A Case of Possible Neurosarcoidosis Presenting as Intractable Headache and Panhypopituitarism

Sarcoidosis is a chronic multisystemic inflammatory disease of unknown etiology, which is characterized by noncaseating granulomatous inflammation of the involved organs. It is known that neurosarcoidosis involving the nervous system occurs in about 5% of patients with sarcoidosis. However, neurosarcoidosis without systemic involvement is extremely rare. We present a case of suspicious neurosarcoidosis affecting the pituitary gland, which was manifested as chronic uncontrolled headache, panhypopituitarism, central diabetes insipidus, and hypercalcemia. Though the biopsy at the pituitary lesion was not performed due to the high risk of surgical complication, treatment was needed urgently and we started steroid therapy. After steroid therapy, we observed the immediate symptom relief with improved hypercalcemia. According to the follow-up examination, no recurrent symptom was seen, and resolution of the pituitary lesion with improving panhypopituitarism was noted. 1. Introduction Sarcoidosis is a noncaseating granulomatous disease that can affect any system of the body [1]. Neurosarcoidosis involves the nervous system and occurs in less than 5% of patients with systemic sarcoidosis. Isolated neurosarcoidosis without systemic involvement is extremely rare [2]. We describe a case of possible neurosarcoidosis of the pituitary gland without any other systemic involvement. The patient presented with panhypopituitarism, central diabetes insipidus, and hypercalcemia. Sellar magnetic resonance imaging (MRI) showed an infiltrating mass of the pituitary gland with invasion of stalk and cavernous sinus. Steroid therapy resulted in the resolution of the pituitary lesion on sellar MRI and all symptoms. 2. Case Presentation A 39-year-old man presented to our clinic with nausea and headache. He reported that these symptoms had waxed and waned for five years and were aggravated for three weeks before admission. His medical history revealed that he had been diagnosed with a pituitary microadenoma at the age of thirty four with symptoms of polyuria, polydipsia, and severe headache. Initial sellar MRI showed a pituitary microadenoma with stalk deviation and thickening (Figure 1(a)). An anterior pituitary function test revealed minimal elevation of prolactin (20.2？ng/mL) with no other significant abnormalities. He began to take lisuride hydrogen maleate, which decreased his serum prolactin level. Although intranasal vasopressin therapy significantly relieved the polyuria and polydipsia, his headache did not subside, and, thus, intermittent low-dose steroid therapy was