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Sahara K, Shinno K, Sato K, Watari Y, Tamura T, Kudo E. A Case of Multiple Brain Tuberculomas in the Subarachnoid Cisterns: Recognition of Radiological Characteristics Regarding the Development of Paradoxical Response during Antituberculosis Treatment. NMC Case Rep J 2024; 11:93-98. [PMID: 38666034 PMCID: PMC11043798 DOI: 10.2176/jns-nmc.2023-0270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/30/2024] [Indexed: 04/28/2024] Open
Abstract
Brain tuberculoma and its occurrence within the subarachnoid cisterns is rare in Japan. Serological and cerebrospinal fluid (CSF) examinations and imaging findings lack specificity; thus, preoperative diagnosis is often challenging. This report presents the case of a 70-year-old woman admitted to our hospital with a one-month history of low-grade fever and altered mental status. Based on the CSF analysis and her history of latent tuberculosis infection seven years ago, she was strongly suspected of suffering from tuberculous meningitis (TBM). Consequently, the patient was enrolled in a clinical trial for antituberculosis treatment (ATT). CSF soluble interleukin-2 receptor level decreased from 2,926 U/mL on day 1 to 225 U/mL 42 days after initiating ATT. Her condition improved after five weeks; however, contrast-enhanced T1-weighted magnetic resonance imaging (MRI) revealed multiple enhanced lesions within the basal subarachnoid cisterns 25 days after admission. As the number and size of these lesions increased, a biopsy confirmed brain tuberculoma diagnosis, and the treatment was continued. In conclusion, when intracisternal scattered mass lesions are identified during TBM treatment, we should consider the possibility of tuberculoma developments arising from a paradoxical response (PR) during the treatment. Serial MRIs are crucial in monitoring PR development in cisternal tuberculomas, an extension of severe TBM. Finally, a PR can be effectively managed by continuing ATT with adjunctive corticosteroids.
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Affiliation(s)
- Kazuma Sahara
- Department of Neurosurgery, Tokushima Prefectural Central Hospital, Tokushima, Tokushima, Japan
| | - Kiyohito Shinno
- Department of Neurosurgery, Tokushima Prefectural Central Hospital, Tokushima, Tokushima, Japan
| | - Kenta Sato
- Department of Neurology, Tokushima Prefectural Central Hospital, Tokushima, Tokushima, Japan
| | - Yuya Watari
- Department of Neurosurgery, Tokushima Prefectural Central Hospital, Tokushima, Tokushima, Japan
| | - Tetsuya Tamura
- Department of Neurosurgery, Tokushima Prefectural Central Hospital, Tokushima, Tokushima, Japan
| | - Eiji Kudo
- Department of Pathology, Tokushima Prefectural Central Hospital, Tokushima, Tokushima, Japan
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Aziz Khan A, Ahuja S, Malik S, Naaz S, Zaheer S. Pituitary tuberculoma with panhypopituitarism masquerading as a pituitary adenoma. Neuropathology 2023; 43:496-499. [PMID: 37254443 DOI: 10.1111/neup.12925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/09/2023] [Accepted: 05/10/2023] [Indexed: 06/01/2023]
Abstract
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.
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Affiliation(s)
- Adil Aziz Khan
- Department of Pathology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Sana Ahuja
- Department of Pathology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Shaivy Malik
- Department of Pathology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Saba Naaz
- Department of Pathology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Sufian Zaheer
- Department of Pathology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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Elfarissi MA, Dahamou M, Dehneh Y, Lhamlili M, Khoulali M, Oulali N, Moufid F. Pediatric sellar-suprasellar tuberculosis: A case report and review of the literature. Surg Neurol Int 2023; 14:379. [PMID: 37941637 PMCID: PMC10629335 DOI: 10.25259/sni_476_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 08/26/2023] [Indexed: 11/10/2023] Open
Abstract
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.
