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Rotondaro JC, Bettaza C, Clifton Goldney D, Martinez G, Paz L, Gazzi C, González Abbati S, Tarnogol M, Miguel S, Iungman A. [Pituitary cryptococcoma: a strange case of secondary granulomatous hypophysitis]. Medicina (B Aires) 2023; 83:1007-1012. [PMID: 38117724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023] Open
Abstract
Hypophysitis is a pathology with low incidence and prevalence. Likewise, deep fungal infections in immunocompetent patients also represent a rare phenomenon. Even rarer is the case described below, where these two mentioned elements are combined, namely: pituitary cryptococcoma or granulomatous hypophysitis caused by said pathogen in a host without altered immune response. After research in PubMed, there are limited cases in the medical literature of granulomatous hypophysitis caused by Cryptococcus spp., which simulated a pituitary macroadenoma by clinical and imaging manifestations. We did not find reports in which there is no evidence of involvement of the meningeal tissue. The fungal etiology is scarcely described in the reference guidelines for hypophysitis and we believe that Cryptococcus spp. it should be taken into account in the differential diagnosis of secondary granulomatous hypophysitis since it is a ubiquitous pathogen and the treatment is substantially different from other entities. It becomes more relevant given the current trend towards the use of high-dose systemic glucocorticoids for the treatment of hypophysitis, which could have generated greater damage if the correct diagnosis had not been made.
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Affiliation(s)
- Julio C Rotondaro
- Servicio de Clínica Médica, Instituto de investigaciones Médicas Alfredo Lanari, Buenos Aires, Argentina. E-mail:
| | - Celeste Bettaza
- Servicio de Clínica Médica, Instituto de investigaciones Médicas Alfredo Lanari, Buenos Aires, Argentina
| | - Dolores Clifton Goldney
- Servicio de Endocrinología, Instituto de investigaciones Médicas Alfredo Lanari, Buenos Aires, Argentina
| | - Gabriela Martinez
- Servicio de Infectología, Instituto de investigaciones Médicas Alfredo Lanari, Buenos Aires, Argentina
| | - Leonardo Paz
- Servicio de Patología, Instituto de investigaciones Médicas Alfredo Lanari, Buenos Aires, Argentina
| | - Carla Gazzi
- Servicio de Patología, Instituto de investigaciones Médicas Alfredo Lanari, Buenos Aires, Argentina
| | - Santiago González Abbati
- Servicio de Neurocirugía, Instituto de investigaciones Médicas Alfredo Lanari, Buenos Aires, Argentina
| | - Mariano Tarnogol
- Servicio de Diagnóstico por Imágenes, Instituto de investigaciones Médicas Alfredo Lanari, Buenos Aires, Argentina
| | - Silvia Miguel
- Instituto clínico Madre Teresa de Corrientes, Argentina
| | - Ariel Iungman
- Servicio de Clínica Médica, Instituto de investigaciones Médicas Alfredo Lanari, Buenos Aires, Argentina
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Yan R, Jin YB, Li XR, Luo L, Liu XM, He J. Clinical characteristics of rheumatic disease-associated hypophysitis: A case series and review of literature. Medicine (Baltimore) 2022; 101:e31338. [PMID: 36316923 PMCID: PMC9622606 DOI: 10.1097/md.0000000000031338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Rheumatic diseases have been reported to sometimes involve the pituitary gland. This study aims to characterize the clinical features and outcomes of patients with rheumatic disease-associated hypophysitis. We used the electronic medical record system in our hospital to identify nine patients with pituitary involvement in rheumatoid disease. We summarized the clinical characteristics, radiographic findings, treatments, and clinical outcomes of the 9 patients. We also performed a systematic literature review of systemic lupus erythematosus (SLE) cases with pituitary involvement published in PubMed and Wanfang databases from 1995 to 2021, and eight patients with complete information were selected. In the nine-patient cohort, the median age was 54 years, and the spectrum of rheumatic diseases included immunoglobulin G4-related disease (IgG4RD) (4/9), SLE (2/9), vasculitis (2/9), and Sjögren syndrome (SS) (1/9). All patients had pituitary abnormalities on radiological assessment, 6 developed diabetes insipidus (DI), and 8 presented with anterior pituitary hormone deficiencies in the disease duration. All the patients had multisystem involvement. As compared to hypophysitis with IgG4RD (IgG4-H), the age at onset of hypophysitis with SLE (SLE-H) patients was younger [(30.4 ± 16.4) years vs. (56.0 ± 0.8) years] and the disease duration was shorter [(14.0 ± 17.5) months vs. (71.0 ± 60.9) months] (P < .05). All patients were managed with glucocorticoids (GC) in combination with another immunosuppressant, and the majority of patients improved within 4 months. Six patients achieved disease remission while four required at least one hormone replacement therapy. Hypophysitis is a rare complication secondary to a variety of various rheumatic diseases that can occur at any stage. GC combined with additional immunosuppressants could improve patients' symptoms; however some patients also required long-term hormone replacement therapy in pituitary disorders.
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Affiliation(s)
- Rui Yan
- Department of Rheumatology and Immunology, Beijing Shunyi Hospital, Beijing, China
| | - Yue-Bo Jin
- Department of Rheumatology and Immunology, Beijing Key Laboratory for Rheumatism and Immune Diagnosis, Peking University People’s Hospital, Beijing, China
| | - Xue-Rong Li
- Department of Rheumatology and Immunology, Chongqing University Three Gorges Hospital, Chongqing, China
| | - Liang Luo
- Department of Chinese Medical, Chongqing Yubei People’s Hospital, Chongqing, China
| | - Xiao-Min Liu
- Department of Rheumatology and Immunology, Beijing Shunyi Hospital, Beijing, China
| | - Jing He
- Department of Rheumatology and Immunology, Beijing Key Laboratory for Rheumatism and Immune Diagnosis, Peking University People’s Hospital, Beijing, China
- * Correspondence: Jing He, Department of Rheumatology and Immunology, Peking University People’s Hospital, No. 11. Xizhimen South Street, Beijing 100044, China (e-mail: )
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Takahashi Y, Kameda H, Miya A, Nomoto H, Cho KY, Nakamura A, Nishimura H, Kimura H, Suzuki M, Konno S, Shimizu A, Matsuno Y, Okamoto M, Motegi H, Iwata N, Fujisawa H, Suzuki A, Sugimura Y, Miyoshi H, Atsumi T. Lymphocytic panhypophysitis and anti-rabphilin-3A antibody with pulmonary sarcoidosis. Pituitary 2022; 25:321-327. [PMID: 35088194 DOI: 10.1007/s11102-021-01200-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To explore the clinical significance of anti-rabphillin-3A antibody for the differential diagnosis of lymphocytic panhypophysitis. METHODS AND RESULTS A 58-year-old Japanese man developed uveitis of unknown cause in 2017. In 2019, he became aware of polyuria. In August 2020, he noticed transient diplopia and was diagnosed with right abducens nerve palsy. At the same time, he complained of fatigue and loss of appetite. Head magnetic resonance imaging demonstrated enlargement of the pituitary stalk and pituitary gland, corresponding to hypophysitis. Hormone stimulation tests showed blunted responses with respect to all anterior pituitary hormones. Central diabetes insipidus was diagnosed on the basis of a hypertonic saline loading test. Taking these findings together, a diagnosis of panhypopituitarism was made. Computed tomography showed enlargement of hilar lymph nodes. Biopsies of the hilar lymph nodes revealed non-caseating epithelioid cell granulomas that were consistent with sarcoidosis. Biopsy of the anterior pituitary revealed mild lymphocyte infiltration in the absence of IgG4-positive cells, non-caseating granulomas, or neoplasia. Western blotting revealed the presence of anti-rabphilin-3A antibody, supporting a diagnosis of lymphocytic panhypophysitis. Because the patient had no visual impairment or severe uveitis, we continued physiological hormone replacement therapy and topical steroid therapy for the uveitis. CONCLUSION To the best of our knowledge, this is the first case of anti-rabphilin 3A antibody positive lymphocytic panhypophysitis comorbid with sarcoidosis, diagnosed by both pituitary and hilar lymph node biopsy. The utility of anti-rabphilin-3A antibody for the differential diagnosis of hypophysitis like this case should be clarified with further case studies.
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Affiliation(s)
- Yuka Takahashi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Hiraku Kameda
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, 060-8638, Japan.
| | - Aika Miya
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Hiroshi Nomoto
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Kyu Yong Cho
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Akinobu Nakamura
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Hiroki Nishimura
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hirokazu Kimura
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Masaru Suzuki
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Satoshi Konno
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Ai Shimizu
- Department of Surgical Pathology, Hokkaido University Hospital, Sapporo, Japan
| | - Yoshihiro Matsuno
- Department of Surgical Pathology, Hokkaido University Hospital, Sapporo, Japan
| | - Michinari Okamoto
- Department of Neurosurgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroaki Motegi
- Department of Neurosurgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Naoko Iwata
- Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, Toyoake, Japan
- Department of Endocrinology and Diabetes, Daido Hospital, Nagoya, 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
| | - Hideaki Miyoshi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, 060-8638, Japan
- Division of Diabetes and Obesity, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, 060-8638, Japan
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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5
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Yerawar C, Patil D, Kabde A, Deokar P. Autoimmune hypophysitis: vanishing pituitary mass. QJM 2022; 114:816-817. [PMID: 34373912 DOI: 10.1093/qjmed/hcab218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- C Yerawar
- Department of Endocrinology, Narayana Institute of Medical Superspeciality, Nanded, Maharashtra 431602, India
| | - D Patil
- Department of Neurology, Abhyuday Lifecare Superspecialitry Hospital, Nanded, Maharashtra 431602, India
| | - A Kabde
- Department of Endocrinology, Narayana Institute of Medical Superspeciality, Nanded, Maharashtra 431602, India
| | - P Deokar
- Department of Biochemistry, Narayana Institute of Medical Superspeciality, Nanded, Maharashtra 431602, India
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Krishnappa B, Shah R, Sarathi V, Lila AR, Sehemby MK, Patil VA, Sankhe S, Shah N, Bandgar T. Early Pulse Glucocorticoid Therapy and Improved Hormonal Outcomes in Primary Hypophysitis. Neuroendocrinology 2022; 112:186-195. [PMID: 33744880 DOI: 10.1159/000516006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 03/19/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The role of glucocorticoids in primary autoimmune hypophysitis (PAH) has been fraught with variability in regimens, leading to inconsistent outcomes in terms of anterior pituitary (AP) hormonal recovery. Hence, we aimed to compare the clinical, hormonal, and radiological outcomes of a standardized high-dose glucocorticoid therapy group (GTG) in PAH with a matched clinical observation group (COG). METHODS Thirty-nine retrospective patients with PAH evaluated and treated at a single center in western India from 1999 to 2019 with a median follow-up duration of 48 months were subdivided into the GTG (n = 18) and COG (n = 21) and compared for the outcomes. RESULTS Baseline demographic, hormonal, and radiological features matched between the groups, except pituitary height, which was significantly higher in GTG. Cortisol, thyroid, and gonadal axes were affected in 25 (64%), 22 (56%), and 21 (54%) patients, respectively, and central diabetes insipidus was seen in 7 (18%) patients. Panhypophysitis (PH) was the most common radiological subtype (n = 33, 84.6%). Resolution of mass effects was similar in both groups. Overall and complete AP hormonal recovery was significantly higher in the GTG than in the COG (12/14 [85.7%) vs. 6/14 [42.8%], p = 0.02; 10/14 [71.4%] vs. 1/14 [7.7%], p = 0.0007, respectively). Proportion of cases with empty sella were significantly higher in the COG (9/20 [45%] vs 1/17 [5.9%], p = 0.001). Among PH patients in the GTG (n = 17), we found duration from symptoms onset to treatment as the predictor of recovery. CONCLUSION In a PH subtype-predominant PAH cohort, a standardized high-dose glucocorticoid regimen resulted in higher overall and complete AP hormonal recovery than that in the COG. Initiation of glucocorticoids in the early disease course may have been contributory.
