Aspergillosis of the sphenoid sinus simulating a pituitary tumor

Pituitary abscess: a case report and systematic review of 488 cases

BACKGROUND

Pituitary abscess (PA) is a rare condition and not well understood. We aimed to describe a case and perform a comprehensive systematic review to explore presenting symptoms, radiological findings, endocrine abnormalities and mortality.

AIM

To identify presenting symptoms, radiological findings, endocrinological abnormalities and predictors of mortality for PA.

METHODS

We systematically reviewed the literature to identify all case reports of PA. Data regarding presentation, mortality, radiological findings, endocrinological abnormalities and treatment was extracted.

RESULTS

We identified 488 patients from 218 articles meeting the inclusion criteria. Mortality was 5.1%, with days to presentation (OR 1.0005, 95% CI 1.0001-1.0008, p < 0.01) being the only identified independent predictor of mortality. Mortality rates have decreased over time, with cases published prior to 2000 having higher mortality rates (OR 6.92, 95% CI 2.80-17.90, p < 0.001). The most common symptom was headache (76.2%), followed by visual field defects (47.3%). Classical signs of infection were only present in 43%. The most common imaging feature on magnetic resonance imaging (MRI) was high T2 and low T1 signal of the pituitary gland with peripheral contrast enhancement. Over half (54.8%) were culture negative, with the most common bacterial organism being staphylococcus aureus (7.8%) and fungal organism being aspergillus (8.8%). The most common endocrine abnormality was hypopituitarism (41.1%), followed by diabetes insipidus (24.8%). Whilst symptoms resolved in most patients, persistent endocrine abnormalities were present in over half of patients (61.0%).

CONCLUSION

PA is associated with significant mortality, with delayed presentation increasing risk of mortality. Ongoing endocrinological abnormalities are common. Given the non-specific clinical presentation, the appearance of high T2, low T1 and peripheral contrast enhancement of the pituitary on MRI should prompt consideration of this rare disease.

Demonstration of Infectious Transgression Through the Skull Base Occurring 9 Years After Pituitary Adenoma Resection

BACKGROUND

Sellar infections represent less than 1% of all sellar lesions and can be life-threatening. These infections occur de novo in up to 70% of patients or can less commonly develop after surgical treatment of another primary lesion, such as a pituitary adenoma.

CASE DESCRIPTION

We report a unique case of a 27-year-old woman with a recurrent pituitary adenoma treated with 2 previous transsphenoidal resections. She ultimately presented with hypopituitarism, followed by headaches, malaise, chills, and visual-field and acuity deficits 9 years after her second transsphenoidal resection. During the second operation, the sellar floor was reconstructed with hydroxyapatite bone cement. On the most recent presentation, magnetic resonance imaging of the brain and pituitary demonstrated a residual sellar mass accompanied by significant enhancement and T2 hyperintensity of the infundibulum, hypothalamus, optic chiasm, and optic tracts. The patient was started on empiric antibiotics and steroids before frank purulence in the sella was discovered and removed by transsphenoidal endoscopy. Cultures were positive for methicillin-sensitive Staphylococcus aureus and Propionibacterium acnes. At her 3-month follow-up evaluation, the patient had complete resolution of her symptoms and radiographic findings.

CONCLUSIONS

This case demonstrates the fact that patients with pituitary lesions who have foreign material used for surgical closure can present with infections many years after the initial intervention. Furthermore, with appropriate clinical diagnosis and treatment, the reactive inflammation caused by sellar infection is reversible. We review the literature regarding the risk factors and management strategies for delayed postoperative sellar infections.

Invasive fungal sinusitis: treatment of the orbit

PURPOSE OF REVIEW

To summarize diagnostic techniques for invasive fungal rhinosinusitis and provide a review of treatment options once disease has spread to the orbit.

