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?
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*
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…
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.
⬇️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
•Lymphocytic hypophysitis •Neurosarcoidosis
•Metastasis •Inflammatory hypophysitis eg. IgG4 disease
Our patient's MRI was similar to cases described by Sawai et al, 1998
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.
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!
•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
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
•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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