Escolar Documentos
Profissional Documentos
Cultura Documentos
DOI 10.1007/s11102-016-0773-7
Abstract
Purpose IgG4-related hypophysitis is a rare disease, with
only 34 cases published in English (2015). Available short
reviews may not present complete details of IgG4-related
hypophysitis. We aimed to survey case reports of IgG4related hypophysitis, including abstracts of scientific
meetings, in English and Japanese.
Methods We searched for information about IgG4-related
hypophysitis in PubMed and Igakuchuozasshi (Japan
Medical Abstracts Society). Among 104 case reports
found, we reviewed 84 fulfilling Leporatis diagnostic
criteria.
Results The mean SD age of onset was 64.2 13.9,
67.5 9.8, and 56.4 18.6 years for all subjects,
men, and women, respectively. Men:women was 2.4:1. On
magnetic resonance imaging, pituitary, stalk, and pituitarystalk mass were observed at frequencies of 14.3, 21.4, and
64.3%, respectively. Manifestations were anterior hypopituitarism in 26.2% (22 cases), central diabetes insipidus in
17.9% (15 cases), and panhypopituitarism in 52.4% (44
cases). The median level of serum IgG4 was 264.5 mg/dL
for all subjects, 405 mg/dL for men, and 226 mg/dL for
women. The mean number of IgG4-related systemic diseases was 2.7 1.5 in all subjects, 3.0 1.5 in men,
and 1.8 1.1 in women. Among the IgG4-related diseases, retroperitoneal fibrosis was the most frequent
(26.2%), followed by salivary gland diseases (25%). Glucocorticoid therapy was generally effective, except for two
cases that received replacement doses. There were significant differences between sexes in terms of age, serum
IgG4 levels, and number of IgG4-related diseases.
Conclusion IgG4-related hypophysitis may have different
clinical characteristics between genders. This survey may
lack some information because the Japanese abstracts did
not contain certain details.
Keywords IgG4-related hypophysitis Hypopituitarism
Diabetes insipidus Pituitary Glucocorticoid
Introduction
Primary hypophysitis is a rare disease; in fact, only 750
cases of primary hypophysitis were published until 2013.
Interestingly, approximately 30% of primary hypophysitis
cases were from Japan [1]. Primary hypophysitis is classified by histologic appearance as lymphocytic, granulomatous, xanthomatous, necrotizing, immunoglobulin G4
(IgG4) plasmacytic, and mixed form. Among these, IgG4related hypophysitis is a particularly rare disease and only
1.3% comprises primary hypophysitis cases.
To the best of our knowledge, only 26 reports on 34
cases of IgG4-related hypophysitis have been published in
English as of 2015 and among these, 14 reports were from
Japan. In general, IgG4-related diseases are known to
likely develop in elderly men. According to a review of 31
published English case reports, the age at onset was
66.3 9.8 years and the ratio of men to women was 9.3:1
[2]. Among all IgG4-related diseases, autoimmune pancreatitis was well-defined with respect to organ-specific
diagnostic criteria. According to a survey on 5475 Japanese
patients, autoimmune pancreatitis, which belongs to the
same disease group as IgG4-related disease, had a mean
123
Pituitary
Diagnostic criteria
Hormone deficiency
English literature
Japanese literature
Abstract
44 reports (57cases)
Duplicated reports
English literature: three reports (12 cases)
Japanese literature: one report (1 case)
40 reports (42cases)
123
Pituitary
Results
This review included 71 reports on 84 cases of IgG4-related hypophysitis (Table 1) [2, 46, 874]. Applying this
review to the guidelines of IgG4-related disease, 37, 14, 21,
and 12 cases were definite, probable, possible, and unknown, respectively.
Patient background
Analysis of the 84 cases showed that the mean SD age at
the time of onset was 64.2 13.9 years; women
(56.4 18.6 years)
were
younger
than
men
(67.5 9.8 years) (Table 3). The ratio of men to women
was 2.4:1.
