Hypophyseal tuberculoma: Direct radiosurgery is contraindicated for a lesion with a thickened pituitary stalk: Case report

OBJECTIVE AND IMPORTANCE: Hypophyseal tuberculomas are extremely rave lesio ns. The recognition of hypophyseal tuberculomas in the differential diagnos is of pituitary tumors is important, even with no evidence of systemic tube rculosis. CLINICAL PRESENTATION: A 27-year-old female patient presented with continuo us, dull, generalized headaches and amenorrhea, with no history of visual d iminution, galactorrhea, or endocrinological abnormalities and no evidence of systemic tuberculosis. The patient exhibited a normal water balance, wit hout polyuria or polydipsia. A gynecological examination, including an endo metrial biopsy for amenorrhea, did not reveal any abnormalities. Perimetric and endocrinological examination results were normal. Contrast magnetic re sonance imaging revealed a dense enhancing intrasellar mass, with thickenin g of the pituitary stalk. INTERVENTION: Sublabial rhinoseptal transsphenoidal decompression of the le sion was performed. The histopathological features were consistent with a d iagnosis of tuberculoma, and acid-fast bacilli were demonstrated in the sur gically removed tissue with Ziehl-Neelsen staining. As soon as the histopat hological features were known, the patient underwent a lumbar puncture for cerebrospinal fluid analysis, which indicated normal findings. An intraderm al tuberculin test yielded negative results. The patient was treated with m edical therapy for 18 months, and complete resolution of the lesion was obs erved in follow-up examinations. CONCLUSION: Hypophyseal tuberculomas are often mistaken for pituitary adeno mas. The finding of a thickened pituitary stalk in contrast magnetic resona nce imaging scans may be useful for the differentiation of these lesions fr om pituitary adenomas. Direct radiosurgery is not an appropriate primary tr eatment method for pituitary adenomas and is principally restricted to elde rly, medically unfit patients with microadenomas and patients with residual or recurrent tumors after microsurgery. It is contraindicated for patients who exhibit a thickened pituitary stalk in contrast magnetic resonance ima ging scans.