Treatment of hypothalamic obesity with GLP-1 agonists and extreme diet in a patient with hypothalamic inflammatory infiltration

EM. Erfurth*^a (Prof), S. Fjalldal^a (Dr), S. Karlsson^a (Dr), S. Gabery^a (Dr)

^a Clinical Sciences, Lund University, Lund Sweden, Lund, SWEDEN

* eva_marie.erfurth@med.lu.se

Introduction: Hypothalamic damage can lead to intractable weight gain known as hypothalamic obesity (HO). The pathogenesis of HO includes increased parasympathetic tone causing increase in insulin resulting in lipogeneses (1). HO has been resistant to all kinds of intervention but long acting incretin glucagon-like receptor (GLP-1R) agonist, has been used (2) binds to receptors in the hypothalamus (HT) increasing satiety and reduce stomach emptying (3).

Methods: The HT injury was graded by the definition of Puget et al (4) (Figure I). The hypothalamic volume was estimated by Gabery et al (5) (Figure II).

Case presentation: A 19 year old woman presented with headache and vision loss but with normal weight (75 kg). She was operated by the zygomatiotemporal rout on the suspicion of a craniopharyngioma. After operation her weight doubled due to hypothalamic damage (Fig III). The microscopic examination revealed however inflammatory cells. No malignant transformation was recorded. Cerebrospinal fluid cytology showed no malignant cells, only plasma cells, granulocytes and lymphocytes. Further tests excluded lymphoma, germinoma or sarcoidosis. Autoimmune hypothalamitis (AHT) is the possible diagnosis. The operation reduced the inflammation and 4 months postoperatively she was started on 30 mg with further reduction of the inflammation. The HT volume was estimated to 63 mm³ (right side) and 22 mm³ (left side), total 85 mm³ (normal HT volume 850 mm³).

Twice the patient’s weight was reduced dramatically by a very strict caloric diet (Xtravaganza 500 kcal/day) but when ordinary diet was introduced, her weight increased dramatically (Fig III). She was treated with (GLP-1R) agonists and metformin for her DM type II and with supplementation of her pituitary insufficiencies.

Conclusion: The coexistence of AHT and HO is extremely difficult to treat as the former involves Prednisone treatment. Pharmacological intervention of HO has had limited effect on weight but extreme diet was successful, however with short endurance.

1. Frohlich A. Diabetologia. 1981, 20(Suppl 1).
2. Zoicas F et al. Eur J Endocrinol. 2013 Apr 15;168(5).
3. Kanoski SE et al. Am J Physiol Regul Integr 2016 May15.
4. Puget S et al. J Neurosurg. 2007.
5. Gabery S et al PLoS ON 2015.

The author has declared no conflict of interest.