Sellar-suprasellar tuberculomas in children: 2 cases and literature review

A pituitary mass is not always an adenoma: A rare case of pituitary tuberculoma in an adolescent

INTRODUCTION AND IMPORTANCE

Tuberculosis of the central nervous system is unusual and accounts for 1 % of all cases of tuberculosis in the world. The pituitary location is even scarcer.

CASE PRESENTATION

A 14-year-old girl presented with polyuria-polydipsia syndrome and menstrual irregularity. MRI showed an intrasellar lesion of the pituitary gland. She underwent transsphenoidal surgery for histopathological diagnosis and removal of the lesion. Histological findings were consistent with a tuberculoma. She was put on anti-tuberculosis drugs and is being followed up.

CLINICAL DISCUSSION

In endemic areas, pituitary tuberculosis should be considered in the differential diagnosis of pituitary tumors. The histological examination will guide the diagnosis. Sometimes, other complementary examinations such as the tuberculin skin test can be of great help when the histology is not conclusive. Medical treatment can be curative, however, surgery can be necessary for decompression.

CONCLUSION

In addition to being the first case of histologically proven primary pituitary tuberculosis in a child reported in Morocco, the present case is unique in the way that the extensive radiological examinations did not reveal any evidence of other systemic or pulmonary tuberculosis.

Pediatric sellar-suprasellar tuberculosis: A case report and review of the literature

Background

Pediatric sellar-suprasellar tuberculosis is a rare form of tuberculosis that affects the pituitary gland and surrounding areas in the brain. It can be difficult to diagnose based on clinical and radiological signs alone, as they can be similar to other pituitary masses. A combination of biological, hormonal, and imaging examinations can aid in making an accurate diagnosis. It is important to consider tuberculosis in the differential diagnosis of sellar-suprasellar masses in the pediatric population, especially in areas with a high prevalence of tuberculosis.

Case Description

A 17-year-old male with no history of illness showed up with a series of symptoms, including headaches and vision problems. A sellar-suprasellar lesion was seen on imaging, along with several minor lesions. The diagnosis of tuberculosis meningitis with cerebral and pituitary tuberculoma was made after cerebrospinal fluid analysis revealed the presence of tuberculosis. Treatment with anti-tuberculosis drugs led to clinical improvement and lesion resolution.

Conclusion

Children's sellar tuberculomas can be difficult to diagnose since they resemble other pituitary tumors. It is essential to take them into account in the differential diagnosis, especially in regions with a high incidence of tuberculosis. Long-term chemotherapy is the recommended course of treatment, and monthly follow-up visits are necessary to check hormone levels and evaluate whether a permanent hormone replacement is necessary.

Reversible Hypothalamic Obesity in a Girl with Suprasellar Tuberculoma

INTRODUCTION

Suprasellar tuberculoma are extremely rare in children and most of those patients present with headache, vomiting, visual disturbances, and hypofunction of the pituitary gland. In this case report, we present a girl with tuberculosis, who developed significant weight gain in combination with pituitary dysfunction, which recovered after antituberculosis treatment.

CASE PRESENTATION

An 11-year old girl presented with headache, fever and anorexia that progressively evolved into an encephalopathic status with cranial nerves III and VI paresis. Brain MRI showed meningeal contrast capture along cranial nerves II (including optic chiasm), III, V and VI bilaterally and multiple contrast enhancing brain parenchyma lesions. Tuberculin skin test was negative but interferon-gamma release assay was positive. The clinical and radiological working diagnosis was consistent with tuberculous meningoencephalitis. Pulse corticosteroids for 3 days and quadruple antituberculosis therapy were started and the girl demonstrated obvious improvement of her neurological symptoms. However, after a few months of therapy she developed remarkable weight gain (+20 kg in 1 year) and growth arrest. Her hormone profile revealed insulin resistance (homeostasis model assessment-estimated insulin resistance [HOMA-IR] 6.8) despite putative growth hormone deficiency (circulating insulin-like growth factor-I [IGF-I] 104 μg/L [-2.4 SD]). Follow-up brain MRI showed a decrease in basal meningitis, but increased parenchymal lesions in the suprasellar region extending medially into the nucleus lentiformis, with now a voluminous tuberculoma at this site. Antituberculosis treatment was continued for a total of 18 months. The patient improved clinically, she regained her pre-illness Body Mass Index (BMI) SDS and her growth rate increased slightly. On the hormonal side, disappearance of insulin resistance (HOMA-IR 2.5) and an increase in IGF-I (175 μg/L, -1.4 SD) was noted, and her last brain MRI showed a remarkable volume reduction of the suprasellar tuberculoma.