Pituitary function
Pituitary function was normal in 1 (1.2%) case, but presented with panhypopituitarism in 44 (52.4%), anterior
hypopituitarism in 22 (26.2%), and central diabetes insipidus in 15 (17.9%); data was not available for 2 cases
(2.4%). Analysis of hormone deficiency showed that antidiuretic hormone (ADH) deficiency was the most frequent
type found in 59 cases (70.2%), followed by LH/FSH
deficiency found in 40 cases (47.6%), adrenocorticotropic
hormone deficiency found in 39 cases (46.4%), and growth
hormone and thyroid stimulating hormone deficiency found
in 34 cases (40.5%). Among anterior hypopituitarism,
although various combinations of hormone deficiencies
were observed, only one case showed isolated anterior
pituitary hormone (TSH) deficiency.
MRI of the pituitary
On pituitary MRI, there were 54 cases (64.3%) of both
pituitary gland and stalk enlargements, 18 cases (21.4%) of
stalk enlargement, and 12 cases (14.3%) of pituitary gland
enlargement.
Laboratory findings
In the 84 cases, 61 cases had serum IgG4 level available.
Data for 11 cases was lacking. Seven cases showed elevated, while five cases showed normal (no detailed data
available) serum IgG4 levels. Serum IgG4 level was elevated in 56 cases (seven cases had no detailed data available) and normal in 13 cases (four cases had no detailed
data available). Data on outcomes after steroid
Discussion
IgG4-related disease is a chronic disease with hypertrophic,
massive lesion characterized by elevated serum IgG4 levels
and tissue infiltration of IgG4-positive plasma cells. It
predominantly occurs in elderly men who show a favorable
response to glucocorticoids [7]. Although IgG4-related
hypophysitis is a rare disease, reported cases are increasing
recently.
In this review, we included 84 cases of IgG4-related
hypophysitis that were reported in publications and
abstracts of scientific meetings in both English and
123
123
61
73
20
21
60
71
78
71
73
63
67
74
57
26
27
28
29
30
31
32
33
34
71
55
24
25
73
81
19
75
68
18
22
74
17
23
72
70
74
70
13
14
15
49
12
16
77
11
59
70
62
77
55
10
62
M
M
F
M
70
67
Sex
66
71
Age
No
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
Anterior
hypopituitarism
Pituitary function
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
DI
Pituitary mass
Stalk
Stalk
Stalk
Stalk
Stalk
Stalk
Stalk
Stalk
Stalk
Stalk
Pituitary mass
Stalk
Pituitary mass
MRI
212
Normal
Normal
295
203
194
143
240
2620
127*
169
nd
nd
Elevated
1980
376
151
170
924
229
115*
nd
nd
1950
949
111
229
292
1860
720
Elevated
2220
405
485
IgG4
2
2
0
0
IgG4 related
disease
Number of other
?
?
Pituitary
Biopsy
Other
organ
References
Pituitary
53
68
58
76
53
46
38
57
32
52
53
54
55
56
57
58
59
60
69
70
73
66
68
72
65
67
70
85
63
64
25
67
51
37
76
50
61
58
62
25
49
68
66
44
45
48
52
43
55
68
42
40
80
41
46
47
40
47
78
75
37
70
72
36
38
82
35
39
Age
No
Table 1 continued
F
F
M
M
Sex
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
Normal
nd
AF
AF
AF
AF
nd
AF
AF
AF
Anterior
hypopituitarism
Pituitary function
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
Normal
nd
AF
nd
AF
AF
AF
AF
DI
Stalk
Pituitary mass
Stalk pituitary mass
Pituitary mass
Stalk
Stalk
Pituitary mass
MRI
722
226
153
106
244
300
nd
nd
Elevated
205
Normal
nd
24.5
513
405
16.9
16.9
82.5
2100
1250
Normal
413
1010
202
nd
423
226
296
317
203
143
87
181
194
IgG4
1
2
2
5
IgG4 related
disease
Number of other
?
