PMC8727105_01
A 60-year-old male presented with sudden-onset severe headache and vision loss. (a) Bilateral ptosis and abducted right eye; (b) bilateral gynaecomastia; (c) axial NCCT head demonstrating a large sellar mass with areas of hyperdensity within suggestive of acute hemorrhage; and (d) coronal noncontrast T1-weighted MRI sellar demonstrating a 3.1 x 2.7 x 4.1 cm pituitary adenoma with peripheral T1 hyperintensity suggestive of acute bleed.
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Positive findings on examination included bilateral absent light perception, complete external ophthalmoplegia, bilateral ptosis, optic atrophy, and gynaecomastia (Figures 1(a) and 1(b)). A noncontrast computed tomography (NCCT) scan revealed a hyperdense sellar mass (Figure 1(c)), and contrast-enhanced magnetic resonance imaging showed a 3.1 x 2.7 x 4.1 cm sellar mass with the peripheral rim of T1 hyperintensity suggestive of adenoma with an acute to early subacute bleed (Figure 1(d)). The initial pituitary hormone profile was suggestive of secondary hypothyroidism (T4: 3.79 ug/dl (4.8-12.7); T3: 0.804 ng/ml (0.8-2); and TSH: 7.01 uIU/ml (0.27-4.2)), secondary hypogonadism (LH: 0.270 mIU/ml; testosterone 0.0868 nmol/l (9.9-27.8); and low prolactin 3.01 ng/ml (4.0-15.2)).
Lymphoblasts were rare in the peripheral blood (a) and comprised 70% of all cells in the bone marrow (b, c) (May-Grunwald-Giemsa stain, x1000). On flow cytometry, they were CD45 negative to dim positive with low side scatter (d) and coexpressed CD19 and CD10 (e) as well as showed dim to negative CD20 expression (f).
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The final hematological diagnosis was precursor B-lineage CALLA-positive acute lymphoblastic leukaemia (Figure 2).