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LETTER TO EDITOR
Year : 2013  |  Volume : 61  |  Issue : 2  |  Page : 210-212

Fungal pituitary abscess: Case report and review of the literature


1 Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu; Sichuan Provincial People's Hospital, Sichuan, China
2 Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
3 Department of Neurosurgery, Sichuan Provincial People's Hospital, Sichuan, China

Date of Submission16-Mar-2013
Date of Decision28-Mar-2013
Date of Acceptance01-Apr-2013
Date of Web Publication29-Apr-2013

Correspondence Address:
Chao You
Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.111168

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How to cite this article:
Liu J, You C, Tang J, Chen L. Fungal pituitary abscess: Case report and review of the literature. Neurol India 2013;61:210-2

How to cite this URL:
Liu J, You C, Tang J, Chen L. Fungal pituitary abscess: Case report and review of the literature. Neurol India [serial online] 2013 [cited 2019 Dec 7];61:210-2. Available from: http://www.neurologyindia.com/text.asp?2013/61/2/210/111168


Sir,

Fungal pituitary abscess is extremely rare and often misdiagnosed as pituitary tumor pre-operatively. [1] We reported a rare case of Aspergillus pituitary abscess successfully treated with transsphenoidal surgery and antifungal therapy.

A 40-year-old man was admitted with headache and dizziness of 1 week duration. There was no history to suggest sinus or otic infection. Neurological examination showed minimal visual field impairment on the left side. The rest of neurological examination was essentially normal. Magnetic resonance imaging (MRI) revealed an intrasellar mass and an exceptionally large sphenoidal sinus cavity [Figure 1]. Endocrinological workup revealed an elevated level of adrenocorticotrophic hormone (ACTH 117 pg/ml). Other laboratory investigations were normal. With a preoperative diagnosis of pituitary adenoma, transsphenoidal surgery was planned. Intraoperative findings revealed a large sphenoidal sinus with no infection and a paper-thin sellar floor with bone destruction. A small lump of grey granular debris was found at the pituitary fossa when the dura was opened. The pituitary gland was xanthochromic and invaded, and the diaphragma sellae was found to be intact after the removal of the lesion. The specimens were negative for aerobic and anaerobic bacterial cultures and fungal cultures. Histopathological examination of the sellar mass consisted of numerous hyphae, characteristic of Aspergillus species [Figure 2]. Voriconazole 200 mg (300 mg for the first day) was given twice a day intraveneously for 1 week, and continued on a dosage of 200 mg twice a day orally for 4 weeks. His postoperative course was uneventful. He had relief from headache and improvement in visual fields. The levels of ACTH returned to normal limit (22.5 pg/ml). The patient was asymptomatic during a 2-year follow-up.
Figure 1: (a) Preoperative sagittal MRI revealed an intrasellar mass which was hypo-iso-intense on T1-weighted images; (b) Slight hypo-intense was demonstrated on axial T2-weighted images; (c) A heterogeneous enhance was demonstrated on the contrasted sagittal MRI image. Notice the exceptionally large sphenoidal sinus with paper thin destructed sellar floor (arrow)

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Figure 2: Photomicrograph of the intra sellar mass showing fungal organisms with septate hyphae and dichotomous branching, consistent with Aspergillus. (a) hematoxylin and eosin ×100; (b) hematoxylin and eosin ×400

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Pituitary abscess is most often of bacterial origin. [2] True fungal pituitary abscess is extremely rare and only 10 cases have been reported since the first description by Goldhammer and collegues [3] in 1974 [Table 1]. The major fungal pathogen in these patients is Aspergillus species [11] and the exact pathogenesis is uncertain. Spread of infection may be by hematogenous spread, contiguous spread from paranasal sinuses, osteomyelitis or by contaminated cerebrospinal fluid fistula. [2],[12] Iatrogenic infection by transsphenoidal surgery had also been described. [13] Local venous channels of sphenoidal sinus may play a role in the development of pituitary abscess because the sellar floor is frequently found to be intact at operation. [8] In our patient, we propose the possible root of infection was through sphenoid sinus with a paper-thin sellar floor.
Table 1: Summary of the reported cases of fungal pituitary abscess

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Preoperative diagnosis of pituitary aspergillosis is difficult because the presenting symptoms in these patients are similar to that in patients with pituitary adenomas. [7],[9] The most common symptoms are headache, vision disturbances [4],[5],[6],[7],[9],[10] and endocrinological abnormalities. [4],[6],[8] Symptoms may evolve over months to years and there may not be features of infections. [14] Computed tomographic (CT) features include enlarged sella and hypodense sellar mass with contrast enhanced rim. MRI is the best imaging modality for sellar abscess [5],[15] and the features include a hypo- or iso-intense sellar mass on T1-weighted sequences and a hypointense mass on T2-weighted sequences. Low signal on T2-weighted is due to an increase in paramagnetic substances in the fungal elements. Diffusion-weighted imaging has been reported useful for the diagnosis of pituitary abscesses and should be performed in cases of suspected pituitary abscess. However, preoperative diagnosis of fungal pituitary abscess is, most often, difficult.

