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Table of Contents    
CASE REPORT
Year : 2021  |  Volume : 69  |  Issue : 5  |  Page : 1414-1420

A Rare Case of Primary Pituitary Tubercular Abscess Mimicking a Pituitary Adenoma


1 Department of Neurosurgery, Dr. D.Y. Patil Medical College and Hospital, Pune, Maharashtra, India
2 Department of Ophthalmology and Neurosurgery, Dr. D.Y. Patil Medical College and Hospital, Pune, Maharashtra, India

Date of Submission02-Jul-2020
Date of Decision14-Aug-2020
Date of Acceptance12-Feb-2021
Date of Web Publication30-Oct-2021

Correspondence Address:
Sarang Gotecha
Department of Neurosurgery, Dr. D.Y. Patil Medical College, Hospital and Research Center, Sant Tukaram Nagar, Pimpri, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.329622

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 » Abstract 


Primary pituitary tuberculosis (PTA) is a very rare disease. The clinical diagnosis is difficult as it is clinically radiologically indistinguishable from other sellar lesions. We present a case of PTA without any predisposing etiology and radiologically mimicking a pituitary macroadenoma. The patient underwent endoscopic transsphenoidal resection where pus admixed with mucoid was seen coming out of the lesion intraoperatively. Histology of the cyst wall was suspective of tuberculous etiology and QuantiFERON Tb Gold done for confirmation was positive. Postoperatively patient showed obvious improvement in visual symptoms. Patient developed diabetes insipidus and was put on desmopressin and was started with anti-tuberculosis medication for 18 months. Timely surgical intervention followed by anti-tubercular therapy and hormone replacement is the mainstay of treatment in these cases. For intraoperative management, we advise thorough wash with antibiotic and saline rather than curetting the walls of the abscess to decrease the postoperative incidence of endocrine abnormalities.


Keywords: Pituitary abscess, primary pituitary tubercular abscess, sellar lesions, tubercular abscess
Key Message: High index of suspicion of tuberculous abscess in patients presenting with a cystic sellar lesion with contrast enhancing wall in tuberculosis endemic countries. For intraoperative management, thorough wash with antibiotic and saline rather than curetting the walls of the abscess.


How to cite this article:
Gotecha S, Chugh A, Punia P, Kotecha M, Kashyap D. A Rare Case of Primary Pituitary Tubercular Abscess Mimicking a Pituitary Adenoma. Neurol India 2021;69:1414-20

How to cite this URL:
Gotecha S, Chugh A, Punia P, Kotecha M, Kashyap D. A Rare Case of Primary Pituitary Tubercular Abscess Mimicking a Pituitary Adenoma. Neurol India [serial online] 2021 [cited 2021 Nov 28];69:1414-20. Available from: https://www.neurologyindia.com/text.asp?2021/69/5/1414/329622




Pituitary abscess is potentially life threatening condition and accounts for approximately 0.24 to 0.6% of all pituitary lesions.[1],[2] The clinical diagnosis is difficult due to the vague and nonspecific clinical symptoms or signs and it is radiologically indistinguishable from other sellar lesions.[1],[2] Primary pituitary tuberculous abscess (PTA) is a very rare disease with only five cases reported in English literature to the best of our knowledge.[3] Because of the rarity of this condition even in endemic areas of the world, absence of constitutional symptoms and nonspecific clinical and radiological features, majority of these cases are managed with an initial diagnosis of pituitary adenoma and tuberculous abscess being diagnosed in postoperative histopathology. We present a rare case of a 34 year old patient presenting with a de novo pituitary abscess with no predisposing etiology and radiologically micking a pituitary macroadenoma.


