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Koenen L, Elbelt U, Olze H, Zappe S, Dommerich S. Granulomatosis with polyangiitis in a patient with polydipsia, facial nerve paralysis, and severe otologic complaints: a case report and review of the literature. J Med Case Rep 2022; 16:291. [PMID: 35897050 PMCID: PMC9331564 DOI: 10.1186/s13256-022-03492-7] [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: 04/05/2021] [Accepted: 06/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Granulomatosis with polyangiitis, formerly known as Wegener granulomatosis, is a necrotizing vasculitis with granulomatous inflammation that belongs to the class of antineutrophil cytoplasmic antibodies-positive diseases. It occurs in a localized and a systemic form and may present with a variety of symptoms. Involvement of the upper respiratory tract is very common, while neurologic, endocrinological, and nephrological dysfunction may occur. CASE PRESENTATION We describe the case of a 29-year-old Central European male patient presenting with severe bilateral sensorineural hearing loss, otorrhea, and one-sided facial nerve paralysis. The patient was unsuccessfully treated with i.v. antibiotics at another hospital in Berlin, and tympanic tubes were inserted. After presentation to our emergency room, he was hospitalized and further diagnostics started. Increased fluid intake and 12 kg weight gain over the last months were reported. The patient was diagnosed with granulomatosis with polyangiitis and diabetes insipidus. The patient's condition improved after treatment with rituximab. DISCUSSION A comprehensive PubMed search of all articles with granulomatosis with polyangiitis and diabetes insipidus was conducted to assess which combination of symptoms occurs simultaneously and whether other parts of the pituitary are commonly involved. The 39 selected articles, describing 61 patients, showed that ear-nose-throat involvement occurred most commonly, in 71% of cases. Of patients, 59% had involvement of the anterior pituitary gland, while true panhypopituitarism occurred in 13% of cases. Only one case report featured the same set of symptoms as described herein. CONCLUSION Granulomatosis with polyangiitis is a highly variable disease, commonly involving the upper airways, but that may present with symptoms solely related to the pituitary gland. Clinicians should have a low threshold to investigate for granulomatosis with polyangiitis in patients with therapy-resistant otorrhea. Patients may present with a complex set of symptoms, and integrating different specialists when additional symptoms occur may lead to faster diagnosis.
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Affiliation(s)
- Lukas Koenen
- Department of Otolaryngology, Head and Neck Surgery, Charité-Universitätsmedizin Berlin, Mittelallee 2, 13353, Berlin, Germany.
| | - Ulf Elbelt
- Department of Medicine B-Hepatology, Gastroenterology, Endocrinology, Diabetes, Hematology, Oncology, Palliative Care, Brandenburg Medical School, Neuruppin, Germany
| | - Heidi Olze
- Department of Otolaryngology, Head and Neck Surgery, Charité-Universitätsmedizin Berlin, Mittelallee 2, 13353, Berlin, Germany
| | - Sören Zappe
- Department of Otolaryngology, Head and Neck Surgery, Charité-Universitätsmedizin Berlin, Mittelallee 2, 13353, Berlin, Germany
| | - Steffen Dommerich
- Department of Otolaryngology, Head and Neck Surgery, Charité-Universitätsmedizin Berlin, Mittelallee 2, 13353, Berlin, Germany
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Liu S, Xu Y, Li N, Chen S, Zhang S, Peng L, Bai W, Wang J, Gao J, Zeng X, Shi J, Wang M. Pituitary Involvement in Granulomatosis with Polyangiitis: A Retrospective Analysis in a Single Chinese Hospital and a Literature Review. Int J Endocrinol 2019; 2019:2176878. [PMID: 31781205 PMCID: PMC6874975 DOI: 10.1155/2019/2176878] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 09/26/2019] [Indexed: 11/18/2022] Open
Abstract
PURPOSE Granulomatosis with polyangiitis (GPA) is an anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis that can involve virtually many organs, including the pituitary. Pituitary involvement in GPA is rare, with only case reports or small case series published previously. METHODS We used the electronic medical record system in our hospital to identify four patients of pituitary involvement in GPA. We summarized the clinical characteristics, radiographic findings, treatments, and clinical outcomes of the four patients. We further performed a systematic literature review of 66 GPA cases with pituitary involvement that were published on the PubMed database. RESULTS The four women in our report were between 57 and 73 years of age. All patients had pituitary abnormalities on radiology; three developed diabetes insipidus (DI). All patients had multisystem involvement. After treatment with glucocorticoids and cyclophosphamide (CYC), all patients showed clinical improvement but pituitary function did not resume. Literature review identified 66 additional patients with pituitary involvement in GPA; diabetes insipidus (57/66, 86.4%) and hypogonadism (34/66, 51.5%) were the most frequent pituitary disorders, and the most frequent imaging lesion was an enlarged pituitary (25/64, 39.1%). After treatment with corticosteroids and/or immunosuppressive agents, most patients (45/66, 68.2%) developed remission from systemic disease, 13 patients (13/57, 22.8%) showed remission of DI, and 8 patients (8/46, 17.4%) showed remission of hormone deficiencies. CONCLUSIONS GPA should be carefully considered as a potential cause of pituitary dysfunction (PD), especially when multisystem dysfunction exists. Conventional treatment with corticosteroids and/or immunosuppressive agents improves systemic symptoms, but pituitary disorders persisted in most patients.
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Affiliation(s)
- Shixuan Liu
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yan Xu
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Naishi Li
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Shi Chen
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Shangzhu Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Linyi Peng
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Wei Bai
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jinglan Wang
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jinming Gao
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Juhong Shi
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Mengzhao Wang
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Bando H, Iguchi G, Fukuoka H, Taniguchi M, Kawano S, Saitoh M, Yoshida K, Matsumoto R, Suda K, Nishizawa H, Takahashi M, Morinobu A, Kohmura E, Ogawa W, Takahashi Y. A diagnostic pitfall in IgG4-related hypophysitis: infiltration of IgG4-positive cells in the pituitary of granulomatosis with polyangiitis. Pituitary 2015; 18:722-30. [PMID: 25822111 DOI: 10.1007/s11102-015-0650-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Immunoglobulin (Ig) G4-related hypophysitis is an emerging clinical entity, which is characterized by an elevated serum IgG4 concentration and infiltration of IgG4-positive plasma cells in the pituitary. Although some criteria for its diagnosis have been proposed, they have not been fully established. In particular, differential diagnosis from secondary chronic inflammation including granulomatosis with polyangiitis (GPA) is difficult in some cases. We describe central diabetes insipidus with pituitary swelling exhibiting infiltration of IgG4-positive cells. PATIENT A 43-year-old woman in the remission stage of GPA presented with sudden-onset polyuria and polydipsia. Pituitary magnetic resonance imaging revealed swelling of the anterior and posterior pituitary and stalk, with heterogeneous gadolinium enhancement and disappearance of the high signal intensity of the posterior pituitary. Evaluation of biochemical markers for GPA suggested that the disease activity was well-controlled. Endocrinological examination revealed the presence of central diabetes insipidus and growth hormone deficiency. Pituitary biopsy specimen showed IgG4-positive cells, with a 43% IgG4(+)/IgG(+) ratio, which met the criteria for IgG4-related hypophysitis. However, substantial infiltration of polymorphonuclear neutrophils with giant cells was also noted, resulting in a final diagnosis of pituitary involvement of GPA. CONCLUSION These results suggest that pituitary involvement of GPA should be taken into account for the differential diagnosis of IgG4-related hypophysitis.
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Affiliation(s)
- Hironori Bando
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
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