Toxoplasmosis presenting as panhypopituitarism in a patient with the acquired immune deficiency syndrome

doi:10.1016/0002-9343(84)90381-4

The American Journal of Medicine

Volume 77, Issue 4, October 1984, Pages 760-764

https://doi.org/10.1016/0002-9343(84)90381-4 Get rights and content

Abstract

A 57-year-old man with a prior episode of lymphatic toxoplasmosis presented with signs of anterior panhypopituitarism, which was confirmed by standard endocrinologic evaluation. The diagnosis of central nervous system toxoplasmosis was established by brain biopsy after nondlagnostic serologic and radiographic studies. At autopsy, the anterior pituitary was necrotic, with Toxoplasma abscesses in neighboring brain structures. Clinical and laboratory data met the criteria for the acquired immune deficiency syndrome. Although this is the first reported case of toxoplasmosis presenting as panhypopituitarism, future cases may be identified since central nervous system toxoplasmosis is being recognized more frequently in patients with immunodeficiency.

References (28)

C Urmacher et al.
Outbreak of Kaposi's sarcoma with cytomegalovirus infection in young homosexual men
Am J Med
(1982)
BJ Luft et al.
Outbreak of central-nervous-system toxoplasmosis in Western Europe and North America
Lancet
(1983)
RM Carey et al.
Toxoplasmosis. Clinical experiences in a cancer hospital
Am J Med
(1973)
R McLeod et al.
Toxoplasmosis presenting as brain abscesses. Diagnosis by computerized tomography and cytology of aspirated purulent material
Am J Med
(1979)
JP Alenghat et al.
Computed tomography in opportunistic cerebral toxoplasmosis: report of two cases
Comput Tomogr
(1981)
LA Frohman
Diseases of the anterior pituitary
MS Gottlieb et al.
Pneumocystis carinii pneumonia and mucosal candidiasis in previously healthy homosexual men. Evidence of a new acquired cellular immunodeficiency
N Engl J Med
(1981)
H Masur et al.
An outbreak of community-acquired Pneumocystis carinii pneumonia. Initial manifestation of cellular immune dysfunction
N Engl J Med
(1981)
FP Siegal et al.
Severe acquired immunodeficiency in male homosexuals, manifested by chronic perianal ulcerative herpes simplex lesions
N Engl J Med
(1981)
SE Follansbee et al.
An outbreak of Pneumocystis carinii pneumonia in homosexual men
Ann Intern Med
(1982)

AE Pitchenik et al.

Opportunistic infections and Kaposi's sarcoma among Haitians: evidence of a new acquired immunodeficiency state

Ann Intern Med

(1983)

GC Borst et al.

Discordant cortisol response to exogenous ACTH and insulin-induced hypoglycemia in patients with pituitary disease

N Engl J Med

(1982)

K Kovacs

Necrosis of anterior pituitary in humans

Neuroendocrinology (Basel)

(1969)

JJ Townsend et al.

Acquired toxoplasmosis. A neglected cause of treatable nervous system disease

Arch Neurol

(1975)

Cited by (73)

