Autoimmune hypophysitis: a case of follow-up during the COVID-19 pandemic period

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Abstract

Hypophysitis is a rare inflammatory disorder that affects the pituitary gland and infundibulum, stems from autoimmune, infiltrative, infectious, or unknown causes. Its clinical diagnosis can be challenging because several pituitary lesions, including adenomas and metastases, may clinically present with similar characteristics. Magnetic resonance imaging is crucial for diagnosing suspected cases of hypophysitis and categorizing them as adenohypophysitis (anterior pituitary gland involvement) or infundibulo-neurohypophysitis (pituitary stalk and posterior pituitary involvement). Hypophysitis can be categorized as primary (autoimmune) or secondary due to local lesions (e.g., granulomas, cysts, adenomas) or systemic diseases (e.g., sarcoidosis, Wegener’s granulomatosis). Different factors may have impact on clinical course of hypophysitis. Among them background treatment. These cases have not been sufficiently studied and are practically not presented in publications.

A 37-year-old female with a history of hyperprolactinemia was being treated symptomatically with cabergoline. At first magnetic resonance imaging heterogeneity of the hypophysis was revealed. In September 2021 the follow-up magnetic resonance imaging revealed an increase in the size and heterogeneity of the pituitary gland. In December 2021, the patient developed severe COVID-19-associated pneumonia and was treated with corticosteroids and oxygen support. In May 2022 magnetic resonance imaging revealed a marked increase in the size and heterogeneity of the pituitary gland. Significant clinical and radiological improvement were stated after adding prednisone (10 mg in the morning and 5 mg in the evening) to her treatment.

The patient was followed-up during the COVID-19 pandemic. The management and imaging studies of such patients may be tricky due to the effects related to COVID-19 and its treatment.

During monitoring of hypophysitis, physicians should consider the impact of COVID-19 treatment, particularly corticosteroid therapy, when evaluating the radiological changes.

About the authors

Evgeniy N. Surovcev

Samara State Medical University; Diagnostic and treatment center of International institution for biological systems named after Sergey Berezin

Email: evgeniisurovcev@mail.ru
ORCID iD: 0000-0002-8236-833X
SPIN-code: 5252-5661

MD, Cand. Sci. (Medicine)

Russian Federation, Samara; Tolyatti

Pavel M. Zelter

Samara State Medical University; Meir Hospital

Email: pzelter@mail.ru
ORCID iD: 0000-0003-1346-5942
SPIN-code: 3678-3932

MD, Cand. Sci. (Medicine)

Russian Federation, Samara; Kfar-Sava, Israel

Aleksandr V. Kapishnikov

Samara State Medical University

Email: a.kapishnikov@gmail.com
ORCID iD: 0000-0002-6858-372X
SPIN-code: 6213-7455

MD, Dr. Sci. (Medicine), Professor

Russian Federation, Samara

Yuliya S. Pyshkina

Samara State Medical University

Author for correspondence.
Email: yu.pyshkina@yandex.ru
ORCID iD: 0000-0002-7241-6828
SPIN-code: 4225-1020

MD, Cand. Sci. (Medicine), Assistant Professor

Russian Federation, Samara

References

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2. Fig. 1. MRI of the pituitary gland that was obtained on May 2, 2020. a) sagittal T1-weighted image, b) coronal T2-weighted image, and с) contrast-enhanced sagittal T1-weighted image. The size of the pituitary gland (*) was normal and slightly heterogeneous.

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3. Fig. 2. MRI of the pituitary gland that was obtained on July 9, 2021. а) sagittal T1-weighted image, b) coronal T2-weighted image, and с) contrast-enhanced sagittal T1-weighted image. Note. There is a moderate increase in the size of the pituitary gland, an increase in the signal intensity in the pituitary gland substance in the T2-weighted images (*), and heterogeneous enhancement in the central region of the gland.

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4. Fig. 3. MRI of the pituitary gland that was obtained on February 4, 2022. а) sagittal T1-weighted image, b) coronal T2-weighted image, and c) contrast-enhanced sagittal T1-weighted image. Note. Progression of the lesion is noted. Thickening of the chiasm (arrows) and infundibulum and increase in the size and structure of the pituitary gland were noted without pronounced dynamics when compared with the imaging study obtained on July 9, 2021.

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5. Fig. 4. MRI of the pituitary gland that was obtained on May 2, 2022. a) sagittal T1-weighted image, b) coronal T2-weighted image, and c) contrast-enhanced sagittal T1-weighted image. The dimensions of the pituitary gland are markedly enlarged (mainly due to the suprasellar component), its structure is heterogeneous, and its contours are uneven. The chiasm is compressed. There is a pronounced uneven thickening of the mucous membrane of the sphenoid sinus, exhibiting increased signal intensity on the T2-weighted image (*).

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6. Fig. 5. MRI of the pituitary gland that was obtained on October 3, 2022. а) sagittal T1-weighted image, b) coronal T2-weighted image, and c) contrast-enhanced sagittal T1-weighted image. The pituitary gland is not enlarged with heterogeneous contrast enhancement in the central regions. The chiasm is thickened, and its structure is moderately heterogeneous. These changes are positive in comparison with the findings of the previous MRI.

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7. Fig. 6. Contrast-enhanced T1-weighted coronal MR images of the pituitary gland obtained on a) May 2, 2020, b) July 9, 2021, c) February 4, 2022, d) May 2, 2022, and e) October 3, 2022. Over 1.5 years, the MRI findings pertaining to the pituitary gland in a patient with autoimmune hypophysitis evolved. First a, then an abrupt The size and heterogeneity of the pituitary gland increased, with the appearance of a non-contrasting area, probably due to necrosis (*). This increase was gradual at first (within 21 months: May 2, 2020 to February 4, 2022) and subsequently rapid (within three months: May 2, 2022 to October 3, 2022). The changes completely disappeared within 5 months after the administration of glucocorticosteroids.

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