?
Pituitary
Biopsy
?
-
?
?
Other
organ
References
Pituitary
123
123
81
72
72
73
75
84
F
M
Sex
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
Anterior
hypopituitarism
Pituitary function
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
DI
Stalk
Stalk
Pituitary mass
Pituitary mass
Stalk
Pituitary mass
Pituitary mass
Stalk
Pituitary mass
Pituitary mass
MRI
AF Affected function, nd not described, DI diabetes insipidus; measured after steroid therapy
55
38
81
73
43
80
82
32
72
78
79
83
87
38
76
77
62
71
71
73
69
70
74
76
69
75
Age
No
Table 1 continued
298
Elevated
95
377
79.2
nd
853
Normal*
285
Elevated
1500
Elevated
333*
nd
Elevated
Elevated
IgG4
0
1
nd
IgG4 related
disease
Number of other
?
-
Pituitary
Biopsy
Other
organ
Jo et al. [65]
References
Pituitary
Pituitary
Table 2 Other IgG4-related
systemic diseases
Number of cases
Frequency (%)
Retroperitoneal fibrosis
Mikuliczs disease, Kuttners tumor
22
26.2
21
25.0
20
23.8
17
20.2
Autoimmune pancreatitis
12
14.3
10
11.9
Hypertrophic pachymeningitis
8.3
8.3
3.6
2.4
Sclerosing cholangitis
2.4
Riedels thyroiditis
1.2
Inflammatory aneurism
1.2
1.2
Iliopsoas muscle
Prostatitis
1
1
1.2
1.2
Men
Women
p value
67.5 9.8
56.4 18.6
0.018
405 (24.52620)
226 (16.9485)
0.028
3.0 1.5
1.8 1.1
\0.001
123
Pituitary
4.
5.
6.
7.
8.
Limitation
In this report, we reviewed cases of IgG4-related
hypophysitis in 26 English publications, 13 Japanese publications, and 36 Japanese abstracts of scientific meetings.
This survey may lack some information because Japanese
abstracts did not contain certain details.
9.
10.
11.
Conclusion
12.
13.
14.
References
1. Patrizio C, Shintaro I (2013) From japan with love: another tessera in the hypophysitis mosaic. J Clin Endocrinol Metab
98:18651868
2. Iseda I, Hida K, Tone A, Tenta M, Shibata Y, Matsuo K,
Yamadori I, Hashimoto K (2014) Prednisolone markedly reduced
serum IgG4 levels along with the improvement of pituitary mass
and anterior pituitary function in a patient with IgG4-related
infundibulo-hypophysitis. Endocr J 61:195203
3. Kanno A, Masamune A, Okazaki K, Kamisawa T, Kawa S,
Nishimori I, Tsuji I, Shimosegawa T (2015) Research committee
123
16.
17.
18.
19.
of intractable disease of the pancreas.: nationwide epidemiological survey of autoimmune pancreatitis in Japan in 2011. Pancreas
44:535539
Leporati P, Landek-Salgado MA, Lupi I, Chiovato L, Caturegli P
(2011) IgG4-related hypophysitis: a new addition to the
hypophysitis spectrum. J. Clin. Endocr. Metab. 96:19711980
van der Vliet HJ, Perenboom RM (2004) Multiple pseudotumors
in IgG4-associated multifocal systemic fibrosis. Ann Intern Med
141:896897
Wong S, Lam WY, Wong WK, Lee KC (2007) Hypophysitis
presented as inflammatory pseudotumor in immunoglobulin G4related systemic disease. Hum Pathol 38:17201723
Shimatsu A, Oki Y, Fujisawa I, Sano T (2009) Pituitary and stalk
lesions (infundibulo-hypophysitis) associated with immunoglobulin G4-related systemic disease: an emerging clinical entity.
