Endocrine Abstracts

Introduction: Hypophysitis is a rare condition characterized by inflamation of the pituitary gland, causing mass effect and hypopituitarism. The incidence is estimated to be 1in9 million/year. The diagnosis of hypophysitis is based on clinical and laboratory findings, imaging methods and histopathology in selected cases. The aim of the treatment is to eliminate the compression effects of the mass and to treat hypopituitarsim. The first choice in medical treatment is immunsupressive drugs. Surgical treatment can be considered for patients with progressive visual defects unresponsive to medications. Certain cases may be followed without immunesupression or surgical intervention. Here in we present cases with hipophysitis of atypical presentation.

Clinical Cases: Case 1:

A 20-year female presented with headache, blurred vision, oligomenorrhea and galactorrhea. Basal cortisol was 1.89µg/dl, other anterior pituitary hormones were in referance ranges. A 22 x 17 mm hemorrhagic atypical macroadenoma was present on the pituitary MRI. The stalk thickness was not increased. The patient underwent transsphenoidal surgery; pathologic specimen showed infiltration with lymphocytes, plasmacells and CD68(+) histiocytes; which were evaluated as xantamatous hypopysitis. After the operation the patient’s complaints regressed. However glucocorticoid replacement was continued.

Case 2: A 55-year male presented with headache, vomiting, fever, diplopia, polyuria and polydipsia for 10 days. Laboratory findings at first presentation showed hypocortisolemia, partial central diabetes inspidus, central hypothyroidism and lymphopenia. On the pituitary MRI, a 22 x 17 mm macroadenoma was observed. Initially an adenoma was suspected based on imaging, however hypophysitis was considered in the differantial diagnosis due to a spontaneous decrease in dimensions to 17 x 9 mm (>50%) and increased stalk thickness in control imaging. Lymphopenia improved spontaneously. For the differantial diagnosis laboratory invesitgations including inflammatory markers, IgG4, Covid-PCR and antibodies and, investigations for other infectious and inflammatory/infiltrative diseases showed only increased Covid antibody (IgG>250 U/ml). Patient was evaluated as a secondary hypophysitis after an unrecognised Covid infection.

Case 3: A 35-year male with acute onset headache, double vision and 6^th cranial nerve palsy had 16 x 18 x 21 mm cystic lesion (macroadenoma) with increased stalk thickness on pituitary MRI. Pituitary hormones and other laboratory findings were within normal levels. Hipophysitis was considered, however with the acute presentation of mass effects transsphenodial surgery was performed. The intraoperative mass had a purulent apperance, and the pathology was evaluated as abscess and lymphocytic hypophysitis. The microbiologic evaluation confirmed a sterile abscess. Postoperatively the patients complains regressed completely and there was no need for any hormonreplacement therapy.

Conclusion: Hypophysitis is a rare condition with variable presentations. Diagnostic and treatment modalities may vary for each case. Not all cases require immunesupressive treatment and, a case based specific approach is necessary.