Pituitary abscess: a descriptive analysis of a series of 19 patients-a multi-center experience.

OBJECTIVES: Pituitary abscess (PA) accounts for only 0.3-0.5% of sellar masses, and the lack of specific clinical symptoms makes diagnosing PA difficult without a surgical biopsy. In clinical practice, PA is often mistaken for cystic pituitary adenoma, craniopharyngioma, and Rathke's cyst. Thus, this study aims to investigate challenges in diagnosing PA and evaluate the importance of combining intraoperative surgery with postoperative antibiotic treatment. METHODS: We conducted a retrospective analysis of 19 patients diagnosed with PA through histopathology. All patients underwent transsphenoidal surgery (TSS) for pituitary adenomas after undergoing comprehensive preoperative evaluations, including routine tests, endocrine assay, and imaging examination. Furthermore, we compared different treatments for pituitary abscess (PA) to determine the most effective approach for achieving a favorable prognosis. RESULTS: The most prevalent symptom of PA was headache, especially in the frontal-temporal and vertex regions, ranging from mild to moderate severity. Hypopituitarism-related symptoms were also frequently observed, including hypaphrodisia, cold sensitivity, fatigue, weight loss, polyuria, and amenorrhea. Twelve patients exhibited abnormalities in endocrinology examinations. Diagnosing PA correctly is challenging. In our study, none of the patients were correctly diagnosed with PA prior to surgery, and many sellar lesions were misdiagnosed. The favorable prognosis was largely attributed to surgical intervention and active postoperative antibiotic therapy. CONCLUSIONS: Given the lack of clarity in preoperative diagnosis, typical intraoperative findings and effective antibiotics treatment are more indicative of the correct diagnosis than other tests. In terms of therapy, optimal surgical intervention and active postoperative antibiotic treatment contribute to resolving the challenges posed by PA.

Pituitary abscess: a case report and systematic review of 488 cases.

BACKGROUND: Pituitary abscess (PA) is a rare condition and not well understood. We aimed to describe a case and perform a comprehensive systematic review to explore presenting symptoms, radiological findings, endocrine abnormalities and mortality. AIM: To identify presenting symptoms, radiological findings, endocrinological abnormalities and predictors of mortality for PA. METHODS: We systematically reviewed the literature to identify all case reports of PA. Data regarding presentation, mortality, radiological findings, endocrinological abnormalities and treatment was extracted. RESULTS: We identified 488 patients from 218 articles meeting the inclusion criteria. Mortality was 5.1%, with days to presentation (OR 1.0005, 95% CI 1.0001-1.0008, p < 0.01) being the only identified independent predictor of mortality. Mortality rates have decreased over time, with cases published prior to 2000 having higher mortality rates (OR 6.92, 95% CI 2.80-17.90, p < 0.001). The most common symptom was headache (76.2%), followed by visual field defects (47.3%). Classical signs of infection were only present in 43%. The most common imaging feature on magnetic resonance imaging (MRI) was high T2 and low T1 signal of the pituitary gland with peripheral contrast enhancement. Over half (54.8%) were culture negative, with the most common bacterial organism being staphylococcus aureus (7.8%) and fungal organism being aspergillus (8.8%). The most common endocrine abnormality was hypopituitarism (41.1%), followed by diabetes insipidus (24.8%). Whilst symptoms resolved in most patients, persistent endocrine abnormalities were present in over half of patients (61.0%). CONCLUSION: PA is associated with significant mortality, with delayed presentation increasing risk of mortality. Ongoing endocrinological abnormalities are common. Given the non-specific clinical presentation, the appearance of high T2, low T1 and peripheral contrast enhancement of the pituitary on MRI should prompt consideration of this rare disease.

Pituitary Abscess: A Challenging Preoperative Diagnosis-A Multicenter Study.

