- Department of Neurosurgery, Yamagata University Faculty of Medicine, 2-2-2 Iidanishi, Yamagata City, Japan
- National Cancer Center, 5-1-1 Tsukiji, Chuo-ku, TOKYO, Japan
Department of Neurosurgery, Yamagata University Faculty of Medicine, 2-2-2 Iidanishi, Yamagata City, Japan
National Cancer Center, 5-1-1 Tsukiji, Chuo-ku, TOKYO, Japan
DOI:10.4103/2152-7806.76140Copyright: © 2011 Kuge A This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Kuge A, Sato S, Takemura S, Sakurada K, Kondo R, Kayama T. Abscess formation associated with pituitary adenoma: A case report: Changes in the MRI appearance of pituitary adenoma before and after abscess formation. Surg Neurol Int 24-Jan-2011;2:3
How to cite this URL: Kuge A, Sato S, Takemura S, Sakurada K, Kondo R, Kayama T. Abscess formation associated with pituitary adenoma: A case report: Changes in the MRI appearance of pituitary adenoma before and after abscess formation. Surg Neurol Int 24-Jan-2011;2:3. Available from: http://sni.wpengine.com/surgicalint_articles/abscess-formation-associated-with-pituitary-adenoma-a-case-report-changes-in-the-mri-appearance-of-pituitary-adenoma-before-and-after-abscess-formation/
Background:Pituitary abscess is an extremely rare finding. The abscess may arise as a primary pituitary lesion or be associated with parasellar pathology. It is important for pituitary abscess treatments to perform early diagnosis. In this report, we describe a case of pituitary adenoma in which MRI findings changed during the follow-up period and strongly suggested progression to pituitary abscess arising from adenoma.
Case Description:In a 73-year-old female, pituitary adenoma had been incidentally detected; MRI showed typical findings of pituitary adenoma, and we had followed up the pituitary lesion and clinical symptoms. Six months later, she had oculomotor nerve palsy and symptoms of hypopituitarism. Hematological examination revealed inflammation and hypopituitarism. MRI showed striking changes in the signal intensity of the pituitary lesion, and strongly suggested occurrence of sinusitis and pituitary abscess ascribed to pituitary adenoma. She was admitted and endoscopic transsphenoidal surgery was performed. The sellar floor was destroyed, and yellowish-white creamy pus was observed. A histopathological study using hematoxylin-eosin staining showed adenoma and inflammatory cells. Aerobic, anaerobic, and fungal cultures were negative. Antibiotics were administered and hormonal replacement was started. Neurological and general symptoms were improved, and postoperative MRI revealed complete evacuation of abscess and removal of tumor.
Conclusions:Pituitary abscess within invasive pituitary adenoma is a rare entity, and shows high mortality. Early diagnosis of pituitary abscess is very important for the prompt surgery and initiation of treatment with antibiotics. In our case, changes in MRI findings were helpful to diagnose pituitary abscess, and endoscopic transsphenoidal surgery was an optimal surgical treatment.
Keywords: Endoscopic transsphenoidal surgery, pituitary abscess, MRI findings
Pituitary abscess is an extremely rare finding. Some reports described finding pituitary abscess as a primary pituitary lesion or be associated with an underlying parasellar pathology, such as pituitary adenomas,[
In a 73-year-old female, pituitary adenoma had been incidentally detected, and she had been followed up as an outpatient at our neurosurgery department. Magnetic resonance imaging (MRI) showed solid intra- and suprasellar lesions with hypoenhancement after the administration of the contrast medium [
Six months later, she had bilateral ophthalmoplegia, and ptosis and diplopia in the right eye. Symptoms were worsened, and she started to have general fatigue. She had no history of diabetes mellitus, immunosuppression, malignancy, or head trauma.
Neurological examination revealed ptosis and restricted eye movement in the right eye caused by oculomotor and abducens nerve paralysis. Pupils were equal (3 mm), and light reflex was bilaterally prompt. Papilledema was not seen on examination of the fundi. Impairment of visual acuity and bitemporal hemianopsia were detected. She had no sensory or motor deficit, or meningeal signs.
Hematological examination showed that hemoglobin and hematocrit were normal, and white blood cells were 11.7 (1000/μl) with 88.84% neutrophils and 8.19% lymphocytes. C-reacted protein was 14.3 mg/dl. Endocrinological examination revealed 4.8 pg/ml adrenocorticotropic hormone (ACTH), 0.274 μIU/ml thyroid stimulating hormone (TSH), 0.74 pg/ml free T3, 0.74 ng/ml free T4, 0.05 ng/ml growth hormone (GH), 40 ng/ml insulin-like growth factor-1 (IGF-1), and 9.79 ng/ml prolactin (PRL).
The X-ray craniogram showed ballooning of the sella turcica and cloudiness of the sphenoid sinus. Computed tomography (CT) revealed the intra- and suprasellar enhanced mass lesion, and the bone image showed a defect of the sellar floor and extension of the pituitary lesion toward the sphenoid sinus. MRI showed striking changes in the signal intensity of the pituitary enhanced lesion: low intensity on the T1-weighted image and isointensity on the T2-weighted image. After the administration of the contrast medium, the prominent rim enhancement extending toward the sphenoid sinus was seen [
Magnetic resonance images and CT images after neurological and hormonal symptoms appeared. Upper left and center: T1-weighted images, upper right: T2-weighted image. Middle left and center: T1 weighted images after administration of contrast medium showing enhancement of the outline of sellar lesion. Lower left and center: CT image showing intra- and supra-sellar enhanced mass lesions, defect of the sella floor, and extension of the pituitary lesion toward the shpenoid sinus.
Transsphenoidal surgery was performed. The intrasphenoidal mucosa was thickened, and purulent materials were seen. The sellar floor was destroyed and yellowish-white creamy pus was observed [
A histopathological study with hematoxylin and eosin staining revealed hypostaining adenoma cells with round nuclei and acidophilic cytoplasm, and inflammatory cells [
Pituitary abscess is a rare clinical entity. The abscess may arise as a primary pituitary lesion or be associated with an underlying parasellar pathology, such as pituitary adenomas,[
In our case, typical findings of pituitary adenoma were detected on MRI before abscess formation, and changes in MRI findings and clinical symptoms strongly suggested the occurrence of inflammatory changes at the parasellar lesion. In addition, the finding of the destruction of the sellar floor on CT indicated inflammation spread from the sphenoid sinus. Kroppenstedt et al.[
The recommendations of pituitary abscess management are surgical drainage, administration of antibiotics, and hormonal replacement.[
The administration of antibiotics should be started preoperatively if pituitary abscess is suspected. An appropriate and more specific antibiotic or antifungal agent should be administered and continued for 4-6 weeks.[
Panhypopituitarism is usually seen in patients with pituitary abscess. The replacement of hormones, particularly corticosteroids, is necessary.[
In conclusion, pituitary abscess within invasive pituitary adenoma is a rare entity and shows high mortality. Early diagnosis of pituitary abscess is very important for prompt surgery and initiation of treatment with antibiotics. In our case, changes in MRI findings were helpful to diagnose pituitary abscess, and endoscopic transsphenoidal surgery was an optimal surgical treatment.
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