Turkish Neiirosiirgen) 11: 142 - 145, 2001 Tiiiia: Isola/ed Sel/ar Tiibereiilama

Isolated Sellar Tuberculoma With a ThickenedPituitary Stalk: Case Report

Hipofiz Sapini Kalinlastiran Izole Sellar Tüberküloma:Olgu Sunumu

METIN TUNA, T AHSIN ERMAN, FARUK ILDAN, ALP ISKENDER GÖÇER,

SUZAN ZORLUDEMIR, SEBAHA TTIN HACIYAKUPOGLU

Çukurova University School of Medicine Department of Neurosurgery (MT, TE, FI, AIG, SH),Çukurova University School of Medicine Department of Pathology (5Z), Adana

Received : 22.1.2001 c::> Accepted : 28.5.2001

Abstract: This report is of a patient with an isolated seiiartuberculoma with supraseiiar extension in association withthickening of the pituitary stalk who presented with signsand symptoms of hypopituitarism. Magnetic resonanceimaging showed a seiiar mass with supraseiiar extensionassociated with thickening of the pituitary stalk.Endocrinological parameters indicated hypopituitarism.The patient underwent a transsphenoidal procedure. Thepathological diagnosis was of a typical structure oftuberculoma. if a pituitary tumor with suprasellarextension in association with the thickening of the pituitarystalk is suspected, the possibility of seiiar tuberculomamust be considered in the differential diagnosis ofnonsecreting sellar masses, even when no history oftuberculosis exists.

Key words: Granulomatous hypophysitis, pituitary stalk,seiiar tuberculoma

INTRODUCTION

Thirty-four surgieal eases of pituitarytubereulomas have been reported in the literature.In only five cases was the loealization exc1usivelyintrasellar. Clinieally, they can present as

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Özet: Hipopituitarizmin belirti ve bulgularini gösterenhipofiz sapi kalinlasmasi ile birlikte supraseiiar uzanimiolan izole seiiar tüberkülomali bir olgu sunulmaktadir.Manyetik rezonans görüntül,emede hipofiz sapininkalinlasmasi ile beraber supraseiiar uzanimli seiiar kitletespit edildi. Hipofiz hormonlari sonuçlarihipopituitarizm ile uyumluydu. Olgu transsfenoidalgirisim ile opere edildi. Eksize edilen kitleninhistopatolojik muayenesi sonucunda seiiar tüberküloinatanisi konuldu. Hipofiz sapi kalinlasmasi ile berabersupraseiiar uzanimli pituiter tümör süphesi oldugunda,tüberküloz öyküsü alinmasa dahi nonsekretuvar seiiarkitlelerin ayrici tanisinda sellar tüberküloma olasiligidüsünülmelidir.

Anahtar kelimeler: Granülomatoz hipofizitis, hipofizsapi, seiiar tüberküloma

nonsecreting masses or mimie secreting adenomas(1,2,4,6,7,9,10,11,13,15,16,18,19,20).

This report is of a patient with an isolated sellartubereuloma with suprasellar extension inassociation with thiekening of the pituitary stalk who

Tiirkisii Neiirosiirgery 11: 142 - 145, 2001

presented with signs and symptoms ofhypopituitarism.

CASE REPORT

A 25-year-old woman was admitted with ahistory of headaches in the past 6 months. Duringthe last 3 years, she noted irregular menses withfrequent amenorrheic episodes. She had one normaldelivery, and never noticed any unusual dischargefrom the breasts. However, galactorrhea wasdemonstrated on expression of both breasts. Generalphysical and neurological examinations were normaL.She was examined in consultation with the

Ophthalmology Service: She had 6/10 of visualacuity and loss of the temporal half of the visual fieldin the right eye. Complete blood count, erythrocytesedimentation rate, chest x-ray films andelectrocardiography were also normaL. There was nopast or family history of tuberculosis or any knowncontact with the disease.

Magnetic resonance imaging showed a sellarmass with suprasellar extension associated withthickening of the pituitary stalk (Fig. 1-a, b and c).

Endocrinological studies yielded the followingresults: T3, 56 ng/dl (normal: 85 to 215 ng/dl); T4,3.5 mg/di (normal: 4.0 to 12 mg/dI); thyroidstimulating hormone, 0.7 mU/mI following

Tiiiin: lsoln/ed Sel/iir Tiiberciilonin

thyrotropin-releasing hormone stimula tion (TRH)(normal: 0.5 to 3.5 mU /ml); growth hormon e: 0.7 ng/ml (normal: 2 to 5 ng/ml), without response afterinsulin hypoglycemia; luteinizing hormone andfollicle-stimulating hormone, 0.8 and 3.1 ng/ml,respectively, without modification followingadministration of GnRH; basal prolactin, 25 ng/ml

Figure 1: Magnetie resonance image after paramagnetie contrast agent injeetion showing the seIlar mass with suprasellarextension and the thiekened pituitary sta!k (arrow). (a), eorona! view; (b), sagitta! view. (c), magnetie resonanceimage without paramagnetie contrast agent, eorona! view.