Pituitary Dysfunction in Systemic Disorders
2017, The Pituitary: Fourth Edition
The pituitary gland may be affected by a wide variety of systemic disorders. The pituitary could be directly involved by the same processes that affect other organs (e.g., inflammatory, autoimmune, or infectious disorders), or the primary disease process may elicit indirect, distant effects on pituitary–hypothalamic hormonal function. Changes in pituitary function associated with a multitude of systemic diseases (both frequent and more rare ones) include pituitary granulomas, Langerhans histiocytosis, Erdheim–Chester disease, autoimmune, and infectious diseases. Detailed changes in pituitary morphology and function are also related to aging, obesity, and general effects of systemic illnesses and these include anorexia nervosa, chronic kidney disease, and liver failure leading to pituitary hormonal dysfunction.
Sellar Toxoplasmosis and Nonfunctioning Pituitary Adenoma
2015, World Neurosurgery
Citation Excerpt :
During oral infection of T gondii, a rapid systemic dissemination by blood and the lymphatic system to multiple organs, including immunoprivileged sites, may occur within a few hours (4). Involvement of the neuroendocrine structures is uncommon; however, involvement of the hypothalamus and the pituitary has been described in congenital toxoplasmosis (13, 15, 20, 23) and in patients with acquired immunodeficiency syndrome (14). The etiology of hyperprolactinemia in the present case remains unclear because the pathologic samples of the adenoma did not stain for PRL, and only a modest elevation of PRL could be detected.
Sellar toxoplasmosis is associated with congenital infections or immunodeficiency. The finding of Toxoplasma bradycysts in a pituitary adenoma is very unusual.
An otherwise healthy 27-year-old woman presented with secondary amenorrhea and moderately elevated prolactin levels. A macroprolactinoma was suspected on magnetic resonance imaging, and cabergoline was initiated. Although dopamine levels decreased, the tumor did not show significant shrinkage; after 2 years, transsphenoidal resection was indicated to clarify the diagnosis and to cure hyperprolactinemia. Histology showed an inactive pituitary adenoma and Toxoplasma bradycysts. Seropositivity for Toxoplasma gondii, but neither immunodeficiency nor intracerebral spread, was found. During a postoperative follow-up period of 15 months, the patient did not show any recurrence.
Sellar toxoplasmosis in conjunction with pituitary adenoma is extremely rare. Nonfunctioning lesions should be suspected in cases of sellar masses and moderate hyperprolactinemia.
Alternative causes of hypopituitarism: Traumatic brain injury, cranial irradiation, and infections
2014, Handbook of Clinical Neurology
Citation Excerpt :
T. gondii forms cysts that are located at various anatomic sites including the brain during chronic infection. The involvement of the pituitary in cases with toxoplasmosis is extremely rare and includes patients with congenital toxoplasmosis and in patients with central nervous system toxoplasmosis with AIDS (Milligan et al., 1984). Recently two cases of pituitary adenoma (prolactinomas) were found to be associated with T. gondii infection (Zhang et al., 2002).
Hypopituitarism often remains unrecognized due to subtle clinical manifestations. Anterior pituitary hormone deficiencies may present as isolated or multiple and may be transient or permanent. Traumatic brain injury (TBI) is recognized as a risk factor for hypopituitarism, most frequently presenting with isolated growth hormone deficiency (GHD). Data analysis shows that about 15% of patients with TBI have some degree of hypopituitarism which if not recognized may be mistakenly ascribed to persistent neurologic injury and cognitive impairment. Identification of predictors for hypopituitarism after TBI is important, one of them being the severity of TBI. The mechanisms involve lesions in the hypothalamic–pituitary axis and inflammatory changes in the central nervous system (CNS). With time, hypopituitarism after TBI may progress or reverse. Cranial irradiation is another important risk factor for hypopituitarism. Deficiencies in anterior pituitary hormone secretion (partial or complete) occur following radiation damage to the hypothalamic–pituitary region, the severity and frequency of which correlate with the total radiation dose delivered to the region and the length of follow-up. These radiation-induced hormone deficiencies are irreversible and progressive. Despite numerous case reports, the incidence of hypothalamic–pituitary dysfunction following infectious diseases of the CNS has been underestimated. Hypopituitarism usually relates to the severity of the disease, type of causative agent (bacterial, TBC, fungal, or viral) and primary localization of the infection. Unrecognized hypopituitarism may be misdiagnosed as postencephalitic syndrome, while the presence of a sellar mass with suprasellar extension may be misdiagnosed as pituitary macroadenoma in a patient with pituitary abscess which is potentially a life-threatening disease.
Multisystemic toxoplasmosis associated with a type II-like Toxoplasma gondii strain in a New Zealand fur seal (Arctocephalus forsteri) from New South Wales, Australia
2014, Veterinary Parasitology
Citation Excerpt :
Histopathological findings were similar to other cases of toxoplasmosis in marine mammals where the most commonly reported lesions are nonsuppurative meningoencephalitis and myocarditis, in association with tissue cysts and tachyzoites, and necrosis (Miller, 2008). The presence of T. gondii cysts in areas of nonsuppurative hypophysitis are rarely reported in immunocompromised humans, and as congenital infections (Milligan et al., 1984; Zhang et al., 2002). Tissue cysts of Sarcocystis sp. are known from several marine mammal species and reports in otariids include California sea lions (Zalophis californicus) and northern fur seals (Callorhinus ursinus) (Dubey et al., 2003; Miller, 2008; Dubey, 2010).
We report the first confirmed case of toxoplasmosis in an Australian pinniped. Presence of Toxoplasma gondii DNA was detected in the brain of a free-ranging subadult New Zealand fur seal (Arctocephalus forsteri) with nonsuppurative meningoencephalitis, hypophysitis, posterior uveitis, retrobulbar cellulitis, and myocarditis associated with protozoan cysts and tachyzoites. The emaciated seal stranded moribund on a beach in northern Sydney in New South Wales. Histopathology coupled with specific immunohistochemistry and PCR assays confirmed the presence of T. gondii. The T. gondii sample (NZfs8825) identified in this study has an identical genotype as the type II (ToxoDB PCR-RFLP genotype #1) based on the direct sequencing and virtual RFLP of multilocus DNA markers including SAG1, 5′- and 3′-SAG2, alt.SAG2, SAG3, BTUB, GRA6, c22-8, c29-2, L358, PK1, and Apico. Direct sequencing of T. gondii B1 DNA marker from the T. gondii sample (NZfs8825) identified a type II-like strain, based on presence of non-archetypal B1 gene polymorphisms previously reported as unique to Australia. This study suggests that T. gondii oocysts originating from mainland Australia, which has a large population of feral cats, may act as a disease threat to native marine fauna. Therefore, emerging toxoplasmosis in the Arctic has a relevant parallel in the Southern Ocean within Australian waters with yet unknown relevance to Antarctica.
Pituitary Function in Systemic Disorders
2011, The Pituitary
The pituitary gland may be affected by a wide variety of systemic disorders. In some instances, the pituitary is directly involved by the same processes that also afflict other organs, while in other disorders, the primary disease process has indirect, distant effects on pituitary function. Patients with excessive tissue iron deposits, either from idiopathic hemochromatosis, multiple transfusions, or prolonged use of pharmaceutic iron supplements, often develop hypogonadism. Female patients appear to suffer from this complication less frequently than males, perhaps because of the protective effects of monthly menstrual blood loss. Tuberculosis has a predilection for involvement of the basilar meninges and may therefore occasionally involve tissues in the sellar region, sometimes producing anterior or posterior pituitary insufficiency. In polyglandular autoimmune states, clinical involvement of the pituitary is rare. Lymphocytic hypophysitis, an uncommon disorder of pregnant and postpartum women, is associated in some cases with other evidence of endocrine autoimmunity. Antibodies to pituitary tissue have been found in some patients with lymphocytic hypophysitis and in a variety of other endocrine autoimmune disorders, as well as in some patients with the primary empty sella syndrome and Sheehan's syndrome, but, to date, the functional significance of these antibodies remains unclear. Illness, injury and stress, if sufficiently severe, produce a constellation of endocrine changes that are, in general, independent of the specific type of illness.
Pituitary Function in Systemic Disorders
2010, The Pituitary, Third Edition
The pituitary gland may be affected by a wide variety of systemic disorders. In some instances, the pituitary is directly involved by the same processes that also afflict other organs, while in other disorders, the primary disease process has indirect, distant effects on pituitary function. Patients with excessive tissue iron deposits, either from idiopathic hemochromatosis, multiple transfusions, or prolonged use of pharmaceutic iron supplements, often develop hypogonadism. Female patients appear to suffer from this complication less frequently than males, perhaps because of the protective effects of monthly menstrual blood loss. Tuberculosis has a predilection for involvement of the basilar meninges and may therefore occasionally involve tissues in the sellar region, sometimes producing anterior or posterior pituitary insufficiency. In polyglandular autoimmune states, clinical involvement of the pituitary is rare. Lymphocytic hypophysitis, an uncommon disorder of pregnant and postpartum women, is associated in some cases with other evidence of endocrine autoimmunity. Antibodies to pituitary tissue have been found in some patients with lymphocytic hypophysitis and in a variety of other endocrine autoimmune disorders, as well as in some patients with the primary empty sella syndrome and Sheehan's syndrome, but, to date, the functional significance of these antibodies remains unclear. Illness, injury and stress, if sufficiently severe, produce a constellation of endocrine changes that are, in general, independent of the specific type of illness.

