Eelco W. Hoving

GE Vates

J Rennert

KC Jain

Nicolaas A. Bakker

P Ciappetta

P Dutta

P Sabbah

S Utsuki

English

PubMed

Bakker, Nicolaas A.

Hoving, Eelco W.

University of Groningen

A rare case of sudden blindness due to a pituitary adenoma coincidentally infected with methicillin-resistant Staphylococcus aureus (MRSA)

Proceedings - University of Groningen

Dissertations of the University of Groningen

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LETTER TO THE EDITOR
A rare case of sudden blindness due to a pituitary adenoma
coincidentally infected with methicillin-resistant
Staphylococcus aureus (MRSA)
Nicolaas A. Bakker & Eelco W. Hoving
Received: 7 September 2009 /Accepted: 19 October 2009 /Published online: 14 November 2009
# The Author(s) 2009. This article is published with open access at Springerlink.com
Keywords Pituitary . Abscess . Sudden blindness
Dear editor,
A patient with sudden complete loss of vision is presented,
which ultimately turned out to be caused by a pituitary
adenoma coincidentally infected with MRSA.
A 39-year-old male patient woke up with complete
blindness of both eyes. History taking revealed slightly
blurred vision for several weeks. Also, the patient suffered
from a nose bleeding and nasal discharge for which he
visited his general practitioner. No further action was taken
at that time. On physical examination, we saw an acutely ill
patient (body temperature, 39 °C) with complete blindness,
but without any focal neurological deficit. Magnetic
resonance imaging (MRI) showed a sellar mass with
suprasellar expansion and compression of the optic chiasm
(Fig. 1a). Also, the right sphenoid sinus was filled with
debris, possibly in continuity with the suprasellar region.
Laboratory testing did not reveal any endocrine distur-
bances, while leukocyte and C-reactive protein count were
slightly elevated.
An emergency left-sided pterional craniotomy was
performed to decompress the optic system. During surgery,
to our surprise, extensive signs of infection were seen, with
debris and pus in the interhemispheric fissure and around
the suprasellar mass. After surgery, the patient was
admitted to the intensive care unit, while upfront therapy
with broad spectrum antibiotics (intravenous ceftriaxone,
metrodinazole and penicillin) was initiated. Pathologic
examination revealed a non-functioning adenoma, while
infection with MRSA was determined in the same
specimen 1 day after surgery. Subsequently, intravenous
Vancomycin was added.
Direct postoperative MRI showed adequate decompres-
sion of the optic system. However, the right sphenoid sinus
was still filled with debris. Subsequently, the ear, nose and
throat physician performed a sphenoidectomy. A mass was
evacuated that contained MRSA. Additional history taking
revealed that, approximately 6 months before admission,
the patient had adopted a child from Brazil who was treated
for MRSA.
In the days after surgery, the patients' clinical course
declined dramatically with cerebritis, ventriculitis and
meningitis, also requiring external ventricular drainage.
The patient still suffered from complete blindness. Howev-
er, after 3 weeks of intensive antibiotic treatment (systemic
and intrathecal), the patient showed signs of recovery, after
which he was weaned from the ventilator. Two months after
surgery, the patient was discharged with a ventriculoper-
itoneal shunt device. At that time, the patient was able to
have light perception. On a visit at our outpatient
department 6 months after surgery, the patient's vision
was almost completely recovered, and he did not suffer
from any focal neurological deficit. MRI showed adequate
decompression of the optic system with a small tumour
remnant (Fig. 1b). Because of the involvement of the
cavernous sinus within the remnant, total surgical resection
was considered to be impossible. For that reason, the
patient received radiotherapy on the remnant.
N. A. Bakker (*) : E. W. Hoving
Department of Neurosurgery,
University Medical Center Groningen, University of Groningen,
P.O. Box 30.001, 9700 RB Groningen, The Netherlands
e-mail: n.a.bakker@nchir.umcg.nl
Acta Neurochir (2010) 152:1079–1080
DOI 10.1007/s00701-009-0551-7
Pituitary abscess itself is rare, with an incidence of
