What a headache! The Difficulties of Diagnosis and Management of Pituitary Masses in Pregnancy

Transcription

1 What a headache! The Difficulties of Diagnosis and Management of Pituitary Masses in Pregnancy Dr Kelly Carruthers Endocrinology Advanced Trainee Royal Brisbane and Women s Hospital Brisbane, Queensland

2 Declaration of Interests Nil

3 Case 26 yr old woman 28 weeks gestation, G 1 P 0 Presented to Emergency Department 5 day history of bifrontal headache and visual loss

4 History Past Medical History BMI 36 Medications Nil regular Family History Mother Graves Disease

5 Examination Normal examination: Cardiovascular Respiratory Neurological No evidence clinically of Cushing s disease or acromegaly

6 Eye Examination Right Eye Left Eye Visual Acuity 6/5 6/60 6/36 (pinhole) Ishihara Colour Plates 13/15 8/15 Visual Field Index Extraocular movements 96% - patchy changes Normal 80% - L hemitemporal loss Normal Papilloedema Nil Nil

7 Visual Fields Left Right

8 Anterior Pituitary Function Bloods taken at 8am

9 Initial Imaging MRI Brain (T1) Non contrast Ht 15mm Coronal

10 Initial Imaging MRI Brain (T1) Non contrast Sagittal

11 Case Discussion What is the likely diagnosis? How would you treat her?

12 Initial Treatment Endocrinology consult: Cortisone acetate 25mg BD Thyroxine 100μg daily Bromocriptine 2.5mg BD Obstetric management: Betamethasone 11.4mg daily for 2 days (Equivalent to prednisolone 100mg)

13 Progress 24 hours post corticosteroids and bromocriptine Headache completely resolved Vision improved Right Eye Left Eye Visual Acuity 6/5 6/12 Visual Field Index 98% 91%

14 Provisional Diagnosis Autoimmune hypophysitis: Clinical presentation in pregnancy MRI appearance and biochemical findings Response to glucocorticoids Treatment Bromocriptine ceased Prednisolone 25mg commenced

15 Further Progress Prednisolone weaned over 4 weeks to 10mg Left sided visual changes recurred Right Eye Left Eye Visual Acuity 6/5 6/36 Visual Field Index 98% 79% - left temporal visual field defect

16 Further Progress Prednisolone weaned over 4 weeks to 10mg Left sided visual changes recurred Right Eye Left Eye Visual Acuity 6/5 6/36 Visual Field Index 98% 79% - left temporal visual field defect Recommenced 25mg prednisolone with resolution of symptoms once again

17 Peripartum Management Birth of baby girl (39+5 weeks gestation) Spontaneous vaginal delivery with no complications Prednisolone 25mg orally Hydrocortisone 50mg x2 IV during labour

18 Discharge from Obstetric Ward Endocrinology plan: Prednisolone 25mg (with plan to wean) Thyroxine 100μg MRI scan postpartum Review of biochemistry at 6 weeks

19 6 Week Post Partum Review Off prednisolone, on thyroxine 100μg Unable to breastfeed Denied symptoms of cortisol deficiency Denied headache or visual symptoms Right Eye Left Eye Visual Acuity 6/5 6/5 Visual Field Index 100% 96%

20 Anterior Pituitary Function

21 MRI Pituitary - Coronal 2 weeks PP 10 weeks PP

22 MRI Pituitary - Coronal 2 weeks PP 10 weeks PP Ht = 12.6mm Ht = 8.2mm

23 MRI Pituitary - Sagittal 2 weeks PP 10 weeks PP

24 Autoimmune Hypophysitis (AH) Annual incidence 1 : 7-9 million Presentation: headache and visual changes Often presents in pregnancy or post partum Associated with other autoimmune conditions: Autoimmune thyroid disease Recurrent optic neuritis IgG4-related systemic disease Iuliano, SL. & Laws, ER. (2011)

25 Autoimmune Hypophysitis Most involve anterior pituitary alone (65%) Anterior and posterior pituitary (25%) or posterior pituitary alone rare Incidence of anterior pituitary dysfunction ACTH > TSH > LH/FSH = Prolactin Mainstay of treatment is glucocorticoids Steroid sparing agents have been used Iuliano, SL. & Laws, ER. (2011)

26 Clinical Questions Why does AH occur in pregnancy? Should AH be diagnosed without surgical biopsy? What is the prognosis of AH? Can AH recur in future pregnancies?

