Pituitary abscess: our experience with a case and a review of the literature

Primary pituitary abscess with atypical imaging features: A rare case report

INTRODUCTION AND IMPORTANCE

A pituitary abscess (PA) is an extremely rare disease. It is characterized by the presence of an infected purulent collection within the Sella turcica. PAs are categorized in two categories: primary, when the pituitary is normal before the infection, or secondary, when there is a pre-existing sellar pathology (e.g., pituitary adenoma, Rathke's cleft cysts, or craniopharyngioma), meningitis, paranasal sinusitis, or head surgery, which may be indicative of the source of infection.

CASE PRESENTATION

We presented a case of a 52-year-old male with visual disturbances. Both a computerized tomography scan and magnetic resonance imaging revealed a sellar mass lesion, initially suspected to be a pituitary tumor. During transsphenoidal surgery for excision of the pituitary mass, an amount of pus was drained, indicating a pituitary abscess, which was confirmed by positive Staphylococcus aureus colonies in the culture. After surgery, the patient received antibiotic treatment for 12 weeks. After two years of follow-up, the patient remained free of complications and did not require hormone replacement therapy.

CLINICAL DISCUSSION

In previous research, there were a total of 488 patients, of those, 318 were primary pituitary abscess. Preoperative diagnosis is still difficult due to a combination of nonspecific symptoms and imaging findings. Endonasal trans-sphenoidal pus evacuation, culture, and individualized antibiotic therapy are available treatment options.

CONCLUSION

Pituitary abscess is a rare illness, but it should always be considered when evaluating a patient with a fast visual decline. Following the diagnosis, surgery and antibiotics should be started immediately. Proper therapy usually yields a positive effect.

Pituitary abscess: a descriptive analysis of a series of 19 patients-a multi-center experience

OBJECTIVES

Pituitary abscess (PA) accounts for only 0.3-0.5% of sellar masses, and the lack of specific clinical symptoms makes diagnosing PA difficult without a surgical biopsy. In clinical practice, PA is often mistaken for cystic pituitary adenoma, craniopharyngioma, and Rathke's cyst. Thus, this study aims to investigate challenges in diagnosing PA and evaluate the importance of combining intraoperative surgery with postoperative antibiotic treatment.

METHODS

We conducted a retrospective analysis of 19 patients diagnosed with PA through histopathology. All patients underwent transsphenoidal surgery (TSS) for pituitary adenomas after undergoing comprehensive preoperative evaluations, including routine tests, endocrine assay, and imaging examination. Furthermore, we compared different treatments for pituitary abscess (PA) to determine the most effective approach for achieving a favorable prognosis.

RESULTS

The most prevalent symptom of PA was headache, especially in the frontal-temporal and vertex regions, ranging from mild to moderate severity. Hypopituitarism-related symptoms were also frequently observed, including hypaphrodisia, cold sensitivity, fatigue, weight loss, polyuria, and amenorrhea. Twelve patients exhibited abnormalities in endocrinology examinations. Diagnosing PA correctly is challenging. In our study, none of the patients were correctly diagnosed with PA prior to surgery, and many sellar lesions were misdiagnosed. The favorable prognosis was largely attributed to surgical intervention and active postoperative antibiotic therapy.

CONCLUSIONS

Given the lack of clarity in preoperative diagnosis, typical intraoperative findings and effective antibiotics treatment are more indicative of the correct diagnosis than other tests. In terms of therapy, optimal surgical intervention and active postoperative antibiotic treatment contribute to resolving the challenges posed by PA.

Secondary hypophysitis associated with Rathke's cleft cyst resembling a pituitary abscess

Background

Although rare, cases of hypophysitis resembling a pituitary abscess (PA) have been reported. Differential diagnosis between hypophysitis and PA is crucial as the two diseases require different treatments.

Case Description

A 38-year-old woman with headaches underwent head magnetic resonance imaging (MRI), which revealed an 11-mm mass lesion in the sella turcica. Due to breastfeeding, contrast-enhanced MRI was avoided. Pituitary adenomas and Rathke's cleft cyst (RCC) were suspected, and she was initially treated conservatively. Five months later, she acquired syndrome coronavirus two infections, and while the fever subsided with acetaminophen, the headache persisted. One month later, the headache worsened, followed by fever and diabetes insipidus. MRI revealed a pituitary cystic mass with ring-shaped contrast enhancement on T1-weighted MRI and increased signal intensity on diffusion-weighted imaging (DWI). PA was suspected, and emergency endoscopic transsphenoidal surgery was performed. The microbiological examination of the yellowish-brown content drained from the cystic mass was negative. Microscopically, the cystic lesion was covered with ciliated columnar epithelium and stratified squamous epithelium, with a dense inflammatory cell infiltrate consisting mainly of lymphocytes and plasma cells observed around the cyst. This supported the diagnosis of secondary hypophysitis associated with RCC without PA.

Conclusion

We report a case of hypophysitis secondary to RCC resembling PA with ring-shaped contrast enhancement on MRI and increased signal intensity on DWI. This case emphasizes the need for cautious diagnosis of secondary hypophysitis due to RCC in individuals with MRIs and clinical manifestations resembling an abscess.

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.

Evaluation of the Value of Perfusion-Weighted Magnetic Resonance Imaging in the Differential Diagnosis of Sellar and Parasellar Tumors

The purpose of this study was to assess the value of perfusion-weighted imaging (PWI) in the differential diagnosis of sellar and parasellar tumors, as an additional sequence in the magnetic resonance imaging (MRI) protocol. Analysis was based on a substantial group of subjects and included 124 brain and pituitary MRI examinations with a dynamic susceptibility contrast (DSC) PWI sequence. The following perfusion parameters were determined for the tumors: relative cerebral blood volume (rCBV), relative peak height (rPH) and relative percentage of signal intensity recovery (rPSR). To ensure greater repeatability, each of the aforementioned parameters was calculated as: arithmetic mean of the values of the whole tumor, arithmetic mean of the maximum values on each axial slice within the tumor and maximum values derived from the whole tumor. In our study, we established that meningiomas compared to both non-functional and hormone-secreting pituitary adenomas (pituitary neuroendocrine tumors-PitNET) had significantly higher values of rCBV with cut-off points set at 3.45 and 3.54, respectively (mean rCBV). Additionally, meningiomas presented significantly higher maximum and mean maximum rPH values compared to adenomas. DSC PWI imaging adds significant value to conventional MRI examinations and can be helpful in differentiating equivocal pituitary tumors.