CONCLUSION

Suprasellar tuberculoma can have a very dynamic presentation during the active stage of the disease, which can be reversed by prolonged antituberculosis treatment. Previous studies showed that the tuberculous process can also cause long term and irreversible changes in the hypothalamic-pituitary axis. Prospective studies are however needed in the pediatric population to know the exact incidence and type of pituitary dysfunction.

Pediatric Neurotuberculosis: A cases series and review of the literature

Neurotuberculosis or central nervous system tuberculosis is a form of tuberculous infection that affects any part of the nervous system. Although it is more frequent in adults, pediatric cases have been reported in endemic countries and it is potentially a deadly affection. Therefore, any unusual neurological manifestation in a formerly healthy child, independently of their vaccination status, must bring suspicion of CNS tuberculosis among other diagnoses. We report four cases of pediatric neurotuberculosis with various clinical presentations and outcome and a brief review of the litterature. We conclude that clinical manifestations of pediatric neurotuberculosis are extremely variable and could be misleading. Extra-neurological sites are a key element for diagnosis especially in the pediatric population. A diagnosis and clinical outcome score, especially designed for children might help personalize the therapeutic approach and outcome measures.

Primary pituitary tuberculosis

Tuberculosis is an infectious disease that involves any organ. However, the primary pituitary tuberculosis is an extremely rare disease. Intracranial tuberculomas account for 0.15-5% of intracranial space-occupying lesions, of which, pituitary as the primary site is unusual, and easily misdiagnosed as pituitary adenoma. In this setting, the late diagnosis can result in permanent endocrine dysfunction. We report the case of a 50-year-old woman who presented to the neurosurgery outpatient department with complaints of progressively increasing headache and diminished vision over the last year. On the clinical examination, the patient was conscious and oriented. The routine hematological and biochemical workup showed an increased erythrocyte sedimentation rate (ESR) and increased prolactin levels. The radiological working diagnosis was consistent with pituitary macroadenoma. No other radiological and/or clinical clue that could elicit the suspicion of pulmonary or extrapulmonary lesions of tuberculosis was found. The transsphenoidal endonasal tumor excision was done. The histopathology showed numerous epithelioid cell granulomas, Langhans giant cells along with scant necrosis. Ziehl Neelsen staining demonstrated acid-fast bacilli, and the final diagnosis of pituitary tuberculoma was made. We report this rare case of pituitary lesion that may be included in the differential diagnosis of sellar lesions to avoid unnecessary surgical interventions, especially in regions where the disease is endemic.

MRI in intracranial tuberculosis: Have we seen it all?

Tuberculosis is emerging worldwide across diverse populations and geographies; unrestricted by the social divide and the geographical barriers in today's interconnected world. This rise in its prevalence can be linked to multiple factors including urbanisation, spurt in global travel, population explosion, migration and HIV infection. The varied and complex clinical presentation of intracranial tuberculosis tricks even the best of the clinicians. This along with the other facets associated with its management including drug resistance, paradoxical reaction, underlying HIV infection can make it particularly challenging. Imaging has a definitive role in the evaluation and follow-up of intracranial tuberculosis and MRI is the cornerstone in this regard. Typical features of intracranial tuberculosis are well-described. However, it is not infrequent to encounter atypical and bizarre presentations, both clinically and on imaging. A holistic clinical and imaging review of difficult cases, including newer MRI techniques, is necessary for the neuroradiologist, neurologist and the neurosurgeon to arrive at the right diagnosis in a timely fashion.

A study of neuroendocrine dysfunction in patients of tuberculous meningitis

BACKGROUND

Endocrine dysfunction is known to occur in various infectious diseases of the brain. The neuroendocrine dysfunction is not well studied in patients of Tuberculous meningitis (TBM). In this study, we aimed at knowing pattern of endocrine dysfunction in newly diagnosed patients of tuberculous meningitis, structural changes occurring in hypothalamic-pituitary region, assessing its predictors and correlative factors related to outcome.

MATERIALS AND METHODS

This was a prospective observational study. All newly diagnosed patients of tuberculous meningitis were subjected to clinical, laboratory, and hormonal evaluation along with neuroimaging of hypothalamic-pituitary region. All the patients were treated with antituberculous drugs along with corticosteroids as per WHO guidelines. The clinical outcomes of the patients were assessed at the end of 3months.

