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Combined granulomatous and lymphocytic hypophysitis presenting as pituitary incidentaloma in a middle-aged woman.

Gundgurthi A, Kharb S, Garg MK, Brar KS, Bharwaj R, Gupta S, Pathak HC - Indian J Endocrinol Metab (2012)

Bottom Line: She had normal pituitary function and visual perimetry.Histopathological examination revealed combined granulomatous and lymphocytic hypophysitis most likely of autoimmune in origin.As most cases of autoimmune hypophysitis are surgically treated, patients should be assessed on individual basis for requirement of steroids in postoperative period.

View Article: PubMed Central - PubMed

Affiliation: Department of Endocrinology, Army Hospital (Research and Referral), Delhi Cantt, India.

ABSTRACT
We report a case of 41-year-old lady who presented with chronic headache of 6-month duration and a sellar mass with a suprasellar extension on imaging, which was interpreted as pituitary macroadenoma. She had normal pituitary function and visual perimetry. On clinical examination and imaging it was provisionally diagnosed as pituitary incidentaloma due to hypophysitis and she was advised steroid therapy, but underwent transnasal resection of the tumor against suggestion. Histopathological examination revealed combined granulomatous and lymphocytic hypophysitis most likely of autoimmune in origin. Definitive diagnosis of hypophysitis can be made only on histopathological examination. As most cases of autoimmune hypophysitis are surgically treated, patients should be assessed on individual basis for requirement of steroids in postoperative period.

No MeSH data available.


Related in: MedlinePlus

IHC showing (a) CD68 positive histiocytes in granulomas and in surrounding inflammatory infiltrate (10×) (b) CD20 positive lymphocytes around granulomas (10×) (c) CD 20 positive lymphocytes scattered amidst pituicytes (10×) (d) extensive CD3 positive lymphocytic infiltrate around granulomas (circled) (4×)
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Figure 3: IHC showing (a) CD68 positive histiocytes in granulomas and in surrounding inflammatory infiltrate (10×) (b) CD20 positive lymphocytes around granulomas (10×) (c) CD 20 positive lymphocytes scattered amidst pituicytes (10×) (d) extensive CD3 positive lymphocytic infiltrate around granulomas (circled) (4×)

Mentions: However, before initiation of steroids she had an episode of severe headache with vomiting without any neurological deficits. The episode made the patient apprehensive of her underlying sellar mass and she favored surgery. She underwent successful transnasal transsphenoidal excision of the mass. Postoperatively she had transient diabetes insipidus on the second and third postoperative days, revealed by marked polyuria and raised serum sodium [154 meq/l (135-145 meq/l)]. It was managed with subcutaneous injection vasopressin, followed by no further requirement of vasopressin from the fourth postoperative day onward. The histopathological examination of the tissue showed the lesion to be filled with well-defined epitheloid granulomas, lymphocytic infiltration, and histiocytes [Figure 2]. Immunohistochemistry stained positive for CD3 (T-lymphocytes), CD20 (B-lymphocytes), and CD68 (histiocytes) [Figure 3]. In view of these findings a diagnosis of combined granulomatous and lymphocytic hypophysitis was made. There were no acid-fast bacilli seen. Tissue PCR could not be done due to financial constraints. Postoperatively she was asymptomatic, had normal pituitary functions, and there was no residual lesion on MRI.


Combined granulomatous and lymphocytic hypophysitis presenting as pituitary incidentaloma in a middle-aged woman.

Gundgurthi A, Kharb S, Garg MK, Brar KS, Bharwaj R, Gupta S, Pathak HC - Indian J Endocrinol Metab (2012)

IHC showing (a) CD68 positive histiocytes in granulomas and in surrounding inflammatory infiltrate (10×) (b) CD20 positive lymphocytes around granulomas (10×) (c) CD 20 positive lymphocytes scattered amidst pituicytes (10×) (d) extensive CD3 positive lymphocytic infiltrate around granulomas (circled) (4×)
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3475921&req=5

Figure 3: IHC showing (a) CD68 positive histiocytes in granulomas and in surrounding inflammatory infiltrate (10×) (b) CD20 positive lymphocytes around granulomas (10×) (c) CD 20 positive lymphocytes scattered amidst pituicytes (10×) (d) extensive CD3 positive lymphocytic infiltrate around granulomas (circled) (4×)
Mentions: However, before initiation of steroids she had an episode of severe headache with vomiting without any neurological deficits. The episode made the patient apprehensive of her underlying sellar mass and she favored surgery. She underwent successful transnasal transsphenoidal excision of the mass. Postoperatively she had transient diabetes insipidus on the second and third postoperative days, revealed by marked polyuria and raised serum sodium [154 meq/l (135-145 meq/l)]. It was managed with subcutaneous injection vasopressin, followed by no further requirement of vasopressin from the fourth postoperative day onward. The histopathological examination of the tissue showed the lesion to be filled with well-defined epitheloid granulomas, lymphocytic infiltration, and histiocytes [Figure 2]. Immunohistochemistry stained positive for CD3 (T-lymphocytes), CD20 (B-lymphocytes), and CD68 (histiocytes) [Figure 3]. In view of these findings a diagnosis of combined granulomatous and lymphocytic hypophysitis was made. There were no acid-fast bacilli seen. Tissue PCR could not be done due to financial constraints. Postoperatively she was asymptomatic, had normal pituitary functions, and there was no residual lesion on MRI.

Bottom Line: She had normal pituitary function and visual perimetry.Histopathological examination revealed combined granulomatous and lymphocytic hypophysitis most likely of autoimmune in origin.As most cases of autoimmune hypophysitis are surgically treated, patients should be assessed on individual basis for requirement of steroids in postoperative period.

View Article: PubMed Central - PubMed

Affiliation: Department of Endocrinology, Army Hospital (Research and Referral), Delhi Cantt, India.

ABSTRACT
We report a case of 41-year-old lady who presented with chronic headache of 6-month duration and a sellar mass with a suprasellar extension on imaging, which was interpreted as pituitary macroadenoma. She had normal pituitary function and visual perimetry. On clinical examination and imaging it was provisionally diagnosed as pituitary incidentaloma due to hypophysitis and she was advised steroid therapy, but underwent transnasal resection of the tumor against suggestion. Histopathological examination revealed combined granulomatous and lymphocytic hypophysitis most likely of autoimmune in origin. Definitive diagnosis of hypophysitis can be made only on histopathological examination. As most cases of autoimmune hypophysitis are surgically treated, patients should be assessed on individual basis for requirement of steroids in postoperative period.

No MeSH data available.


Related in: MedlinePlus