An case of Pituitary Tuberculosis
M.Pratibha, F Wernig, K.Baynes, S.Mehta, GS Sandhu. Ealing Hospital NHS Trust and the Pituitary MDT team at Charing Cross Hospital.
60 year old gentleman presented to A&E with 6 weeks history of headache, dizziness and feeling generally unwell. He had a history of pulmonary TB resistsnt to isoniazide and streptomycin in 2009. Following initial assessment a CT head revealed? Pituitary macroadenoma. He had biochemical evidence of pan hypopituitarism with supressed gonadotrophins and suboptimal response of cortisol to short synacten test, secondary hypothyroidism. CSF analysis revealed predominant lymphocytosis and elevated protein. A MRI pituitary showed a suprasellar mass 1.7×2.4×1.6 cm with cystic changes with extension in to cavernous sinuses and optic chiasma compression mostly on the right. He was commenced on prednisolone and levothyroxine. At this stage TB meningitis was diagnosed and he was commenced on ethambutol, moxifloxacin and rifampicin. Repeat analysis of CSF prior to discharge has been normalised. MRI pituitary in 3 months interval was unchanged.
He was readmitted to the current hospital with a history of falls. Initial assessment revealed postural drop. His prednisolone dose was doubled. LH<1, FSH<1, prolactin 1214. MRI brain revealed 2.8×1.8×2.6 cm suprasellar mass with solid and cystic areas. This has worsened despite of 4 months of anti TB medications. Ophthalmology review: no perception in right eye in the left eye 5/60 with residual visual field in upper nasal left field. As he was very unwell presumed MDT TB diagnosis was made and he has been started on the MDR TB medications.
His case has been discussed in pituitary MDT, suggested to continue with the current treatment and for repeat MRI after a few weeks.
Neurologists found the long tract signs and MRI spine was done this revealed 2 ring enhancing lesions at T6 and T11. He had endobronchial ultrasound biopsy of the hilar and paratracheal nodes, histology revealed suppurative necrotising granulomatous lymphadenitis. He has been discharged with complex MDR TB regimen. Recent MRI pituitary has shown regression in the size of suprasellar mass measuring 1.8×0.9×1.4 cm.
Conclusion: In this patient presumptive diagnosis of pituitary TB has been established due to complexity of the case. The suprasellar mass has responded to the MDR TB treatment. Pituitary TB is a rare condition accounting to 4% in the reported literature.