Background and Objectives: Pituitary abscess (PA) is a rare occurrence, representing less than 1% of pituitary lesions, and is defined by the presence of an infected purulent collection within the sella turcica. Pas can be classified as either primary, when the underlying pituitary is normal prior to infection, or secondary, when there is associated a pre-existing sellar pathology (i.e., pituitary adenoma, Rathke's cleft cysts, or craniopharyngioma), with or without a recent history of surgery. Preoperative diagnosis, owing to both non-specific symptoms and imaging features, remains challenging. Treatment options include endonasal trans-sphenoidal pus evacuation, as well as culture and tailored antibiotic therapy. Methods: A retrospective multicenter study, conducted on a prospectively built database over a 20-year period, identified a large series of 84 patients harboring primary sellar abscess. The study aimed to identify crucial clinical and imaging features in order to accelerate appropriate management. Results: The most common clinical presentation was a symptom triad consisting of various degrees of asthenia (75%), visual impairment (71%), and headache (50%). Diagnosis was achieved in 95% of cases peri- or postoperatively. Functional recovery was good for visual disturbances and headache. Pituitary function recovery remained very poor (23%), whereas the preoperative diagnosis represented a protective factor. Conclusions: In light of the high prevalence of pituitary dysfunction following the management of PAs, early diagnosis and treatment might represent a crucial issue. Currently, there are no standard investigations to establish a conclusive preoperative diagnosis; however, new, emerging imaging methods, in particular nuclear imaging modalities, represent a very promising tool, whose potential warrants further investigations.

A case of pituitary gland abscess associated with granulomatous hypophysitis.

BACKGROUND: Granulomatous hypophysitis is a rare disease that presents with chronic inflammation of the pituitary gland. In this study, we reported a case of granulomatous hypophysitis associated with a pituitary abscess. CASE PRESENTATION: A 39-year-old woman presented with a 2-year history of infertility. For the past six months, she has suffered from amenorrhea, decreased libido, headaches, and vertigo. She was referred to our hospital with a suspected diagnosis of nonfunctioning pituitary adenoma based on her presentation and brain MRI findings. She underwent trans-sphenoidal surgery (TSS). Direct observation during surgery revealed drainage of malodor pus and pituitary gland abscess. The histopathological evaluation also showed granulomatous hypophysitis and neutrophilic microabscess formation. The patient was initially treated with high doses of ceftriaxone (2 g twice daily) and metronidazole (500 mg (mg) four times per day). Also, the patient received cortisol replacement therapy after the operation. After obtaining the antibiogram and culture results, the treatment regimen was continued for 4 weeks postoperatively, followed by amoxicillin-clavulanate (500/125 mg three times daily) for a total duration of 12 weeks. CONCLUSION: The patient recovered uneventfully and the postoperative MRI was normal without any remnant lesions.

A rare case of a secondary pituitary abscess arising in a craniopharyngioma with atypical presentation and clinical course / Un caso raro de absceso hipofisario secundario derivado de un craneofaringioma con presentación y evolución clínica atípicas

Pituitary abscesses are very uncommon. They are divided into primary, arising within a healthy gland, and secondary, observed with an underlying pre-existing lesion. Here we present the eighth case reported of a secondary abscess within a craniopharyngioma. A 59-year-old-woman presented with a 3-week history of headache, and fever. Physical examination was unremarkable. An Magnetic Resonance Imaging (MRI) showed a pituitary lesion suggestive of a chronic inflammatory process. She was diagnosed with lymphocytic meningitis with hypophysitis and she was treated with corticosteroids. Two months later she presented with headache and fever again. Control MRI showed enlargement of the pituitary lesion. Therefore, a transsphenoidal biopsy was performed. During the procedure, purulent material was released. Histological study demonstrated a craniopharyngioma and meningeal inflammation. Empiric antibiotics were started. Three months post-operatively, a follow-up MRI showed a suspect minimal residual mass. Secondary pituitary abscesses are rare. The key to successful management is a high index of suspicion. Transsphenoidal surgical evacuation plus antibiotics is the mainstay of treatment. Although most symptoms resolve, endocrinopathies improve only rarely (AU)

