| Identifier |
Lymphocytic_Hypophysitis_1080p |
| Title |
Lymphocytic Hypophysitis |
| Creator |
Andrew G. Lee, MD; Prraneeth Kambhampati |
| Affiliation |
(AGL) Chairman, Department of Ophthalmology, The Methodist Hospital, Houston, Texas; Professor of Ophthalmology, Weill Cornell Medicine, New York City, New York; (PK) Baylor College of Medicine, Houston, Texas |
| Subject |
Hypophysitis; Lymphocytes; Pituitary |
| Description |
Dr. Andrew Lee lectures about lymphocytic hypophysitis, which is defined as inflammatory infiltration of the pituitary gland by lymphocytes. It presents similarly to other sellar lesions involving the optic chiasm with junctional scotomas and, most classically, bitemporal hemianopsia. Consequently, pituitary adenoma should be considered in the differential diagnosis. In contrast to other sellar lesions, lymphocytic hypophysitis is associated with more acute features, including headache and bitemporal hemianopsia; and MRI presents characteristically with suprasellar extensions, symmetric and homogenous enhancement, as well as stalk enhancement. It also often presents acutely in pregnant or post-partum patients. A biopsy can be done for confirmation of the diagnosis, and steroids are given to treat the inflammation. In addition to other sellar lesions, sarcoidosis, IgG4-related disease, and other infectious or inflammatory conditions should be considered in the differential diagnosis. |
| Transcript |
So today, we are going to be talking to you about lymphocytic hypophysitis. It's lymphocytic, because it's cells (-cyto), which are lymphocytes. And it's going to be infiltrating inflammation (-itis) in the hypophysis, either the adenohypophysis or the neurohypophysis of the pituitary gland. And so, the clinical presentation of this is going to be like any sellar lesion involving the optic chiasm: either optic neuropathies or junctional scotomas, like the junctional scotoma or the junctional scotoma of Traquair or the bitemporal hemianopsia, which would be the classic, or even optic tract homonymous hemianopsia. So, we can mimic pituitary adenoma, and that is the main consideration in the differential diagnosis. The MRI scan is going to show the sellar mass with suprasellar extension compressing the chiasm. The clinical features that suggest that it might be lymphocytic hypophysitis are the acute nature of the inflammatory process in LH: acute with headache, bitemporal hemianopsia. And the radiograph normally shows symmetric and homogenous enhancement - which is a little bit atypical for pituitary adenoma, which is usually asymmetric, causes stalk deviation, and is inhomogeneous (heterogenous) in its enhancement pattern. And if we see the stalk enhancement, it's also a clue that we have an infiltrative process, like hypophysitis, rather than a compressive lesion, like pituitary adenoma. And it often occurs in the setting of pregnancy or post-partum. And so, if you've got an acute bitemporal hemianopsia in a pregnant patient, you're going to be worried about pituitary adenoma and pituitary apoplexy; but if we see symmetric and homogenous enhancement or stalk enhancement, we really should be thinking about lymphocytic hypophysitis. And in that setting, even though a biopsy may be necessary to confirm the diagnosis, steroids are the treatment initially, because it's inflammatory. So, because lymphocytic hypophysitis might respond to steroids, we're going to give steroids. And we're going to be looking for what else can mimic lymphocytic hypophysitis on an idiopathic basis, because it doesn't have to be lymphocytes. It could be sarcoidosis, or it could be inflammatory infiltrative disease from IgG4. And that means we are going to be looking elsewhere in the body: CAT scan or PET scan of the chest looking for hilar lymphadenopathy or other evidence of pulmonary involvement in sarcoid or IgG4 infiltration in other organ systems; retroperitoneal or other glands, parotid, lacrimal gland, other glands can be infiltrated with IgG4 disease. And then the infectious and inflammatory conditions also have to be considered in the differential. The usual suspects - we would call that syphilis, ANCA-related disease, all sorts of things that could mimic an infiltrative process at the level of the pituitary gland. So, you should be worried about lymphocytic hypophysitis in an acute presentation of a bitemporal hemianopsia in a pregnant lady. You're going to do the MRI scan. If we see symmetric, homogenous enhancement or stalk involvement or if they're presenting with diabetes insipidus - that is a very atypical feature of pituitary adenoma - you should be thinking about infiltrative processes. You might have to have a biopsy to confirm the diagnosis. We're going to treat it with steroids. And we are going to work it up for sarcoid, IgG4, and the usual suspects. |
| Date |
2021-06 |
| Language |
eng |
| Format |
video/mp4 |
| Type |
Image/MovingImage |
| Collection |
Neuro-Ophthalmology Virtual Education Library: Andrew G. Lee Collection: https://novel.utah.edu/Lee/ |
| Publisher |
North American Neuro-Ophthalmology Society |
| Holding Institution |
Spencer S. Eccles Health Sciences Library, University of Utah, 10 N 1900 E SLC, UT 84112-5890 |
| Rights Management |
Copyright 2019. For further information regarding the rights to this collection, please visit: https://NOVEL.utah.edu/about/copyright |
| ARK |
ark:/87278/s6g50q25 |
| Setname |
ehsl_novel_lee |
| ID |
1701572 |
| Reference URL |
https://collections.lib.utah.edu/ark:/87278/s6g50q25 |