Endocr J 56:10331041
Tanabe T, Tsushima K, Yasuo M, Urushihata K, Hanaoka M,
Koizumi T, Fujimoto K, Kubo K, Uehara T, Shigematsu S,
Hamano H, Kawa S (2006) IgG4-associated multifocal systemic
fibrosis complicating sclerosing sialadenitis, hypophysitis, and
retroperitoneal fibrosis, but lacking pancreatic involvement.
Intern Med 45:12431247
Yamamoto M, Takahashi H, Ohara M, Suzuki C, Naishiro Y,
Yamamoto H, Shinomura Y, Imai K (2006) A case of Mikuliczs
disease (IgG4-related plasmacytic disease) complicated by
autoimmune hypophysitis. Scand J Rheumatol 35:410411
Ralli S, Lin J, Farrell J (2007) Autoimmune pancreatitis. N. Engl.
J. Med. 356:1586
Isaka Y, Yoshioka K, Nishio M, Yamagami K, Konishi Y, Inoue
T, Hirano A, Hosoi M, Imanishi M (2008) A case of IgG4-related
multifocal fibrosclerosis complicated by central diabetes insipidus. Endocr J 55:723728
Tsuboi H, Inokuma S, Setoguchi K, Shuji S, Hagino N, Tanaka
Y, Yoshida N, Hishima T, Kamisawa T (2008) Inflammatory
pseudotumors in multiple organs associated with elevated serum
IgG4 level: recovery by only a small replacement dose of steroid.
Intern Med 47:11391142
Uehara K, Atumi H, Nakagawa J, Tachibana O, Kurose N,
Nishizawa M, Fujii M, Furuya K, Tsuda S, Ito T, Nojima T,
Iizuka H, Koya D (2008) A case of IgG4-related hypophysitis
occured with partial diabetes inspidus and hypertrophic pachymeningitis. Nihon Naibunpi Gakkai Zasshi 84:825 (Absract; in
Japanese)
Taji K, Takamura T, Mouri K, Kawano M, Akahori H, Ishikura
K, Takeshita Y, Goren H, Kawano M, Takamura T, Hayashi Y,
Hayashi Y, Hamada J (2009) A male case of lymphocytic
hypophysitis in the course of IgG4-related disease. Nihon Naibunpi Gakkai Zasshi 85:4244 (Absract; in Japanese)
Ando T, Hori S, Makita N, Takiyama H, Yajima Y, Sakatani T,
Fukumoto S, Fujita T (2009) A case of multifocal IgG4-related
systemic disease manifested as a hypophysitis, after 15 years
onset of Mikulicz disease,autoimmune hepatitis and intestitial
pneumonitis. In: The 564th Kanto Regional Meeting of Japan
Society of Internal Medicine, p 21 (Absract; in Japanese)
Takeuchi S, Takeuchi A, Takakuwa M, Akahane K, Shinoda J
(2009) A case of IgG4-related hypophysitis with multiple lesions.
