1
|
Samha R, Raya M, Mansour M, Mansour A, Mohsen MA, Alromhain B. Primary pituitary abscess with atypical imaging features: A rare case report. Int J Surg Case Rep 2024; 119:109753. [PMID: 38761689 PMCID: PMC11127560 DOI: 10.1016/j.ijscr.2024.109753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 05/07/2024] [Accepted: 05/11/2024] [Indexed: 05/20/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Raghad Samha
- Faculty of Medicine, AlBaath University, Homs, Syrian Arab Republic.
| | - Maria Raya
- Faculty of Medicine, University of Kalamoon, Damascus, Syria
| | - Marah Mansour
- Faculty of Medicine, Tartous University, Tartous, Syrian Arab Republic
| | - Amal Mansour
- Faculty of Medicine, Tishreen University, Lattakia, Syria
| | - Mohammad Ayham Mohsen
- Faculty of Medicine, Department of Neurosurgery, Damascus University Hospital, Damascus, Syrian Arab Republic
| | - Basel Alromhain
- Faculty of Medicine, Department of Neurosurgery, Al Assad University Hospital, Damascus, Syrian Arab Republic
| |
Collapse
|
2
|
Zhuang BB, Chen J, Zhang Q, Zhang GL, Shi SS. Diagnosis of pituitary abscess and treatment via transsphenoidal surgery: experience from 15 cases. Neurochirurgie 2023; 69:101478. [PMID: 37598621 DOI: 10.1016/j.neuchi.2023.101478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/01/2023] [Accepted: 08/01/2023] [Indexed: 08/22/2023]
Abstract
OBJECTIVE Pituitary abscess is an often misdiagnosed, rare clinical disorder. To improve diagnostic accuracy and the efficacy of surgical and antibiotic therapy for patients with pituitary abscess, herein, we retrospectively reviewed 15 patients who presented with pituitary abscesses from 2005 to 2022. DESIGN Retrospective study. PATIENTS Fifteen patients underwent transsphenoidal surgery and received antibiotic treatment. MEASUREMENTS Complete details regarding medical history, clinical manifestations, laboratory examinations, imaging studies, and treatment strategies were obtained for all patients. RESULTS Most patients presented with hypopituitarism and headaches, while some presented with fever, visual disturbances, and diabetes insipidus (DI). Abscesses showed significant annular enhancement post gadolinium injection. In most patients, pituitary abscess can be cured via microscopic or endoscopic drainage of the abscess followed by antibiotic treatment. Complete cure of pituitary abscess was observed in nine patients, with six cases of prolonged hypopituitarism and only one case of recurrence. Long-term hormone replacement therapy was effective in the postoperative management of hypopituitarism. CONCLUSIONS The typical manifestations of pituitary abscess include hypopituitarism and headaches; the presence of an enhanced ring at the edge of the mass on contrast-enhanced magnetic resonance images (MRI) is highly suggestive of pituitary abscess. We recommend antibiotic treatment for 4-6 weeks postoperatively, based on the results of bacterial cultures or metagenomic next-generation sequencing (mNGS).
Collapse
Affiliation(s)
- Bing-Bo Zhuang
- Department of Neurosurgery, Fujian Medical University Union Hospital, 29# Xinquan Road, Fuzhou, 350001, Fujian, China
| | - Jing Chen
- Department of Neurosurgery, Fujian Medical University Union Hospital, 29# Xinquan Road, Fuzhou, 350001, Fujian, China.
| | - Qiang Zhang
- Department of Neurosurgery, Fujian Medical University Union Hospital, 29# Xinquan Road, Fuzhou, 350001, Fujian, China
| | - Guo-Liang Zhang
- Department of Neurosurgery, Fujian Medical University Union Hospital, 29# Xinquan Road, Fuzhou, 350001, Fujian, China
| | - Song-Sheng Shi
- Department of Neurosurgery, Fujian Medical University Union Hospital, 29# Xinquan Road, Fuzhou, 350001, Fujian, China
| |
Collapse
|
3
|
Stringer F, Foong YC, Tan A, Hayman S, Zajac JD, Grossmann M, Zane JNY, Zhu J, Ayyappan S. Pituitary abscess: a case report and systematic review of 488 cases. Orphanet J Rare Dis 2023; 18:165. [PMID: 37365629 DOI: 10.1186/s13023-023-02788-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/18/2023] [Indexed: 06/28/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Felicity Stringer
- Barwon Health, Geelong, VIC, Australia
- St Vincent's Health, Melbourne, VIC, Australia
| | - Yi Chao Foong
- Barwon Health, Geelong, VIC, Australia.