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Affiliation(s)
- Brijesh Krishnappa
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Ravikumar Shah
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Vijaya Sarathi
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research center, Bengaluru, India
| | - Anurag Ranjan Lila
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Manjeet Kaur Sehemby
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Virendra A Patil
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Shilpa Sankhe
- Department of Radiology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Nalini Shah
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Tushar Bandgar
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, India
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Vasaitis L, Wikström J, Ahlström S, Gudjonsson O, Kumlien E, Edén Engström B, Casar-Borota O. Histopathological findings in the landscape of IgG4-related pathology in patients with pituitary dysfunction: Review of six cases. J Neuroendocrinol 2021; 33:e12942. [PMID: 33615590 DOI: 10.1111/jne.12942] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/05/2021] [Accepted: 01/19/2021] [Indexed: 12/18/2022]
Abstract
IgG4-related hypophysitis (IgG4-RH) is increasingly being reported as an isolated entity or, less frequently, as a manifestation of a multiorgan IgG4-related disease (IgG4-RD), in which typical histopathology is a cornerstone for the diagnosis. We aimed to describe the histopathological changes in the surgical specimens from patients with clinical signs of pituitary disease that fulfilled the current diagnostic criteria for IgG4-RH. Histopathological features were correlated with clinical and radiological findings. Of 19 patients with pituitary dysfunction and inflammatory changes in the surgical pituitary specimen operated on during 2011-2019, we identified five patients with typical IgG4-related pathology (lymphoplasmacytic infiltration with more than 10 IgG4-positive plasma cells per one high power microscopic field, representing at least 40% of all plasma cells and at least focal storiform fibrosis). One patient with diabetes insipidus and pachymeningitis with IgG4-related changes in a biopsy from the dura was also included. Additional histopathological changes that typically are not part of the IgG4-RH were observed: Rathke's cleft cyst in four and granulomatous changes in two patients. One patient had an elevated serum IgG4 level and systemic manifestations that could be associated with the systemic IgG4-RD. Our findings indicate that pure IgG4-RH is uncommon. All patients with pituitary dysfunction, beyond typical IgG4-related pathology, had other pathological findings that could trigger the secondary IgG4-response. Both primary pathology and secondary IgG4-related features should be reported in patients with pituitary dysfunction because their co-occurrence may cause atypical clinical and imaging features, and unexpected response to surgical and pharmacological treatment. The current criteria for the diagnosis of IgG4-RH can lead to overdiagnosis of IgG4-RH if additional pathological changes are not taken into consideration. The classification criteria of IgG4-RD proposed by the American College of Rheumatology/European League Against Rheumatism could help classify patients more properly as IgG4-RH if applied to the pituitary gland.
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Affiliation(s)
- Lilian Vasaitis
- Department of Medical Sciences, Rheumatology, Uppsala University, Uppsala, Sweden
| | - Johan Wikström
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Sengul Ahlström
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
- Department of Clinical Pathology, Uppsala University Hospital, Uppsala, Sweden
| | | | - Eva Kumlien
- Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Britt Edén Engström
- Department of Medical Sciences, Endocrinology and Mineral Metabolism, Uppsala University, Uppsala, Sweden
| | - Olivera Casar-Borota
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
- Department of Clinical Pathology, Uppsala University Hospital, Uppsala, Sweden
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Kong Z, Wang Y, Ma W, Cheng X. Role of 18F-fluorodeoxyglucose (FDG) and 18F-2-fluorodeoxy sorbitol (FDS) in autoimmune hypophysitis: a case report. BMC Endocr Disord 2020; 20:84. [PMID: 32517690 PMCID: PMC7285776 DOI: 10.1186/s12902-020-00567-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 06/03/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Autoimmune hypophysitis is a rare disease characterized by the infiltration of lymphocytic cells into the pituitary gland. 18F-fluorodeoxyglucose (FDG) and 18F-2-fluorodeoxy sorbitol (FDS) positron emission tomography (PET) are well-established and emerging techniques, respectively, which may aid in the diagnosis and classification of autoimmune hypophysitis. CASE PRESENTATION Here, we report a 40-year-old female diagnosed with central diabetes insipidus and multiple pituitary hormone deficiencies, and MRI revealed homogeneous signals in the pituitary gland as well as thickened in the pituitary stalk. FDG PET localized the pituitary and pituitary stalk lesions and displayed an SUVmax of 5.5. FDS, a sensitive radiotracer for bacterial infections but remains unproven under aseptic inflammation, also demonstrated elevated radioactivity, with an SUVmax of 1.1 at 30 min and 0.73 at 120 min. Transnasal biopsy suggested a diagnosis of autoimmune hypophysitis, and the patient displayed radiological and clinical improvement after treatment with glucocorticoids and hormone replacement. CONCLUSIONS Autoimmune hypophysitis can display elevated FDG uptake, which aids in the localization of the lesions. In addition to revealing bacterial infection specifically, FDS can also accumulate under autoimmune conditions, suggesting that it could serve as a potential radiotracer for both bacterial and aseptic inflammation. TRIAL REGISTRATION The patient was enrolled in study NCT02450942 (clinicaltrials.gov, Registered May 21, 2015).
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Affiliation(s)
- Ziren Kong
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, China
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, China
| | - Yu Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, China
| | - Wenbin Ma
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, China
| | - Xin Cheng
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, China
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Vakrakou AG, Evangelopoulos ME, Boutzios G, Tzanetakos D, Tzartos J, Velonakis G, Toulas P, Anagnostouli M, Andreadou E, Koutsis G, Stefanis L, Fragoulis GE, Kilidireas C. Recurrent myelitis and asymptomatic hypophysitis in IgG4-related disease: case-based review. Rheumatol Int 2020; 40:337-343. [PMID: 31898763 DOI: 10.1007/s00296-019-04502-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 12/11/2019] [Indexed: 12/24/2022]
Abstract
IgG4-related disease (IgG4-RD) is a disorder with various clinical manifestations. Central nervous system (CNS) involvement is well recognized, with hypertrophic pachymeningitis and hypophysitis being the most common manifestations. Spinal cord involvement is an extremely rare manifestation. We present the first case of an IgG4-RD patient with spinal cord parenchymal disease and concurrent hypophysitis. We review also the current literature about CNS parenchymal involvement in the context of IgG4-RD. A young female presented with clinical symptoms of myelitis. Cervical spinal cord magnetic resonance imaging (MRI) displayed features of longitudinally extensive transverse myelitis (LETM). Brain MRI showed a small number of high-intensity lesions in the deep white matter and enlargement of hypophysis with homogeneous gadolinium enhancement (asymptomatic hypophysitis). Diagnostic workup revealed elevated IgG4 serum levels (146 mg/dL). Our patient fulfilled the organ-specific diagnostic criteria of IgG4-hypophysitis. Treatment with intravenous glucocorticoids led to rapid clinical response, and to the substantial resolution of imaging findings. Azathioprine was used as a maintenance treatment. One relapse occurred 2 years after the initial diagnosis and patient was re-treated with glucocorticoids. Three years after relapse, patient is in remission with azathioprine. We present the first case of myelitis with radiological features of LETM associated with increased IgG4 serum levels and the simultaneous presence of asymptomatic IgG4-related hypophysitis.
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Affiliation(s)
- Aigli G Vakrakou
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece.
| | - Maria-Eleptheria Evangelopoulos
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - Georgios Boutzios
- Endocrine Unit, Department of Pathophysiology, Laikon General Hospital, University of Athens Medical School, Athens, Greece
| | - Dimitrios Tzanetakos
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - John Tzartos
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - Georgios Velonakis
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - Panagiotis Toulas
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - Maria Anagnostouli
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - Elissavet Andreadou
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - Georgios Koutsis
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - Leonidas Stefanis
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - George E Fragoulis
- First Department of Propaedeutic Internal Medicine, National and Kapodistrian University of Athens, "Laiko" General Hospital, Athens, Greece
| | - Constantinos Kilidireas
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
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Xiang P, Wu Q, Zhang H, Luo C, Zou H. Autoimmune Hypophysitis With Systemic Lupus Erythematosus: A Case Report and Literature Review. Front Endocrinol (Lausanne) 2020; 11:579436. [PMID: 33117291 PMCID: PMC7575781 DOI: 10.3389/fendo.2020.579436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 09/14/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Autoimmune hypophysitis (AH) is a primary autoimmune inflammatory disorder of the pituitary gland, which usually presents as a mass in the sella turcica. Systemic lupus erythematosus (SLE) is another inflammatory disorder in which the immune system attacks healthy cells and tissues throughout the body. Although both diseases are autoimmune disorders, they rarely coexist, and the relationship between them is unclear. CASE REPORT A 66-year-old man was evaluated at the endocrinology clinic because of worsening fatigue, anorexia, drowsiness, and leg oedema. Examination revealed alertness impairment and lower limb oedema. Laboratory tests showed anterior pituitary hypofunction. The treatment approach, with glucocorticoids and immunosuppressive agents, resulted in long-term remission of symptoms of hypopituitarism and hyponatraemia. CONCLUSIONS Our case demonstrates a potential association between AH and SLE. AH may need to be considered in the evaluation of SLE patients with headache, hyperprolactinemia, a pituitary mass, and hypopituitarism.