Los abscesos hipofisarios son infrecuentes. Se pueden dividir en primarios o secundarios, si se producen sobre una lesión previa. Presentamos el octavo caso de un absceso asentado sobre un craneofaringioma. Una mujer de 59 años consultó por fiebre y cefalea de tres semanas de evolución. La exploración física era anodina. Una resonancia magnética (RMN) evidenció una lesión hipofisaria sugestiva de un proceso inflamatorio crónico. Finalmente, se diagnosticó de una meningitis linfocítica e hipofisitis y se trató con corticoides. Dos meses después reconsultó por los mismos síntomas. En la RMN se evidenció crecimiento de la lesión, por lo que se biopsia endoscópicamente. Durante el procedimiento salió pus. En el examen histológico se evidenció un craneofaringioma y una inflamación meníngea. Se iniciaron antibióticos empíricamente. En el seguimiento a tres meses, la RMN evidenciaba un dudoso resto. Los abscesos hipofisarios secundarios son raros y hay que tener un alto índice de sospecha para diagnosticarlos. El tratamiento se basa en antibioterapia y evacuación transesfenoidal. Aunque los síntomas se suelen resolver, las endocrinopatías no (AU)

A rare case of a secondary pituitary abscess arising in a craniopharyngioma with atypical presentation and clinical course.

Pituitary abscesses are very uncommon. They are divided into primary, arising within a healthy gland, and secondary, observed with an underlying pre-existing lesion. Here we present the eighth case reported of a secondary abscess within a craniopharyngioma. A 59-year-old-woman presented with a 3-week history of headache, and fever. Physical examination was unremarkable. An Magnetic Resonance Imaging (MRI) showed a pituitary lesion suggestive of a chronic inflammatory process. She was diagnosed with lymphocytic meningitis with hypophysitis and she was treated with corticosteroids. Two months later she presented with headache and fever again. Control MRI showed enlargement of the pituitary lesion. Therefore, a transsphenoidal biopsy was performed. During the procedure, purulent material was released. Histological study demonstrated a craniopharyngioma and meningeal inflammation. Empiric antibiotics were started. Three months post-operatively, a follow-up MRI showed a suspect minimal residual mass. Secondary pituitary abscesses are rare. The key to successful management is a high index of suspicion. Transsphenoidal surgical evacuation plus antibiotics is the mainstay of treatment. Although most symptoms resolve, endocrinopathies improve only rarely.

Sella Bugged! Abscess Inside a Craniopharyngioma: Case Report with Literature Review.

INTRODUCTION: Abscess within a craniopharyngioma (CPG) is extremely rare and only 8 such cases have been reported in literature. Most patients present with hypopituitarism and visual disturbances. We report the first ever case of a CPG with abscess in a pediatric patient. CASE REPORT: A 10-year-old girl presented with visual deterioration and bitemporal hemianopia. Her CT and MRI brain suggested of a sellar-suprasellar CPG. Due to ill-developed sino-nasal anatomy, a transcranial approach was made for the lesion. The lesion was well capsulated, thick walled, and appeared inflamed. Upon incising the wall, thick yellowish pus was drained out in a controlled manner. This was followed by a partial resection of the CPG wall and eccentric, adhered, calcified residue was left behind with an Ommaya drain. The abscess culture grew Enterococcus species and histopathology revealed adamantinomatous CPG. Patient underwent culture sensitive antibiotics course followed by radiation for the residue. She was doing well at 1-year follow-up with clinical and radiological improvement. CONCLUSION: This is the first report of a pediatric case with secondary abscess in CPG. Operative management of such a case includes controlled drainage of pus without dissemination into the surrounding arachnoid space. The tumor and abscess have to be addressed as separate surgical entities; infection control and wherever complete resection is not feasible, partial safe resection followed by radiotherapy is a viable option.

Case of an atypical pituitary abscess.

A pituitary abscess is a rare intrasellar infection. Correct identification can be challenging preoperatively given its non-specific symptoms and imaging findings. We report a case of a young woman presenting with secondary amenorrhea, visual field deficits and a 2.6 cm pituitary lesion diagnosed to be a craniopharyngioma. A concomitant unexpected pituitary abscess was diagnosed intraoperatively without associated meningeal symptoms.

A Rare Case of Primary Pituitary Tubercular Abscess Mimicking a Pituitary Adenoma.