 » Procedure Top


A 34-year-old male patient presented with history of diminution of vision since 15 days followed by headache since 8 days. Patient had no constitutional symptoms or history suggestive of hormonal abnormalities or cranial nerve palsies. Fundus examination was normal. Visual field examination was suggestive of right eye nasal field depression with severely depressed visual fields in the left eye. Ocular movements were normal and symmetrical in all directions. Endocrine profile was within normal limits. Computed tomography of the brain showed extra axial lobulated mass lesion in the sellar and suprasellar region which was iso to hypodense measuring 23 mm × 13 mm × 19 mm with enlargement of the sella suggestive of pituitary macroadenoma. Magnetic Resonance Imaging was suggestive of well-defined predominantly cystic lesion in the sella appearing isointense on T1WI and hyperintense on T2WI with a nonenhancing intra-cystic nodule appearing hypointense on T2WI. The lesion was seen in the midline extending from the floor of sella superiorly into the suprasellar space up to the third ventricle causing significant mass effect on optic chiasm and effacement of adjacent supra sellar cistern. On contrast, the lesion shows wall enhancement with no enhancement within the lesion [Figure 1]. Features were suggestive of cystic pituitary macroadenoma. The other diagnoses that could be considered were Rathke's cleft cyst and pituitary apoplexy. The patient underwent endoscopic transsphenoidal resection of the pituitary lesion. Intraoperatively pus admixed with mucoid was seen coming out of the lesion [Figure 2]a. The capsule of the lesion and the purulent material was sent for examination. Pus was negative for atypical or malignant cells and culture showed no growth of microorganisms. Histology of the cyst wall showed granulomatous inflammation with necrosis suspective of tuberculous etiology. Hence the sample was sent for QuantiFERON Tb Gold test which confirmed tuberculosis. Post- operatively patient showed obvious improvement in visual symptoms. However patient developed diabetes insipidus and was put on desmopressin. Once the diagnosis of tuberculosis etiology was confirmed, workup for disseminated tuberculosis was done which turned out to be negative. Patient was started with anti-tuberculosis medication for 18 months. Postoperative MRI showed complete decompression of the sellar cystic lesion [Figure 2]b,[Figure 2]c,[Figure 2]d.
Figure 1: Preoperative (a) Sagittal T2WI showing cystic lesion in the sella hyperintense on T2WI with a non-enhancing intra-cystic nodule appearing hypointense on T2WI. Preoperative (b) Sagittal (c) Coronal and (d) Axial: Contrast Enhanced MRI showing wall enhancement of the lesion with no enhancement within the lesion

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Figure 2: (a) Intraoperative image showing mucoid admixed with pus was seen coming out of the lesion. Postoperative (b) Coronal T2WI MRI (c) Coronal Contrast enhanced MRI and (d) Sagittal Contrast enhanced MRI showing complete resolution of the sellar cystic lesion

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 » Discussion Top


Although the first reported case of a sellar tuberculoma was from Britain in 1924, the literature on sellar tuberculomas largely arises from the Indian subcontinent and other developing countries.[4] Tuberculoma of the central nervous system represent 0.15% to 4% of intracranial space occupying lesions frequently affecting the cerebrum and cerebellum and less frequently the brainstem, basal ganglia and thalamus.[5] Isolated involvement of the sellar and suprasellar region by tuberculous process is very rare and presents mostly as a solid tuberculoma which comprise of 1% of all intracranial tuberculomas.[3],[6]

The pathway for spreading mycobacterium tuberculosis to the sellar and parasellar region is unclear. Hematogenous spreading or contiguous extension from a local tuberculous infection of the paranasal sinuses has been proposed.[7]

Patients with pituitary tubercular abscess or tuberculoma present with headache and vomiting followed by visual and endocrine abnormalities. Constitutional symptoms of tuberculosis are usually absent.[6]

MRI is considered to be the best modality to diagnose pituitary lesions. However, differentiation between pituitary tuberculous abscess and pituitary adenoma can be very difficult. The differential diagnosis of a cystic lesion in the sella includes adenoma, carcinoma, arachnoid cyst, abscess, Rathke's cleft cyst, craniopharyngioma and metastasis.[2] The confirmation of diagnosis on the basis of clinical and radiological features is extremely difficult because of the similar presentation of all these cases.[8]

