Hypophyseal tuberculoma: direct radiosurgery is contraindicated for a lesion with a thickened pituitary stalk: case report

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.

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.

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.

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.

Granulomatous hypophysitis by Mycobacterium gordonae in a non HIV-infected patient

Lymphocytic or granulomatous hypophysitis is a rare entity with a difficult diagnosis. Our objective was to report a patient with non-tuberculous granulomatous hypophysitis. An HIV-negative 45-year old man with confusional state, subacute ophthalmoplegia, and clinical and laboratory findings of panhypopituitarism was seen in the emergency unit. A cranial MRI showed a sellar mass suggestive of hypophysitis. After an unsuccessful attempt with steroids and antituberculous drugs the patient died. Post-mortem histopathology revealed granulomatous lesions and restriction fragment length polymorphism analysis confirmed the presence of Mycobacterium gordonae’s DNA. In conclusion, we should consider granulomatous hypophysitis in the differential diagnosis of non-secreting hypophyseal tumors. The etiology of a pituitary granuloma by a non-tuberculous mycobacteria is best reached by histopathological techniques and molecular assays. The optimal therapy is yet to be established.

Permanent central diabetes insipidus with complete regression of pituitary stalk enlargement after 4 years of follow-up

A 14 year-old patient was admitted because of a history of polyuria and polydipsia. A diagnosis of central diabetes insipidus (CDI) accompanied by growth hormone (GH) and gonadotropin deficiency was made. Hypophyseal magnetic resonance imaging (MRI) of the patient demonstrated isolated pituitary stalk enlargement. Although GH deficiency and gonadotropin deficiency were transient, CDI was persistent despite the regression of the pituitary stalk enlargement over the 4 years of follow-up.

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.

Imaging features of intrasellar tuberculoma: two cases

Hypophyseal tuberculoma is extremely rare. It may be confused with other more common sellar tumors such as adenomas. Characteristic, but not specific, radiological features are in the majority of cases: intense enhancement on contrast CT and thickening of the pituitary stalk better visible on MRI. We describe imaging findings in two patients with pituitary tuberculosis. In these cases an accurate non-invasive diagnosis was found to be important as antituberculous chemotherapy is curative.

Optic pathways tuberculoma mimicking glioma: case report

BACKGROUND

Optochiasmatic tuberculomas are very rare lesions. They can occur with concomitant tuberculous meningitis, and pulmonary tuberculosis or as the only manifestation of the disease. The authors present a case of optic pathways tuberculoma with radiologic appearance simulating an optic pathways glioma.

CASE DESCRIPTION

We report a case of a 20-year-old man with mental retardation due to anoxic encephalopathy who developed a sudden bilateral amaurosis. He also presented with diabetes insipidus, panhypopituitarism, right proptosis, and chemosis. Computed tomography (CT) and magnetic resonance imaging (MRI) showed an enhancing lesion in the optochiasmatic region extending to both optic nerves, with a mass in the right orbit, mimicking an optic pathways glioma. There was no other evidence of systemic involvement of the tuberculosis. The lesion was explored through a right pterional transylvian approach with opening of the optic canal and orbital roof, and a biopsy and an internal decompression were performed. Histopathological studies demonstrated a granulomatous lesion with central caseous necrosis with acid-fast bacilli. The patient improved after treatment with tuberculostatic drugs, but vision recovery could not be achieved.

CONCLUSIONS

Visual compromise in tuberculosis is associated with hydrocephalus, optical neuritis or tuberculomas involving the optic pathways. Reviewing the literature on tuberculomas of the optochiasmatic area, we could not find any other case with such extensive involvement of the optic pathways that was radiologically suggestive of an infiltrating glioma. Histopathological studies remain crucial in the diagnosis of intrinsic expansive processes of the optochiasmatic region.

Tuberculomas of the hypophysis cerebri: report of five cases

Tuberculomas involving the hypophysis cerebri are extremely rare lesions, and these may occur even in the absence of systemic tuberculosis. This report presents the clinical data of 5 patients harbouring tuberculomas of the pituitary gland. Sellar tuberculomas commonly mimic pituitary adenoma. Histological diagnosis of a sellar lesion is mandatory irrespective of the clinical presentation and radiological findings. 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 a sellar tuberculoma. The aim of surgery is tissue diagnosis and tumour debulking. The response to long-term antituberculous chemotherapy is excellent. There is often a complete resolution of the granuloma and a satisfactory recovery of visual and endocrinological function.

Diabetes insipidus in sellar-suprasellar tuberculoma

Tuberculoma involving the sellar and suprasellar region is extremely rare. Sellar region tuberculoma usually presents with endocrinopathy of hypofunction, rarely hyperfunction or normal function of the anterior pituitary. However, sellar-suprasellar tuberculoma presenting with diabetes insipidus (DI) is very rare. We report the case of a 32 year old housewife presenting with DI and secondary amenorrhea, who had a sellar-suprasellar mass on MRI. She underwent a transnasal transsphenoidal surgical removal of the pituitary mass, which was tubercular in nature on histology. She received antitubercular treatment and hormonal replacement therapy. She was well at last follow-up, 3 years after surgery.

Pituitary tuberculoma: an unusual lesion of sellar region

Pituitary tuberculomas are extremely rare lesions, with only few cases described in the literature, usually mistaken as pituitary tumors. Its heterogeneous clinical and imaging profile preclude preoperative diagnosis which ultimately relies on the histopathological examination. We describe a 46 years old woman who presented with an episode of confusion and hypopituitarism with no evidence of systemic tuberculosis. Computed tomography (CT) showed a central calcified and enhancing sellar mass. Magnetic resonance imaging (MRI) showed a sellar mass with suprasellar extension and associated optic chiasm compression. She was submitted a craniotomy for biopsy and resection. A caseous material was found at the center of the lesion involved by a thick wall. Due to the wall adherence to the optic chiasm and the inflammatory aspects of the lesion, subtotal removal was achieved and the patient followed on anti-tuberculous and hormonal replacement therapy. Sellar tuberculomas should be considered in the differential diagnosis of sellar tumors in order to offer appropriate treatment.

Pituitary stalk tuberculoma

Pituitary tuberculomas are exceptionally rare. Even with no evidence of systemic tuberculosis, it is important to recognize these lesions in the differential diagnosis of the intrasuprasellar tumors because they are curable. At present, in developed countries the frequency of intracranial tuberculomas of nervous system tumors is around 0.5-4%, whereas in under developed countries is 15-30%. It mainly affects children and young adults. In some cases, an accurate diagnosis may lead to an efficient medical therapy on the basis of biological, hormonal and imaging scans examinations. The case we studied shows the difficulties encountered in the diagnosis of a thickened stalk having normal pituitary image. It is to be highlighted the usage of the Polymerase Chain Reaction (PCR) technique.

Pituitary tuberculoma mimicking adenoma: magnetic resonance imaging

A case of a pituitary mass with clinical and MRI findings consistent with adenoma is presented. Transnasal transphenoidal excision biopsy showed it to be a pituitary tuberculoma. The patient was treated with antituberculous drugs, and a follow-up MRI 18 months later showed good response. MRI features and a review of published reports of the sellar tuberculoma are briefly discussed.