An unusual association of acromegaly and pituitary tuberculosis

A Rare Case of Headache in a Patient With McCune-Albright Syndrome: A Triple Threat

A 26-year-old male presented with facial asymmetry since 11 years of age and painless progressive diminution of vision in the left eye since 16 years of age. He presented with an exacerbation of headaches for the past two months. On examination, he was tall and had acral enlargement, craniofacial deformity, and bilateral asymmetric testicular enlargement. Investigations revealed high insulin-like growth factor 1, non-suppressible growth hormone on oral glucose tolerance tests, and multiple pituitary hormone deficiencies. MRI showed pituitary macroadenoma with craniofacial and sphenoid fibrous dysplasia as well as multiple tuberculomas. Cerebrospinal fluid testing showed high protein, low glucose, and high adenosine deaminase, all consistent with a diagnosis of central nervous system (CNS) tuberculosis. His headache did not respond significantly to either octreotide or zoledronic acid. The patient was then initiated on antitubercular therapy, which led to near-complete resolution of the headache and CNS lesions within three months of therapy. CNS tuberculosis was a masquerader in the index case of acrogigantism due to McCune-Albright syndrome. Headaches may be multifactorial in a given case of acromegaly, and investigating for alternative or additional causes especially when dealing with treatment-refractory cases can be rewarding.

Invasive sphenocavernous aspergilloma complicating an operated case of acromegaly

There is a surge in fungal infections of the central nervous system due to an increase in the incidence of immunocompromised state and widespread use of antimicrobials. Despite myriad clinical presentations and skull base syndromes associated with Aspergillus infections, aspergilloma in the sella is relatively rare. We report a rare case of aspergilloma of the sella and parasellar region in a patient operated for acromegaly. A 30-year-old diabetic patient underwent two surgeries for a growth hormone-secreting pituitary adenoma, which included a transsphenoidal approach. During his last admission, magnetic resonance imaging revealed a heterogeneous mass in the sella, suprasellar region, sphenoid sinus, and cavernous sinus with multiple areas of necrosis. His presentation, surgical treatment, and response to antifungal therapy are discussed. The role of prior surgery and related comorbidities in developing the invasive granuloma are highlighted.

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.

Pituitary adenoma with tumoral granulomatous reaction

Herein, we report a unique case of an adult male with a corticotrophic pituitary adenoma of silent subtype 1 exhibiting conspicuous idiopathic tumoral noncaseating granulomatous inflammation. The lesion was unassociated with clinical or laboratory evidence of either systemic sarcoidosis or infection. Histochemical and polymerase chain reaction (PCR) studies revealed neither fungi nor tubercle bacilli. We suggest that tumoral production of an as yet uncharacterized antigen may have induced the granulomatous inflammatory reaction.