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

Abstract

Pituitary tuberculoma is extremely rare, even in endemic regions of tuberculosis and much less frequently as a presentation of pituitary apoplexy. We describe a 25-year-old female presented with sudden onset of headache and vision loss of left eye which mimicking symptoms of pituitary apoplexy. MRI of the pituitary gland showed a rim-enhancing lesion at the intrasellar region extending into the suprasellar area, but absence of posterior bright spot with enhancement of the pituitary stalk. Pituitary hormonal evaluation revealed panhypopituitarism and diabetes insipidus. An urgent transphenoidal surgery of the pituitary gland was undertaken for which the histopathology showed necrotizing granulomatous inflammation with infarcted adjacent pituitary tissue. Despite negative fungal and AFB staining, pituitary tuberculoma was presumptively diagnosed based on imaging, pathology and the high incidence of tuberculosis in the country. After the course of anti-tuberculosis therapy, the clinical findings were dramatically improved, supporting the diagnosis. Pituitary tuberculoma is extremely rare in particular with an apoplexy-like presentation but should be one of the differential diagnosis list of intrasellar lesions in the patient presenting with sudden onset of headache and visual loss. The presence of diabetes insipidus and thickened with enhancement of pituitary stalk on MRI were very helpful in diagnosing pituitary tuberculosis.

Endocrine and Metabolic Aspects of Tuberculosis

“…Patients may be relatively asymptomatic, and the endocrine abnormalities may be subtle and noted only on detailed investigation. Any portion of the pituitary (including anterior, posterior, and the stalk) or the hypothalamus can be involved; consequently, presentations can vary and include growth retardation, hypogonadism, galactorrhea-amenorrhea related to excess prolactin secretion, diabetes insipidus, and even panhypopituitarism (68, 70–74). Because of the small numbers of cases reported and the incomplete documentation of many of the reported cases, there is not a pathognomonic presentation associated with pituitary gland tuberculosis.…”

“…Appearance on CT or MRI suggests intrasellar tumor, and angiography results are normal (69, 70, 79). In some cases, thickening of the pituitary stalk, with or without pituitary extension into the sphenoid sinus, may be noted on CT or MRI (74, 80, 81). …”

“…Infrequently, hypernatremia secondary to diabetes insipidus has been recognized in patients with either pituitary tuberculosis or tuberculous meningitis (71, 74). Hyponatremia is more frequently seen in patients with active tuberculosis, with reported incidences of 11%, 43%, and 51% in three large case series (83– 85).…”

Pituitary tuberculoma with subsequent drug-resistant tuberculous lymphadenopathy: an uncommon presentation of a common disease

“…Central nervous system (CNS) tuberculosis accounts for <4% of all intracranial tumours 2. Although tuberculosis has been described as a cause of granulomatous hypophysitis, tuberculosis of the pituitary is a very rare entity.…”

Endocrine and Metabolic Aspects of Tuberculosis

“…Patients may be relatively asymptomatic, and the endocrine abnormalities may be subtle and noted only on detailed investigation. Any portion of the pituitary (including anterior, posterior, and the stalk) or the hypothalamus can be involved; consequently, presentations can vary and include growth retardation, hypogonadism, galactorrhea-amenorrhea related to excess prolactin secretion, diabetes insipidus, and even panhypopituitarism (68,(70)(71)(72)(73)(74). Because of the small numbers of cases reported and the incomplete documentation of many of the reported cases, there is not a pathognomonic presentation associated with pituitary gland tuberculosis.…”