A 28-year-old man noticed the decreased visual acuity of both eyes and visited our institution. Since he was diagnosed as visual disturbance and brain computer tomography (CT) showed a mass in the pituitary fossa, he was hospitalized in our institution. On admission, his height and body weight were 171.4 cm and 83.7 kg. Blood pressure and heart rate were 113/63 mmHg and 63 bpm. Vision: (right) 30 cm manual valve, (left) 0.06. Field-of-view range: (right) nasal hemianopia, (left) normal. In contrast-enhanced brain magnetic resonance imaging (MRI), suspected neoplastic lesion was observed in the pituitary fossa (Fig.
1 A). Its maximal diameter was approximately 50 mm. It was a mixture of solid and cystic lesion which seemed to be hematoma. Invasion of the cavernous sinus and compression of the optic nerve were confirmed. In addition, large elastic mass was palpable in right cervical region, and the mass was isoechoic in neck ultrasonography (Fig.
1B). Intact-parathyroid hormone (PTH) level was high (273 pg/mL) and hypercalcemia (Ca, 12.1 mg/dL) were observed. Hyperprolactinemia (prolactin, 3,794.0 ng/mL) (normal range: 4.29–13.69 ng/mL) was also observed. Other endocrine hormone levels were within normal range as follows: ACTH, 59.9 pg/mL (7–63 pg/mL); cortisol, 13.5 µg/dL (7.07–19.6 mg/dL); DHEA-S, 388 µg/dL (85–690 mg/dL); GH, 0.08 ng/mL (0-2.47 ng/mL); IGF-1, 177 ng/mL (114–315 ng/mL); TSH, 1.90 µIU/mL (0.5-5.0 mIU/mL); FT3, 3.12 pg/mL (2.3–4.3 pg/mL); FT4, 0.52 ng/dL (0.9–1.7 ng/dL); LH, 0.8 mIU/mL (0.79–5.72 mIU/mL); FSH, 2.0 mIU/mL (2.0-8.3 mIU/mL); testosterone, 0.34 ng/mL (1.31–8.71 ng/mL). Hepatic dysfunction and dyslipidemia were observed: AST, 53 U/L; ALT, 102 U/L, γ-GTP, 69 U/L; LDL cholesterol, 145 mg/dL; HDL cholesterol, 44 mg/dL; triglycerides, 355 mg/dL. Neck ultrasonography showed two parathyroid tumors which maximal diameters were 38 mm and 14 mm, respectively (Fig.
1 C). In
99mTc methoxyisobutylisonitrile (MIBI) scintigraphy, MIBC accumulation was observed in the neck lesion at 15 min and at 2 h which was thought to be the accumulation in the parathyroid lesion (Fig.
2 A). Furthermore, contrast-enhanced abdominal computer tomography (CT) showed a small tumor in the pancreas head (diameter: 5 mm) and multiple fat density lesions in the whole pancreas (Fig.
2B). These lesions were thought to be multiple abnormal fatty deposits in the pancreas. Various pancreatic hormone levels were almost within normal range as follows: glucagon, 137 pg/mL (reference range: 70–174 pg/mL); gastrin, 213 pg/mL (30–200 pg/mL); insulin, 18.4 µU/mL (2.2–12.4 µU/mL); trypsin, 340 ng/mL (100–550 ng/mL).
Based on these findings, we diagnosed this subject with MEN1 accompanied by pituitary neoplasia, primary hyperparathyroidism, a giant cervical lipoma and multiple abnormal fatty deposits in the pancreas. Cervical lipoma is considered as a cutaneous manifestation of the disease. Endoscopic trans-sphenoidal hypophysectomy was performed, and the treatment with carbergoline (1 mg/week) was performed for size reduction of residual pituitary tumor and the control of hyperprolactinemia. Such trans-sphenoidal intervention on the pituitary gland promptly resolved his visual disturbance. After then, prolactin level was gradually decreased to approximately 500 ng/mL, and there was no progression of pancreatic lesions in follow-up CT. After then, total parathyroidectomy with auto-transplantation and resection of cervical lipoma were performed. Furthermore, in genetic search, we found a germline frameshift mutation (c.1613delA in MEN1 gene (adenine deletion in exon 10)) in MEN1 gene in this subject which leads to the appearance of new stop codon at codon 588. This mutation was previously reported in another subject [
6]. His parents were not genotyped at the MEN1 locus, but they did not have any symptom related to MEN1. Therefore, although MEN1 is known to be one of the genetic diseases, it is likely that this case is a propositus case. It is noted here that we cannot totally exclude the possibility this subject did not have family history because it is well known that there are many subjects who have MEN1 but do not have any symptoms even after the onset of the disease. About 1 year later, follow-up CT was taken, but there was no progression in pancreatic lesions.
Taken together, this subject with MEN1 had various characteristics including a germline frameshift mutation in MEN1 gene, the development of a giant cervical lipoma and multiple abnormal fatty deposits in the pancreas, and the absence of family history in addition to typical characteristics of MEN1 such as pituitary neoplasia and primary hyperparathyroidism.