Lymphocytic hypophysitis with cystic MRI appearance

Idiopathic granulomatous hypophysitis mimicking adenoma

Hypophysitis is a rare disease of pituitary gland, which, although it is usually a primary lesion, can also occur secondary to systemic conditions. Granulomatous hypophysitis is an inflammatory disease condition which accounts for less than 1% of all cellular lesions and can mimic adenoma. A 32-year-old woman presented with weight gain, galactorrhea and blurred vision. The MRI showed a cystic, nodular lesion in the intermediate lobe of the pituitary gland and the initial diagnosis was adenoma. She underwent surgery and the histopathology revealed granulomas composed of epithelioid histiocytes, multinuclear giant cells and mononuclear inflammatory cells. Inflammatory diseases of the pituitary gland are much less frequent than pituitary adenomas and idiopathic granulomatous hypophysitis is extremely rare. Histopathology and the ruling out of a systemic cause are the gold standards for its diagnosis.

Mycophenolate mofetil treatment in a patient with recurrent lymphocytic hypophysitis

Lymphocytic hypophysitis (LHP) is a relatively rare disease characterised by lymphocytic infiltration of the pituitary gland, resulting in pituitary dysfunction. LHP is generally responsive to corticosteroid therapy, but cases with recurrence require clinicians to select second-line therapy. We report here the case of a 58-year-old patient with LHP who developed panhypopituitarism and bitemporal hemianopia. He responded to prednisolone 40 mg/day but relapsed during tapering. The prednisolone dose was increased again and mycophenolate mofetil (MMF) was added. Thereafter, over the course of 1 year, prednisolone was tapered to 8 mg/day without relapse. Because of the rarity of LHP, there are no standard treatment protocols that support the choice of a specific immunosuppressive drug. MMF was effective for recurrent LHP in our case. Further accumulation of cases is needed to establish the standard treatment for this disease.

Autoimmune Hypophysitis Presenting as Solid-Cystic Mass Managed Conservatively

BACKGROUND

Autoimmune hypophysitis (AH) is a rare inflammatory condition of the pituitary gland and usually affects women of childbearing age. It commonly leads to pituitary dysfunction. Moreover, pituitary enlargement may lead to compressive symptoms, which necessitates urgent surgical decompression. Resection of the pituitary gland causes iatrogenic hypopituitarism which requires lifelong hormonal supplementation. With an increasing number of suspected cases of pituitary diseases, there has been a paradigm shift in the management by conservative measures, especially, when surgery is not urgently needed.

CASE REPORT

We report a case of AH in a premenopausal woman presenting with headache. MRI revealed a solid-cystic mass involving the anterior lobe of the pituitary gland. The infundibulum was also thickened and enhancing; however, it was still in the midline. Ancillary MRI findings and hormonal profile were favouring the diagnosis of AH over pituitary neoplasm. The patient was managed conservatively with high doses of glucocorticoids, which resulted in prompt resolution of the lesion. During subsequent follow-up over 6 years, there was no recurrence and partial restoration of the pituitary function was seen. This case is interesting due to an unusual MRI appearance of AH, presenting as a solid-cystic mass. Moreover, disease resolution with conservative treatment strengthens the approach to limit surgery to those patients with compressive symptoms or uncertain diagnosis.

CONCLUSIONS

AH should be included in the differential diagnosis of solid-cystic pituitary masses along with clinical correlation, which includes early involvement of ACTH and TSH and a relatively rapid development of hypopituitarism. In uncertain cases or with lack of compressive symptoms, a trial of steroids is worthwhile.

Revisitation of autoimmune hypophysitis: knowledge and uncertainties on pathophysiological and clinical aspects

PURPOSE

This publication reviews the accepted knowledges and the findings still discussed on several features of autoimmune hypophysitis, including the most recently described forms, such as IgG4 and cancer immunotherapy- related hypophysitis.

METHODS

The most characteristic findings and the pending controversies were derived from a literature review and previous personal experiences. A single paragraph focused on some atypical examples of the disease presenting under confounding pretences.

RESULTS

Headache, visual field alterations and impaired pituitary secretion are the most frequent clinical findings of the disease. Pituitary biopsy, still considered the gold diagnostic standard, does not always receive consent from the patients. The role of magnetic resonance imaging is limited, as this disease may generate images similar to those of other diseases. The role of antipituitary and antihypothalamus antibodies is still discussed owing to methodological difficulties and also because the findings on the true pituitary antigen(s) are still debated. However, the low sensitivity and specificity of immunofluorescence, one of the more widely employed methods to detect these antibodies, may be improved, considering a predetermined cut-off titre and a particular kind of immunostaining.