Primary pituitary tuberculosis (PTA) is a very rare disease. The clinical diagnosis is difficult as it is clinically radiologically indistinguishable from other sellar lesions. We present a case of PTA without any predisposing etiology and radiologically mimicking a pituitary macroadenoma. The patient underwent endoscopic transsphenoidal resection where pus admixed with mucoid was seen coming out of the lesion intraoperatively. Histology of the cyst wall was suspective of tuberculous etiology and QuantiFERON Tb Gold done for confirmation was positive. Postoperatively patient showed obvious improvement in visual symptoms. Patient developed diabetes insipidus and was put on desmopressin and was started with anti-tuberculosis medication for 18 months. Timely surgical intervention followed by anti-tubercular therapy and hormone replacement is the mainstay of treatment in these cases. For intraoperative management, we advise thorough wash with antibiotic and saline rather than curetting the walls of the abscess to decrease the postoperative incidence of endocrine abnormalities.

Primary pituitary abscess mimicking meningitis in a pediatric patient.

INTRODUCTION: Pituitary abscess is a rare lesion of the pituitary gland that can cause morbidity and mortality in the absence of appropriate treatment. They are classified as primary and secondary pituitary abscesses. Primary pituitary abscesses occur in patients with no previous pituitary pathology. Secondary pituitary abscesses are detected in patients with existing pituitary pathologies. CASE PRESENTATION: We report a 16-year-old female patient with primary pituitary abscess who was misdiagnosed initially and treated as meningitis. Following the visual disturbances, pituitary abscess was diagnosed, and she underwent abscess drainage via endoscopic endonasal transsphenoidal surgery and antibiotic treatment. CONCLUSION: Primary pituitary abscess can be clinically confused with other pathologies affecting the central nervous system. In order to avoid permanent sequelae in such patients, it should be kept in mind by physicians in similar cases. Satisfying results are obtained in these patients after appropriate treatment and dramatic improvement is achieved.

A rare case of a secondary pituitary abscess arising in a craniopharyngioma with atypical presentation and clinical course.

Pituitary abscesses are very uncommon. They are divided into primary, arising within a healthy gland, and secondary, observed with an underlying pre-existing lesion. Here we present the eighth case reported of a secondary abscess within a craniopharyngioma. A 59-year-old-woman presented with a 3-week history of headache, and fever. Physical examination was unremarkable. An Magnetic Resonance Imaging (MRI) showed a pituitary lesion suggestive of a chronic inflammatory process. She was diagnosed with lymphocytic meningitis with hypophysitis and she was treated with corticosteroids. Two months later she presented with headache and fever again. Control MRI showed enlargement of the pituitary lesion. Therefore, a transsphenoidal biopsy was performed. During the procedure, purulent material was released. Histological study demonstrated a craniopharyngioma and meningeal inflammation. Empiric antibiotics were started. Three months post-operatively, a follow-up MRI showed a suspect minimal residual mass. Secondary pituitary abscesses are rare. The key to successful management is a high index of suspicion. Transsphenoidal surgical evacuation plus antibiotics is the mainstay of treatment. Although most symptoms resolve, endocrinopathies improve only rarely.

Rathke's cleft cyst infections and pituitary abscesses: case series and review of the literature.

PURPOSE: Pituitary abscesses (PAs) are a rare clinical entity which may arise from normal pituitary tissue or underlying lesions within the gland. Rathke's cleft cysts (RCCs) are not commonly associated with the development of PA. METHODS: Retrospective chart review of three patients with PAs within RCCs at a single university center and review of the literature. RESULTS: Three cases are reported. The first case presented with fever and headache and a history of prior surgery due to RCC and a recent respiratory tract infection. The second case had a history of recent skin infections and presented with sudden onset headache and hypopituitarism. In the third case, chronic visual field impairment prompted an ophthalmologic evaluation resulting in a diagnosis of an adenoma and an infected RCC. In all three cases, an endoscopic endonasal approach was performed to drain infected tissue and allowed microbiological identification of gram-positive cocci, followed by treatment with antibiotics for at least three weeks. Cases in the literature are scarce and the diagnosis is usually made intraoperatively due to non-specific manifestations and imaging. PAs arising from underlying pituitary lesions are less common than primary PAs. Differential diagnosis should include pituitary apoplexy, hypophysitis and other cystic lesions. CONCLUSION: PAs occurring in RCCs are infrequent. Clinical manifestations are commonly subacute, without septic symptoms. Imaging is usually non-specific. Preoperative diagnosis is infrequent and a broad differential diagnosis should be considered. Empirical antimicrobial therapy should be initiated and adjusted after obtaining cultures to reduce the rate of recurrence and improve clinical outcomes.

