中枢神经系统结核合并垂体结核伴尿崩症一例并文献复习

doi:10.19983/j.issn.2096-8493.20250095

摘要/Abstract

摘要：

目的: 分析中枢神经系统结核(central nervous system tuberculosis,CNS-TB)伴尿崩症(diabetes insipidus,DI)患者临床特点,以期为临床诊疗提供更多经验。方法: 对1例以DI为首发表现的CNS-TB患者临床表现、实验室检查、影像学特点、治疗及预后进行报道,并回顾分析国内外文献。以“Tuberculosis”“Tuberculous Meningitis”“Diabetes Insipidus”为检索词检索PubMed数据库;以“结核”“尿崩症”“结核性脑膜炎”为检索词检索中国知网、万方、维普数据库,检索时间为2000年1月至2025年6月,剔除综述类、重复及资料不全文献,最终纳入16篇临床资料完整的案例报道文献。收集患者临床表现、病程、CNS-TB累及部位及影像学特征、颅外结核伴随情况、垂体功能受累情况,治疗及转归预后。结果: 患者,男性,54岁,主诉“烦渴、多饮、多尿、头痛、纳差”,化验尿比重低,血渗透压高,限水加压试验提示中枢性尿崩症,CT检查显示右肺炎性改变,右侧胸腔积液,继发邻近肺组织膨胀不全。MRI检查显示垂体柄增粗,垂体、松果体区异常强化,垂体后叶高信号存在。给予诊断性抗结核治疗3个月,患者自行停药。出院6个月后复查肺部CT,未提示胸腔积液,垂体MRI未见明显异常,但DI仍存在。通过文献复习与筛选,共获得CNS-TB伴DI患者16例,加上本例患者共计17例,包括男性10例,女性7例,年龄范围为5~63岁,伴肺结核6例,皮下结节结核1例。影像学表现为鞍区/鞍上结核瘤10例,垂体柄增粗7例,脑水肿2例。6例患者出现全垂体功能低下,2例患者DI合并中枢性甲状腺功能减退。6例患者视力下降行减压术,1例视野缺损。随访3例DI未恢复,1例甲状腺功能减退未恢复,2例肾上腺皮质功能减退和甲状腺功能减退未恢复;患者视力视野受损均改善;14例患者影像学病变有吸收或病灶消失;2例死亡。结论: CNS-TB可累及鞍区,出现垂体功能受损及视神经压迫,需评估垂体功能并定期随访,出现危及视力的压迫症状可行减压手术。

关键词: 结核,中枢神经系统, 结核,脑膜, 尿崩症

Abstract:

