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CASE REPORT Table of Contents   
Year : 2008  |  Volume : 51  |  Issue : 2  |  Page : 269-270
Sellar lesion: Not always a pituitary adenoma


Department of Pathology, Sri Ramachandra Medical College and Research Institute, Chennai, Tamil Nadu, India

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   Abstract 

Inflammatory lesions of the hypophysis account for 0.5% of all symptomatic diseases of the pituitary, which include lymphocytic hypophysitis, granulomatous hypophysitis with or without specific etiology and pituitary abscess. Sellar tuberculoma is a rare type of granulomatous hypophysitis. We document a case of a postmenopausal lady who presented with galactorrhea, headache and blurring of vision. Based on preliminary investigations, a clinical diagnosis of pituitary adenoma was made and the pituitary gland was surgically excised. Histopathological examination showed caseating granulomas, along with normal areas of preserved pituitary gland and a final diagnosis of tuberculous hypophysitis was made. This case is being documented due to the extremely rare involvement of the pituitary gland by granulomatous lesions such as tuberculosis and to emphasize the role of intraoperative consultation to obviate the need for radical surgery in such lesions.

Keywords: Granulomatous hypophysitis, pituitary gland, tuberculosis

How to cite this article:
Rao S, Rajkumar A, Kuruvilla S. Sellar lesion: Not always a pituitary adenoma. Indian J Pathol Microbiol 2008;51:269-70

How to cite this URL:
Rao S, Rajkumar A, Kuruvilla S. Sellar lesion: Not always a pituitary adenoma. Indian J Pathol Microbiol [serial online] 2008 [cited 2019 Oct 17];51:269-70. Available from: http://www.ijpmonline.org/text.asp?2008/51/2/269/41688



   Introduction Top


Hypophysitis is a rare entity and accounts for 0.5% of all symptomatic diseases involving the anterior pituitary. [1] Inflammatory lesions of the pituitary gland include lymphocytic hypophysitis, pituitary abscess and granulomatous inflammation. Granulomatous inflammation involving pituitary may occur secondary to infection or may be idiopathic in nature. Langerhan's cell histiocytosis affecting the hypophysis can also show histiocytic collections. These lesions produce symptoms of hormonal dysfunction, as seen in pituitary adenoma. Tuberculoma of brain is a common finding in India. However, isolated tubercular involvement of pituitary is unusual. [2],[3]


   Case History Top


A 47-year-old postmenopausal lady, a known diabetic, hypothyroid and hypertensive, presented to the outpatient department with complaints of headache of severe intensity associated with vomiting. For the initial 6 months, it was of moderate intensity and was associated with transient blurring of vision, but had worsened prior to presentation. The patient also had galactorrhea for 6 months and was being treated with Bromocriptine. There was no history of loss of consciousness or seizures. Her bladder and bowel habits were normal.

On examination, her higher mental functions and cranial nerves were normal. There were no cerebellar or meningeal signs. Findings from fundus examination were within normal limits.

X-ray cone view of the sella turcica showed enlarged sella with erosion of the posterior clinoid process and demineralization of the floor of the sella.

MRI brain showed a well-circumscribed contrast-enhancing lesion in the sella, eroding the bone and extending on to the suprasellar region pushing the chiasma from above. Rest of the brain appeared unremarkable.

Endocrine evaluation showed an elevated basal serum prolactin. Other hormones were also evaluated [Table 1]. Fasting plasma glucose level was 179 mg/dL (normal value, 70-110 mg/dL). Results of renal function tests, liver function tests and hemogram were within normal limits.

A clinical diagnosis of pituitary adenoma was made and the patient was subjected to a midline sublabial rhinoseptal transphenoidal excision of the lesion. Intraoperatively, the lesion was found to be firm and it was removed totally until the sella turcica was visualized.

Histopathological examination

The tissue fragments were received in 10% buffered formalin fixative and were processed by standard techniques. Hematoxylin and eosin-stained sections showed multiple necrotizing granulomas with Langerhans' giant cells interspersed with dense lymphocyte infiltrate and few plasma cells [Figure 1]. However, acid-fast stain failed to demonstrate any bacilli and special stain for fungus was negative. Special stains for reticulin showed fragments of intact normal pituitary with preserved reticulin network, thus ruling out a diagnosis of pituitary adenoma [Figure 1 inset].

No tissue was obtained for frozen section.


