Neuroendocrine Unit, Division of Endocrinology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
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10
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Menotti S, Giampietro A, Raia S, Veleno M, Angelini F, Tartaglione T, Gaudino S, Doglietto F, De Marinis L, Pontecorvi A, Bianchi A, Chiloiro S. Unveiling the Etiopathogenic Spectrum of Hypophysitis: A Narrative Review. J Pers Med 2023; 13:1210. [PMID: 37623461 PMCID: PMC10455260 DOI: 10.3390/jpm13081210] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 07/25/2023] [Accepted: 07/27/2023] [Indexed: 08/26/2023] Open
Abstract
Hypophysitis, a rare inflammatory disorder of the pituitary gland, has seen an uptick in reported cases in recent years. Our objective is to summarize the most recent research on the etiopathogenesis, molecular mechanisms, and genetics of both primary and secondary hypophysitis. Primary autoimmune hypophysitis (PAH): During the acute phase of the disease, the pituitary gland in enlarged due to the infiltration of T and B lymphocytes. The chronic phase is characterized by progressive and irreversible pituitary atrophy. APA may play a role in the management, diagnosis, and prognosis of PAH. Specific autoantibodies such as anti-GH, anti-PIT-1, and anti-T-PIT have been found in patients with hypophysitis and hypopituitarism. A recent study suggested that a mechanism of escaping clonal deletion and mounting an immune response against self antigens can explain the unusual nature of the immune response observed in PAH patients. A cytokine array shows the presence of gamma-interferon and interleukin-17. Patients carrying mutations in the PIT1 or PROP1 genes may present PAH. Individuals carrying the HLA DQ8 haplotype are four times more likely to develop PAH. Immune checkpoint inhibitors induce hypophysitis (IIHs): IIHs is an increasingly frequent toxicity of in patients on treatment with inhibitors targeting cytotoxic T-lymphocyte antigen 4 (CTLA-4) and programmed cell death-1 (PD-1). ICIs inhibit the CTLA-4 pathway, leading to overactivation of T lymphocytes. The binding of PD-1/PD-L1 suppresses the activity of T cells, promotes the conversion of T-helpers into T-regulatory cells, and activates pro-survival signaling pathways in cancer cells. Cytokines play a crucial role in IIHs. B-cell infiltration has been observed in IIHs, suggesting that antibody-mediated pituitary injury may contribute. Genetic polymorphisms of CTLA-4 and PD-1 genes can increase the risk of IIHs. HLA alleles may also be involved in the onset of IIHs; this HLA association presents a possible alternative mechanistic hypothesis. IIHs may also be linked to a paraneoplastic syndrome triggered by ectopic expression of pituitary specific antigens. SARS-CoV-2-related hypophysitis: Recently, the literature has reported occurrences of hypophysitis associated with the SARS-CoV-2 virus; long COVID-19 may also present as infundibulo-neuro-hypophysitis. The virus enters the central nervous system because of its distinct interaction with angiotensin-converting enzyme receptors via spike proteins binding the capillary endothelium, and it directly damages the pituitary cells. The effect of SARS-CoV-2 can occur indirectly through inflammation and the release of cytokines. The exact mechanism remains ambiguous. The available data on endocrine complications associated with the SARS-CoV-2 vaccine are scant. Nonetheless, isolated cases of hypophysitis have been documented. Treatment of hypophysitis: Glucocorticoids are the cornerstone in managing primary hypophysitis, given their targeted action on inflammation. A better understanding of the etiopathogenesis and molecular mechanism of hypophysitis can lead to more effective and personalized treatment strategies.
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Affiliation(s)
- Sara Menotti
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (S.M.); (A.G.); (S.R.); (M.V.); (F.A.); (L.D.M.); (A.P.); (S.C.)
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (T.T.); (S.G.); (F.D.)
| | - Antonella Giampietro
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (S.M.); (A.G.); (S.R.); (M.V.); (F.A.); (L.D.M.); (A.P.); (S.C.)
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (T.T.); (S.G.); (F.D.)
| | - Salvatore Raia
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (S.M.); (A.G.); (S.R.); (M.V.); (F.A.); (L.D.M.); (A.P.); (S.C.)
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (T.T.); (S.G.); (F.D.)
| | - Miriam Veleno
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (S.M.); (A.G.); (S.R.); (M.V.); (F.A.); (L.D.M.); (A.P.); (S.C.)
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (T.T.); (S.G.); (F.D.)
| | - Flavia Angelini
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (S.M.); (A.G.); (S.R.); (M.V.); (F.A.); (L.D.M.); (A.P.); (S.C.)
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (T.T.); (S.G.); (F.D.)
| | - Tommaso Tartaglione
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (T.T.); (S.G.); (F.D.)
- Department of Radiodiagnostic, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Simona Gaudino
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (T.T.); (S.G.); (F.D.)
- Department of Radiodiagnostic, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Francesco Doglietto
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (T.T.); (S.G.); (F.D.)
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Laura De Marinis
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (S.M.); (A.G.); (S.R.); (M.V.); (F.A.); (L.D.M.); (A.P.); (S.C.)
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (T.T.); (S.G.); (F.D.)
| | - Alfredo Pontecorvi
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (S.M.); (A.G.); (S.R.); (M.V.); (F.A.); (L.D.M.); (A.P.); (S.C.)
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (T.T.); (S.G.); (F.D.)
| | - Antonio Bianchi
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (S.M.); (A.G.); (S.R.); (M.V.); (F.A.); (L.D.M.); (A.P.); (S.C.)
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (T.T.); (S.G.); (F.D.)
| | - Sabrina Chiloiro
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (S.M.); (A.G.); (S.R.); (M.V.); (F.A.); (L.D.M.); (A.P.); (S.C.)
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (T.T.); (S.G.); (F.D.)
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Patra S, Trivedi P. A unique coexistence of a plurihormonal pituitary adenoma with granulomatous hypophysitis. INDIAN J PATHOL MICR 2023; 66:618-620. [PMID: 37530354 DOI: 10.4103/ijpm.ijpm_439_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023] Open
Abstract
Dual pathology in the pituitary gland is a unique phenomenon. Coexistence of a pituitary adenoma with primary hypophysitis has been reported rarely with very few cases in the literature. Among the primary hypophysitis, primary granulomatous subtype has been proposed to be idiopathic and autoimmune in nature. Plurihormonal pituitary adenomas produce hormones of more than one different pituitary cell lineage. Pituitary adenoma with a single hormonal content has been documented with concurrent primary granulomatous hypophysitis. The present case describes the unique coexistence of a plurihormonal adenoma showing somatotroph, lactotroph, and corticotroph lineage with primary granulomatous inflammation in the sellar region in a 36-year-old woman.
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Affiliation(s)
- Sanjiban Patra
- Department of Oncopathology, The Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
| | - Priti Trivedi
- Department of Oncopathology, The Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
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12
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Naser PV, Papadopoulou P, Teuber J, Kopf S, Jesser J, Unterberg AW, Beynon C. Characteristics of inflammatory and infectious diseases of the pituitary gland in patients undergoing transsphenoidal surgery. Pituitary 2023:10.1007/s11102-023-01333-4. [PMID: 37389775 PMCID: PMC10397134 DOI: 10.1007/s11102-023-01333-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/15/2023] [Indexed: 07/01/2023]
Abstract
PURPOSE Inflammatory and infectious diseases of the pituitary gland (IIPD) are rare lesions often misdiagnosed preoperatively. Immediate surgery is indicated especially in cases of neurological impairment. However, (chronic) inflammatory processes can mimic other pituitary tumors, such as adenomas, and data on the preoperative diagnostic criteria for IIPD are sparse. METHODS We retrospectively reviewed medical records of 1317 patients who underwent transsphenoidal surgery at our institution between March 2003 and January 2023. A total of 26 cases of histologically confirmed IIPD were identified. Patient records, laboratory parameters, and postoperative course were analyzed and compared with an age, sex, and tumor volume-matched control group of nonfunctioning pituitary adenomas. RESULTS Pathology confirmed septic infection in ten cases, most commonly caused by bacteria (3/10) and fungi (2/10). In the aseptic group, lymphocytic hypophysitis (8/26) and granulomatous inflammation (3/26) were most frequently observed. Patients with IIPD commonly presented with endocrine and/or neurological dysfunction. No surgical mortality occurred. Preoperative radiographic findings (cystic/solid tumor mass, contrast enhancement) did not significantly differ between IIPD and adenomas. At follow-up, 13 patients required permanent hormone substitution. CONCLUSION In conclusion, correct preoperative diagnosis of IIPD remains challenging, as neither radiographic findings nor preoperative laboratory workup unequivocally identify these lesions. Surgical treatment facilitates decompression of supra- and parasellar structures. Furthermore, this low-morbidity procedure enables the identification of pathogens or inflammatory diseases requiring targeted medical treatment, which is crucial for these patients. Establishing a correct diagnosis through surgery and histopathological confirmation thus remains of utmost importance.
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Affiliation(s)
- Paul Vincent Naser
- Department of Neurosurgery, Heidelberg University, Im Neuenheimer Feld 400, Heidelberg, 69120, Germany.
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, Heidelberg, 69120, Germany.
| | - Penelope Papadopoulou
- Department of Neurosurgery, Heidelberg University, Im Neuenheimer Feld 400, Heidelberg, 69120, Germany
| | - Jan Teuber
- Department of Neurosurgery, Heidelberg University, Im Neuenheimer Feld 400, Heidelberg, 69120, Germany
| | - Stefan Kopf
- Department of Endocrinology, Heidelberg University, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany
| | - Jessica Jesser
- Department of Neuroradiology, Heidelberg University, Im Neuenheimer Feld 400, Heidelberg, 69120, Germany
| | - Andreas W Unterberg
- Department of Neurosurgery, Heidelberg University, Im Neuenheimer Feld 400, Heidelberg, 69120, Germany
| | - Christopher Beynon
- Department of Neurosurgery, Heidelberg University, Im Neuenheimer Feld 400, Heidelberg, 69120, Germany
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13
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Rawanduzy CA, Winkler-Schwartz A, Couldwell WT. Hypophysitis: Defining Histopathologic Variants and a Review of Emerging Clinical Causative Entities. Int J Mol Sci 2023; 24:ijms24065917. [PMID: 36982990 PMCID: PMC10057821 DOI: 10.3390/ijms24065917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/10/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
Inflammatory disease of the pituitary gland is known as hypophysitis. There are multiple histological subtypes, the most common being lymphocytic, and the pathogenesis is variable and diverse. Hypophysitis can be primary and idiopathic or autoimmune related, or secondary to local lesions, systemic disease, medications, and more. Although hypophysitis was previously accepted as an exceedingly rare diagnosis, a greater understanding of the disease process and new insights into possible etiologic sources have contributed to an increased frequency of recognition. This review provides an overview of hypophysitis, its causes, and detection strategies and management.