Pituitary Abscess: A Challenging Preoperative Diagnosis—A Multicenter Study

Background and Objectives: Pituitary abscess (PA) is a rare occurrence, representing less than 1% of pituitary lesions, and is defined by the presence of an infected purulent collection within the sella turcica. Pas can be classified as either primary, when the underlying pituitary is normal prior to infection, or secondary, when there is associated a pre-existing sellar pathology (i.e., pituitary adenoma, Rathke’s cleft cysts, or craniopharyngioma), with or without a recent history of surgery. Preoperative diagnosis, owing to both non-specific symptoms and imaging features, remains challenging. Treatment options include endonasal trans-sphenoidal pus evacuation, as well as culture and tailored antibiotic therapy. Methods: A retrospective multicenter study, conducted on a prospectively built database over a 20-year period, identified a large series of 84 patients harboring primary sellar abscess. The study aimed to identify crucial clinical and imaging features in order to accelerate appropriate management. Results: The most common clinical presentation was a symptom triad consisting of various degrees of asthenia (75%), visual impairment (71%), and headache (50%). Diagnosis was achieved in 95% of cases peri- or postoperatively. Functional recovery was good for visual disturbances and headache. Pituitary function recovery remained very poor (23%), whereas the preoperative diagnosis represented a protective factor. Conclusions: In light of the high prevalence of pituitary dysfunction following the management of PAs, early diagnosis and treatment might represent a crucial issue. Currently, there are no standard investigations to establish a conclusive preoperative diagnosis; however, new, emerging imaging methods, in particular nuclear imaging modalities, represent a very promising tool, whose potential warrants further investigations.

A case of pituitary gland abscess associated with granulomatous hypophysitis

BACKGROUND

Granulomatous hypophysitis is a rare disease that presents with chronic inflammation of the pituitary gland. In this study, we reported a case of granulomatous hypophysitis associated with a pituitary abscess.

CASE PRESENTATION

A 39-year-old woman presented with a 2-year history of infertility. For the past six months, she has suffered from amenorrhea, decreased libido, headaches, and vertigo. She was referred to our hospital with a suspected diagnosis of nonfunctioning pituitary adenoma based on her presentation and brain MRI findings. She underwent trans-sphenoidal surgery (TSS). Direct observation during surgery revealed drainage of malodor pus and pituitary gland abscess. The histopathological evaluation also showed granulomatous hypophysitis and neutrophilic microabscess formation. The patient was initially treated with high doses of ceftriaxone (2 g twice daily) and metronidazole (500 mg (mg) four times per day). Also, the patient received cortisol replacement therapy after the operation. After obtaining the antibiogram and culture results, the treatment regimen was continued for 4 weeks postoperatively, followed by amoxicillin-clavulanate (500/125 mg three times daily) for a total duration of 12 weeks.

CONCLUSION

The patient recovered uneventfully and the postoperative MRI was normal without any remnant lesions.

Endoscopic Endonasal Surgery for Uncommon Pathologies of the Sellar and Parasellar Regions

Endoscopic skull base surgery has become an integral part of the present neurosurgical armamentarium. The pioneering efforts in which the purely endoscopic transsphenoidal approach was introduced have triggered a growing tide of using the endoscopic endonasal procedures for a large variety of skull base lesions. Because of their anatomical peculiarities, lesions of the sellar and parasellar regions lend themselves very well to the endoscopic endonasal approaches. Apart from the common pathological entities, many other less frequent pathologies are encountered in the sellar and parasellar area. In this chapter, we review the surgical technique of the endoscopic endonasal transsphenoidal approach and its extensions applied to a variety of rare and uncommon pathological entities involving the sella turcica and clivus. An overview of these pathological entities is also presented and exemplified.

Pituitary insufficiency with masked inflammation: Pituitary abscess

A 29‐year‐old woman presented with fever and amenorrhea. Laboratory findings showed no elevation inflammatory markers; however, hormonal evaluation revealed panhypopituitarism. She was finally diagnosed with pituitary abscess, and underwent transsphenoidal excision. The patient was treated with antibiotics and oral hormonal supplementation, and her pituitary function finally normalized.

A rare case of a secondary pituitary abscess arising in a craniopharyngioma with atypical presentation and clinical course

Pituitary abscesses are very uncommon. They are divided into primary, arising within a healthy gland, and secondary, observed with an underlying pre-existing lesion. Here we present the eighth case reported of a secondary abscess within a craniopharyngioma. A 59-year-old-woman presented with a 3-week history of headache, and fever. Physical examination was unremarkable. An Magnetic Resonance Imaging (MRI) showed a pituitary lesion suggestive of a chronic inflammatory process. She was diagnosed with lymphocytic meningitis with hypophysitis and she was treated with corticosteroids. Two months later she presented with headache and fever again. Control MRI showed enlargement of the pituitary lesion. Therefore, a transsphenoidal biopsy was performed. During the procedure, purulent material was released. Histological study demonstrated a craniopharyngioma and meningeal inflammation. Empiric antibiotics were started. Three months post-operatively, a follow-up MRI showed a suspect minimal residual mass. Secondary pituitary abscesses are rare. The key to successful management is a high index of suspicion. Transsphenoidal surgical evacuation plus antibiotics is the mainstay of treatment. Although most symptoms resolve, endocrinopathies improve only rarely.

