Case Report
Anterior panhypopituitarism in diffuse large B-cell stage IV lymphoma

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Abstract

The most common presentation of metastases to the pituitary gland in systemic lymphoma is diabetes insipidus resulting from infiltration of the infundibulum/posterior lobe. We describe a 69-year-old man with diffuse large B-cell stage IV lymphoma who presented with anterior pituitary hypofunction, without features of posterior pituitary involvement. He presented with a few months of postural dizziness and hypotension, weight loss, fever, strabismus of right eye and a superficial abdominal wall mass. At this time he had no history of malignancy. Biochemically he had hypovolemic hyponatremia, secondary hypothyroidism and adrenal insufficiency. Further hormonal work-up revealed panhypopituitarism but no diabetes insipidus. Imaging of the brain, thorax and abdomen demonstrated diffuse intracranial pachymeningeal thickening and enhancement, multiple lymphadenopathies, a bulky right adrenal gland and a large left suprarenal mass, which were indicative of an infiltrative disease. Imaging of the pituitary showed heterogeneous enhancement of the anterior lobe with an unremarkable pituitary stalk and posterior lobe. Biopsy of the superficial abdominal wall mass revealed diffuse large B-cell lymphoma confirmed by bone marrow aspiration biopsy. Positron emission tomography (PET) scan confirmed diffuse systemic disease involving the right orbital apex, bilateral adrenal glands, bone and bone marrow, retroperitoneum and subcutaneous tissues; however, the pituitary gland, infundibulum and hypothalamus did not show any lesions on the PET scan. The patient was commenced on two cycles of chemotherapy but unfortunately died, thus recovery of pituitary function was not tested. Pure anterior pituitary hypofunction can uncommonly present in individuals with metastases to the pituitary gland, in contrast to the more common posterior pituitary/infundibulum involvement.

Section snippets

Case report

A 69-year-old man presented with dizziness at the emergency room. He had a history of a few months of weight loss, strabismus of the right eye and a superficial mass on the right upper abdomen. He had fever and postural hypotension. The superficial abdominal wall mass was in the right upper quadrant and approximately 2–3 cm in size, and the patient also had a right third cranial nerve palsy. Initial laboratory work-up showed hyponatremia and anemia with an elevated erythrocyte sedimentation

Discussion

Reports of individuals with metastatic lymphoma of the pituitary gland often describe involvement of the stalk and/or posterior pituitary, or both lobes [1]. In these cases, diabetes insipidus (DI) is the most common clinical manifestation. The posterior lobe is more susceptible to metastases due to its systemic blood supply from the hypophyseal arteries whereas the anterior lobe is nourished by the portal venous system and secondarily by the lower infundibular stem which partly arises from the

Conflicts of Interest/Disclosures

The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.

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