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Affiliation(s)
- Cameron A Rawanduzy
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT 84112, USA
| | - Alexander Winkler-Schwartz
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT 84112, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT 84112, USA
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Tsukamoto T, Miki Y. Imaging of pituitary tumors: an update with the 5th WHO Classifications-part 2. Neoplasms other than PitNET and tumor-mimicking lesions. Jpn J Radiol 2023:10.1007/s11604-023-01407-0. [PMID: 36913010 PMCID: PMC10366287 DOI: 10.1007/s11604-023-01407-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 02/24/2023] [Indexed: 03/14/2023]
Abstract
Many types of tumors can develop in the pituitary gland. In the recently revised 5th editions of the World Health Organization (WHO) classifications (2021 WHO Classification of Central Nervous System Tumors and the 2022 WHO Classification of Endocrine and Neuroendocrine Tumors), various changes have been made to the tumors other than pituitary neuroendocrine tumor (PitNET)/pituitary adenoma, as well as PitNET. Adamantinomatous craniopharyngioma and papillary craniopharyngioma are now considered separate tumors in the 5th edition of the WHO classification. Tumors positive for thyroid transcription factor 1, a marker of posterior pituitary cells, are now grouped together in the pituicyte tumor family in the 5th edition of the WHO classification of Endocrine and Neuroendocrine Tumors. Poorly differentiated chordoma is newly listed in the 5th edition of the WHO Classification of Endocrine and Neuroendocrine Tumors. In this paper, we present the latest WHO classification of pituitary tumors (adamantinomatous craniopharyngioma, papillary craniopharyngioma, pituitary blastoma, pituicyte tumor family, tumors of pituitary origin other than those of the pituicyte tumor family, germinoma, meningioma, chordoma, metastatic tumors, lymphoma, and pituitary incidentaloma), review diseases requiring differentiation from tumors (pituitary abscess, hypophysitis, pituitary hyperplasia, Rathke's cleft cyst, arachnoid cyst, and aneurysm), and discuss diagnoses based on imaging findings.
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Affiliation(s)
- Taro Tsukamoto
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan.
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15
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Iglesias P, Biagetti B, Guerrero-Pérez F, Vicente A, Cordido F, Díez JJ. Executive summary of the consensus document on hypophysitis of the Neuroendocrinology Area of Knowledge of the Spanish Society of Endocrinology and Nutrition. ENDOCRINOL DIAB NUTR 2023; 70 Suppl 1:116-125. [PMID: 36894450 DOI: 10.1016/j.endien.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 01/14/2023] [Indexed: 03/09/2023]
Abstract
The term hypophysitis is used to designate a heterogeneous group of pituitary conditions characterized by the presence of inflammatory infiltration of the adenohypophysis, neurohypophysis, or both. Although hypophysitis are rare disorders, the most common in clinical practice is lymphocytic hypophysitis, a primary hypophysitis characterized by lymphocytic infiltration, which predominantly affects women. Other forms of primary hypophysitis are associated with different autoimmune diseases. Hypophysitis can also be secondary to other disorders such as sellar and parasellar diseases, systemic diseases, paraneoplastic syndromes, infections, and drugs, including immune checkpoint inhibitors. The diagnostic evaluation should always include pituitary function tests and other analytical tests based on the suspected diagnosis. Pituitary magnetic resonance imaging is the investigation of choice for the morphological assessment of hypophysitis. Glucocorticoids are the mainstay of treatment for most symptomatic hypophysitis.
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Affiliation(s)
- Pedro Iglesias
- Servicio de Endocrinología y Nutrición, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro - Segovia de Arana (IDIPHISA), Majadahonda, Madrid, Spain; Departamento de Medicina, Universidad Autónoma de Madrid, Madrid, Spain.
| | - Betina Biagetti
- Servicio de Endocrinología y Nutrición, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Fernando Guerrero-Pérez
- Servicio de Endocrinología y Nutrición, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Almudena Vicente
- Servicio de Endocrinología y Nutrición, Hospital Universitario de Toledo, Toledo, Spain
| | - Fernando Cordido
- Servicio de Endocrinología y Nutrición, Complexo Hospitalario Universitario de A Coruña, Universidad de A Coruña, A Coruña, Spain
| | - Juan J Díez
- Servicio de Endocrinología y Nutrición, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro - Segovia de Arana (IDIPHISA), Majadahonda, Madrid, Spain; Departamento de Medicina, Universidad Autónoma de Madrid, Madrid, Spain
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Iglesias P, Biagetti B, Guerrero-Pérez F, Vicente A, Cordido F, Díez JJ. Resumen ejecutivo del documento de consenso sobre hipofisitis del Área de Conocimiento de Neuroendocrinología de la Sociedad Española de Endocrinología y Nutrición. ENDOCRINOL DIAB NUTR 2023. [DOI: 10.1016/j.endinu.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Prencipe N, Marinelli L, Varaldo E, Cuboni D, Berton AM, Bioletto F, Bona C, Gasco V, Grottoli S. Isolated anterior pituitary dysfunction in adulthood. Front Endocrinol (Lausanne) 2023; 14:1100007. [PMID: 36967769 PMCID: PMC10032221 DOI: 10.3389/fendo.2023.1100007] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/21/2023] [Indexed: 03/29/2023] Open
Abstract
Hypopituitarism is defined as a complete or partial deficiency in one or more pituitary hormones. Anterior hypopituitarism includes secondary adrenal insufficiency, central hypothyroidism, hypogonadotropic hypogonadism, growth hormone deficiency and prolactin deficiency. Patients with hypopituitarism suffer from an increased disability and sick days, resulting in lower health status, higher cost of care and an increased mortality. In particular during adulthood, isolated pituitary deficits are not an uncommon finding; their clinical picture is represented by vague symptoms and unclear signs, which can be difficult to properly diagnose. This often becomes a challenge for the physician. Aim of this narrative review is to analyse, for each anterior pituitary deficit, the main related etiologies, the characteristic signs and symptoms, how to properly diagnose them (suggesting an easy and reproducible step-based approach), and eventually the treatment. In adulthood, the vast majority of isolated pituitary deficits are due to pituitary tumours, head trauma, pituitary surgery and brain radiotherapy. Immune-related dysfunctions represent a growing cause of isolated pituitary deficiencies, above all secondary to use of oncological drugs such as immune checkpoint inhibitors. The diagnosis of isolated pituitary deficiencies should be based on baseline hormonal assessments and/or dynamic tests. Establishing a proper diagnosis can be quite challenging: in fact, even if the diagnostic methods are becoming increasingly refined, a considerable proportion of isolated pituitary deficits still remains without a certain cause. While isolated ACTH and TSH deficiencies always require a prompt replacement treatment, gonadal replacement therapy requires a benefit-risk evaluation based on the presence of comorbidities, age and gender of the patient; finally, the need of growth hormone replacement therapies is still a matter of debate. On the other side, prolactin replacement therapy is still not available. In conclusion, our purpose is to offer a broad evaluation from causes to therapies of isolated anterior pituitary deficits in adulthood. This review will also include the evaluation of uncommon symptoms and main etiologies, the elements of suspicion of a genetic cause and protocols for diagnosis, follow-up and treatment.
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Keys PH, Hunt PJ, Anozie C, Cayenne S, Davila-Siliezar P, Laylani N, Lee AG. Lymphocytic Panhypophysitis Mimicking Glaucoma: Case Report. Case Rep Ophthalmol 2023; 14:319-325. [PMID: 37485239 PMCID: PMC10359672 DOI: 10.1159/000531445] [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: 04/10/2023] [Accepted: 06/01/2023] [Indexed: 07/25/2023] Open
Abstract
Lymphocytic hypophysitis (LH) is a primary inflammatory disorder of the pituitary gland and infundibulum that commonly manifests in both mass effect and endocrinologic symptoms. Although the exact pathophysiology remains unclear, it has been increasingly linked to an autoimmune process. Complications arise by two separate mechanisms. Inflammation in the sella can lead to headaches and visual field defects. Pituitary inflammation and, chronically, fibrosis interfere with the gland's hormone-secreting capacity, often resulting in various endocrinopathies such as polyuria, polydipsia, amenorrhea, and others. While final histologic classification requires pathologic evaluation, diagnosis can often be made clinically with appropriate imaging. Treatment often consists of conservative management but can also include glucocorticoids or surgical resection. We present a case of biopsy-proven LH involving the entire pituitary, dubbed lymphocytic panhypophysitis (LPH) that was misdiagnosed for years as glaucoma due to the lack of endocrinopathy as well as delay in magnetic resonance imaging. After imaging revealed the sellar mass, the patient responded symptomatically to surgical resection and glucocorticoid treatment. LPH may present without endocrinologic symptoms and therefore mimic alternate diagnoses such as glaucoma. Clinicians should be suspicious of a diagnosis of glaucoma in the setting of a temporal field defect and lack of response to traditional therapy. A personal or family history of autoimmune disease in such patients should prompt further imaging and investigation. Therefore, endocrinopathy is supportive but not present in every case of LPH.