CONCLUSION

Autoimmune hypophysitis is a multifaceted disease, which may certainly be diagnosed by pituitary biopsy. However, the possible different clinical, laboratory and imaging features must be considered by the physician to avoid a misdiagnosis when examining a possibly affected patient. Therapeutic choice has to be made taking into account the clinical conditions and the degree of hypothalamic-pituitary involvement, but also considering that spontaneous remissions can occur.

Idiopathic Granulomatous Hypophysitis Mimicking Pituitary Abscess

Idiopathic granulomatous hypophysitis (IGH) is a rare inflammatory disease of the pituitary that commonly presents with enlargement of the pituitary gland. Clinically and radiologically, IGH is a rare sellar entity easily to be misdiagnosed as a pituitary adenoma. Through such a case, we aim to present this rarity and emphasize the importance to correctly diagnose confusing pituitary lesions comprehensively by clinical presentations, radiological signs, and biopsy. We present an uncommon case of IGH in a 19-year-old man. The patient was admitted to the hospital with severe headache, vomiting, and vision's sharp decline. Magnetic resonance imaging showed a sellar lesion with obvious cystic change and ring enhancement. The disease course including diagnosis and treatment was presented and analyzed in detail. The pertinent literature is reviewed regarding this uncommon entity. The patient underwent surgical exploration and partial resection via the transsphenoidal approach. The pathologic findings suggested IGH giving no significant evidences of systemic granulomatous disease and venereal disease. Large dose methylprednisolone was then used. The pituitary function recovered, but there was no apparent improvement of his vision. IGH is a rarely occurred inflammatory disease of unknown etiology. It is difficult to diagnose preoperatively and is often misdiagnosed. Although rare, IGH should be kept in mind in terms of differential diagnosis of sellar region lesions.

A 15-year-old adolescent with a rare pituitary lesion

Cystic sellar lesions are a rare cause of hypopituitarism and extremely rare in the pediatric age group. The differential diagnosis is large and includes both primary pituitary abscesses and cystic components on pre-existing lesions, such as adenoma, craniopharyngioma, Rathke's cleft cyst, leukemia, granulomatous disease and lymphocytic hypophysitis. In the absence of a definitive diagnosis, treatment can be challenging. We report a case of a 15-year-old female, who presented with headaches, altered consciousness and diplopia after a molar extraction, for which she had received oral antibiotics. Broad-spectrum i.v. antibiotics were given for presumed meningitis. Blood cultures failed to identify pathogens. Cerebral magnetic resonance imaging showed a pituitary cystic lesion. Endocrine studies revealed abnormal pituitary function. In the absence of a therapeutic response, the patient underwent a transsphenoidal biopsy of the pituitary gland, which yielded a purulent liquid, but cultures were negative. Histopathology showed lymphocytic infiltrates but no neutrophils, compatible with an inflammation of autoimmune or infectious origin. High-dose glucocorticoid therapy was started and pursued, along with i.v. antibiotics, for 6 weeks, leading to clinical and radiological improvement but with persistence of endocrine deficits. In conclusion, this is a case of secondary panhypopituitarism due to a cystic pituitary lesion, with a differential diagnosis of lymphocytic hypophysitis vs abscess in a context of decapitated meningitis. Combination therapy with antibiotics and glucocorticoids is a legitimate approach in the face of diagnostic uncertainty, given the morbidity, and even mortality, associated with these lesions.

Lymphocytic hypophysitis in children: a novel presentation and literature review

Lymphocytic hypophysitis, an autoimmune mediated chronic inflammation of the pituitary gland, is uncommon in children.(1) The usual presentation is with symptoms secondary to pressure from the enlargement of the gland itself and or impairment of pituitary hormones of varying degrees, in conjunction with a sellar mass.( 2,3) In 80% of cases, partial or panhypopituitarism is present with approximately 75% of cases having multiple hormonal deficiencies.(2) We report the case of a prepubertal female who presented with cyclical vomiting, as her initial symptom of lymphocytic hypophysitis which resolved promptly after pituitary biopsy. This case suggests that cyclical vomiting can be a symptom associated with lymphocytic hypophysitis. Therefore, it should be considered in the differential diagnosis of any child presenting with cyclical vomiting.

Parasellar T2 dark sign on MR imaging in patients with lymphocytic hypophysitis

BACKGROUND AND PURPOSE

MR imaging findings of LYH and pituitary adenomas are similar, but the therapeutic strategies are completely different. The purpose of this study was to evaluate sellar and parasellar MR imaging findings in patients with both diseases, as well as characteristic clinical findings.

MATERIALS AND METHODS

Clinical findings, including endocrinologic study and MR images of 20 patients with LYH and 22 patients with pituitary adenoma, were retrospectively reviewed. We evaluated the MR images in relation to the following: 1) the PPHI on T1-weighted images, 2) thickened stalk (>3.5 mm), 3) pituitary symmetry, 4) pituitary enhancement pattern, 5) a dural tail, and 6) parasellar signal intensity on T2- and T1-weighted images.

