Endocrine Abstracts

A 34-year-old woman presented with a worsening headache 4 weeks post-partum following emergency caesarean section. She described the headache as the worst that she had experienced, and this was made worse by bending forwards and with associated photophobia. A CT head scan revealed pan sinusitis and a suggestion of a pituitary tumour while lab results showed mild hyponatremia along with low TSH and FT4. An initial working diagnosis of likely meningitis was made, and she commenced on ceftriaxone and acyclovir. A LP was carried out which revealed xanthochromia and raised CSF protein while the CSF cell count revealed 324 cells with 70% lymphocytes and 30%neutrophils. A visual field testing showed no visual deficit. A baseline pituitary hormone profile showed elevated prolactin and normal cortisol and IGF-1 and she continued to become more hyponatraemic with a sodium of 117 mmol/l. The patient was commenced on levothyroxine as it was thought that the hyponatremia was the result of secondary hypothyroidism. An MRI pituitary revealed possible cystic macroadenoma or pituitary abscess. She was discussed at the pituitary MDT and advised to undergo a further MRI pituitary with diffusion weighted imaging as it felt the pituitary lesion was an abscess. She received a intravenous broad spectrum antibiotics while in the hospital though her inflammatory markers continued to remain normal. A repeat LP was carried out which showed the CSF cell count to be only 20 with 95%lymphocytes and the CSF protein had dropped. A workup for other infectious conditions including screening for HIV, TB, Hepatitis B, Hepatitis C and cryptococcus were all negative. The patient developed a recurrence of her headache post discharge with increasing tiredness and fatigue. A short synacthen test now showed central adrenal insufficiency while MRI pituitary suggested a likely pituitary abscess which was now multi septate with further progression to encroach on the optic chiasm with compression. She commenced steroid replacement and underwent a transsphenoidal drainage of the sellar abscess with frank pus noted intra operatively but no organism was isolated. She had an extended course of intravenous antibiotics over 4 weeks due to the nature of the pituitary lesion and had uneventful post operative recovery with improvement in her hyponatremia which had now normalized. This case highlights the rarity of the pituitary abscess and its close mimic to meningitis. The importance of recognising the need for prompt endocrine work up alongside other causes cannot be over emphasised.