Endocrine Abstracts

Introduction: Pituitary abscesses are rare entities that can occur either as primary infections or secondarily to different causes. Primary pituitary abscess arises within a previously healthy gland, while secondary abscess occurs in pituitary gland that harbors a pre-existing lesion (adenoma, craniopharyngioma, or Rathke’s cleft cyst). Only 23 cases of secondarily infected adenomas were reported in the literature.

Case report: A 38-years-old man presented with an acute worsening of headaches, double vision and mild left ptosis. His medical history was notable for a known and untreated pituitary adenoma. He denied any fevers, chills, night sweats, neck pain, nuchal rigidity, or photophobia. On examination, he was alert and fully oriented. Vital signs were normal without evidence of fever. His neurologic examination was notable for left ptosis and a dysconjugate gaze with mild impairment of the left medial, superior, and inferior rectus muscles. Visual field assessment was normal. The remaining cranial nerve and neurologic examination were normal. After 3 days of hospitalization, the patient developed fever with no meningitis symptoms. C-reactive protein was increased from 20 mg/l to 305 mg/l with hyperleucocytosis at 21000/ml. Magnetic resonance imaging showed a 4.5 cm partially cystic, partially solid contrast-enhancing sellar mass with extension into the suprasellar cistern, the cavernous sinus and to the left internal carotid. Laboratory analysis revealed no hematologic or electrolyte abnormalities. Endocrine studies were notable for central hypothyroidism with low levels of prolactin, adrenocorticotropic hormone, luteinizing hormone, follicle-stimulating hormone and testosterone. Growth hormone and insulinlike growth factor 1 were not measured. An endoscopic endonasal transphenoidal approach to the sella was used to treat this lesion. Clear fluid and thicker purulent discharge were released on opening the cyst wall. The patient was started on broadspectrum intravenous antibiotics, including vancomycin, ceftriaxone, and metronidazole at meningitic doses. Histopathologic Analysis showed pituitary adenoma and robust inflammatory infiltrate composed of predominantly neutrophils admixed within the neoplastic cells. Tumor cells were positive for human growth hormone, prolactin, adrenocorticotropic hormone.

Conclusion: Pituitary abscesses are rare disorders responsible for high mortality risk. Mortality and morbidity can be reduced by early surgical drainage and appropriate antibiotic treatments. The typical MRI findings are of high importance for the diagnosis of the disorder. The transsphenoidal approach should be preferred in surgery and appropriate antimicrobial therapy should be administered according to the surgical specimen’s culture. Additionally, these cases should closely be followed up in terms of pituitary insufficiency, surgical complications and infection.