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Affiliation(s)
- Mohammed Alamine Elfarissi
- Department of Neurosurgery, Faculty of Medicine and Pharmacy of Oujda, Mohammed First University Morocco, Oujda, Morocco
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Stringer F, Foong YC, Tan A, Hayman S, Zajac JD, Grossmann M, Zane JNY, Zhu J, Ayyappan S. Pituitary abscess: a case report and systematic review of 488 cases. Orphanet J Rare Dis 2023; 18:165. [PMID: 37365629 DOI: 10.1186/s13023-023-02788-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/18/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Pituitary abscess (PA) is a rare condition and not well understood. We aimed to describe a case and perform a comprehensive systematic review to explore presenting symptoms, radiological findings, endocrine abnormalities and mortality. AIM To identify presenting symptoms, radiological findings, endocrinological abnormalities and predictors of mortality for PA. METHODS We systematically reviewed the literature to identify all case reports of PA. Data regarding presentation, mortality, radiological findings, endocrinological abnormalities and treatment was extracted. RESULTS We identified 488 patients from 218 articles meeting the inclusion criteria. Mortality was 5.1%, with days to presentation (OR 1.0005, 95% CI 1.0001-1.0008, p < 0.01) being the only identified independent predictor of mortality. Mortality rates have decreased over time, with cases published prior to 2000 having higher mortality rates (OR 6.92, 95% CI 2.80-17.90, p < 0.001). The most common symptom was headache (76.2%), followed by visual field defects (47.3%). Classical signs of infection were only present in 43%. The most common imaging feature on magnetic resonance imaging (MRI) was high T2 and low T1 signal of the pituitary gland with peripheral contrast enhancement. Over half (54.8%) were culture negative, with the most common bacterial organism being staphylococcus aureus (7.8%) and fungal organism being aspergillus (8.8%). The most common endocrine abnormality was hypopituitarism (41.1%), followed by diabetes insipidus (24.8%). Whilst symptoms resolved in most patients, persistent endocrine abnormalities were present in over half of patients (61.0%). CONCLUSION PA is associated with significant mortality, with delayed presentation increasing risk of mortality. Ongoing endocrinological abnormalities are common. Given the non-specific clinical presentation, the appearance of high T2, low T1 and peripheral contrast enhancement of the pituitary on MRI should prompt consideration of this rare disease.
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Affiliation(s)
- Felicity Stringer
- Barwon Health, Geelong, VIC, Australia
- St Vincent's Health, Melbourne, VIC, Australia
| | - Yi Chao Foong
- Barwon Health, Geelong, VIC, Australia.
- Monash Health, Melbourne, VIC, Australia.
- Alfred Health, Melbourne, VIC, Australia.
- Eastern Health, Melbourne, VIC, Australia.
| | - Alanna Tan
- Austin Health, Melbourne, VIC, Australia
| | | | | | | | - Justin Ng Yau Zane
- Monash Health, Melbourne, VIC, Australia
- Monash University, Melbourne, VIC, Australia
- Royal Hobart Hospital, Hobart, TAS, Australia
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Rochtus A, Lagae L, Jansen K, De Somer L, Vermeulen F, de Zegher F. Reversible Hypothalamic Obesity in a Girl with Suprasellar Tuberculoma. Horm Res Paediatr 2023; 97:165-171. [PMID: 36977392 DOI: 10.1159/000530384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
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.
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Affiliation(s)
- Anne Rochtus
- Department of Development and Regeneration, Section Pediatric Endocrinology, University Hospital Leuven, Leuven, Belgium
- Department of Development and Regeneration, Section Pediatric Neurology, University Hospital Leuven, Leuven, Belgium
| | - Lieven Lagae
- Department of Development and Regeneration, Section Pediatric Neurology, University Hospital Leuven, Leuven, Belgium
| | - Katrien Jansen
- Department of Development and Regeneration, Section Pediatric Neurology, University Hospital Leuven, Leuven, Belgium
| | - Lien De Somer
- Department of Microbiology, Immunology and Transplantation, Section Pediatric Rheumatology, University Hospital Leuven, Leuven, Belgium
| | - François Vermeulen
- Department of Development and Regeneration, Section Pediatric Infectiology, University Hospital Leuven, Leuven, Belgium
| | - Francis de Zegher
- Department of Development and Regeneration, Section Pediatric Endocrinology, University Hospital Leuven, Leuven, Belgium
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Raja Shariff RE, Wan Muhamad Hatta SF, Kasim S. A rare cause of acute hypernatraemia: Diabetes insipidus secondary to suprasellar tuberculoma. PROCEEDINGS OF SINGAPORE HEALTHCARE 2021. [DOI: 10.1177/2010105820978669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
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.
