Diagnosis Of Pituitary Abscess Research Articles

Unusual Presentations of Sellar and Suprasellar Space Occupying Lesion: Our Institutional Experience

AbstractA pituitary abscess (PA) is a rare intracranial lesion. It is a critical disorder caused by an infectious process where purulent material accumulates inside the sella turcica. It occurs either as a primary disease or because of an infection and is associated with poor prognosis. In this article, we share our experience with PA. At our institution, we operated on five cases of pituitary abscess since 2016. All the cases presented with bitemporal hemianopia and headache. None of them had fever. Pituitary hormones were normal except in two patients with a previous history of hypothyroidism. Magnetic resonance imaging (MRI) of the brain showed pituitary macroadenoma. They underwent the endoscopic transnasal transsphenoidal approach. Postoperatively their vision has improved. Endocrine functions were normal in all the patients following surgery. Culture sensitivity was sterile in all the patients. Diagnosis of pituitary abscess is highly difficult before surgery. Hence, the diagnosis should be considered when a patient presents with fever, headache, and signs of pituitary dysfunction and meningeal inflammation. Surgical and medical management leads to a lower mortality rate and a higher probability of hormone function recovery.

Diagnosis of pituitary abscess and treatment via transsphenoidal surgery: experience from 15 cases

ObjectivePituitary 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. DesignRetrospective study. PatientsFifteen patients underwent transsphenoidal surgery and received antibiotic treatment. MeasurementsComplete details regarding medical history, clinical manifestations, laboratory examinations, imaging studies, and treatment strategies were obtained for all patients. ResultsMost 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. ConclusionsThe 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).

MON-261 Pituitary Abscess Presenting as Pituitary Macroadenoma Causing Hypopituitarism and Acute Meningitis; A Wolf in Sheep’s Clothing

Background: Pituitary abscess (PA) is a rare but life-threatening cause of suprasellar (SS) lesion and pituitary hormonal deficiencies with an incidence of 0.2% - 1.1%. Clinical Case: A 65‐year woman with history of transient ischemic attacks, presented with double vision for 3 months (mon) and sudden onset, severe headache. She was diagnosed with cranial nerve (CN) VI palsy. MRI brain showed 1.7 cm SS mass suggestive of pituitary macroadenoma abutting optic chiasm. Visual field testing was unreliable due to underlying visual defects. She had progressive improvement in her diplopia. She was referred to Endocrinology for worsening fatigue. Physical exam was unremarkable. Pituitary hormonal work up showed secondary hypothyroidism with TSH 1.17 mIU/L (0.4-4.5), free T4 0.6 ng/dL (0.8-1.8); hypogonadotropic hypogonadism with FSH 12 mIU/ml (23-116.3), LH 1.7 mIU/ml (10-54.7), estradiol <15 (<31); elevated prolactin due to stalk affect with prolactin level of 83.3 ng/mL (3-30). She had normal IGF-1 of 154 ng/mL (41-279), ACTH 12 pg/mL (6-50), cortisol 14.1 mcg/dL (4-22) and mildly low sodium 134 mmol/L (135-146). Levothyroxine 50 mcg daily was started. The MRI brain at 2 mon and 6 mon follow up showed stable 1.8 cm peripherally enhancing SS mass. She was planned for elective pituitary adenoma resection but prior to that that was emergently admitted to ICU with high grade fever, confusion, seizures, severe hyponatremia with sodium of 122 mmol/L (135-146) and a concern for meningitis. She had a dental crown placed 3 weeks ago. MRI brain showed increase in size of the cystic component of SS mass. She was started on empiric IV antibiotics and high dose steroids. She underwent trans-sphenoidal surgery (TSS), and actually found to have a pituitary abscess. Gram stain of purulent material was positive for neutrophils. Pathology showed pituitary gland with focal infarct and surrounding acute on chronic inflammation and fibrosis. The intra-operative abscess cultures grew Cutibacterium (Proprionibacterium) acnes. She is planned to receive 6 weeks of IV antibiotics. Conclusion: We present a case of pituitary abscess presenting as a SS mass causing hypopituitarism. It was presumed pituitary macroadenoma due to the sub-acute onset and lack of progression. She developed acute deterioration in sensorium leading to concern for meningitis and PA requiring timely diagnosis and management with trans-sphenoidal resection and IV antibiotics. Definitive diagnosis of PA is usually made post-operatively. 60% of patients with PA and new onset hypopituitarism may require long term hormone replacement.

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.

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

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. 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. 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±4.9years, 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. 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.

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

SummaryPituitary 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.Learning pointsPituitary abscesses typically develop in patients who have other sources of infection or disruption of the normal suprasellar anatomy by either surgery, irradiation or pre-existing pathology; however, they can develop in the absence of known risk factors.Patients with pituitary abscesses typically complain of headache, visual changes and symptoms of pituitary hormone deficiencies.As other pituitary neoplasms present with similar clinical findings, the diagnosis of pituitary abscess is often not suspected until transsphenoidal resection is performed.Prompt surgical and medical treatment of pituitary abscess is necessary, which typically results in improvement in headache and visual changes; however, pituitary hormone deficiencies are typically often permanent.

Pituitary abscess: a case report and review of the literature.

SummaryPituitary 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 pointsPituitary 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.

Decreased pituitary hormone levels in a sheep with pituitary abscess

A four-year-old Akkaraman ewe was presented to the Firat University Veterinary Teaching Hospital for circling, dullness, weakness and sternal recumbency. On physical examination, opisthotonus, mydriasis in the right eye and myosis in the left eye, absence of the pupillary reflex, ruminal tympany were detected. Serum pituitary hormone analyses indicated the hypopituitarism characterized by thyroid stimulating hormone (TSH) < 0.05 IU/L, follicle stimulating hormone (FSH) < 0.13 IU/L, luteinizing hormone (LH) < 0.10 IU/L and prolactin (PRL) < 0.50 ng/ml. On the basis of clinical presentation and hypopituitarism, tentative diagnosis of pituitary abscess was made. The animal was euthanized due to the poor prognosis. Morphological examination revealed coexistence of hypophyseal-carotid rete abscess and hyaline thrombosis in carotid rete, heteropic ossification in carotid rete and tuberal muscles. Microbiologically; Arcanobacterium pyogenes was isolated in blood agar culture from the hypophysis. Decreased serum pituitary hormone levels including TSH, FSH, LH and PRL in conjunction with the clinical findings were a useful diagnostic tool for antemortem diagnosis of pituitary abscess in the sheep.