View all citing articles on Scopus

¹: From the Department of Medicine, University of Texas Health Science Center and Audie L. Murphy Memorial Veterans' Hospital, San Antonio, Texas.

View full text

Case reportToxoplasmosis presenting as panhypopituitarism in a patient with the acquired immune deficiency syndrome

Abstract

Am J Med

Lancet

Am J Med

Am J Med

Comput Tomogr

Diseases of the anterior pituitary

Pneumocystis carinii pneumonia and mucosal candidiasis in previously healthy homosexual men. Evidence of a new acquired cellular immunodeficiency

N Engl J Med

An outbreak of community-acquired Pneumocystis carinii pneumonia. Initial manifestation of cellular immune dysfunction

N Engl J Med

Severe acquired immunodeficiency in male homosexuals, manifested by chronic perianal ulcerative herpes simplex lesions

N Engl J Med

An outbreak of Pneumocystis carinii pneumonia in homosexual men

Ann Intern Med

Opportunistic infections and Kaposi's sarcoma among Haitians: evidence of a new acquired immunodeficiency state

Ann Intern Med

Discordant cortisol response to exogenous ACTH and insulin-induced hypoglycemia in patients with pituitary disease

N Engl J Med

Necrosis of anterior pituitary in humans

Neuroendocrinology (Basel)

Acquired toxoplasmosis. A neglected cause of treatable nervous system disease

Arch Neurol

Case report
Toxoplasmosis presenting as panhypopituitarism in a patient with the acquired immune deficiency syndrome