Intrasellar tuberculoma--an enigmatic pituitary infection: a series of 18 cases

Pituitary tuberculoma with panhypopituitarism masquerading as a pituitary adenoma

Tuberculosis of the hypothalamo-pituitary axis is extremely uncommon. The presentation of panhypopituitarism in a case of sellar tuberculosis is an even rarer occurrence. We present a case of a 44-year-old man who presented with complaints of headache and right-sided diminution of vision for six months. A hormone profile showed abnormal anterior pituitary assay suggestive of panhypopituitarism. Magnetic Resonance imaging of the brain showed a sellar mass measuring 1.8 × 1.5 × 1.3 cm with suprasellar extension suggestive of a pituitary adenoma. Histopathological examination showed multiple epithelioid cell granulomas along with Langhans giant cells and mixed inflammatory infiltrates against a necrotic background. Zeihl Neelson stain demonstrated the presence of acid-fast bacilli. Thus, a final diagnosis of pituitary tuberculoma was made, and the patient started on antitubercular therapy. It is extremely important to correctly diagnose sellar tuberculosis as the treatment is entirely different, and the patient usually responds well to therapy.

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.

A rare cause of acute hypernatraemia: Diabetes insipidus secondary to suprasellar tuberculoma

Suprasellar tuberculomas are uncommon causes of intracranial tumours worldwide, even in areas endemic for tuberculosis. Often, they present with combinations of pituitary hormone involvement, which can lead to various complications due to hypopituitarism. We present a rare case of suprasellar tuberculoma leading to diabetes inspidus.

Insights into non-classic and emerging causes of hypopituitarism

Hypopituitarism is defined as one or more partial or complete pituitary hormone deficiencies, which are related to the anterior and/or posterior gland and can have an onset in childhood or adulthood. The most common aetiology is a sellar or suprasellar lesion, often an adenoma, which causes hypopituitarism due to tumour mass effects, or the effects of surgery and/or radiation therapy. However, other clinical conditions, such as traumatic brain injury, and autoimmune and inflammatory diseases, can result in hypopituitarism, and there are also genetic causes of hypopituitarism. Furthermore, the use of immune checkpoint inhibitors to treat cancer is increasing the risk of hypopituitarism, with a pattern of hormone defects that is different from the classic patterns and depends on mechanisms that are specific for each drug. Moreover, autoantibody production against the pituitary and hypothalamus has been demonstrated in studies investigating the development or worsening of some cases of hypopituitarism. Finally, evidence suggests that posterior pituitary damage can affect oxytocin secretion. The aim of this Review is to summarize current knowledge on non-classic and emerging causes of hypopituitarism, so as to help clinicians improve early identification, avoid life-threatening events and improve the clinical care and quality of life of patients at risk of hypopituitarism.

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.

Secondary Pituitary Abscess Inside Adenoma: A Case Report and Review of Literature

BACKGROUND

Pituitary abscesses within pre-existing pituitary conditions, such as craniopharyngioma, pituitary adenoma, or Rathke cleft cyst, are quite rare. A case of pituitary abscess secondary to adenoma is presented, and the literature is reviewed.

CASE DESCRIPTION

An 11-year-old boy presented with a 3-day history of sudden-onset headache and visual loss. Magnetic resonance imaging demonstrated a sellar region lesion with intralesional hemorrhage. Preoperative diagnosis was pituitary adenoma with apoplexy. An endoscopic transnasal transsphenoidal approach was used for emergent total tumor resection. Pathology confirmed the diagnosis of pituitary adenoma with apoplexy and inflammation, and microbiologic examination was positive for Staphylococcus aureus.

CONCLUSIONS

Secondary pituitary abscess is a rare entity, and preoperative diagnosis is challenging. The treatment strategy includes prompt surgical resection and drainage of the abscess, followed by prolonged antibiotic therapy.