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Affiliation(s)
- Pengyue Xiang
- Department of Endocrinology, Jingmen No.2 People’s Hospital, Jingmen, China
| | - Qiuxia Wu
- Department of Endocrinology, Jingmen No.2 People’s Hospital, Jingmen, China
| | - Hua Zhang
- Department of Endocrinology, Jingmen No.2 People’s Hospital, Jingmen, China
| | - Chaoyang Luo
- Department of Endocrinology, Jingmen No.2 People’s Hospital, Jingmen, China
| | - Huajie Zou
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Huajie Zou,
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11
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Force BK, Vogel TP, Nguyen DM, Heck KA, Sebastian S, Takashima M, Yoshor D, Samson SL. A Remarkable Response of Granulomatous Hypophysitis to Infliximab in a Patient With a Background of Crohn's Disease-A Case Report. Front Endocrinol (Lausanne) 2020; 11:350. [PMID: 32547497 PMCID: PMC7272571 DOI: 10.3389/fendo.2020.00350] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 05/04/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Hypophysitis is primary or idiopathic or secondary to another disease process. The histologic subtypes of hypophysitis are lymphocytic, granulomatous, xanthomatous, xanthogranulomatous, or IgG4-related. Granulomatous hypophysitis is the second most common form and is characterized by multinucleated giant cells with granulomas and histiocytes. It can be idiopathic or secondary to another process such as infection, sarcoidosis, vasculitis, dendritic cell disorders, Crohn's disease (CD) or a reaction to rupture of a Rathke's cyst or pituitary adenoma. We present a case of granulomatous hypophysitis in a patient with CD who had resistance to corticosteroids but a dramatic response to immunosuppressive therapy with anti-tumor necrosis factor (TNF)-α therapy. Case description: A 43-year-old woman with a 9-year history of ileal and colonic CD presented to the Pituitary Center with headaches, visual disturbance, fatigue, nausea, and secondary amenorrhea. She was not on active therapy for her CD at the time of presentation and had no gastrointestinal symptoms. Hormonal evaluation revealed hyperprolactinemia, secondary hypothyroidism and adrenal insufficiency. MRI revealed a 12 × 12 × 19 mm sellar lesion abutting the optic chiasm, reported as a macroadenoma. The patient underwent endoscopic transsphenoidal biopsy of the pituitary mass. Pathology revealed granulomatous hypophysitis. Evaluation for secondary causes of hypophysitis, apart from CD, was negative. Despite a course of high dose prednisone, her symptoms and MRI findings worsened and she developed symptoms consistent with diabetes insipidus. Using a personalized medicine approach, she was started on anti-(TNF)-α therapy with infliximab combined with azathioprine, which are indicated for treatment of CD. Her headaches and polyuria resolved and her menstrual cycles resumed. MRI at 3 months and more than 1.5 years after initiation of anti-TNF-α therapy revealed durable resolution of the pituitary mass. Conclusion: To our knowledge, this is the first report of successful use of anti-TNF-α therapy for a patient with granulomatous hypophysitis, in this case associated with a previous diagnosis of CD. Although glucocorticoids are used frequently as first-line therapy for primary hypophysitis, granulomatous hypophysitis can be corticosteroid resistant and other immunosuppressive approaches may need to be considered within the context of the patient.
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Affiliation(s)
- Bahar K. Force
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
- Baylor St. Luke's Pituitary Center, Houston, TX, United States
| | - Tiphanie P. Vogel
- Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | - Dang M. Nguyen
- Greater Houston Gastroenterology, Houston, TX, United States
| | - Kent A. Heck
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, United States
| | - Sherly Sebastian
- Baylor St. Luke's Pituitary Center, Houston, TX, United States
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Mas Takashima
- Houston Methodist Hospital, Department of Otolaryngology, Houston, TX, United States
| | - Daniel Yoshor
- Baylor St. Luke's Pituitary Center, Houston, TX, United States
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Susan L. Samson
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
- Baylor St. Luke's Pituitary Center, Houston, TX, United States
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
- *Correspondence: Susan L. Samson
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Abstract
BACKGROUND Langerhans cell histiocytosis (LCH) is a rare disease that mainly affects children, but this disease is significantly rarer in patients who are older than 15 years. In this disease, any organ can be involved. The skeleton, skin and lung are commonly affected, and isolated hypothalamic-pituitary (HP) involvement is relatively rare. Here we report a 17-year-old adolescent with isolated HP-LCH of enlarged pituitary stalk presented with central diabetes insipidus (CDI). CASE PRESENTATION A 17-year-old male adolescent with polydipsia and polyuria accompanied with elevated serum sodium level and low urine osmolality for 3 weeks was referred to our hospital. After admission, hormonal evaluation showed that his growth hormone (GH) was slightly elevated, and serum osmolality and glucose were normal. The fluid deprivation-vasopressin test demonstrated CDI. Imaging examination showed an obvious thickening of the pituitary stalk. Lymphocytic hypophysitis, sarcoidosis and granulation tissue lesions were suspected. After oral 1-deamino-8-Darginine vasopressin (DDAVP) and prednisone were administered for 2 months, symptoms were relieved, and he discontinued taking the drugs by himself. On reexamination, imaging revealed changes in the size and shape of the pituitary stalk, with thickened nodules. Then, a diagnostic biopsy of the pituitary stalk lesion was performed. Immunohistochemistry confirmed the definitive diagnosis of LCH. The clinical symptoms subsided with oral hormone replacements. CONCLUSION CDI is a rare symptom in children and adolescents. Most of the causes are idiopathic, while others are caused by central nervous system (CNS) disorders. Meanwhile, lymphocytic hypophysitis, germinoma, LCH and other CNS disorders can all present as thickening of the pituitary stalk, diffuse enlargement of the pituitary gland, and weakening of high signal intensity in the neurohypophysis on magnetic resonance imaging (MRI). The differential diagnosis among these diseases depends on immunohistochemistry evidence.
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Affiliation(s)
- Weibin Zhou
- Department of Endocrinology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310003 Zhejiang China
| | - Jia Rao
- Department of Endocrinology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310003 Zhejiang China
| | - Chengjiang Li
- Department of Endocrinology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310003 Zhejiang China
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13
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Igarashi H, Kokubun N, Funakoshi K, Sakurai S, Hirata K. [Oculomotor nerve compression on MRI in a 56-year-old man with pituitary apoplexy due to panhypophisitis]. Rinsho Shinkeigaku 2018; 58:668-672. [PMID: 30369523 DOI: 10.5692/clinicalneurol.cn-001192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
A 56-year-old man noted sudden onset of headache, fever, right pupil-spared oculomotor nerve palsy and consciousness disturbance. Swelling of pituitary with T1 high intensity on brain MRI suggested the diagnosis of pituitary apoplexy. Considering significant decrease of pituitary anterior lobe hormone and central diabetes insipidus, high dose of hydrocortisone was administered. Eight days after onset, consciousness level and headache improved. On day 30, brain MRI revealed the reduction of mass size, and on day 46, photophobia and double vision disappeared. Following the rapid response to steroid and disappearance of pituitary lesion, pituitary apoplexy was probably caused by panhypophisitis. Thin-slice brain MRI confirmed the compression of oculomotor nerve at inlet zone of cavernous sinus, suggesting the mechanism of oculomotor palsy was perfusion impairment of feeding artery.
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Affiliation(s)
| | | | | | - Shintaro Sakurai
- Department of Endocrinology and Metabolism, Dokkyo Medical University
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14
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Chiloiro S, Tartaglione T, Capoluongo ED, Angelini F, Arena V, Giampietro A, Bianchi A, Zoli A, Pontecorvi A, Colosimo C, De Marinis L. Hypophysitis Outcome and Factors Predicting Responsiveness to Glucocorticoid Therapy: A Prospective and Double-Arm Study. J Clin Endocrinol Metab 2018; 103:3877-3889. [PMID: 30085134 DOI: 10.1210/jc.2018-01021] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 07/27/2018] [Indexed: 02/05/2023]
Abstract
CONTEXT Primary autoimmune hypophysitis (PAH) evolves in most untreated cases in irreversible hypopituitarism. PAH outcome, instead, after immunosuppressive treatment has not been completely clarified. OBJECTIVE To evaluate hypophysitis and pituitary function outcomes. DESIGN A prospective, double-arm study with a 2-year follow-up. SETTING Referral center for pituitary disease. PATIENTS Twenty PAH cases. INTERVENTIONS Oral prednisone 50 mg/d or conservative strategy by observation. MAIN OUTCOME MEASURES Primary endpoint was the improvement/stabilization/worsening of PAH from baseline to a 2-year visit. Secondary endpoint was the improvement/stabilization/worsening of pituitary function from baseline to a 2-year visit. RESULTS Twelve patients (57.1%) were treated with a glucocorticoid-immunosuppressive therapy, and eight patients (42.9%) were observed. At the 2-year visit, PAH improvement/recovery occurred in eight immunosuppressive-treated (66.7%) patients and in two untreated patients (25%). PAH worsened in three untreated patients (37.5%) and was considered stable in four immunosuppressive-treated (33.3%) and three untreated patients (37.5%). Improvement/recovery of pituitary function occurred more frequently in immunosuppressive-treated patients (58.3%) compared with untreated ones (25%; P = 0.04). Responsiveness to immunosuppressive treatment is correlated with antipituitary antibody presence (P = 0.01), occurrence of diabetes insipidus at PAH diagnosis (P = 0.01), absence of the physiological neuropituitary "bright spot" on T1-weighed images (P = 0.01), and pituitary stalk at optical chiasm larger than 3.9 mm (area under the curve: 0.97, sensibility: 100%, specificity: 100%; P = 0.04). On the other hand, we failed to identify factors predicting the outcome, among untreated patients. CONCLUSIONS Glucocorticoid treatment of hypophysitis improves pituitary secretion and should be encouraged in accordance with the evaluation of endocrine-, immunological-, and morphological-predictive markers.
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Affiliation(s)
- Sabrina Chiloiro
- Pituitary Unit, Department of Endocrinology, Catholic University of the Sacred Heart, School of Medicine, Rome, Italy
| | - Tommaso Tartaglione
- Department of Radiology, Istituto Dermopatico dell'Immacolata, Rome, Italy
- Catholic University of the Sacred Heart, School of Medicine, Rome, Italy
| | - Ettore Domenico Capoluongo
- Department of Laboratory Medicine, Genetic and Toxicology, Istituto Dermopatico dell'Immacolata, Rome, Italy
- Institute of Biochemistry and Clinical Biochemistry, Catholic University of the Sacred Heart, School of Medicine, Rome, Italy
| | - Flavia Angelini
- Laboratory of Vascular Biology and Genetics, Department of Medicine, Catholic University of the Sacred Heart, School of Medicine, Rome, Italy
| | - Vincenzo Arena
- Department of Pathology, Catholic University of the Sacred Heart, School of Medicine, Rome, Italy
| | - Antonella Giampietro
- Pituitary Unit, Department of Endocrinology, Catholic University of the Sacred Heart, School of Medicine, Rome, Italy
| | - Antonio Bianchi
- Pituitary Unit, Department of Endocrinology, Catholic University of the Sacred Heart, School of Medicine, Rome, Italy
| | - Angelo Zoli
- Institute of Rheumatology and Affine Sciences, Division of Rheumatology, Catholic University of the Sacred Heart, School of Medicine, Rome, Italy
| | - Alfredo Pontecorvi
- Pituitary Unit, Department of Endocrinology, Catholic University of the Sacred Heart, School of Medicine, Rome, Italy
| | - Cesare Colosimo
- Department of Pathology, Catholic University of the Sacred Heart, School of Medicine, Rome, Italy
| | - Laura De Marinis
- Pituitary Unit, Department of Endocrinology, Catholic University of the Sacred Heart, School of Medicine, Rome, Italy
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15
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Yuen KCJ, Moloney KJ, Mercado JU, Rostad S, McCullough BJ, Litvack ZN, Delashaw JB, Mayberg MR. A case series of atypical features of patients with biopsy-proven isolated IgG4-related hypophysitis and normal serum IgG4 levels. Pituitary 2018; 21:238-246. [PMID: 29248982 DOI: 10.1007/s11102-017-0852-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND IgG4-related hypophysitis is a rare clinical entity that forms part of an emerging group of multi-organ IgG4-related fibrosclerotic systemic diseases. The rare prevalence of the disease, presenting features that overlap with other sellar pathologies, and variable imaging features can make preoperative identification challenging. PURPOSE AND METHODS We report three cases of isolated IgG4-related hypophysitis with atypical clinical and imaging features that mimicked those of pituitary apoplexy and other sellar lesions. Additionally, we review the literature of IgG4-related hypophysitis to provide context for individual patient data described herein. RESULTS All patients presented with symptoms that mimicked those of pituitary apoplexy and visual disturbance, and MRI findings suggestive of pituitary macroadenoma, Rathke's cleft cyst and craniopharyngioma. The clinical presentation warranted surgical decompression, resulting in rapid symptomatic improvement. Preoperative high-dose followed by postoperative low-dose glucocorticoid replacement therapy was administered in all cases. Histopathology showed dense infiltrate of IgG4 cells. Post-operative follow-up monitoring for 12-26 months revealed normal serum IgG4 levels with no other organ involvement, while endocrinological testing revealed persistent pituitary hormone deficiencies. CONCLUSIONS Our cases highlight the importance of considering IgG4-related hypophysitis in the differential diagnosis of solid and cystic sellar lesions presenting acutely with pituitary apoplexy symptoms. Existing diagnostic criteria may not be sufficiently precise to permit rapid and reliable identification, or avoidance of surgery in the acute setting. In contrast to other reports of the natural history of this condition, despite the severity of presenting features, the disease in our cases was pituitary-restricted with normal serum IgG4 levels.
