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Abstract
Hypophysitis is a rare pituitary inflammatory disorder classified in different ways. Immunoglobulin G4-related disease (IgG4-RD), also a rare disease is a systemic fibro-inflammatory condition characterized by infiltration of tissue with IgG4-positive plasma cells; however prevalence of both of them probably is underestimated. In this paper, we present an Iranian patient with biopsy-proven IgG4-related hypophysitis and then review the clinical characteristics, laboratory, imaging, pathologic findings and therapeutic management as well as prognosis of 115 published cases of hypophysitis secondary to IgG4-related disease.
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Affiliation(s)
| | - Fatemeh Esfahanian
- Department of Endocrinology and Metabolism, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran.
| | - Marjan Mouodi
- Department of Endocrinology and Metabolism, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Nasser Rakhshani
- Department of Pathology, Firoozgar Hospital, Iran University of medical sciences, Tehran, Iran
| | - Mehdi Zeinalizadeh
- Department of Neurological Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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Boharoon H, Tomlinson J, Limback-Stanic C, Gontsorova A, Martin N, Hatfield E, Meeran K, Nair R, Mendoza N, Levy J, McAdoo S, Pusey C, Wernig F. A Case Series of Patients with Isolated IgG4-related Hypophysitis Treated with Rituximab. J Endocr Soc 2020; 4:bvaa048. [PMID: 32537540 PMCID: PMC7278280 DOI: 10.1210/jendso/bvaa048] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 04/17/2020] [Indexed: 12/13/2022] Open
Abstract
Context The acute presentation of immunoglobulin G4 (IgG4)-related hypophysitis can be indistinguishable from other forms of acute hypophysitis, and histology remains the diagnostic gold standard. The high recurrence rate necessitates long-term immunosuppressive therapy. Rituximab (RTX) has been shown to be effective in systemic IgG4-related disease (IgG4-RD), but experience with isolated pituitary involvement remains limited. Case Description We report 3 female patients with MRI findings suggestive of hypophysitis. All patients underwent transsphenoidal biopsy and fulfilled diagnostic criteria for IgG4-related hypophysitis. Treatment with glucocorticoids (GCs) resulted in good therapeutic response in Patients 1 and 2, but the disease recurred on tapering doses of GCs. GC treatment led to emotional lability in Patient 3, necessitating a dose reduction. All 3 patients received RTX and Patients 2 and 3 received further courses of treatment when symptoms returned and B-cells repopulated. Patient 3 did not receive RTX until 12 months from the onset of symptoms. Patient 1 was not able to have further RTX treatments due to an allergic reaction when receiving the second dose. Rituximab treatment resulted in sustained remission and full recovery of anterior pituitary function in Patients 1 and 2, with complete resolution of pituitary enlargement. By contrast, Patient 3 only showed a symptomatic response following RTX treatment, but pituitary enlargement and hypofunction persisted. Conclusion Rituximab treatment for IgG4-related hypophysitis resulted in sustained remission in 2 patients treated early in the disease process but only achieved partial response in a patient with chronic disease, suggesting that early therapeutic intervention may be crucial in order to avoid irreversible changes.
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Affiliation(s)
- Hessa Boharoon
- Department of Endocrinology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - James Tomlinson
- Renal Unit, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Clara Limback-Stanic
- Department of Cellular Pathology, Imperial College Healthcare NHS Trust, London, UK
| | | | - Niamh Martin
- Department of Endocrinology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.,Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
| | - Emma Hatfield
- Department of Endocrinology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Karim Meeran
- Department of Endocrinology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.,Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
| | - Ramesh Nair
- Department of Neurosurgery, Imperial College Healthcare NHS Trust, London, UK
| | - Nigel Mendoza
- Department of Neurosurgery, Imperial College Healthcare NHS Trust, London, UK
| | - Jeremy Levy
- Renal Unit, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.,Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
| | - Steve McAdoo
- Renal Unit, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Charles Pusey
- Renal Unit, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Florian Wernig
- Department of Endocrinology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
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