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Angelousi A, Mytareli C, Xekouki P, Kassi E, Barkas K, Grossman A, Kaltsas G. Diabetes insipidus secondary to sellar/parasellar lesions. J Neuroendocrinol 2021; 33:e12954. [PMID: 33769630 DOI: 10.1111/jne.12954] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 01/24/2021] [Accepted: 02/09/2021] [Indexed: 12/25/2022]
Abstract
Diabetes insipidus (DI) is a well-recognised transient or permanent complication following transsphenoidal surgery for pituitary adenomas or other sellar/parasellar lesions. However, data regarding the prevalence of pre-operative DI in sellar/parasellar lesions other than pituitary adenomas are scarce. We systematically reviewed the existing data for defining the prevalence of DI before any treatment in adult patients with sellar/parasellar lesions, excluding pituitary adenomas and metastatic lesions. In total, 646 patients with sellar/parasellar lesions presenting with DI at diagnosis were identified. The most common pathologies of sellar/parasellar lesions presenting with DI at diagnosis were lymphocytic hypophysitis (26.5%), craniopharyngiomas (23.4%), Langerhans's cell histiocytosis (18.9%) and Rathke's cleft cyst (12.7%), accounting for the vast majority (more than 80%) of these lesions. Overall, DI at diagnosis was found in 23.4% of all patients with sellar/parasellar lesions, albeit with a wide range from 10.6% to 76.7%, depending on the nature of the pathology. The highest prevalence of DI was found in less commonly encountered lesions namely germ-cell tumours (76.7%), abscesses (55.4%) and neurosarcoidosis (54.5%), each accounting for less than 3% of all sellar/parasellar lesions. Most DI cases (68.8%) were associated with anterior pituitary hormonal deficiencies, in contrast to pituitary adenomas that rarely present with DI. The enlargement and enhancement of the pituitary stalk were the most common findings on magnetic resonance imaging besides the loss of the high signal of the posterior pituitary on T1-weighted images. Resolution of DI spontaneously or following systemic and surgical management occurred in 22.4% of cases. Post-operative DI, not evident before surgery, was found in 27.8% of non-adenomatous sellar/parasellar lesions, and was transient in 11.6% of them. Besides distinctive imaging features and symptoms, early recognition of DI in such lesions is important because it directs the diagnosis towards a non-adenomatous sellar/parasellar tumour and the early initiation of appropriate treatment.
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Affiliation(s)
- Anna Angelousi
- 1st Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Chrysoula Mytareli
- 1st Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Paraskevi Xekouki
- Endocrinology and Diabetes Clinic, University General Hospital of Heraklion, Heraklion, Greece
| | - Eva Kassi
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, Athens, Greece
- 1st Department of Propaedeutic and Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Barkas
- Department of Neurosurgery, General Hospital of Nikaia-Pireas, Agios Panteleimon, Athens, Greece
| | - Ashley Grossman
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
- Centre for Endocrinology, Barts and the London School of Medicine, London, UK
| | - Gregory Kaltsas
- 1st Department of Propaedeutic and Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
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Sankar J, Majumdar SS, Unniyal M, Singh H, Khullar A, Kumar K. Bilateral ptosis: An unusual presentation of mid brain tuberculoma. Med J Armed Forces India 2021; 77:96-100. [PMID: 33487874 DOI: 10.1016/j.mjafi.2018.12.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 12/26/2018] [Indexed: 11/28/2022] Open
Abstract
Central nervous system tuberculoma can have different clinical manifestations like headache, seizures, papilledema or other signs of raised intracranial pressure depending up on the site and number of tuberculoma. We report a case of 56 year old female reported with history of bilateral asymmetric ptosis of one month duration,with no other neurological defecit. Magnetic resonance imaging (MRI) brain revealed well defined ring enhancing lesion in the medial aspect of left hemi midbrain with diffuse disproportionate perilessional edema. Contrast Enhanced Computed Tomogram (CECT) of chest and abdomen revealed features of disseminated tuberculosis. She was diagnosed as a case of disseminated tuberculosis and started on antitubercular therapy with steroids and the ptosis almost resolved after 01 month of antitubercular therapy. Our case report is unique in the sense that only few cases of midbrain tuberculoma causing occulomotor abnormalities are reported in literature.
