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      Primary pituitary tuberculosis

      case-report
      1 , 1 , , 2 , 3
      Autopsy & Case Reports
      Hospital Universitário da Universidade de São Paulo
      Tuberculosis, Granuloma, Adenoma, Pituitary Gland

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          ABSTRACT

          Tuberculosis is an infectious disease that involves any organ. However, the primary pituitary tuberculosis is an extremely rare disease. Intracranial tuberculomas account for 0.15-5% of intracranial space-occupying lesions, of which, pituitary as the primary site is unusual, and easily misdiagnosed as pituitary adenoma. In this setting, the late diagnosis can result in permanent endocrine dysfunction. We report the case of a 50-year-old woman who presented to the neurosurgery outpatient department with complaints of progressively increasing headache and diminished vision over the last year. On the clinical examination, the patient was conscious and oriented. The routine hematological and biochemical workup showed an increased erythrocyte sedimentation rate (ESR) and increased prolactin levels. The radiological working diagnosis was consistent with pituitary macroadenoma. No other radiological and/or clinical clue that could elicit the suspicion of pulmonary or extrapulmonary lesions of tuberculosis was found. The transsphenoidal endonasal tumor excision was done. The histopathology showed numerous epithelioid cell granulomas, Langhans giant cells along with scant necrosis. Ziehl Neelsen staining demonstrated acid-fast bacilli, and the final diagnosis of pituitary tuberculoma was made. We report this rare case of pituitary lesion that may be included in the differential diagnosis of sellar lesions to avoid unnecessary surgical interventions, especially in regions where the disease is endemic.

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          Intrasellar tuberculoma--an enigmatic pituitary infection: a series of 18 cases.

          Intrasellar tuberculomas are rare and only few case reports have been described in the literature. We report a series of 18 cases of histologically proven intrasellar tuberculomas, which, to the best of our knowledge, is the largest series in the English literature. A total of 1143 pituitary lesions, between 1984 and June 1999, were operated for various reasons in our institute. Of these, 18 cases were histopathologically proven intrasellar tuberculomas. The clinical profile was reviewed in detail. Radiological data and histopathological slides were also reviewed. The age ranged from 8 to 43 years (average 23.6 years) with a female preponderance. The duration of symptoms varied from 15 days to 2 years (average 4 months), the most common symptoms being headache followed by decrease or loss of vision. Five patients had features of pan-hypopituitarism whereas three had raised prolactin (PRL) levels. In six patients, both sella as well as sphenoid sinus were involved. In one patient the lesion was extending from the sella over the clivus. Clinically as well as radiologically, these lesions were mistaken for pituitary adenomas except for one case where tuberculoma was suspected on imaging. In three patients, there was past history of pulmonary tuberculosis, in one patient of tuberculous meningitis, and in one patient, of spondilytis of the spine. In one patient there was cervical lymphadenopathy along with features of acromegaly (also proved by high levels of serum growth hormone) and radiology revealed a pituitary pathology. Microscopic examination of the excised lesion revealed a composite lesion consisting of a pituitary adenoma and tuberculoma, which has not been documented in literature to date. One patient died during the hospital stay. All the other patients were put on antitubercular chemotherapy following surgery and had good outcomes. Intrasellar tuberculomas are rare. These may be suspected in female patients especially if radiological imaging shows involvement of paranasal sinuses and pituitary fossa along with thickening of pituitary stalk. Simultaneous involvement of clivus may also be an additional feature. The incidence of pituitary tuberculosis is likely to increase with a rise in the incidence of AIDS.
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            Retrospective study of 23 pathologically proven cases of central nervous system tuberculomas.

            Extrapulmonary manifestations of tuberculosis involving the central nervous system (CNS) due to haematogenous spread are not a rare entity. It presents as meningitis or tuberculoma. Tuberculoma is a granulomatous inflammatory process mimicking a neoplasm radiologically, so usually a biopsy is performed. Our study consisted of 23 pathologically proven cases of tuberculomas between 1988 and 2003. Patients were discussed clinically, radiologically and histologically. Headache, fever, weight loss and weakness are the most common clinical manifestations. Our patient's ages vary from 3 to 67 years with a mean of 31.8 years. Ninety-five percent of patients had bad social, economic and nutritional conditions. None of them were infected by human immunodeficiency virus (HIV). All patients had similar contrast-enhancing lesions radiologically. The majority of tuberculomas were located supratentorially. Only one patient presented two foci of (cerebral and cerebellar) tuberculomas. Nineteen tuberculomas were intracerebral; two were located in the cerebellum and one was intramedullary. Among those lesions, one cavernous sinus tuberculoma and one sellar tuberculoma were identified. Only two patients underwent stereotactic biopsy and 21 patients underwent surgical excision. Histopathologic examination revealed granulomatous inflammation with central caseous necrosis in all patients. Diagnosis of tuberculoma can be difficult, and in most of our cases, the clinical diagnosis was 'neoplasm'. For this reason, clinicians must always be aware of it and consider it in the differential diagnosis of central nervous system mass lesions.
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              Global tuberculosis report: 2016

              (2016)
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                Author and article information

                Journal
                Autops Case Rep
                Autops Case Rep
                acrep
                Autopsy & Case Reports
                Hospital Universitário da Universidade de São Paulo
                2236-1960
                08 December 2020
                2021
                : 11
                : e2020228
                Affiliations
                [1 ] originalAll India Institute of Medical Science, Department of Pathology, Patna, Bihar, India.
                [2 ] originalIndira Gandhi Institute of Medical Sciences, Department of Hematology, Patna, Bihar, India.
                [3 ] originalAll India Institute of Medical Science, Department of Neurosurgery, Patna, Bihar, India.
                Author notes

                Authors’ contributions: Tarun Kumar, Jitendra Singh Nigam, Iffat Jamal were responsible for the study conception/design, manuscript’s Drafting, literature research, and Data analysis & interpretation. Tarun Kumar, Vikas Chandra Jha were in charge of the Data acquisition. Tarun Kumar, Jitendra Singh Nigam prepared the Manuscript. All authors collectively edited and review the final version of the manuscript.

                Conflict of interest: The authors have no conflicts of interest to declare

                Correspondence Jitendra Singh Nigam All India Institute of Medical Science, Department of Pathology Phulwarisharif, 801507, Patna, Bihar, India Phone: (+91) 9412628083 E-mail: nigamjs@ 123456gmail.com
                Author information
                http://orcid.org/0000-0001-5554-3975
                http://orcid.org/0000-0003-0725-0494
                http://orcid.org/0000-0001-5574-5569
                http://orcid.org/0000-0002-0080-061X
                Article
                autopsy073220 00504
                10.4322/acr.2020.228
                8101658
                34277492
                2724ce36-8b57-46bb-8baa-afd6770bc064
                Copyright: © 2020 The Authors.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 12 June 2020
                : 23 August 2020
                Page count
                Figures: 3, Tables: 0, Equations: 0, References: 65
                Categories
                Clinical Case Report and Review

                tuberculosis,granuloma,adenoma,pituitary gland
                tuberculosis, granuloma, adenoma, pituitary gland

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