tuberculosis is an infectious disease caused by mycobacterium tuberculosis . despite the advance of therapeutic treatment , tuberculosis still remains one of the world s biggest problems . in 2014 , 9.6 million people were estimated to be new cases of active tuberculosis worldwide . the lungs are the most common sites for m. tuberculosis infection , presenting either asymptomatic latent infection or active pulmonary tuberculosis . extrapulmonary sites of infection , representing about 20% of immunocompetent patients , can occurred in any organ with or without overt pulmonary involvement . central nervous system ( cns ) tuberculosis accounts for only 1% of tuberculosis cases worldwide , mostly in areas where the prevalence of tuberculosis are high . hematogenous spreading which later developed the tuberculous foci in the brain , meninges , or adjacent bone is the main pathogenesis of cns tuberculosis . the forms of cns and most other forms of extrapulmonary tuberculosis , such as tuberculous meningitis , tuberculous encephalitis , tuberculoma or tuberculous brain abscess , depend on the location of tuberculous foci and host immune factors . pituitary tuberculoma is extremely rare , with the first case reported by coleman et al . in 1940 . up to 2015 , only 81 cases of pituitary tuberculoma had been documented in the previous literatures commonly presenting with gradual onset of headache and visual disturbances with or without systemic symptoms . pituitary apoplexy is a rare condition that occurs only 27% in pituitary adenoma and characterized by acute infacrtion and/or hemorrhage of the pituitary gland . moreover , pituitary tuberculoma manifesting as apoplexy is extremely rare , , . without history of fever or multi - organ tuberculosis , the diagnosis of pituitary tuberculoma in a patient with apoplexy - like presentation is even harder to establish . we herein report pituitary apoplexy - like presentation of pituitary tuberculoma in a young female without associated systemic tuberculosis and demonstrate the clues in the differential diagnosis . a 25-year - old laotian female , who lived in thailand for ten years , presented with low - grade fever , sudden onset of headache , and rapidly progressive visual loss in both eyes for 5  days . there was no previous history of headache , chronic cough , weight loss , prolonged fever or history of exposure to tuberculosis . she gave birth to her second child 2 years before without any complications and successfully breastfed for 9 months , indicating intact hypothalamic - pituitary - gonadal axis previously . vital signs were : body temperature 37.8  c , blood pressure 100/60  mmhg , pulse rate 60 beats / min and respiratory rate 16 breaths / min . best corrected visual acuity was hand movements of the left eye and 20/40 of the right eye . a magnetic resonance imaging ( mri ) of brain showed rim - enhancing lesion , hypointense on t1-weighted image , mixed hypo- and hyperintense on t2-weighted image , occupying the sellar region with suprasellar extension , measuring about 1.4    2.5    2.2  cm ( fig . 1 ) . meningeal enhancement and thickened enhancement of pituitary stalk was seen with absence of posterior bright spot . the lesion compressed optic chiasm causing hyperintense signal in t2-weighted image of both optic nerves and optic chiasm . anterior pituitary hormone evaluation revealed panhypopituitarism ; thyroid stimulating hormone 0.081  uiu / ml ( 0.354.94 ) , serum free t4 0.71  ng / dl ( 0.701.48 ) , early morning cortisol < 1  mcg / dl , prolactin < 0.6  ng / ml ( 5.1826.53 ) , insulin like growth factor-1 81  ng / ml ( 117329 ) . hyponatremia with serum sodium of 124  mmol / l was found . with regular menstrual cycles by using oral contraceptive pill , luteinizing hormone ( lh ) and follicle - stimulating hormone ( fsh ) were not evaluated . polyuria from central diabetes insipidus was unmasked after hydrocortisone therapy . due to acute visual loss , a firm un - suckable mass at sellar and suprasellar region , appeared like caseous necrotic tissue , was found separately from normal adjacent pituitary gland . in addition , polymerase chain reaction ( pcr ) of mycobacterium spp . was negative . the combination of histological findings , enhanced pituitary stalk in post - contrast mri and the fact that patient living in endemic area highly suggested the diagnosis of pituitary tuberculoma . treatment was initiated with a 2-month combination of isoniazid , rifampin , pyrazinamide and ethambutol , followed by 7 months of isoniazid and rifampin . short - term therapy of oral desmopressin was given for 3 