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Affiliation(s)
- Kevin C J Yuen
- Swedish Pituitary Center, Department of Neuroendocrinology, Swedish Neuroscience Institute, Seattle, WA, 98122, USA.
- Barrow Pituitary Center, Departments of Neuroendocrinology and Neurosurgery, Barrow Neurological Institute, University of Arizona College of Medicine, Phoenix, AZ, 85013, USA.
| | - Kelley J Moloney
- Swedish Pituitary Center, Department of Neuroendocrinology, Swedish Neuroscience Institute, Seattle, WA, 98122, USA
| | - Jennifer U Mercado
- Swedish Pituitary Center, Department of Neuroendocrinology, Swedish Neuroscience Institute, Seattle, WA, 98122, USA
| | | | - Brendan J McCullough
- Department of Neuroradiology, Swedish Neuroscience Institute, Seattle, WA, 98122, USA
- Radia, Inc., 19020 33rd Avenue West, Suite 210, Lynnwood, WA, 98036, USA
| | - Zachary N Litvack
- Department of Neurosurgery, Swedish Neuroscience Institute, Seattle, WA, 98122, USA
| | - Johnny B Delashaw
- Department of Neurosurgery, Swedish Neuroscience Institute, Seattle, WA, 98122, USA
| | - Marc R Mayberg
- Department of Neurosurgery, Swedish Neuroscience Institute, Seattle, WA, 98122, USA
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16
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Tao T, Zhang Z, Li H. Lymphocytic hypophysitis associated with Behcet's disease: A case report and review of the literature. Neuro Endocrinol Lett 2018; 39:43-48. [PMID: 29803206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 02/18/2018] [Indexed: 06/08/2023]
Abstract
Lymphocytic hypophysitis (LH) is a rare inflammatory disorder involving the pituitary gland, often with other autoimmune diseases combined. The coexistence of LH and Behçet\'s disease (BD) is a rare combination and only one case was reported in the previous literatures. A 50-year-old man was admitted into Sir Run Run Shaw Hospital presented with frontal headache and fatigue which had lasted for four months. Endocrinological inspection indicated anterior pituitary dysfunction. Magnetic resonance imaging (MRI) revealed homogeneous pituitary enlargement and thickened pituitary stalk. Administration of glucocorticoids could effectively relieve headache and reduced pituitary mass volume. Oral aphthosis, skin lesions and positive pathergy tests were recognized later, which were characteristic features of BD. Although the diagnosis of BD is mainly dependent on clinical manifestations, PT is still a useful diagnostic tool 0f high specificityfor BD. And this male patient was diagnosed with both LH and BD afterwards. Then he was treated with cyclophosphamide and medium doses of methylprednisolone and remained in good conditions at the follow-up. LH and BD might share a common underlying autoimmune pathogenesis. The presentation of endocrinologic disturbances such as anterior pituitary dysfunction with typical features of skin lesions should prompt further investigation of possible comorbid autoimmune disease involving multiple organ systems. Early diagnosis and close monitoring are vitally important to ensure a stable endocrinologic status.
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Affiliation(s)
- Tingting Tao
- Department of Endocrinology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Ziyi Zhang
- Department of Endocrinology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Hong Li
- Department of Endocrinology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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17
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Koide H, Shiga A, Komai E, Yamato A, Fujimoto M, Tamura A, Kono T, Nakayama A, Takiguchi T, Higuchi S, Sakuma I, Nagano H, Hashimoto N, Suzuki S, Takeda Y, Shibuya M, Nishioka H, Yamada S, Inoshita N, Ishiwatari N, Horiguchi K, Yokote K, Tanaka T. Prednisolone-responsive Postpartum IgG4-related Hypophysitis. Intern Med 2018; 57:367-375. [PMID: 29093382 PMCID: PMC5827318 DOI: 10.2169/internalmedicine.8446-16] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
We herein report the case of a 25-year-old woman who presented with severe headache and visual field defects after childbirth. Magnetic resonance imaging revealed marked swelling of the pituitary gland, and an endocrinological examination revealed panhypopituitarism and diabetes insipidus. An immunohistological analysis of a transsphenoidal biopsy sample of the pituitary gland showed the significant accumulation of an immunogloblin G4 (IgG4)-positive population, leading to the diagnosis of IgG4-related hypophysitis. The patient was treated with prednisolone, which markedly reduced the swelling of the pituitary gland, in association with recovery of the pituitary function. This is a rare case of biopsy-proven IgG4-related hypophysitis with a postpartum onset.
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Affiliation(s)
- Hisashi Koide
- Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Japan
- Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Japan
| | - Akina Shiga
- Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Japan
- Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Japan
| | - Eri Komai
- Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Japan
- Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Japan
| | - Azusa Yamato
- Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Japan
- Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Japan
| | - Masanori Fujimoto
- Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Japan
- Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Japan
| | - Ai Tamura
- Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Japan
- Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Japan
| | - Takashi Kono
- Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Japan
- Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Japan
| | - Akitoshi Nakayama
- Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Japan
| | - Tomoko Takiguchi
- Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Japan
- Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Japan
| | - Seiichiro Higuchi
- Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Japan
- Department of Molecular Diagnosis, Chiba University Graduate School of Medicine, Japan
| | - Ikki Sakuma
- Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Japan
- Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Japan
| | - Hidekazu Nagano
- Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Japan
- Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Japan
| | - Naoko Hashimoto
- Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Japan
- Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Japan
| | - Sawako Suzuki
- Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Japan
- Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Japan
| | - Yasuaki Takeda
- Department of Neurosurgery, Tokyo Yamate Medical Center, Japan
| | - Makoto Shibuya
- Central Laboratory, Hachioji Medical Center, Tokyo Medical University, Japan
| | - Hiroshi Nishioka
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Japan
| | - Shozo Yamada
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Japan
| | | | - Norio Ishiwatari
- Department of Neurological Surgery, Chiba University Hospital, Japan
| | - Kentaro Horiguchi
- Department of Neurological Surgery, Chiba University Hospital, Japan
| | - Koutaro Yokote
- Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Japan
- Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Japan
| | - Tomoaki Tanaka
- Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Japan
- Department of Molecular Diagnosis, Chiba University Graduate School of Medicine, Japan
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18
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Wang S, Wang L, Yao Y, Feng F, Yang H, Liang Z, Deng K, You H, Sun J, Xing B, Jin Z, Wang R, Pan H, Zhu H. Primary lymphocytic hypophysitis: Clinical characteristics and treatment of 50 cases in a single centre in China over 18 years. Clin Endocrinol (Oxf) 2017; 87:177-184. [PMID: 28423475 DOI: 10.1111/cen.13354] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 03/28/2017] [Accepted: 04/12/2017] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Primary lymphocytic hypophysitis (LYH) is rare, and it is often evaluated in a small case series. This study aimed to describe the diagnosis and treatment of primary LYH in a larger cohort. DESIGN A retrospective study of the diagnosis and treatment of primary LYH was conducted at Peking Union Medical College Hospital from 1999 to 2016. PATIENTS Fifty patients (28 histologically diagnosed and 22 clinically-diagnosed) were eligible for inclusion. MEASUREMENTS Clinical, endocrine, pathological and imaging findings; therapies and outcomes were assessed. Ordinal logistic regression analysis was used to evaluate the association between the clinical parameters and outcomes (eg, improvements in pituitary function, regression of lesion size on MRI and disease recurrence). RESULTS Central diabetes insipidus (CDI) (72.0%) was the most common endocrine dysfunction. Hypogonadotropic hypogonadism was the most frequently observed (60.0%) manifestation of anterior pituitary dysfunction; adrenal insufficiency was the third most common (26.0%) manifestation; and IGF-1 axis defects were the least frequent (22.0%). Thickening of the pituitary stalk was the most frequent (96.0%) imaging finding, and 78.0% of the patients exhibited both intrasellar and suprasellar expansion. Pharmacological dose of glucocorticoids was identified to be significantly associated with increased odds of anterior pituitary function improvement. No observed covariates were significantly associated with improvement of CDI and recurrence. CONCLUSION The sequence of anterior pituitary deficiencies in Chinese primary LYH patients was atypical (LH/FSH>TSH>ACTH>IGF-1 axis deficiency). A pharmacological dose of glucocorticoids was significantly associated with the improved anterior pituitary insufficiency.
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Affiliation(s)
- Shuchang Wang
- Key Laboratory of Endocrinology of National Health and Family Planning Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Linjie Wang
- Key Laboratory of Endocrinology of National Health and Family Planning Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yong Yao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Feng Feng
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongbo Yang
- Key Laboratory of Endocrinology of National Health and Family Planning Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhiyong Liang
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kan Deng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui You
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jian Sun
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bing Xing
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zimeng Jin
- Key Laboratory of Endocrinology of National Health and Family Planning Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Pan
- Key Laboratory of Endocrinology of National Health and Family Planning Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Huijuan Zhu
- Key Laboratory of Endocrinology of National Health and Family Planning Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Lupi I, Cosottini M, Caturegli P, Manetti L, Urbani C, Cappellani D, Scattina I, Martino E, Marcocci C, Bogazzi F. Diabetes insipidus is an unfavorable prognostic factor for response to glucocorticoids in patients with autoimmune hypophysitis. Eur J Endocrinol 2017. [PMID: 28626085 DOI: 10.1530/eje-17-0123] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Autoimmune hypophysitis (AH) has a variable clinical presentation and natural history; likewise, its response to glucocorticoid therapy is often unpredictable. OBJECTIVE To identify clinical and radiological findings associated with response to glucocorticoids. DESIGN AND METHODS 12 consecutive patients with AH, evaluated from 2008 to 2016. AH was the exclusion diagnosis after ruling out other pituitary masses and secondary causes of hypophysitis. Mean follow-up time was 30 ± 27 months (range 12-96 months). RESULTS MRI identified two main patterns of presentation: global enlargement of the pituitary gland or panhypophysitis (n = 4, PH), and pituitary stalk abnormality only, or infundibulo-neuro-hypophysitis (n = 8, INH). Multiple tropin defects were more common in PH (100%) than those in INH (28% P = 0.014), whereas diabetes insipidus was more common in INH (100%) than that in PH (50%; P = 0.028). All 4 PH and 4 out of 8 INH were treated with glucocorticoids. Pituitary volume significantly reduced in all PH patients (P = 0.012), defective anterior pituitary function recovered only in the two patients without diabetes insipidus (50%) and panhypopituitarism persisted, along with diabetes insipidus, in the remaining 2 (50%). In all INH patients, either treated or untreated, pituitary stalk diameter reduced (P = 0.008) but diabetes insipidus persisted in all. CONCLUSIONS Glucocorticoid therapy may improve anterior pituitary function in a subset of patients but has no effect on restoring posterior pituitary function. Diabetes insipidus appears as a negative prognostic factor for response to glucocorticoids.