RECENT FINDINGS

Improved imaging criteria, polymerase chain reaction and other serologic tests show promise in advancing our ability to accurately diagnose invasive fungal disease. Currently, there exists three treatment options for infected orbital tissue: exenteration, conservative debridement and transcutaneous retrobulbar injection of amphotericin B. Exenteration, the most frequently reported intervention, has not been proven to enhance survival. Conservative debridement and transcutaneous retrobulbar injection of amphotericin B are increasingly considered reasonable first-line options.

SUMMARY

Although investigative tools are improving, invasive fungal rhinosinusitis can still pose a diagnostic challenge. No one treatment option for the orbit has been proven superior to another. Therefore, it is justified to initiate therapy by prioritizing less morbid procedures. If deterioration is continually noted, more invasive interventions can then be employed. The treatment algorithm established at our institution is provided.

Secondary headache due to aspergillus sellar abscess simulating a pituitary neoplasm: case report and review of literature

Fungal sellar abscess is rare. A 42-year-old man was admitted with 2-month headache characterized by right peri-orbital pain. An intrasellar mass was found to be simulated a pituitary neoplasm after magnetic resonance imaging examination, and operated on via an endoscopic trans-sphenoidal approach. Milk-like pus and a mass of ash black mixed and necrotic material were found and removed. Histopathology revealed numerous aspergillus hyphae. Itraconazole was given on a dosage of 200 mg twice a day orally for 6 weeks. No recurrence was observed during follow-up. Complete surgical resection through endoscopic trans-sphenoidal approach combined with systemic anti-fungal therapy, should be considered as the optimal treatment.

Pituitary tumours: inflammatory and granulomatous expansive lesions of the pituitary

Inflammatory and granulomatous diseases of the pituitary are rare causes of sellar masses. Lymphocytic hypophysitis is the most relevant of these disorders, and it is characterised by autoimmune pathogenesis with focal or diffuse inflammatory infiltration and varying degrees of pituitary gland destruction. Endocrine symptoms may include partial or total hypopituitarism, with adrenocorticotropic hormone (ACTH) deficiency being the earliest and most frequent alteration. Pituitary abscess is a rare but potentially life-threatening disease and, in 30-50% of patients, anterior pituitary hormone deficiencies or central diabetes insipidus (DI) at onset may be observed: the earliest manifestation being growth hormone deficiency (GHD), followed by follicle-stimulating hormone (FSH)/luteinising hormone (LH), thyroid-stimulating hormone (TSH) and ACTH deficiencies. Fungal infections of the pituitary are also very rare and include aspergillosis and coccidioidomycosis. Concerning pituitary involvement in systemic diseases, in sarcoidosis endocrine complications are rare, but the hypothalamus and pituitary are the glands most commonly affected. DI is reported in approximately 25-33 % of all neurosarcoidosis cases and is the most frequently observed endocrine disorder. Hyperprolactinaemia and anterior pituitary deficiencies may also occur. Rarely, partial or global anterior pituitary dysfunction may be present also in Wegener's granulomatosis, either at onset or in the course of the disease, resulting in deficiency of one or more of the pituitary axes. Other forms of granulomatous pituitary lesions include idiopathic giant cell granulomatous hypophysitis, Takayasu's disease, Cogan's syndrome and Crohn's disease. The hypotalamic-pituitary system is involved mainly in children with Langerhans' cells histiocytosis who develop DI, which is the most common endocrine manifestation. Anterior pituitary dysfunction is found more rarely and is almost invariably associated with DI. Pituitary involvement may also be observed in another form of systemic hystiocitosis, that is, Erdheim-Chester disease. Tuberculosis is a rare cause of hypophysitis, which may present with features of anterior pituitary dysfunction, such as hypopituitarism with hyperprolactinaemia. In conclusion, in patients with a sellar mass and unusual clinical presentation (DI, neurological symptoms), aggressiveness and onset and in the presence of systemic diseases, inflammatory and granulomatous pituitary lesions should be carefully considered in differential diagnosis.