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Affiliation(s)
- J Sankar
- Graded Specialist (Medicine), Military Hospital Chennai, Tamilnadu, India
| | - S S Majumdar
- Graded Specialist (Medicine), Military Hospital Chennai, Tamilnadu, India
| | - Manish Unniyal
- Classified Specialist (Radiodiagnosis), Military Hospital Chennai, Tamilnadu, India
| | - Harmanpreet Singh
- Graded Specialist(Ophthalmology), Military Hospital Chennai, Tamilnadu, India
| | - Atul Khullar
- Commandant, Military Hospital Chennai, Tamilnadu, India
| | - Kishore Kumar
- Senior Advisor (Medicine&Oncology), Command Hospital (Air Force), Bengaluru, India
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Kumar T, Nigam JS, Jamal I, Jha VC. Primary pituitary tuberculosis. AUTOPSY AND CASE REPORTS 2020; 11:e2020228. [PMID: 34277492 PMCID: PMC8101658 DOI: 10.4322/acr.2020.228] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/23/2020] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Tarun Kumar
- All India Institute of Medical Science, Department of Pathology, Patna, Bihar, India
| | - Jitendra Singh Nigam
- All India Institute of Medical Science, Department of Pathology, Patna, Bihar, India
| | - Iffat Jamal
- Indira Gandhi Institute of Medical Sciences, Department of Hematology, Patna, Bihar, India
| | - Vikas Chandra Jha
- All India Institute of Medical Science, Department of Neurosurgery, Patna, Bihar, India
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Baloji A, Ghasi RG. MRI in intracranial tuberculosis: Have we seen it all? Clin Imaging 2020; 68:263-277. [PMID: 32916507 DOI: 10.1016/j.clinimag.2020.08.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 07/27/2020] [Accepted: 08/24/2020] [Indexed: 01/13/2023]
Abstract
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.
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Affiliation(s)
- Abhiman Baloji
- Department of Radiodiagnosis, Vardhman Mahavir Medical College, Safdarjung Hospital, New Delhi 110029, India
| | - Rohini Gupta Ghasi
- Department of Radiodiagnosis, Vardhman Mahavir Medical College, Safdarjung Hospital, New Delhi 110029, India.
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Gupta PK, Pandey S, Pandey D. Pituitary Tuberculoma: An Uncommon Pathology. INDIAN JOURNAL OF NEUROSURGERY 2020. [DOI: 10.1055/s-0039-3401334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
AbstractPituitary 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.
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Affiliation(s)
- Praveen Kumar Gupta
- Department of NeuroSurgery, Sir Sunder Lal Hospital, IMS, BHU, Varanasi, Uttar Pradesh, India
| | - Sharad Pandey
- Department of NeuroSurgery, P.G.I.M.E.R., Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Deepa Pandey
- Department of Pathology and Microbiology, Northern Railway Central Hospital, New Delhi, India
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12
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Muniz BC, Ribeiro BNDF, Ventura N, Gasparetto EL, Marchiori E. Isolated suprasellar involvement in tuberculosis: findings on magnetic resonance imaging. Radiol Bras 2019; 52:60-61. [PMID: 30804618 PMCID: PMC6383531 DOI: 10.1590/0100-3984.2017.0091] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Bernardo Carvalho Muniz
- Instituto Estadual do Cérebro Paulo Niemeyer - Departamento de Radiologia, Rio de Janeiro, RJ, Brazil
| | | | - Nina Ventura
- Instituto Estadual do Cérebro Paulo Niemeyer - Departamento de Radiologia, Rio de Janeiro, RJ, Brazil
| | | | - Edson Marchiori
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
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13
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Pamidimukkala V, Sahebrao Mandwe D, K SR, Batsala H. Primary pituitary tubercular abscess as a differential diagnosis for sellar suprasellar mass. Br J Neurosurg 2017; 33:437-438. [PMID: 28741962 DOI: 10.1080/02688697.2017.1358355] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Only four cases of primary pituitary tubercular abscess have been reported. A 20-year-old ladypresented to us with headache and pituitary dysfunction. Radiology showedsellar tubercular abscess with suprasellar extension. Microscopic examination of pus collected during surgery showed granulomatous tissues and Acid Fast Bacilli. The response to antitubercular therapy was remarkable.