   Discussion Top


Although tuberculomas are intracranial lesions commonly found in India, intrasellar tuberculoma is rare. [2],[3] Tuberculous hypophysitis can occur as a localized lesion or can be a part of a widespread disease. The usual mode of spread of infection to the pituitary is via hematogenous route or direct spread from the paranasal sinus. [4] Tuberculous hypophysitis may clinically pose a diagnostic dilemma as it mimics the features of a pituitary adenoma. Headache and visual disturbances are the common complaints. The patient may also present with features of hypopituitarism, such as galactorrhea, amenorrhea, polyuria and polydipsia.

Histologically, the differential diagnosis of granulomatous hypophysitis includes tuberculosis, sarcoidosis, mycotic infection, hypophysitis due to ruptured intrasellar Rathke cleft cyst and idiopathic causes. [2],[5],[6],[7],[8] Histiocytosis X is also a lesion which may show infiltration of hypophysis with histiocytes, if the pituitary parenchyma is involved by the disease. Granulomas in tuberculosis are characterized by a central area of caseous necrosis surrounded by epithelioid cells, macrophages, lymphocytes and plasma cells. Caseation is diagnostic of tuberculosis. Caseation was present in this case, but acid-fast stain for acid-fast bacilli (AFB) was negative. Faiz et al. have also documented that it may be difficult to demonstrate AFB in pituitary lesions. [2] There was no evidence of tuberculous infection elsewhere in the body. Hence correlating the finding from histopathological examination with the radiological data, we concluded that this patient had an isolated tuberculous hypophysitis.

In a country where the incidence of tuberculosis is high, when an intracranial spaceoccupying lesion is operated, the differential diagnosis of tuberculosis should be considered. It is advisable to do an intraoperative frozen section to rule out tuberculosis, since it can be managed conservatively and radical surgery can be avoided.

In summary, a definite diagnosis of tuberculous hypophysitis can be made by a systematic approach, which includes taking a detailed history, careful physical examination, hormonal assay, radiological examination and frozen section of the lesion. An accurate diagnosis and specific management are important because pituitary tuberculosis can be cured completely by antituberculous therapy, thereby eliminating the need for surgery and preserving the pituitary gland and function.

Postoperative course was uneventful and the patient was treated with antituberculous drugs [four-drug regimen (Isoniazid, Rifampicin, Pyrazinamide and Ethambutol)] for 3 months. This was followed by a two-drug regimen (Isoniazid, Rifampicin) for 15 months. She was additionally on antibiotics, Eltroxin, Atenolol and insulin. The patient improved gradually during the follow-up period and there was no recurrence of any of the symptoms.

 
   References Top

1.Alexander L, Appleton D, Hall R, Ross WM, Wilkinson R. Epidemiology of acromegaly in the Newcastle region. Clin Endocrinol 1980;12:71-9.  Back to cited text no. 1    
2.Ahmad FU, Sarat Chandra P, Sanyal S, Garg A, Mehta VS. Sellar tuberculoma: An unusual infection. Indian J Tuberc 2005;52:215-7.  Back to cited text no. 2    
3.Sinha S, Singh AK, Tatke M, Singh D. Hypophyseal tuberculoma: Direct radiosurgery is contraindicated for a lesion with a thickened pituitary stalk: Case report. Neurosurgery 2000;46:735.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Sharma MC, Arora R, Mahapatra AK, Sarat P, Gaikwad SD, Sarkar C. Intrasellar tuberculoma: An enigmatic pituitary infection: A series of 18 cases. Clin Neurol Neurosurg 2000;102:72-7.  Back to cited text no. 4    
5.Gazioglu N. Lymphocytic and granulomatous hypophysitis: Experience with nine cases. J Endocrinol Invest 2000;23:189-92.  Back to cited text no. 5    
6.Bullmann C, Faust M, Hoffmann A, Heppner C, Jockenhovel F, Muller-Wieland D, et al. Five cases with central diabetes insipidus and hypogonadism as first presentation of neurosarcoidosis. Eur J Endocrinol 2000;142:365-72.  Back to cited text no. 6    
7.Vasile M, Marsot-Dupuch K, Kujas M, Brunereau L, Bouchard P, Comov J, et al. Idiopathic granulomatous hypophysitis: Clinical and imaging features. Neuroradiology 1997;39:7-11.  Back to cited text no. 7    
8.Roncaroli F, Bacci A, Frank G, Calbucci F. Granulomatous hypophysitis caused by ruptured intrasellar Rathke's cleft cyst: Report of a case and review of the literature. Neurosurgery 1998;43:146-9.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]

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Correspondence Address:
Sarah Kuruvilla
Department of Pathology, Sri Ramachandra Medical College and Research Institute, (Deemed University), Porur, Chennai - 600 116, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.41688

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    Figures

  [Figure 1], [Figure 1 inset]
 
 
    Tables

  [Table 1]

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