Sella Bugged! Abscess Inside a Craniopharyngioma: Case Report with Literature Review

INTRODUCTION

Abscess within a craniopharyngioma (CPG) is extremely rare and only 8 such cases have been reported in literature. Most patients present with hypopituitarism and visual disturbances. We report the first ever case of a CPG with abscess in a pediatric patient.

CASE REPORT

A 10-year-old girl presented with visual deterioration and bitemporal hemianopia. Her CT and MRI brain suggested of a sellar-suprasellar CPG. Due to ill-developed sino-nasal anatomy, a transcranial approach was made for the lesion. The lesion was well capsulated, thick walled, and appeared inflamed. Upon incising the wall, thick yellowish pus was drained out in a controlled manner. This was followed by a partial resection of the CPG wall and eccentric, adhered, calcified residue was left behind with an Ommaya drain. The abscess culture grew Enterococcus species and histopathology revealed adamantinomatous CPG. Patient underwent culture sensitive antibiotics course followed by radiation for the residue. She was doing well at 1-year follow-up with clinical and radiological improvement.

CONCLUSION

This is the first report of a pediatric case with secondary abscess in CPG. Operative management of such a case includes controlled drainage of pus without dissemination into the surrounding arachnoid space. The tumor and abscess have to be addressed as separate surgical entities; infection control and wherever complete resection is not feasible, partial safe resection followed by radiotherapy is a viable option.

Atypical pituitary abscess lacking rim enhancement and diffusion restriction with an unusual organism, Moraxella catarrhalis: A case report and review of the literature

Background:

Pituitary abscess (PA) can be fatal if diagnosed late. Rim enhancement is a typical radiological finding of PA on postgadolinium T1-weighted magnetic resonance imaging (MRI). Diffusion-weighted imaging is helpful in distinguishing PA from other sellar cystic lesions. Herein, we report the first atypical case of PA showing neither rim enhancement nor diffusion restriction with an unusual organism, Moraxella catarrhalis.

Case Description:

A 77-year-old woman presented with headache, polyuria, polydipsia, and fatigue for a month before presenting to a local hospital. MRI showed pituitary enlargement with contrast enhancement. She had neither fever nor visual deficits and was followed up with hormonal replacement. Six months later, she complained of visual impairment, and MRI showed further pituitary enlargement with a thickened stalk compressing the optic chiasma. Neither rim enhancement nor diffusion restriction was observed. Endoscopic endonasal transsphenoidal surgery was performed based on the radiological diagnosis of lymphocytic hypophysitis or pituitary tumors. A thick, creamy yellow pus was drained from the sellar lesion. Intraoperative rapid histopathological findings revealed polymorphonuclear leukocytes infiltrating the pituitary gland. PA was diagnosed, and irrigation and open drainage of the abscess was performed. Bacterial culture of the pus detected M. catarrhalis by mass spectrometer, confirming the diagnosis. She underwent appropriate antibiotic administration, and her visual deficits improved.

Conclusion:

We report the first atypical case of PA showing neither rim enhancement nor diffusion restriction with M. catarrhalis. Even if preoperative findings are not suggestive of PA, it should be considered as a differential diagnosis. Intraoperative rapid histopathological findings are useful for accurately diagnosing PA and initiating appropriate surgical treatment.

Rathke’s Cleft Cyst Abscess—An Unusual Guest in The Sella

Abscess formation within a Rathkes’s cleft cyst (RCC) is extremely rare, particularly at a young age. We report the case of a young girl with abscess formation in RCC. A 21-year-old female presented with headache, vomiting, visual deterioration and features suggestive of hypopituitarism. She had bitemporal hemianopia with impairment of visual acuity. MRI revealed a cystic lesion in the sella with suprasellar extension and peripheral rim enhancement. On the basis of history and imaging, this was indistinguishable from more commonly encountered pituitary pathology. She underwent transsphenoidal decompression, which revealed yellowish purulent material that when cultured grew Staphylococcus epidermidis. Histological examination revealed numerous neutrophils and cyst wall lining with features characteristic of RCC. Postoperatively, she received antibiotics and replacement therapy for hypopituitarism. Three months later, she experienced deterioration in visual fields. Considering persistent disease, she underwent redo surgery which revealed similar findings. Postsurgery, pituitary MRI revealed an empty sella syndrome. Thereafter, follow-up for 1 year was stable with permanent diabetes insipidus and multiple pituitary hormone deficiency on supplementation. Although uncommon, we recommend considering RCC abscess as a differential diagnosis of a pituitary mass lesion, as predicting its presence can be difficult preoperatively. Persistent or recurrent disease is common in these cases, so timely diagnosis and adequate surgical drainage leads to lower morbidity and mortality.

Sellar and parasellar lesions: multidisciplinary management

Introduction

The endoscopic endonasal transsphenoidal approach to the sella and parasellar regions is now increasingly used for removal of a variety of lesions localized in the ventral skull base. The advantage of the endoscope is enhanced visualization and improved panoramic view that can result in more complete removal of the tumor. An extensive knowledge of the anatomy is mandatory to approach this region.

Materials and methods

From February 2009 to March 2020, the endoscopic endonasal approach was used in 153 patients with sellar and parasellar lesions, at our Institution: 136 pituitary adenomas, 7 craniopharyngiomas, 3 Rathke’s cysts, a tuberculum sellae meningioma, an aneurysm of the internal carotid artery (ICA), a clivus chordoma, a papillary glioneuronal tumor, an histiocytosis, a pituitary metastasis from breast cancer and a chondrosarcoma.

Results

The most common surgical complications were cerebral spinal fluid leak (9), bleeding (2), pituitary abscess (2). Among endocrinological complications, the most important were diabete insipidus (23) and panhypopituitarism (3). Two patients complicated with meningitis. There were no visual worsening and no operative mortality. We had persistence of disease in 20 cases. Twelve patients underwent surgical revision for recurrence of the disease.

Conclusions

Pre-operative planning and collaboration with several specialists are necessary in order to offer the patient the best treatment, minimizing complications.

