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Table of Contents    
LETTER TO EDITOR
Year : 2017  |  Volume : 65  |  Issue : 5  |  Page : 1167-1169

Primary pituitary abscess in preadolescence mimicking a sellar mass


Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA

Date of Web Publication6-Sep-2017

Correspondence Address:
Bharat Guthikonda
Department of Neurosurgery, Louisiana State University Health Sciences Center – Shreveport, 1501 Kings Highway, Shreveport, Louisiana, 71130-3932
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/neuroindia.NI_997_16

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How to cite this article:
Akbarian-Tefaghi H, Sharma K, Kalakoti P, Cangiano-Heath A, Patra DP, Bollam P, Nanda A, Guthikonda B. Primary pituitary abscess in preadolescence mimicking a sellar mass. Neurol India 2017;65:1167-9

How to cite this URL:
Akbarian-Tefaghi H, Sharma K, Kalakoti P, Cangiano-Heath A, Patra DP, Bollam P, Nanda A, Guthikonda B. Primary pituitary abscess in preadolescence mimicking a sellar mass. Neurol India [serial online] 2017 [cited 2019 Aug 19];65:1167-9. Available from: http://www.neurologyindia.com/text.asp?2017/65/5/1167/214104


Sir,

Primary pituitary abscess constitutes less than 1% of all disorders affecting the pituitary gland,[1],[2] and is seldom encountered in clinical practice. Since the earliest description of pituitary abscess by Heslop in 1848, followed by Simmond in 1914,[3],[4] a little over 200 cases have been reported in the literature. Most of them have been incidental discoveries during autopsy in patients who died following generalized sepsis.[5] Despite recent advancements in neuro-imaging modalities, the means to unequivocally establish the definitive pre-operative diagnosis of this purulent and inflammatory lesion of the pituitary gland are limited; this is mainly due to the lack of specific clinical symptoms or markers, as well as its radiological overlap with other pituitary lesions. In this report, we describe the clinical and radiological findings in a preadolescent female patient presenting with a long-term history of cyclic vomiting syndrome (CVS). On imaging, the abscess mimicked a contrast-enhancing sellar mass. Intraoperative presence of purulent fluid within this mass, affirmed the diagnosis of a primary pituitary abscess in the absence of any other systemic infectious process. A primary pituitary abscess poses the risk of significant and potentially life-threatening complications. This report discusses the dilemmas surrounding its diagnosis and the importance of considering pituitary abscess in the differential diagnoses of sellar masses.

A10-year-old Caucasian female patient presented with a history of CVS, the initial emetic episode being 16 months prior to her presentation to the hospital. The patient reported an unintented weight loss of greater than 7 pounds in the last 3 months prior to her illness, due to the recurrent episodes of emesis that occurred at a high frequency of 12-15 per hour. She also complained of intermittent, localized left fronto-parietal headache for the last several months. Endocrinal work up revealed hypothyroidism with increased thyroid-stimulating hormone, decreased level of growth hormone, and signs of diabetes insipidus (DI). Hypothyroidism, suspected due to a family history of the presence of thyroid nodules, was refractory to thyroid hormone administration. Computed tomography and magnetic resonance imaging studies indicated an infundibular mass that was contrast-enhancing and had a a cystic component [Figure 1a-f].
Figure 1: Magnetic resonance imaging: Preoperative (T1-weighted) sagittal section (a) demonstrating a gadolinium-enhanced sellar lesion with peripheral rim enhancement. An axial (b) and a coronal (c) section depict the lesion that is mimicking a sellar mass. Postoperative T1-weighted sections (d and f) show post-surgical changes (following drainage of the abscess and excision of the capsule of the lesion)

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The patient underwent neuro-navigation guided, microsurgical transsphenoidal resection of the mass. The endoscopic approach was not preferred due to the small nostril size of the patient. The bony midline septum was removed, and the sphenoidal cavity was visualized. The dura was exposed following removal of the thin rim of the sellar bone. A sellar lesion with an intact capsule was visualized. During surgery, the mass was noted to be a mixture of purulent material, and necrotic debris. The capsule was punctured, following which approximately 3 ml of turbid, yellow-colored fluid was drained. Subsequently, the remaining lesion was resected and adequate decompression was achieved. The surgical site was reconstructed with harvested abdominal fat and covered with a piece of the removed ethmoidal bone. Closure and nasal packing was performed in a routine fashion. Histopathology was strongly suggestive of an abscess but no bacterial growth was noted. Necrotic cell debris with non-malignant chronic inflammatory cells were also present. In view of the intraoperative and histopathological findings, a diagnosis of a sterile abscess was made. The lack of bacterial growth could be attributed to the administration of pre-operative antibiotic treatment.[2],[6]

The post-operative period was uneventful and the patients did not have any neurological deficits. There was resolution of the emetic episodes and headaches. The patient was discharged on the post-operative day 5. She has been followed up for 8 years since her surgery, and has been neurologically intact. On endocrinal examination, signs of hypopituitarism and diabetes insipidus still persist, and are being managed with desmopressin, growth hormone replacement, and levothyroxine, in consultation with the endocrinology team. She observed menarche at 16 years of age and has had regular menses since then. Her vision remains normal. She is currently in the 51st percentile for weight and 32nd percentile for height.

Pituitary abscesses can arise either within a pre-existing lesion such as an adenoma, Rathke's cleft cyst or craniopharyngioma, or can occur secondary to a surgical intervention. Pituitary abscesses secondary to infectious pathologies have been well described. An association with leukemia or lymphoma has also been documented.[5] Fortunately, none were observed in our patient.

In over 90% of the cases, pituitary abscesses are reported in adults (mean age: 40.4 years; range: 12–76 years), with the most common presenting symptom being headache (90%).[5] Other symptoms include diabetes insipidus (40%), visual impairment (34%), fever (29%), and hypopituitarism (21%), and the less common, non-specific features such as meningismus, cranial nerve palsies, proptosis, seizures, hearing loss, hydrocephalus, optic atrophy, and papilloedema.[5] The establishment of an early diagnosis due to the non-specific clinical symptomatology (cyclic emetic episodes) at presentation was unique to our case. Ciappetta et al., have emphasized the management of a pituitary abscess utilizing an endoscopic approach considering the safety, minimal blood loss, shorter operative duration, and lower morbidity associated with it.[5] Although the patient did well from a neurological standpoint, post-operatively, an endocrinal consultation and follow up was warranted based on signs of hypopituitarism, including diabetes insipidus. We recommend to including pituitary abscess as possible differential diagnosis for suspected mass lesions involving the sellar region especially in younger patients. This can potentially aid in directing prompt management strategies including appropriate pre-operative antibiotic regimen for optimal outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
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. 1
[PUBMED]    
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
[PUBMED]    
3.
Heslop TP. A case of hypertrophy with abscess of the pituitary body. Dublin Quart J Med Sci 1848;6:466-9.  Back to cited text no. 3
    
4.
Simmonds M. Zur pathologie derag hypophysis. Verh Dtsch Pathol 1914;17:208-12.  Back to cited text no. 4
    
5.
Ciappetta P, Calace A, D'Urso PI, De Candia N. Endoscopic treatment of pituitary abscess: Two case reports and literature review. Neurosurg Rev 2008;31:237-46.  Back to cited text no. 5
    
6.
Liu F, Li G, Yao Y, Yang Y, Ma W, Li Y, et al. Diagnosis and management of pituitary abscess: Experiences from 33 cases. Clin Endocrinol 2011;74:79-88.  Back to cited text no. 6
    


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