- Monash Health, Melbourne, VIC, Australia.
- Alfred Health, Melbourne, VIC, Australia.
- Eastern Health, Melbourne, VIC, Australia.
| | - Alanna Tan
- Austin Health, Melbourne, VIC, Australia
| | | | | | | | - Justin Ng Yau Zane
- Monash Health, Melbourne, VIC, Australia
- Monash University, Melbourne, VIC, Australia
- Royal Hobart Hospital, Hobart, TAS, Australia
| | | | | |
Collapse
|
4
|
Pituitary Abscess: A Challenging Preoperative Diagnosis—A Multicenter Study. Medicina (B Aires) 2023; 59:medicina59030565. [PMID: 36984566 PMCID: PMC10056522 DOI: 10.3390/medicina59030565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/07/2023] [Accepted: 03/08/2023] [Indexed: 03/15/2023] Open
Abstract
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.
Collapse
|
5
|
Kiran MM, Bal E, Kuratmer AD, Ercan K, Gumuskaya B, Erdogan F. Idiopathic granulomatous hypophysitis mimicking adenoma. REVISTA ESPANOLA DE PATOLOGIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ANATOMIA PATOLOGICA Y DE LA SOCIEDAD ESPANOLA DE CITOLOGIA 2022; 55:203-206. [PMID: 35779888 DOI: 10.1016/j.patol.2019.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/06/2019] [Accepted: 11/20/2019] [Indexed: 06/15/2023]
Abstract
Hypophysitis is a rare disease of pituitary gland, which, although it is usually a primary lesion, can also occur secondary to systemic conditions. Granulomatous hypophysitis is an inflammatory disease condition which accounts for less than 1% of all cellular lesions and can mimic adenoma. A 32-year-old woman presented with weight gain, galactorrhea and blurred vision. The MRI showed a cystic, nodular lesion in the intermediate lobe of the pituitary gland and the initial diagnosis was adenoma. She underwent surgery and the histopathology revealed granulomas composed of epithelioid histiocytes, multinuclear giant cells and mononuclear inflammatory cells. Inflammatory diseases of the pituitary gland are much less frequent than pituitary adenomas and idiopathic granulomatous hypophysitis is extremely rare. Histopathology and the ruling out of a systemic cause are the gold standards for its diagnosis.
Collapse
Affiliation(s)
| | - Ercan Bal
- Department of Neurosurgery, Ankara Yildirim Beyazit University, Ankara, Turkey
| | - Ayca Dilsad Kuratmer
- Department of Pathology, Ankara Bilkent State Hospital, Ankara, Turkey; Department of Pathology, Ankara Yildirim Beyazit University, Ankara, Turkey
| | - Karabekir Ercan
- Department of Radiology, Ankara Bilkent State Hospital, Ankara, Turkey
| | - Berrak Gumuskaya
- Department of Pathology, Ankara Bilkent State Hospital, Ankara, Turkey; Department of Pathology, Ankara Yildirim Beyazit University, Ankara, Turkey
| | - Fazli Erdogan
- Department of Pathology, Ankara Bilkent State Hospital, Ankara, Turkey; Department of Pathology, Ankara Yildirim Beyazit University, Ankara, Turkey
| |
Collapse
|
6
|
Ono R, Nishiguchi S, Kitagawa I. Pituitary insufficiency with masked inflammation: Pituitary abscess. Clin Case Rep 2022; 10:e05943. [PMID: 35662773 PMCID: PMC9163484 DOI: 10.1002/ccr3.5943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 05/05/2022] [Accepted: 05/20/2022] [Indexed: 11/06/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Ryohei Ono
- Department of General Internal Medicine Shonan Kamakura General Hospital Kamakura City Japan
| | - Sho Nishiguchi
- Department of General Internal Medicine Shonan Kamakura General Hospital Kamakura City Japan
| | - Izumi Kitagawa
- Department of General Internal Medicine Shonan Kamakura General Hospital Kamakura City Japan
| |
Collapse
|
7
|
Bloomer ZW, Knee TS, Rubin ZS, Hoang TD. Case of an atypical pituitary abscess. BMJ Case Rep 2021; 14:14/11/e246776. [PMID: 34848428 PMCID: PMC8634284 DOI: 10.1136/bcr-2021-246776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Zachary W Bloomer
- Endocrinology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.,Medicine, Uniformed Services University of the Health Sciences, F. Edward Hebert School of Medicine, Bethesda, Maryland, USA
| | - Treyce S Knee
- Endocrinology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.,Medicine, Uniformed Services University of the Health Sciences, F. Edward Hebert School of Medicine, Bethesda, Maryland, USA
| | - Zachary S Rubin
- Pathology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Thanh Duc Hoang
- Endocrinology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA .,Medicine, Uniformed Services University of the Health Sciences, F. Edward Hebert School of Medicine, Bethesda, Maryland, USA
| |
Collapse
|
8
|
