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| Year : 2001 | Volume
: 49
| Issue : 3 | Page : 299-301 |
Pituitary tuberculoma--a case report.
Manghani DK, Gaitonde PS, Dastur DK
Department of Neuropathology, MRC 15th Floor, Bombay Hospital, Mumbai-400 020, India.
Correspondence Address:
Department of Neuropathology, MRC 15th Floor, Bombay Hospital, Mumbai-400 020, India.
Pituitary tuberculomas, mimicking adenomas are very unusual. We describe a rare case of a patient with an exclusively intrasellar mass, and who presented with severe headaches and loss of libido. The lesion was approached trans-sphenoidally and pathological examination revealed a tuberculoma. Complete removal was achieved and the patient followed on anti-tuberculous therapy.
How to cite this article:
Manghani D K, Gaitonde P S, Dastur D K. Pituitary tuberculoma--a case report. Neurol India 2001;49:299-301 |
Tuberculomas constitute approximately 30% of intracranial space occupying lesions in adults[1],[2] and 50% of those in children. Pituitary tuberculomas, mimicking adenomas and causing disruption of endocrine function are very unusual. Clinically, they manifest as non-secretory masses or simulate secreting adenoma and are diagnosed on histopathological examination. Only 17 surgical cases have been reported in literature.[3],[4],[5],[6]
A 24 years old male was admitted with a history of severe headache for the last one year and recent loss of libido. His blood serum levels of prolactin and ACTH were minimally increased. MRI showed an enlarged, homogeneously enhancing pituitary gland bulging upwards through the diaphragma sellae [Figure. 1a]. The patient was initially treated with low doses of wysolone, eltroxin and bromocriptine. Repeat MRI after 4 months treatment showed slight thickening of the stalk and minimal decrease in the size and enhancement of the lesion [Figure. 1b]. The medication was tapered but the headaches persisted and a followup MRI again revealed an increase in the size of the gland. Clinically, a provisional diagnosis was intrasellar pituitary adenoma and the lesion was excised trans-sphenoidally. Grossly, the lesion was lobulated and greyish-yellow in colour.
Histopathology of the surgically excised mass showed the bulk of the lesion to consist of chronic inflammatory/granulomatous reaction, including small and large mononuclear cells representing
lymphocytes and epithelioid cells respectively [Figure. 2a] and [Figure. 2b]. The epithelioid cells were seen to fuse to form giant cells of Langhans type (arrow, [Figure. 2a] and 2c). Gomori's reticulin staining confirmed the matrix to be fibro-collagenous with rich reticulin framework and pale oval areas of fusing epithelioid cells, confirming these to be 'histological tubercles'. In places the granulomatous lesions were bordered by well defined acinar cells of the non-tumourous pituitary gland [Figure. 2a]. Ziehl Neelsen stain did not show any acid fast bacilli (AFB). Lymphocytes were strongly positive for leucocyte common antigen (LCA), with immunohistochemical staining. The epithelioid cells and the giant cells were immunopositive for macrophage CD68 factor. CD68 labels human monocytes, macrophages and giant cells and can be used for identifying a population of cells of phagocytic origin.
Thus, on the above histopathological and immunohistochemical features, this intrasellar lesion was diagnosed as florid granuloma of the nature of tuberculoma. The patient was put on antituberculous drugs and has remained symptom-free so far.
Intrasellar tuberculomas, mimicking adenomas and causing disruption of endocrine function are very unusual. To the best of our knowledge, only about 17 surgical specimens have been reported in the world literature.[3],[4],[5],[6],[7],[8] Clinically and radiologically, it is difficult to distinguish intrasellar tuberculomas, from pituitary adenomas, to the extent that the patient may manifest increased levels of hormones like prolactin due to pituitary stalk compression. Pituitary apoplexy, subarachnoid haemorrhage and thickening of the dura at the floor of the sella are some other features of intrasellar granulomas, reported by Ranjan and Chandy.[3] The differential diagnosis of intrasellar granulomas also includes lymphocytic hypophysitis, sarcoidosis or Langherhan's histiocytosis.[9] Lymphocytic hypo-physitis consists of diffuse lymphocytic infiltrate within the anterior lobe, and has been reported to respond to steroid treatment,[10] whereas sarcoidosis consists of non-caseating granulomatous inflammation. A typical tuberculous granuloma reveals small and large mononuclear cells of lymphocytic and macrophagic origin. Epithelioid cells, fusing to form giant cells and concentration of lymphocytic infiltrates around histological tubercles among the areas of necrosis is the characteristic histological feature of the tubercular granuloma, as seen in the case being discussed.
In conclusion, in the absence of typical MRI of the lesion and with no history or symptoms of tuberculosis, the diagnosis of intrasellar tuberculoma is possible only on histopathological and by immunohistochemical methods. Therefore, in developing countries with high prevalence of intracranial tuberculomas, pituitary tuberculomas must be considered as a differential diagnosis of nonsecreting adenomas, especially when associated with dural thickening of the hypophysial stalk. Intense enhancement on contrast CT and thickening of the pituitary stalk on MRI are characteristic radiological features reported in 86% of cases.[5]
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