RESULTS

Out of 115 patients enrolled in the study, endocrine dysfunction was seen in 62 (53.9%) patients. Out of these 62 patients, single axis involvement was seen in 35 (30.4%) patients, while multiple axis dysfunction was observed in 27 (23.5%) patients. Most common hormonal axis involved was gonadotropic axis (33.9%) followed by hyperprolactinemia (22.6%), thyrotropic axis (17.4%), corticotropic axis (13%), SIADH (Syndrome of Inappropriate Antidiuretic Hormone secretion) (9.6%) and somatotropic axis (7.8%). None had diabetes insipidus. The presence of multiple cranial nerve palsies, hypotension, stage II and III of TBM, baseline MBI ≤12 and basal exudates were significantly higher in endocrine dysfunction group, while the presence of basal exudates independently predicted the occurrence of endocrine dysfunction on multivariate analysis. Though the poor outcome was significantly higher in endocrine dysfunction group at the end of 3months, on multivariate analysis factors independently associated with poor outcome were the presence of altered sensorium and stage III of TBM.

CONCLUSION

Endocrine dysfunction occurs in a significant proportion of patients with tuberculous meningitis. The presence of basal exudates is significantly associated with the occurrence of endocrine dysfunction. Patients with endocrine dysfunction had a poorer outcome although it was not an independent predictor of the same nor associated with increased mortality.

Third ventricular tuberculoma mimicking as a tumor: Report of a very rare case

Intracranial tuberculoma is a common neurosurgical problem in developing countries; however, intraventricular tuberculoma is a rare entity. Here, we report a rare case of third ventricular tuberculoma in a 21-year-old girl who presented with features of raised intracranial pressure. Radiological findings and management of third ventricular tuberculoma would be discussed and literature regarding such lesions will be reviewed.

Reversible hypopituitarism with pituitary tuberculoma

A 50-year-old woman presented with a headache and nausea. A sellar and suprasellar mass was detected on MRI; the tumor was heterogeneously enhanced with gadolinium, and the pituitary stalk was slightly thickened. Laboratory tests revealed severe growth hormone, luteinizing hormone, follicle-stimulating hormone and thyroid-stimulating hormone deficiencies. A pathological examination of the tumor showed scattered granulomas with central necrosis and Langhans giant cells. Tuberculin skin and QuantiFERON TB-Gold tests (QFT-2G) were positive. Accordingly, we diagnosed the patient with pituitary tuberculoma presenting with pituitary dysfunction. Following treatment with antituberculous drugs, the pituitary hormone function normalized and the pituitary tuberculoma disappeared.

Paradoxical reaction in HIV negative tuberculous meningitis

This review focusses on paradoxical reactions occurring during the treatment of tuberculous meningitis (TBM) in human immunodeficiency virus-negative cases. A paradoxical reaction is defined as the worsening of a pre-existing lesion or the appearance of new lesion in a patient whose clinical symptoms initially improved with anti-tuberculosis treatment. A number of different paradoxical reactions have been reported in patients with TBM including expansion of existing cerebral tuberculomas, and appearance of new tuberculomas, hydrocephalus, and optochiasmatic and spinal arachnoiditis. While the exact mechanism of paradoxical reactions is uncertain, an exaggerated immune reaction against Mycobacterium tuberculosis-associated antigens is currently the most accepted theory for tuberculous paradoxical reaction. Corticosteroids are considered to have a beneficial effect in the management of paradoxical reactions. Immuno-modulatory drugs, including tumor necrosis factor-α antagonists, thalidomide and interferon-γ have been used in isolated cases with more severe forms of paradoxical reactions.

Childhood tubercular meningitis: an institutional experience and analysis of predictors of outcome

Tubercular meningitis constitutes an important cause of morbidity and mortality in developing countries, and various factors determine its outcome. We studied demographic and clinical profiles of childhood tubercular meningitis, and identified predictors of outcome. This prospective study was performed in 65 children aged ≤ 18 years, hospitalized with a diagnosis of tubercular meningitis. Boys outnumbered girls. Most patients presented with a poor clinical grade. Headache and vomiting comprised common features. Cerebrospinal fluid was characterized by predominant lymphocytosis. Many patients were diagnosed for Mycobacterium tuberculosis via polymerase chain reaction. Hydrocephalus comprises a common finding via computed tomography. Low Glasgow Coma Scores, seizures, basal exudates, and infarcts predict outcomes. Children with headaches, fevers, and altered sensorium should be investigated promptly for tubercular meningitis. Timely intervention may lead to early diagnoses and reductions in morbidity and mortality.