An unusual case of macro adenoma of the pituitary gland and atypical mycobacterium infection.

History

A 58 years old Haitian male who admitted at the hospital due to fever of unknown origin.  At the time of the admission, his fever was 103.4°F. The patient continues having fever and developed a mild to moderate nonspecific progressive headache with some dizziness.  The patient also has some weight loss. He denied night sweat, joint pain, shortness of breath, cough, abdominal pain, nausea and vomiting. He was diagnosed previously with diabetes mellitus, alcohol, and tobacco abuse. The patient’s family history was non-contributory. He had no history of trauma or surgery.

Physical examination 

The physical exam reveals vital signs; blood pressure 142/92, pulse 86 bpm and regular, respiration 15/min and regular, temperature 103.4 0F, height 69 in, weight 180 lbs. The patent appears alert, and oriented x 3. Abdomen soft, non-tender, non-distended, normal bowl sounds, no lymphadenopathy, no joint pain or swelling, no skin rash. Neurologic, heart and lungs, ear nose and throat examinations were all normal.

Diagnostic Testing

Initial workup for the patient indicated that his WBC 3.9, RBC count 4.26, hemoglobin 12, hematocrit 34.4, platelet 92, neutrophils 75.2, lymphocytes 17.3, monocytes 7.2 , eosinophil 0, basophils 0.3, BUN 8, creatinine 0.5, sodium 131, potassium 4, chloride 101, CO2 25, calcium 8.1, albumin 3.4, AST 26, ALT 26, alkaline phosphatase 37, glucose 296, HgA1C 15.3. Blood culture collected repeatedly for aerobic and anaerobic organisms but showed no growth. Multiple urine culture also did not showed any growth of organisms. Chest x-ray was done with no abnormalities of the heart and lungs. The patient also been checked for sputum for AFBX3 and the results were negative. Only test came back with positive result was QuantiFERON-TB Gold test. MRI of the brain was done due to continuous headache and it showed massive pituitary macro adenoma. CT scan of the brain shows no hemorrhage, but significant pituitary macro-adenoma. 

(A)

Figure 1. (A) MRI scan showing the pituitary macro adenoma, (B and C) histopathological slides of the pituitary tumor.

(B)

 

 (C)

Discussion 

      Fever of unknown origin is one of the most difficult entity in the clinical medicine, where all investigation need to be focused on possible occult infections. In this interesting case the positive Quantiferon Gold TB test indicated the patient must have occult TB infection in the body. Subsequently after resection of pituitary macro-adenoma, the TB medications were given to the patient. The following anti-TB regimen were given including, Isoniazid, Rifampicin, Pyrazinamide, and ethambutol.  Clinically patient improved and became afebrile, after the admiration of Anti-TB medication. 

Intrasellar TB continues to be a rare presentation, but incidence and prevalence are expected to grow with increasing numbers of multidrug-resistant TB and shrinking geographical boundaries across the world. Pituitary TB can present with features of a typical adenoma, but has certain radiological and histological features that help to differentiate from an adenoma. Patients can present with a variety of endocrine abnormalities at different times. The presence of an intrasellar mass in individuals at a high risk of developing TB, or with a previous history of systemic TB, should prompt the diagnosis of pituitary TB. In such individuals, it may be worth considering a trial of anti-tuberculous therapy, before considering surgery.1-3 Intracranial tuberculomas account for 0.15-4% of all intracranial tumours (2) (3). TB affecting the sellar region, however, is extremely rare, with no reported incidence or prevalence. AFB are rarely demonstrated within the lesions.4

ATT was recommenced (initially supervised directly observed treatment), with a plan to continue for a minimum period of 1 year and possibly extending to 18 months. Standard course of ATT was provided with an initial 2-month phase of intensive therapy with isoniazid, rifampicin, pyrazinamide and ethambutol, followed by isoniazid and rifampicin for the remaining duration of therapy.

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