Ryu B, Khatri D, Zlochower A, Maslak S, D'Amico RS. Erosion of the sella turcica and pituitary expansion secondary to polymicrobial brain abscesses: a case report. Access Microbiol 2021; 3:000270. [PMID: 34816090 PMCID: PMC8604177 DOI: 10.1099/acmi.0.000270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 08/16/2021] [Indexed: 11/28/2022] Open
Abstract
Introduction Brain abscesses can lead to a diverse array of complications, especially when they are polymicrobial in nature. Multiple underlying pathogens may present with a unique set of clinical symptoms which require an early identification and treatment. Skull base osteomyelitis with sellar floor erosion and pituitary involvement with SIADH are such rare complications of brain abscesses which have never been reported previously in the literature. Case Presentation We report the case of an immunocompetent 38-year-old male with altered mental sensorium and left hemiparesis due to polymicrobial brain abscess which required surgical evacuation. The post-operative recovery was complicated by severe hyponatremia secondary to SIADH which was treated uneventfully. Radiological imaging demonstrated pituitary enlargement with herniation through an eroded sella turcica without active CSF leak. Patient responded well to the antibiotic therapy based on microbiological susceptibility testing with a complete resolution of the pituitary enlargement on radiological follow-up. Conclusion Conservative treatment with targeted antibiotics can lead to the resolution of pituitary enlargement secondary to a brain abscess. However, a close clinical follow-up is required to look for a CSF leak considering the sellar floor erosion due to osteomyelitis.
Collapse
Affiliation(s)
- Brendan Ryu
- Department of Neurosurgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Deepak Khatri
- Department of Neurosurgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Avraham Zlochower
- Department of Radiology, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Stephen Maslak
- Department of Internal Medicine, Division of Infectious Diseases, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Randy S D'Amico
- Department of Neurosurgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| |
Collapse
|
9
|
Zheng K, Fei H, Bai Z, Hao L, Liu Y, Shi Y. Pituitary abscess misdiagnosed as pituitary adenoma stroke: Case report and literature review. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2019.100574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
|
10
|
Li Z, Yang C, Bao X, Yao Y, Feng M, Deng K, Liu X, Xing B, Wang R. Secondary pituitary abscess following transsphenoidal surgery with recurrent meningitis: A case report. Medicine (Baltimore) 2018; 97:e13458. [PMID: 30508969 PMCID: PMC6283055 DOI: 10.1097/md.0000000000013458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
RATIONALE The transsphenoidal surgical (TS) approach to sellar masses is the preferred surgical route in most cases. Secondary pituitary abscess (PA) following TS is an extremely rare but serious postoperative complication with potentially high disability and mortality. PATIENT CONCERNS We describe an uncommon case of secondary PA in a 42-year-old woman, who underwent uncomplicated transsphenoidal procedures without cerebrospinal fluid leak, to treat primary Rathke cleft cyst. Without obvious cause, the patient suffered recurrent meningitis with complaints of headache, hyperpyrexia, and chills from 1 month after the operation. DIAGNOSIS There were no significant imaging findings until a new rim-enhancement lesion was seen in the sellar region on magnetic resonance imaging during the 6th episode of meningitis 11 months after the initial surgery. A diagnosis of secondary PA was considered; INTERVENTIONS:: Therefore, she underwent a 2nd TS with pus evacuation and antibiotic treatment. OUTCOMES She improved remarkably and had no recurrence of symptoms during the 9-month follow-up. LESSONS Our aim was to present this rare case and discuss the most likely etiologies and preventive measures for this condition. In patients with recurrent meningitis but dormant imaging manifestations after TS, the possibility of secondary PA should considered. Adequate surgical drainage with microbiology-guided antibiotic therapy is the 1st choice for treatment.
Collapse
Affiliation(s)
| | - Chengxian Yang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xinjie Bao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yong Yao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Ming Feng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Kan Deng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaohai Liu
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Bing Xing
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| |
Collapse
|