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Affiliation(s)
- Phillip Howard Keys
- John Sealy School of Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Patrick J. Hunt
- Medical Scientist Training Program, Baylor College of Medicine, Houston, TX, USA
| | - Clement Anozie
- John Sealy School of Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Samir Cayenne
- John Sealy School of Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Pamela Davila-Siliezar
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA
| | - Noor Laylani
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA
| | - Andrew G. Lee
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA
- Department of Ophthalmology, University of Texas Medical Branch, Galveston, TX, USA
- Departments of Ophthalmology, Neurology, and Neurosurgery, Weill Cornell Medicine, New York, NY, USA
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Texas A and M College of Medicine, Bryan, TX, USA
- Department of Ophthalmology, The University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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19
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Sasaki H, Suga H, Takeuchi K, Nagata Y, Harada H, Kondo T, Ito E, Maeda S, Sakakibara M, Soen M, Miwata T, Asano T, Ozaki H, Taga S, Kuwahara A, Nakano T, Arima H, Saito R. Subcutaneous transplantation of human embryonic stem cells-derived pituitary organoids. Front Endocrinol (Lausanne) 2023; 14:1130465. [PMID: 36936140 PMCID: PMC10018142 DOI: 10.3389/fendo.2023.1130465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 02/13/2023] [Indexed: 03/06/2023] Open
Abstract
INTRODUCTION The pituitary gland, regulating various hormones, is central in the endocrine system. As spontaneous recovery from hypopituitarism is rare, and exogenous-hormone substitution is clumsy, pituitary replacement via regenerative medicine, using pluripotent stem cells, is desirable. We have developed a differentiation method that in mice yields pituitary organoids (POs) derived from human embryonic stem cells (hESC). Efficacy of these POs, transplanted subcutaneously into hypopituitary mice, in reversing hypopituitarism was studied. METHODS hESC-derived POs were transplanted into inguinal subcutaneous white adipose tissue (ISWAT) and beneath dorsal skin, a relatively avascular region (AR), of hypophysectomized severe combined immunodeficient (SCID) mice. Pituitary function was evaluated thereafter for ¾ 6mo, assaying basal plasma ACTH and ACTH response to corticotropin-releasing hormone (CRH) stimulation. Histopathologic examination of organoids 150d after transplantation assessed engraftment. Some mice received an inhibitor of vascular endothelial growth factor (VEGF) to permit assessment of how angiogenesis contributed to subcutaneous engraftment. RESULTS During follow-up, both basal and CRH-stimulated plasma ACTH levels were significantly higher in the ISWAT group (p < 0.001 - 0.05 and 0.001 - 0.005, respectively) than in a sham-operated group. ACTH secretion also was higher in the ISWAT group than in the AR group. Histopathologic study found ACTH-producing human pituitary-cell clusters in both groups of allografts, which had acquired a microvasculature. POs qPCR showed expression of angiogenetic factors. Plasma ACTH levels decreased with VEGF-inhibitor administration. CONCLUSIONS Subcutaneous transplantation of hESC-derived POs into hypopituitary SCID mice efficaciously renders recipients ACTH-sufficient.
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Affiliation(s)
- Hiroo Sasaki
- Department of Neurosurgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Hidetaka Suga
- Department of Endocrinology and Diabetes, Graduate School of Medicine, Nagoya University, Nagoya, Japan
- *Correspondence: Hidetaka Suga,
| | - Kazuhito Takeuchi
- Department of Neurosurgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Yuichi Nagata
- Department of Neurosurgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Hideyuki Harada
- Department of Neurosurgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Tatsuma Kondo
- Department of Neurosurgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Eiji Ito
- Department of Neurosurgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Sachi Maeda
- Department of Neurosurgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Mayu Sakakibara
- Department of Endocrinology and Diabetes, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Mika Soen
- Department of Endocrinology and Diabetes, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Tsutomu Miwata
- Department of Endocrinology and Diabetes, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Tomoyoshi Asano
- Department of Endocrinology and Diabetes, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Hajime Ozaki
- Department of Endocrinology and Diabetes, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Shiori Taga
- Department of Endocrinology and Diabetes, Graduate School of Medicine, Nagoya University, Nagoya, Japan
- Regenerative & Cellular Medicine Kobe Center, Sumitomo Pharma Co., Ltd., Kobe, Japan
| | - Atsushi Kuwahara
- Regenerative & Cellular Medicine Kobe Center, Sumitomo Pharma Co., Ltd., Kobe, Japan
| | - Tokushige Nakano
- Environmental Health Science Laboratory, Sumitomo Chemical Co., Ltd., Osaka, Japan
| | - Hiroshi Arima
- Department of Endocrinology and Diabetes, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Ryuta Saito
- Department of Neurosurgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
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20
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Racca G, D’Agnano S, Fasano N, Gianotti L. Pituitary Apoplexy With Transition to Acute Hypophysitis in a Patient With Sars-CoV-2 Pneumonia. JCEM CASE REPORTS 2023; 1:luac010. [PMID: 37908272 PMCID: PMC10578393 DOI: 10.1210/jcemcr/luac010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Indexed: 11/02/2023]
Abstract
COVID-19 is a systemic disease associated with respiratory insufficiency, systemic inflammation, as well as coagulation, neurological, and endocrine disorders. Among them pituitary apoplexy (PA) as well as, more rarely, acute hypophysitis (AH) have been reported. In the present report, we described a case of PA in an 84-year-old man with SARS-CoV-2 pneumonia, with a previous unknown pituitary adenoma and a possible but not confirmed overlap with transitory AH. After reviewing the available literature, we discuss the potential clinical and pathophysiological relationship between PA and AH. Furthermore, we focus on the neuroradiological features of pituitary lesions in the presence of SARS-CoV-2 infection.
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Affiliation(s)
- Giulia Racca
- Division of Internal Medicine, Department of Medicine, Hospital S. Croce & Carle Cuneo, Cuneo, Italy
| | - Salvatore D’Agnano
- Division of Internal Medicine, Department of Medicine, Hospital S. Croce & Carle Cuneo, Cuneo, Italy
| | - Nicoletta Fasano
- Division of Neuroradiology, Department of Radiology, Hospital S. Croce & Carle Cuneo, Cuneo, Italy
| | - Laura Gianotti
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, S. Croce & Carle Hospital Cuneo, Cuneo, Italy
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21
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Denaro N, Garrone O, Morelli A, Pellegrino B, Merlano MC, Vacca D, Pearce J, Farci D, Musolino A, Scartozzi M, Tommasi C, Solinas C. A narrative review of the principal glucocorticoids employed in cancer. Semin Oncol 2022; 49:429-438. [PMID: 36737303 DOI: 10.1053/j.seminoncol.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 01/15/2023] [Accepted: 01/16/2023] [Indexed: 01/29/2023]
Abstract
Glucocorticoids (GCs) are a pharmacological class of drugs widely used in oncology in both supportive and palliative settings. GCs differentially impact organs with immediate and long-term effects; with suppressive effect on the immune system anchoring their use to manage the toxicities of immune checkpoint inhibitors (ICIs). In addition, GCs are often used in the management of symptoms related to cancer or chemotherapy and as adjuvants in the treatment of pain in the management of other. In the palliative setting, GCs, especially administered subcutaneously can be to assist in the control of nausea, dyspnea, asthenia, and anorexia-cachexia syndrome. In this narrative review, we aim to summarize the role of GCs in the different settings (curative, supportive, and palliative) to help clinicians use these important drugs in their daily clinical practice with cancer patients.
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Affiliation(s)
- Nerina Denaro
- Medical Oncology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Ornella Garrone
- Medical Oncology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | | | - Benedetta Pellegrino
- Medical Oncology and Breast Unit, University Hospital of Parma, Italy; Department of Medicine and Surgery, University of Parma, Italy
| | | | - Denise Vacca
- Palliative Care Unit, Ospedale Sirai, Carbonia, ASSL Carbonia, Italy
| | - Josie Pearce
- Harvard Premedical Program, Harvard University, Cambridge, MA, USA
| | - Daniele Farci
- Medical Oncology, Nuova Casa di Cura, Decimomannu, Cagliari, Italy
| | - Antonino Musolino
- Medical Oncology and Breast Unit, University Hospital of Parma, Italy; Department of Medicine and Surgery, University of Parma, Italy
| | - Mario Scartozzi
- Medical Oncology, AOU Cagliari, Policlinico di Monserrato, Cagliari, Italy
| | - Chiara Tommasi
- Medical Oncology and Breast Unit, University Hospital of Parma, Italy; Department of Medicine and Surgery, University of Parma, Italy.
| | - Cinzia Solinas
- Medical Oncology, AOU Cagliari, Policlinico di Monserrato, Cagliari, Italy
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22
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Luo YL, Gu F, Fan HQ, Du JH, Yu Y, Liu LK, Liao X. Diagnostic value of magnetic resonance imaging ectopic posterior pituitary hyperintense signal in pituitary macroadenoma. Front Oncol 2022; 12:971730. [DOI: 10.3389/fonc.2022.971730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 09/23/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveWhen the lesions in the sellar region are large, they can involve both the inside and outside the sella, which brings challenges to the differential diagnosis of pituitary macroadenoma and lesions other than macroadenoma. Therefore, this study explored the diagnostic value of an ectopic posterior pituitary hyperintense signal (EPPHS) in pituitary macroadenoma and its possible causes.MethodsThe clinical and imaging data of 131 patients with sellar tumors or tumor-like lesions involving both intrasellar and extrasellar regions in the Affiliated Hospital of Guizhou Medical University from February 2011 to December 2021 were analyzed retrospectively. The diagnostic value of EPPHS in pituitary macroadenoma was analyzed. The differences in clinical and imaging indexes between the EPPHS-positive group and the EPPHS-negative group were compared.ResultsThese 131 cases of sellar tumors or tumor-like lesions involving both intrasellar and extrasellar regions included 91 cases of pituitary macroadenoma and 40 cases of lesions other than macroadenoma. The receiver operator characteristic (ROC) curve analysis suggested that EPPHS had a diagnostic value in diagnosing pituitary macroadenoma [area under the curve (AUC) = 0.857, P = 0.0001]. Compared with the EPPHS negative group, the median prolactin level in the EPPHS positive group was significantly higher (P < 0.05). Through ROC curve analysis, prolactin value was found to be of diagnostic value for EPPHS (AUC = 0.612, P = 0.0312).ConclusionIn sellar tumors or tumor-like lesions involving both intrasellar and extrasellar regions, the appearance of EPPHS is helpful in the diagnosis of pituitary macroadenoma. The formation of EPPHS may be related to injuries to the pituitary stalk.
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23
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Siewe N, Friedman A. Optimal timing of steroid initiation in response to CTLA-4 antibody in metastatic cancer: A mathematical model. PLoS One 2022; 17:e0277248. [PMID: 36355837 PMCID: PMC9648769 DOI: 10.1371/journal.pone.0277248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 10/23/2022] [Indexed: 11/12/2022] Open
Abstract
Immune checkpoint inhibitors, introduced in recent years, have revolutionized the treatment of many cancers. However, the toxicity associated with this therapy may cause severe adverse events. In the case of advanced lung cancer or metastatic melanoma, a significant number (10%) of patients treated with CTLA-4 inhibitor incur damage to the pituitary gland. In order to reduce the risk of hypophysitis and other severe adverse events, steroids may be combined with CTLA-4 inhibitor; they reduce toxicity, but they also diminish the anti-cancer effect of the immunotherapy. This trade-off between tumor reduction and the risk of severe adverse events poses the following question: What is the optimal time to initiate treatment with steroid. We address this question with a mathematical model from which we can also evaluate the comparative benefits of each schedule of steroid administration. In particular, we conclude that treatment with steroid should not begin too early, but also not very late, after immunotherapy began; more precisely, it should start as soon as tumor volume, under the effect of CTLA-4 inhibitor alone, begins to decrease. We can also compare the benefits of short term treatment of steroid at high doses to a longer term treatment with lower doses.