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Affiliation(s)
- Isabella Lupi
- Department of Clinical and Experimental Medicine, Section of Endocrinology, University of Pisa, Pisa, Italy
| | - Mirco Cosottini
- Department of Translational Research and New Surgical and Medical Technologies, University of Pisa, Pisa, Italy
| | - Patrizio Caturegli
- Division of Immunology, Department of Pathology, The Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Luca Manetti
- Department of Clinical and Experimental Medicine, Section of Endocrinology, University of Pisa, Pisa, Italy
| | - Claudio Urbani
- Department of Clinical and Experimental Medicine, Section of Endocrinology, University of Pisa, Pisa, Italy
| | - Daniele Cappellani
- Department of Clinical and Experimental Medicine, Section of Endocrinology, University of Pisa, Pisa, Italy
| | - Ilaria Scattina
- Department of Clinical and Experimental Medicine, Section of Endocrinology, University of Pisa, Pisa, Italy
| | - Enio Martino
- Department of Clinical and Experimental Medicine, Section of Endocrinology, University of Pisa, Pisa, Italy
| | - Claudio Marcocci
- Department of Clinical and Experimental Medicine, Section of Endocrinology, University of Pisa, Pisa, Italy
| | - Fausto Bogazzi
- Department of Clinical and Experimental Medicine, Section of Endocrinology, University of Pisa, Pisa, Italy
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Iwata N, Iwama S, Sugimura Y, Yasuda Y, Nakashima K, Takeuchi S, Hagiwara D, Ito Y, Suga H, Goto M, Banno R, Caturegli P, Koike T, Oshida Y, Arima H. Anti-pituitary antibodies against corticotrophs in IgG4-related hypophysitis. Pituitary 2017; 20:301-310. [PMID: 27896569 DOI: 10.1007/s11102-016-0780-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE IgG4-related disease is a systemic inflammatory disease characterized by infiltration of IgG4-positive plasma cells into multiple organs, including the pituitary gland. Autoimmunity is thought to be involved in the pathogenesis of IgG4-related disease. The diagnosis of IgG4-related hypophysitis (IgG4-RH) is difficult because its clinical features, such as pituitary swelling and hypopituitarism, are similar to those of other pituitary diseases, including lymphocytic hypophysitis and sellar/suprasellar tumors. The presence and significance of anti-pituitary antibodies (APA) in IgG4-RH is unclear. METHODS In this case-control study, we used single indirect immunofluorescence on human pituitary substrates to assess the prevalence of serum APA in 17 patients with IgG4-RH, 8 control patients with other pituitary diseases (lymphocytic infundibulo-neurohypophysitis, 3; craniopharyngioma, 2; germinoma, 3), and 9 healthy subjects. We further analyzed the endocrine cells targeted by the antibodies using double indirect immunofluorescence. RESULTS APA were found in 5 of 17 patients with IgG4-RH (29%), and in none of the pituitary controls or healthy subjects. The endocrine cells targeted by the antibodies in the 5 IgG4-RH cases were exclusively corticotrophs. Antibodies were of the IgG1 subclass, rather than IgG4, in all 5 cases, suggesting that IgG4 is not directly involved in the pathogenesis. Finally, antibodies recognized pro-opiomelanocortin in 2 of the cases. CONCLUSIONS Our study suggests that autoimmunity is involved in the pathogenesis of IgG4-RH and that corticotrophs are the main antigenic target, highlighting a possible new diagnostic marker for this condition.
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Affiliation(s)
- Naoko Iwata
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - Shintaro Iwama
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan.
- Research Center of Health, Physical Fitness and Sports, Nagoya University, Furo-cho, Chikusa-ku, Nagoya, 464-8601, Japan.
| | - Yoshihisa Sugimura
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - Yoshinori Yasuda
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - Kohtaro Nakashima
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - Seiji Takeuchi
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - Daisuke Hagiwara
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - Yoshihiro Ito
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - Hidetaka Suga
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - Motomitsu Goto
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - Ryoichi Banno
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - Patrizio Caturegli
- Department of Pathology, Johns Hopkins University, Baltimore, MD, 21205, USA
- Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA
| | - Teruhiko Koike
- Research Center of Health, Physical Fitness and Sports, Nagoya University, Furo-cho, Chikusa-ku, Nagoya, 464-8601, Japan
| | - Yoshiharu Oshida
- Research Center of Health, Physical Fitness and Sports, Nagoya University, Furo-cho, Chikusa-ku, Nagoya, 464-8601, Japan
| | - Hiroshi Arima
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
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Gu WJ, Zhang Q, Zhu J, Li J, Wei SH, Mu YM. Rituximab was used to treat recurrent IgG4-related hypophysitis with ophthalmopathy as the initial presentation: A case report and literature review. Medicine (Baltimore) 2017; 96:e6934. [PMID: 28614220 PMCID: PMC5478305 DOI: 10.1097/md.0000000000006934] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
RATIONALE Immunoglobulin G4 (IgG4)-related hypophysitis is a type of IgG4-related disease (IgG4-RD), which is characterized by plasma cells infiltration in the pituitary causing functional changes and (or) space-occupying effect in the pituitary. IgG4-related hypophysitis is sensitive to hormone therapy in most patients, but recurrence is very likely. PATIENT CONCERNS Here, we report a 57-year-old male patient with bilateral eye redness as the initial presentation. He later presented with pituitary hypofunction that involved multiple organs, including eyes, lacrimal gland, pituitary, lung, gall bladder, and intestine. There was an elevation of C-reactive protein and blood sedimentation, but the IgG and IgG4 levels of the serum and the cerebrospinal fluid did not increase obviously following irregular glucocorticoid therapy. Magnetic resonance imaging revealed enlarged pituitary and obviously thickened pituitary stalk. IgG4-related hypophysitis was confirmed by biopsy of the pituitary. DIAGNOSES The patient was diagnosis of IgG4-related hypophysitis with ophthalmopathy by pathological and molecular tests. INTERVENTIONS The patient responded to methylprednisolone pulse therapy but relapsed during the maintenance therapy using small-dose hormones combined with azathioprine. Methylprednisolone pulse therapy was given for 3 days followed by rituximab injection for 4 weeks. OUTCOMES After use methylprednisolone pulse therapy with rituximab the patient achieved complete remission. LESSONS Rituximab achieved good effect for recurrent IgG4-related hypophysitis after glucocorticoid therapy combined with immunosuppressant in this case. Moreover, comparative analysis was carried out with other reported cases of IgG4-related hypophysitis in terms of clinical features, treatment, and follow-up.
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Affiliation(s)
- Wei-Jun Gu
- Department of Endocrinology, Chinese PLA General Hospital
| | - Qian Zhang
- Department of Endocrinology, Chinese PLA General Hospital
- Department of Endocrinology, PLA Army General Hospital, Nanmencang
| | | | | | - Shi-Hui Wei
- Department of Ophthalmology, Chinese PLA General Hospital, Beijing, China
| | - Yi-Ming Mu
- Department of Endocrinology, Chinese PLA General Hospital
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Abstract
PURPOSE IgG4-related hypophysitis is a rare disease, with only 34 cases published in English (2015). Available short reviews may not present complete details of IgG4-related hypophysitis. We aimed to survey case reports of IgG4-related hypophysitis, including abstracts of scientific meetings, in English and Japanese. METHODS We searched for information about IgG4-related hypophysitis in PubMed and Igakuchuozasshi (Japan Medical Abstracts Society). Among 104 case reports found, we reviewed 84 fulfilling Leporati's diagnostic criteria. RESULTS The mean ± SD age of onset was 64.2 ± 13.9, 67.5 ± 9.8, and 56.4 ± 18.6 years for all subjects, men, and women, respectively. Men:women was 2.4:1. On magnetic resonance imaging, pituitary, stalk, and pituitary-stalk mass were observed at frequencies of 14.3, 21.4, and 64.3%, respectively. Manifestations were anterior hypopituitarism in 26.2% (22 cases), central diabetes insipidus in 17.9% (15 cases), and panhypopituitarism in 52.4% (44 cases). The median level of serum IgG4 was 264.5 mg/dL for all subjects, 405 mg/dL for men, and 226 mg/dL for women. The mean number of IgG4-related systemic diseases was 2.7 ± 1.5 in all subjects, 3.0 ± 1.5 in men, and 1.8 ± 1.1 in women. Among the IgG4-related diseases, retroperitoneal fibrosis was the most frequent (26.2%), followed by salivary gland diseases (25%). Glucocorticoid therapy was generally effective, except for two cases that received replacement doses. There were significant differences between sexes in terms of age, serum IgG4 levels, and number of IgG4-related diseases. CONCLUSION IgG4-related hypophysitis may have different clinical characteristics between genders. This survey may lack some information because the Japanese abstracts did not contain certain details.
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Affiliation(s)
- Junpei Shikuma
- Department of Diabetology, Metabolism, and Endocrinology, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Kenshi Kan
- Department of Diabetology, Metabolism, and Endocrinology, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Rokuro Ito
- Department of Diabetology, Metabolism, and Endocrinology, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Kazuo Hara
- Department of Diabetology, Metabolism, and Endocrinology, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Hiroyuki Sakai
- Department of Diabetology, Metabolism, and Endocrinology, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Takashi Miwa
- Department of Diabetology, Metabolism, and Endocrinology, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Akira Kanazawa
- Department of Diabetology, Metabolism, and Endocrinology, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Masato Odawara
- Department of Diabetology, Metabolism, and Endocrinology, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
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Abstract
PURPOSE We set out to describe the modern day management of Lymphocytic hypophysitis (LH) with respect to its diagnosis, treatment and long-term endocrine and visual outcomes. We deliberately included patients with a clinical diagnosis of LH and compared them with those with a histological diagnosis following surgery. METHODS A multi-centre observational study was performed. Twenty-two patients were included and studied over a mean follow-up period of 8.6 years (range 4-26 years). RESULTS Patients presented with headache (N = 15; 68 %), visual field disturbances (N = 7; 32 %) or a combination of these symptoms (N = 5; 23 %). The time lag between onset of symptoms and diagnosis was <1 month, 1-6 months or >6 months in approximately a third of the patients each, respectively. In two-thirds of the patients (N = 14) LH was diagnosed based on their clinical, biochemical and radiological findings. The surgical cohort (N = 8) was statistically more likely to have presented with larger lesions, with suprasellar extension and greater visual field defects. During follow-up there was improvement in headaches and visual symptoms, but the rate of hypopituitarism as reflected by the need for on-going pituitary hormone replacement persisted. At the 1, 5 and 10 year follow-up there was no significant difference between the medically and surgically managed cohorts in terms of ongoing symptomatology or need for pituitary hormone replacement. CONCLUSIONS In the modern era, most patients with LH are diagnosed by non-surgical means and managed medically. There remains a significant time lag between the onset of symptoms and the eventual diagnosis of LH. Despite the considerable morbidity attached to LH, overall prognosis is good.