Characteristics of Isolated Sphenoid Sinus Aspergilloma: Report of Twelve Cases and Literature Review

Objectives:

Isolated sphenoid sinus aspergilloma (ISSA) is a form of fungal sinus infection that is distinct from allergic fungal sinusitis, invasive fungal disease, and Aspergillus granulomas. In this study, we identify the characteristics of patients with ISSA to achieve timelier intervention for this easily neglected disease.

Methods:

In a retrospective study of patients with ISSA in our institution (1995 to 2006), 12 were identified.

Results:

Sixty-seven percent of our patients were more than 50 years of age, and a female preponderance was noted. Headache and postnasal drip were the two most common symptoms, and the samples from 78% of our patients with postnasal drip were blood-tinged. Computed tomographic scanning provided a sensitivity of 64%, whereas endoscopic examination failed to identify abnormalities in any patients.

Conclusions:

Four characteristics were identified in the diagnosis of ISSA: Female; usually above 50 years of age; with postnasal drip (especially blood-tinged); and headache (particularly periorbital or retro-orbital).

Endoscopic treatment of pituitary abscess: two case reports and literature review

Pituitary abscess is a rare entity and the correct diagnosis is still difficult before surgery. More than 210 cases have been reported in the medical literature, mostly in the form of isolated case reports. We report two cases of pituitary abscess treated endoscopically and we review the literature. A 30-year-old woman and a 35-year-old man were admitted with a history of pituitary dysfunction. Patient 1 presented with polyuria, polydipsia, amenorrhea, headache, and visual impairment. Magnetic resonance imaging showed a cystic intra- and supra-sellar lesion with ring enhancement after contrast injection. Patient 2 presented with frontal headache, proptosis, painful ophthalmoplegia, visual impairment, and fever. Eight years before the patient had undergone a transphenoidal surgery for Prolactinoma. Magnetic resonance imaging revealed a sellar lesion extending into the cavernous sinus and carotid artery bilaterally. Both patients underwent endoscopic transnasal-transsphenoidal exploration. Intraoperative diagnosis of pituitary abscess was made. The postoperative courses were uneventful. Antibiotic therapy was performed in both cases. Only three cases of endoscopic treatment of pituitary abscess have been reported in the literature. We recommend early management by endoscopic transphenoidal surgery for pituitary abscess: this technique is safe, with minimal blood loss, short operating time, low morbidity, and brief hospital stay.

Abscesso hipofisário simulando apoplexia

O abscesso hipofisário representa uma patologia rara, que, contudo, deve ser considerada na avaliação das massas selares, uma vez que o seu prognóstico depende da drenagem cirúrgica e do uso de antibióticos específicos. A principal manifestação clínica é cefaléia crônica e nem sempre está associada à identificação de um foco infeccioso, o que diminui a probabilidade da sua inclusão nas hipóteses diagnósticas. Apresenta-se o caso de um paciente com abscesso de hipófise e história pregressa de adenoma operado, cefaléia de início recente e hipopituitarismo adquirido, cujo diagnóstico inicial foi de apoplexia pituitária.

Primary aspergillosis of the sphenoid sinus with pituitary invasion - a rare differential diagnosis of sellar lesions

Aspergillosis belongs to the group of mycotic diseases of paranasal sinuses. The invasive forms, and particularly the fulminant forms, are potentially fatal. Isolated aspergillosis of the sphenoid sinus or the clivus is a difficult diagnosis, since the often misleading clinical manifestations of this rare disease develop late. These patients become apparent by neurological signs such as cavernous sinus syndrome, pseudotumor of the pituitary or the orbit. Diagnosis is often made intra-operatively or on histological examination. We report a case of invasive aspergillosis uniquely involving the sellar area revealed by clinical features suggesting a pseudotumor of the pituitary. Although such lesions are almost always seen in immune suppressed subjects, in our case, the patient was immune competent and had no past history of sinusitis.The question of whether, and when to perform limited or extensive surgery remains an issue for discussion, owing to the rarity of this disease honed by lack of experience. It depends on several factors: the kind of disease, the immunity, the subtype of invasive fungal sinusitis and the degree of tissue invasion.

