Development of Graves' disease in a patient with lymphocytic hypophysitis following glucocorticoid treatment

Abstract

Summary: We report the case of a 41-year-old Japanese woman with visual field disturbances during late pregnancy. At 39 weeks of gestation, she was diagnosed with bitemporal hemianopsia at the ophthalmology department. An MRI revealed a symmetrical pituitary gland enlargement, compressing the optic chiasm. An emergency cesarean section was performed immediately, resulting in the delivery of a male infant weighing 3,112 grams. Laboratory tests indicated low serum free thyroxine (T4), thyroid-stimulating hormone (TSH), cortisol, luteinizing hormone, and follicle-stimulating hormone. The patient was clinically diagnosed with lymphocytic hypophysitis (LHy). Due to her visual field impairment, she was administered 60 mg of prednisolone daily. After 2 days, her visual field impairment improved rapidly, leading to a gradual tapering of the dose. Six months after treatment initiation, an MRI showed shrinkage of the pituitary gland. Her prednisolone dose was reduced to 5 mg daily, and she was switched to hydrocortisone at 15 mg daily. Twelve months after starting treatment, the patient developed thyrotoxicosis. Testing revealed a positive TSH receptor antibody, resulting in a diagnosis of Graves' disease (GD). Treatment with thiamazole (15 mg daily) and potassium iodide (76 mg daily) was initiated, and her thyroid function normalized after 2 months. LHy is believed to have an autoimmune mechanism and is frequently associated with other autoimmune diseases; however, the development of GD is rare. Development of Graves' disease should be considered in patients with LHy, particularly during the postpartum period and the glucocorticoid treatment process.

Learning points: Females with lymphocytic hypophysitis often experience local symptoms, such as visual field disorders, when pregnant. This condition is frequently associated with autoimmune diseases, particularly autoimmune thyroid disorders. However, reports explicitly linking it to Graves' disease have been limited. The postpartum period is considered a trigger of the onset of Graves' disease. In addition, the high-dose glucocorticoid treatment and its tapering may affect it.

Keywords: Graves’ disease; glucocorticoids; lymphocytic hypophysitis; pregnancy.

Figure 1

Temporal evolution of MRI findings on the pituitary gland. T1-weighted image, frontal (A) and sagittal (C) views taken 3 days postpartum. Gadolinium-enhanced image, frontal view (B), 3 days postpartum. T1-weighted image, sagittal view captured at 3 months (D), 6 months (E), and 17 months (F) after the start of treatment. The height of the pituitary gland was indicated in MRI images in (C), (D), (E), and (F).