A rare case of a secondary pituitary abscess arising in a craniopharyngioma with atypical presentation and clinical course

Pituitary abscesses are very uncommon. They are divided into primary, arising within a healthy gland, and secondary, observed with an underlying pre-existing lesion. Here we present the eighth case reported of a secondary abscess within a craniopharyngioma. A 59-year-old-woman presented with a 3-week history of headache, and fever. Physical examination was unremarkable. An Magnetic Resonance Imaging (MRI) showed a pituitary lesion suggestive of a chronic inflammatory process. She was diagnosed with lymphocytic meningitis with hypophysitis and she was treated with corticosteroids. Two months later she presented with headache and fever again. Control MRI showed enlargement of the pituitary lesion. Therefore, a transsphenoidal biopsy was performed. During the procedure, purulent material was released. Histological study demonstrated a craniopharyngioma and meningeal inflammation. Empiric antibiotics were started. Three months post-operatively, a follow-up MRI showed a suspect minimal residual mass. Secondary pituitary abscesses are rare. The key to successful management is a high index of suspicion. Transsphenoidal surgical evacuation plus antibiotics is the mainstay of treatment. Although most symptoms resolve, endocrinopathies improve only rarely.

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.

Abscess inside craniopharyngioma: diagnostic and management implications

Abscess inside the pituitary fossa is very rare. Such abscess can be primary, occurring in an otherwise healthy pituitary gland, or secondary, developing inside a diseased gland (ie, harbouring craniopharyngioma, Rathke's cleft cyst, etc). Secondary pituitary abscess inside a craniopharyngioma remains an extremely rare occurrence. Our literature search revealed only six such cases reported so far. In this report, we present the seventh case of craniopharyngioma with abscess in a 38-year-old woman. We describe the uniqueness of the clinical presentation of our case, the radiological pointers to the possible diagnosis and the management issues in our patient. A review of literature is also included to provide a comprehensive picture of this rare condition to the readers.

Endoscopic Endonasal Transsphenoidal Drainage of a Spontaneous Candida glabrata Pituitary Abscess

BACKGROUND

Noniatrogenic pituitary abscess remains a rare clinical entity, and is the indication for surgery in <1% of transsphenoidal approaches. Correct diagnosis of this rare entity is often delayed. Without timely treatment, morbidity and mortality are high. Of the 200 cases reported to date, less than one-half have identified a causative organism. We report the second case of a pituitary abscess caused by Candida species, and also provide an intraoperative video showing the endoscopic management of this pathology.

CASE DESCRIPTION

A 33-year-old woman presented with headache, hypopituitarism, and vision loss in the setting of diabetic ketoacidosis, and was found to have multiple abscesses in the liver, lung, kidney, and uterus. Brain magnetic resonance imaging revealed a 15-mm cystic sellar mass with restricted diffusion. The patient underwent urgent evacuation of the abscess via an endoscopic endonasal transsphenoidal route, with obvious purulent material filling the sella, later identified as Candida glabrata. Antimicrobial therapy was refined appropriately, and she exhibited significant improvement in neurologic function, although endocrinopathy has persisted.

CONCLUSIONS

With timely management, including a combination of surgical drainage and appropriate antimicrobial therapy, neurologic outcomes are good in most cases of pituitary abscess; however, endocrinopathy often does not improve. Although most reported cases with identified causative organisms speciate bacteria, some cases are of fungal etiology and require different antimicrobial agents. This further underscores the importance of identifying the causative agent.

Spontaneous rupture of a secondary pituitary abscess causing acute meningoencephalitis: Case report and literature review

BACKGROUND

Pituitary abscess (PA) is an uncommon finding that is rarely diagnosed preoperatively. If not properly treated it is associated with high morbidity and mortality rates. Nowadays standard diagnostic procedures allow early detection and successful treatment of this lesion in a high number of cases and mortality has been significantly reduced in recent years. PA arising de novo in a healthy gland are defined as primary, whereas those complicating a pre-existing disease of the hypophysis are called secondary abscesses.

CASE DESCRIPTION

We present a case of a secondary PA mimicking a large pituitary adenoma extending in the nasal cavity, which was wrongly diagnosed as such. The abscess showed an unexpected evolution in 48 h from presentation due to a sudden, extensive intracranial leakage of pus.

CONCLUSIONS

To our knowledge, it is rare to find PA showing a rapid evolution like this, and in the literature only one previous case of a PA not reaching medical or surgical therapy was reported. In that case, hypothalamus involvement was identified as the cause of death. This should be the first case reported of a spontaneous PA rupture causing acute meningoencephalitis. Along with a short review of the literature on the major features of PA, we also tried to identify some features which could be supportive of a diagnosis of secondary PA.

Pituitary abscess: clinical manifestations, diagnosis and treatment of 66 cases from a large pituitary center over 23 years

PURPOSE

Pituitary abscess (PA) is rare and commonly described in case reports or small case series. This study aimed to better determine salient clinical manifestations related to the diagnosis and appropriate treatment of PA using by far the largest case series of this disease.

METHODS

A total of 6361 consecutive patients underwent surgery for pituitary diseases in Peking Union Medical College Hospital between January 1991 and December 2013. Among this cohort, sixty-six patients were diagnosed with PA based on both intraoperative findings and postoperative histopathological evidence.

RESULTS

The most common clinical presentation was anterior pituitary hypofunction (81.8 %), followed by common headache (69.7 %), diabetes insipidus (DI; 47.9 %), visual disturbances (45.5 %) and symptoms related to infection (43.9 %). Forty patients (66.7 %) showed typical rim enhancement after gadolinium injection on magnetic resonance imaging (MRI). Most patients (63 of 66, 95.5 %) underwent transsphenoidal surgery (TSS), and the remaining 3 patients (4.5 %) were treated with transcranial surgery (TC). After follow-up for 7.2 ± 4.9 years, PA was diminished in most patients (81.8 %), as demonstrated by post-operative MRI, and eight patients underwent at least one additional operation due to recurrence.

