Pituitary apoplexy syndrome as the manifestation of intracranial tuberculoma

Abstract

Pituitary apoplexy syndrome is characterised by acute neuro-ophthalmological features and usually occurs due to bleeding in a pituitary adenoma. It is an unusual presentation of tuberculoma, as only few similar cases have been reported previously. A 17-year-old girl presented with headache, vomiting, altered sensorium and vision loss. MRI of the brain revealed ring enhancing sellar lesions with other enhancing lesions and leptomeningeal enhancement. Cerebrospinal fluid microscopy, biochemistry and PCR for tuberculosis confirmed tubercular meningitis. The patient was treated with antituberculous therapy and was asymptomatic at the end of treatment.

Clinical and imaging features of pituitary apoplexy and role of imaging in differentiation of clinical mimics

“…It is possible that this peculiar vascularity and sudden alterations in perfusion pressure by various triggering factors (Table 1) (25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37), may predispose to sudden hemorrhage and/or infarction in micro adenomas as well as non-adenomatous lesions. Diabetes and arterial hypertension do not predispose patients to PA as reported in previous studies (16).…”

“…Moreover, the existence of an adenoma is not often suspected at the time of PA episode because in more than 80% of the patients, PA is often the first presentation of an underlying pituitary tumor (especially nonfunctioning adenomas) (9,10). However, apoplexy can also occur in non-adenomatous lesions, such as craniopharyngioma (14), Rathke's cleft cyst (RCC) (15), sellar tuberculoma (16), hypophysitis (17,18), sellar abscess (19), sellar metastasis (20), or even in normal pituitary gland during peri or post-partum period as a consequence of sever hypovolemic shock (Sheehan's syndrome) (21).…”

Pituitary tuberculoma: A consideration in the differential diagnosis in a patient manifesting with pituitary apoplexy-like syndrome

“…To best of our knowledge, there were 81 case reports of pituitary tuberculoma until now and only 3 cases presented with apoplexy-like symptoms ( Table 1 ) [6] , [7] , [8] . In the summary of 81 cases ( Table 1 and Supplemental material), mean age was 34.1 ± 13.6 years (range, 8–68 years) and majority of them were female (72.8%) without underlying diseases.…”

“…The pituitary apoplexy-like symptoms could be resulted from caseous necrosis within the tuberculoma itself [6] , [8] or may be partly explained by infarction of normal pituitary gland seen in histopathology. Tuberculous vasculitis may be the cause of ischemic or hemorrhagic necrosis in tuberculoma, pituitary gland or adjacent tissue [7] .…”

“…Pituitary apoplexy is a rare condition that occurs only 2–7% in pituitary adenoma and characterized by acute infacrtion and/or hemorrhage of the pituitary gland [5] . Moreover, pituitary tuberculoma manifesting as apoplexy is extremely rare [6] , [7] , [8] . Without history of fever or multi-organ tuberculosis, the diagnosis of pituitary tuberculoma in a patient with apoplexy-like presentation is even harder to establish.…”