Endocrine Abstracts

We present the case of a 44-year-old woman from Afghanistan who had lived in the UK for 2 years. She was admitted to hospital with headache. She gave an 8 months history of generalised headache, secondary amenorrhoea and weight gain. There was no history of polyuria or polydypsia. Examination revealed a bitemporal hemianopia to red pin confrontation. Investigations confirmed that she was panhypopituitary. In addition, she was vitamin D deficient. Imaging of the pituitary gland revealed a mass measuring 1.3 cm×1.8 cm with radiological features consistent with a pituitary macroadenoma.

The patient was prepared for trans-sphenoidal hypophysectomy. At operation a tough pituitary mass was identified but could not be completed resected. A biopsy was obtained. Post-operatively, the patient suffered transient diabetes insipidus, which required treatment with desmopressin. Histology from the pituitary biopsy was reported as showing a granulomatous hypophysitis with caseating granulomata in keeping with tuberculosis. Ziell Nielson staining of the biopsy was negative.

The patient went on to have a CT scan of the chest, which showed no evidence of pulmonary tuberculosis. Samples of cerebrospinal fluid revealed no acid fast bacilli and normal levels of angiotensin converting enzyme. The patient has been commenced on quadruple therapy for tuberculosis with the intention to treat for 6 months.

Granulomatous hypophysitis can be due to sarcoidosis, tuberculosis, eosinophilic granuloma, syphilis and Wegener’s granulomatosis. In developing countries, it is estimated that up to 4% of space occupying lesions involving the pituitary are due to tuberculosis. The incidence of tuberculosis in Afghanistan was over 50 000 cases last year, making our patients country of origin a vital clue to her presumed final diagnosis.