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Year : 1999  |  Volume : 9  |  Issue : 4  |  Page : 203-204
Granulomatous hypophysitis - A rare entity mimicking pituitary adenoma


Consultant Radiologist, NM Medical Centre, Mumbai, India

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How to cite this article:
Bhaya A. Granulomatous hypophysitis - A rare entity mimicking pituitary adenoma. Indian J Radiol Imaging 1999;9:203-4

How to cite this URL:
Bhaya A. Granulomatous hypophysitis - A rare entity mimicking pituitary adenoma. Indian J Radiol Imaging [serial online] 1999 [cited 2018 Apr 23];9:203-4. Available from: http://www.ijri.org/text.asp?1999/9/4/203/30614
Sir,

We would like to report a rare case of granulomatous hypophysitis presenting as a pituitary mass and associated with hypopituitarism.

A twenty-four-years old businessman presented one and half years ago with severe splitting headaches. Screening CT scan revealed a bulky pituitary gland. This was followed by contrast enhanced MR which revealed an enlarged, homogeneously enhancing gland bulging upward through the diaphragma sellae in a pyramidal shape

[Figure - 1]. Serum prolactin levels were mildly elevated (67 ng/ml) and further studies revealed low cortisol levels due to adrenal hypofunction. The patient was put on low dose steroids, bromocriptine and thyroid hormones. A repeat MR performed four months later showed a reduction in size and degree of enhancement of the gland, which now measured 8 mm in height [Figure - 2]. The medication was tapered but the headaches persisted and a follow-up MR again revealed an increase in the height of the gland.

The provisional diagnosis was a chromophobe adenoma and the patient underwent trans-sphenoidal micro-resection.

Histopathology revealed a chronic inflammatory reaction with epitheloid and giant cells bordered by a heavy lymphocytic reaction, resembling tubercles. Some sections even more clearly revealed Langhans type of giant cells. Immunostaining for WBCs with the leucocyte common antigen showed that the lymphocytes were strongly positive throughout. With staining for macrophage factor, many of the large mononuclear cells were found to be positive. The pathology report was suggestive of granulomatous hypophysitis, possibly an intrasellar tuberculoma. However AFB could not be isolated.

The patient was put on antituberculous drugs and replacement doses of thyroid hormones and steroids.

Granulomatous hypophysitis is a rare entity and presents commonly with enlargement of the pituitary gland, mimicking an adenoma. Clinical presentation often includes features such as headache in almost all cases, with fewer cases presenting as hypopituitarism. On imaging, the gland is seen to be diffusely enlarged with a thickened stalk seen infrequently [1]. It is impossible to distinguish this entity from pituitary adenoma on clinical / imaging data. Honegger et al in a retrospective study of nine cases reported certain clinico-radiological features presumably characteristic for granulomatous hypophysitis. These include headache, thickening of sphenoid sinus mucosa, pituitary stalk enlargement and tongue-shaped extension of the lesion along the basal hypothalamus [2]. However granulomatous/lymphocytic hypophysitis has been reported to respond to steroid treatment [3]. Surgery should be restricted to patients who fail to respond or suffer a relapse [4]. Some authors justify early surgical exploration in view of the insidious clinical course of the illness [2]. The common histological findings include vermiculous destruction of the anterior pituitary, scattered lymph follicles accompanying infiltration by numerous lymphocytes and multinucleated foreign body giant cells and deposition of calcium [5].

In conclusion, granulomatous hypophysitis is a rare entity that mimics a pituitary adenoma both clinically and radiologically. Most of the times, the diagnosis is arrived at, while doing a histopathological study. However clinico-radiological improvement has been reported with steroid therapy, which may help in differentiating the two. The various reported causes of granulomatous hypophysitis include tuberculosis, syphilis, sarcoidosis, mycotic granuloma and foreign body granuloma due to a ruptured Rathke's cleft cyst. In our case empirical anti-tuberculous therapy was justified in view of the ubiquitous presence of tuberculosis and suggestive pathological features. The patient has been symptom-free at the time of writing this report.

 
   References Top

1.Sato N, Sze G, Endo K. Hypophysitis: endocrinologic and dynamic MR findings. AJNR, 1998; 19: 439-44.   Back to cited text no. 1    
2.Honegger J, Fahlbusch R, Bornemann A et al . Lymphocytic and granulomatous hypophysitis experience with nine cases. Neurosurgery 1997; 40: 713-722..   Back to cited text no. 2    
3.Beressi N; Cohan R; Beressi JP et al Pseudotumoral lymphocytic hypophysitis successfully treated by corticosteroid alone: first case report. Neurosurgery 1994; 35: 505-508.   Back to cited text no. 3    
4.Shimon I, Berzin M, Hadani M et al . A pituitary mass and hypopituitarismi; improvement after corticosteroid therapy. Isr J Med Sci Jan 1997; 33: 58-62.   Back to cited text no. 4    
5.Tanaka R, Kameya J, Kasai K et al . A case of granulomatous hypophysitis. No Shinkei Geka 1992; 20: 1283-1288  Back to cited text no. 5    

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Correspondence Address:
Anil Bhaya
Consultant Radiologist, NM Medical Centre, Mumbai
India
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Source of Support: None, Conflict of Interest: None


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[Figure - 1], [Figure - 2]

This article has been cited by
1 Granulomatous hypophysitis: Two case reports and literature review
Shi, J., Zhang, J.-M., Wu, Q., Chen, G., Zhang, H., Bo, W.-L.
Journal of Zhejiang University: Science B. 2009; 10(7): 552-558
[Pubmed]



 

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