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CASE REPORT
Year : 2016  |  Volume : 11  |  Issue : 2  |  Page : 175-176

Supra-sellar tubercular abscess


1 Department of Neurosurgery, Ashwini Sahakari Rugnalaya and Research Center, Solapur, Maharashtra, India
2 MM Institute of Medical Sciences and Research, Mullana (Ambala), Haryana, India
3 Department of Neurology, Ashwini Sahakari Rugnalaya and Research Center, Solapur, Maharashtra, India
4 Department of Pathology, Ashwini Sahakari Rugnalaya and Research Center, Solapur, Maharashtra, India

Date of Web Publication1-Mar-2016

Correspondence Address:
Dr. Amit Agrawal
Department of Neurosurgery, MM Institute of Medical Sciences and Research, Mullana, Ambala, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1793-5482.177658

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  Abstract 

Intracranial tuberculomas are less common lesions; sellar, suprasellar, or parasellar involvement is further rarer with only few case reports in the literature. We describe a case of 44-year-old female, discussing the imaging findings that were managed successfully for tubercular hypothalamic-pituitary abscesses.

Keywords: Abscess, hypothalamic abscess, magnetic resonance imaging, sellar, tubercular abscess, tuberculoma, tuberculosis


How to cite this article:
Joshi VP, Agrawal A, Mudkanna A, Rudrakshi S S, Kelkar G P. Supra-sellar tubercular abscess. Asian J Neurosurg 2016;11:175-6

How to cite this URL:
Joshi VP, Agrawal A, Mudkanna A, Rudrakshi S S, Kelkar G P. Supra-sellar tubercular abscess. Asian J Neurosurg [serial online] 2016 [cited 2020 Jul 7];11:175-6. Available from: http://www.asianjns.org/text.asp?2016/11/2/175/177658


  Introduction Top


Intracranial tuberculomas are less common lesions, accounting for 0.15-5% of intracranial space occupying lesions;[1],[2] sellar, suprasellar, or parasellar involvement is further rarer with only few case reports in the literature.[1],[2],[3],[4],[5],[6] Although there are cases of pyogenic hypothalamic-pituitary abscesses,[4],[7] in the present case, we describe an extremely rare case of supra-sellar tubercular abscess managed successfully.


  Case Report Top


A 44-year-old lady presented with altered behavior and increased frequency of micturation, since six months. She was a known case of tuberculous meningitis, on treatment since one year. On examination, patient did not have any focal neurological deficit. Cranial nerves and fundus examination were normal. Her magnetic resonance imaging (MRI) scan revealed a hypointense lesion on T1 images, iso-hyperintense lesion on T2 images in the hypothalamic region, and restricted diffusion on DW images [Figure 1]a,[Figure 1],[Figure 1]c. On contrast, administration the lesion was ring enhancing with lobulation [Figure 1]d,[Figure 1]e. Patient was operated through pterional craniotomy and sylvian fissure opening. The lesion was identified and it was containing pus. It could be totally excised. The pus was sent for culture and sensitivity testing and the abscess wall was sent to histopathological examination, which revealed changes suggestive of tuberculosis [Figure 2]. After surgery, the patient had type II diabetes insipidus that recovered completely and was discharged without any neurological deficit after 13 days. Follow-up MRI showed disappearance of the abscess [Figure 3].
Figure 1: MRI T1W axial images (a) Hypointense lesion becoming hyperintense lesion on T2W image, (b) Restricted diffusion on DW images, (c) and Contrast enhanced MRI, (d, e and f) Axial, sagittal and coronal images showing a large cystic ring enhancing lesion in the suprasellar region with multiple small ring enhancing lesions

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Figure 2: Left image showing multiple epithelioid cell granulomas with Langhan type giant cells and mixed inflammatory infilterate (H and E, ×10), right image high power view of the same focus showing Langhan type giant cell surrounded by epithelioid cells (H and E, ×10)

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Figure 3: Follow up sagittal image shows that the abscess was largely disappeared