27 AH and pregnancy

28 Association with pregnancy 69% of women with AH age yrs present in pregnancy or post-partum Caturegli et al (2005) Landek-Salgado et al (2010)

29 Pathogenesis Immune tolerance in pregnancy is selective and transient Inconsistent effects on autoimmune diseases Why AH worsens in pregnancy is unknown

30 1) Molecular Mimicry Autoantigen expressed in pituitary gland and placenta Multiple target antigens proposed Gamma-Enolase Peptide (KDLEEGIQTLMGRL) Pituitary gland-specific factors 1a and 2 Seratogranin II Alpha-Enolase Landek-Salgado et al (2010) Lupi et al (2008)

31 Gamma-Enolase Isoenzyme Involved in glycolysis Expressed: Neuronal tissue/neuroendocrine cells: Hypothalamus Pituitary Placenta Localised in syncytiotrophoblasts exposed to mother s systemic immune system O Dwyer et al (2002)

32 Peptide (KDLEEGIQTLMGRL) Found in pituitary growth hormone and chorionic somatomammotropins (CSHs) CSH at highest concentration at end of pregnancy Possible immune recognition of CSH spreads during pregnancy to GH1 Recognized by serum of AH patients but not controls Lupi et al. (2008)

33 2) Exposure to systemic immunity Increased estrogen leads to changes in blood supply Caturegli et al (2005)

34 2) Exposure to systemic immunity Hyperplasia of lactotrophs Increase release of pituitary antigens Increased antigen exposure to the systemic immune system

35 Diagnosis of AH

36 Diagnosis of AH Histological diagnosis Risks of surgery Risk of transsphenoidal surgery Bleeding, cerebrospinal fluid leaks, diabetes inspidius Anaesthetic risk in pregnancy Teratogenic risk especially 1st trimester Premature delivery, intrauterine growth restriction, intrauterine death Mazze RI, Källén B. (1989)

37 Pituitary antibodies (APA) In diagnosis of AH: Sensitivity: poor (26 67%) Specificity: poor Associated with other pituitary diseases Non pituitary autoimmune diseases Caturegli et al (2005) Landek-Salgado et al (2010)

38 Pituitary antibodies (APA) Prognostic utility: 199 patients with autoimmune polyendocrine syndromes and no pre-existing pituitary dysfunction followed for 5 yrs 19% of APA positive patients developed hypopituitarism 0% of APA negative group Bellastella et al (2010)

39 Radiological Diagnosis Case-control study Pre-surgical pituitary MRI and clinical features 302 patients with AH 98 with non-secreting pituitary macroadenomas Gutenberg et al (2009)

40 Diagnostic Score Gutenberg et al (2009)

41 Interpretation Score <1 favours AH Sensitivity 92% Specificity 99% Positive predictive value 97% Negative predictive value 97% Gutenberg et al (2009)

42 Diagnostic Score Gutenberg et al (2009)

43 Prognosis

44 Obstetric outcomes No known increased risk to fetus or complications in labour Risk of glucocorticoids in pregnancy Prednisone, prednisolone, methylprednisolone preferred due to placental metabolism Maternal risks: Premature rupture of membranes, weight gain, exacerbation GDM, hypertension Foetal risks: Neonatal hypoadrenalism Caturegli et al (2005) Janssen, NM. & Genta, MS. (2000)

45 Long term outcome Follow up of 320 cases: Less than 1 year to 11 years 73% required long term replacement 1 hormone 16% resolved with no long term replacement required 3% resolved spontaneously with no treatment 8% died, thought to be due to unrecognised steroid deficiency Caturegli et al (2005)

