Summary: Patients treated with immunosuppressive drugs, especially methotrexate (MTX), rarely develop lymphoproliferative disorders (LPDs), known as MTX-related LPD (MTX-LPD). The primary site of MTX-LPD is often extranodal. This is the first reported case of MTX-LPD in the pituitary. A 65-year-old woman was admitted to our hospital with symptoms of oculomotor nerve palsy and multiple subcutaneous nodules. She had been treated with MTX for 11 years for rheumatoid arthritis. Computed tomography showed multiple masses in the orbit, sinuses, lung fields, anterior mediastinum, kidney, and subcutaneous tissue. Brain magnetic resonance imaging revealed a sellar mass. She was diagnosed with hypopituitarism and central diabetes insipidus based on endocrine examination. Although pituitary biopsy could not be performed, we concluded that the pituitary lesion was from MTX-LPD, similar to the lesions in the sinuses, anterior mediastinum, and subcutaneous tissue, which showed polymorphic LPD on biopsy. MTX was discontinued, and methylprednisolone was administered to improve the neurologic symptoms. After several weeks, there was marked improvement of all lesions, including the pituitary lesion, but the pituitary function did not improve. When pituitary lesions are caused by MTX-LPD, the possibility of anterior hypopituitarism and central diabetes insipidus needs to be considered. Further studies are needed to investigate the effectiveness of early diagnosis and treatment of MTX-LPD in restoring pituitary dysfunction.
Learning points: Pituitary lesions from MTX-LPD may cause hypopituitarism and central diabetes insipidus. Pituitary metastasis of malignant lymphoma and primary pituitary lymphoma, which have the same tissue types with MTX-LPD, have poor prognosis, but the lesions of MTX-LPD can regress only after MTX discontinuation. In cases of pituitary lesions alone, a diagnosis of MTX-LPD may be difficult, unless pituitary biopsy is performed. This possibility should be considered in patients treated with immunosuppressive drugs. Pituitary hypofunction and diabetes insipidus may persist, even after regression of the lesions on imaging due to MTX discontinuation.
Keywords: 2019; ACTH; Anti-citrullinated protein antibody; Asian - Japanese; Biopsy; C-reactive protein; CD-20*; CD-30*; CD-79 alpha*; CT scan; Cortisol; Creatinine; DDAVP test*; Desmopressin; Diabetes insipidus; Diabetes insipidus - neurogenic/central; Epstein-Barr virus*; FSH; FT3; FT4; Facial palsy; Facies - abnormal; Female; Geriatric; Haematoxylin and eosin staining; Histopathology; Hypopituitarism; Hypotonic saline infusion*; IGF1; Iatrogenic disorder; Immunosuppressants*; Interstitial lung disease*; Japan; Krebs von den Lungen 6*; LH; Lactate dehydrogenase; Lung biopsy*; Lymphoproliferative disorders*; MRI; Matrix metalloproteinase 3*; Methotrexate*; Methylprednisolone; Mydriasis; New disease or syndrome: presentations/diagnosis/management; October; Oculomotor nerve palsy*; Ophthalmalgia*; Pituitary; Prednisolone; Prolactin; Ptosis; Rheumatoid arthritis; Serum osmolality; Sinus biopsy*; Skin biopsy; Soluble IL-2 receptor*; Splenomegaly; Subcutaneous nodules*; TSH; Thyroid antibodies; Thyroxine (T4); Triiodothyronine (T3); Urine osmolality.