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Tiirkis/i Neitrosiirgery 11: 142 - 145, 2001

(normal: 2.7 to 26 ng/ml). These parametersindicated hypopituitarism.

The patient underwent a transsphenoidalprocedure. The sellar floor was normaL.A gray-white,nonbleeding, fibrous mass that occupied the wholesellar cavity and extended upward was completelyexcised, and no remains of anormal pituitary glandwere found.

The histopathological examinationdemonstrated that, among rests of pituitary cellularelements, there were many inflammatory granulomacells surrounded by a rich network of collagen andreticulin. Necrosis and Langhans' giant cells wereseen in the center and periphery of the granuloma.There was also diffuse inflammatory infiltration bylymphocytes, eosinophils, and plasma cells. Noalcohol acid-fast organisms or Treponema were seen.The pathological diagnosis was of a typical structureof tuberculoma (Fig. 2).

Microscopic examination of the sputum, gastricjuice, and cerebrospinal fluid centrifugate with Ziehl­Neelsen staining and culture tests diselosed nothingabnormal. On the other hand, there was a positiveintradermal reaction to tuberculin (swelling, 35 mmin diameter).

For anti-tuberculosis treatment, the patient wasstarted on a combination of isoniazid, 300 mg, and

Figure 2: Histological photomicrograph of the specimenshowing epithelioid granuloma surrounded byfibrablasts, giant cell of Langhans (arrowhead),infiltration by Iymphocytes and plasma cells. Onthe right side, remains of pituitary cells can beseen (H & E, X 400).

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rifampicin, 600 mg, daily. During a 24-month follaw­up, a persistent hypopituitarism with minimalresponse of prolactin to TRH stimulation wasobserved.

DISCUSSION

Granulomatous hypophysitis is a rare conditionthat may present with a sellar-suprasellar mass andhypopituitarism and is most commonly seen inmiddle aged and older women. The hypothalamusis not likely to be involved in this disease, and,therefore, diabetes insipidus is less common (5,8,12).

The differential diagnosis of intrasellar lesionsmust inelude granulomatous diseases. Tuberculosis,syphilis and sarcoidosis have been most of tenconsidered etiological factors in pituitary granuloma.Microscopic granulomatous tubercles are notuncommonly found in either the anterior or theposterior lobe as part of a generalized hematogenousdissemination. Furthermore, the gland is quite ofteninvolved by direct extension from basal tuberculausmeningitis (3,17). As manyas 4 % of cases of Iategeneralized tuberculosis can lead to hypopituitarismfrom either hematogenous or direct spread throughthe meninges (5,8,12).Both of these mechanisms wereruled out in our case. No known reason clearlyexplains this atypicallocalization.

Because of the variability of signs andsymptoms and the absence of characteristic aspectson CT and magnetic resonance imaging; thediagnosis can be made only postoperatively,especially if there is no history of symptoms oftuberculosis (15).

In our case, the magnetic resonance imagingfindings were consistent with those of an adenoma.As Higuchi (14) and Pereira (15) have reported it,we also found thickening of the hypophyseal stalk.That finding, although not specific, as it can arise inother neoplastic or inflammatory diseases, such assarcoidosis and syphilis, can also occur in sellartuberculoma (15). When faced with a sellar massassociated with a thickened stalk, it is wise to considerthe possibility of a tuberculoma (11,14,18,19).

The transsphhenoidal approach is the mostsuitable way for dealing with sellar tuberculoma,because, besides allowing a local cure and the finaldiagnosis, it also avoids cerebrospinal fluidcontamination (13,15,16,20).

Tiirkish Neiirosiirgery 11: 142 - 145, 2001 Tiiiin: Isola/ed Sel/ar Tiiberciiloma

Conclusivelyi if a pituitary tumor withsuprasellar extension in association with thethickening of the pituitary stalk is suspectedi thepossibility of sellar tuberculoma mu st be consideredin the differential diagnosis of nonsecreting seliarmassesi even when no history of tuberculosis exists.

Correspondence: Dr. Metin Tuna

Çukurova Üniversitesi Tip Fakültesi

Nörosirürji ABD

Adana, 01330 Türkiye

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stalk isdiatneter.

of the pituitarybasilar artery

• not adenotna

• lytnphotna• lytnphocytic hypophysitis• granulatnatous disease• hypothalatnic gliotna

1Vortnal thickness

approxitnately equal toThickening Of stalk ---7

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