CONCLUSIONS

For patients with hypopituitarism and DI with rim enhancement on MRI, we should consider the possible diagnosis of PA. Proper use of antibiotics, complete drainage via surgery and hormone replacement for hypopituitarism are the key treatments for PA.

Rathke cleft cyst masquerading as pituitary abscess: A case report

BACKGROUND

Rathke cleft cyst (RCC) is a rare cystic sellar entity, which is usually small in size and asymptomatic in most patients. RCC presenting panhypopituitarism and a cystic lesion with rim enhancement on magnetic resonance imaging is extremely rare. Therefore, it is easy to be misdiagnosed as pituitary abscess because of the similar clinical manifestations and neuroimaging changes.

CASE SUMMARY

We report a rare case of RCC masquerading as pituitary abscess clinically and radiologically with no evidence of central nervous system infection. The patient was initially suspected to be diagnosed with pituitary abscess, which was denied by the histopathological findings of RCC with no intraoperative drainage of abscess.We present an uncommon case of RCC masquerading as pituitary abscess in a 62-year-old Chinese male patient. The patient was admitted to Peking Union Medical College Hospital complaining of severe frontal pulsatile headache, visual acuity deficit, polyuria, polydipsia, and slight disturbance of consciousness. The biochemical and endocrinological examinations revealed severe hyponatremia and panhypopituitarism. Magnetic resonance imaging showed a sellar lesion with the apparent cystic change and rim enhancement. Accordingly, pituitary abscess was misdiagnosed at the beginning.The patient received hormone replacement therapy and underwent a trans-sphenoidal surgery. The surgical findings were uneventful. The histopathological examinations showed no infiltration of inflammatory cells or pus, and proved the lesion to be RCC.

CONCLUSION

Through this rare case, we aim to emphasize that the differential diagnosis of sellar lesions requires constant vigilance and that RCC may lead to clinical and radiological changes similar with pituitary abscess.

Pituitary tuberculoma with subsequent drug-resistant tuberculous lymphadenopathy: an uncommon presentation of a common disease

We report a case of pituitary tuberculosis which presented as a non-functioning pituitary macroadenoma, and subsequently developed multidrug-resistant tuberculous lymphadenopathy. Pituitary tuberculosis continues to be a rare presentation of tuberculosis, but incidence and prevalence are expected to grow with increasing numbers of multidrug-resistant tuberculosis. Isolated pituitary tuberculosis is rare. Tuberculosis should be considered in the differential diagnosis in evaluation of a sellar mass.

Computed tomographic findings and treatment of a bull with pituitary gland abscess

BACKGROUND

In cattle, the prognosis of brain abscess is unfavourable and treatment is therefore not recommended. To the knowledge of the authors, there has been no report of successful treatment of a brain abscess in cattle.This report describes the clinical, computed tomographic and postmortem findings in a Holstein-Friesian bull with a hypophyseal abscess.

CASE REPORT

The main clinical findings were generalised ataxia, ptyalism, prolapse of the tongue, dropped jaw, dysphagia, head tilt and unilateral ptosis. Cerebrospinal fluid evaluation revealed 2437 leukocytes/µl and severe pleocytosis. CT examination of the head showed a cavitary lesion consistent with an abscess in the hypophysis. Treatment consisted of gentamicin and flunixin meglumine for 3 days and amoxicillin for 40 days. The neurological signs resolved within 8 days of the start of treatment. The bull was slaughtered 11 months later because of infertility, and a postmortem examination was carried out. Histologically, a mild chronic non suppurative meningoencephalitis restricted to the ventral diencephalon was diagnosed. In addition, there was mild to moderate multifocal chronic lymphoplasmacytic hypophysitis with mild multifocal fibrosis.

CONCLUSIONS

This case report stresses the significance of CT in confirming the clinical and laboratory diagnosis of central nervous system disorders in cattle and for localising brain lesions. Treatment of the brain abscess resulted, with respect to the central nervous disorder, in a successful outcome and was encouraging considering that most cases have an unfavourable prognosis.

Increased 18F-2-Fluorodeoxysorbitol (18F-FDS) Activity in a Pituitary Spindle Cell Carcinoma

A 33-year-old woman presented with progressive visual loss. An MRI examination revealed a pituitary lesion which was suspicious of abscess. FDG and F-2-fluorodeoxysorbitol (F-FDS) PET were performed to differentiate malignancy from inflammation. FDS is a new tracer with potential in differentiating inflammatory tissues based on results from animal studies. However, intense tracer uptake was found in the pituitary in both PET studies. The lesion was proved to be spindle cell carcinoma following biopsy.

Etiology of Hypopituitarism in Adult Patients: The Experience of a Single Center Database in the Serbian Population

There are only a few published studies related to the population-based etiology of hypopituitarism. New risks for developing hypopituitarism have been recognized in the last 10 years. Aim. To present data regarding the etiology of hypopituitarism collected in a tertiary center over the last decade. This is a cross-sectional database study. Patients and Methods. We included 512 patients (pts) with hypopituitarism, with a mean age of 45.9 ± 1.7 yrs (range: 18-82; male: 57.9%). Results. Nonfunctional pituitary adenomas were presented in 205 pts (40.5%), congenital causes in 74 pts (14.6%), while acromegaly and prolactinomas were presented in 37 (7.2%) and 36 (7.0%) patients, respectively. Craniopharyngiomas were detected in 30 pts (5.9%), and head trauma due to trauma brain injury-TBI and subarachnoid hemorrhage-SAH in 27 pts (5.4%). Survivors of hemorrhagic fever with renal syndrome (HFRS) and those with previous cranial irradiation were presented in the same frequency (18 pts, 3.5% each). Conclusion. The most common causes of hypopituitarism in our database are pituitary adenomas. Increased awareness of the other causes of pituitary dysfunction, such as congenital, head trauma, extrapituitary cranial irradiation, and infections, is the reason for a higher frequency of these etiologies of hypopituitarism in the presented database.