Pituitary Tuberculoma: An Uncommon Pathology

Pituitary tuberculomas are extremely rare with only few cases reported in the literature. Intracranial tuberculoma commonly presents with gradual onset of headache and visual disturbances with or without systemic symptoms. We reported such a case who presented with headache without any visual symptoms, occasional vomiting, and significant weight loss. Contrast magnetic resonance imaging scan was suggestive of pituitary macroadenoma. Transnasal transsphenoidal excision of the lesion (microscopic + endoscopic) was done. Histopathological examination revealed possibility of tuberculosis. Patient was put on standard antituberculosis treatment and discharged in a stable condition.

Tuberculosis: A Common Infection with Rare Presentation, Isolated Sellar Tuberculoma with Panhypopituitarism

Isolated sellar tuberculoma is a very rare condition and usually presents with headache and decreased vision. It can present with panhypopituitarism with 3^rd nerve palsy. Tuberculoma mimics pituitary adenoma clinically as well as radiologically and requires endoscopic transsphenoidal surgery and histopathological examination for the final diagnosis. We present a rare case of a 40-year-old female presented with headache, decreased vision, and unilateral 3^rd nerve palsy with panhypopituitarism.

Single center study of 53 consecutive patients with pituitary stalk lesions

BACKGROUND

The etiological spectrum of pituitary stalk lesions (PSL) is wide and yet specific compared to the other diseases of the sellar and suprasellar region. Because of the pituitary stalk's (PS) critical location and role, biopsies of these lesions are rarely performed, and their underlying pathology is often a conundrum for clinicians. A pituitary MRI in association with a clinical context can facilitate their diagnosis.

AIM

To present the various causes of PSL-their clinical, hormonal, histopathological, and MRI characteristics in order to gain better insight into this pathology.

METHOD

A retrospective observational study consisting of 53 consecutive patients with PSL of the mean age 32 ± 4.2 years (range 6-67), conducted at the Department for Neuroendocrinology, Clinical Center of Serbia 2010-2018.

RESULTS

Congenital malformations were the most common cause of PSL in 25 of 53 patients (47.1%), followed by inflammatory (9/53; 16.9%) and neoplastic lesions (9/53; 16.9%). The exact cause of PSL was established in 31 (58.4%) patients, of whom 23 were with congenital PS abnormalities and 8 with histopathology of PSL (7 neoplastic and 1 Langerhans Cell Hystiocytosis). A probable diagnosis of PSL was stated in 12 patients (22.6%): 6 with lymphocytic panhypophysitis, while Rathke cleft cyst, tuberculosis, dissemination of malignancy in PS were each diagnosed in 2 patients. In 10 patients (18.8%), the etiology of PSL remained unknown.

CONCLUSION

Due to the inability of establishing an exact diagnosis, the management and prognosis of PSL are difficult in many patients. By presenting a wide array of causes implicated in this condition, we believe that our study can aid clinicians in the challenging cases of this pathology.

Cerebral tuberculomas in a 6-year-old girl causing central diabetes insipidus

A 6-year-old girl presented acutely with worsening frontal headaches. She had a 3-month history of lethargy, reduced appetite, weight loss, cough and intermittent fevers. A chest X-ray showed a left upper lobe consolidation, and a CT head showed multiple enhancing lesions with significant surrounding oedema in both cerebral hemispheres. Due to the strong suspicion of tuberculosis (TB), she was admitted and treated with anti-TB therapy and steroids. Following this, pulmonary infection with Mycobacterium tuberculosis was confirmed by a positive PCR from induced sputum. Cerebral spinal fluid (CSF) analysis was normal and tested negative for M. tuberculosis on PCR. During her first week of treatment, she developed polyuria, nocturia and polydipsia and was diagnosed with central diabetes insipidus. She was started on desmopressin which rapidly improved her symptoms, and she was continued on desmopressin for 3 months. Currently, she remains well and has shown a good response to TB treatment.

Translabyrinthine approach to internal auditory meatus: A retrospective study

Background

Ear and the lateral skull base surgery is challenging and yet fascinating for a Neuro-otologist. A thorough knowledge of the complex anatomy is indispensable for the surgeon in order to provide the best possible care.

Methods

The aim of the study was to highlight the present day indications for translabyrinthine approach to IAM from a Neuro-otologist perspective.

