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LETTER
Year : 2016  |  Volume : 62  |  Issue : 1  |  Page : 50-51

Lymphocytic hypophysitis in nonpregnant middle-aged females mimicking pituitary adenoma


1 Department of Radiology, Seth GS Medical College and King Edward Memorial Hospital (KEM) Hospital, Mumbai, Maharashtra, India
2 Department of Endocrinology, Seth GS Medical College and King Edward Memorial Hospital (KEM) Hospital, Mumbai, Maharashtra, India

Date of Web Publication5-Jan-2016

Correspondence Address:
J Gandhi
Department of Radiology, Seth GS Medical College and King Edward Memorial Hospital (KEM) Hospital, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0022-3859.173216

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How to cite this article:
Sankhe S, Gandhi J, Shah N S, Khare S. Lymphocytic hypophysitis in nonpregnant middle-aged females mimicking pituitary adenoma. J Postgrad Med 2016;62:50-1

How to cite this URL:
Sankhe S, Gandhi J, Shah N S, Khare S. Lymphocytic hypophysitis in nonpregnant middle-aged females mimicking pituitary adenoma. J Postgrad Med [serial online] 2016 [cited 2019 Jun 18];62:50-1. Available from: http://www.jpgmonline.com/text.asp?2016/62/1/50/173216


Sir,

This letter pertains to the original letter to the editor "Lymphocytic hypophysitis in nonpregnant middle-aged female mimicking pituitary adenoma" by Gulwani et al. [1] We would further like to point out some more diagnostic features to accurately diagnose lymphocytic hypophysitis (LYH).

In LYH, there can be symmetric or asymmetric enlargement and homogeneous or heterogeneous enhancement of the pituitary gland. [2] Moreover, there is the thickening of the pituitary stalk (the diameter of the pituitary stalk exceeded 3.5 mm at the level of the median eminence of the hypothalamus) [Figure 1]a, loss of posterior pituitary bright spot on T1-weighted (T1w) images, and the presence of parasellar T2 dark sign [Figure 1]c. [2],[3] Parasellar extension can be seen as well [Figure 1]b and d. [2],[3]
Figure 1: (a) MRI T1w sagittal postcontrast image shows enlargement of pituitary with thickened stalk, marked by an arrow (b) Homogeneous postcontrast enhancement and b/l parasellar extension (right > left) (c) MRI coronal T1w and T2w images showing parasellar T2 dark sign (d) MRI axial T1w postcontrast image showing right parasellar extension of lesion

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Parasellar T2 dark sign is specific for LYH. [4] All other features are sensitive but not specific for LYH and can be present in either case. Parasellar T2 dark sign suggests fibrosis and represents chronicity of disease. [4] Although parasellar T2 dark sign is specific for LYH, it is not present in all cases, hence its presence suggests diagnosis but its absence does not rule out the diagnosis of LYH. [4]

We had few cases of pituitary LYH that were proven clinically and on follow-up magnetic resonance imaging (MRI) scan showed the abovementioned features. One 39-year-old woman presented with amenorrhea, headache, vomiting, diplopia, and right eyelid ptosis. On MRI of the brain, there was thickening of the pituitary stalk with enlarged homogeneously enhancing pituitary gland and parasellar extension (right > left). Another 34-year-old female presented with amenorrhea and headache. MRI showed parasellar T1 and T2 hypointensity that was referred to as T2 dark sign. It suggests fibrosis due to long-standing inflammation.

These features on MRI are pointers to accurate diagnosis in appropriate clinical setting and could avoid unnecessary surgery.

 
 :: References Top

1.
Gulwani H, Tripathi M, Garg N. Lymphocytic hypophysitis in non-pregnant middle-aged females mimicking pitutary adenoma: A report of two cases. J Postgrad Med 2014;60:421-2.  Back to cited text no. 1
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2.
Khare S, Jagtap VS, Budyal SR, Kasaliwal R, Kakade HR, Bukan A, et al. Primary (autoimmune) hypophysitis: A singe centre experience. Pituitary 2015;18:16-22.  Back to cited text no. 2
    
3.
Gutenberg A, Larsen J, Lupi I, Rohde V, Caturegli P. A radiologic score to distinguish autoimmune hypophysitis from nonsecreting pituitary adenoma preoperatively. AJNR Am J Neuroradiol 2009;30:1766-72.  Back to cited text no. 3
    
4.
Nakata Y, Sato N, Masumoto T, Mori H, Akai H, Nobusawa H, et al. Parasellar T2 dark sign on MR imaging in patients with lymphocytic hypophysitis. AJNR Am J Neuroradiol 2010;31:1944-50.  Back to cited text no. 4
    


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