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Affiliation(s)
- Nourridine Siewe
- School of Mathematical Sciences, College of Science, Rochester Institute of Technology, Rochester, New York, United States of America
- * E-mail:
| | - Avner Friedman
- Department of Mathematics, The Ohio State University, Columbus, Ohio, United States of America
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24
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Thomas J, Jain A, Chong H. Lymphocytic Hypophysitis in a Patient With Suspected Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH). Cureus 2022; 14:e30178. [PMID: 36397915 PMCID: PMC9648682 DOI: 10.7759/cureus.30178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 10/11/2022] [Indexed: 11/07/2022] Open
Abstract
Lymphocytic hypophysitis (LH) is a rare, autoimmune condition that presents with a range of symptoms that must garner the attention of medical practitioners. Clinically, it is characterized by symptoms of a compressive sellar mass with varying degrees of hypopituitarism due to chronic inflammatory infiltrate of the pituitary gland. It is often seen in women in their third trimester or postpartum and is associated with other autoimmune phenomena. Our case report describes a 73-year-old female with a past medical history of hypothyroidism and hypertension, who presented with continued intermittent dizziness, fatigue, and mild subjective hearing loss for the past several months. She was referred to the emergency department due to a sodium level of 119 and was initially diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH). The patient was treated accordingly; however, she failed to show signs of improvement. Due to her clinical presentation, imaging studies, and laboratory results, the patient was suspected to have LH, which was confirmed with the improvement of her symptoms after treatment with steroids. Because of the rare occurrence and possible atypical presentation of LH, this case illustrates the importance of maintaining a high index of clinical suspicion when diagnosing a patient with an unknown cause of hyponatremia, especially in patients with coexisting autoimmune disorders.
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25
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DeCou S, Recinos PF, Prayson RA, Karakasis C, Haider A, Patel N. Successful immunomodulatory treatment for recurrent xanthogranulomatous hypophysitis in an adolescent: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 4:CASE22191. [PMID: 36051774 PMCID: PMC9426350 DOI: 10.3171/case22191] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/09/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND Xanthomatous lesions of the pituitary have been linked to ruptured or hemorrhagic Rathke’s cleft cysts. Most cases are reported to resolve following radical resection. When recurrence does occur, there is no established treatment regimen. High-dose glucocorticoids have been reported to be beneficial in several published cases; however, their effects are often not sustained once therapy is discontinued. OBSERVATIONS The authors report the case of an adolescent male who developed recurrent xanthogranulomatous hypophysitis associated with a Rathke’s cleft cyst despite two surgical interventions. He was treated with a short course of dexamethasone followed by a maintenance course of celecoxib and mycophenolate mofetil. This regimen proved to be safe and well-tolerated, and it successfully prevented another recurrence of his xanthogranulomatous hypophysitis. LESSONS This case demonstrates a novel nonsurgical approach to the management of recurrent xanthogranulomatous hypophysitis. It suggests a potential application of a combined corticosteroid-sparing immunosuppressive and anti-inflammatory regimen in other cases of refractory xanthogranulomatous hypophysitis.
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Affiliation(s)
- Sarah DeCou
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Pablo F. Recinos
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
- Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Richard A. Prayson
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
- Department of Anatomic Pathology, The Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Christopher Karakasis
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
- Department of Radiology, Cleveland Clinic, Cleveland, Ohio; and
| | - Anzar Haider
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
- Center for Pediatric Endocrinology, Cleveland Clinic Children’s, Cleveland, Ohio
| | - Neha Patel
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
- Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Pediatric Hematology Oncology and Bone Marrow Transplant, Cleveland Clinic Children’s, Cleveland, Ohio
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26
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Wright K, Kim H, Hill T, Lee M, Orillac C, Mogar N, Pacione D, Agrawal N. Preoperative differentiation of hypophysitis and pituitary adenomas using a novel clinicoradiologic scoring system. Pituitary 2022; 25:602-614. [PMID: 35622211 DOI: 10.1007/s11102-022-01232-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2022] [Indexed: 01/29/2023]
Abstract
PURPOSE Hypophysitis can clinically and radiologically mimic other nonfunctioning masses of the sella turcica, complicating preoperative diagnosis. While sellar masses may be treated surgically, hypophysitis is often treated medically, so differentiating between them facilitates optimal management. The objective of our study was to develop a scoring system for the preoperative diagnosis of hypophysitis. METHODS A thorough literature review identified published hypophysitis cases, which were compared to a retrospective group of non-functioning pituitary adenomas (NFA) from our institution. A preoperative hypophysitis scoring system was developed and internally validated. RESULTS Fifty-six pathologically confirmed hypophysitis cases were identified in the literature. After excluding individual cases with missing values, 18 hypophysitis cases were compared to an age- and sex-matched control group of 56 NFAs. Diabetes insipidus (DI) (p < 0.001), infundibular thickening (p < 0.001), absence of cavernous sinus invasion (CSI) (p < 0.001), relation to pregnancy (p = 0.002), and absence of visual symptoms (p = 0.007) were significantly associated with hypophysitis. Stepwise logistic regression identified DI and infundibular thickening as positive predictors of hypophysitis. CSI and visual symptoms were negative predictors. A 6-point hypophysitis-risk scoring system was derived: + 2 for DI, + 2 for absence of CSI, + 1 for infundibular thickening, + 1 for absence of visual symptoms. Scores ≥ 3 supported a diagnosis of hypophysitis (AUC 0.96, sensitivity 100%, specificity 75%). The scoring system identified 100% of hypophysitis cases at our institution with an estimated 24.7% false-positive rate. CONCLUSIONS The proposed scoring system may aid preoperative diagnosis of hypophysitis, preventing unnecessary surgery in these patients.
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Affiliation(s)
- Kyla Wright
- NYU Grossman School of Medicine, NYU Langone Health, 1st Ave, New York, NY, 10016, USA
| | - Hyon Kim
- Division of Endocrinology, Metabolism and Nutrition, Rutgers-Robert Wood Johnson Medical School, 125 Paterson St, New Brunswick, NJ, 0890, USA
| | - Travis Hill
- Department of Neurosurgery, NYU Grossman School of Medicine, 550 1st Avenue, New York, NY, 10016, USA
| | - Matthew Lee
- Department of Radiology, NYU Grossman School of Medicine, 550 1st Avenue, New York, NY, 10016, USA
| | - Cordelia Orillac
- Department of Neurosurgery, NYU Grossman School of Medicine, 550 1st Avenue, New York, NY, 10016, USA
| | - Nikita Mogar
- Department of Medicine, NYU Grossman School of Medicine, 550 1st Avenue, New York, NY, 10016, USA
| | - Donato Pacione
- Department of Neurosurgery, NYU Langone Medical Center, 530 1st Ave Skirball Suite 8R, New York, NY, 10016, USA
| | - Nidhi Agrawal
- Division of Endocrinology, Diabetes and Metabolism, NYU Langone Medical Center, 550 1st Avenue, New York, NY, 10016, USA.
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27
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Sahin S, Yildiz G, Oguz SH, Civan O, Cicek E, Durcan E, Comunoglu N, Ozkaya HM, Oz AB, Soylemezoglu F, Oguz KK, Dagdelen S, Erbas T, Kizilkilic O, Kadioglu P. Discrimination between non-functioning pituitary adenomas and hypophysitis using machine learning methods based on magnetic resonance imaging‑derived texture features. Pituitary 2022; 25:474-479. [PMID: 35334029 DOI: 10.1007/s11102-022-01213-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/27/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Hypophysitis is a heterogeneous condition that includes inflammation of the pituitary gland and infundibulum, and it can cause symptoms related to mass effects and hormonal deficiencies. We aimed to evaluate the potential role of machine learning methods in differentiating hypophysitis from non-functioning pituitary adenomas. METHODS The radiomic parameters obtained from T1A-C images were used. Among the radiomic parameters, parameters capable of distinguishing between hypophysitis and non-functioning pituitary adenomas were selected. In order to avoid the effects of confounding factors and to improve the performance of the classifiers, parameters with high correlation with each other were eliminated. Machine learning algorithms were performed with the combination of gray-level run-length matrix-low gray level run emphasis, gray-level co-occurrence matrix-correlation, and gray-level co-occurrence entropy. RESULTS A total of 34 patients were included, 17 of whom had hypophysitis and 17 had non-functioning pituitary adenomas. Among the 38 radiomics parameters obtained from post-contrast T1-weighted images, 10 tissue features that could differentiate the lesions were selected. Machine learning algorithms were performed using three selected parameters; gray level run length matrix-low gray level run emphasis, gray-level co-occurrence matrix-correlation, and gray level co-occurrence entropy. Error matrices were calculated by using the machine learning algorithm and it was seen that support vector machines showed the best performance in distinguishing the two lesion types. CONCLUSIONS Our analysis reported that support vector machines showed the best performance in distinguishing hypophysitis from non-functioning pituitary adenomas, emphasizing the importance of machine learning in differentiating the two lesions.
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Affiliation(s)
- Serdar Sahin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Gokcen Yildiz
- Department of Radiology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Seda Hanife Oguz
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Orkun Civan
- Department of Radiology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Ebru Cicek
- Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Istanbul University- Cerrahpasa, Istanbul, Turkey
| | - Emre Durcan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Nil Comunoglu
- Department of Pathology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Hande Mefkure Ozkaya
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Aysim Buge Oz
- Department of Pathology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Figen Soylemezoglu
- Department of Pathology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Kader Karli Oguz
- Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Selçuk Dagdelen
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Tomris Erbas
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Osman Kizilkilic
- Department of Radiology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Pinar Kadioglu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey.
- Cerrahpasa Medical Faculty, Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University-Cerrahpasa, Kocamustafapasa Street No: 53, 34098, Fatih, Istanbul, Turkey.