Results

There were a total of 7 patients who underwent Translabyrinthine approach at our centre. In the present study we have reported cases of Vestibular Schwannoma, Facial nerve schwannoma, Cholesteatoma involving the IAM, Meniere's disease with refractory vertigo which were managed via translabyrinthine approach. We also encountered, probably the first reported case, tuberculoma of the IAM which was clinical suspected to be vestibular schwannoma.

Conclusion

The article presents different clinical situations where this approach can be suitably utilized and has been dealt with via a retrospective study encountered at our centre.

Upper Respiratory Tract Tuberculosis

Upper respiratory tract involvement in cases of tuberculosis (TB) of the head and neck continues to be described in the most recent reports from several different regions, including some from developed countries. Laryngeal TB is the most common of all forms of upper respiratory tract TB (URT-TB). Pulmonary lesions in URT-TB are present in about 20% of adults and about 50 to 60% of children. Systemic manifestations are uncommon. URT-TB is especially seen in patients with a variety of risk factors, such as the presence of human immunodeficiency virus (HIV) infection, diabetes, smoking, alcoholism, drug abuse, malignancies, and use of immunosuppressive drugs. Nodules or ulcerative lesions are seen on morphological examination. Endoscopic examination is required for mucosal lesions. Diagnosis of TB is suspected on an epidemiological basis in high-prevalence countries or from the failure of a patient to respond to routine treatment. Smear and/or histopathological examinations help in establishing the final etiological diagnosis. Treatment includes standard anti-TB chemotherapy for at least 6 months with four primary drugs during the initial intensive phase of 2 months and two or three primary drugs during the remaining maintenance phase of 4 months. Treatment is modified on the basis of culture and sensitivity reports in cases of suspected drug resistance. Surgical intervention may be required for some patients with abscess formation and progressive disease unresponsive to medical therapy. Airway obstruction, although rare, even in fulminant cases may require tracheostomy for relief.

Pituitary tuberculoma: a rare cause of sellar mass

INTRODUCTION

Pituitary tuberculosis is an uncommon cause of sellar mass [1]; the estimated prevalence worldwide is not known, and there have been no reports of the condition occurring in Ireland. Tuberculosis of the pituitary gland may present as a sellar mass or with symptoms of hypopituitarism.

CASE PRESENTATION

A 41-year-old woman, with a short prodromal history without endocrine symptoms, was found to have pituitary tuberculosis after the demonstration of a sellar mass on MRI, and lumbar puncture findings consistent with lymphocytic meningitis.

CONCLUSION

To our knowledge, this is the first published case of pituitary tuberculoma in Ireland.

Endocrine and Metabolic Aspects of Tuberculosis

Endocrine and metabolic derangements are infrequent in patients with tuberculosis, but they are important when they occur. The basis for these abnormalities is complex. While Mycobacterium tuberculosis has been described to infect virtually every endocrine gland, the incidence of gland involvement is low, especially in the era of effective antituberculosis therapy. Furthermore, endocrine and metabolic abnormalities do not always reflect direct infection of the gland but may result from physiological response or as a consequence of therapy. Metabolic disease may also predispose patients to the development of active tuberculosis, particularly in the case of diabetes mellitus. While hormonal therapy may be necessary in some instances, frequently these endocrine complications do not require specific interventions other than antituberculous therapy itself. With the exception of diabetes mellitus, which will be covered elsewhere, this chapter reviews the endocrinologic and metabolic issues related to tuberculosis.

DIAGNOSIS OF ENDOCRINE DISEASE: Expanding the cause of hypopituitarism

Hypopituitarism is defined as one or more pituitary hormone deficits due to a lesion in the hypothalamic-pituitary region. By far, the most common cause of hypopituitarism associated with a sellar mass is a pituitary adenoma. A high index of suspicion is required for diagnosing hypopituitarism in several other conditions such as other massess in the sellar and parasellar region, brain damage caused by radiation and by traumatic brain injury, vascular lesions, infiltrative/immunological/inflammatory diseases (lymphocytic hypophysitis, sarcoidosis and hemochromatosis), infectious diseases and genetic disorders. Hypopituitarism may be permanent and progressive with sequential pattern of hormone deficiencies (radiation-induced hypopituitarism) or transient after traumatic brain injury with possible recovery occurring years from the initial event. In recent years, there is increased reporting of less common and less reported causes of hypopituitarism with its delayed diagnosis. The aim of this review is to summarize the published data and to allow earlier identification of populations at risk of hypopituitarism as optimal hormonal replacement may significantly improve their quality of life and life expectancy.