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Affiliation(s)
- Angelos Kyriacou
- Department of Endocrinology, Salford Royal NHS Foundation Trust (SRFT), Stott Lane, Salford, Greater Manchester, M6 8HD, UK.
| | - Kanna Gnanalingham
- Department of Neurosurgery, Salford Royal NHS Foundation Trust, Stott Lane, Salford, Greater Manchester, UK
- Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - Tara Kearney
- Department of Endocrinology, Salford Royal NHS Foundation Trust (SRFT), Stott Lane, Salford, Greater Manchester, M6 8HD, UK
- Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
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24
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Byrne TN, Stone JH, Pillai SS, Rapalino O, Deshpande V. Case Records of the Massachusetts General Hospital. Case 31-2016. A 53-Year-Old Man with Diplopia, Polydipsia, and Polyuria. N Engl J Med 2016; 375:1469-1480. [PMID: 27732818 DOI: 10.1056/nejmcpc1610097] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Thomas N Byrne
- From the Departments of Neurology (T.N.B.), Rheumatology (J.H.S.), Radiology (O.R.), and Pathology (V.D.), Massachusetts General Hospital, and the Departments of Neurology (T.N.B.), Rheumatology (J.H.S.), Radiology (O.R.), and Pathology (V.D.) and the Ragon Institute (S.S.P.), Harvard Medical School - all in Boston
| | - John H Stone
- From the Departments of Neurology (T.N.B.), Rheumatology (J.H.S.), Radiology (O.R.), and Pathology (V.D.), Massachusetts General Hospital, and the Departments of Neurology (T.N.B.), Rheumatology (J.H.S.), Radiology (O.R.), and Pathology (V.D.) and the Ragon Institute (S.S.P.), Harvard Medical School - all in Boston
| | - Shiv S Pillai
- From the Departments of Neurology (T.N.B.), Rheumatology (J.H.S.), Radiology (O.R.), and Pathology (V.D.), Massachusetts General Hospital, and the Departments of Neurology (T.N.B.), Rheumatology (J.H.S.), Radiology (O.R.), and Pathology (V.D.) and the Ragon Institute (S.S.P.), Harvard Medical School - all in Boston
| | - Otto Rapalino
- From the Departments of Neurology (T.N.B.), Rheumatology (J.H.S.), Radiology (O.R.), and Pathology (V.D.), Massachusetts General Hospital, and the Departments of Neurology (T.N.B.), Rheumatology (J.H.S.), Radiology (O.R.), and Pathology (V.D.) and the Ragon Institute (S.S.P.), Harvard Medical School - all in Boston
| | - Vikram Deshpande
- From the Departments of Neurology (T.N.B.), Rheumatology (J.H.S.), Radiology (O.R.), and Pathology (V.D.), Massachusetts General Hospital, and the Departments of Neurology (T.N.B.), Rheumatology (J.H.S.), Radiology (O.R.), and Pathology (V.D.) and the Ragon Institute (S.S.P.), Harvard Medical School - all in Boston
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25
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Karaca Z, Kelestimur F. The management of hypophysitis. MINERVA ENDOCRINOL 2016; 41:390-399. [PMID: 26963662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Hypophysitis is generally accepted as an autoimmune disease which is characterized by inflammation and cellular infiltration of the pituitary gland. It can be either primary or secondary. In this review, treatment of primary hypophysitis of various histological subtypes are discussed. Management of primary hypophysitis is usually symptomatic aiming to reduce the size of the pituitary mass and/or replace deficient pituitary hormones. Observation with replacement for deficient pituitary hormones can be applied in some group of patients. Keeping the complications of surgery in mind, surgical intervention should be limited to cases with severe and/or deteriorating compressive signs or cases with inconclusive findings of hypophysitis in whom treatment would be based on histopathological examination. The most commonly used drugs in the treatment of hypophysitis are glucocorticoids. They are able to reduce the size of the mass lesion with their anti-inflammatory effects and sometimes pituitary functions may also recover. However, there is no consensus about the optimal duration and dose of glucocorticoid use. When glucocorticoids and/or surgery fail, azathioprine, methotrexate, cyclosporin A and novel immunotherapies can be tried as third or forth line treatment. Radiotherapy and radiosurgery have been seldom used for treatment of hypophysitis in order to reduce the mass effect.
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Affiliation(s)
- Zuleyha Karaca
- Erciyes University Medical School, Department of Endocrinology, Kayseri, Turkey -
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26
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Katsiveli P, Sfakiotaki M, Voulgaris N, Papanastasiou L, Kounadi T, Lymperopoulos K, Piaditis G. A complicated case of primary hypophysitis with bilateral intracavernous carotid artery occlusion. Hormones (Athens) 2016; 15:291-296. [PMID: 27376431 DOI: 10.14310/horm.2002.1657] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 03/22/2016] [Indexed: 02/06/2023]
Abstract
UNLABELLED Primary hypophysitis (PH) is a rare clinical entity characterized by inflammatory infiltration of the pituitary gland with various degrees of pituitary dysfunction. OBJECTIVE To present a complicated case of aggressive PH with bilateral cavernous sinuses infiltration, successfully treated with azathioprine after failure of corticosteroid treatment. METHODS AND RESULTS A 48-year-old woman presented with episodes of recurrent headache and progressively worsening muscle weakness. Magnetic resonance imaging (MRI) identified an intrasellar pituitary lesion with thickened pituitary stalk extending to the cavernous sinuses and causing asymptomatic occlusion of both internal carotid arteries (ICAs). Hormonal investigation showed severe anterior pituitary deficiency. The diagnosis of PH, and more specifically of lymphocytic hypophysitis (LYH), was suspected and glucocorticoid treatment was initiated. Because of the patient's susceptibility to infections, the attempt to gradually reduce glucocorticoid dosage induced a relapse of PH. Immunosuppressive therapy with azathioprine was administered. Significant pituitary mass reduction with regression of the inflammation to the cavernous sinuses was documented. At follow-up the pituitary function was normal, while the patient was on the minimum dose of azathioprine. Thereafter, azathioprine was discontinued without any clinical/biochemical or radiological evidence of PH except for the permanent ICA occlusion. CONCLUSIONS Despite its rarity, PH should be included in the differential diagnosis of pituitary masses and involvement of ICAs occlusion should not be underestimated. Azathioprine, applied as an alternative treatment, was shown to result in remarkable PH improvement.
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Affiliation(s)
- Pinelopi Katsiveli
- Department of Endocrinology and Diabetes Center, Athens General Hospital "G. Gennimatas", 154 Mesogion Avenue, 115 27, Athens, Greece
| | - Maria Sfakiotaki
- Department of Endocrinology and Diabetes Center, Athens General Hospital "G. Gennimatas", 154 Mesogion Avenue, 115 27, Athens, Greece
| | - Nikolaos Voulgaris
- Department of Endocrinology and Diabetes Center, Athens General Hospital "G. Gennimatas", 154 Mesogion Avenue, 115 27, Athens, Greece
| | - Labrini Papanastasiou
- Department of Endocrinology and Diabetes Center, Athens General Hospital "G. Gennimatas", 154 Mesogion Avenue, 115 27, Athens, Greece.
| | - Theodora Kounadi
- Department of Endocrinology and Diabetes Center, Athens General Hospital "G. Gennimatas", 154 Mesogion Avenue, 115 27, Athens, Greece
| | | | - George Piaditis
- Department of Endocrinology and Diabetes Center, Athens General Hospital "G. Gennimatas", 154 Mesogion Avenue, 115 27, Athens, Greece
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Louvet C, Maqdasy S, Tekath M, Grobost V, Rieu V, Ruivard M, Le Guenno G. Infundibuloneurohypophysitis Associated With Sjögren Syndrome Successfully Treated With Mycophenolate Mofetil: A Case Report. Medicine (Baltimore) 2016; 95:e3132. [PMID: 27043673 PMCID: PMC4998534 DOI: 10.1097/md.0000000000003132] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Hypophysitis is an inflammatory disorder of the pituitary gland and corticosteroids are usually recommended as the first-line treatment. Hypophysitis related to primary Sjögren syndrome (pSS) is uncommon. We describe the unusual case of a patient with infundibuloneurohypophysitis associated with pSS successfully treated with mycophenolate mofetil (MMF).We describe a case of a 60-year-old man with a medical history of pSS presented with central diabetes insipidus and panhypopituitarism. Magnetic resonance imaging (MRI) revealed a thickening of the pituitary stalk and intense enhancement of the posterior pituitary, pituitary stalk, and hypothalamus. We diagnosed infundibuloneurohypophysitis associated with pSS. Hormonal replacement was started immediately and MMF was introduced without corticosteroids. After 9 months of treatment, MRI of the pituitary revealed a complete regression of the nodular thickening of the pituitary stalk, with normal enhancement and appearance of the pituitary. The pituitary axes had completely recovered, whereas the diabetes insipidus was partially restored. Our findings suggest that MMF is an effective alternative to corticosteroids for the treatment of lymphocytic hypophysitis associated with an autoimmune disease. Furthermore, this report could contribute to extend the spectrum of the neurological and endocrinological manifestations of pSS.
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Affiliation(s)
- Camille Louvet
- From the Department of Internal Medicine (CL, VG, VR, MR, GLG) and Department of Radiology (MT), Centre Hospitalier Universitaire Estaing; and Department of Endocrinology and Diabetology (SM), Centre Hospitalier Universitaire Gabriel Montpied, Clermont-Ferrand, France
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De Bellis A, Bellastella G, Maiorino MI, Aitella E, Lucci E, Cozzolino D, Bellastella A, Bizzarro A, Giugliano D, Esposito K. Longitudinal behavior of autoimmune GH deficiency: from childhood to transition age. Eur J Endocrinol 2016; 174:381-7. [PMID: 26598530 DOI: 10.1530/eje-15-0766] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 11/23/2015] [Indexed: 11/08/2022]
Abstract
BACKGROUND Some cases of apparently idiopathic GH deficiency (GHD) may be caused by pituitary autoimmunity. OBJECTIVE To study the variations in pituitary function and antipituitary antibodies (APA) from childhood to transition age in patients with apparently idiopathic GHD. DESIGN We conducted a longitudinal study. PATIENTS AND METHODS Pituitary function and APA detection by immunofluorescence were investigated in 24 childhood patients with isolated GHD before starting recombinant GH therapy and after the stopping of this therapy in transition age. Sera of patients positive for APA were processed by double immunofluorescence to identify their pituitary target. RESULTS At diagnosis, 16 out of 24 patients were APA positive targeting only somatotrophs (group 1), while the remaining eight were APA negative (group 2). When retested off therapy, 12 out of 16 patients in group 1 persisted being APA positive, while the remaining four became negative with recovery of pituitary function. All patients in group 2 persisted being APA negative but still showing GHD. Of the 12 patients persistently APA positive, eight with confirmed GHD showed APA still targeting somatotrophs, whereas four showed APA targeting only gonadotrophs associated with isolated hypogonadotropic hypogonadism (HH). CONCLUSION Patients with APA at middle but not at high titer in childhood may show a remission of autoimmune GHD in childhood after GH replacement therapy. As APA may shift their target in transition period, an early characterization of APA by double immunofluorescence is advisable in APA positive GHD patients showing delayed puberty, to allow an early diagnosis and an appropriate therapy, thus preventing the progression toward HH.
