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Year : 2015 | Volume : 3 | Issue : 3 | Page : 235 - 236  


Case Reports
A rare case of pituitary macroadenoma presenting as 3rd nerve palsy

Kolli.Anudeep1, Dilip M Rampure2, Irappa Ganiger3

Department of general medicine, Mamata General and Super Speciality Hospital, Khammam

Corresponding Author:

Dr. K. Anudeep

Email: kollianu98@gmail.com 

Abstract:

It is rare for a pituitary adenoma to present with isolated 3rd cranial nerve palsy .pituitary adenomas come into medical attention because of endocrine or visual abnormalities .Here is a 50 year old Female presented to OPDof mamata hospital, khammam with headache which was sudden in onset more on frontal region associated with vomiting and diarrhea , after few days patient again presented with unilateral left sided ptosis for which patient underwent thorough examination and found to have left sided dilated pupil with restriction of eye movements on left side . Patient underwent Subsequent routine blood investigations which were with in normal limits and hormone essays which showed hypothyroidism. MRI-Brain was done which revealed a pituitary macro adenoma . All the 3rd nerve palsy features recovered slowly after few days with out any surgical intervention.

Key words: Nerve palsy, pituitary, adenoma

INTRODUCTION:

Pituitary adenomas account for 10-15 % of intracranialneoplasms(1).They are most common benign adenomas ,although pituitary carcinomas and metastases to the pituitary do occur(2).Tumours can produce symptoms and signs through hyper secretions of hormones or related to the mass effect of the tumour on the optic nerve or structures adjacent to pituitary gland (2).Pituitary tumors are classified according to size and invasive characteristics by Hardy .Stage-I are microadenomas (less than 10mm in diameter) they may cause hormonal over secretion but are not associated with structural problems. Stage-II tumors are macro adenomas (greater than 10mm) with or without suprasellar extension. Stage-III tumors are macro adenomas that locally invade the floor of the sella and may cause sellar enlargement and suprasellar extension with multiple cranial nerve palsy(1) . Tumours generally have to be ˃1 cm before they cause any symptoms of neural or vascular compression(2).Pituitary macro- adenomas are the most common cause of hypopituitarism, and in the majority of cases they are non-secreting adenomas(3).A majority of pituitary microadenomas often remain undiagnosed and those that are diagnosed are often found as an incidental finding, and are referred to as incidentalomas(4) (5). Extra ocular palsy may be a sign of cavernous sinus invasion or extrinsic compression by pituitary tumors, suggestive of advanced disease. It develops in patients with established visual field defects and pituitary apoplexy and may be associated with other cranial nerve palsies, including nerves 3rd,4th , 6th and less commonly nerve 5th (6). Isolated third nerve palsy is rarely associated with pituitary adenomas.

CASE REPORT:

A 50 year old Female presented to OPD of mamata hospital, khammam with headache which was sudden in onset more on frontal region associated with vomiting and diarrhea , after few days patient presented with unilateral left sided ptosis for which patient underwent thorough ocular examination and found to have dilated pupil of size 5.5 mm on left eye with sluggishly reacting to light and 3mm on right eye with a normally reacting to light . Unaided visual acuity was 6/6 in both eyes. The left eye movements were restricted and was down and out positioned , the right eye was normal. Fundoscopy showed well defined optic disc with normal vessels . The remaining cranial nerves were intact. Subsequent hormone essays revealed raised TSH levels suggestive of hypothyroidism (100 mcU/mL) with normal ACTH, prolactin and GH levels with in normal ,all other routine blood parameters with in normal . MRI was done to rule out the cause of left sided ptosis which revealed a pituitary mass of size measuring 1.1x5x2 cm extending into cavernous sinus suggestive of pituitary macro adenoma. With this evidence patient diagnosed as 3rd cranial nerve palsy lead by pituitary macroadenoma with hypothyroidism . Subsequently patient was treated with L-Thyroxine 100mcg and T.Decadron 4mgplanned for surgical resection . All the 3rd nerve palsy features recovered after few days with out any surgical intervention.

DISCUSSION:

The most common ophthalmic presentation of pituitary tumours is with visual field defects.Isolated third nerve palsy is rarely associated with pituitary Adenomas.It could be due to tumor invasion or Apoplexy(6).It may occur slowly secondary to mechanical compression against the interclinoid ligament, or by compression and invasion of the cavernous sinus by the tumour. Secondly it may occur rapidly, associated with headache due to compressive effects or by compromise of the vascular supply to the nerve itself(7)

REFERENCES:

  1. Shlomo M, Jameson L. Disorders of anterior pituitary and hypothalamus. Harrison’s principles of internal medicine, 16th ed. Editors: Dennis L K, Eugene B, AntonyS, Stephen LH, Dan LL, J Larry. Mc Graw Hill Inc, New York :1998.2076-2101).
  2. Intracranial extracerebral tumours by Robert grant textbook of Brain’s diseases of the nervous system 12th edition)
  3. Hyperthyroidism unmasked several years after the medical and radiosurgical treatment of an invasive macroprolactinoma inducing hypopituitarism: a case report. L Foppiani, A Ruelle, P Cavazzani, P del Monte - Cases journal, 2009).
  4. Ezzat, Shereen; Asa, Sylvia L.; Couldwell, William T.; Barr, Charles E.; Dodge, William E.; Vance, Mary Lee; McCutcheon, Ian E. (2004). "The prevalence of pituitary adenomas".Cancer101(3): 613–9.doi:1002/cncr.20412.PMID15274075)
  5. Asa, Sylvia L. (2008)."Practical Pituitary Pathology: What Does the Pathologist Need to Know.Archives of Pathology & Laboratory Medicine132(8): 1231–40.doi:10.1043/1543-2165(2008)132[1231:PPPWDT]2.0.CO;2 (inactive 2015-01-09).PMID18684022.)
  6. Lau KK, Joshi SM, Ellamushi H, Afshar F: Isolated bilateral oculomotor nerve palsy in pituitary apoplexy: case report and review Br J Neurosurg 2007; 21: 399–402.)
  7. Saul RF, Hilliker JK. Third nerve palsy: the presenting sign of a pituitary adenoma in five patients and the only neurological sign in four patients.J Clin Neuro-ophthalmol1985;5: 185–193)





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