The Great Imitator in Endocrinology: A Painful Hypophysitis Mimicking a Pituitary Tumor

Executive summary of the consensus document on hypophysitis of the Neuroendocrinology Area of Knowledge of the Spanish Society of Endocrinology and Nutrition

The term hypophysitis is used to designate a heterogeneous group of pituitary conditions characterized by the presence of inflammatory infiltration of the adenohypophysis, neurohypophysis, or both. Although hypophysitis are rare disorders, the most common in clinical practice is lymphocytic hypophysitis, a primary hypophysitis characterized by lymphocytic infiltration, which predominantly affects women. Other forms of primary hypophysitis are associated with different autoimmune diseases. Hypophysitis can also be secondary to other disorders such as sellar and parasellar diseases, systemic diseases, paraneoplastic syndromes, infections, and drugs, including immune checkpoint inhibitors. The diagnostic evaluation should always include pituitary function tests and other analytical tests based on the suspected diagnosis. Pituitary magnetic resonance imaging is the investigation of choice for the morphological assessment of hypophysitis. Glucocorticoids are the mainstay of treatment for most symptomatic hypophysitis.

Multi-syphilitic gummas in pituitary and cerebellopontine angle in a patient

PURPOSE

Multi-syphilitic gummas in pituitary and cerebellopontine angle (CPA) are extremely rare and easily misdiagnosed especially in patients with antibiotic abuse. We write this paper for clinicians to better understanding of cerebral gumma.

METHODS

We report a patient with syphilitic gummas in pituitary and left CPA. The definite diagnosis is made by histopathology after surgery.

RESULTS

A 49-years-old woman suffered from headaches with tinnitus and hypoacusis in left ear. She was diagnosed with syphilis but untreated. There were no chancre and rashes in the course of disease. Syphilis serological tests were positive. Brain MRI found two masses located in the left CPA and hypophysial fossa. The two masses were removed successively. We found a large number of Treponemapallidum in paraffin-embedded specimens by immunohistochemical staining.

CONCLUSIONS

Syphilitic gummas in pituitary and CPA are similar to benign or malignant brain tumors, easily leading to misdiagnosis. Gumma should be considered in differential diagnosis when a patient has unexplained nervous system symptoms or signs and imaging findings suggest intracranial mass in syphilis seropositive patients.

Hypophysitis Due to Paranasal Sinusitis: Neurosurgical Perspective from Developing World

BACKGROUND

Sinusitis is a common clinical condition, but sphenoid sinusitis is a less common form and even rarer is hypophysitis as a complication of the latter. Clinically, hypophysitis may mimic a pituitary neoplasm in presenting with mass effect and pituitary hormone dysfunction.

CASE DESCRIPTION

We present 5 cases of sinusitis-related hypophysitis treated at the Royal Care International Hospital in Khartoum, Sudan. Clinical symptoms at presentation included headache, fever, ptosis, ophthalmoplegia, and history of sinusitis with running nose (nasal discharge). None of the patients were immunocompromised or showed signs of meningitis. Laboratory tests indicated neutrophilia and elevated inflammatory indices, namely C-reactive protein and erythrocyte sedimentation rate. There was also a disturbance of the hypothalamic-pituitary hormone axis, particularly impaired cortisol level. Magnetic resonance imaging scans on all patients revealed swollen masses in the pituitary fossa and enhancement of the sellar region and paranasal sinuses, especially the sphenoid sinus. All cases were empirically treated with hydrocortisone and amoxicillin-clavulanate, resulting in reversal of symptoms.

CONCLUSIONS

Sinusitis is common in tropical regions where the climate is usually warm and often hot and dry. Here, the condition is considered a common incidental finding in magnetic resonance imaging examinations done for various indications. Hence it is not considered to be a serious health problem. Though our cohort of cases is small, we emphasize the importance of keeping a high index of suspicion for the diagnosis of hypophysitis in relevant case settings. This would help make an early diagnosis and ensure appropriate medical, perhaps nonsurgical, management.

DIAGNOSIS OF ENDOCRINE DISEASE: Expanding the cause of hypopituitarism

Hypopituitarism is defined as one or more pituitary hormone deficits due to a lesion in the hypothalamic-pituitary region. By far, the most common cause of hypopituitarism associated with a sellar mass is a pituitary adenoma. A high index of suspicion is required for diagnosing hypopituitarism in several other conditions such as other massess in the sellar and parasellar region, brain damage caused by radiation and by traumatic brain injury, vascular lesions, infiltrative/immunological/inflammatory diseases (lymphocytic hypophysitis, sarcoidosis and hemochromatosis), infectious diseases and genetic disorders. Hypopituitarism may be permanent and progressive with sequential pattern of hormone deficiencies (radiation-induced hypopituitarism) or transient after traumatic brain injury with possible recovery occurring years from the initial event. In recent years, there is increased reporting of less common and less reported causes of hypopituitarism with its delayed diagnosis. The aim of this review is to summarize the published data and to allow earlier identification of populations at risk of hypopituitarism as optimal hormonal replacement may significantly improve their quality of life and life expectancy.

[Syphilis]

Syphilis is back since the beginning of this century. The epidemic affects mainly men having sex with men with a high proportion of HIV-infected patients. The classification of syphilis distinguishes early syphilis where patients are contagious (primary, secondary and early latent of less than one year) and late syphilis where patients are not (or less) contagious (late latent of more than one year and tertiary). The clinical presentation of syphilis has not changed. However, we must insist on the early forms of neurosyphilis, notably ophthalmic syphilis often under-diagnosed, as it affects the treatment. Serologic tests may be improved but are very helpful for the positive diagnosis and the follow-up after treatment. Treatment of early syphilis is based on one injection of benzathine benzyl penicillin G. Patients who have had syphilis must be regularly followed-up after treatment, as re-infections are common and are often asymptomatic.

Bilateral Carotid-Cavernous Fistulas: An Uncommon Cause of Pituitary Enlargement and Hypopituitarism

Carotid-cavernous fistulas (CCFs) are rare, pathologic communications of the carotid artery and the venous plexus of the cavernous sinus. They can develop spontaneously in certain at risk individuals or following traumatic head injury. Typical clinical manifestations include headache, proptosis, orbital pain, and diplopia. We report a case of bilateral carotid-cavernous fistulas associated with these symptoms and also with pituitary enlargement and hypopituitarism, which improved following surgical intervention. Arterialization of the cavernous sinus and elevated portal pressure may interfere with normal venous drainage and the conveyance of inhibiting and releasing hormones from the hypothalamus, resulting in pituitary enlargement and hypopituitarism. This condition should be considered in the differential diagnosis of hypopituitarism associated with anterior pituitary enlargement.