Pituitary tuberculosis presenting as pituitary apoplexy

Field: Medicine (Health Sciences)

Pituitary tuberculosis (TB) is an uncommon form of intracranial TB. Isolated pituitary TB in the absence of other forms of intracranial or systemic TB is extremely rare and difficult to diagnose. Very few cases of isolated pituitary TB are documented in the literature.1Harzallah L. Migaw H. Harzallah F. Kraiem C. Imaging features of intrasellar tuberculoma: two cases.Ann Endocrinol (Paris). 2004; 65: 209-212Crossref PubMed Scopus (7) Google Scholar, 2Singh S. Pituitary tuberculoma: magnetic resonance imaging.Neurol India. 2003; 51: 548-550PubMed Google Scholar, 3Desai K.I. Nadkarni T.D. Goel A. Tuberculomas of the hypophysis cerebri: report of five cases.J Clin Neurosci. 2003; 10: 562-566Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar, 4Paramo C. de L. Nodar A. Miramontes S. Quintela J.L. Garcia-Mayor R.V. Intrasellar tuberculoma—a difficult diagnosis.Infection. 2002; 30: 35-37Crossref PubMed Scopus (17) Google Scholar, 5Sharma M.C. Arora R. Mahapatra A.K. Sarat-Chandra P. Gaikwad S.B. Sarkar C. Intrasellar tuberculoma—an enigmatic pituitary infection: a series of 18 cases.Clin Neurol Neurosurg. 2000; 102: 72-77Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar They usually mimic a pituitary adenoma. Until now only one case has been reported presenting with 'pituitary apoplexy'.6Arunkumar M.J. Rajshekhar V. Intrasellar tuberculoma presenting as pituitary apoplexy.Neurol India. 2001; 49: 407-410PubMed Google Scholar We report another case of pituitary TB presenting with sudden onset headaches and neuro-deficits mimicking a pituitary apoplexy. A 27-year-old female patient, living in Kolkata, India presented with a history of sudden onset of headaches followed by left ptosis and left facial numbness. She had no history of pulmonary or systemic TB. On examination she was found to be drowsy and obtunded. She had tachycardia (pulse 92/min) but her blood pressure was normal. Her Glasgow Coma Score was 13 (E3, M6, V4). She had left-sided complete ptosis and her direct and consensual pupillary reflexes were normal on both sides. There were no obvious visual field defects on bedside testing. She had left facial hypoesthesia in left V1 and V2 distribution. She had no other neuro-deficits or signs of endocrine disturbances. Her hormone profile did not reveal any abnormality except marginally elevated prolactin levels (150 mIU/L). Computerized tomography (CT) scan showed a sellar and suprasellar mass with evidence of hemorrhage that was enhancing brightly on contrast. A magnetic resonance imaging (MRI) scan showed well-defined sellar mass with suprasellar extension that was heterogeneously hyperintense on T-2-weighted images and there was marked heterogeneous enhancement of the mass and pituitary stalk on post-gadolinium scan (Figure 1A ). With an initial diagnosis of pituitary adenoma with apoplexy, the patient underwent trans-sphenoidal excision of the pituitary tumor. Intra-operatively, the sellar mass was firm, gray, fibrous and densely adherent to the surrounding structures and was partially excised. Histopathology showed dense aggregates of lymphoid cells with occasional plasma cells around a few ill-defined granulomas composed of epitheloid cells and Langhans' type multinucleated giant cells (Figure 1B). There was no evidence of acid-fast bacilli (AFB) and AFB culture was negative. Histological diagnosis was that of granulomatous inflammation of pituitary suggestive of tuberculosis. These histological findings coupled with pituitary stalk thickening on the post-contrast MRI and the fact that the patient lived in a TB endemic area pointed towards a diagnosis of pituitary TB rather than lymphocytic hypophysitis or sarcoidosis. The post-operative course was uneventful except for a transient diabetes insipidus. She was started on anti-TB medication after