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Kadowaki Y, Nishiyama M, Nakamura M, Morisaka H, Fujimoto S, Terada Y, Kojima K. Adult-onset Langerhans cell histiocytosis changing CNS lesion from pituitary to suprasellar extension. Endocrinol Diabetes Metab Case Rep 2022; 2022:22-0232. [PMID: 35642690 PMCID: PMC9175615 DOI: 10.1530/edm-22-0232] [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: 05/05/2022] [Accepted: 05/10/2022] [Indexed: 11/28/2022] Open
Abstract
Summary Langerhans cell histiocytosis (LCH) is a rare disease characterized by the proliferation of abnormal Langerhans cells in various tissues and organs, including bone, skin, the lungs, and the pituitary gland. Hypothalamic-pituitary lesions in LCH often cause central diabetes insipidus (CDI), but the natural course of LCH in the CNS remains to be elucidated. In this study, we report an interesting case of altered LCH lesions in the CNS from the pituitary to the hypothalamus in a 45-year-old woman. She developed symptoms of polyuria and was diagnosed with CDI with lymphocytic hypophysitis due to an enlarged pituitary gland with stalk thickening shown on MRI. Short-term glucocorticoid therapy cured pituitary enlargement, but serum prolactin levels gradually increased. Six years later, the immunohistological findings of a skin biopsy revealed positive for leukocyte common antigen, S-100, and CD1a expression, indicating a diagnosis of LCH. MRI revealed a new lesion in the hypothalamus without pituitary involvement, likely due to LCH. Chemotherapy improved LCH lesions both in the skin and hypothalamus, but therapy was stopped on the patient's request. Although adult-onset LCH is rare, it should be considered as a differential diagnosis in cases of CDI as the primary disease. The clinical course in the present case indicated that LCH lesion was altered from pituitary to suprasellar extension; where such changes were observed, the possibility of LCH should be considered. Learning points Diagnosing the primary disease of CDI is challenging; therefore, careful observation is necessary in pathologically unknown cases. Enhanced MRI should be performed in cases with suspected hypothalamic lesions, such as elevated serum prolactin. Although adult-onset LCH is rare, it should be considered a differential diagnosis in cases of CDI as the primary disease. The direction of changing CNS lesion from pituitary to suprasellar extension might be a unique MRI finding in LCH.
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Affiliation(s)
- Yuji Kadowaki
- Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kochi University, Nankoku City, Kochi, Japan
| | - Mitsuru Nishiyama
- Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kochi University, Nankoku City, Kochi, Japan
- Health Care Center, Kochi University, Kochi City, Kochi, Japan
| | - Makoto Nakamura
- Department of Hematology, Kochi Medical School, Kochi University, Nankoku City, Kochi, Japan
| | - Hiroyuki Morisaka
- Department of Dermatology, Kochi Medical School, Kochi University, Nankoku City, Kochi, Japan
| | - Shimpei Fujimoto
- Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kochi University, Nankoku City, Kochi, Japan
| | - Yoshio Terada
- Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kochi University, Nankoku City, Kochi, Japan
| | - Kensuke Kojima
- Department of Hematology, Kochi Medical School, Kochi University, Nankoku City, Kochi, Japan
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29
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Morota K, Tadokoro H, Sawano K, Watanabe K, Iwata N, Fujisawa H, Suzuki A, Sugimura Y, Nagasaki K. A 7-year-old boy with central diabetes insipidus presenting with thickened pituitary stalk and anti-rabphilin-3A antibody positivity. J Pediatr Endocrinol Metab 2022; 35:687-690. [PMID: 35119230 DOI: 10.1515/jpem-2021-0674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 01/17/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES A highly invasive pathological diagnosis is necessary to differentiate central diabetes insipidus (CDI) with a thickened pituitary stalk. Lymphocytic infundibulo-hypophysitis (LIH) due to autoimmune involvement of the pituitary stalk is a differentiating disease, and anti-rabphilin-3A antibody (Rab3A-Ab) positivity was recently reported. CASE PRESENTATION A 7-year-old boy was diagnosed with CDI after having polyuria for two months. He showed growth hormone deficiency with reduced growth rate. Brain magnetic resonance imaging (MRI) revealed a thickened pituitary stalk. The placental alkaline phosphatase level of the cerebrospinal fluid, tumor marker for germ cell tumors, was below the level of sensitivity. No skin or bone findings suggestive of Langerhans cell histiocytosis were detected. Eight months after CDI onset, Rab3A-Ab was positive, and MRI showed shrinking of the thickened pituitary stalk, leading to the diagnosis with LIH. CONCLUSIONS Rab3A-Ab is a useful adjunctive diagnostic tool for childhood-onset LIH.
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Affiliation(s)
- Kazutaka Morota
- Department of Paediatrics, Nagaoka Red Cross Hospital, Niigata, Japan
| | - Hiroaki Tadokoro
- Department of Paediatrics, Nagaoka Red Cross Hospital, Niigata, Japan
| | - Kentaro Sawano
- Division of Paediatrics, Department of Homeostatic Regulation and Development, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Kenichi Watanabe
- Department of Paediatrics, Nagaoka Red Cross Hospital, Niigata, Japan
| | - Naoko Iwata
- Department of Endocrinology and Diabetes, Daido Hospital, Nagoya, Aichi, Japan.,Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, Toyoake, Japan
| | - Haruki Fujisawa
- Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, Toyoake, Japan
| | - Atsushi Suzuki
- Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, Toyoake, Japan
| | - Yoshihisa Sugimura
- Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, Toyoake, Japan
| | - Keisuke Nagasaki
- Department of Paediatrics, Nagaoka Red Cross Hospital, Niigata, Japan.,Division of Paediatrics, Department of Homeostatic Regulation and Development, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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30
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Abstract
Pituitary autoimmunity is one of the principal causes of hypopituitarism. Additionally, hypophysitis is one of the immune-related adverse events associated with immunotherapy. Recent case-oriented research has revealed a novel type of autoimmune hypophysitis, anti-PIT-1 hypophysitis, related to isolated adrenocorticotropic hormone (ACTH) deficiency and immune checkpoint inhibitor-related hypophysitis, as a form of paraneoplastic syndrome. Under these conditions, the ectopic expression of pituitary antigens present in tumors evokes a breakdown of immune tolerance, resulting in the production of autoantibodies and autoreactive cytotoxic T cells that specifically harm pituitary cells. Consequently, an innovative clinical entity of paraneoplastic autoimmune hypophysitis has been purported. This novel concept and its underlying mechanisms provide clues for understanding the pathogenesis of autoimmune pituitary diseases and can be applied to other autoimmune diseases. This review discusses the etiology of paraneoplastic autoimmune hypophysitis and its future.
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Affiliation(s)
- Hironori Bando
- Division of Development of Advanced Therapy for Metabolic Diseases, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan; Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan.
| | - Keitaro Kanie
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan.
| | - Yutaka Takahashi
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan; Department of Diabetes and Endocrinology, Nara Medical University, Kashihara, Japan.
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Горбова НЮ, Владимирова ВП, Рожинская ЛЯ, Белая ЖЕ. [Hypophysitis and reversible hypopituitarism developed after COVID-19 infection - a clinical case report]. PROBLEMY ENDOKRINOLOGII 2022; 68:50-56. [PMID: 35841168 PMCID: PMC9762539 DOI: 10.14341/probl12896] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 03/23/2022] [Accepted: 03/24/2022] [Indexed: 01/09/2023]
Abstract
AIM To present a clinical case of reversible hypopituitarism due to hypophysitis developed after COVID-19 infection. MATERIALS AND METHODS A patient with residual clinical manifestations of hypopituitarism underwent clinical evaluation at the time of symptoms of hypopituitarism and in follow-up. Morning serum cortisol (171-536 nmol/l) was measured by electrochemiluminescence immunoassay. Morning ACTH (7.2-63.3 pg/ml), prolactin (66-436 mU/l), TSH (0.25-3.5 mIU/L), fT4 (9-19 pmol/l) and fT3 (2.6-5.7 pmol/l) were measured by chemiluminescence immunoassay. Data were analyzed throughout the course of the disease. RESULTS A 35-year-old female developed clinical symptoms of hypopituitarism two months after recovery from a confirmed COVID-19 infection. Laboratory investigation confirmed hypocorticism, hypothyroidism, hypogonadism and the patient was prescribed appropriate hormonal therapy in January 2021. Four months later the symptoms were alleviated (April 2021) and there were signs of recovery shown by imaging and hormonal: morning serum cortisol 227 nmol/l, morning ACTH 33.96 pg/ml, prolactin 68.3 mU/l, TSH 2.626 mIU/L, fT4 10.75 pmol/l, fT3 3.96 pmol/l. Thyroid hormone was discontinued, but hypogonadism and hypocorticism persisted with estradiol - 51.48 pmol/l, 24h urine cortisol level - 41.8 nmol/day. MRI results showed that the signs of hypophysitis were alleviated in comparison with MRI from January 2021. Full recovery of pituitary axis was reported in October 2021, with recovery of normal menstrual cycle. Furthermore, hormonal profile was likewise normal. CONCLUSION This report provides evidence of delayed damage to the pituitary gland after infection with the COVID-19, with recovery of its function and structure. To date, the mechanisms of such an impact are not entirely clear; further collection of data on such cases and analysis is required.
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Affiliation(s)
- Н. Ю. Горбова
- Национальный медицинский исследовательский центр эндокринологии
| | | | - Л. Я. Рожинская
- Национальный медицинский исследовательский центр эндокринологии
| | - Ж. Е. Белая
- Национальный медицинский исследовательский центр эндокринологии
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Donegan D, Saeed Z, Delivanis DA, Murad MH, Honegger J, Amereller F, Oguz SH, Erickson D, Bancos I. Outcomes of Initial Management Strategies in Patients With Autoimmune Lymphocytic Hypophysitis: A Systematic Review and Meta-analysis. J Clin Endocrinol Metab 2022; 107:1170-1190. [PMID: 35137155 PMCID: PMC8947799 DOI: 10.1210/clinem/dgab839] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Indexed: 02/08/2023]
Abstract
CONTEXT Lymphocytic hypophysitis (LyHy) is characterized by inflammation of the pituitary and or neuroinfundibulum and is uncommon. Treatment options include observation, high-dose glucocorticoids (HD-GCs) or surgery. Optimal first-line management strategy, however, remains unknown. OBJECTIVE This work aimed to assess response to first-line treatment options (observation, HD-GCs, or surgery) of clinically relevant outcomes (symptomatic, hormonal, and radiographic improvement) among patients with LyHy. METHODS A systematic review was conducted in 6 databases through 2020. Meta-analysis was conducted when feasible using a random-effects model. RESULTS We included 33 studies reporting on 591 patients (423 women, 72%) with LyHy. Improvement/resolution of anterior pituitary dysfunction was highest when HD-GCs was first-line treatment. Surgery was associated with the greatest proportion of patients who had regression on imaging. Subgroup analysis comparing HD-GCs to observation showed the odds of anterior pituitary hormone recovery (OR 3.41; 95% CI, 1.68-6.94) or radiographic regression (OR 3.13; 95% CI, 1.54-6.36) were higher with HD-GCs, but so was the need for additional forms of treatment (OR 4.37; 95% CI, 1.70-11.22). No statistically significant difference was seen in recovery of diabetes insipidus (OR 0.9; 95% CI, 0.26-3.10). Certainty in these estimates was very low. CONCLUSION Observation and use of HD-GCs both are successful first-line management strategies in LyHy. Although use of HD-GCs was associated with increased recovery of anterior pituitary hormone deficit, it also was associated with greater likelihood of additional treatment after withdrawal. Optimal dosing and duration of HD-GCs remains unknown.