RESULTS

Between patients with LYH and those with pituitary adenoma, a significant difference was identified for the number of patients with loss of PPHI, thickened stalk, pituitary symmetry, homogeneous enhancement, and parasellar dark signal intensity on T2-weighted images by statistical analysis (Fisher exact probability test, P < .05). Among them, only parasellar dark signal intensity on T2-weighted images had no false-positive cases.

CONCLUSIONS

The parasellar T2 dark sign can be a specific finding used to distinguish pituitary adenoma from LYH.

A radiologic score to distinguish autoimmune hypophysitis from nonsecreting pituitary adenoma preoperatively

BACKGROUND AND PURPOSE

Autoimmune hypophysitis (AH) mimics the more common nonsecreting pituitary adenomas and can be diagnosed with certainty only histologically. Approximately 40% of patients with AH are still misdiagnosed as having pituitary macroadenoma and undergo unnecessary surgery. MR imaging is currently the best noninvasive diagnostic tool to differentiate AH from nonsecreting adenomas, though no single radiologic sign is diagnostically accurate. The purpose of this study was to develop a scoring system that summarizes numerous MR imaging signs to increase the probability of diagnosing AH before surgery.

MATERIALS AND METHODS

This was a case-control study of 402 patients, which compared the presurgical pituitary MR imaging features of patients with nonsecreting pituitary adenoma and controls with AH. MR images were compared on the basis of 16 morphologic features besides sex, age, and relation to pregnancy.

RESULTS

Only 2 of the 19 proposed features tested lacked prognostic value. When the other 17 predictors were analyzed jointly in a multiple logistic regression model, 8 (relation to pregnancy, pituitary mass volume and symmetry, signal intensity and signal intensity homogeneity after gadolinium administration, posterior pituitary bright spot presence, stalk size, and mucosal swelling) remained significant predictors of a correct classification. The diagnostic score had a global performance of 0.9917 and correctly classified 97% of the patients, with a sensitivity of 92%, a specificity of 99%, a positive predictive value of 97%, and a negative predictive value of 97% for the diagnosis of AH.

CONCLUSIONS

This new radiologic score could be integrated into the management of patients with AH, who derive greater benefit from medical as opposed to surgical treatment.

Lymphocytic hypophysitis occurring simultaneously with a functioning pituitary adenoma

Lymphocytic Hypophysitis (LH) is a rare and previously under-recognised disorder, most commonly affecting young females in the post-partum period. It presents clinically with symptoms and signs related to either a pituitary mass or hypopituitarism, frequently mimicking a pituitary adenoma; the diagnosis of LH can only be made histologically with the presence of a dense lymphocytic infiltration usually confined to the anterior pituitary. We present two case histories of patients who presented with symptoms suggestive of a functioning pituitary adenoma who also had concomitant LH confirmed histologically. The first case was a 39 year old lady, with a history of primary hypothyroidism, who presented with weight gain and hirsutism and clinical and biochemical features of Cushing's syndrome. The second case was a 61 year old male, also with a history of primary hypothyroidism, who presented with visual field loss and biochemically with hyperprolactinaemia. In both patients, magnetic resonance (MR) imaging of the pituitary demonstrated an enlarged partially cystic pituitary mass with slight suprasellar extension. Both patients were treated surgically with transphenoidal drainage and excision and histological examination of the surgical specimens demonstrated a mixture of pathologies with fragments of adenohypophyseal tissue (staining positive for ACTH and prolactin respectively) with a dense chronic inflammatory cell infiltrate suggestive of LH in nearby normal anterior pituitary. In both cases a joint diagnosis of a functioning pituitary adenoma with LH was made. There have been only several reported cases of this combination of pathologies but LH even in isolation is becoming increasingly recognised.

Sequential pituitary MR imaging in Sheehan syndrome: report of 2 cases

We present the evolution of pituitary changes in the cases of 2 patients with Sheehan syndrome as assessed by MR imaging. Both patients had severe postpartum hemorrhage, symptoms of pituitary gland apoplexy, and hypopituitarism. Sequential MR imaging demonstrated evidence of ischemic infarct in the pituitary gland with enlargement followed by gradual shrinkage during several months, to pituitary atrophy.

Inflammatory and infectious processes involving the pituitary gland

Inflammatory and infectious diseases of the pituitary gland are rare, and imaging diagnosis may be difficult. They encompass a wide spectrum of pathology including autoimmune (lymphocytic) hypophysitis, granulomatous hypophysitis, local manifestations of systemic disease, and a multitude of infectious processes. Based on extensive review of the literature, this article will present a classification scheme, description of pathology, and imaging findings of the various inflammatory and infectious entities, along with selected images from our case material.