weeks which was later stopped during follow up . she regained her 20/20 vision of both eyes within 1 week with only a small visual field defect in left periphery before discharge from hospital . unfortunately , her secondary adrenal insufficiency and hypothyroidism are still persistent at 9-month follow - up . our patient presented with pituitary apoplexy - like symptoms and rim - enhancing sellar - suprasellar lesion with enhanced pituitary stalk on the pituitary mri favored non - adenoma etiologies . the preoperative differential diagnosis included inflammatory and granulomatous lesions of pituitary gland , including lymphocytic hypophysitis , pituitary abscess , tuberculosis , fungal infection , sarcoidosis , wegener s granulomatosis and langerhans cell histiocytosis . for the differential diagnosis , lymphocytic hypophysitis typically affected women during peripartum period with symmetrical enlargement of pituitary gland and homogeneous contrast enhancement from mri . pituitary abscess often presented with an indolent course , with or without fever , rarely with acute onset . mri of the pituitary gland showed intrasellar cystic lesion and peripheral enhancement after contrast , which resembled our cases . fungal infection , such as aspergillosis , usually observed in immunocompromised patients , frequently extended from paranasal sinus infection . confirmed by intraoperative and histological finding of caseous necrotic mass , the most likely diagnosis was pituitary tuberculoma . not surprisingly , the acid fast bacilli stain was negative and no evidence of extracranial tuberculosis from physical examination and chest x - ray , as reported in most of the past literatures , and the response to antituberculous therapy supports the diagnosis of a pituitary tuberculoma . to best of our knowledge , there were 81 case reports of pituitary tuberculoma until now and only 3 cases presented with apoplexy - like symptoms ( table 1 ) , , . in the summary of 81 cases ( table 1 and supplemental material ) , mean age was 34.1    13.6 years ( range , 868 years ) and majority of them were female ( 72.8% ) without underlying diseases . the most common symptoms were headache ( 85.2% ) followed by visual disturbances ( 48.1% ) . only 12 of 81 patients ( 14.8% ) had a history of low - grade fever , thus it is not very helpful for diagnosis . endocrine disturbances were the first presenting symptoms including galactorrhea ( 23.7% of female ) , amenorrhea ( 37.3% of female ) and polyuria from central diabetes insipidus ( 8.6% ) . the presence of central diabetes insipidus was one of the key features in distinguishing pituitary tuberculoma from pituitary adenoma . twenty - four of 81 patients ( 29.6% ) had evidence of tuberculosis in other organs , either precedingly or concomitantly , such as pulmonary tuberculosis ( 11/24 ) , lymphadenitis ( 8/24 ) , spine ( 1/24 ) , prostate gland ( 1/24 ) , sinusitis ( 1/24 ) and skin abscess ( 2/24 ) . prior history of extracranial tuberculosis as long as 22 years before the episode of pituitary tuberculoma had been reported . evidence of extracranial tuberculosis is very helpful for the diagnosis of pituitary tuberculoma , and avoids unnecessary transphenoidal pituitary surgery . however , if the rapid visual deterioration is found with significant pressure effect on the optic apparatus on mri , urgent endoscopic transphenoidal surgery must be done . the pituitary apoplexy - like symptoms could be resulted from caseous necrosis within the tuberculoma itself ,   or may be partly explained by infarction of normal pituitary gland seen in histopathology . tuberculous vasculitis may be the cause of ischemic or hemorrhagic necrosis in tuberculoma , pituitary gland or adjacent tissue . this patient s imaging showed hypo- to isointense signal on t1-weighted image and hyperintense signal on t2-weighted image . these signal characteristics are nonspecific and resemble those of a pituitary adenoma . however , peripheral contrast enhancement of sellar lesion after gadolinium is unusual for pituitary adenoma . contrast mri typically demonstrated thickening and enhancement of pituitary stalk in many cases of pituitary tuberculoma . from previous literatures of 79 cases , 20 from 42 cases with available mri ( 47.6% ) demonstrated thickened with enhancement of pituitary stalk , probably one of the most important clues to the diagnosis . recently , magnetic resonance spectroscopy ( mrs ) has emerged as a noninvasive modality to detect specific chemicals in tissues of interest . mrs of a tuberculoma demonstrated elevated lipid peaks at 0.9 , 1.3 , 2.0 