Neurosarcoidosis
Presentation:
Acquired hypogandotrophic hypogonadism.
Patient Data:
MRI of the pituitary and brain demonstrates abnormal contrast enhancement within the hypophyseal stalk, tuber cinereum and midline portion of hypo-thalamus as well as the subependymal portions of the third ventricle, particularly on the left. Contrast enhancement of soft tissue within the third ventricle at the level of the foramina of Monro appears more prolific than expected, suggesting the process may have also extended to this region with nodular enhancement also seen along veins running along the posterior aspect of the third ventricle. Faint parenchymal enhancement is also noted, particularly in the right parietal lobe. The delayed sagittal images appear to show more vivid contrast enhancement of the capsule of the pituitary.
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Abnormal contrast enhancement of the:
- hypophyseal stalk, tuber cinereum and midline portion of hypo-thalamus as well as the subependymal portions of the third ventricle (blue arrows)
- nodular enhancement also seen along veins running along the posterior aspect of the third ventricle (red arrows)
- faint parenchymal enhancement particularly in the right parietal lobe (yellow arrows)
- soft tissue within the third ventricle at the level of the foramina of Monro (green arrow)
There are multiple enlarged mediastinal, hilar and axillary
nodes. The largest subcarinal node measures 33.5 by 21.5 x
33.5 mm. The largest right paratracheal
node measures 19 mm in short axis diameter
and the largest
left hilar node measures 17 mm in short axis diameter.
Apart from minor dependent changes and a band in the right middle lobe, lungs and pleural cavities are clear with no evidence of a pulmonary infiltrate.
This patient went on to have a supraclavicular lymph node core biopsy.
Histology
MICROSCOPIC DESCRIPTION: The sections show cores of lymphoid parenchyma which are replaced by well formed non-necrotizing granulomas. The granulomas are composed of epithelioid histiocytes and scattered giant cells. Focal calcification is also noted. There is no evidence of a primary lymphoid neoplasm, malignancy, or organisms (including on ZN or FITE staining).
CONCLUSION: Non-necrotizing grnaulomatous lymphadenitis. These findings are consistent with sarcoidosis.
Case Discussion:
The case demonstrates typical features of neurosarcoidosis, which are often subtle and require good quality contrast images to identify.
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