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Affiliation(s)
| | | | - Siva Ramakrishna K
- a Neurosurgery and Spine, SevenHills Hospital , Visakhapatnam , Andhra Pradesh , India
| | - Harshavardhan Batsala
- a Neurosurgery and Spine, SevenHills Hospital , Visakhapatnam , Andhra Pradesh , India
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14
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More A, Verma R, Garg RK, Malhotra HS, Sharma PK, Uniyal R, Pandey S, Mittal M. A study of neuroendocrine dysfunction in patients of tuberculous meningitis. J Neurol Sci 2017; 379:198-206. [PMID: 28716240 DOI: 10.1016/j.jns.2017.06.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 05/15/2017] [Accepted: 06/12/2017] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Aniruddha More
- Department of Neurology, King George's Medical University, Lucknow 226003, India
| | - Rajesh Verma
- Department of Neurology, King George's Medical University, Lucknow 226003, India.
| | - Ravindra Kumar Garg
- Department of Neurology, King George's Medical University, Lucknow 226003, India
| | | | - Praveen Kumar Sharma
- Department of Neurology, King George's Medical University, Lucknow 226003, India
| | - Ravi Uniyal
- Department of Neurology, King George's Medical University, Lucknow 226003, India
| | - Shweta Pandey
- Department of Neurology, King George's Medical University, Lucknow 226003, India
| | - Madhukar Mittal
- Department of Endocrinology, King George's Medical University, Lucknow, India
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15
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Ghali MGZ, Srinivasan VM, Kim MJ, Malik A. Spinal Intramedullary Tuberculosis with Concurrent Supra- and Infratentorial Intracranial Disease in a 9-Month-Old Boy: Case Report and Comprehensive Review of the Literature. World Neurosurg 2017; 106:37-45. [PMID: 28532916 DOI: 10.1016/j.wneu.2017.05.069] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 05/09/2017] [Accepted: 05/11/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Tuberculous involvement of the spinal cord parenchyma is an exceedingly rare clinical entity; even more so is concurrent intracranial tuberculosis (TB). Spinal intramedullary TB presents with a characteristic subacute myelopathy, with slowly progressive paraplegia, sensory deficits, and/or bowel and bladder dysfunction. Diagnosis is strongly suspected with a clinical history of known TB in conjunction with characteristic findings on magnetic resonance imaging. Management involves multiagent antitubercular chemotherapy without or with operative intervention. CASE DESCRIPTION We present a case of a 9-month-old boy with a retrospectively recognized history of pulmonary TB presenting with fever and back tenderness found to have lower-extremity hypertonia and clonus. Imaging revealed concurrent intracranial and spinal intramedullary tuberculomas. The patient was treated for hydrocephalus with external ventricular drainage followed by T8-T10 laminectomy, drainage of abscess, and duraplasty. Parietal lobe biopsies proved the tuberculous etiology of intracranial lesions. CONCLUSION Etiopathogenesis, diagnosis, and management considerations of spinal intramedullary tuberculosis are reviewed and discussed.
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Affiliation(s)
- Michael George Zaki Ghali
- Department of Neurobiology & Anatomy, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA; Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA.
| | | | - Marc J Kim
- Department of Internal Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Archana Malik
- Department of Pediatric Radiology, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania, USA
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16
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Sharma GR, Kaushal P, Vaidya B, Kumar P. Third ventricular tuberculoma mimicking as a tumor: Report of a very rare case. Asian J Neurosurg 2017; 12:58-61. [PMID: 28413535 PMCID: PMC5379806 DOI: 10.4103/1793-5482.145061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Gopal R Sharma
- Department of Neurosurgery, Om Hospital, Chabahil, Kathmandu, Nepal
| | - Prashant Kaushal
- Department of Neurosurgery, Om Hospital, Chabahil, Kathmandu, Nepal
| | - Bivek Vaidya
- Department of Neurosurgery, Om Hospital, Chabahil, Kathmandu, Nepal
| | - Pawan Kumar
- Department of Neurosurgery, Om Hospital, Chabahil, Kathmandu, Nepal
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17
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Djoubairou BO, Gazzaz M, Hammi S, Bouya SM, Salami M, Mostarchid BE. Panhypopituitarism revealing sellar tuberculoma. ANNALES D'ENDOCRINOLOGIE 2015; 76:286-8. [DOI: 10.1016/j.ando.2015.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 01/16/2015] [Accepted: 02/03/2015] [Indexed: 10/23/2022]
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18
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Clinical presentation and magnetic resonance findings in sellar tuberculomas. Case Rep Med 2014; 2014:961913. [PMID: 25114688 PMCID: PMC4119910 DOI: 10.1155/2014/961913] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Accepted: 03/31/2014] [Indexed: 11/17/2022] Open
Abstract
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.
