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A Remarkable Response of Granulomatous Hypophysitis to Infliximab in a Patient With a Background of Crohn's Disease—A Case Report

Authors
  • Force, Bahar K.1, 2
  • Vogel, Tiphanie P.3
  • Nguyen, Dang M.4
  • Heck, Kent A.5
  • Sebastian, Sherly2, 6
  • Takashima, Mas7
  • Yoshor, Daniel2, 6
  • Samson, Susan L.1, 2, 6
  • 1 Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, Baylor College of Medicine, Houston, TX , (United States)
  • 2 Baylor St. Luke's Pituitary Center, Houston, TX , (United States)
  • 3 Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine, Houston, TX , (United States)
  • 4 Greater Houston Gastroenterology, Houston, TX , (United States)
  • 5 Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX , (United States)
  • 6 Department of Neurosurgery, Baylor College of Medicine, Houston, TX , (United States)
  • 7 Houston Methodist Hospital, Department of Otolaryngology, Houston, TX , (United States)
Type
Published Article
Journal
Frontiers in Endocrinology
Publisher
Frontiers Media SA
Publication Date
May 29, 2020
Volume
11
Identifiers
DOI: 10.3389/fendo.2020.00350
PMID: 32547497
PMCID: PMC7272571
Source
PubMed Central
Keywords
License
Unknown

Abstract

Background: Hypophysitis is primary or idiopathic or secondary to another disease process. The histologic subtypes of hypophysitis are lymphocytic, granulomatous, xanthomatous, xanthogranulomatous, or IgG4-related. Granulomatous hypophysitis is the second most common form and is characterized by multinucleated giant cells with granulomas and histiocytes. It can be idiopathic or secondary to another process such as infection, sarcoidosis, vasculitis, dendritic cell disorders, Crohn's disease (CD) or a reaction to rupture of a Rathke's cyst or pituitary adenoma. We present a case of granulomatous hypophysitis in a patient with CD who had resistance to corticosteroids but a dramatic response to immunosuppressive therapy with anti-tumor necrosis factor (TNF)-α therapy. Case description: A 43-year-old woman with a 9-year history of ileal and colonic CD presented to the Pituitary Center with headaches, visual disturbance, fatigue, nausea, and secondary amenorrhea. She was not on active therapy for her CD at the time of presentation and had no gastrointestinal symptoms. Hormonal evaluation revealed hyperprolactinemia, secondary hypothyroidism and adrenal insufficiency. MRI revealed a 12 × 12 × 19 mm sellar lesion abutting the optic chiasm, reported as a macroadenoma. The patient underwent endoscopic transsphenoidal biopsy of the pituitary mass. Pathology revealed granulomatous hypophysitis. Evaluation for secondary causes of hypophysitis, apart from CD, was negative. Despite a course of high dose prednisone, her symptoms and MRI findings worsened and she developed symptoms consistent with diabetes insipidus. Using a personalized medicine approach, she was started on anti-(TNF)-α therapy with infliximab combined with azathioprine, which are indicated for treatment of CD. Her headaches and polyuria resolved and her menstrual cycles resumed. MRI at 3 months and more than 1.5 years after initiation of anti-TNF-α therapy revealed durable resolution of the pituitary mass. Conclusion: To our knowledge, this is the first report of successful use of anti-TNF-α therapy for a patient with granulomatous hypophysitis, in this case associated with a previous diagnosis of CD. Although glucocorticoids are used frequently as first-line therapy for primary hypophysitis, granulomatous hypophysitis can be corticosteroid resistant and other immunosuppressive approaches may need to be considered within the context of the patient.

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