histological diagnosis. Her ptosis and numbness improved completely within three weeks after operation. A post-operative hormone profile repeated after 6 months was normal and follow-up MRI showed complete resolution of the granuloma. Though tuberculomas form 0.15 to 4% of all intracranial lesions, isolated pituitary TB is rare. Clinically and radiologically, it is difficult to distinguish pituitary tuberculomas from pituitary adenomas. A history of extracranial tuberculosis in the past associated with radiological findings like leptomeningeal enhancement, parenchymatous brain tuberculomas or a thickened pituitary stalk on contrast MRI, are indicative of the possibility of pituitary tuberculosis.3Desai K.I. Nadkarni T.D. Goel A. Tuberculomas of the hypophysis cerebri: report of five cases.J Clin Neurosci. 2003; 10: 562-566Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar Pituitary TB presenting as 'apoplexy-like' symptoms has only been reported once before in the literature.6Arunkumar M.J. Rajshekhar V. Intrasellar tuberculoma presenting as pituitary apoplexy.Neurol India. 2001; 49: 407-410PubMed Google Scholar Pituitary apoplexy is seen in 6 to 10% of all pituitary tumors and presents with intense headaches, sudden neurological deficits like ptosis or visual impairment and altered sensorium.7Wakai S. Fukushima T. Teramoto A. Sano K. Pituitary apoplexy: its incidence and clinical significance.J Neurosurg. 1981; 55: 187-193Crossref PubMed Scopus (341) Google Scholar In these patients early surgical decompression is warranted as it prevents persistent neuro-ophthalmic deficit. It is well documented that the efficacy of surgery for the relief of neuro-ophthalmic symptoms decreases with increasing duration of symptoms.8Elsasser Imboden P.N. De Tribolet N. Lobrinus A. Gaillard R.C. Portmann L. Pralong F. et al.Apoplexy in pituitary macroadenoma: eight patients presenting in 12 months.Medicine (Baltimore). 2005; 84: 188-196Crossref PubMed Scopus (44) Google Scholar It has been speculated that tuberculous vasculitis can cause ischemic or hemorrhagic necrosis in the tuberculoma, pituitary gland or adjacent tissue and could give rise to these symptoms.6Arunkumar M.J. Rajshekhar V. Intrasellar tuberculoma presenting as pituitary apoplexy.Neurol India. 2001; 49: 407-410PubMed Google Scholar The main role of surgery in pituitary TB is to achieve diagnosis and decompression3Desai K.I. Nadkarni T.D. Goel A. Tuberculomas of the hypophysis cerebri: report of five cases.J Clin Neurosci. 2003; 10: 562-566Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar, 6Arunkumar M.J. Rajshekhar V. Intrasellar tuberculoma presenting as pituitary apoplexy.Neurol India. 2001; 49: 407-410PubMed Google Scholar, 9Chandy M.J. Thickening of the pituitary stalk: suggestive of intrasellar tuberculoma.Neurosurgery. 1995; 37: 1232-1233Crossref PubMed Scopus (12) Google Scholar and the preferred route is trans-sphenoidal.9Chandy M.J. Thickening of the pituitary stalk: suggestive of intrasellar tuberculoma.Neurosurgery. 1995; 37: 1232-1233Crossref PubMed Scopus (12) Google Scholar, 10Ranjan A. Chandy M.J. Intrasellar tuberculoma.Br J Neurosurg. 1994; 8: 179-185Crossref PubMed Scopus (58) Google Scholar Histologically the differential diagnoses of intrasellar granulomas include lymphocytic hypophysitis, sarcoidosis or Langerhans' histiocytosis.11Manghani D.K. Gaitonde P.S. Dastur D.K. Pituitary tuberculoma—a case report.Neurol India. 2001; 49: 299-301PubMed Google Scholar Trans-sphenoidal excision followed by a proper histological diagnosis and long-term anti-TB chemotherapy generally leads to a good outcome. In conclusion, pituitary TB presenting as pituitary apoplexy is very rare. This is only the second case reported in the literature. A high index of clinical suspicion of pituitary TB is warranted in endemic areas, even when the patient presents with apoplexy-like symptoms.