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Affiliation(s)
- Annamaria De Bellis
- Department of Cardiothoracic and Respiratory SciencesEndocrinology and Metabolic Diseases Unit, Second University of Naples, Piazza L. Miraglia 2, 80131 Napoli, ItalyDepartment of MedicalSurgical, Neurological, Metabolic and Geriatric Sciences, Endocrinology and Metabolic Diseases UnitDepartment of Clinical and Experimental MedicineSecond University of Naples, Napoli, Italy
| | - Giuseppe Bellastella
- Department of Cardiothoracic and Respiratory SciencesEndocrinology and Metabolic Diseases Unit, Second University of Naples, Piazza L. Miraglia 2, 80131 Napoli, ItalyDepartment of MedicalSurgical, Neurological, Metabolic and Geriatric Sciences, Endocrinology and Metabolic Diseases UnitDepartment of Clinical and Experimental MedicineSecond University of Naples, Napoli, Italy
| | - Maria Ida Maiorino
- Department of Cardiothoracic and Respiratory SciencesEndocrinology and Metabolic Diseases Unit, Second University of Naples, Piazza L. Miraglia 2, 80131 Napoli, ItalyDepartment of MedicalSurgical, Neurological, Metabolic and Geriatric Sciences, Endocrinology and Metabolic Diseases UnitDepartment of Clinical and Experimental MedicineSecond University of Naples, Napoli, Italy
| | - Ernesto Aitella
- Department of Cardiothoracic and Respiratory SciencesEndocrinology and Metabolic Diseases Unit, Second University of Naples, Piazza L. Miraglia 2, 80131 Napoli, ItalyDepartment of MedicalSurgical, Neurological, Metabolic and Geriatric Sciences, Endocrinology and Metabolic Diseases UnitDepartment of Clinical and Experimental MedicineSecond University of Naples, Napoli, Italy
| | - Emma Lucci
- Department of Cardiothoracic and Respiratory SciencesEndocrinology and Metabolic Diseases Unit, Second University of Naples, Piazza L. Miraglia 2, 80131 Napoli, ItalyDepartment of MedicalSurgical, Neurological, Metabolic and Geriatric Sciences, Endocrinology and Metabolic Diseases UnitDepartment of Clinical and Experimental MedicineSecond University of Naples, Napoli, Italy
| | - Domenico Cozzolino
- Department of Cardiothoracic and Respiratory SciencesEndocrinology and Metabolic Diseases Unit, Second University of Naples, Piazza L. Miraglia 2, 80131 Napoli, ItalyDepartment of MedicalSurgical, Neurological, Metabolic and Geriatric Sciences, Endocrinology and Metabolic Diseases UnitDepartment of Clinical and Experimental MedicineSecond University of Naples, Napoli, Italy
| | - Antonio Bellastella
- Department of Cardiothoracic and Respiratory SciencesEndocrinology and Metabolic Diseases Unit, Second University of Naples, Piazza L. Miraglia 2, 80131 Napoli, ItalyDepartment of MedicalSurgical, Neurological, Metabolic and Geriatric Sciences, Endocrinology and Metabolic Diseases UnitDepartment of Clinical and Experimental MedicineSecond University of Naples, Napoli, Italy
| | - Antonio Bizzarro
- Department of Cardiothoracic and Respiratory SciencesEndocrinology and Metabolic Diseases Unit, Second University of Naples, Piazza L. Miraglia 2, 80131 Napoli, ItalyDepartment of MedicalSurgical, Neurological, Metabolic and Geriatric Sciences, Endocrinology and Metabolic Diseases UnitDepartment of Clinical and Experimental MedicineSecond University of Naples, Napoli, Italy
| | - Dario Giugliano
- Department of Cardiothoracic and Respiratory SciencesEndocrinology and Metabolic Diseases Unit, Second University of Naples, Piazza L. Miraglia 2, 80131 Napoli, ItalyDepartment of MedicalSurgical, Neurological, Metabolic and Geriatric Sciences, Endocrinology and Metabolic Diseases UnitDepartment of Clinical and Experimental MedicineSecond University of Naples, Napoli, Italy
| | - Katherine Esposito
- Department of Cardiothoracic and Respiratory SciencesEndocrinology and Metabolic Diseases Unit, Second University of Naples, Piazza L. Miraglia 2, 80131 Napoli, ItalyDepartment of MedicalSurgical, Neurological, Metabolic and Geriatric Sciences, Endocrinology and Metabolic Diseases UnitDepartment of Clinical and Experimental MedicineSecond University of Naples, Napoli, Italy
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Ngaosuwan K, Trongwongsa T, Shuangshoti S. Clinical course of IgG4-related hypophysitis presenting with focal seizure and relapsing lymphocytic hypophysitis. BMC Endocr Disord 2015; 15:64. [PMID: 26510826 PMCID: PMC4625849 DOI: 10.1186/s12902-015-0062-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 10/23/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND This is the first case report of focal seizure as a manifestation of Immunoglobulin G4 (IgG4)-related hypophysitis. IgG4-related hypophysitis is a novel category of hypophysitis. The clinical presentations, imaging studies and initial pathology studies can mimic lymphocytic hypophysitis. Here we report additional clinical clues in differentiating these two conditions. CASE PRESENTATION A 43-year-old Thai male presented with focal seizure, headache, and anterior pituitary hypofunction. His MRI study showed typical hypophysitis lesion with abnormal cerebral parenchymal signal intensity at right frontal lobe. The pituitary biopsied was obtained and the patient was initially diagnosed with lymphocytic hypophysitis. Following initial low-dose steroid therapy, his seizure and headache resolved but his anterior pituitary hormones remained deficient. However, during steroid tapering, he developed new onset acute visual loss. Upon rigorous pathologic review, his diagnosis of IgG4-related hypophysitis with suspected CNS involvement was established. He was subsequently treated with high-dose steroid and rapidly regained his sight. CONCLUSION This case report highlights the important distinguishing features of IgG4-related hypophysitis from lymphocytic hypophysitis. These include the relapsing clinical course of hypophysitis after steroid decrement and concomitant pachymeningitis particularly in middle-aged to elderly Asian male who presented with hypophysitis. With appropriate dosage of steroids, medical treatment is usually sufficient to control the disease and surgical interventions are usually not required.
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Affiliation(s)
- Kanchana Ngaosuwan
- Department of Internal Medicine, Faculty of Medicine, Srinakharinwirot University, Ongkarak, Nakhon Nayok, Thailand.
| | - Therdkiat Trongwongsa
- Department of Pathology, Faculty of Medicine, Srinakharinwirot University, Ongkarak, Nakhon Nayok, Thailand.
| | - Shanop Shuangshoti
- Department of Pathology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
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Honegger J, Buchfelder M, Schlaffer S, Droste M, Werner S, Strasburger C, Störmann S, Schopohl J, Kacheva S, Deutschbein T, Stalla G, Flitsch J, Milian M, Petersenn S, Elbelt U. Treatment of Primary Hypophysitis in Germany. J Clin Endocrinol Metab 2015; 100:3460-9. [PMID: 26091204 DOI: 10.1210/jc.2015-2146] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
CONTEXT The best treatment of primary hypophysitis (PrHy) is a matter of debate. OBJECTIVE Our main objective was to analyze the treatment practice for PrHy in Germany and to compare the outcome of the main treatment options. DESIGN The Pituitary Working Group of the German Society of Endocrinology conducted a nationwide retrospective cross-sectional cohort study. PATIENTS Seventy-six patients with PrHy were eligible for the study. MAIN OUTCOME MEASURES Clinical and endocrinological outcomes, side effects and complications of therapy, initial response, and recurrence rates were assessed. Outcome depending on the treatment modality was evaluated. RESULTS For mere observation, regression of space-occupying lesions was observed in 46%, unchanged size in 27%, and progression reported in 27%. Pituitary function improved in 27% of patients during observation. Deterioration of pituitary function was only found in patients with progressive lesions. The initial response to glucocorticoid pulse therapy was most favorable, with early failure in only 3%. However, the overall failure and recurrence rate was 41%. Recurrence rate was not related to duration of steroid administration. Side effects of steroids occurred in 63%. The surgical approach was transsphenoidal in 94%. The histological subtype was lymphocytic hypophysitis in 70% and granulomatous hypophysitis in 30%. Progression or recurrence was observed in 25% after surgical treatment. CONCLUSION Glucocorticoid pulse therapy is associated with a high recurrence rate. Evidence suggests that surgery is not able to prevent recurrence. Considering the favorable results of observation, conservative management is recommended in PrHy unless symptoms are severe or progressive.
