Immunoglobulin G4 hypophysitis in a 63-year-old woman with no autoimmune history: a case report.

BACKGROUND: Immunoglobulin-G4-related hypophysitis is a rare inflammatory disease that can present as a tumefactive pituitary lesion mimicking hypophyseal neoplasms such as pituitary adenoma or craniopharyngioma. The literature on this entity is sparse, with fewer than 100 cases reported across 19 publications; a recent review found only 24 cases published from 2007 to 2018. Previous reports have described demographic differences, with immunoglobulin-G4-related hypophysitis in females tending to present in the second and third decades in association with other autoimmune disease, while males tend to present in the fifth and sixth decades of life without an autoimmune history. CASE PRESENTATION: In contrast to the reported demographic trends, here we describe a unique case of immunoglobulin-G4-related hypophysitis in a 63-year-old white female with no history of autoimmune disease who presented with a rapidly enlarging sellar and hypothalamic mass causing headaches and cranial nerve palsies, prompting biopsy for diagnosis. The patient experienced rapid response to treatment with high-dose steroids and rituximab. CONCLUSION: The case contributes to the growing clinicopathologic description of immunoglobulin-G4-related hypophysitis and illustrates that this diagnosis should be a consideration even outside the conventional demographic setting.

A novel endocrinology-based wellness program to reduce medication expenditures and improve glycemic outcomes.

AIMS: The purpose of this study was to determine the difference in diabetes-related medication expenditures as a result of a 16-week lifestyle intervention program. Medical expenditures for patients with diabetes are twice as high compared to patients without this condition. Secondary objectives were changes in HbA1C, BMI, weight, body fat, and program satisfaction. METHODS: The Wellness Life! Program includes educational sessions focused on nutrition, fitness, and behavioral therapy. Medication costs were based on Average Wholesale Prices, tabulated from the 2010 Red Book. RESULTS: A total of 36 patients (49-80 years old) enrolled, of which 27 patients have diabetes mellitus (Type 2=26, Type 1=1). Mean 30-day anti-diabetic medication costs decreased by $142.92. Clinical mean parameters improved in both the overall group and the diabetic subgroup, respectively: HbA1C (%) -0.69, -0.82; weight (lbs) -16.94, -17.11; BMI -2.73, -2.88; and body fat (%) -1.71, -1.79. Participants were generally satisfied with the program. CONCLUSIONS: Employing a multidisciplinary wellness program within an endocrinology practice can reduce anti-diabetic medication expenses; however, long term follow-up is needed to determine if medication reductions and improved clinical parameters persist.

Hypoglycemia-associated autonomic failure in advanced type 2 diabetes.

We tested the hypotheses that the glucagon response to hypoglycemia is reduced in patients who are approaching the insulin-deficient end of the spectrum of type 2 diabetes and that recent antecedent hypoglycemia shifts the glycemic thresholds for autonomic (including adrenomedullary epinephrine) and symptomatic responses to hypoglycemia to lower plasma glucose concentrations in type 2 diabetes. Hyperinsulinemic stepped hypoglycemic clamps (85, 75, 65, 55, and 45 mg/dl steps) were performed on two consecutive days, with an additional 2 h of hypoglycemia (50 mg/dl) in the afternoon of the first day, in 13 patients with type 2 diabetes---7 treated with oral hypoglycemic agents (OHA R(X); mean [+/- SD] HbA(1c) 8.6 +/- 1.1%) and 6 requiring therapy with insulin for an average of 5 years and with reduced C-peptide levels (insulin R(X), HbA(1c) 7.5 +/- 0.7%)---and 15 nondiabetic control subjects. The glucagon response to hypoglycemia was virtually absent (P = 0.0252) in the insulin-deficient type 2 diabetic patients (insulin R(X) mean [+/- SE] final values of 52 plus minus 16 vs. 93 plus minus 15 pg/ml in control subjects and 98 +/- 16 pg/ml in type 2 diabetic patients, OHA R(X) on day 1). Glucagon (P = 0.0015), epinephrine (P = 0.0002), and norepinephrine (P = 0.0138) responses and neurogenic (P = 0.0149) and neuroglycopenic (P = 0.0015) symptom responses to hypoglycemia were reduced on day 2 after hypoglycemia on day 1 in type 2 diabetic patients; these responses were not eliminated, but their glycemic thresholds were shifted to lower plasma glucose concentrations. In addition, the glycemic thresholds for these responses were at higher-than-normal plasma glucose concentrations (P = 0.0082, 0.0028, 0.0023, and 0.0182, respectively) at baseline (day 1) in OHA R(X) type 2 diabetic patients, with relatively poorly controlled diabetes. Because the glucagon response to falling plasma glucose levels is virtually absent and the glycemic thresholds for autonomic and symptomatic responses to hypoglycemia are shifted to lower glucose concentrations by recent antecedent hypoglycemia, patients with advanced type 2 diabetes, like those with type 1 diabetes, are at risk for hypoglycemia-associated autonomic failure and the resultant vicious cycle of recurrent iatrogenic hypoglycemia.