Objective: To investigate the clinical characteristics of central nervous system tuberculosis (CNS-TB) complicated by diabetes insipidus (DI), with the aim of providing insights to inform and improve clinical diagnosis and management. Methods: We present a case of central nervous system tuberculosis (CNS-TB) in which DI was the initial manifestation, describing the clinical presentation, laboratory findings, imaging characteristics, treatment course, and clinical outcome. In addition, a comprehensive literature review was conducted by searching PubMed, Wanfang, VIP, and the China National Knowledge Infrastructure (CNKI) databases using the keywords “tuberculosis” “tuberculous meningitis” and “diabetes insipidus”. The search covered publications from January 2000 to June 2025. Case reports with complete clinical data were included, while reviews, duplicate publications, and studies with incomplete information were excluded. A total of 16 eligible cases of CNS-TB complicated by DI were identified and analyzed. Results: A 54-year-old male patient presented with polydipsia, polyuria, headache, and loss of appetite. Laboratory investigations revealed low urine specific gravity and elevated plasma osmolality. A water deprivation test followed by desmopressin administration confirmed a diagnosis of central diabetes insipidus (CDI). Chest computed tomography (CT) demonstrated inflammatory changes in the right lung, accompanied by right-sided pleural effusion and secondary atelectasis of adjacent lung tissue. Magnetic resonance imaging (MRI) of the brain revealed thickening of the pituitary stalk, abnormal enhancement in the pituitary and pineal regions, and preserved hyperintensity in the posterior pituitary. The patient received diagnostic anti-tuberculosis therapy for three months but discontinued treatment on his own. Six months after discharge, repeat chest CT showed resolution of the pleural effusion, and pituitary MRI no longer showed abnormal findings; however, CDI persisted. A total of 16 additional cases of CNS-TB complicated by DI were identified through literature review, yielding 17 cases including the present report. Among these, 10 patients were male and 7 were female, with ages ranging from 5 to 63 years. Pulmonary tuberculosis was documented in 6 cases and subcutaneous nodular tuberculosis in 1 case. Imaging findings revealed sellar or suprasellar tuberculomas in 10 patients, pituitary stalk thickening in 7 patients, and cerebral edema in 2 patients. Six patients developed panhypopituitarism, and two had CDI accompanied by central hypothyroidism. Six patients with visual impairment underwent decompressive surgery, and one had visual field defects. During follow-up, CDI remained unresolved in 3 patients, hypothyroidism persisted in 1, and both adrenal insufficiency and hypothyroidism persisted in 2. All patients with visual acuity or field deficits showed clinical improvement. Imaging abnormalities resolved or regressed in 14 patients. Two patients died. Conclusion: CNS-TB may involve the sellar region, resulting in pituitary dysfunction and compression of the optic apparatus. Early assessment of pituitary function and regular follow-up are essential. Decompressive surgery should be considered in cases where visual function is threatened by mass effect.

Key words: Tuberculosis, central nervous system, Tuberculosis, meningeal, Diabetes insipidus

中图分类号:

陈芳, 赵亚军, 王瑞, 冯燕国, 张德智. 中枢神经系统结核合并垂体结核伴尿崩症一例并文献复习[J]. 结核与肺部疾病杂志, 2025, 6(5): 532-537. doi: 10.19983/j.issn.2096-8493.20250095

Chen Fang, Zhao Yajun, Wang Rui, Feng Yanguo, Zhang Dezhi. A case of central nervous system tuberculosis with pituitary involvement and diabetes insipidus: A literature review[J]. Journal of Tuberculosis and Lung Disease, 2025, 6(5): 532-537. doi: 10.19983/j.issn.2096-8493.20250095

