A Rare Presentation of Severe Headache with Panhypopituitarism and Bilateral Lateral Rectus Palsy: Pituitary Tuberculosis

Panhypopituitarism, characterised by deficient secretion of one or more anterior pituitary hormones, is most frequently caused by pituitary adenomas, with infectious and infiltrative disorders such as tuberculosis (TB), sarcoidosis, and Langerhans cell histiocytosis accounting for a small minority of cases. Pituitary TB is an exceedingly rare manifestation of central nervous system TB, even in TB-endemic regions such as India, and its non- specific presentation often leads to diagnostic delay or misclassification as a pituitary adenoma. We report a 49-year-old man who presented with a 4 - 5 day history of severe headache, non-projectile vomiting, constipation, and weight gain without fever, and who was found on examination to have bilateral lateral rectus palsy. Biochemical evaluation confirmed panhypopituitarism, with low cortisol, adrenocorticotropic hormone (ACTH), gonadotropins, and testosterone, together with a thyroid-stimulating hormone (TSH)-predominant hypothyroid pattern. Contrast- enhanced magnetic resonance imaging (MRI) of the brain revealed a heterogeneously enhancing sellar lesion that subsequently enlarged and caused extrinsic compression of both cavernous sinuses, without a discrete adenomatous appearance or optic chiasmal involvement. Cerebrospinal fluid (CSF) analysis showed a lymphocyte-predominant pleocytosis with negative staining for acid-fast bacilli (AFB), and chest imaging showed only old fibrotic changes without evidence of active TB. In the absence of typical adenomatous features and given the overall clinical and radiological suspicion of an infiltrative process, a multidisciplinary team initiated empirical antitubercular therapy (ATT), which the patient tolerated well, with gradual clinical improvement on follow-up. This case underscores the importance of considering pituitary TB in the differential diagnosis of a sellar mass associated with panhypopituitarism and ocular motor palsy, particularly in TB-endemic settings, and illustrates that empirical ATT may be justified even without histopathological confirmation when the index of clinical suspicion is high.