It's #TweetorialTuesday!Created by @NamithaNair24 and @KAgarwal899! Let's dive into a recent case from our CPC:
1/ 55 yo M w/ HTN presents with headache x 8 wks. Pertinent ROS and PE mentioned ⬇️
What could this be due to?
2/Firstly, can we group these symptoms into a syndrome?
3/ Yes! Let's try:
Combining it with the duration of the constellation of these symptoms, we are looking for causes of:
*Subacute hypopituitarism*
4/ Let's look at some common causes of subacute hypopituitarism:
Image:ncbi.nlm.nih.gov/books/NBK47041…
5/Moving on, our patient's labs showed:
⬇️TSH,⬇️FT4,⬇️ACTH,⬇️cortisol,⬇️LH, ⬇️FSH-> all indicating panhypopituitarism.
In addition, blood cx, Autoimmune workup was unremarkable.
MRI Brain showed an enlarged homogenous mass involving hypothalamus, pituitary stalk & gland.
6/What causes a homogeneously enhancing mass of the hypothalamus, pituitary stalk & pituitary gland?
•Lymphocytic hypophysitis •Neurosarcoidosis
•Metastasis •Inflammatory hypophysitis eg. IgG4 disease
Our patient's MRI was similar to cases described by Sawai et al, 1998
7/So what does that lead us to?
Lymphocytic Hypophysitis!
link.springer.com/article/10.100…
8/ Headache and visual disturbances are common, as described by Caturegli et al:academic.oup.com/edrv/article/2…
In addition, ACTH deficiency usually is the earliest functional alteration in Lymphocytic Hypophysitis.
9/ How do you diagnose?
•While it is a diagnosis of exclusion, demonstrating impaired pituitary function and MRI abnormalities can be helpful!
10/ A score developed by Gutenberg et al, 2009 with 92% sensitivity and 99% specificity, can be a helpful clinicoradiological tool to identify lymphocytic hypophysitis.
Score > 1 → favors pituitary adenoma
Score of zero or less → favors lymphocytic hypophysitis
11/Management:
12/ Key take away:
•Suspect panhypopituitarism when evaluating multiple hormone deficiencies.
•Homogenous enhancing pituitary mass : think lymphocytic hypophysitis, sarcoidosis, metastasis or IgG4 related disease
•Clinical scores can help to identify autoimmune hypophysitis
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