Endocrine Abstracts

Background: Tuberculosis (TB) is an important cause of mortality and morbidity globally. Only a small proportion cases of systemic TB present with lesions spreading to meninges, sella, or ventricles. Cases of intra-sellar pituitary adenoma secondary to TB have been rarely identified, often with uncertainty on medical management as opposed to more aggressive surgical therapy. We report an interesting case of pituitary adenoma presenting with pan-hypopituitarism and posterior pituitary dysfunction and discuss the clinical conundrums of medical management.

Case Presentation: A 42-year old South Asian gentleman initially presented with low libido and erectile dysfunction, found to have secondary hypogonadism. He subsequently described features of headaches, lethargy, and excessive tiredness, but was apyrexial, and did not report weight loss or night sweats. Pituitary magnetic resonance imaging (MRI) demonstrated enlarged bulky pituitary with stalk pushed posteriorly, initially managed as a non-functioning pituitary adenoma.

Investigations: Dynamic pituitary function testing confirmed growth hormone deficiencies, secondary adrenal insufficiency, secondary hypothyroidism. Insulin tolerance test was performed with a peak cortisol of 103 nmol/l and peak GH of 0.36 microgram/l. Prolactin 360 mU/l. IGF1 14. Testosterone 6.4 nmol/l; LH 1.2 U/l, FSH 2.2 U/l. Hypertonic saline infusion test also confirmed cranial diabetes insipidus.

Progress in medical management: Treatment for pan-hypopituitarism was initiated accordingly. The patient was managed under joint care with infectious diseases and neurosurgical team due to clinical suspicion of intra-sellar TB. Due to lack of constitutional features of systemic TB, and presence of cranial diabetes insipidus, a trans-sphenoidal pituitary biopsy was organised. Pituitary histology demonstrated evidence of granulomatous adenoma, but negative for AAFB. After 8 months of anti-TB treatment, there was radiological evidence of reduction in size of pituitary lesion and improvement in symptoms of headache. In this rare case presentation, we discuss the consideration of trial of anti-tuberculous therapy and our experience in managing this scenario with follow-up radiological imaging, before considering pituitary surgery.