Neurosarcoidosis (pituitary gland involvement)

Case contributed by Dr Bruno Di Muzio

Presentation

Shortness of breath and lymphadenopathy.

Patient Data

Age: 60 years
Gender: Male

Apart from prominent and nonspecific submandibular lymph nodes, the remainder of the neck lymph nodes are not abnormally enlarged and do not have suspicious imaging features. 

There are prominent mediastinal and bilateral hilar lymph nodes, as well as a few scattered pulmonary centrilobular nodules. There are no features of interstitial involvement. 

There is an enhancing mass involving the sella and suprasellar region. 

Ultrasound guided submandibular lymph node core biopsy

Pre-procedure ultrasound demonstrated bilateral enlarged submandibular lymph nodes. The largest on the right measures 18 mm, and the largest on the left measures 30 mm.

The pituitary gland and its infundibulum are diffusely and homogeneously enlarged and demonstrate intense enhancement. No pituitary suprasellar extension is noted. The enlarged infundibulum compresses the optic chiasm inferiorly, and mild edema is seen proximally in the chiasm. Mildly restricted diffusion is observed within the infundibulum. No signs of cavernous sinus invasion.

 

MICROSCOPIC DESCRIPTION: Chronically inflamed and fibrotic salivary gland parenchyma with a single non-necrotizing granuloma. No mycobacteria are identified.

DIAGNOSIS:

Chronic fibrosing sialadenitis and non-necrotizing granulomatous inflammation. Features suggestive of sarcoidosis.

MYCOBACTERIAL INVESTIGATIONS

Left submandibular lymph node core biopsy

MICROSCOPY Auramine-Rhodamine stain: No acid fast bacilli detected

MYCOBACTERIUM CULTURE SCREEN MGIT bottle: <56 days negative

MYCOBACTERIAL CULTURE: No growth after 8 weeks

When compared to the previous MRI, the thickened homogeneously enhancing pituitary infundibulum has reduced in size and the pituitary gland does not have a bulky appearance anymore. The cavernous sinuses have a normal appearance. No abnormal region of restricted diffusion. No hydrocephalus. 

Case Discussion

This case illustrates presumed neurosarcoidosis involvement of the pituitary gland and pituitary stalk that improved after corticosteroid treatment for sarcoidosis.

There were no other signs of neurosarcoidosis on another full brain MRI performed in between the two scans above, not shown in this case. Other brain pathologies that are commonly described in neurosarcoidosis are periventricular lesions and leptomeningeal enhancement.

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