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

We report a case of pituitary tuberculosis which presented as a non-functioning pituitary macroadenoma, and subsequently developed multidrug-resistant tuberculous lymphadenopathy. Pituitary tuberculosis continues to be a rare presentation of tuberculosis, but incidence and prevalence are expected to grow with increasing numbers of multidrug-resistant tuberculosis. Isolated pituitary tuberculosis is rare. Tuberculosis should be considered in the differential diagnosis in evaluation of a sellar mass.

Pituitary stalk lesions: systematic review and clinical guidance

The spectrum of pituitary stalk (PS) pathology is vast, presenting a diagnostic challenge. Published large series of PS lesions demonstrate neoplastic conditions are most frequent, followed by inflammatory, infectious and congenital diseases. Inflammatory pathologies however, account for the majority of PS lesions in published small case series and case reports. Physicians must be familiar with the major differential diagnoses and necessary investigations. A comprehensive history and thorough clinical examination is critical. Although magnetic resonance imaging of the PS in disease is nonspecific, associated intracranial features may narrow the differential diagnosis. Initial investigations include basic pathology and computer tomography imaging of the neck, chest, abdomen and pelvis. Further investigations should be guided by the clinical context. PS biopsy should be considered when a diagnosis is regarded essential in centres where an experienced neurosurgeon is available. Treatment is dependent on the underlying disease process and may necessitate pituitary hormone replacement.

Bilateral Carotid-Cavernous Fistulas: An Uncommon Cause of Pituitary Enlargement and Hypopituitarism

Carotid-cavernous fistulas (CCFs) are rare, pathologic communications of the carotid artery and the venous plexus of the cavernous sinus. They can develop spontaneously in certain at risk individuals or following traumatic head injury. Typical clinical manifestations include headache, proptosis, orbital pain, and diplopia. We report a case of bilateral carotid-cavernous fistulas associated with these symptoms and also with pituitary enlargement and hypopituitarism, which improved following surgical intervention. Arterialization of the cavernous sinus and elevated portal pressure may interfere with normal venous drainage and the conveyance of inhibiting and releasing hormones from the hypothalamus, resulting in pituitary enlargement and hypopituitarism. This condition should be considered in the differential diagnosis of hypopituitarism associated with anterior pituitary enlargement.

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

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.

Supra-sellar tubercular abscess

Intracranial tuberculomas are less common lesions; sellar, suprasellar, or parasellar involvement is further rarer with only few case reports in the literature. We describe a case of 44-year-old female, discussing the imaging findings that were managed successfully for tubercular hypothalamic-pituitary abscesses.

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.

Tuberculosis in the pituitary fossa: a common pathology in an uncommon site

Tuberculosis (TB) is an important cause of mortality and morbidity across the world. In 2–5% of all cases of systemic TB, the C is affected, with lesions reported in the meninges, cortex and ventricles. Intrasellar tuberculomas, however, are extremely rare. We report the interesting case of a young female patient who presented with secondary hypothyroidism and hyperprolactinaemia. She was treated successfully for pituitary TB. We also highlight and discuss some interesting (and hitherto unreported) endocrine issues. Radiological and histological features and treatment of pituitary TB are discussed using this case as an example.