The invasive and saprophytic syndromes due to Aspergillus spp

Aspergillus spp. produce a wide range of invasive and sapropytic syndromes which may involve any tissue. Within a given tissue or organ the pathology and pathogenesis varies enormously, ranging from angioinvasive disease to noninvasive saprophytic disease. The individual invasive and saprophytic syndromes in which a causative role can be attributed to Aspergillus spp. are detailed specifically with reference to the underlying pathology and pathogenesis, the clinical setting and features, and the manner in which a diagnosis can be established.

Fungal granuloma of the sphenoid sinus and clivus in a patient presenting with cranial nerve III paresis: case report rand review of the literature

OBJECTIVE AND IMPORTANCE

Isolated fungal granulomas originating within the sphenoid sinus are extremely rare in immunocompetent patients. In their symptoms and morphological appearance, these lesions may be mistaken for pituitary tumors. We report such a case and review the literature.

CLINICAL PRESENTATION

A 74-year-old man presented with a 3-week history of Cranial Nerve III paresis. The patient had a long-term history of snuff abuse. Computed tomography demonstrated a space-occupying lesion of the sellar and sphenoid sinus region with displacement of the cavernous sinus.

INTERVENTION

The lesion was operated on via a transnasal-transsphenoidal approach. After the sphenoid sinus was opened, mucus extruded spontaneously, and a brownish, crumbly mass was found and removed. The lesion had completely eroded the sella and clivus. Histological analysis revealed numerous Aspergillus hyphae. Postoperatively, the IIIrd cranial nerve paresis resolved completely within a few days. No systemic fungal infection was found in extensive serological studies. There was no evidence of immunosuppression.

CONCLUSION

Fungal granuloma must be included in the differential diagnosis of lesions in the sellar region, even in nonimmunosuppressed patients. Early diagnosis and transsphenoidal extirpation is crucial with this potentially life-threatening disease.

Primary pituitary abscess: case report

Pituitary abscesses are potentially life-threatening lesions if not appropriately diagnosed and treated. The authors have operated on more than five hundred cases of pituitary tumors and only one represented a case of pituitary abscess. A 35-year-old woman was investigated for chronic frontal headache. CT scan showed a cystic sellar lesion with ring enhancement after contrast injection leading to an initial diagnosis of pituitary adenoma. She underwent a sublabial transsphenoidal approach to the pituitary gland. After dural opening, purulent material was obtained and no tumor or other associated lesion was detected. There was no evidence of current or previous septicemic illness, meningitis, cavernous sinus thrombosis or sinus infection. Cultures were negative. She was put on antibiotics and discharged after 4 weeks. Nowadays, 10 years after treatment, she is doing well, with no anterior pituitary hormone deficit. MRI shows a partially empty sella without residual lesion and the pituitary stalck is in the midline. The early diagnosis and adequate treatment of this life-threatening lesion may result in excellent prognosis.

Diagnosis and management of pituitary abscess: a review of twenty-four cases

OBJECT

Pituitary abscess is a rare but serious intrasellar infection. To better determine the salient signs and symptoms that help in making the diagnosis, and to determine the most appropriate treatment, the authors reviewed their experience in a series of 24 patients treated at the University of California at San Francisco.

