A case series of atypical features of patients with biopsy-proven isolated IgG4-related hypophysitis and normal serum IgG4 levels.

Publication Title

Pituitary

Authors

Kevin C J Yuen, Swedish Pituitary Center, Department of Neuroendocrinology, Swedish Neuroscience Institute, Seattle, WA, 98122, USA.
Kelley J Moloney, Swedish Pituitary Center, Department of Neuroendocrinology, Swedish Neuroscience Institute, Seattle, WA, 98122, USA.Follow
Jennifer U Mercado, Swedish Pituitary Center, Department of Neuroendocrinology, Swedish Neuroscience Institute, Seattle, WA, 98122, USA.
Steven Rostad
Brendan J McCullough
Zachary N Litvack
Johnny B Delashaw
Marc R Mayberg

Document Type

Article

Publication Date

6-1-2018

Keywords

Atypical; Craniopharyngioma; IgG4; IgG4-related hypophysitis; Imaging; Rathke’s cleft cyst

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.

Specialty/Research Institute

Endocrinology