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Affiliation(s)
- Diane Donegan
- Division of Endocrinology, Diabetes and Metabolism, Indiana University School of Medicine, Indianapolis, Indiana 46206, USA
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, Minnesota 55905, USA
- Correspondence: D. Donegan, MB, BCh, BAO, Division of Endocrinology, Diabetes and Metabolism, Indiana University School of Medicine, 1120 W. Michigan St, CL 459, Indianapolis, IN 46206, USA.
| | - Zeb Saeed
- Division of Endocrinology, Diabetes and Metabolism, Indiana University School of Medicine, Indianapolis, Indiana 46206, USA
| | - Danae A Delivanis
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, Minnesota 55905, USA
| | | | - Juergen Honegger
- Department of Neurosurgery, University of Tübingen, 72076 Tübingen, Germany
| | - Felix Amereller
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, 80336 Munich, Germany
| | - Seda Hanife Oguz
- Department of Endocrinology and Metabolism, Hacettepe University Medical School, 06230 Ankara, Turkey
| | - Dana Erickson
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, Minnesota 55905, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, Minnesota 55905, USA
- I. Bancos, MD, Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, MN 55905, USA.
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Zhao K, Nimchinsky E, Agarwalla PK. Differential Diagnosis and Radiographic Imaging of Pituitary Lesions. Otolaryngol Clin North Am 2022; 55:247-264. [DOI: 10.1016/j.otc.2021.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Amereller F, Deutschbein T, Joshi M, Schopohl J, Schilbach K, Detomas M, Duffy L, Carroll P, Papa S, Störmann S. Differences between immunotherapy-induced and primary hypophysitis-a multicenter retrospective study. Pituitary 2022; 25:152-158. [PMID: 34518996 PMCID: PMC8821509 DOI: 10.1007/s11102-021-01182-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/24/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Immune checkpoint inhibitors can cause various immune-related adverse events including secondary hypophysitis. We compared clinical characteristics of immunotherapy-induced hypophysitis (IIH) and primary hypophysitis (PH) DESIGN: Retrospective multicenter cohort study including 56 patients with IIH and 60 patients with PH. METHODS All patients underwent extensive endocrine testing. Data on age, gender, symptoms, endocrine dysfunction, MRI, immunotherapeutic agents and autoimmune diseases were collected. RESULTS Median time of follow-up was 18 months in IIH and 69 months in PH. The median time from initiation of immunotherapy to IIH diagnosis was 3 months. IIH affected males more frequently than PH (p < 0.001) and led to more impaired pituitary axes in males (p < 0.001). The distribution of deficient adenohypophysial axes was comparable between both entities, however, central hypocortisolism was more frequent (p < 0.001) and diabetes insipidus considerably less frequent in IIH (p < 0.001). Symptoms were similar except that visual impairment occurred more rarely in IIH (p < 0.001). 20 % of IIH patients reported no symptoms at all. Regarding MRI, pituitary stalk thickening was less frequent in IIH (p = 0.009). Concomitant autoimmune diseases were more prevalent in PH patients before the diagnosis of hypophysitis (p = 0.003) and more frequent in IIH during follow-up (p = 0.002). CONCLUSIONS Clinically, IIH and PH present with similar symptoms. Diabetes insipidus very rarely occurs in IIH. Central hypocortisolism, in contrast, is a typical feature of IIH. Preexisting autoimmunity seems not to be indicative of developing IIH.
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Affiliation(s)
- Felix Amereller
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ziemssenstr. 1, 80336, München, Germany.
| | - Timo Deutschbein
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
- Medicover Oldenburg MVZ, Oldenburg, Germany
| | - Mamta Joshi
- Department of Endocrinology, Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Jochen Schopohl
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ziemssenstr. 1, 80336, München, Germany
| | - Katharina Schilbach
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ziemssenstr. 1, 80336, München, Germany
| | - Mario Detomas
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
| | - Leo Duffy
- Department of Endocrinology, Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Paul Carroll
- Department of Endocrinology, Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Sophie Papa
- School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Sylvère Störmann
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ziemssenstr. 1, 80336, München, Germany
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Chiloiro S, Bianchi A, Giampietro A, Milardi D, De Marinis L, Pontecorvi A. The changing clinical spectrum of endocrine adverse events in cancer immunotherapy. Trends Endocrinol Metab 2022; 33:87-104. [PMID: 34895977 DOI: 10.1016/j.tem.2021.10.009] [Citation(s) in RCA: 8] [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] [Received: 08/04/2021] [Revised: 10/18/2021] [Accepted: 10/29/2021] [Indexed: 12/15/2022]
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of several malignancies, improving patient survival and quality of life. Endocrinopathies have emerged as a clinically significant group of immune-related adverse events (IRAEs). Although the mechanism of ICI toxicities has not been clarified, inhibition of immune checkpoints reduces immune tolerance to autoantigens, resulting in the development of autoimmunity disorders. We report current evidence regarding endocrine IRAEs that may have diagnostic and therapeutic implications. Management should be focused on a multidisciplinary approach to reach a prompt diagnosis and an appropriate and safe treatment.
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Affiliation(s)
- Sabrina Chiloiro
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, Italy; Unità Operativa Complessa (UOC) Endocrinology and Diabetology, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Roma, Italy.
| | - Antonio Bianchi
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, Italy; Unità Operativa Complessa (UOC) Endocrinology and Diabetology, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Roma, Italy
| | - Antonella Giampietro
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, Italy; Unità Operativa Complessa (UOC) Endocrinology and Diabetology, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Roma, Italy
| | - Domenico Milardi
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, Italy; Unità Operativa Complessa (UOC) Endocrinology and Diabetology, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Roma, Italy
| | - Laura De Marinis
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, Italy; Unità Operativa Complessa (UOC) Endocrinology and Diabetology, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Roma, Italy
| | - Alfredo Pontecorvi
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, Italy; Unità Operativa Complessa (UOC) Endocrinology and Diabetology, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Roma, Italy
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Vorontsov AV, Babaeva DM, Vladimirova VP, Dubovitskaya TA, Gavrilova AO, Belaya ZE, Mokryshevа NG. [Clinical and radiological diagnosis of hypophysitis: a review of literature and own data]. PROBLEMY ENDOKRINOLOGII 2022; 68:16-33. [PMID: 35488753 PMCID: PMC9764276 DOI: 10.14341/probl12777] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 12/04/2021] [Accepted: 01/25/2022] [Indexed: 01/09/2023]
Abstract
This article presents a literature review of the various forms of hypophysitis, its varieties, as well as the problem of radiation diagnosis and treatment of this pathology. Hypophysitis is a poorly understood and multifactorial disease which the difficulty of diagnosing is not only to a variety of nonspecific clinical manifestations and hormonal research data, but also the ambiguous results of MRI studies, the lack of clear MR patterns. The article reflects the main histological types of hypophysitis, the peculiarities of diagnosis in connection with general clinical symptoms, outlines the features of each type of hypophysitis with their own clinical observations. This review is devoted to modern ideas about the clinical course of hypophysitis, presented a set of characteristic diagnostic signs of the disease according to MRI and the treatment algorithms recommended today are also highlighted. The article summarizes data from foreign literature and our own clinical observations in order to develop an optimal protocol for MRI studies in patients with suspected hypophysitis, to develop recommendations for radiologists and endocrinologists for the correct results interpretation. The uniqueness of this review is the lack of data on the clinic, diagnosis and treatment of hypophysitis in the Russian literature today.
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Langlois F, Varlamov EV, Fleseriu M. Hypophysitis, the Growing Spectrum of a Rare Pituitary Disease. J Clin Endocrinol Metab 2022; 107:10-28. [PMID: 34528683 PMCID: PMC8684465 DOI: 10.1210/clinem/dgab672] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Indexed: 01/13/2023]
Abstract
Hypophysitis is defined as inflammation of the pituitary gland that is primary or secondary to a local or systemic process. Differential diagnosis is broad (including primary tumors, metastases, and lympho-proliferative diseases) and multifaceted. Patients with hypophysitis typically present with headaches, some degree of anterior and/or posterior pituitary dysfunction, and enlargement of pituitary gland and/or stalk, as determined by imaging. Most hypophysitis causes are autoimmune, but other etiologies include inflammation secondary to sellar tumors or cysts, systemic diseases, and infection or drug-induced causes. Novel pathologies such as immunoglobulin G4-related hypophysitis, immunotherapy-induced hypophysitis, and paraneoplastic pituitary-directed autoimmunity are also included in a growing spectrum of this rare pituitary disease. Typical magnetic resonance imaging reveals stalk thickening and homogenous enlargement of the pituitary gland; however, imaging is not always specific. Diagnosis can be challenging, and ultimately, only a pituitary biopsy can confirm hypophysitis type and rule out other etiologies. A presumptive diagnosis can be made often without biopsy. Detailed history and clinical examination are essential, notably for signs of underlying etiology with systemic manifestations. Hormone replacement and, in selected cases, careful observation is advised with imaging follow-up. High-dose glucocorticoids are initiated mainly to help reduce mass effect. A response may be observed in all auto-immune etiologies, as well as in lymphoproliferative diseases, and, as such, should not be used for differential diagnosis. Surgery may be necessary in some cases to relieve mass effect and allow a definite diagnosis. Immunosuppressive therapy and radiation are sometimes also necessary in resistant cases.
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Affiliation(s)
- Fabienne Langlois
- Department of Medicine, Division of Endocrinology, Centre intégré universitaire de santé et de services sociaux de l’Estrie - Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Elena V Varlamov
- Departments of Medicine (Division of Endocrinology, Diabetes and Clinical Nutrition) and Neurological Surgery, and Pituitary Center, Oregon Health & Science University, Portland, Oregon, USA
| | - Maria Fleseriu
- Departments of Medicine (Division of Endocrinology, Diabetes and Clinical Nutrition) and Neurological Surgery, and Pituitary Center, Oregon Health & Science University, Portland, Oregon, USA
- Correspondence: Maria Fleseriu, MD, Oregon Health & Science University, Mail Code CH8N, 3303 S Bond Ave, Portland, Oregon 97239, USA.