METHODS

Nine of the patients were female and 15 were male, and their mean age was 41.2 years (range 12-71 years). Surprisingly, most patients in our series presented with complaints and physical findings consistent with a pituitary mass, but rarely with evidence of a serious infection. Headache, endocrine abnormalities, and visual changes were the most common clinical indicators; fever, peripheral leukocytosis, and meningismus were present in 33% or fewer of the patients. Imaging tests demonstrated a pituitary mass in all patients, but the features evident on computerized tomography and magnetic resonance studies did not distinguish pituitary abscesses from other, more common intrasellar lesions. Because of the ambiguous clinical features and imaging findings, most abscesses were not diagnosed before treatment; rather, the diagnosis was made during surgical exploration of the sella turcica, when the surgeon encountered a cystic mass containing pus. There were only two deaths in this series (8.3%). Patients presenting with headache and visual changes noted improvement in almost all cases; patients with endocrine dysfunction generally did not recover normal pituitary function, but were easily treated with hormone replacement therapy.

CONCLUSIONS

Antibiotic therapy is suggested for patients who have symptoms of sepsis, or for patients in whom specific organisms are identified from cultures obtained during surgery. The transsphenoidal approach is recommended over open craniotomy for surgical drainage.

Pituitary abscess presenting with cranial nerve paresis. Case report and review of literature

Non-adenomatosus lesions of the pituitary represent a small part of the intrasellar processes and they have heterogeneous presentation. Making a precise diagnosis is of great importance, as it may lead to more efficient management. A 65-year-old man was admitted to the hospital because of headache and right cranial nerve III palsy. Basic laboratory work-up was normal whereas endocrinological assessment revealed hypopituitarism without diabetes insipidus. Plain radiography showed an enlarged sella and frontal and paranasal sinusitis. Computed tomography (CT) and magnetic resonance imaging (MRI) of the sella revealed an intrasellar lesion with extension to the sphenoid and cavernous sinuses as well as the suprasellar region, exerting pressure on the optic chiasm. On T1-weighted images the mass had a low-intensity signal with a smooth enhancing rim with bright signal. Given the presence of multiple sinusitis and imaging characteristics a pre-operative diagnosis of pituitary abscess was made. The patient was operated via transphenoidal route and purulent material was drained out. Cultures of the material were positive for Staphylococcus aureus. Antibiotics as well as cortisol replacement therapy were given. Three months later hypopituitarism persisted but there was significant improvement in the neurological findings. We report a case of an unusual presentation of a pituitary abscess. High index of suspicion, the presence of associated conditions such as pituitary tumors, meningitis or sinusitis, as well as diabetes insipidus and specific imaging features are the main diagnostic clues. Pre-operative diagnosis, which will lead to prompt antibiotic therapy and transphenoidal drainage, can decrease high mortality and morbidity associated with this disease.

Value of Ga-67 SPECT in monitoring the effects of therapy in invasive aspergillosis of the sphenoid sinus

PURPOSE

We report a case of invasive sphenoid sinus aspergillosis clinically presenting as a pituitary mass.

METHODS

After exploration via the trans-sphenoidal approach and subsequent treatment with amphotericin-B, Ga-67 brain SPECT was performed twice to monitor the therapeutic effect.

RESULTS

Three months after antifungal treatment, Ga-67 brain SPECT showed partial resolution of the lesion in the sella turcica region. The patient continued with fluconazole treatment for another 2 months and received another Ga-67 brain SPECT, which showed complete clearing of the previous lesion.

CONCLUSION

Ga-67 brain SPECT may play a potentially useful role in monitoring the therapeutic effect of treatment of invasive sphenoid sinus aspergillosis.

Differential diagnosis of sellar masses

The differential diagnosis of nonpituitary sellar masses is broad; differentiating among potential etiologies may not always be straightforward because many of these lesions, tumorous and nontumorous, may mimic the clinical, endocrinologic, and radiologic presentations of pituitary adenomas. This article provides an overview of the clinical and radiographic characteristics of both pituitary tumors and the nonpituitary lesions found in the sellar/parasellar region and discusses, in detail, the specific nonpituitary origins of the sellar masses.