A case of pituitary abscess presenting without a source of infection or prior pituitary pathology

Pituitary abscess is a relatively uncommon cause of pituitary hormone deficiencies and/or a suprasellar mass. Risk factors for pituitary abscess include prior surgery, irradiation and/or pathology of the suprasellar region as well as underlying infections. We present the case of a 22-year-old female presenting with a spontaneous pituitary abscess in the absence of risk factors described previously. Her initial presentation included headache, bitemporal hemianopia, polyuria, polydipsia and amenorrhoea. Magnetic resonance imaging (MRI) of her pituitary showed a suprasellar mass. As the patient did not have any risk factors for pituitary abscess or symptoms of infection, the diagnosis was not suspected preoperatively. She underwent transsphenoidal resection and purulent material was seen intraoperatively. Culture of the surgical specimen showed two species of alpha hemolytic Streptococcus, Staphylococcus capitis and Prevotella melaninogenica. Urine and blood cultures, dental radiographs and transthoracic echocardiogram failed to show any source of infection that could have caused the pituitary abscess. The patient was treated with 6weeks of oral metronidazole and intravenous vancomycin. After 6weeks of transsphenoidal resection and just after completion of antibiotic therapy, her headache and bitemporal hemianopsia resolved. However, nocturia and polydipsia from central diabetes insipidus and amenorrhoea from hypogonadotrophic hypogonadism persisted.

Pituitary abscess: a case report and review of the literature

Pituitary abscess is a rare life-threating entity that is usually misdiagnosed as a pituitary tumor with a definite diagnosis only made postoperatively. Over the last several decades, advances in healthcare have led to a significant decrease in morbidity and mortality due to pituitary abscess. We report a case of a 34-year-old woman who was admitted to our department for investigation of a pituitary mass and with symptoms of pituitary dysfunction, headaches and impaired vision. During her admission, she developed meningitis-like symptoms and was treated with antibiotics. She eventually underwent transsphenoidal surgery for excision of the pituitary mass. A significant amount of pus was evident intraoperatively; however, no pathogen was isolated. Six months later, the patient was well and had full recovery of the anterior pituitary function. Her menses returned, and she was only on treatment with desmopressin for diabetes insipidus that developed postoperatively.

LEARNING POINTS

Pituitary abscess is a rare disease and the reported clinical features vary mimicking other pituitary lesions.The diagnosis of pituitary abscess is often very difficult to make and rarely included in the differential.The histological findings of acute inflammatory infiltration confirm the diagnosis of pituitary abscess.Medical and surgical treatment is usually recommended upon diagnosis of a pituitary abscess.

Neuroendocrine disorders: pituitary imaging

Significant advances in pituitary imaging have taken place in the past several decades, including the introduction of magnetic resonance imaging (MRI). This imaging modality has vastly improved our ability to detect and characterize sellar masses and more accurately characterize the extent and spread of lesions in and around the sella. Intraoperative MRI may help improve the completeness of resection of sellar masses. Other imaging modalities, including magnetic resonance angiography, computed tomography (CT), and CT angiography, have an important role in specific cases. Interventional methods, including bilateral inferior petrosal sinus sampling, may establish the pituitary origin of corticotropin (ACTH) excess in patients with ACTH-dependent Cushing's syndrome. Pituitary imaging should be obtained in patients with pituitary hormone excess, hypopituitarism, or mass effect in the sella. Despite rapid advances in pituitary imaging, there are several diagnostic challenges remaining. Future research may help improve the radiographic detection of small sellar lesions, such as ACTH-secreting adenomas causing Cushing's disease, accurately characterize the type and extent of sellar pathologies, and provide prognostic information regarding their growth potential.

Intrasellar abscess following pituitary surgery

PURPOSE

Intrasellar abscess is an uncommon cause of mass lesions in the sella turcica. Few cases have been reported in the literature, and much remains unknown about the etiology and diagnosis of these lesions. We sought to review a series of patients with intrasellar abscess encountered at our institution and identify defining characteristics of their presentation and management.

METHODS

We conducted a retrospective chart review for intrasellar infection cases associated with a mass lesion. Included cases had clear demonstration of a mass lesion on imaging with subsequent positive microbiological cultures. Clinical presentation, management, post-operative course, neuroimaging, microbiology, and any perturbations in serum pituitary biochemical markers were examined.

RESULTS

All examined patients had a history of antecedent transsphenoidal pituitary surgery within the preceding 10 months. All presented with headaches, three with progressive visual loss, one with meningismus, one with fever in the setting of an active cerebrospinal fluid leak, and one with fever, meningismus, hypotension, and progressive somnolence. No patient presented with acute endocrine abnormalities. A majority did not initially have any diffusion restriction present on MRI, but in one case we were able to track the evolution of diffusion restriction over sequential MRI scans. Two patients had complete resolution of presenting symptoms, while three experienced improvement or stabilization of their neurologic deficit. There were no mortalities.

CONCLUSIONS

Pituitary abscess remains a rare diagnosis that can be difficult to make and to confirm. In our series we found a strong association between culture-positive abscess and recent pituitary surgery. When present, prompt treatment with surgical drainage and aggressive post-operative antibiotics can lead to a favorable outcome.

Pituitary abscess in an adolescent girl: a case report and review of the literature

We report the case of a 15-year-old girl who presented with a history of recurrent bitemporal headaches for the last 2 months. In the prior few days, she complained of neck pain, emesis, phonophobia and photophobia, but no fever. Additional symptoms included polydipsia, polyuria and weight gain in the last year. Magnetic resonance imaging (MRI) of the brain demonstrated a cystic sellar and suprasellar mass with peripheral enhancement. Cerebrospinal fluid studies showed pleocytosis. Serum hormone levels were consistent with panhypopituitarism. Transnasal sphenoidotomy was performed, and 2 mL of purulent material was drained, confirming the diagnosis of pituitary abscess. The patient completed 6 weeks of parenteral antibiotics. She improved but continued to require home hormonal replacement therapy. A repeated MRI 3 months later showed abscess resolution. In addition to tumors, pituitary abscess should be considered in children who present with headache and panhypopituitarism, particularly in those who present with signs of meningeal inflammation. Prolonged parenteral antibiotics and surgical drainage are effective.

