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LETTER TO EDITOR
Year : 2017  |  Volume : 65  |  Issue : 4  |  Page : 909-911

Tuberculoma of the pituitary gland presenting as diabetes insipidus


Department of Radiology, St. John's Medical College, Bengaluru, Karnataka, India

Date of Web Publication5-Jul-2017

Correspondence Address:
Ravikanth Reddy
Department of Radiology, St. John's Medical College, Bengaluru - 560 034, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/neuroindia.NI_1051_16

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How to cite this article:
Reddy R. Tuberculoma of the pituitary gland presenting as diabetes insipidus. Neurol India 2017;65:909-11

How to cite this URL:
Reddy R. Tuberculoma of the pituitary gland presenting as diabetes insipidus. Neurol India [serial online] 2017 [cited 2019 Nov 14];65:909-11. Available from: http://www.neurologyindia.com/text.asp?2017/65/4/909/209465




Sir,

A 52-year old gentleman was admitted in our hospital for evaluation of a sellar mass with complaints of polyuria, polydypsia, polyphagia, and decreased libido. The patient was detected to be having diabetes insipidus. His hormonal profile was as follows: serum cortisol at 8 am: 5.7 mg/dL (normal: 10–20 mg/dL) on prednisolone, thyroxine (T) 3: 190 ng/dL (normal: 70–200 ng/dL), T4: 9.5 mg/dL (normal: 5.5–13.5 mg/dL), thyroid stimulating hormone (TSH): 0.77 mU/mL (0.2–5 mU/ml), and prolactin 17.3 ng/mL (normal: 5–25 ng/mL). A contrast-enhancing sellar mass of 2.1 × 2.3 × 2.0 cm size with suprasellar extension and elevation of the optic chiasm [Figure 1] along with a central necrotic region was noted [Figure 2]. There was marked thickening of the infundibular stalk [Figure 3]. The lesion was isointense on TI-weighted image (T1WI), and the necrotic component was predominantly hypointense on T2-weighted image (T2WI) [Figure 4]. The patient underwent surgery via a trans-sphenoidal approach under glucocorticoid cover. Histopathological examination of the specimen revealed ill-formed epithelioid granulomas with giant cells and caseous necrosis. The pituitary parenchyma was infiltrated by inflammatory cells. Ziehl–Neelsen staining demonstrated acid fast bacilli, and special staining for fungi were negative. A diagnosis of tuberculosis of the pituitary was made, and the patient was started on anti-tuberculous treatment (ATT).
Figure 1: Sagittal contrast-enhanced T1W MRI image of sella showing a markedly enhancing lesion elevating the optic chiasma

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Figure 2: Coronal contrast-enhanced T1W MRI image of sella obtained at presentation showing marked enhancement of the pituitary lesion (arrow head) except for the central cystic or necrotic portion (thin arrow)

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Figure 3: Sagittal T1W MRI image of sella showing marked thickening of the infundibular stalk (arrows)

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Figure 4: Coronal T2W MRI image of sella showing the well-defined pituitary lesion (arrow head) with the necrotic component appearing predominantly hypointense (thin arrow)

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Tuberculosis (TB) of the pituitary gland, although extremely infrequent, is a cause of secondary granulomatous hypophysitis, which is sometimes reported in developing countries.[1] TB accounts for 0.15–4% of all intracranial lesions.[2] It primarily manifests as a tuberculoma. Intrasellar tuberculomas are well-known for masquerading as pituitary adenomas, and hence it should be considered in the differential diagnosis of suprasellar masses.

Central nervous system (CNS) tuberculosis accounts for only 1% of all tuberculosis cases worldwide, and occurs mainly in areas where the prevalence of tuberculosis is high.[3],[4],[5],[6] A hematogenous spread, which later developed the tuberculous foci in the brain, meninges, or adjacent bone, is the main pathogenesis of CNS tuberculosis. Patterns of extrapulmonary CNS tuberculosis, such as tuberculous meningitis, tuberculous encephalitis, tuberculoma, or tuberculous brain abscess, depend on the location of tuberculous foci and host immune factors.[4],[5],[6],[7]

The radiological differential diagnosis considered were inflammatory and granulomatous lesions of the pituitary gland, including lymphocytic hypophysitis, pituitary abscess, tuberculosis, fungal infection, sarcoidosis, Wegener's granulomatosis, and Langerhans' cell histiocytosis and lymphocytic hypophysitis, which typically affect women during the peripartum period with symmetrical enlargement of the pituitary gland and homogeneous contrast enhancement on MRI.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Freda PU. Tuberculosis of the pituitary and sellar region. Pituitary 2002;5:147-8.  Back to cited text no. 1
[PUBMED]    
2.
Glezer A, Paraiba DB, Bronstein MD. Rare sellar lesions. Endocrinol Metab Clin North Am 2008;37:195-211.  Back to cited text no. 2
[PUBMED]    
3.
Domingues FS, de Souza JM, Chagas H, Chimelli L, Vaisman M. Pituitary tuberculoma: An unusual lesion of sellar region. Pituitary 2002;5:149-53.  Back to cited text no. 3
[PUBMED]    
4.
Arunkumar MJ, Rajshekhar V. Intrasellar tuberculoma presenting as pituitary apoplexy. Neurol India 2001;49:407.  Back to cited text no. 4
[PUBMED]    
5.
Pruthi N, Karanth S, Nagarjun MN, Pandey P, Pruthi N, Karanth S, et al. Suprasellar tuberculoma associated with unilateral moyamoya phenomenon: Case report. Neurol India 2014;62:453-5.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Manghani DK, Gaitonde PS, Dastur DK. Pituitary tuberculoma - A case report. Neurol India 2001;49:299-301.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Garg RK, Malhotra HS, Jain A. Neuroimaging in tuberculous meningitis. Neurol India 2016;64:219-27.  Back to cited text no. 7
[PUBMED]  [Full text]  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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