Optimal treatment of sellar abscess is transsphenoidal surgery combined with antifungal therapy. Craniotomy may increase the risk of subarachnoid spread of infection which may be lethal. [3] Transsphenoidal approach minimizes the likelihood of cerebrospinal fluid (CSF) contamination. However, still there may be some risk of contamination of CSF even with this procedure. Major efforts must be taken to carefully keep the diaphragma sellae intact, any damage to the integrity of subarachnoid space should be avoided. Using a fat graft in the transsphenoidal surgery for pituitary abscess may also increase the risk of recurrent infection. [15] In our case, we did not use a graft as there was no CSF leak.

The consensus is that patients with Aspergillus sellar abscess should be treated with amphotericine-B alone or in combination with 5-fluorocytosine immediately after the histopathological diagnosis. [5] However, amphotericine-B treatment is associated with significant toxicity and prolonged hospital stay. [5] Sometimes, the infection may recur in spite of adequate treatment as in the case reported by Jain and colleagues. [6] Variconazole or caspofungin can be safe and effective alternative antifungal agents. [9],[10] Our patient was successfully treated initially with intravenous voriconazole and later with oral voriconazole.

In conclusion, fungal sellar abscess should be considered in the differential diagnosis of a pituitary mass. The correct diagnosis of this rare disease can only be established by histopathological examination of tissue obtained at surgery. The optimal treatment is surgical resection through transsphenoidal approach combined with antifungal therapy preferably with voriconazole, which has made good prognosis in most cases of fungal pituitary abscess.

 
  References Top

1.Ahmed YS, Bradey N, Halaka AN, Belchetz PE, Ironside JW. Primary pituitary abscess: Surgical management and endocrine assessment in three cases. Br J Neurosurg 1989;3:409-14.  Back to cited text no. 1
    
2.Vates GE, Berger MS, Wilson CB. Diagnosis and management of pituitary abscess: A review of twenty-four cases. J Neurosurg 2001;95:233-41.  Back to cited text no. 2
    
3.Goldhammer Y, Smith JL, Yates MB. Mycotic intrasellar abscess. Am J Ophthalmol 1974;78:478-84.  Back to cited text no. 3
    
4.Ramos-Gabatin A, Jordan RM. Primary pituitary aspergillosis responding to transsphenoidal surgery and combined therapy with amphotericine-B and 5-fluorocytosine: Case report. J Neurosurg 1981;54:839-41.  Back to cited text no. 4
    
5.Heary RF, Maniker AH, Wolansky LJ. Candidal pituitary abscess: Case report. Neurosurgery 1995;36:1009-12.  Back to cited text no. 5
    
6.Jain KC, Varma A, Mahapatra AK. Pituitary abscess: A series of six cases. Br J Neurosurg 1997;11:139-43.  Back to cited text no. 6
    
7.Lee JH, Park YS, Kim KM, Kim KJ, Ahn CH, Lee SY, et al. Pituitary aspergillosis mimicking pituitary tumor. AJR Am J Roentgenol 2000;175:1570-2.  Back to cited text no. 7
    
8.Iplikcioglu AC, Bek S, Bikmaz K, Ceylan D, Gökduman CA. Aspergillus pituitary abscess. Acta Neurochir (Wien) 2004;146:521-4.  Back to cited text no. 8
    
9.Hao L, Jing C, Bowen C, Min H, Chao Y. Aspergillus sellar abscess: Case report and review of the literature. Neurol India 2008;56:186-8.  Back to cited text no. 9
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10.Liu W, Chen H, Cai B, Li G, You C, Li H. Successful treatment of sellar Aspergillus abscess. J Clin Neurosci 2010;17:1587-9.  Back to cited text no. 10
    
11.Epstein NE, Hollingsworth R, Black K, Farmer P. Fungal brain abscesses (aspergillosis/mucormycosis) in two immunosuppressed patients. Surg Neurol 1991;35:286-9.  Back to cited text no. 11
    
12.Post KD, McCormick PC, Bello JA. Differential diagnosis of pituitary tumors. Endocrinol Metab Clin North Am 1987;16:609-45.  Back to cited text no. 12
    
13.Feely M, Steinberg M. Aspergillus infection complicating transsphenoidal Yttrium-90 pituitary implant. Report of two cases. J Neurosurg 1977;46:530-2.  Back to cited text no. 13
    
14.Lindholm J, Rasmussen P, Korsgaard O. Intrasellar or pituitary abscess. J Neurosurg 1973;38:616-9.  Back to cited text no. 14
    
15.Jadhav RN, Dahiwadkar HV, Palande DA. Abscess formation in invasive pituitary adenoma: Case report. Neurosurgery 1998;43:616-9.  Back to cited text no. 15
    


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