Hypothalamic pituitary abnormalities in tubercular meningitis at the time of diagnosis

Abstract

Tubercular meningitis (TBM) is the most dreaded form of extra pulmonary tuberculosis associated with high morbidity and mortality. Various hypothalamic pituitary hormonal abnormalities have been reported to occur years after recovery from disease but there are no systematic studies in the literature to evaluate the pituitary hypothalamic dysfunction in patients with TBM at the time of presentation. Therefore, the present study was designed to evaluate hypothalamic pituitary abnormalities in newly diagnosed patients with TBM. Patient case series. This prospective study included 75 untreated adult patients with TBM diagnosed as "definite", "highly probable" and "probable" TBM by Ahuja's criteria and in clinical stage 1, 2 or 3 at the time of presentation to hospital. Basal hormonal profile was measured by electrochemilumniscence technique for serum cortisol, luetinizing hormone (LH), follicular stimulating hormone (FSH), prolactin (PRL), thyrotropin (TSH), free tri-iodothyronine (fT3), and free thyroxine (fT4). All patients were subjected to MRI to image brain and hypothalamic pituitary axis and CT for adrenal glands. Thirty-two (42.7%) cases showed relative or absolute cortisol insufficiency. Twenty-three (30.7%) cases showed central hypothyroidism and 37 (49.3%) cases had hyperprolactinemia. No patient had evidence of diabetes insipidus. Multiple hormone deficiency was seen in 22 (29.3%) cases. MRI of hypothalamic pituitary axis using dynamic scanning and thin cuts revealed abnormalities in 10 (13.3%) of the cases. CT adrenal gland was normal in all the patients. Tubercular meningitis is associated with both hormonal and structural abnormalities in the hypothalamic pituitary axis at the time of diagnosis.

Clinical spectrum of hypopituitarism in India: A single center experience

“…In a recent study from India, hypopituitarism was observed in about 30% of newly diagnosed TBM. [7] The study stated TBM to be a severe stressful condition and conveniently used the controversial cortisol cut-off values for diagnosing adrenal insufficiency. The thyroid dysfunction could well be interpreted as sick euthyroid syndrome.…”

“…[1] It is at best limited to case series involving childhood hypopituitarism,[2] Sheehan syndrome,[34] post radiotherapy,[5] pituitary adenomas,[6] or tubercular meningitis (TBM). [7] A study from Spain documented an incidence and prevalence of hypopituitarism to be 4.21 and 45.5 cases per 100 000 population, respectively. [8] Hypopituitarism follows a smoldering course unless it has an onset with pituitary apoplexy; hence, more often it is likely to be missed.…”

DIAGNOSIS OF ENDOCRINE DISEASE: Expanding the cause of hypopituitarism

“…In an Indian study, multiple pituitary hormone deficiency was reported in 29.3% of cases, and no patient had evidence of diabetes insipidus (72). After treatment with antituberculous drugs, the pituitary tuberculoma may disappear with the reversal of hypopituitarism in some cases (71).…”

Pituitary dysfunction in infective brain diseases

“…Multiple pituitary hormone deficiency was seen in 22 (29.3%) cases. [5] While tubercular abscess of the brain has been reported, primary tubercular abscess of the pituitary is extremely rare. The literature review yields only few cases of primary tubercular lesion of the pituitary and the diagnosis was reached only after surgery.…”