[A 19-year-old woman with fever and high blood pressure]. / Eine 19-jährige Frau mit Fieber und Bluthochdruck.

A 19-year-old female patient was admitted to hospital for further diagnostics and treatment of a febrile infection. The cause was found to be a bronchopulmonary infection due to methicillin-sensitive Staphylococcus aureus (MSSA), which led to an infective endocarditis with mitral valve infestation and two splenic abscesses. Under treatment according to the antibiogram and laparoscopic excision of the splenic abscesses, the infection-related complications could be successfully resolved. Even during the physical examination there was a suspicion of Cushing's syndrome, which was confirmed by laboratory and radiological investigations and is associated with a general immune deficiency. Remarkable was that the initially difficult to adjust high blood pressure became normalized after transsphenoidal resection of the pituitary adenoma.

Secondary Pituitary Abscess Inside Adenoma: A Case Report and Review of Literature.

BACKGROUND: Pituitary abscesses within pre-existing pituitary conditions, such as craniopharyngioma, pituitary adenoma, or Rathke cleft cyst, are quite rare. A case of pituitary abscess secondary to adenoma is presented, and the literature is reviewed. CASE DESCRIPTION: An 11-year-old boy presented with a 3-day history of sudden-onset headache and visual loss. Magnetic resonance imaging demonstrated a sellar region lesion with intralesional hemorrhage. Preoperative diagnosis was pituitary adenoma with apoplexy. An endoscopic transnasal transsphenoidal approach was used for emergent total tumor resection. Pathology confirmed the diagnosis of pituitary adenoma with apoplexy and inflammation, and microbiologic examination was positive for Staphylococcus aureus. CONCLUSIONS: Secondary pituitary abscess is a rare entity, and preoperative diagnosis is challenging. The treatment strategy includes prompt surgical resection and drainage of the abscess, followed by prolonged antibiotic therapy.

Multidisciplinary team efforts improve the surgical outcomes of sellar region lesions during pregnancy.

PURPOSE: Treatment of space-occupying lesions (SOLs) in the sellar region is a clinical challenge, especially in pregnant women because many treatment decisions are restrained due to pregnancy. We attempt to discuss the surgical indications and timing for pregnant patients and highlight the importance of multidisciplinary team (MDT) treatment. METHODS: From August 2017 to February 2018, four pregnant women were admitted to our hospital with severe visual impairment due to sellar region SOLs, including two cases of tuberculum sellae meningioma, one case of giant pituitary adenoma and one case of a pituitary abscess. All four patients were safely treated by surgery during the second and third trimesters of pregnancy through concerted efforts of the MDT, including a neurosurgeon as the team leader in combination with experts in obstetrics, ophthalmology and endocrinology. RESULTS: The SOLs were removed completely from all four patients, resulting in significantly improved vision without operation-related complications. Pregnancy continued postoperatively to full-term delivery in three of the four patients. The other patient with a pituitary abscess selected to terminate the pregnancy at a gestational age of 20 weeks because of her own concerns. The four babies (including a pair of twins) were born healthy and had developed normally at the 6-week postpartum follow-up. CONCLUSIONS: With the MDT guiding the decision-making process, surgical resection of sellar region SOLs in pregnant women with severe visual impairment is practical to improve the prognosis without affecting the outcomes of pregnancy for either the mother or the infant.

Primary pituitary tubercular abscess as a differential diagnosis for sellar suprasellar mass.

