Pituitary Abscess Mimicking Pituitary Adenoma: A Review of Three Cases seen at the Philippine General Hospital from 2004-2007

Philippine Journals Online

View Archive Info
 
 
Field Value
 
Title Pituitary Abscess Mimicking Pituitary Adenoma: A Review of Three Cases seen at the Philippine General Hospital from 2004-2007
 
Creator Michelle V Lemoncito; Fellow, Section of Endocrinology, Diabetes & Metabolism, University of the Philippines - Philippine General Hospital
Frances Lina Lantion-Ang; Consultant, Section of Endocrinology, Diabetes & Metabolism, University of the Philippines - Philippine General Hospital
 
Subject Endocrinology
Pituitary abscess; thyromegaly; hypernatremia; hypocortisolemia
 
Description Synopsis: Pituitary abscesses are rare but potentially life-threatening disorders. Headaches, pituitary insufficiency and visual disturbances are the most common clinical manifestations mimicking pituitary adenoma. Clinical Presentation: We report 3 patients with pituitary abscesses at the Philippine General Hospital since 2004. Case 1 is a 24 year-old male with a 2-year history of severe generalized headache, blurring of vision, and hypothyroid symptoms. Case 2 is a 42 year old woman admitted due to severe generalized headache, amenorrhea and polyuria of 3 months duration. Case 3 is a 37 year-old female with a 3-year history of headache and amenorrhea. Physical Examination: Case 1 was a stunted, morbidly obese (BMI of 36kg/m2) myxedematous patient, with no thyromegaly, and coarse skin, absence of body hair and hypoactive reflexes. His visual acuity was light perception on the left eye and 20/70 on the right eye. Case 2 was normal except for bitemporal hemianopsia. Case 3 had a visual acuity of 20/100 on the right eye and papilledema and light perception on the left eye and the presence of sparse axillary hair. Laboratory Results: Case 1 Admission CBC showed mild leukocytosis. He had a low thyroxine, slightly elevated TSH, low luteinizing hormone, normal folliclestimulating hormone, cortisol and prolactin levels. Sellar MRI showed a large (4.4 x 3.2 x 3.4 cm) well-defined rim enhancing sellar-suprasellar mass with cystic component consistent with pituitary macroadenoma. Case 2 She had mild anemia, hypernatremia with elevated serum osmolality, and failure to concentrate urine. Hormonal studies showed normal thyroxine and growth hormone levels, low basal serum cortisol, and elevated prolactin levels. Cranial CT scan showed widening of the sella turcica with a homogenous, isodense, slightly enhancing focus in the sellar and suprasellar area. Water deprivation test was performed and consistent with partial central diabetes insipidus. Case 3 Hormonal studies revealed moderately elevated prolactin levels and persistently low cortisol and free thyroxine levels despite hormonal replacement. Cranial CT scan showed a large, 5 x 2 x 2 cm hypodense, multi-loculated, rim-enhancing focus at the sellar-suprasellar area with compression of the 3rd and right lateral ventricle. Course: Case 1 Transphenoidal surgery was performed and intraoperatively, purulent fluid was noted. Aspirate showed 0-2 cocci in pairs per high power field but no growth on culture. Final histopathology revealed acute inflammatory pattern with histiocytes consistent with abscess. Intravenous antibiotics were given for 8 weeks. Two weeks post-surgery, cranial CT scan showed regression of the abscess (3 x 2 x 3 cm) with return of sellar structures to their normal location. He had complete recovery of visual acuity on discharge. Case 2 Transphenoidal surgery was done and intraoperatively, purulent fluid was noted. Aspirate gram stain showed 1-2 polymorphonuclear cells per high power field but with no growth on culture. Intravenous Chloramphenicol and Ampicillin were given. Subsequently, vision was fully restored but prolactin levels continued to be slightly elevated. Basal cortisol and urine specific gravity were persistently low. Repeat CT scan showed disappearance of the mass. Six months postoperatively, she was able to resume work but continues to take Prednisone for hypocortisolemia and Carbamazepine for the diabetes insipidus. Case 3 Left frontal craniotomy was performed and intraoperatively, a pinkish fluctuant mass abutted the optic nerve anterior to the optic chiasm, which on opening, yielded purulent fluid. Drainage and marsupialization was done. Aspirate gram stain showed 0-5 polymorphonuclear cells per high power field with no microorganisms noted. Bacteriologic cultures likewise yielded negative results. Intravenous Oxacillin, Chloramphenicol and Metronidazole were given for 1 week. Postoperatively, her visual acuity improved but she developed transient diabetes insipidus responsive to fluid hydration. Repeat Cranial CT scan results showed marked decrease in the size of the previously noted sellar-suprasellar focus. Six months post-operatively, repeat hormonal studies showed persistently low-normal cortisolemia (5.26 øg/dL) and low free thyroxine (10.7 pmol/L) despite hormonal replacement. She is maintained on lifetime physiologic doses of Prednisone, Levothyroxine and conjugated estrogen with progesterone. Significance: Literature review describes over 123 cases since Simmond's published case in 1914. We review 3 cases of pituitary abscesses seen at the Philippine General Hospital since 2004. Recommendations: The diagnosis of a pituitary abscess is difficult and relies on a thorough history and physical examination and a high index of suspicion. Unfortunately no preoperative diagnostic maneuvers are specific for pituitary abscess. In the evaluation of a patient with symptoms of hypopituitarism having a pituitary cystic mass with heterogenous intensity signal on imaging, a pituitary abscess should be considered as a differential diagnosis preoperatively. Keywords: Pituitary abscess; thyromegaly; hypernatremia; hypocortisolemia DOI: 10.3860/pjim.v47i3.1657 Phil. J. Internal Medicine, 47: 143-150, May-June, 2009
 
Publisher The Philippine College of Physicians
 
Contributor —
 
Date 2010-07-23
 
Type Peer-Reviewed Item
—
 
Format application/pdf
 
Identifier http://www.philjol.info/index.php/PJIM/article/view/1657
 
Source Philippine Journal of Internal Medicine; Vol 47, No 3 (2009); 143-150
 
Language en
 
Coverage Philippines
—
—