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Shekhawat V, Das A, Pan S, Sudhan MD. Central diabetes insipidus: A case series and literature review. JOURNAL OF MARINE MEDICAL SOCIETY 2022. [DOI: 10.4103/jmms.jmms_124_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Joshi M, Gunawardena S, Goenka A, Ey E, Kumar G. Post COVID-19 Lymphocytic Hypophysitis: A Rare Presentation. Child Neurol Open 2022; 9:2329048X221103051. [PMID: 35615060 PMCID: PMC9125064 DOI: 10.1177/2329048x221103051] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Introduction: Lymphocytic hypophysitis (LH) is a rare autoimmune disorder involving the destruction of the anterior pituitary due to lymphocytic infiltration. The disease shows a female predominance, commonly affecting women during late pregnancy into the postpartum period. The etiology of LH has not been well established and is presumed to be autoimmune based on the histopathological findings of lymphocytic infiltration and postpartum cases. Lymphocytic hypophysitis has yet to be studied in the context of a patient status post-recovery from COVID-19. Since the initial outbreak, additional information regarding the symptoms and outcomes has emerged on the virus's effects on the nervous system. Case: We present a novel case of post-COVID lymphocytic hypophysitis in a pediatric patient at Dayton Children's Hospital. An 18-year-old previously healthy girl presented to the emergency department (ED) with acute onset headache and dizziness for 5 days. She had a history of symptomatic COVID-19 three weeks prior to the onset of current symptoms. Contrast enhanced magnetic resonance imaging (MRI) of the brain revealed diffuse thickening and enlargement of the infundibulum with homogenous contrast enhancement of the hypophyseal axis. Based on the suspicion for lymphocytic hypophysitis, she was started on Methylprednisolone 250 mg IV Q6hrs on day 1-3. Symptomatic clinical improvement was seen on day 3 with a significant decrease in the intensity of the headache. Conclusion: The case illustrates the varied presentation and neurological sequalae associated with the COVID-19 virus. The case described here is the first ever reported post-COVID manifestation of lymphocytic hypophysitis.
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Affiliation(s)
- Meha Joshi
- Wright State University Boonshoft School of Medicine, Dayton, OH, USA
| | | | - Ajay Goenka
- Divison of Neurology, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
| | - Elizabeth Ey
- Division of Radiology, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
| | - Gogi Kumar
- Divison of Neurology, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
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Montero Pérez O, Sánchez Escudero L, Guzmán Ramos MI, Aviñó Tarazona V. Hypophysitis secondary to pembrolizumab: a case report and review of the literature. Anticancer Drugs 2022; 33:94-99. [PMID: 34261922 DOI: 10.1097/cad.0000000000001129] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Pembrolizumab is a mAb against the programmed cell death protein-1 (PD-1). It has been approved for the treatment of advanced melanoma (unresectable or metastatic) in adults. Side effects associated with the use of anti-PD-1 are usually considered well tolerated; nevertheless, there are immune-related adverse events that may require treatment discontinuation. A 79-year-old man diagnosed with stage IV right scapular melanoma experienced unspecific symptoms and alterations of the hypothalamus-hypophysis axis after six cycles with pembrolizumab. The case was compatible with immune-related hypophysitis. Autoimmune thyroiditis and primary hypophysitis were excluded and toxicity due to pembrolizumab was considered the cause of hypophysitis. Pembrolizumab was discontinued and toxicity was managed with corticosteroids and hormonal replacement therapy (HRT). After 7 months of follow-up, symptoms were controlled with HRT but thyrotropin and corticotropin hormones had not recovered. It was decided not to reintroduce immunotherapy. Although endocrine disorders are common with the use of anti-PD-1, hypophysitis is very rare. However, clinical signs and symptoms can be nonspecific, therefore, it has probably been underdiagnosed. Monitoring hormones before and during the treatment is important for an early diagnosis and also to replace the alterations with HRT to control the symptoms. Hormonal function does not always recover, but it does not mean immunotherapy cannot be restarted and it should be evaluated in every case.
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Kruse M, Olesen TB, Markovic L, Glintborg D, Andersen MS. Recurrent autoimmune hypophysitis treated with rituximab: a case report. J Med Case Rep 2021; 15:591. [PMID: 34906226 PMCID: PMC8672614 DOI: 10.1186/s13256-021-03146-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 10/08/2021] [Indexed: 12/22/2022] Open
Abstract
Background Autoimmune hypophysitis is a rare condition that often results in enlargement of the pituitary gland and hypopituitarism due to inflammatory infiltration. Management of autoimmune hypophysitis can include long-term hormonal replacement and close control of the inflammatory pituitary mass. Mass-related symptoms in patients with autoimmune hypophysitis are treated with anti-inflammatory therapy, surgery, and/or radiotherapy. Case presentation We present a 25-year-old White man with visual field defects of the right eye, headache, and weight loss. Magnetic resonance imaging showed a sellar mass, and the patient underwent transcranial surgery. Histopathology revealed autoimmune hypophysitis with predominantly CD20 positive B-cell infiltration. Progression of visual field defects necessitated postoperatively anti-inflammatory treatment with prednisolone. Azathioprine was initiated under gradual tapering of prednisolone with stable conditions at first, but relapse followed after dose reduction. Therefore, rituximab treatment was initiated, which resulted in regression of the pituitary mass. Rituximab treatment was discontinued after 25 months. The patient has continuously been in remission for 4 years after rituximab treatment was stopped. Conclusion This case illustrates that rituximab might be an effective alternative treatment in B-cell predominant autoimmune hypophysitis.
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Affiliation(s)
- Maria Kruse
- Department of Internal Medicine, Hospital of Littlebelt, Kolding, Denmark
| | | | - Ljubo Markovic
- Department of Radiology, Odense University Hospital, Odense, Denmark
| | - Dorte Glintborg
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark
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de Vries F, van Furth WR, Biermasz NR, Pereira AM. Hypophysitis: A comprehensive overview. Presse Med 2021; 50:104076. [PMID: 34687912 DOI: 10.1016/j.lpm.2021.104076] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/27/2021] [Accepted: 10/12/2021] [Indexed: 10/20/2022] Open
Abstract
Hypophysitis is defined as inflammation of the pituitary gland. It is a heterogeneous condition as it can originate from different parts of the pituitary gland, can be caused by different pathophysiological processes, and can be isolated or the manifestation of a underlying systemic disease. Hypophysitis usually presents with endocrine deficiencies, including diabetes insipidus, with varying patterns. A subset of patients presents with mass effects. The last decades major progress has been made in the understanding of this disease. New forms are now recognized, new diagnostics are being developed, and specific treatments are proposed. This review provides an overview of the current knowledge on hypophysitis using an aetiology-based approach and provides the clinician with a stepwise approach to the patient with (suspected) hypophysitis.
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Affiliation(s)
- F de Vries
- Department of Neurosurgery and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands; Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands
| | - W R van Furth
- Department of Neurosurgery and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands
| | - N R Biermasz
- Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands
| | - A M Pereira
- Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands
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Antoniou S, Bazazo G, Röckl L, Papadakis M, Berg C. Late-onset hypophysitis after discontinuation of nivolumab treatment for advanced skin melanoma: a case report. BMC Endocr Disord 2021; 21:191. [PMID: 34544399 PMCID: PMC8454065 DOI: 10.1186/s12902-021-00854-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 09/09/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Nivolumab is an anti-programmed cell death protein 1 antibody, typically used as cancer immunotherapy agent. Despite multiple clinical benefits it might cause autoimmune-related side-effects, often involving the endocrine system. To our knowledge, this is the first case of nivolumab-induced hypophysitis manifesting several months after treatment discontinuation. CASE PRESENTATION We, herein, report a 53-year-old patient with hypophysitis and isolated adrenocorticotropic hormone deficiency, who presented with recurring syncopal episodes and persistent mild hyponatremia. The performed challenged tests were consistent with secondary adrenal insufficiency, while responses of other anterior pituitary hormones were preserved. Magnetic resonance imaging revealed thickened pituitary stalk, consistent with hypophysitis. The patient's condition gradually improved after administration of hydrocortisone, with normalization of sodium and glucose-levels. The related literature is discussed. CONCLUSIONS We conclude that even after discontinuation of nivolumab, isolated adrenal insufficiency can occur. Therefore, in case of administration of such agents, clinical assessment, and routine monitoring of blood pressure, sodium-, glucose-levels, pituitary hormones as well as magnetic resonance imaging are needed to identify such conditions and prevent an adrenal crisis.
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Affiliation(s)
- Sofia Antoniou
- Department of Internal Medicine, Angiology, Endocrinology and Diabetology, Protestant Hospital Mettmann, Gartenstrasse 4-8, 40822, Mettmann, Germany
| | - Georgios Bazazo
- Department of Internal Medicine, Angiology, Endocrinology and Diabetology, Protestant Hospital Mettmann, Gartenstrasse 4-8, 40822, Mettmann, Germany
| | - Ludwig Röckl
- Department of Internal Medicine, Angiology, Endocrinology and Diabetology, Protestant Hospital Mettmann, Gartenstrasse 4-8, 40822, Mettmann, Germany
| | - Marios Papadakis
- Department of Surgery II, University of Witten-Herdecke, Heusnerstrasse 40, 42283, Wuppertal, Germany.
| | - Christian Berg
- Department of Internal Medicine, Angiology, Endocrinology and Diabetology, Protestant Hospital Mettmann, Gartenstrasse 4-8, 40822, Mettmann, Germany
- Department of Infectious Diseases, Department of Nephrology, University Hospital Essen, University Duisburg Essen, Duisburg, Germany
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Shadmani G, Simkins TJ, Assadsangabi R, Apperson M, Hacein-Bey L, Raslan O, Ivanovic V. Autoimmune diseases of the brain, imaging and clinical review. Neuroradiol J 2021; 35:152-169. [PMID: 34490814 DOI: 10.1177/19714009211042879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
There is an extensive spectrum of autoimmune entities that can involve the central nervous system, which has expanded with the emergence of new imaging modalities and several clinicopathologic entities. Clinical presentation is usually non-specific, and imaging has a critical role in the workup of these diseases. Immune-mediated diseases of the brain are not common in daily practice for radiologists and, except for a few of them such as multiple sclerosis, there is a vague understanding about differentiating them from each other based on the radiological findings. In this review, we aim to provide a practical diagnostic approach based on the unique radiological findings for each disease. We hope our diagnostic approach will help radiologists expand their basic understanding of the discussed disease entities and narrow the differential diagnosis in specific clinical scenarios. An understanding of unique imaging features of these disorders, along with laboratory evaluation, may enable clinicians to decrease the need for tissue biopsy.
