Endocrine Abstracts

Introduction: 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, and easily misdiagnosed as pituitary adenoma. In this setting, the late diagnosis can result in permanent endocrine dysfunction.

We hereby report the case of a patient with pituitary tuberculoma discovered following the onset of diabetes insipidus.

Case report: The patient was a 36-year-old woman. She presented with polyuro-polydipsic syndrome (PPS) associated with holocranial headaches and secondary amenorrhea. Hormonal exploration identified corticotropic insufficiency with hyperprolactinemia. Central DI was retained in view of the hypothalamo-pituitary MRI aspect showing the disappearance of the spontaneous T1 hypersignal and the presence of a thickening of the pituitary stem. The tubercular origin of this thickening was oriented by the presence of a history of erythema nodosum with a positive intradermal reaction to tuberculin. It was confirmed by the presence of Mycobacterium Tuberculosis in the sputum, urine and bronchial fluid. Anti-tubercular drugs were combined with hormone replacement therapy: Hydrocortisone at a dose of 20 mg/d, ddVAP at a dose of 0.3 ml/d and dopamine agonist at a dose of 5 mg/d. After 3 months of treatment, the patient showed a clear improvement of her symptoms with a weight gain of 8 kg, disappearance of headaches, PPS and galactorrhea. But she still had amenorrhea despite normoprolactinemia (PRL<0.4 ng/ml) with a normal LH level at 3.5 mUI/ml and an elevated FSH level at 11.6 mUI/ml. MRI control after 8 months of anti-tuberculosis treatment also showed a clear improvement with a fine pituitary stalk taking contrast correctly and a normal looking pituitary gland. The total duration of treatment was extended to 24 months. At the last MRI check-up after 24 months of treatment, the tubercular pituitary abscess had completely disappeared and clinically, the patient no longer had PPS or galactorrhea. However, the amenorrhea persisted, with a negative progestin test. The diagnosis of a physiological menopause was retained in view of an explosive gonadotropin response under LHRH.

Conclusion: The non-specific radiological findings challenge the diagnosis of primary pituitary tuberculomas. However, a high clinical suspicion, especially in endemic regions, can minimize unnecessary invasive procedures and surgical interventions. The early clinical suspicion and prompt use of anti-tubercular drugs help to prevent irreversible endocrine dysfunction.