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Affiliation(s)
- Jürgen Honegger
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, Hoppe-Seyler-Straße 3, 72076 Tuebingen, Germany; Department of Neurosurgery (M.B., S.Sc.), University of Erlangen-Nuremberg, Schwabachanlage 6, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), Elisenstraße 12, 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes and Nutrition (C.S., U.E.), Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; Department of Medicine IV (S.St., J.S.), Campus Innenstadt, University of Munich, Ziemssenstraße 1, 80336 Munich, Germany; Division of Endocrinology and Diabetes (S.K.), RWTH Aachen University, Pauwelsstraße 30, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080 Würzburg, Germany; Max Planck Institute Psychiatry (G.S.), Kraepelinstraße 2, 80804 Munich, Germany; Pituitary Surgery/Interdisciplinary Endocrinology (J.F.), UKE Hamburg, Martinistraße 52, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), Altonaer Straße 59, 20357 Hamburg, Germany
| | - Michael Buchfelder
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, Hoppe-Seyler-Straße 3, 72076 Tuebingen, Germany; Department of Neurosurgery (M.B., S.Sc.), University of Erlangen-Nuremberg, Schwabachanlage 6, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), Elisenstraße 12, 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes and Nutrition (C.S., U.E.), Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; Department of Medicine IV (S.St., J.S.), Campus Innenstadt, University of Munich, Ziemssenstraße 1, 80336 Munich, Germany; Division of Endocrinology and Diabetes (S.K.), RWTH Aachen University, Pauwelsstraße 30, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080 Würzburg, Germany; Max Planck Institute Psychiatry (G.S.), Kraepelinstraße 2, 80804 Munich, Germany; Pituitary Surgery/Interdisciplinary Endocrinology (J.F.), UKE Hamburg, Martinistraße 52, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), Altonaer Straße 59, 20357 Hamburg, Germany
| | - Sven Schlaffer
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, Hoppe-Seyler-Straße 3, 72076 Tuebingen, Germany; Department of Neurosurgery (M.B., S.Sc.), University of Erlangen-Nuremberg, Schwabachanlage 6, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), Elisenstraße 12, 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes and Nutrition (C.S., U.E.), Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; Department of Medicine IV (S.St., J.S.), Campus Innenstadt, University of Munich, Ziemssenstraße 1, 80336 Munich, Germany; Division of Endocrinology and Diabetes (S.K.), RWTH Aachen University, Pauwelsstraße 30, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080 Würzburg, Germany; Max Planck Institute Psychiatry (G.S.), Kraepelinstraße 2, 80804 Munich, Germany; Pituitary Surgery/Interdisciplinary Endocrinology (J.F.), UKE Hamburg, Martinistraße 52, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), Altonaer Straße 59, 20357 Hamburg, Germany
| | - Michael Droste
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, Hoppe-Seyler-Straße 3, 72076 Tuebingen, Germany; Department of Neurosurgery (M.B., S.Sc.), University of Erlangen-Nuremberg, Schwabachanlage 6, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), Elisenstraße 12, 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes and Nutrition (C.S., U.E.), Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; Department of Medicine IV (S.St., J.S.), Campus Innenstadt, University of Munich, Ziemssenstraße 1, 80336 Munich, Germany; Division of Endocrinology and Diabetes (S.K.), RWTH Aachen University, Pauwelsstraße 30, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080 Würzburg, Germany; Max Planck Institute Psychiatry (G.S.), Kraepelinstraße 2, 80804 Munich, Germany; Pituitary Surgery/Interdisciplinary Endocrinology (J.F.), UKE Hamburg, Martinistraße 52, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), Altonaer Straße 59, 20357 Hamburg, Germany
| | - Sandy Werner
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, Hoppe-Seyler-Straße 3, 72076 Tuebingen, Germany; Department of Neurosurgery (M.B., S.Sc.), University of Erlangen-Nuremberg, Schwabachanlage 6, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), Elisenstraße 12, 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes and Nutrition (C.S., U.E.), Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; Department of Medicine IV (S.St., J.S.), Campus Innenstadt, University of Munich, Ziemssenstraße 1, 80336 Munich, Germany; Division of Endocrinology and Diabetes (S.K.), RWTH Aachen University, Pauwelsstraße 30, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080 Würzburg, Germany; Max Planck Institute Psychiatry (G.S.), Kraepelinstraße 2, 80804 Munich, Germany; Pituitary Surgery/Interdisciplinary Endocrinology (J.F.), UKE Hamburg, Martinistraße 52, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), Altonaer Straße 59, 20357 Hamburg, Germany
| | - Christian Strasburger
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, Hoppe-Seyler-Straße 3, 72076 Tuebingen, Germany; Department of Neurosurgery (M.B., S.Sc.), University of Erlangen-Nuremberg, Schwabachanlage 6, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), Elisenstraße 12, 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes and Nutrition (C.S., U.E.), Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; Department of Medicine IV (S.St., J.S.), Campus Innenstadt, University of Munich, Ziemssenstraße 1, 80336 Munich, Germany; Division of Endocrinology and Diabetes (S.K.), RWTH Aachen University, Pauwelsstraße 30, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080 Würzburg, Germany; Max Planck Institute Psychiatry (G.S.), Kraepelinstraße 2, 80804 Munich, Germany; Pituitary Surgery/Interdisciplinary Endocrinology (J.F.), UKE Hamburg, Martinistraße 52, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), Altonaer Straße 59, 20357 Hamburg, Germany
| | - Sylvère Störmann
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, Hoppe-Seyler-Straße 3, 72076 Tuebingen, Germany; Department of Neurosurgery (M.B., S.Sc.), University of Erlangen-Nuremberg, Schwabachanlage 6, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), Elisenstraße 12, 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes and Nutrition (C.S., U.E.), Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; Department of Medicine IV (S.St., J.S.), Campus Innenstadt, University of Munich, Ziemssenstraße 1, 80336 Munich, Germany; Division of Endocrinology and Diabetes (S.K.), RWTH Aachen University, Pauwelsstraße 30, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080 Würzburg, Germany; Max Planck Institute Psychiatry (G.S.), Kraepelinstraße 2, 80804 Munich, Germany; Pituitary Surgery/Interdisciplinary Endocrinology (J.F.), UKE Hamburg, Martinistraße 52, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), Altonaer Straße 59, 20357 Hamburg, Germany
| | - Jochen Schopohl
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, Hoppe-Seyler-Straße 3, 72076 Tuebingen, Germany; Department of Neurosurgery (M.B., S.Sc.), University of Erlangen-Nuremberg, Schwabachanlage 6, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), Elisenstraße 12, 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes and Nutrition (C.S., U.E.), Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; Department of Medicine IV (S.St., J.S.), Campus Innenstadt, University of Munich, Ziemssenstraße 1, 80336 Munich, Germany; Division of Endocrinology and Diabetes (S.K.), RWTH Aachen University, Pauwelsstraße 30, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080 Würzburg, Germany; Max Planck Institute Psychiatry (G.S.), Kraepelinstraße 2, 80804 Munich, Germany; Pituitary Surgery/Interdisciplinary Endocrinology (J.F.), UKE Hamburg, Martinistraße 52, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), Altonaer Straße 59, 20357 Hamburg, Germany
| | - Stella Kacheva
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, Hoppe-Seyler-Straße 3, 72076 Tuebingen, Germany; Department of Neurosurgery (M.B., S.Sc.), University of Erlangen-Nuremberg, Schwabachanlage 6, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), Elisenstraße 12, 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes and Nutrition (C.S., U.E.), Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; Department of Medicine IV (S.St., J.S.), Campus Innenstadt, University of Munich, Ziemssenstraße 1, 80336 Munich, Germany; Division of Endocrinology and Diabetes (S.K.), RWTH Aachen University, Pauwelsstraße 30, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080 Würzburg, Germany; Max Planck Institute Psychiatry (G.S.), Kraepelinstraße 2, 80804 Munich, Germany; Pituitary Surgery/Interdisciplinary Endocrinology (J.F.), UKE Hamburg, Martinistraße 52, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), Altonaer Straße 59, 20357 Hamburg, Germany
| | - Timo Deutschbein
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, Hoppe-Seyler-Straße 3, 72076 Tuebingen, Germany; Department of Neurosurgery (M.B., S.Sc.), University of Erlangen-Nuremberg, Schwabachanlage 6, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), Elisenstraße 12, 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes and Nutrition (C.S., U.E.), Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; Department of Medicine IV (S.St., J.S.), Campus Innenstadt, University of Munich, Ziemssenstraße 1, 80336 Munich, Germany; Division of Endocrinology and Diabetes (S.K.), RWTH Aachen University, Pauwelsstraße 30, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080 Würzburg, Germany; Max Planck Institute Psychiatry (G.S.), Kraepelinstraße 2, 80804 Munich, Germany; Pituitary Surgery/Interdisciplinary Endocrinology (J.F.), UKE Hamburg, Martinistraße 52, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), Altonaer Straße 59, 20357 Hamburg, Germany
| | - Günter Stalla
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, Hoppe-Seyler-Straße 3, 72076 Tuebingen, Germany; Department of Neurosurgery (M.B., S.Sc.), University of Erlangen-Nuremberg, Schwabachanlage 6, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), Elisenstraße 12, 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes and Nutrition (C.S., U.E.), Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; Department of Medicine IV (S.St., J.S.), Campus Innenstadt, University of Munich, Ziemssenstraße 1, 80336 Munich, Germany; Division of Endocrinology and Diabetes (S.K.), RWTH Aachen University, Pauwelsstraße 30, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080 Würzburg, Germany; Max Planck Institute Psychiatry (G.S.), Kraepelinstraße 2, 80804 Munich, Germany; Pituitary Surgery/Interdisciplinary Endocrinology (J.F.), UKE Hamburg, Martinistraße 52, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), Altonaer Straße 59, 20357 Hamburg, Germany
| | - Jörg Flitsch
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, Hoppe-Seyler-Straße 3, 72076 Tuebingen, Germany; Department of Neurosurgery (M.B., S.Sc.), University of Erlangen-Nuremberg, Schwabachanlage 6, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), Elisenstraße 12, 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes and Nutrition (C.S., U.E.), Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; Department of Medicine IV (S.St., J.S.), Campus Innenstadt, University of Munich, Ziemssenstraße 1, 80336 Munich, Germany; Division of Endocrinology and Diabetes (S.K.), RWTH Aachen University, Pauwelsstraße 30, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080 Würzburg, Germany; Max Planck Institute Psychiatry (G.S.), Kraepelinstraße 2, 80804 Munich, Germany; Pituitary Surgery/Interdisciplinary Endocrinology (J.F.), UKE Hamburg, Martinistraße 52, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), Altonaer Straße 59, 20357 Hamburg, Germany
| | - Monika Milian
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, Hoppe-Seyler-Straße 3, 72076 Tuebingen, Germany; Department of Neurosurgery (M.B., S.Sc.), University of Erlangen-Nuremberg, Schwabachanlage 6, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), Elisenstraße 12, 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes and Nutrition (C.S., U.E.), Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; Department of Medicine IV (S.St., J.S.), Campus Innenstadt, University of Munich, Ziemssenstraße 1, 80336 Munich, Germany; Division of Endocrinology and Diabetes (S.K.), RWTH Aachen University, Pauwelsstraße 30, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080 Würzburg, Germany; Max Planck Institute Psychiatry (G.S.), Kraepelinstraße 2, 80804 Munich, Germany; Pituitary Surgery/Interdisciplinary Endocrinology (J.F.), UKE Hamburg, Martinistraße 52, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), Altonaer Straße 59, 20357 Hamburg, Germany
| | - Stephan Petersenn
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, Hoppe-Seyler-Straße 3, 72076 Tuebingen, Germany; Department of Neurosurgery (M.B., S.Sc.), University of Erlangen-Nuremberg, Schwabachanlage 6, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), Elisenstraße 12, 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes and Nutrition (C.S., U.E.), Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; Department of Medicine IV (S.St., J.S.), Campus Innenstadt, University of Munich, Ziemssenstraße 1, 80336 Munich, Germany; Division of Endocrinology and Diabetes (S.K.), RWTH Aachen University, Pauwelsstraße 30, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080 Würzburg, Germany; Max Planck Institute Psychiatry (G.S.), Kraepelinstraße 2, 80804 Munich, Germany; Pituitary Surgery/Interdisciplinary Endocrinology (J.F.), UKE Hamburg, Martinistraße 52, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), Altonaer Straße 59, 20357 Hamburg, Germany
| | - Ulf Elbelt
- Department of Endocrinology, Diabetes and Nutrition, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
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Xu C, Ricciuti A, Caturegli P, Keene CD, Kargi AY. Autoimmune lymphocytic hypophysitis in association with autoimmune eye disease and sequential treatment with infliximab and rituximab. Pituitary 2015; 18:441-7. [PMID: 25224140 DOI: 10.1007/s11102-014-0592-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Autoimmune lymphocytic hypophysitis associates predominantly with other autoimmune endocrinopathies and is most commonly treated with glucocorticoids and/or decompressive pituitary surgery. Here we report a new association and treatment modality for lymphocytic hypophysitis. METHODS A 52-year-old woman presented with scleritis, uveitis, facial palsy, and central diabetes insipidus, accompanied by thickened pituitary stalk and enlarged pituitary on cranial MRI. Neurosarcoidosis was suspected and treatment with glucocorticoids and methotrexate initiated. Since symptoms persisted, infliximab (a monoclonal antibody that antagonizes tumor necrosis factor alpha) was added to her regimen. The patient initially improved but after 6 months developed recurrent pituitary enlargement, bilateral optic neuritis, and panhypopituitarism. To ascertain the nature of the pituitary lesion, she underwent transsphenoidal biopsy, which revealed lymphocytic hypophysitis with numerous CD20 positive B lymphocytes. The pathological finding suggested to us that administration of rituximab (a monoclonal antibody that lyzes B cells expressing CD20) could be useful. Following two courses of rituximab, the pituitary mass resolved and the corticotroph axis partially recovered. The patient has remained in remission during 3 years of follow up. CONCLUSION This is the first report of hypophysitis occurring with the triad of scleritis, uveitis, and optic neuritis, as well as the first immunotherapy based on the sequential use of infliximab and rituximab.
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Affiliation(s)
- Chengyu Xu
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA,
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