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19
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Saito K, Toda M, Shido S, Tomita T, Ogawa K, Yoshida K. Isolated Pituitary Tuberculoma. NMC Case Rep J 2014; 1:33-36. [PMID: 28663950 PMCID: PMC5364942 DOI: 10.2176/nmccrj.2013-0330] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 02/12/2014] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Katsuya Saito
- Department of Neurosurgery, Head and Neck Surgery, Keio University School of Medicine, Tokyo
| | - Masahiro Toda
- Department of Neurosurgery, Head and Neck Surgery, Keio University School of Medicine, Tokyo
| | - Satoka Shido
- Department of Neurosurgery, Head and Neck Surgery, Keio University School of Medicine, Tokyo
| | - Toshiki Tomita
- Department of Otorhinolaryngology, Head and Neck Surgery, Keio University School of Medicine, Tokyo
| | - Kaoru Ogawa
- Department of Otorhinolaryngology, Head and Neck Surgery, Keio University School of Medicine, Tokyo
| | - Kazunari Yoshida
- Department of Neurosurgery, Head and Neck Surgery, Keio University School of Medicine, Tokyo
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20
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Abstract
Infectious diseases of the central nervous system (CNS) are increasingly being recognized as important causes of hypopituitarism. Although tuberculosis is the most common agent involved, non-mycobacterial agents like viruses, bacteria, fungus, and protozoa are important causes in our country. Involvement post infections could be due to a strategically located tuberculoma, or pituitary abscess, or meningoencephalitis. Although it might not be reasonable to screen all patients with CNS infections for hypopituitarism, awareness of the possibility and clinical follow-up for suggestive symptoms is required.
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Affiliation(s)
- Anne M. Beatrice
- Department of Endocrinology and Metabolism, Institute of Post-Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - Chitra Selvan
- Department of Endocrinology and Metabolism, Institute of Post-Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - Satinath Mukhopadhyay
- Department of Endocrinology and Metabolism, Institute of Post-Graduate Medical Education and Research, Kolkata, West Bengal, India
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21
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Sharma K, Kanaujia V, Jaiswal S, Jain A, Kumar S, Srivastava AK, Jaiswal AK. Brain stem tuberculoma presenting with isolated ocular motility abnormality: A series of two cases and review of literature. Oman J Ophthalmol 2012; 5:61-3. [PMID: 22557882 PMCID: PMC3339680 DOI: 10.4103/0974-620x.94782] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Kumudini Sharma
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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22
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Ranjan R, Agarwal P, Ranjan S. Primary pituitary tubercular abscess mimicking as pituitary adenoma. Indian J Endocrinol Metab 2011; 15 Suppl 3:S263-S266. [PMID: 22029038 PMCID: PMC3183533 DOI: 10.4103/2230-8210.84882] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Tubercular abscess of the pituitary fossa is rare and may lead to diagnostic uncertainty in a patient with absence of tuberculosis elsewhere in the body. We present a rare case report of a young lady who presented with sellar and suprasellar cystic mass. She was diagnosed as a case of pituitary macroadenoma and was intraoperatively found to harbor pus in the lesion. She did not have any symptoms of infection. The case underlines the importance of considering such a possibility in the differential diagnosis of cystic sellar lesions and further diagnostic tests should be done for confirmation and treatment of this rare and potential life threatening illness.
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Affiliation(s)
- Rakesh Ranjan
- Department of Neurosurgery, Aditya Birla Memorial Hospital, Pune, India
| | - Pankaj Agarwal
- Department of Neurology, Aditya Birla Memorial Hospital, Pune, India
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23
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Nayil K, Singh S, Makhdoomi R, Ramzan A, Wani A. Sellar-suprasellar tuberculomas in children: 2 cases and literature review. Pediatr Neurol 2011; 44:463-6. [PMID: 21555059 DOI: 10.1016/j.pediatrneurol.2011.01.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Revised: 11/16/2010] [Accepted: 01/24/2011] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Khursheed Nayil
- Department of Neurosurgery, Sheri-Kashmir-Institute of Medical Sciences, Kashmir.
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24
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Furtado SV, Venkatesh PK, Ghosal N, Hegde AS. Isolated sellar tuberculoma presenting with panhypopituitarism: clinical, diagnostic considerations and literature review. Neurol Sci 2010; 32:301-4. [PMID: 20886253 DOI: 10.1007/s10072-010-0409-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2009] [Accepted: 09/01/2010] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Sunil V Furtado
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, EPIP Area, Whitefield, Bangalore, 560066, Karnataka, India.
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