46 Recurrence in future pregnancies

47 Risk in future pregnancies Scant literature 16 case reports of women with further pregnancy without recurrence of symptoms At least one case report of recurrence Developed AH first pregnancy (week 32) Recurred second pregnancy (week 16) Caturegli et al (2005) Sinha et al (2006)

48 Take Home Messages AH is a rare autoimmune disorder occurring in pregnancy or immediately post partum The pathogenesis is still unknown In a typical presentation, a presumptive diagnosis may be made without histology Most patients will require long term hormone replacement Recurrence is rare

49 References Abbassi-Ghanavati, M. Greer, LG. Cunningham, FG. (2009) Pregnancy and laboratory studies: a reference table for clinicians. Obstetrics and Gynaecology. 114 (16): Dinc, H. Esen, F. Demirci, A. Saril, A. & Gumelel HR (1998) Pituitary dimensions and volume measurements in pregnancy and post partum. Acta Radiologica, 39 (1): Iuliano, SL. & Laws, ER. (2011) The diagnosis and management of lymphocytic hypophysitis. Expert reviews in Endocrinology and Metabolism. 6 (60): Caturegli, P. Newschaffer, C. Olivi, A. Pomper, MG. Burger, PC & Rose, NR.(2005) Autoimmune Hypophysitis. Endocrine Reviews, 26(5): Crock, PA (1998) Cytosolic autoantigens in lymphocytic hypophysitis. Journal of Clinical Endocrinology and Metabolism. 83: Landek-Salgado, MA. Gutenberg, A. Lupi, I. Kimura, H. Mariotti, S. Rose, NR. & Caturegli, P. (2010) Pregnancy, postpartum autoimmune thyroiditis, and autoimmune hypophysitis: Intimate relationships. Autoimmunity Reviews, 9: Lupi, I. Broman, KW. Tzou, S. Gutenberg, A. Martino, E & Caturegli, P (2008) Novel autoantigens in autoimmune hypophysitis, Clinical Endocrinology. 69 (6): O Dwyer, DT. Clinton, V. Hall, A. Smith, R. Robinson, PJ, Crock PA. (2002) Pituitary autoantibodies in lymphocytic hypophysitis target both gamma and alpha enolase a link with pregnancy? Archives of Physiology and Biochemistry. 110: 94:98

50 References Mazze, RI, Källén, B. (1989) Reproductive outcome after anesthesia and operation during pregnancy: a registry study of 5405 cases. American Journal of Obstetrics and Gynecololgy 161(5): Carmichael, JD. (2012) Update on the diagnosis and management of hypophysitis. Current Opinion in Endocrinology, Diabetes & Obesity. 19: Bellastella, G. Rotondi, M. & Pane E (2010) Predictive role of immunostaining pattern of immunofluorescence and the titres of APA. Journal of Clinical Endocrinology and Metabolism. 95: Gutenberg, A. Larsen, J. Lupi, I. Rohde, V. & Caturegli, P (2009) A radiologic score to distinguish autoimmune hypophysitis from nonsecreting pituitary adenoma preoperatively. American Journal of Neuroradiology, 30: Howlett, TA, Levy, MJ & Robertson, IJ (2010) How reliably can autoimmune hypophysitis be diagnosed without pituitary biopsy. Clinical Endocrinology 73: Janssen, NM. & Genta, MS. (2000) The effects of immunosuppressive and antiinflammatory medications on fertility, pregnancy, and lactation. Archives of Internal Medicine. 160(5): Sinha, d. Sinha, A. & Pirie, AM (2006) A case of recurrent lymphocytic hypophysitis in pregnancy. Journal of Obstetrics and Gynaecology 26(3):

51 Acknowledgements A/Prof Michael d Emden A/Prof Emma Duncan Dr Amanda Love Drs Dev Kevat and Geoff Fanning

52 MRI Pituitary 2 weeks Post Partum Coronal

53 Potential Steroid Sparing Agents Recurrence or side effects from long term high dose glucocorticoids Azathioprine most common in literature (6 cases) Mixed results, one episode hepatotoxicity Safe in pregnancy and breastfeeding Other agents Methotrexate, cyclosporin, rituximab Stereotactic radiation Carmichael (2012)