Benson, Carolyn

de Ribaupierre, Sandrine

Rotenberg, Brian W.

St-Pierre, Godefroy Hardy

English

Scholarship@Western

Western University Scholarship@Western Paediatrics Publications Paediatrics Department 1-1-2013 Pituitary abscess: review and highlight of a case mimicking pituitary apoplexy. Godefroy Hardy St-Pierre Sandrine de Ribaupierre sderibau@uwo.ca Brian W. Rotenberg Carolyn Benson Follow this and additional works at: https://ir.lib.uwo.ca/paedpub Citation of this paper: St-Pierre, Godefroy Hardy; de Ribaupierre, Sandrine; Rotenberg, Brian W.; and Benson, Carolyn, "Pituitary abscess: review and highlight of a case mimicking pituitary apoplexy." (2013). Paediatrics Publications. 1145. https://ir.lib.uwo.ca/paedpub/1145      Initially described by Heslop in 1848 and Simmonds in 1914,there have since been multiple case reports in the literature ofpituitary abscess, but only 3 series of 20 or more patients1-3 withthis disorder, all within the last decade. Even with more then 250cases presented so far, pituitary abscess remains a clinicalenigma with many unknowns. There have been even fewer casesof pituitary abscess acutely symptomatic with pituitaryapoplexy: notably, only one article links these two explicitly4. CASE REPORT     Our patient, a 49-year-old right handed male, presented withacute sudden onset holoencephalic headache. Additionally, hewas feeling unwell, was nauseated with occasional vomiting andcomplained of dizziness. He had been previously suffering fromchronic holoencephalic headaches for six months which were ofinsufficient severity for him to seek medical attention. He alsodescribed a change in his vision, mentioned as blurriness.THE CANADIAN JOURNAL OF NEUROLOGICAL SCIENCES                                                                                                                    743Pituitary Abscess: Review and Highlight of a CaseMimicking Pituitary Apoplexy  Godefroy Hardy St-Pierre, Sandrine de Ribaupierre, Brian W. Rotenberg, Carolyn BensonCan J Neurol Sci. 2013; 40: 743-745BRIEF COMMUNICATIONS     On examination, this patient was alert and oriented to name,time and location. His vision was 20/40 on the right (20/25pinhole) and 20/70 on the left (20/30 pinhole). His visual fieldsboth on confrontation and automated fields showed bitemporalhemianopsia respecting the vertical midline. There was nopapilledema on fundoscopy. The reminder of the cranial nerveexam was unremarkable. Endocrine workup revealed the patientto have central adrenal insufficiency, hypothyroidism andhypogonadism, and appropriate replacement therapy wasinitiated.      Further imaging was ordered and an MRI with gadoliniumrevealed abnormal cystic enhancement of the pituitary gland aswell as thickening of the pituitary stalk. The cyst rim wasisointense on T1 and T2 while its contents were slightlyhypointense on T1 and hyperintense on T2. (Figure) A diffusionsequence was not performed. No compression of the opticchiasm was seen but inflammation and enhancement of thediaphragm sellae was observed. At that point in time, the patientFigure: Pre-operative MRI (T1 Flair Pre & Post; T2).From the London Health Sciences Centre (GHS, SdR, CB), University Hospital; St. Joseph’s Health Care (BWR), London, Ontario, Canada.RECEIVED DECEMBER 4, 2012. FINAL REVISIONS SUBMITTED MARCH 6, 2013.Correspondence to: Godefroy Hardy St-Pierre, LHSC, University Hospital, 339 Windermere Road, London, Ontario, N6A 5A5, Canada. Email: ghardyst@uwo.ca.A B Chttps://doi.org/10.1017/S0317167100015055 Published online by Cambridge University Presssignificantly improved on medication but his visual fieldsremained unchanged. Decision was taken to bring him to the ORfor a pituitary biopsy to confirm the diagnosis of hypophysitis.     An endonasal endoscopic transsphenoidal approach to thepituitary fossa was performed. Upon opening the dura of thesella, thick yellow pus came out under pressure. Cultures sent atthe time were positive for Staphylococcus epidermidis. Thepatient was started on IV cefotriaxone and vancomycin. Ourpatient suffered from diabetes insipidus post operatively andrequired desmopressin (dDAVP) supplementation on dischargeas well as continuation of steroids and levothyroxine. Postoperative imaging showed resolution of the abscess. At initial sixweek follow-up, the patient was still in a state onpanhypopituitarism but had regained full visual fields. He had nofurther headache, no cerebrospinal fluid (CSF) leak and wasoverall much improved.DISCUSSION     Pituitary abscess is a very rare entity. Described in severalsurgical series of pituitary disorders, the reported frequency isbetween 0.2-1%1 with the three largest series reporting 0.7%, 1%and 0.4%. A slight female predominance is seen in most series1.3:12 further compounded by the 1.8:1 and 1.4:1 ratios reportedin the two Chinese series1,3. The University of California SanFransisco (UCSF) series however reports a 1.7:1 malepredominance2. The age ranges from 12-71 year-old with a meanage of 40-years-old.      The vast majority (62%) of patients have no predisposingfactors. Among these cases, while pus is identified at surgery,cultures are usually sterile with only 10% identifying amicroorganism.  