less than 1% of all cases of pituitary disease [2, 3, 7],
and radiological distinction from other sellar masses is
difficult [4, 5]. As a result, pituitary abscesses are often
diagnosed only during surgery when empyema or pus is
found.
Primary pituitary abscess may develop in a normal
pituitary gland, either due to haematogenous seeding or by
direct extension of adjacent infection (either in the CSF or
sphenoid sinus) [2]. Secondary pituitary abscesses occur in
glands that harbour a pre-existing lesion, such as an
adenoma [3]. Other risk factors are an underlying immu-
nocompromised condition, previous pituitary surgery or
irradiation of the pituitary gland.
Our patient probably suffered from a pre-existing
pituitary adenoma, secondarily infected by an infection in
the sphenoid sinus. This may also explain the clinical
course of our patient: a history of blurred vision because of
the macro-adenoma, with a co-existing nasal discharge
because of the sphenoid sinus infection. The sudden loss of
vision may be explained by a sudden rupture of an abscess
wall or because of a sudden breakthrough of pus and debris
from the sphenoid sinus into the pituitary cavity. Another
explanation may be inflammation of the optic nerves due to
the infected adenoma [6].
One could discuss the transcranial approach that was
performed in this patient, as it is argued that a trans-
sphenoidal approach should be favoured over transcranial
surgery as it may limit the spread of micro-organisms [1, 7].
However, because of the sudden complete blindness, we
wanted to be absolutely sure that the optic chiasm was
immediately decompressed in an adequate manner. In
addition, as can be seen on the preoperative coronal view
(Fig. 1b), the process has a somewhat dumbbell shape,
which may limit adequate transsphenoidal decompression.
Also, retrospectively, significant cerebral dissemination was
already present before the patient was operated on.
Open Access This article is distributed under the terms of the
Creative Commons Attribution Noncommercial License which per-
mits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
References
1. Ciappetta P, Calace A, D'Urso PI, De Candia N (2008) Endoscopic
treatment of pituitary abscess: two case reports and literature
review. Neurosurg Rev 31:237–246
2. Dutta P, Bhansali A, Singh P, Kotwal N, Pathak A, Kumar Y
(2006) Pituitary abscess: report of four cases and review of
literature. Pituitary 9:267–273
3. Jain KC, Varma A, Mahapatra AK (1997) Pituitary abscess: a series
of six cases. Br J Neurosurg 11:139–143
4. Rennert J, Doerfler A (2007) Imaging of sellar and parasellar
lesions. Clin Neurol Neurosurg 109:111–124
5. Sabbah P, Bonardel G, Herve R, Marjou F, Hor F, Pharaboz C,
Bauduceau B (1999) CT and MRI findings in primitive pituitary
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Fujii K (2005) Blurred vision caused by inflammation of the optic
nerves due to a pituitary abscess. Neurol Med Chir (Tokyo)
45:327–330
7. Vates GE, Berger MS, Wilson CB (2001) Diagnosis and manage-
ment of pituitary abscess: a review of twenty-four cases. J
Neurosurg 95:233–241
Fig. 1 a Preoperative
T2-weighted coronal MR image
showing a sellar mass with
suprasellar expansion and severe
compression of the chiasm. It
has a somewhat dumbbell shape.
b Postoperative T1-weighted
contrast-enhanced, coronal MR
image showing a contrast-
enhancing sellar mass remnant,
while the optic chiasm is ade-
quately decompressed
1080 N.A. Bakker, E.W. Hoving


Crossref

NARCIS 

Blurred vision caused by inflammation of the optic nerves due to a pituitary abscess. Neurol Med Chir (Tokyo)

CT and MRI findings in primitive pituitary abscess: a case report and review of literature.

Diagnosis and management of pituitary abscess: a review of twenty-four cases.

Doerfler A

Endoscopic treatment of pituitary abscess: two case reports and literature review.

Pituitary abscess: a series of six cases.

Pituitary abscess: report of four cases and review of literature.

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A rare case of sudden blindness due to a pituitary adenoma coincidentally infected with methicillin-resistant Staphylococcus aureus (MRSA)

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Proceedings - University of Groningen