Clinical presentation and magnetic resonance findings in sellar tuberculomas

Background and Importance. Sellar tuberculomas are extremely rare lesions with nonspecific clinical manifestations. The tuberculous infection of the pituitary gland and sellar region is characterized by the presence of an acute or chronic inflammatory reaction and may occur in the absence of systemic tuberculosis. The diagnosis is difficult prior to the surgery. An adequate diagnostic and antituberculous drugs usually result in a good outcome. Clinical Presentation. We report four cases of sellar tuberculoma, 3/1 female/male, age range: 50–57 years. All patients had visual disturbances and low levels of cortisol. Conclusion. The clinical diagnosis of sellar tuberculoma is a challenge and should be suspected when a sellar lesion shows abnormal enhancement pattern and stalk involvement, and absence of signal suppression in FLAIR.

Isolated Pituitary Tuberculoma

Pituitary tuberculomas are extremely rare, even in the developing countries where tuberculosis is endemic. We report a rare case of isolated pituitary tuberculoma mimicking a pituitary adenoma or a Rathke’s cleft cyst in Japan, a developed country. The patient was a 69-year-old woman presented with visual disturbance. Head magnetic resonance imaging (MRI) with contrast enhancement revealed an isolated intrasellar mass showing central hypointensity with an irregularly enhancing rim. She was operated on via an endoscopic transsphenoidal approach. Histopathological findings and an interferon-gamma release assay were highly suspicious of an isolated tuberculous granuloma. After proper infection control management, she was treated with four-drug antituberculous therapy (ATT). Follow-up MRI showed no recurrence 3 years after the discontinuation of ATT. An isolated pituitary tuberculoma has rarely been reported, especially in developed countries. In conclusion, neurosurgeons should consider an isolated pituitary tuberculoma as one of the differential diagnoses for pituitary tumors, because special management for infection control is required for tuberculosis. An interferon-gamma release assay is helpful for the difficult diagnosis of an isolated pituitary tuberculoma with inactive tuberculosis.

Alternative causes of hypopituitarism: traumatic brain injury, cranial irradiation, and infections

Hypopituitarism often remains unrecognized due to subtle clinical manifestations. Anterior pituitary hormone deficiencies may present as isolated or multiple and may be transient or permanent. Traumatic brain injury (TBI) is recognized as a risk factor for hypopituitarism, most frequently presenting with isolated growth hormone deficiency (GHD). Data analysis shows that about 15% of patients with TBI have some degree of hypopituitarism which if not recognized may be mistakenly ascribed to persistent neurologic injury and cognitive impairment. Identification of predictors for hypopituitarism after TBI is important, one of them being the severity of TBI. The mechanisms involve lesions in the hypothalamic-pituitary axis and inflammatory changes in the central nervous system (CNS). With time, hypopituitarism after TBI may progress or reverse. Cranial irradiation is another important risk factor for hypopituitarism. Deficiencies in anterior pituitary hormone secretion (partial or complete) occur following radiation damage to the hypothalamic-pituitary region, the severity and frequency of which correlate with the total radiation dose delivered to the region and the length of follow-up. These radiation-induced hormone deficiencies are irreversible and progressive. Despite numerous case reports, the incidence of hypothalamic-pituitary dysfunction following infectious diseases of the CNS has been underestimated. Hypopituitarism usually relates to the severity of the disease, type of causative agent (bacterial, TBC, fungal, or viral) and primary localization of the infection. Unrecognized hypopituitarism may be misdiagnosed as postencephalitic syndrome, while the presence of a sellar mass with suprasellar extension may be misdiagnosed as pituitary macroadenoma in a patient with pituitary abscess which is potentially a life-threatening disease.

Etiology, prognosis, and management of secondary pituitary abscesses forming in underlying pituitary adenomas

