MON-120 Tolosa Hunt Syndrome And Hypophysitis Secondary To Tuberculosis

Abstract Disclosure: J.M. Piñón: None. C. Lovato: None. T. Duro: None. Introduction: Tolosa Hunt Syndrome (THS) is a rare disorder characterized by recurrent unilateral retro-orbital pain accompanied by extraocular palsies and oculosympathetic paralysis involving one or more of the third, fourth, or fifth cranial nerves. This condition is attributed to indolent granulomatous inflammation of the cavernous sinus. Although uncommon, this granulomatous inflammation can extend to the pituitary gland and lead to hypophysitis. Clinical Case: A 37-year-old healthy female presented with worsening right eye pain, burning, and shooting pain to her right cheek and temple with new onset ptosis, vertical diplopia, and photophobia. A brain MRI revealed a mildly enlarged pituitary gland (1.3 x 1.0 cm) with upward extension into the suprasellar cistern and leftward bowing of the pituitary stalk. Additionally, imaging revealed small, asymmetric enhancing tissue near the right paraclinoid and cavernous sinus regions and possible enlargement of the inferior and medial rectus muscles. A 6-day course of methylprednisolone resulted in significant symptom improvement. A positive QuantiFERON-TB Gold test confirmed the diagnosis of tuberculosis (TB). She underwent an endocrine workup after she shared that she had been experiencing amenorrhea, polydipsia, polyuria, and fatigue for 4 months. Her evaluation revealed the following: 8AM cortisol 14.3 ug/dL (6.0-18.4 ug/dL), ACTH 15 pg/mL (7-63 pg/mL), TSH 3.310 uiu/mL (0.270-4.200 uiu/mL), free T4 0.5 ng/dL (0.9-1.7 ng/dL), prolactin 53.6 ng/mL (4.8-23.3 ng/mL), IGF-1 37 ng/mL (97-234 ng/mL), LH 3.5 mIU/mL (1.0-95.6 mIU/mL), FSH 3.3 mIU/mL (1.7-21.5 mIU/mL), estradiol 80.2 pg/mL (30-400 mIU/mL), serum sodium 139 mmol/L (135-145 mmol/L), serum osmolality 288 mosm/Kg (280-305mosm/Kg), urine osmolality 187 mosm/Kg (50-600 mosm/Kg). In summary, this patient was diagnosed with THS and hypophysitis associated with tuberculosis. She was treated with isoniazid, rifampin, and pyridoxine which led to significant improvement in her symptoms within a few days and reduced pituitary size on MRI three months later. She was started on desmopressin and levothyroxine. She experienced improvement in polyuria and fatigue. Her menstrual periods spontaneously resumed and were regular. Conclusion: We present a case of a patient with an underlying TB infection that revealed itself through rare involvement of the cavernous sinus, and likely triggered a chronic inflammatory response, leading to the development of THS. Although uncommon, the granulomatous inflammation associated with THS has been known to extend to the pituitary gland and cause hypophysitis. In most documented cases, hypophysitis associated with THS results in pituitary enlargement and dysfunction. However, these abnormalities typically resolve spontaneously or with treatment. Presentation: Monday, July 14, 2025