Pituitary abscess: a case report and review of the 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.

Case of an atypical pituitary abscess

A pituitary abscess is a rare intrasellar infection. Correct identification can be challenging preoperatively given its non-specific symptoms and imaging findings. We report a case of a young woman presenting with secondary amenorrhea, visual field deficits and a 2.6 cm pituitary lesion diagnosed to be a craniopharyngioma. A concomitant unexpected pituitary abscess was diagnosed intraoperatively without associated meningeal symptoms.

CENTRAL HYPOTHYROIDISM IN SEVERE SEPSIS

Objective

A partial or complete deficiency of hormone secretion by pituitary gland (hypopituitarism) is commonly seen after a pituitary apoplexy caused by an infarction of a pituitary adenoma or pituitary hyperplasia (as in Sheehan's syndrome). Hypopituitarism may also follow surgery, when hypovolemia, anticoagulation, fat/air/bone marrow microemboli can provoke a pituitary infarction/hemorrhage. Other causes of abrupt hypophyseal hypoperfusion, as hypovolemia during a septic shock, could also contribute. In the last mentioned situation, due to the complex endocrine-immune interrelation, sepsis could be masked and improperly managed.

Case report

We report a case of a 72 years-old Caucasian woman, previously healthy, who underwent an orthopedic surgery for a femoral fracture. This event apparently triggered a central-origin hypothyroidism, misinterpreted as "post-surgical psychosis", which, in turn, masked a symptomatology of a subsequent severe sepsis. The patient was admitted in the infectious diseases department with a severe gut-origin sepsis, needing surgery and long course antibiotics. The pituitary insufficiency was reversed.

Conclusion

Pituitary apoplexy is an uncommon but potentially life-threatening disease, and could be precipitated by successive events - in our case an orthopedic surgery and a subsequent severe sepsis. It needs recognizing (has intrinsic severity and could mask other serious conditions), treat and monitor (could progress and/or reverse).

Recurrent pituitary abscess: case report and review of the literature

A 26-year-old woman presented with severe postpartum headaches. Magnetic resonance imaging (MRI) revealed a symmetric, heterogeneous enlargement of the pituitary gland. Three months later, she developed central diabetes insipidus. A diagnosis of postpartum hypophysitis was suspected and corticosteroids were prescribed. Six months later, the pituitary mass showed further enlargement and characteristics of a necrotic abscess with a peripheral shell and infiltration of the hypothalamus. Transsphenoidal surgery was performed, disclosing a pus-filled cavity which was drained. No bacterial growth was observed, except a single positive blood culture for Staphylococcus aureus, considered at that time as a potential contaminant. A short antibiotic course was, however, administered together with hormonal substitution for panhypopituitarism. Four months after her discharge, severe headaches recurred. Pituitary MRI was suggestive of a persistent inflammatory mass of the sellar region. She underwent a new transsphenoidal resection of a residual abscess. At that time, the sellar aspiration fluid was positive for Staphylococcus aureus and she was treated with antibiotics for 6 weeks, after which she had complete resolution of her infection. The possibility of a pituitary abscess, although rare, should be kept in mind during evaluation for a necrotic inflammatory pituitary mass with severe headaches and hormonal deficiencies.

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: report of two cases and review of the literature

Pituitary abscess is a rare but critical disorder caused by an infectious process where purulent material accumulates inside the sella turcica. Since symptoms, signs and radiographic characteristics of pituitary abscess are similar to several other pituitary lesions, correct diagnosis before surgery is challenging. In this article, two cases of pituitary abscess treated in our department are reported, followed by a literature review. In these two cases, both patients presented with intermittent fever. Magnetic resonance imaging revealed a suprasellar lesion with rim enhancement after contrast injection. After transsphenoidal surgery, the diagnosis of pituitary abscess was confirmed. The patients were then given antibiotic treatment and recovered fully in less than 2 months. Findings of this article support timely diagnosis and proper treatment including transsphenoidal surgery and antibiotic therapy for pituitary abscess, leading to lower mortality rates and higher probability of pituitary hormone function recovery.