Pituitary abscesses occurring in pre-existing pituitary pathology like Rathke's cleft cyst or adenomas (secondary pituitary abscesses) are rare and of unclear etiology. While surgery and antibiotics have been effective in some cases reported to date, leading to the suggestion that secondary pituitary abscesses are mostly indolent, we investigated the hypothesis that infected adenomas, given their propensity to invade the paranasal sinuses and subarachnoid space, could carry a worse prognosis than uninfected adenomas or secondary abscesses forming in other pituitary pathologies. We identified infected adenomas from our center through retrospective review. Given the rarity of this diagnosis at any single center, we also reviewed published cases of secondary pituitary abscesses occurring in pituitary adenomas to look for common features. Twenty-three cases (19 from the literature and four from our center) of infected adenomas were identified. The mean age at presentation was 46 years, with 65 % male. The most common presenting symptoms were visual disturbances (83 %) and headache (65 %), followed by infectious signs like fever (39 %) and meningitis (26 %). The sphenoidal sinus was the most common site of extrasellar invasion. While good outcome occurred in 74 % of patients, and most achieved vision improvement, the mortality was 26 %. Patients with infected pituitary adenomas commonly present with visual disturbances and headache, with symptoms of infection also occurring. Surgery and antibiotics are indicated for these lesions. While the infection is more indolent than other intracranial abscesses, it is associated with high mortality even after prompt operation and antibiotic treatment.

Predictors of neoplastic disease in children with isolated pituitary stalk thickening

BACKGROUND

The significance of pituitary stalk thickening (PST) on magnetic resonance imaging (MRI) is often unclear. We evaluated presenting symptoms, MRI findings, clinical course, and outcome predictors of patients with PST.

PROCEDURE

We used a computerized search of the medical record from 1995 to 2008 to identify patients with PST without pituitary mass on MRI. Baseline and follow-up MRIs were reviewed in a blinded fashion. Relevant clinical data were abstracted.

RESULTS

69 patients with reported PST and adequate imaging for review were identified; 42 met study criteria. Median age at first abnormal MRI was 13.6 years (range: 0.8-19.7); 43% were male. Median follow-up was 3.4 years (range 0-12.8). Patients with diabetes insipidus (DI) were significantly more likely to have a neoplastic process than those without (P = 0.0008). Of 16 patients with DI, 8 (50%) had a neoplastic process, including germ cell tumor (n = 4), Langerhans cell histiocytosis (n = 3), and lymphoma (n = 1). Among patients with DI, 7 (44%) also developed anterior pituitary hormone dysfunction (APD), either at presentation or on pre-biopsy follow-up, including 6/8 patients with stalk neoplasm and only 1/8 patients with non-neoplastic PST (P = 0.04). Twenty-six patients presented without DI; none was found to have neoplasm of the stalk except one patient with craniopharyngioma. Progression of PST on follow-up imaging was significantly associated with a subsequent neoplastic diagnosis (P = 0.04).

CONCLUSION

Patients with PST without DI are unlikely to have a neoplastic process. Among patients with DI, APD or progressive stalk increase over time are predictive of neoplasia.

Pituitary tuberculoma

Tuberculosis of pituitary gland is rare. We report a case of tuberculosis of pituitary gland in a 68-year-old male presented with holocranial headache of four months duration with left temporal hemianopia, with visual acuity of 6/6, without any localizing sign. Magnetic resonance imaging showed a sellar ring enhancing mass with suprasellar extension. Patient was taken up for surgery and put on antitubercular treatment and hormone replacement therapy.

Optochiasmatic tuberculoma as the sole manifestation of late recurrent tuberculosis

Brain tuberculomas account for 10-20% of space occupying brain lesions in developing countries. Most lesions are observed at time of tuberculosis diagnosis or soon after starting treatment. We herein describe a 32 year-old patient with a 14-month history of headache and progressive visual loss. Her past medical history revealed pulmonary tuberculosis treated eight years before. A brain MRI showed a T1- and T2-weighted isointense contrast-enhancing lesion in the optic chiasm. A presumptive diagnosis of optochiasmatic tuberculoma was made and isoniazid, rifampin, pyrazinamide, and ethambutol were started. Despite treatment, the patient evolved to blindness. The prompt recognition of this condition is extremely important since the presence of optochiasmal enhancement is associated with blindness in patients with tuberculosis.

Adult hypopituitarism: Are we missing or is it clinical lethargy?