If a pre-existing local or remote infection (19%)is known, 83% cultures will be positive: more commonly, thisrepresents local extension of infection from the paranasal sinusesalthough cavernous sinus thrombophlebitis and infected CSFfistula are also reported. The other two main factors are aprevious surgery (17%) and the presence of a pituitary lesion(11%)     Presenting symptoms in pituitary abscesses are varied butusually entails headache and endocrine dysfunction. (Table 1).Diabetes insipidus was framed as a distinguishing factorsuggesting pituitary abscess giving its relative rarity in thepituitary adenoma. Indeed, 56% of selected cases had diabetesinsipidus but an even higher 68% had some form of anteriorpituitary dysfunction.      Apoplexy in the setting of a pituitary abscess has beendescribed once4. Contrary to our patient, that particular casepresented with a decreased level of consciousness. Even then,the evacuation procedure took place six weeks after the initialpresentation, further proof that pituitary abscess is a exceedinglydifficult diagnosis to make.     Imaging appearance of pituitary abscess is deceptively nonspecific. Rim enhancement with gadolinium remains the mostsignificant feature suggesting pituitary abscess. Thosecharacteristics are unfortunately shared by the much morecommon necrotic pituitary adenoma as well as potentiallyevoking Rathke’s cleft cyst or craniopharyngioma. The use of adiffusion-weighted sequence to refine the diagnosis appearspromising, although its inclusion usually requires suspicion bythe reporting neuroradiologist of a pituitary abscess.     Treatment of pituitary abscess entails mandatory surgicaldrainage. While transsphenoidal surgery is currently advocatedas the surgical route by most case reports and series in theliterature, cases of endonasal endoscopic transsphenoidaltreatment of a pituitary abscess have been published in theliterature1. Improved visualization of the sellar content alongwith better appreciation of normal anatomy such as thecavernous sinus wall and the pituitary gland are brought forwardas favouring endoscopy, but experience in regards to pituitaryabscess remains minimal to date.     Outcomes are nowadays surprisingly good considering theoriginal grim descriptions of the entity. (Table 2) All mortalityassociated with pituitary abscesses was reported in 19792 orprior with the exception of two cases in 20065 and 20086.Compared to widely quoted mortality of 30-50%, this representsa mortality of 3%. Keeping in mind significant reporting bias,this much lower value is probably in keeping with the chronicindolent pathology often diagnosed post-operatively thatconstitutes most cases of pituitary abscesses in the modernliterature.3THE CANADIAN JOURNAL OF NEUROLOGICAL SCIENCES744Table 1: Presenting symptom Table 2: Outcomehttps://doi.org/10.1017/S0317167100015055 Published online by Cambridge University PressCONCLUSION     Pituitary abscess is a rare clinical occurrence. Most cases arefound incidentally and diagnosed intra-operatively when pus isdelivered from the pituitary fossa. Initially reported as an oftenfatal entity, the recent literature rather suggests that it represent achronic indolent process, explaining its frequent misdiagnosis asa pituitary adenoma. Acute presentation is unique and this reportis, to our knowledge, the second pituitary abscess presentingwith apoplexy ever published. Endocrine dysfunction is acommon clinical presentation, a distinguishing feature helpful indifferential diagnosis. Endonasal endoscopic transsphenoidaldrainage, which offers optimal visualization of the sellar content,is considered to be the current best available treatment.REFERENCES1. Lui F, Li G, Yao Y, et al. Diagnosis and management of pituitaryabscess: experience from 33 cases. Clin Endocrinol (Oxf). 2011;74(1):79-88.2. Vates GE, Berger MS, Wilson CB. Diagnosis and management ofpituitary abscess: a review of 24 cases. J Neurosurg. 2001;95(2):233-41.3. Zhang X, Sun J, Shen M, et al. Diagnosis and minimally invasivesurgery for the pituitary abscess: a review of 29 cases. ClinNeurol Neurosurg. 2012;114(7):957-61.4. Kindgon CC, Sidhu PS, Cohen J. Pituitary apoplexy secondary toan underlying abscess. J Infect. 1996;33(1):53-5.5. Dutta P, Bhansali A, Singh P, Kotwal N, Pathak A, Kumar Y.Pituitary abscess: report of 4 cases and review of the literature.Pituitary. 2006;9(3):267-73.6. Jain KC, Varma A, Mahapatra AK. Pituitary abscess: a series of 6cases. Br J Neurosurg. 1997;11(2):139-43. LE JOURNAL CANADIEN DES SCIENCES NEUROLOGIQUESVolume 40, No. 5 – September 2013                                                                                                                                                                     745https://doi.org/10.1017/S0317167100015055 Published online by Cambridge University Press

Pituitary abscess: review and highlight of a case mimicking pituitary apoplexy.

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Pituitary abscess: review and highlight of a case mimicking pituitary apoplexy.

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