The recommended management of pituitary abscess is surgical drainage, antibiotic treatment and hormonal replacement.[9] In a diagnosed or suspected case of pituitary abscess, transsphenoidal evacuation is strongly recommended over transfrontal craniotomy to prevent diffusion of infection and damage to the suprasellar structures. Intraoperatively, when pus is identified, the surgeon must not be too aggressive with the ring curettes as the edematous inflamed pituitary is easily excised which is the cause of endocrine abnormalities postoperatively in these cases. It would be rather safe to give a thorough wash with antibiotic and saline. Postoperative hormone replacement may be needed if pituitary functions are affected.

In our patient final diagnosis of primary pituitary TB was made by positive QuantiFERON Tb Gold. Polymerase chain reaction for rapid identification of Mycobacterium tuberculosis was not performed on the pituitary tissue due to lack of initial suspicion of TB.

All patients with pituitary TB require anti-tuberculosis drug treatment for 18-month duration although there is no general agreement on the duration of treatment as the site is very rare.[10]


 » Conclusion Top


Primary pituitary tuberculous abscess is difficult to diagnose clinically and radiologically as it mimics pituitary adenoma. A high index of suspicion of tuberculous abscess is necessary in patients presenting with a cystic lesion with contrast enhancing wall in the sella particularly in countries with high TB prevalence. Timely surgical intervention followed by anti-tubercular therapy and hormone replacement is the mainstay of treatment in these cases. For intraoperative management, we would advise thorough wash with antibiotic and saline rather than curetting the walls of the abscess to decrease the postoperative incidence of endocrine abnormalities.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Shuster A, Gunnarsson T, Sommer D, Miller E. Pituitary abscess: An unexpected diagnosis. Pediatr Radiol 2010;40:219-22.  Back to cited text no. 1
    
2.
Ling X, Zhu T, Luo Z, Zhang Y, Chen Y, Zhao P, et al. A review of pituitary abscess: Our experience with surgical resection and nursing care. Transl Cancer Res 2017;6:852-9.  Back to cited text no. 2
    
3.
Pamidimukkala V, Mandwe DS, Siva RK, Batsala H. Primary pituitary tubercular abscess as a differential diagnosis for sellar suprasellar mass. Br J Neurosurg 2019;33:437-8.  Back to cited text no. 3
    
4.
Majumdar K, Barnard M, Ramchandra S, Berovic M, Powell M. Tuberculosis in the pituitary fossa: A common pathology in an uncommon site. Endocrinol Diabetes Metab Case Rep 2014;2014:140091.  Back to cited text no. 4
    
5.
Arunkumar MJ, Rajshekhar V. Intrasellar tuberculoma presenting as pituitary apoplexy. Neurol India 2001;49:407.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Bonifacio-Delgadillo D, Aburto-Murrieta Y, Salinas-Lara C, Sotelo J, Montes-Mojarro I, Garcia-Marquez A. Clinical presentation and magnetic resonance findings in sellar tuberculomas. Case Rep Med 2014;2014:961913.  Back to cited text no. 6
    
7.
Roka YB, Roka N, Pandey SR. Primary pituitary tubercular abscess: A case report. J Nepal Med Assoc 2019;57:206-8.  Back to cited text no. 7
    
8.
Ranjan R, Agarwal P, Ranjan S. Primary pituitary tubercular abscess mimicking pituitary adenoma. Indian J Endocrinol Metab 2011;15(Suppl 3):S263-6.  Back to cited text no. 8
    
9.
Vates GE, Berger MS, Wilson CB. Diagnosis and management of pituitary abscess: A review of twenty-four cases. J Neurosurg 2001;95:233-41.  Back to cited text no. 9
    
10.
Agrawal VM, Giri PJ. Tuberculosis: A common infection with rare presentation, isolated sellar tuberculoma with panhypopituitarism. J Neurosci Rural Pract 2019;10:327-30.  Back to cited text no. 10
[PUBMED]  [Full text]  


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