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Affiliation(s)
- Ghazal Shadmani
- Department of Radiology, Section of Neuroradiology, University of California Davis Medical Center, USA
| | - Tyrell J Simkins
- Department of Neurology (Neuroimmunulogy), University of California Davis Medical center, USA
| | - Reza Assadsangabi
- Department of Radiology, Section of Neuroradiology, University of California Davis Medical Center, USA
| | - Michelle Apperson
- Department of Neurology (Neuroimmunulogy), University of California Davis Medical center, USA
| | - Lotfi Hacein-Bey
- Department of Radiology, Section of Neuroradiology, University of California Davis Medical Center, USA
| | - Osama Raslan
- Department of Radiology, Section of Neuroradiology, University of California Davis Medical Center, USA
| | - Vladimir Ivanovic
- Department of Radiology, Section of Neuroradiology, University of California Davis Medical Center, USA
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Yu M, Liu L, Shi P, Zhou H, Qian S, Chen K. Anti-PD-1 treatment-induced immediate central diabetes insipidus: a case report. Immunotherapy 2021; 13:1255-1260. [PMID: 34424037 DOI: 10.2217/imt-2020-0334] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Modulating PD-1 expression can constrain tumor growth. Hodgkin's lymphoma patients commonly express PD-L1 on tumor cells. We report the case of a 60-year-old male patient with relapsed classical Hodgkin's lymphoma who suffered from immediate-onset chill, hyperthermia and polyuria following initial treatment with sintilimab, an anti-PD-1 monoclonal antibody. The results revealed central diabetes insipidus (cDI). After 3 months of treatment with glucocorticoids and desmopressin acetate, his symptoms and the results were consistent with the resolution of cDI and the treatment course was discontinued. Diabetes insipidus is a rare complication of immunotherapeutic treatment, and this is the first case report to our knowledge to have described immediate-onset cDI caused by anti-PD-1 treatment.
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Affiliation(s)
- Mengxia Yu
- Department of Hematology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, 216 Huansha Road, Hangzhou, Zhejiang Province, 310006, PR China
| | - Lirong Liu
- Department of Hematology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, 216 Huansha Road, Hangzhou, Zhejiang Province, 310006, PR China
| | - Pengfei Shi
- Department of Hematology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, 216 Huansha Road, Hangzhou, Zhejiang Province, 310006, PR China
| | - Hong Zhou
- Department of Hematology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, 216 Huansha Road, Hangzhou, Zhejiang Province, 310006, PR China
| | - Shenxian Qian
- Department of Hematology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, 216 Huansha Road, Hangzhou, Zhejiang Province, 310006, PR China
| | - Kuang Chen
- Department of Hematology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, 216 Huansha Road, Hangzhou, Zhejiang Province, 310006, PR China
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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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Autoimmune Hypophysitis with Late Renal Involvement: A Case Report. ENDOCRINES 2021. [DOI: 10.3390/endocrines2020016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We report a case of a 50-year-old male admitted to the Endocrinology Unit because of persistent headaches, nausea, feeling tired, sudden weight loss, cold intolerance, decreased appetite, and lack of sex interest. Diagnostic workup showed a 6-millimeter pituitary tumor without signs of compression, and a condition of progressive panhypopituitarism. After 12 months of hormone replacement therapy, the patient was hospitalized because of sudden weight gain, periorbital-peripheral edema, severe dyslipidemia, hypertension, and proteinuria. Corticosteroid therapy was shifted from oral to continuous intravenous infusion, and once the diagnosis of “immune complex-mediated glomerulonephritis with mesangial deposits suggestive for membranoproliferative glomerulonephritis type IIIIgG4-positive” was made, the immunosuppressant mycophenolate (1500 mg/day) was started. After a 6-month follow-up, the complete resolution of renal symptoms was accompanied by the disappearance of a pituitary lesion and the patient was back to prior hormone replacement therapy. Autoimmune hypophysitis (AH) is a rare autoimmune inflammatory disease of the pituitary gland that can impair hormone secretion and function. IgG4-hypophysitis is rare and is usually associated with other IgG4-related diseases. Herein, we describe a rare case of AH associated with late renal disease, and without any other organ involvement.
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Sbardella E, Puliani G, Feola T, Pofi R, Pirchio R, Sesti F, Verdecchia F, Gianfrilli D, Moffat D, Isidori AM, Grossman AB. A clinical approach to parasellar lesions in the transition age. J Neuroendocrinol 2021; 33:e12995. [PMID: 34138496 DOI: 10.1111/jne.12995] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/23/2021] [Accepted: 05/11/2021] [Indexed: 12/16/2022]
Abstract
Many reviews have summarised the pathology and management of the parasellar region in adult patients, although an analysis of these aspects in the transition years, from puberty onset to the age of peak bone mass, has been lacking. A comprehensive search of English-language original articles, published from 2000 to 2020, was conducted in the MEDLINE database (December 2019 to March 2020). We selected all studies regarding epidemiology, diagnosis and management of the following parasellar lesions: germinoma, craniopharyngioma, Langerhans cell histiocytosis, optic glioma, hypothalamic hamartoma, tuber cinereum hamartoma, cranial chordoma, Rathke cleft cyst, hypophysitis and hypothalamitis during the transition age from childhood to adulthood. In the present review, we provide an overview of the principal parasellar lesions occurring in the transition age. Symptoms are usually a result of the mass effect of the lesions on nearby structures, as well as anterior pituitary deficits. Diabetes insipidus occurs frequently in these patients. In this age group, pubertal developmental disorders may be more evident compared to other stages of life. Parasellar lesions in the transition age mostly include neoplastic lesions such as germinomas, hamartomas, optic gliomas, craniopharyngiomas Langerhans cell histiocytosis and chordomas, and rarely inflammatory lesions (hypophysitis, hypothalamitis). There are limited data on the management of parasellar lesions in the transition age. Endocrine evaluation is crucial for identifying conditions that require hormonal treatment so that they can be treated early to improve the quality of life of the individual patient in this complex age range. The clinical approach to parasellar lesions involves a multidisciplinary effort.
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Affiliation(s)
- Emilia Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Giulia Puliani
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
- Oncological Endocrinology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Tiziana Feola
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
- Neuroendocrinology, Neuromed Institute, IRCCS, Pozzilli, Italy
| | - Riccardo Pofi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Rosa Pirchio
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Franz Sesti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Federica Verdecchia
- Dipartimento Pediatrico Universitario Ospedaliero, Bambino Gesù Children Hospital, Rome, Italy
| | - Daniele Gianfrilli
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Daniel Moffat
- Department of Neurosurgery, Barts and the London NHS Trust, London, UK
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Ashley B Grossman
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, UK
- Centre for Endocrinology, Barts and the London School of Medicine, London, UK
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Emergency Presentations of Immune Checkpoint Inhibitor-Related Endocrinopathies. J Emerg Med 2021; 61:140-146. [PMID: 33795170 DOI: 10.1016/j.jemermed.2021.02.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 01/07/2021] [Accepted: 02/06/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICI) are an important component of anticancer treatment, with indications across an increasing range of oncological diagnoses. ICIs are associated with a range of immune-mediated toxicities. Immune-related endocrinopathies pose a distinct challenge, given the nonspecific symptom profile and potentially life-threatening sequelae if not recognized. OBJECTIVES To determine the frequency and clinical presentations of immune-mediated endocrinopathies in patients treated with ICIs presenting as emergencies. METHODS A prospective observational cohort study was undertaken at a specialist oncology hospital in North West England from May 20, 2018 to May 19, 2020. Within the hospital, the Oncology Assessment Unit (OAU) acts as the receiving unit in which assessments are undertaken of all emergency presentations. All patients treated with ICIs presenting to the OAU were included. The primary outcome was diagnosis of an immune-mediated endocrinopathy. Length of inpatient stay, and 7- and 30-day mortality rates were examined. RESULTS During the study period, 684 patients treated with ICIs presented to the OAU. Twenty-four (3.5%) patients had an acute immune-mediated endocrinopathy, of which 17 had hypophysitis, 4 diabetes mellitus, 2 thyrotoxicosis, and 1 adrenalitis. Median length of stay for patients with hypophysitis was 1 day. No patient with an immune-mediated endocrinopathy died within 30 days of presentation. CONCLUSIONS Presentations to emergency settings with acute immune-mediated endocrinopathies are rare. Early recognition of immune-mediated toxicities is important, and particularly pertinent in ICI-related endocrinopathies, where even in life-threatening cases, the presentation can be vague and nonspecific.
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50
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Deligiorgi MV, Liapi C, Trafalis DT. Hypophysitis related to immune checkpoint inhibitors: An intriguing adverse event with many faces. Expert Opin Biol Ther 2021; 21:1097-1120. [PMID: 33393372 DOI: 10.1080/14712598.2021.1869211] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The incorporation of immune checkpoint inhibitors in the oncologists' arsenal is a milestone in cancer therapeutics, though not being devoid of toxicities.Areas covered: The present review provides a comprehensive and up-to-date overview of the immune-related hypophysitis with focus on the elusive biological background, the wide spectrum of the epidemiological profile, the varying clinical aspects, and the diagnostic and therapeutic challenges.Expert opinion: Historically considered distinctive of anti-cytotoxic T-lymphocyte antigen 4 (CTLA-4) monoclonal antibodies (mAbs), the immune-related hypophysitis is increasingly correlated with the anti-programmed cell-death (PD) protein 1 (PD-1)/anti-PD ligand 1 (PD-L1) mAbs. The distinct phenotype of hypophysitis related to anti-PD1/anti-PD-L1 mAbs is highlighted with focus on the immune-related isolated adrenocorticotropic (ACTH) deficiency. The immune-related central diabetes insipidus is discussed as a rare aspect of anti-CTL-A4 mAbs-induced hypophysitis, recently related to anti-PD1/anti-PD-L1 mAbs as well. The present review builds on existing literature concerning immune-related hypophysitis underscoring the pending issues still to be addressed, including (i) pathogenesis; (ii) correlation with preexisting autoimmunity; (iii) predictive value; (iv) utility of high-dose glucocorticoids; and (v) establishment of evidence-based diagnostic and therapeutic protocols. Increased awareness and constant vigilance are advocated as cornerstone of a multidisciplinary approach to ensure optimal patients' care.
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Affiliation(s)
- Maria V Deligiorgi
- Department of Pharmacology-Clinical Pharmacology Unit, National and Kapodistrian University of Athens, Faculty of Medicine, Athens, Greece
| | - Charis Liapi
- Department of Pharmacology-Clinical Pharmacology Unit, National and Kapodistrian University of Athens, Faculty of Medicine, Athens, Greece
| | - Dimitrios T Trafalis
- Department of Pharmacology-Clinical Pharmacology Unit, National and Kapodistrian University of Athens, Faculty of Medicine, Athens, Greece
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