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Lee, Kim, Lee, Jeong, Kim, Song, and Jo: A Case of Giant Cell Granulomatous Hypophysitis with Recurrent Hypoosmolar Hyponatremia
Case Report
Endocrinology and Metabolism

Endocrinology and Metabolism 2010; 25(4): 347-353.

Published online: 31 December 2010

DOI: https://doi.org/10.3803/EnM.2010.25.4.347

A Case of Giant Cell Granulomatous Hypophysitis with Recurrent Hypoosmolar Hyponatremia

Yun-Hyeong Lee, Yong-Bum Kim1, Ju-Hee Lee, Kyoung-Hye Jeong, Min-Kyeong Kim, Kyu-Sang Song1, Young-Suk Jo

Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea.

1Department of Pathology, Chungnam National University School of Medicine, Daejeon, Korea.

Corresponding author: Young-Suk Jo. Department of Internal Medicine, Chungnam National University School of Medicine, 640 Daesa-dong, Jung-gu, Daejeon 301-721, Korea. Tel: +82-42-280-7150, Fax: +82-42-280-7995, ysmrj@cnu.ac.kr

Received 10 April 2010       Accepted 4 August 2010

Copyright © 2010 Korean Endocrine Society

Abstract

A 39-year-old woman presented with a 20 day history of recurrent hypoosmolar hyponatremia. Because her volume status seemed to be normal, the most suspected causes of her hyponatremia were adrenal insufficiency and hypothyroidism. Endocrinologic examination, including a combined pituitary function test, showed TSH and ACTH deficiency without GH deficiency, and hyperprolactinemia was also present. Sella MRI showed a pituitary mass, stalk thickening and loss of the normal neurohypophysial hyperintense signal on the T1 weighted image. Pathologic exam demonstrated granulomatous lesions and Langhans' multinucleated giant cells with inflammatory cell infiltration. After high dose methylprednisolone pulse therapy (1 g/day for 3 days) with subsequent prednisolone and levothyoxine replacement, there was no more recurrence of the hyponatremia. The sella MRI on the 6th month showed decreased mass size, narrowed stalk thickening and the reappearance of the normal neurohyphophysial hyperintense signal. She is currently in a good general condition and is receiving hormone replacement therapy.

Keywords: Granulomatous hypophysitis, Hypoosmolar hyponatremia, Methylprednisolone pulse therapy

Figures and Tables

Fig. 1
(A, B) T1-wieghted image of the sella MRI shows homogenously contrast-enhanced soft tissue mass with enlarged pituitary stalk (arrows and arrowheads, respectively). Notice the non-visualization of T1-high signal intensity of the neurohypophysis. (C, D) Follow up MRI of 6 month after High Dose Methylprednisolone Pulse Therapy and prednosolone replacement: Notice the decreased size of remained pituitary mass and improved pituitary stalk thickening (arrows and arrowheads, respectively) with faintly reappeared hyperintense neurohypophysial signal (see the boxed area on right upper part in C).
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Fig. 2
(A, B) The histologic finding of the inflammatory pituitary tissue. Notice a granulomatous lesion (arrows on A) and Langhans' multinucleated giant cell (arrows on B) with lymphocyte infiltration (H&E stain, × 200: A, × 400: B).
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Table 1
Basal pituitary hormone, before treatment
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T4, thyroxine; T3, tri-iodothyronine; TSH, thyroid stimulating hormone; ACTH, adrenocorticotropic hormone; LH, luteinizing hormone; FSH, follicle stimulating hormone; ADH, antidiuretic hormone.

Table 2
Combined pituitary function test, before treatment
enm-25-347-i002

ACTH (adrenocorticotropic hormone) 20.6 pg/mL, Estradiol (E2) 10 pg/mL, Progesterone < 0.03 ng/mL.

TSH, thyroid stimulating hormone; PRL, prolactin; LH, luteinizing hormone; FSH, follicle stimulating hormone; HGH; human growth hormone; GH, growth hormone.

Table 3
Combined pituitary function test after treatment
enm-25-347-i003

ACTH 36.4 pg/mL, Estradiol (E2) 36.4 pg/mL, free T4 1.48 ng/dL.

TSH, thyroid stimulating hormone; PRL, prolactin; LH, luteinizing hormone; FSH, follicle stimulating hormone; HGH; human growth hormone.

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