Abscess formation within a Rathke's cleft cyst

We report and discuss the rare case of a pituitary abscess forming within a Rathke's cleft cyst (RCC). A 66-year-old gentleman presented with visual deterioration and symptoms suggestive of hypopituitarism. The patient underwent transsphenoidal debulking of the lesion whereupon purulent material was discovered. Histological examination was suggestive of RCC together with numerous neutrophils characteristic of abscess. Microbiological culture of the material grew Staphylococcus aureus. The patient was treated for a RCC abscess and received antibiotics and endocrine replacement therapy. The patient has been followed up for 2 years without recurrence. Although uncommon, we recommend the consideration of RCC abscess as a differential diagnosis of a pituitary mass lesion as clinical presentation and radiological assessment are not specific in identifying these lesions preoperatively.

Clinical presentation and magnetic resonance findings in sellar tuberculomas

Background and Importance. Sellar tuberculomas are extremely rare lesions with nonspecific clinical manifestations. The tuberculous infection of the pituitary gland and sellar region is characterized by the presence of an acute or chronic inflammatory reaction and may occur in the absence of systemic tuberculosis. The diagnosis is difficult prior to the surgery. An adequate diagnostic and antituberculous drugs usually result in a good outcome. Clinical Presentation. We report four cases of sellar tuberculoma, 3/1 female/male, age range: 50–57 years. All patients had visual disturbances and low levels of cortisol. Conclusion. The clinical diagnosis of sellar tuberculoma is a challenge and should be suspected when a sellar lesion shows abnormal enhancement pattern and stalk involvement, and absence of signal suppression in FLAIR.

Pituitary abscess following transsphenoidal surgery: the experience of 12 cases from a single institution

OBJECTIVE

To explore possible reasons for the incidence of a pituitary abscess following transsphenoidal surgery and determine the most effective treatment.

METHODS

A series of 12 patients who had undergone transsphenoidal surgery in other hospitals before being treated at Peking Union Medical College Hospital were reviewed. The presence of a pituitary abscess was confirmed when pus was intraoperatively observed within the sella turcica. All patients were treated with debridement of the abscess, nine among whom through a transsphenoidal approach and the other three via a craniotomy, followed by antibiotic treatment and hormone replacement therapy. The mean follow-up time was 27.0 months (range from 3.0 to 79.0 months).

RESULTS

Headache (92%), panhypopituitarism (58%) and visual disturbance (50%) were the most common clinical indicators of a pituitary abscess. Imaging tests demonstrated a pituitary mass in all patients, with seven (58%) manifested with typical magnetic resonance features of an abscess. Ten patients (83%) were correctly diagnosed preoperatively. During surgical exploration, six presented with severe inflammation or an abscess within the sphenoidal sinus. Causative organisms were identified in five patients (42%). After surgical and antibiotic therapies, all patients fully recovered except for two presenting with severe visual impairment. Six patients (50%) required hormone replacement therapy.

CONCLUSION

Retrograde infection from the sphenoid sinus may be a vital mechanism underlying the formation of a pituitary abscess following transsphenoidal surgery. Debridement of the abscess through surgical approaches combined with antibiotic treatment has been found to yield positive outcomes.

The optic chiasm

The optic chiasm is formed when the optic nerves come together in order to allow for the crossing of fibers from the nasal retina to the optic tract on the other side. This enables vision from one side of both the eyes to be appreciated by the occipital cortex of the opposite side. This review makes note of the embryology, anatomy and vascular supply of the optic chiasm, then discusses the clinical syndromes associated with chiasmal disease, and the diseases which commonly influence its function.

Alternative causes of hypopituitarism: traumatic brain injury, cranial irradiation, and infections

Hypopituitarism often remains unrecognized due to subtle clinical manifestations. Anterior pituitary hormone deficiencies may present as isolated or multiple and may be transient or permanent. Traumatic brain injury (TBI) is recognized as a risk factor for hypopituitarism, most frequently presenting with isolated growth hormone deficiency (GHD). Data analysis shows that about 15% of patients with TBI have some degree of hypopituitarism which if not recognized may be mistakenly ascribed to persistent neurologic injury and cognitive impairment. Identification of predictors for hypopituitarism after TBI is important, one of them being the severity of TBI. The mechanisms involve lesions in the hypothalamic-pituitary axis and inflammatory changes in the central nervous system (CNS). With time, hypopituitarism after TBI may progress or reverse. Cranial irradiation is another important risk factor for hypopituitarism. Deficiencies in anterior pituitary hormone secretion (partial or complete) occur following radiation damage to the hypothalamic-pituitary region, the severity and frequency of which correlate with the total radiation dose delivered to the region and the length of follow-up. These radiation-induced hormone deficiencies are irreversible and progressive. Despite numerous case reports, the incidence of hypothalamic-pituitary dysfunction following infectious diseases of the CNS has been underestimated. Hypopituitarism usually relates to the severity of the disease, type of causative agent (bacterial, TBC, fungal, or viral) and primary localization of the infection. Unrecognized hypopituitarism may be misdiagnosed as postencephalitic syndrome, while the presence of a sellar mass with suprasellar extension may be misdiagnosed as pituitary macroadenoma in a patient with pituitary abscess which is potentially a life-threatening disease.