图/表 2

参考文献 23

[1]	Navarro-Flores A, Fernandez-Chinguel JE, Pacheco-Barrios N, et al. Global morbidity and mortality of central nervous system tuberculosis: a systematic review and meta-analysis. J Neurol, 2022, 269(7):3482-3494. doi:10.1007/s00415-022-11052-8.
[2]	Stalldecker G, Diez S, Carabelli A, et al. Pituitary stalk tuberculoma. Pituitary, 2002, 5(3): 155-162. doi:10.1023/a:1023304930479.
[3]	王海玲. 脑垂体部结核瘤并发尿崩症1例. 西藏医药, 2001, 22(2):68-69.
[4]	Jain R, Kumar R. Suprasellar tuberculoma presenting with diabetes insipidus and hypothyroidism--a case report. Neurol India, 2001, 49(3):314-316.
[5]	Satyarthee GD, Mahapatra AK. Diabetes insipidus in sellar-suprasellar tuberculoma. J Clin Neurosci, 2003, 10(4):497-499. doi:10.1016/s0967-5868(02)00285-0.
[6]	Dutta P, Bhansali A, Singh P, et al. Suprasellar tubercular abscess presenting as panhypopituitarism: a common lesion in an uncommon site with a brief review of literature. Pituitary, 2006, 9(1):73-77. doi:10.1007/s11102-006-5420-2.
[7]	韦蓉. 结核性脑膜炎并发尿崩症和耳聋1例. 四川医学, 2007, 28(10):1073. doi:10.3969/j.issn.1004-0501.2007.10.068.
[8]	王瑞, 崔晓迎, 赵兴胜. 结核性脑膜炎诱发尿崩症一例. 内蒙古医学杂志, 2010, 42(7):890-891. doi:10.3969/j.issn.1004-0951.2010.07.056.
[9]	Domiciano DS, de Carvalho JF, Macedo AR, et al. Central diabetes insipidus induced by tuberculosis in a rheumatoid arthritis patient. Acta Reumatol Port, 2010, 35(2):232-235.
[10]	Djoubairou BO, Gazzaz M, Hammi S, et al. Panhypopituitarism revealing sellar tuberculoma. Ann Endocrinol (Paris), 2015, 76(3): 286-288. doi:10.1016/j.ando.2015.02.001.
[11]	Srisukh S, Tanpaibule T, Kiertiburanakul S, et al. Pituitary tuberculoma: A consideration in the differential diagnosis in a patient manifesting with pituitary apoplexy-like syndrome. IDCases, 2016, 5: 63-66. doi:10.1016/j.idcr.2016.07.012.
[12]	贾丽萍, 罗高潮, 朱庭菊, 等. 结核性脑膜炎继发尿崩症一例. 临床内科杂志, 2017, 34(5): 356. doi:10.3969/j.issn.1001-9057.2017.05.024.
[13]	Chellen S, Whittaker E, Eisenhut M, et al. Cerebral tuberculomas in a 6-year-old girl causing central diabetes insipidus. BMJ Case Reports, 2018, 2018:bcr2018226590. doi:10.1136/bcr-2018-226590.
[14]	Santana MF, João GAP, Lacerda MVG, et al. Diabetes insipidus secondary to tuberculous meningoencephalitis with hypothalamic involvement extending to the hypophysis: a case report. Rev Soc Bras Med Trop, 2018, 51(6):865-867. doi:10.1590/0037-8682-0455-2017.
[15]	Shariff RER, Hatta SFWM, Kasim S. A rare cause of acute hypernatraemia: Diabetes insipidus secondary to suprasellar tuberculoma. Proceedings of Singapore Healthcare, 2021, 30(4):316-319.
[16]	李霞, 向茜, 保玉莲. 垂体结核合并隐性中枢性尿崩症1例. 中国乡村医药, 2023, 30(14):33-35. doi:10.3969/j.issn.1006-5180.2023.14.017.
[17]	Aziz Khan A, Ahuja S, Malik S, et al. Pituitary tuberculoma with panhypopituitarism masquerading as a pituitary adenoma. Neuropathology, 2023, 43(6):496-499. doi:10.1111/neup.12925.
[18]	Lazarte-Rantes C, Sinti-Ycochea M, Guillen-Pinto D. Intracranial manifestations of central nervous system tuberculosis in children. Pediatr Radiol, 2025, 55(1): 88-103. doi:10.1007/s00247-024-06057-6.
[19]	Dhanwal DK, Vyas A, Sharma A, et al. Hypothalamic pituitary abnormalities in tubercular meningitis at the time of diagnosis. Pituitary, 2010, 13(4):304-310. doi:10.1007/s11102-010-0234-7.
[20]	Lam KS, Sham MM, Tam SC, et al. Hypopituitarism after tuberculous meningitis in childhood. Ann Intern Med, 1993, 118(9): 701-706. doi:10.7326/0003-4819-118-9-199305010-00007.
[21]	Schaefer S, Boegershausen N, Meyer S, et al. Hypothalamic-pituitary insufficiency following infectious diseases of the central nervous system. Eur J Endocrinol, 2008, 158(1): 3-9. doi:10.1530/EJE-07-0484.
[22]	Behari S, Shinghal U, Jain M, et al. Clinicoradiological presentation, management options and a review of sellar and suprasellar tuberculomas. J Clin Neurosci, 2009, 16(12):1560-1566. doi:10.1016/j.jocn.2008.12.032.
[23]	Kumar I, Shekhar S, Yadav T, et al. The many faces of intracranial tuberculosis: atypical presentations on MRI—a descriptive observational cohort study. Egypt J Radiol Nucl Med, 2023, 54:116. doi:10.1186/s43055-023-01061-6.