Hypopituitarism, a disease of varied etiologies, is a serious endocrine illness that requires early recognition and prompt treatment to avoid its severe deleterious effects. In adults it is often missed due to non-specific symptoms of growth hormone deficiency and hypogonadism or mild deficiencies of other pituitary hormones. In some it may present with acute onset of symptoms suggestive of acute adrenal (corticotropin) insufficiency or symptoms due to mass lesion in/or around pituitary. High index of suspicion is required to seek hypopituitarism in patients with non-specific symptoms such as fatigue and malaise. Treatment of isolated hormone deficiency, partial or panhypopituitarism, has gratifying results although they require lifelong treatment and follow-up.

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

Sellar and suprasellar tuberculomas are rare. Patients with these lesions usually experience headache, vomiting, and hypofunction of pituitary gland; imaging reveals an enhancing sellar-suprasellar mass. We report 2 rare cases of sellar-suprasellar tuberculomas in children aged 8 and 6 years. One child presented with features of headache and vomiting, and the other presented with posterior pituitary dysfunction. In both cases, imaging revealed sellar-suprasellar masses. Both cases were multidrug-resistant tuberculomas. We discuss sellar-suprasellar tuberculomas, a rare form of neurotuberculosis in the background of an overall increase in multidrug-resistant tuberculosis, especially in children.

Magnetic resonance findings in sellar and suprasellar tuberculoma with hemorrhage

Background:

Tuberculosis is endemic in many counteries like India. It can infect any site in the central nervous system. However, islolated involvement of the sellar and suprasellar region is rare. Sellar tuberculoma with hemorrhage is even more rare. We present magnetic resonance (MR) findings in case of sellar and suprasellar tuberculoma with hemorrhage.

Case Description:

A 40-year-old female patient presented with a 1-month history of persistent headache and blurred vision on the left side. A contrast-enhanced MR study revealed peripherally enhancing sellar and suprasellar mass with hemorrhage with compression of the left half of the optic chiasma. There was also evidence of infundibular thickening and enhancement of the adjacent dura. The mass was approached through a transphenoidal approach and was partially resected. Subsequent histopathology was suggestive of tuberculosis. The patient was put on anti-tubercular therapy. Patient reported significant improvement in symptoms. Follow-up MR done 8 months later confirmed complete regression of the mass.

Conclusion:

Because of its rarity, sellar tuberculoma is seldom considered in the differential diagnosis and is often mistaken for pituitary macroadenoma, which is the most common tumor in this region. Although rare, presence of infundibular thickening and enhancement of the adjacent dura should suggest the presence of a granulomatous lesion like tuberculoma.

Isolated sellar tuberculoma presenting with panhypopituitarism: clinical, diagnostic considerations and literature review

Tuberculosis, a common cause for chronic intracranial infections can mimic varied intracranial pathologies including tumours. Pituitary tuberculomas are rare lesions and are often diagnosed pre-operatively as pituitary tumours. We report a case of a 31-year-old lady with a sellar-suprasellar lesion who presented with panhypopituitarism. The patient underwent a trans-nasal, trans-sphenoidal surgical decompression of the lesion. Histopathology revealed a tuberculous lesion in the pituitary. The characteristic radiological features of sellar tuberculomas are discussed along with a review of literature. Atypical sellar radiology in the presence of a thickened pituitary stalk could point to pathology other than pituitary adenoma, possibly a chronic inflammatory condition like tuberculoma.

[Isolated hypophyseal tuberculoma: often mistaken]

Hypophyseal tuberculoma is extremely rare and difficult to diagnose without a clearly suggestive context. Its radiologic features are not specific and are better recognized on MRI with a mass of a variable signal related to the percentage of caseous necrosis. A frequently associated thickening of the pituitary stalk suggests tuberculosis, requiring the search for another tuberculosis location. This paper reports an original case of hypophyseal tuberculoma since it occurred with no other tubercular infection, which delayed the diagnosis despite thickening of the pituitary stalk on MRI.

Rare sellar lesions

Sellar masses are associated most commonly with pituitary adenomas. Many other neoplastic, inflammatory, infectious, and vascular lesions, however, may affect the sellar region and mimic pituitary tumors. These lesions must be considered in a differential diagnosis. This article describes the characteristics of rare sellar masses that provide clues to their differential diagnosis.