Primary pituitary abscess in an adolescent boy: a rare occurrence

Primary pituitary abscess is a rare clinical condition at a young age. It is characterised by atypical clinical features which makes the diagnosis difficult. Correct diagnosis and therapy are mandatory due to the potentially lethal outcome. We report the case of a 14-year-old healthy boy. The onset was acute with fever, gait imbalance, slurring of speech and amnesia. MRI brain revealed a hyperintense lesion in T2-weighted image (T2WI) in sellar and suprasellar region, which was hypointense in T1WI. After administration of contrast, there was peripheral rim enhancement suggesting pituitary abscess. The diagnosis was confirmed following evacuation of purulent material, during surgery, through a trans-sphenoidal approach. Postoperatively, the boy needed prolonged intensive care support. He was discharged on day 42 after surgery. Follow-up at 3 months revealed complete motor recovery. He required hormone replacement and was intermittently showing features suggestive of frontal lobe syndrome.

An unusual cure for acromegaly

The authors present the case of a 30-year-old female patient with acromegaly whose disease had not been cured after transcranial neurosurgery, two transsphenoidal surgeries and stereotactic radiosurgery. She required treatment with octreotide and pegvisomant to normalise growth hormone levels. Seven years after the diagnosis of acromegaly, she noticed acute vision loss in her left eye and presented with meningism. She had an intrasellar abscess which was confirmed and treated by surgical drainage. As a result of the abscess, she was cured of acromegaly and able to discontinue both octreotide and pegvisomant.

A pituitary abscess masquerading as recurrent hypernatremia and aseptic meningitis

Pituitary abscess is a rare condition. In the setting of multiple surgical interventions, the risk of its development increases. A 49-year-old man presented with episodes of altered mental status. He had two surgeries for a recurrent suprasellar arachnoid cyst. The second surgery was complicated by a persistent cerebrospinal fluid (CSF) leak that required two repairs following which he developed panhypopituitarism and central diabetes insipidus. Twelve months after his last surgery he was diagnosed with aseptic meningitis. This was followed by recurrent hospitalisations for severe hypernatremia blamed on poor medication compliance. He was subsequently hospitalised for the evaluation of a febrile illness. Brain MRI showed ventriculitis and enhancement of the sella. Exploratory surgery revealed a purulent collection in the sella and a mucosal graft which had been used to repair the CSF leak. After drainage of pus and replacement of the graft he recovered completely but requiring life-long hormonal replacement.

Primary pituitary tubercular abscess mimicking as pituitary adenoma

Tubercular abscess of the pituitary fossa is rare and may lead to diagnostic uncertainty in a patient with absence of tuberculosis elsewhere in the body. We present a rare case report of a young lady who presented with sellar and suprasellar cystic mass. She was diagnosed as a case of pituitary macroadenoma and was intraoperatively found to harbor pus in the lesion. She did not have any symptoms of infection. The case underlines the importance of considering such a possibility in the differential diagnosis of cystic sellar lesions and further diagnostic tests should be done for confirmation and treatment of this rare and potential life threatening illness.

The optic chiasm

In the first part of this chapter the anatomy and vascular supply of the chiasm are recounted, and the visual symptoms that may arise in chiasmal disease are noted. The neuro-ophthalmic signs, including the pattern of visual field defects, appearance of the optic disc, and various uncommon clinical accompaniments, are described. The second part deals with a comprehensive list of disease processes that may directly or indirectly affect the chiasm. These are divided into inflammatory disorders, including sarcoidosis, multiple sclerosis, and idiopathic chiasmitis; infective disorders, including tuberculosis; and a large section on tumors, including pituitary adenomas, cysts, and choristomas, malignant disorders, including germ cell tumors and glioma, and meningioma; and finally vascular disorders and compression due to hydrocephalus. In each case the clinical features and management of the disorder are noted, as well as the prognosis for visual improvement following treatment.

Seventeen-year-old adolescent with pituitary abscess

Pituitary abscess is a rare but potentially life-threatening infectious process. Diagnosis is challenging as symptoms are non-specific and signs of infection may be absent. We report the case of a previously healthy 17-year-old male who presented with worsening headaches, polyuria, polydipsia and no clinical signs of infection. On evaluation, he was found to have hypopituitarism with diabetes insipidus, hypothyroidism and adrenal insufficiency. An imaging study revealed a pituitary mass. He underwent transsphenoidal biopsy to rule out tumor. The abscess was drained transsphenoidally and he was treated with parental antibiotics. Magnetic resonance imaging one year later revealed a normal pituitary without any evidence of abscess or mass. He continues to require thyroid, adrenal and anti-diuretic hormone replacements. As with any pituitary lesion, prompt complete hypothalamic pituitary evaluation is essential to avoid potentially life-threatening consequences.

Diagnosis and management of pituitary abscess: experiences from 33 cases

OBJECTIVE

Pituitary abscess is a rare disorder with nonspecific presenting manifestations, often making a correct preoperative diagnosis difficult. To better determine the salient signs and symptoms of pituitary abscess and to evaluate the effectiveness of surgical and antibiotic therapies, we conducted a review of patients treated for pituitary abscess at the Peking Union Medical College Hospital (PUMCH).

METHODS

A total of 33 consecutive patients referred to PUMCH between 1991 and 2007 were included. While 30 patients underwent surgery and antibiotic therapy, three patients accepted only antibiotic therapy. A complete history, a thorough record of signs and symptoms, pituitary imaging and biochemical panels were obtained for each patient.

RESULTS

Most of the patients presented with complaints and symptoms consistent with a sellar mass, generally in the absence of any evidence of infection. Diabetes insipidus, hypopituitarism and headache were the most common clinical indicators. Typical magnetic resonance (MR) images after gadolinium injection demonstrated a sellar cystic mass with an enhanced rim. Although there were several recurrences, the abscess resolved in nearly all cases. Hypopituitarism generally did not recover, and hormone replacement therapy was usually necessary.

CONCLUSIONS

Presentation of diabetes insipidus, hypopituitarism and a sellar cystic mass with an enhanced rim may be suggestive of a pituitary abscess. For most patients, a transsphenoidal evacuation, followed by antibiotic therapy, is recommended. However, antibiotic therapy alone may be useful for acute cases. In our experience, pituitary abscesses can usually be treated, though the accompanying hypopituitarism is difficult to cure, and requiring lifelong hormonal replacement.