and 2.8  ppm , and a phosphoserine peak at 3.7  ppm . the lipid resonance , at 0.9 and 1.3  ppm occur due to the presence of methylene and terminal methyl groups on fatty acids found in caseous necrosis of tuberculoma , . the transphenoidal approach was the preferred route of surgery , mainly used for diagnosis confirmation and decompression of adjacent structures without contaminating of organisms into intracranial structures as compared to transcranial approach . a radical surgery , which carried the risk of cerebrospinal fluid leakage , was not necessary since medication treatment was effective postoperatively . typical intraoperative findings are firm to hard , non - suckable greyish lesion with thickening of dura . pituitary tuberculoma may be managed conservatively , without surgery , if the diagnosis was confirmed by other tests , such as cerebrospinal fluid pcr for tuberculosis in cases with co - existing tuberculous meningitis . thirty - one cases ( 59.6% ) had granuloma without caseous necrosis while 20 cases had typical granuloma with caseous necrosis . pus was aspirated in one patient , and no tissue was collected . while microbial identification is straightforward in pulmonary tuberculosis , pituitary tuberculoma is rarely bacteriologically confirmed . only 2 cases reported positive for acid fast bacilli from pathological tissue ,   and 2 cases showed mycobacterial growth on the lwenstein - jensen medium , . in other 2 cases , pcr for m. tuberculosis dna was positive , but negative for acid fast bacilli stains . only one case was tested positive for both acid fast bacilli stain and mycobacterial growth on culture media . moreover , quantiferon tb - gold interferon gamma release assay was tested positive in one case report . presumptive diagnosis is mostly required pathology finding of granulomatous lesion because of commonly negative microbial identification . combination of bactericidal drugs , such as isoniazid , rifampin , pyrazinamide , streptomycin , that penetrate effectively the blood brain barrier should be prescribed . various regimens treated for 924 months had been used , depend on the clinical and imaging responses . a significant reduction in size after treatment have been reported as early as 2 months , usually with complete resolution of sellar mass at the end of the regimen . however , persistent of enhanced pituitary stalk after gadolinium administration without symptoms or evidence of sellar mass had been reported in some cases , . the improvement of endocrinological status was reported in some patients but data were inconsistent regarding courses of endocrine dysfunction in detail . we reported an additional case of pituitary tuberculosis with pituitary infarction that should be in the differential diagnosis of intrasellar lesions presented with sudden onset of headache and visual loss . the presence of diabetes insipidus and thickened with enhancement of pituitary stalk on mri were very helpful in diagnosing pituitary tuberculosis . this research did not receive any specific grant from any funding agency in the public , commercial or not - for - profit sector .
pituitary tuberculoma is extremely rare , even in endemic regions of tuberculosis and much less frequently as a presentation of pituitary apoplexy . 
 we describe a 25-year - old female presented with sudden onset of headache and vision loss of left eye which mimicking symptoms of pituitary apoplexy . 
 mri of the pituitary gland showed a rim - enhancing lesion at the intrasellar region extending into the suprasellar area , but absence of posterior bright spot with enhancement of the pituitary stalk . 
 pituitary hormonal evaluation revealed panhypopituitarism and diabetes insipidus . 
 an urgent transphenoidal surgery of the pituitary gland was undertaken for which the histopathology showed necrotizing granulomatous inflammation with infarcted adjacent pituitary tissue . despite negative fungal and afb staining , 
 pituitary tuberculoma was presumptively diagnosed based on imaging , pathology and the high incidence of tuberculosis in the country . 
 after the course of anti - tuberculosis therapy , the clinical findings were dramatically improved , supporting the diagnosis . 
 pituitary tuberculoma is extremely rare in particular with an apoplexy - like presentation but should be one of the differential diagnosis list of intrasellar lesions in the patient presenting with sudden onset of headache and visual loss . 
 the presence of diabetes insipidus and thickened with enhancement of pituitary stalk on mri were very helpful in diagnosing pituitary tuberculosis .