PMC5854641_01
Brain magnetic resonance imaging (MRI) sections. Brain MRI, showing a homogenous and diffuse pituitary enlargement of up to 1.1 cm, which extended to the suprasellar region and contacted the optic chiasm, blurring of the pituitary stalk, absence of clear differentiation between the anterior and posterior lobes, and no signs of hemorrhage or adenomas. (A) Frontal T1-weighted after gadolinium; (B) frontal T2-weighted; and (C) sagittal T1-weighted after gadolinium.
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F1
One year later, a new MRI was performed due to headache persistence, which revealed a homogenous and diffuse pituitary enlargement of up to 1.1 cm, which extended to the suprasellar region and contacted the optic quiasm, blurring of the pituitary stalk, absence of clear differentiation between the anterior and posterior lobes, and no signs of hemorrhage or adenomas (Figure 1).
Pituitary gland serial sections from a representative area of the patient's pituitary biopsy. Pituitary gland serial sections from a representative area of the patient's pituitary biopsy, showing the most relevant immune-histopathological findings. Note the germinal center consisting of CD20+ B cells and peripheral CD3+ T cells (classified as T lymphocytes). Both CD4+ (helper) and CD8+ (cytotoxic) lymphocytes were found, as well as abundant macrophages (CD68+). T-regulatory cells were present in germinal centers and in the periphery (Foxp3+ and PD1+). Interleukin (IL)-17 staining was found not only in infiltrating lymphocytes but also in cells of pituitary origin in both hypophysitis and normal pituitary (data not shown). (A) Staining by hematoxylin-eosin; (B) synaptophysin; (C) CD20 (note how CD20+ cells form an aggregate, resembling a lymphoid follicle); (D) CD3; (E) CD4; (F) CD8; (G) CD68; (H) IL-17; (I) FOXp3; (J) PD1; (K) GH; and (L) prolactin. Sections (A-H) are shown as 10x and sections (I-L) as 20x.
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F2
Additional immune analysis showed positivity for FOXP3, PD1, and IL-17, and negativity for IgG4 and S-100 protein (Figure 2).