Pituitary abscess: a series of six cases

Pituitary abscess is a rare condition occurring in various age groups. Only about a hundred cases have been reported in the literature. We describe six cases that constitute 0.6% of all the pituitary lesions operated at this centre in the last 10 years. All the patients presented with visual symptoms, though systemic features of infection were present in only two cases. The abscess was seen in association with adenoma in two cases and Rathke's cleft cyst in one. One patient developed an abscess following surgery for pituitary adenoma. The offending organisms was fungal in two cases, mycobacterium in one, bacterial in one and two cultures were sterile. Preoperative diagnosis is difficult and a high degree of suspicion in ring enhancing lesions of the sella is required.

Aspergillosis of the sphenoid sinus: presentation as a pituitary mass and postoperative gallium-67 imaging

Invasive aspergillosis of the paranasal sinuses is an uncommon, but well-recognized, form of fungal infection. We describe an elderly female patient with invasive aspergillosis of the sphenoid sinus and associated osteomyelitis of the skull base, with clinical presentation as a pituitary mass. Postoperative gallium scan showed intense uptake in the sphenoid sinus, which resolved after treatment with amphotericin-B. This case demonstrates some of the pathologic and clinical features of invasive aspergillosis and suggests a potential role for gallium-67 imagining in monitoring clinical response to therapy.

Intrasellar abscess following transsphenoidal surgery

BACKGROUND

Intrasellar abscess following transsphenoidal surgery has been described only twice in the English language medical literature. Overall mortality associated with intrasellar abscesses is 51%, while mortality in reported cases not treated surgically is 100%.

METHODS

Two cases of intrasellar abscess following uncomplicated transsphenoidal surgery for pituitary pathology are reported. The incidence, radiographic features, clinical presentations, and treatment of intrasellar abscesses are discussed.

RESULTS

Both patients described underwent uncomplicated transsphenoidal procedures for treatment of a primary pituitary lesion. Neither developed postoperative CSF rhinorrhea, and initial recovery was uneventful. The first patient presented with new symptoms several weeks after transsphenoidal surgery; the second patient almost two years postoperatively. The first displayed signs of an expanding sellar mass, requiring transsphenoidal drainage and postoperative antibiotics. The second presented with recurrent meningitis without discernible CSF leak, and was treated with transnasal endoscopic drainage in conjunction with antibiotic therapy.

CONCLUSIONS

The high mortality associated with intrasellar abscess mandates its inclusion in the differential diagnosis of patients presenting with symptoms of meningitis or an expanding sellar mass after transsphenoidal intervention. Although antibiotic therapy is an important adjunct, surgical drainage is required for definitive treatment.

Parasellar Aspergillus granuloma extending from the sphenoid sinus: report of two cases

BACKGROUND

Sphenoid sinus aspergillosis is a rare disease known to show an aggressive course with high mortality. Early diagnosis, though difficult, is required to prevent lethal fungal meningoencephalitis.

CASE REPORT

We describe two cases of parasellar Aspergillus granuloma extending from the sphenoid sinus clinically indistinguishable from intracranial neoplasms. In the first patient, the fungus colony was visualized by computed tomography (CT) and magnetic resonance imaging (MRI) as a calcified concretion and total removal was curative. In the second patient, partial removal and subsequent antifungal therapy had minimal effect.

CONCLUSIONS

The prognosis of the patients with this disease depends on prompt surgical treatment before intradural invasion occurs, and CT and MRI are useful diagnostic maneuvers for detecting calcified Aspergillus colonies.

Are intra- and suprasellar masses detected by CT and MR really tumours?

The difficulties of differential diagnosis between intra- and suprasellar tumours resp. inflammatory processes are discussed, based on three personal cases. In all three computed tomography (CT) and magnetic resonance imaging (MR) had demonstrated a tumour, but the clinical signs with discrepancies between radiological and clinical findings were pointing to an inflammatory process. The correct diagnosis of an inflammation was achieved by co-operation between neurologist, neurosurgeon, otologist and ophthalmologist. An unnecessary neurosurgical operation was avoided and the patients were cured by otological intervention and antibiotic therapy.