lymphocytic hypophysitis
Introduction
Introduction to lymphocytic pituitary In 1962, Goudie and Pinkerton reported a 22-year-old female patient with both pituitary and Hashimoto's thyroiditis. In the future, many scholars have reported several cases, which are characterized by pituitary gland inflammation with hypopituitarism. The histological features of these cases are diffuse lymphocytic infiltration of the pituitary gland, hence the name lymphocyticadenohypophysitis. Later studies have shown that these inflammatory lesions may also involve the pituitary gland and pituitary stalk, called lymphocytes. The clinical fungal neurohypophysitis (lymphocyticinfundibuloneurohypophysitis) is mainly characterized by central diabetes insipidus. If the lesion involves the entire pituitary, it is called lymphocytic hypophysitis. basic knowledge The proportion of illness: 0.005% Susceptible people: no specific population Mode of infection: non-infectious Complications: Diabetes insipidus
Cause
Cause of lymphocytic pituitary
(1) Causes of the disease
The etiology of this disease has not been fully elucidated. Because of the obvious lymphocytic infiltration in the pathological pituitary, anti-pituitary antibodies can be detected in some patients' blood. Therefore, it is believed that this disease may be caused by autoimmunity, but the detection of anti-pituitary antibodies is detected. The rate is not high, late, Hashimoto and other analysis of 124 cases of lymphocytic pituitary gland inflammation reported in the literature from 1962 to 1995 (100 cases confirmed by pathology), only 7 cases of anti-pituitary antibody positive, anti-pituitary antibody positive rate Low is not sensitive enough to the detection method (immunofluorescence) used. In addition, many patients have autoimmune inflammation of other endocrine glands, which also supports the view that the disease is caused by autoimmunity.
The reason for autoimmunity is still not very clear. Since most patients are pregnant or postpartum women, some scholars believe that autoimmunity may be related to pregnancy. Pituitary enlargement during pregnancy (especially late pregnancy) and blood supply increase It is prone to some minor damage, so that the pituitary antigen is exposed; in addition, pregnancy can also cause changes in the body's immune status, making the body prone to autoimmune reactions, and other autoimmune endocrine diseases (such as silent thyroiditis). It is related to the idea that pregnancy is related to autoimmunity during pregnancy. It has been reported that this disease can occur after intracranial virus infection, so the autoimmune response of this disease may also be related to viral infection.
At present, the nature of the autoantigen that causes the autoimmune response of the pituitary is unclear. Crock et al. detected an antibody against the 49KDa pituitary protein in lymphocytic pituitaryitis. What is the 49KDa antigen is not clear at present, in addition, The autoantibodies of lymphocytic pituitary gland and autoantibodies of lymphocytic fungal neurohypophysitis are also different, the former is mainly for pituitary cells, and the latter is for cells secreting vasopressin.
(two) pathogenesis
The pathogenesis of this disease is still unclear. According to literature analysis, most authors believe that it is an autoimmune disease. Because women have hypertrophy and hypertrophy in the pituitary during pregnancy, the pituitary gland gradually shrinks after birth, releasing a large number of pituitary antigens and promoting autoimmunity. Reaction, lymphocytes infiltrate the pituitary; cause pituitary tissue destruction. In addition, Vanneste has reported a case of a 49-year-old woman who developed hypopituitarism after viral meningitis. After 1 year, surgery confirmed that the lymphatics directly infect the pituitary gland. There are many medical records of this disease that occur simultaneously with other immune diseases, and it is likely to be related to genetic factors.
Prevention
Lymphocytic pituitaryitis prevention
In addition to medical treatment, Chinese medicine also emphasizes mental adjustment, reasonable arrangement of life and work, and reasonable diet is also very important. If you have symptoms of hyperthyroidism, you should eat light, eat fresh vegetables, fruits and nutritious lean meat, chicken, duck, turtle, freshwater fish, mushrooms, white fungus, lily, mulberry and other foods. . Do not eat hot or irritating foods such as iodine, pepper, lamb, tea, coffee, etc. In the case of hypothyroidism, in addition to avoiding iodine, it is advisable to eat fresh vegetables and fruits with high vitamins, and also eat shrimp, sea cucumber, walnut meat, hazelnuts, yam, medlar and other foods.
Complication
Lymphocytic pituitary complication Complications diabetes insipidus
Diabetes insipidus can occur if the lesion invades the hypothalamus.
Symptom
Lymphocytic pituitary symptoms Symptoms Weak thyroid function, low amenorrhea, edema, lethargy, hair loss, erythrocyte sedimentation
More common in women within 1 year of pregnancy, but also in the postmenopausal period, early clinical manifestations are more concealed, with the development of the disease, clinical manifestations are similar to pituitary non-functional tumors.
1. Pituitary hypofunction: This is the most common and most important clinical manifestation of lymphocytic pituitary inflammation. Patients often have fatigue, lethargy, obesity, hair loss, impotence, amenorrhea and other symptoms, including hypothyroidism and adrenal function. Its more common.
2. galactorrhea: not rare, probably due to:
1 Lymphocytes proliferate, infiltrate, and compress the pituitary stalk in the pituitary gland, so that the prolactin inhibitor (PIF) produced by the hypothalamus can not reach the pituitary, which promotes the increase of PRL secretion.
2 autoantibodies stimulate PRL cells and promote the secretion of PRI.
3. Symptoms like "pituitary tumor" such as headache, vision, visual field changes, lesion invasion to the jugular sinus, can cause oculomotor nerve paralysis.
