An atypical cause of trigeminal neuralgia and panhypopituitarism

Abstract

A 63-year-old man presented to the hospital accident and emergency department with an episode of syncope. He also gave a history describing several weeks of leftsided facial pain, which was initially thought to be secondary to a tooth abscess. On systemic enquiry the patient also reported having intermittent episodes of night sweats and mild anorexia, but he was otherwise well. Physical examination revealed the patient to have significant postural hypotension, allodynia affecting all three divisions of the trigeminal nerve and a palpable liver edge. Laboratory biochemistry investigations revealed profound panhypopituitarism.An MRI with gadolinium contrast of the brain subsequently revealed a hypothalamic mass sitting posterior to the optic chiasm and wrapping around the floor of the third ventricle with extension into the infundibulum. A second mass was also observed within Meckel's cave extending towards the foramen ovale. The masses appeared radiologically similar but anatomically separate (Figures 1 and 2).What is the differential diagnosis? What further investigations are indicated? DiagnosisRadiological assessment of the lesions initially suggested the possibility of (a) metastatic lesions including lymphoma; (b) two coincidental lesions, e.g. hypothalamic astrocytoma and trigeminal schwannoma; or (c) granulomatous pathology such as neurosarcoidosis. There is a 15612 mm hypothalamic mass that wraps around the floor of the third ventricle. The mass lateral to the cavernous sinus is situated within Meckel's cave and is likely to account for the left trigeminal nerve symptoms.

Knowledge About Chronic Orofacial Pain Among General Dentists of Kermanshah, Iran

“…Nearly three-fourth (76.5%) of the dentists correctly reported brain tumor as one of the etiologic factors of trigeminal neuralgia. Some studies have reported trigeminal neuralgia as one of the manifestations of intracranial tumors such as central nervous system lymphoma [ 33 ], meningioma [ 34 ], cerebellopontine angle tumors such as cholesteatoma [ 35 ], and epidermoid tumor [ 36 ]. Therefore, dentists should consider brain tumors as differential diagnoses when facing patients with trigeminal neuralgia.…”

Burkitt's lymphoma presenting with hypopituitarism: a case report and review of literature

“…This is, however, uncommon in this case series. The presence of dural enhancement has also been described as a distinguishing feature of pituitary lymphoma, which is usually absent in pituitary adenomas (5) (8) . It is difficult to distinguish pituitary metastases due to lymphoma from other malignant tumours radiologically unless a pituitary biopsy is performed.…”

Panhipopituitarismo y diabetes insípida central como primera manifestación de linfoma primario del sistema nervioso central en una paciente inmunocompetente

“…Pese a que el LPSNC presenta sensibilidad a la quimio y radioterapia (13) , el pronóstico sigue siendo poco favorable con tiempos de supervivencia que oscilan entre 15 y 45 meses en aquellos pacientes que reciben tratamiento (11) , esto puede deberse tanto a la agresividad que per se posee esta neoplasia (7,12) , como al diagnóstico tardío (2) . La evolución de nuestra paciente fue poco favorable dada la presencia de recaída tumoral temprana posterior a dos ciclos de quimioterapia y trasplante autólogo de médula ósea, que determinó el inicio de terapia de rescate con metotrexate y citarabina en altas dosis, así como la utilización de radioterapia externa holoencefálica.…”