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Diagnosis and management of TB
P50 Pituitary Granulomata - TB or Not TB
  1. K Khan1,
  2. WM Drake1,
  3. S Akker1,
  4. VLC White2
  1. 1Dept. of Endocrinology St. Bartholomew’s Hospital, Bartsthe London NHS Trust, London, UK
  2. 2Dept of Respiratory Medicine, St. Bartholomew’s Hospital, Bartsthe London NHS Trust, London, UK

Abstract

Granulomatous disease of the pituitary gland is rare and of this pituitary tuberculosis (TB) is the rarest, making its diagnosis or exclusion challenging. We discuss six cases. Patients ages ranged between 25–43; 3 were male. 3 were born in UK, the others in Afghanistan, Bangladesh and Somalia respectively. 5 patients presented with headaches, two of whom had bitemporal haeminopia and one also had diabetes inspidus; one presented with cervical lymphadepothy and diabetes inspidus. 3 had weight loss, pyrexia and night sweats. All had MRI scanning; 4 patients showed thickening of pituitary stalk and intense enhancement of the gland, one had a presumed macro-adenoma and another had a cystic mass. 5 patients had trans-sphenoidal surgery (TSS); 3 for diagnostic biopsy, one for urgent decompression of a pituitary mass, another for the macro-adenoma. One had cervical lymphnode biopsy: histology demonstrated granulomatous inflammation in 4 samples, one also had focal necrosis, another was culture positive for AFB. 4 patients had lumbar puncture: CSF cultures for MTB and PCR were non-diagnostic and CSF-ACE was negative; one sample showed lymphocytosis. One patient had abnormal CXR with cavitating lesions and mediastinal lymphadenopathy. 5 patients had vasculitic screens which were negative. All 5 patients who had TSS were left with hypo-pituitarism and on hydrocortisone replacement. The main differential diagnosis was TB or sarcoidosis. 4 patients were treated with anti-TB therapy (ATT) and high dose steroids for one year. The one who grew MTB was treated with ATT alone. The sixth had ATT for six months as well as high dose steroids. Pituitary TB is very rare and only 50–60 cases are reported in literature where not all patients treated with ATT cultured MTB; Imaging modalities are non-specific and show thickening of pituitary stalk and intense post contrast enhancement of the gland as with our patients but this is commonly described in other infections and neoplasm as well. Diagnosis is therefore difficult and challenging and tissue biopsy or microbiology may even not be conclusive. A multidisciplinary discussion of these patients is crucial.

References

  1. Dastur HM. Tubeculoma. Vinken PJ, Bruyn GW editors. Handbook of clinical Neurology.

  2. Colman CC, Richmond VA, Meredith JM, diffuse tuberculosis of pituitary gland simulating tumour.

  3. Nissim J. Sarcoidosis and its neurological manifestation.

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