The disease lacks specific performance, the diagnosis depends on pathological examination, and the pituitary specimen is difficult to obtain, so it is extremely difficult to confirm the diagnosis. This is the reason why the literature has been reported so far (the estimated missed cases are not rare), the key to avoid missed diagnosis is To improve vigilance, patients with hypoplasia of the pituitary gland with imaging suggestion should think of this disease, such as increased ESR or other autoimmune diseases, it is more supportive of this disease.
Examine
Examination of lymphocytic pituitary
Laboratory examination of the disease shows the characteristics of autoimmune diseases, such as accelerated erythrocyte sedimentation rate, anti-pituitary antibody positive, combined with chronic lymphocytic thyroiditis, anti-thyroglobulin antibody and microsomal and peroxidase antibodies can be positive, sometimes Anti-adrenal antibodies, anti-platelet antibodies, anti-smooth muscle antibodies, anti-mitochondrial antibodies and anti-nuclear antibodies were detected, and the CD8 lymphocyte ratio of blood CD4 lymphocytes was increased.
Endocrine function tests show signs of hypopituitarism and corresponding hypogonadism, but blood prolactin, thyrotropin and growth hormone levels can also be elevated.
The flat film is generally normal. However, the flat plate of the patient with a significant increase in the pituitary can also have a manifestation of increased size of the sella. CT and MRI are important for diagnosis. The CT and MRI of the pituitary are: pituitary enlargement Or pituitary space (can be extended with saddle), thickened pituitary stalk, empty saddle, pituitary cystic lesion, pituitary enlargement or pituitary occupying is the most common imaging change, about 90% of patients, on the saddle The expansion is also quite common (see 60% to 70% of patients), and the pituitary gland is diffusely enlarged. This is different from pituitary adenoma. It has a certain significance for differential diagnosis, and the pituitary stalk is thicker. Most patients with neurohypophysis and funnel involvement, empty saddle and pituitary cystic lesions are more rare, long-term patients may have pituitary atrophy but the saddle is still enlarged, a small number of patients with pituitary CT and MRI examination can be found without abnormalities.
Diagnosis
Diagnosis and differentiation of lymphocytic pituitary
Differential diagnosis
The disease needs to be differentiated from pituitary adenoma, bacterial pituitary inflammation, pituitary hyperplasia, Sheehan syndrome.
1. Pituitary adenoma: Secretory pituitary adenoma has a certain expression of excessive pituitary hormones, which can be differentiated from this disease. PRL tumors in secretory pituitary adenomas are easily confused with this disease, but patients with PRL tumors The increase of blood PRL is more obvious than this disease. The non-functioning pituitary adenoma has no symptoms of excessive pituitary hormone (PRL can be mild to moderately elevated), which is characterized by hypopituitarism, which is very similar to this disease, but has no function. The placental symptoms of pituitary adenoma (headache, vision loss, visual field defect, etc.) are more common and significant than this disease. In addition, the hypoplasia of the pituitary gland caused by non-functional pituitary adenoma is the first and most common gonadotropin reduction, ACTH. And TSH reduction appeared later and less common; pituitary dysfunction caused by lymphocytic pituitary inflammation was first seen in the reduction of ACTH and TSH, and most common, gonadotropin reduction appeared later, and relatively rare, imaging The examination is of great value in the identification of pituitary adenomas and the disease: on CT and MRI, the pituitary gland of the pituitary adenoma is focally enlarged, the disease is diffuse and homogenous; the pituitary adenoma can be There is destruction of the sphenoid bone, the disease is generally No.
2. Bacterial pituitary inflammation: Bacterial pituitary inflammation is extremely rare, which is an acute suppurative infection of the pituitary, caused by the spread of bacterial meningitis (very rarely caused by sepsis), acute onset of bacterial pituitary inflammation, Before the illness, there is a history of purulent meningitis. The systemic symptoms such as fever are obvious, and the blood picture is elevated, which can be differentiated from lymphocytic pituitary gland.
3. Pituitary hyperplasia: Pituitary hyperplasia and lymphocytic pituitary gland are almost indistinguishable in imaging. The clinical manifestations of the two are different. Physiological pituitary hyperplasia (such as pituitary hyperplasia during pregnancy) has no clinical symptoms, and there is no laboratory test. Evidence of hypopituitarism, but blood PRL levels can be slightly elevated; pathological pituitary hyperplasia has a certain increase in pituitary hormones, such as the ability to obtain pituitary tissue for pathological examination, can be decisive identification.
4. Sheehan syndrome: This disease occurs in postpartum, and often has the performance of pituitary dysfunction, should be differentiated from Sheehan syndrome, but patients with Sheehan syndrome have a history of postpartum or postpartum hemorrhage, pituitary imaging can be seen pituitary Atrophy, no headache, visual field defect, visual impairment, etc.
5. Necrotic infundibulohypophysitis: Necrotic fungal pituitary inflammation is a rare disease, with central diabetes insipidus as the main manifestation, necrotic fungal pituitary inflammation, such as involving the pituitary gland, is similar to lymphocytic pituitary inflammation, generally It is necessary to identify the lymphocytic pituitary by means of histological examination. Pituitary imaging examination is also meaningful for differential diagnosis: necrotizing fungal pituitary inflammation has more pituitary stalk thickening, while lymphocytic pituitary sinus pituitary stalk is less thickened. see.