Nihon Naibunpi Gakkai Zasshi 85:324 (in Japanese)
Fujisawa I (2009) Imaging diagnosis of lymphocytic hypophysitis
and diencephalohypophysial IgG4-related disease. Folia Endocrinol Jpn 85:5455 (in Japanese)
Osawa S, Ogawa Y, Watanabe M, Tominaga T (2009)
Hypophysitis presenting with atypical rapid deterioration: with
special reference to immunoglobulin G4-related disease-case
report. Neurol Med Chir 49:622625
Kinoshita M, Meguro F, Kato T, Tuchida T, Baba S, Miyagi Y,
Tokuyama T, Yokota N, Namba H, Oki T (2009) A case of IgG4-
Pituitary
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
123
Pituitary
50. Kajimoto T, Hayashi R, Sawamura M, Ohya K, Hirao R,
Sachihara H (2014) A case of IgG4-related hypophysitis associated with type1 diabetes. Nihon Naibunpi Gakkai Zasshi 90:337
(Absract; in Japanese)
51. Tochiya M, Inagaki T, Ito T, Kobauashi T, Sato T, Kakiya S,
Nagatani T, Arima H, Nakamura H, Tatematsu A (2014) A case
of IgG4-related hypophysitis associated with Rathke cleft cyst
involuted by a small dose of steroid therapy. Nihon Naibunpi
Gakkai Zasshi 90:367 (Abstract; in Japanese)
52. Goda M, Naito K, Fujii T, Shimada A, Abe K, Takeda N (2014)
A case of IgG4-related hypophysitis. Nihon Jibiinkoka Gakkai
Kaihou 117:541 (Abstract; in Japanese)
53. Sakai T, Kondo M, Yui S, Tomimoto H (2014) IgG4-related
disease that presented cranial, cervical, lumbar and sacral
hypertrophic pachymeningitis associated with infundibulo-hypophysitis. Rinsho Shinkeigaku 54:664667 (in Japanese)
54. Sosa GA, Bell S, Christiansen SB, Pietrani M, Glerean M, Loto
M, Lovazzano S, Carrizo A, Ajler P, Day PF (2014) Histologically confirmed isolated IgG4-related hypophysitis: two case
reports in young women. Endocrinol Diabetes Metab Case Rep.
doi:10.1530/EDM-14-0062
55. Ohkubo Y, Sekido T, Takeshige K, Ishii H, Takei M, Nishio S,
Yamazaki M, Komatsu M, Kawa S, Suzuki S (2014) Occurrence
of IgG4-ralated hypophysitis lacking IgG4-bearing plasma cell
infiltration during steroid therapy. Intern Med J 53:753757
56. Masaki T, Yamagishi T, Shichiri M, Takano K, Kamata Y,
Ichikawa R, Ogawa J, Kishihara E, Kaise A, Sasaki S (2014) A
case of IgG4-related hypophysitis associated with aortitis diagnosed by persistent disturbance of consciousness. Nihon Naibunpi Gakkai Zasshi 90:922 (Absract; in Japanese)
57. Kikuno S, Nagai M, Hayashi K, Suzuki N, Takeshita A, Ishita N,
Fukuhara N, Nishioka H, Yamada S, Takeuchi Y (2014) A case
of IgG4-related hypophysitis infiltrated only posterior lobe.
Nihon Naibunpi Gakkai Zasshi 90:922 (Absract; in Japanese)
58. Takahashi M, Takei S, Kawamata R, Takei G, Saito S, Sekizawa
D, Nagashima S, Okada K, Komatsu K, Nagasaka S, Ishibashi S
(2014) A case of suspected IgG4-related hypophysitis associated
with retroperitoneal fibrosis. Nihon Naibunpi Gakkai Zasshi
90:922 (Absract; in Japanese)
59. Kaneko C, Yamamoto H, Shigeta M, Oguro H, Kitaoka M (2014)
Two cases of IgG4-related hypophysitis diagnosed by secondory
adrenal insufficiency. Nihon Naibunpi Gakkai Zasshi 90:922
(Absract; in Japanese)
60. Ohno Y, Yasoda A, Fujii H, Hatachi Y, Matuo K, Kanai Y, Taura
D, Ogura M, Sone M, Inagaki N (2014) A case of suspeceted
IgG4-related hypophysitis. Nihon Naibunpi Gakkai Zasshi
90:921 (Absract; in Japanese)
61. Yamashita Y, Kondo T, Ohguro Y, Kurahashi S, Tamaki N, Aki
N, Kuroda A, Endo I, Kuriihara K, Matsuhisa M, Mtsumoto T
(2014) A case of IgG4-related hypophysitis diagnosed by
hypercarcemia. Nihon Naibunpi Gakkai Zasshi 90:922 (Absract;
in Japanese)
123