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      Recurrent pituitary abscess: case report and review of the literature

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          Summary

          A 26-year-old woman presented with severe postpartum headaches. Magnetic resonance imaging (MRI) revealed a symmetric, heterogeneous enlargement of the pituitary gland. Three months later, she developed central diabetes insipidus. A diagnosis of postpartum hypophysitis was suspected and corticosteroids were prescribed. Six months later, the pituitary mass showed further enlargement and characteristics of a necrotic abscess with a peripheral shell and infiltration of the hypothalamus. Transsphenoidal surgery was performed, disclosing a pus-filled cavity which was drained. No bacterial growth was observed, except a single positive blood culture for Staphylococcus aureus, considered at that time as a potential contaminant. A short antibiotic course was, however, administered together with hormonal substitution for panhypopituitarism. Four months after her discharge, severe headaches recurred. Pituitary MRI was suggestive of a persistent inflammatory mass of the sellar region. She underwent a new transsphenoidal resection of a residual abscess. At that time, the sellar aspiration fluid was positive for Staphylococcus aureus and she was treated with antibiotics for 6 weeks, after which she had complete resolution of her infection. The possibility of a pituitary abscess, although rare, should be kept in mind during evaluation for a necrotic inflammatory pituitary mass with severe headaches and hormonal deficiencies.

          Learning points:
          • The possibility of a pituitary abscess, although rare, should be kept in mind during evaluation for a necrotic inflammatory pituitary mass with severe headaches and hormonal deficiencies.

          • In a significant proportion of cases no pathogenic organism can be isolated.

          • A close follow-up is necessary given the risk of recurrence and the high rate of postoperative pituitary deficiencies.

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          Most cited references 20

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

          Pituitary abscess is a rare but serious intrasellar infection. To better determine the salient signs and symptoms that help in making the diagnosis, and to determine the most appropriate treatment, the authors reviewed their experience in a series of 24 patients treated at the University of California at San Francisco. Nine of the patients were female and 15 were male, and their mean age was 41.2 years (range 12-71 years). Surprisingly, most patients in our series presented with complaints and physical findings consistent with a pituitary mass, but rarely with evidence of a serious infection. Headache, endocrine abnormalities, and visual changes were the most common clinical indicators; fever, peripheral leukocytosis, and meningismus were present in 33% or fewer of the patients. Imaging tests demonstrated a pituitary mass in all patients, but the features evident on computerized tomography and magnetic resonance studies did not distinguish pituitary abscesses from other, more common intrasellar lesions. Because of the ambiguous clinical features and imaging findings, most abscesses were not diagnosed before treatment; rather, the diagnosis was made during surgical exploration of the sella turcica, when the surgeon encountered a cystic mass containing pus. There were only two deaths in this series (8.3%). Patients presenting with headache and visual changes noted improvement in almost all cases; patients with endocrine dysfunction generally did not recover normal pituitary function, but were easily treated with hormone replacement therapy. Antibiotic therapy is suggested for patients who have symptoms of sepsis, or for patients in whom specific organisms are identified from cultures obtained during surgery. The transsphenoidal approach is recommended over open craniotomy for surgical drainage.
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            Pituitary abscess: report of four cases and review of literature.

            Pituitary abscess is a rare disorder and its presenting manfestations are non-specific therefore, the diagnosis is usually made either postoperatively or at postmortem. We describe four such cases seen over a period of 10 years. All the patients presented with fever, systemic signs of toxaemia and endocrine dysfunctions. Two of them had pre-existing pituitary pathology. A preoperative diagnosis of pituitary abscess was considered in all in view of characteristic MR findings. Three patients underwent transsphenoidal drainage of abscess, whereas the remaining one succumbed to sepsis and was diagnosed at necropsy. Offending organisms including Pseudomonas, Acinetobacter and Staphylococcus were isolated in three cases respectively. During follow-up for 4 years, 2 patients are doing well, one had a recurrent abscess after 1 year and required redo-surgery.
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              Diagnosis and management of pituitary abscess: experiences from 33 cases.

              Pituitary abscess is a rare disorder with nonspecific presenting manifestations, often making a correct preoperative diagnosis difficult. To better determine the salient signs and symptoms of pituitary abscess and to evaluate the effectiveness of surgical and antibiotic therapies, we conducted a review of patients treated for pituitary abscess at the Peking Union Medical College Hospital (PUMCH). A total of 33 consecutive patients referred to PUMCH between 1991 and 2007 were included. While 30 patients underwent surgery and antibiotic therapy, three patients accepted only antibiotic therapy. A complete history, a thorough record of signs and symptoms, pituitary imaging and biochemical panels were obtained for each patient. Most of the patients presented with complaints and symptoms consistent with a sellar mass, generally in the absence of any evidence of infection. Diabetes insipidus, hypopituitarism and headache were the most common clinical indicators. Typical magnetic resonance (MR) images after gadolinium injection demonstrated a sellar cystic mass with an enhanced rim. Although there were several recurrences, the abscess resolved in nearly all cases. Hypopituitarism generally did not recover, and hormone replacement therapy was usually necessary. Presentation of diabetes insipidus, hypopituitarism and a sellar cystic mass with an enhanced rim may be suggestive of a pituitary abscess. For most patients, a transsphenoidal evacuation, followed by antibiotic therapy, is recommended. However, antibiotic therapy alone may be useful for acute cases. In our experience, pituitary abscesses can usually be treated, though the accompanying hypopituitarism is difficult to cure, and requiring lifelong hormonal replacement. © 2010 Blackwell Publishing Ltd.
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                Author and article information

                Journal
                Endocrinol Diabetes Metab Case Rep
                Endocrinol Diabetes Metab Case Rep
                EDM
                Endocrinology, Diabetes & Metabolism Case Reports
                Bioscientifica Ltd (Bristol )
                2052-0573
                23 February 2018
                2018
                : 2018
                Affiliations
                [1 ]Departments of Endocrinology, Pathology, and Neuroradiology Université catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium
                [2 ]Departments of Pathology, and Neuroradiology Université catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium
                [3 ]Departments of Neuroradiology Université catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium
                Author notes
                Correspondence should be addressed to R M Furnica Email: raluca.furnica@ 123456uclouvain.be
                Article
                EDM-17-0162
                10.1530/EDM-17-0162
                5825836
                © 2018 The authors
                Categories
                Unique/Unexpected Symptoms or Presentations of a Disease

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