Only four cases of primary pituitary tubercular abscess have been reported. A 20-year-old ladypresented to us with headache and pituitary dysfunction. Radiology showedsellar tubercular abscess with suprasellar extension. Microscopic examination of pus collected during surgery showed granulomatous tissues and Acid Fast Bacilli. The response to antitubercular therapy was remarkable.

Secondary pituitary abscess following transsphenoidal surgery with recurrent meningitis: A case report.

RATIONALE: The transsphenoidal surgical (TS) approach to sellar masses is the preferred surgical route in most cases. Secondary pituitary abscess (PA) following TS is an extremely rare but serious postoperative complication with potentially high disability and mortality. PATIENT CONCERNS: We describe an uncommon case of secondary PA in a 42-year-old woman, who underwent uncomplicated transsphenoidal procedures without cerebrospinal fluid leak, to treat primary Rathke cleft cyst. Without obvious cause, the patient suffered recurrent meningitis with complaints of headache, hyperpyrexia, and chills from 1 month after the operation. DIAGNOSIS: There were no significant imaging findings until a new rim-enhancement lesion was seen in the sellar region on magnetic resonance imaging during the 6th episode of meningitis 11 months after the initial surgery. A diagnosis of secondary PA was considered; INTERVENTIONS:: Therefore, she underwent a 2nd TS with pus evacuation and antibiotic treatment. OUTCOMES: She improved remarkably and had no recurrence of symptoms during the 9-month follow-up. LESSONS: Our aim was to present this rare case and discuss the most likely etiologies and preventive measures for this condition. In patients with recurrent meningitis but dormant imaging manifestations after TS, the possibility of secondary PA should considered. Adequate surgical drainage with microbiology-guided antibiotic therapy is the 1st choice for treatment.

Demonstration of Infectious Transgression Through the Skull Base Occurring 9 Years After Pituitary Adenoma Resection.

BACKGROUND: Sellar infections represent less than 1% of all sellar lesions and can be life-threatening. These infections occur de novo in up to 70% of patients or can less commonly develop after surgical treatment of another primary lesion, such as a pituitary adenoma. CASE DESCRIPTION: We report a unique case of a 27-year-old woman with a recurrent pituitary adenoma treated with 2 previous transsphenoidal resections. She ultimately presented with hypopituitarism, followed by headaches, malaise, chills, and visual-field and acuity deficits 9 years after her second transsphenoidal resection. During the second operation, the sellar floor was reconstructed with hydroxyapatite bone cement. On the most recent presentation, magnetic resonance imaging of the brain and pituitary demonstrated a residual sellar mass accompanied by significant enhancement and T2 hyperintensity of the infundibulum, hypothalamus, optic chiasm, and optic tracts. The patient was started on empiric antibiotics and steroids before frank purulence in the sella was discovered and removed by transsphenoidal endoscopy. Cultures were positive for methicillin-sensitive Staphylococcus aureus and Propionibacterium acnes. At her 3-month follow-up evaluation, the patient had complete resolution of her symptoms and radiographic findings. CONCLUSIONS: This case demonstrates the fact that patients with pituitary lesions who have foreign material used for surgical closure can present with infections many years after the initial intervention. Furthermore, with appropriate clinical diagnosis and treatment, the reactive inflammation caused by sellar infection is reversible. We review the literature regarding the risk factors and management strategies for delayed postoperative sellar infections.

Abscess inside craniopharyngioma: diagnostic and management implications.

Abscess inside the pituitary fossa is very rare. Such abscess can be primary, occurring in an otherwise healthy pituitary gland, or secondary, developing inside a diseased gland (ie, harbouring craniopharyngioma, Rathke's cleft cyst, etc). Secondary pituitary abscess inside a craniopharyngioma remains an extremely rare occurrence. Our literature search revealed only six such cases reported so far. In this report, we present the seventh case of craniopharyngioma with abscess in a 38-year-old woman. We describe the uniqueness of the clinical presentation of our case, the radiological pointers to the possible diagnosis and the management issues in our patient. A review of literature is also included to provide a comprehensive picture of this rare condition to the readers.