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  Discussion Top


Rarely, unusual non-adenohypophyseal, inflammatory, and infectious processes can involve sellar and suprasellar region and should be considered in the differential diagnosis of mass lesions in this area.[4],[7],[8],[9],[10] Abscess formation in this region is uncommon, pyogenic abscess can develop through direct expansion of an adjacent infection in the meninges, the sphenoid sinus, or the cavernous sinus,[4],[11] and in many cases it may not be possible to find out any primary source of infection or causative agent.[7] Although in cases of pituitary and suprasellar tubercular lesions there may not be any evidence of systemic or primary active tuberculosis, (9) however, in the present case, the patient was treated for tubercular meningitis. As in the present case, MRI features specific to sellar-suprasellar abscesses characteristically include an isointense to mildly hypointense signal on Tl-weighted sequences, and high signal intensity on T2-weighted sequences [12] associated with ring enhancement after contrast administration. In addition, the presence of infundibular thickening and enhancement of the adjacent dura should suggest the presence of a granulomatous lesion like tuberculoma.[3],[9] Demonstration of acid fast bacilli (AFB) by smear or culture within the abscess can help to confirm the diagnosis of tubercular brain abscess,[13] however in present case, the diagnosis was confirmed by histopathology. The recommended treatment in suspected cases included a complete course of anti-tubercular treatment (ATT) and regular follow-up to confirm the response to chemotherapy and regression of the lesions,[2],[10] however surgical intervention can help to decompress the adjacent structures and also to confirm the diagnosis of tubercular lesion (as in present case).[9] In conclusion, involvement of hypothalamus with tubercular abscess is a rare entity, and sellar-suprasellar abscess should be considered in the differential diagnosis in patients whose sellar-parasellar mass on MRI shows regular or irregular, hypo- or hyperintense areas.[7]

 
  References Top

1.
Sharma MC, Arora R, Mahapatra AK, Sarat-Chandra P, Gaikwad SB, Sarkar C. Intrasellar tuberculoma: An enigmatic pituitary infection: A series of 18 cases. Clin Neurol Neurosurg 2000;102:72-7.  Back to cited text no. 1
    
2.
Jain R, Kumar R. Suprasellar tuberculoma presenting with diabetes insipidus and hypothyroidism: A case report. Neurol India 2001;49:314-6.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.
Mittal P, Dua S, Saggar K, Gupta K. Magnetic resonance findings in sellar and suprasellar tuberculoma with hemorrhage. Surg Neurol Int 2010;1:73.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.
Mohr PD. Hypothalamic-pituitary abscess. Postgrad Med J 1975;51:468-71.  Back to cited text no. 4
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5.
Brooks MH, Dumlao JS, Bronsky D, Waldstein SS. Hypophysial tuberculoma with hypopituitarism. Am J Med 1973;54:777-81.  Back to cited text no. 5
    
6.
Eckland DJ, O'Neill JH, Lightman SL. A pituitary tuberculoma. J Neurol Neurosurg Psychiatry 1987;50:360-1.  Back to cited text no. 6
    
7.
Bayar MA, Elmaci E, Yasitli U. Hypothalamo-Pituitary Abscess: A Case Report. Turkish Neurosurgery 1999;9:151-4.  Back to cited text no. 7
    
8.
Scheithauer BW. Pathology of the pituitary and sellar region: Exclusive of pituitary adenoma. Pathol Annu 1985;20 Pt 1:67-155.  Back to cited text no. 8
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9.
Shukla S, Trivedi A, Singh K, Sharma V. Pituitary tuberculoma. J Neurosci Rural Pract 2010;1:30-1.  Back to cited text no. 9
[PUBMED]  Medknow Journal  
10.
Sundar US, Ramteke VV, Vaidya MS, Asole DC, Moulick ND. Suprasellar tuberculoma presenting as panhypopituitarism. J Assoc Physicians India 2010;58:706-9.  Back to cited text no. 10
    
11.
Lindholm J, Rasmussen P, Korsgaard O. Intrasellar or pituitary abscess. J Neurosurg 1973;38:616-9.  Back to cited text no. 11
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12.
Sartor K, Karnaze MG, Winthrop JD, Gado M, Hodges FJ 3rd. MR imaging in infra-, para- and retrosellar mass lesions. Neuroradiology 1987;29:19-29.  Back to cited text no. 12
    
13.
Chowdhary A, Kaundinya D, Palande D, Bharadwaj R, Menon S. Tuberculous brain abscesses: Case series and review of literature. J Neurosci Rural Pract 2011;2:153-7.  Back to cited text no. 13
[PUBMED]  Medknow Journal  


    Figures

  [Figure 1], [Figure 2], [Figure 3]


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