Isolated intrasellar tuberculoma mimicking pituitary adenoma

A 37-year-old woman presenting with galactorrhea and menstrual irregularity due to an intrasellar lesion of the pituitary gland underwent transsphenoidal surgery for histopathological diagnosis and removal of the lesion. Histological findings were consistent with a tuberculoma. The post-operative course was satisfactory with resolution of galactorrhea and improved ovulatory cycle. The patient was successfully treated with a combination of surgical resection and anti-tuberculous therapy for one year, which resulted in hormonal and tuberculosis control. This patient appears unique regarding the location of the lesion and the dramatic response to surgical treatment. Although differential diagnosis of inflammatory pathologies of the intrasellar region presents difficulties, this patient demonstrates that tuberculoma should be considered.

Granulomatous Adenohypophysitis after Interferon and Ribavirin Therapy

OBJECTIVE

To describe a case of granulomatous hypophysitis occurring after treatment with interferon alfa-2b and ribavirin for hepatitis C.

METHODS

Clinical, radiologic, laboratory, and pathologic assessments of a woman with granulomatous hypophysitis and interferon-induced thyroiditis are presented.

RESULTS

A 42-year-old woman with hepatitis C was treated with interferon alfa-2b and ribavirin for 5 months. She was referred after symptoms of thyrotoxicosis developed, in conjunction with laboratory and radiographic evidence of thyroiditis. During the initial evaluation, she was weak and hypotensive; biochemical evaluation showed undetectable plasma cortisol and corticotropin concentrations. Magnetic resonance imaging revealed diffuse enlargement of the pituitary gland, which encroached on but did not compress the optic chiasm. Treatment with supraphysiologic doses of prednisone resulted in clinical and radiographic improvement. Once physiologic doses of glucocorticoids were instituted, however, follow-up magnetic resonance imaging showed substantial progression of the diffuse pituitary enlargement and mild compression of the optic chiasm. Surgical debulking of the mass and histologic evaluation showed chronic, noncaseating granulomatous hypophysitis. An extensive evaluation for secondary causes of granulomatous inflammation of the pituitary revealed only an elevated angiotensin-converting enzyme level; no organisms were identified. After 2 courses of high-dose glucocorticoids, she had radiographic evidence of decreased size of the pituitary lesion but continued to have multiple anterior pituitary hormone deficiencies.

CONCLUSION

Granulomatous hypophysitis and sarcoidosis of the pituitary are rare disorders. Hypophysitis should be considered in patients receiving interferon and ribavirin therapy who have symptoms consistent with pituitary dysfunction.

[Pituitary tuberculosis: a case report]

Through a case of sellar and suprasellar tuberculoma which presented with central diabetes insipidus, the authors report the frequency of pituitary tuberculoma, its physiopathology, clinical presentation hormonal and radiological findings thus management and evolution. A 42 years old woman, with a history of erythema nodosum, presented with polyuria polydipsia (PUPD), amenorrhea and galactorrhea. Endocrine investigations showed central diabetes insipidus, elevated serum prolactin levels and cortisol failure. Magnetic resonance imagining scans (MRI) revealed a nodular thickening of the pituitary enlargement and loss of posterior pituitary hypointensity signal. Etiologic inquiry has removed the diagnosis of sarcoidosis, Langerhan's histosis, autoimmune hypophysitis and sellar metastasis. The history of erythema nodosum, the positivity of tuberculin skin test and the presence of koch bacillus in the bronchial fluid after culture led to a diagnosis of tuberculosis. Treatment was started with four drug antitubercular chemotherapy regimen for 2 months, and tow drug antitubercular chemotherapy regimen for 16 months. This treatment is associated with hydrocortisone, desmopressin nasal spray and bromocriptine. Under treatment, there was an improvement in clinical condition, disapearence of headache, PUPD and galactorrhea thus normalization of prolactin. A follow-up MRI, 8 months later, showed that pituitary lesion has been completely removed, suggesting our clinical and biology presumption. Pituitary tuberculosis is rare, however, when encountered, they may present a diagnostic difficulty. Accurate diagnosis and management is important because pituitary tuberculoma is curable.