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

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.

Primary Sellar Abscesses: A Systematic Review and 2 Rare Observations

BACKGROUND

Abscesses of the chiasmatic-sellar region are quite rare and are often a result of surgical intervention, trauma, or tumor growth. Primary abscesses are extremely rare and represent a group of abscesses the occur because of internal microbial seeding. Primary abscesses are rarely reported. We present 2 clinical cases featuring primary abscesses of the chiasmal-sellar region. To put into perspective the rarity of these findings, we performed a systematic review of existing clinical reports regarding this pathology.

METHODS

A systematic review of literature was conducted to gather existing clinical reports on primary abscesses of the chiasmatic-sellar region. Two personal findings are added to the literature review, including a 13-year-old girl and a 58-year-old man who presented with chiasmal-sellar region primary abscesses. The diagnostic aspects, treatment strategy, and outcomes are discussed.

RESULTS

Both patients included in the report had positive outcome. The pediatric patient developed a recurrence of the abscess and was treated accordingly. Overall, 41 cases of primary abscesses of this region have been reported in literature, of which 6 are in children under 18 years of age. The main nonspecific clinical manifestations include headaches, visual impairment, and endocrine pathology. Acute inflammatory responses are rarely seen, despite infectious genesis. Transnasal endoscopic surgical treatment offers diagnostic and treatment advantages.

CONCLUSIONS

Proper diagnostic procedures can aid in correct treatment strategy and improve overall outcome.

Corticotroph adenoma and pituitary fungal infection: a rare association

SUMMARY

Pituitary infections, particularly with fungus, are rare disorders that usually occur in immunocompromised patients. Cushing's syndrome predisposes patients to infectious diseases due to their immunosuppression status. We report the case of a 55-year-old woman, working as a poultry farmer, who developed intense headache, palpebral ptosis, anisocoria, prostration and psychomotor agitation 9 months after initial diabetes mellitus diagnosis. Cranioencephalic CT scan showed a pituitary lesion with bleeding, suggesting pituitary apoplexy. Patient underwent transsphenoidal surgery and the neuropathologic study indicated a corticotroph adenoma with apoplexy and fungal infection. Patient had no preoperative Cushing's syndrome diagnosis. She was evaluated by a multidisciplinary team who decided not to administer anti-fungal treatment. The reported case shows a rare association between a corticotroph adenoma and a pituitary fungal infection. The possible contributing factors were hypercortisolism, uncontrolled diabetes and professional activity. Transsphenoidal surgery is advocated in these infections; however, anti-fungal therapy is still controversial.

LEARNING POINTS

Pituitary infections are rare disorders caused by bacterial, viral, fungal and parasitic infections. Pituitary fungal infections usually occur in immunocompromised patients. Cushing's syndrome, as immunosuppression factor, predisposes patients to infectious diseases, including fungal infections. Diagnosis of pituitary fungal infection is often achieved during histopathological investigation. Treatment with systemic anti-fungal drugs is controversial. Endocrine evaluation is recommended at the time of initial presentation of pituitary manifestations.