Objective

Pituitary abscess is an uncommon entity, representing only 0.2-0.6% of all pituitary

lesions. They are divided into primary, when abscess arises within a previously healthy
gland, and secondary, when it arises in pituitary gland that contains a preexisitng
lesion, such as adenoma, craniopharyngioma or Rahtke’s cleft cysts. Most of secondary
types reported are related to adenomas. Only five cases of secondary abscess with
craniopharyngioma have been described until now.
We report a case of a secondary abscess arising within a craniopharyngioma an we
discuss about its diagnosis and management.

Methods

A 59 year-old-woman presented to our medical center with a 3-week history of

asthenia, weight loss, headache, and fever. The general and neurological examination
was normal. Routine blood tests didn´t show any abnormality, but examination of CSF
revealed glucose 40, proteins 228, cells 436 (60% granulocites). Microbiology and
immunology studies were normal.
MRI showed a pituitary lesion suggestive of a chronic inflammatory process. The rest of
imaging studies (including scintigraphy, thoracic CT, craneal CT) didn´t revealed any
other alteration.
Finally, it was diagnosed as a chronic lymphocytic meningitis with hypophystis, and was
treated with antibiotherapy and corticosteroids. However, two months later she
presented headache and fever again, so it was decided to biopsy the pituitary lesion.

Results

An endonasal endoscopic transphenoidal biopsy was performed. After the dural

opening, the exit of a purulent material occurred. We proceed to wash the sellar region
until said material was eliminated. Intrasellar samples were taken, without evidence of
a clear tumor.
Histological study demonstrated a craniopharyngioma and meningeal chronic
inflammation. In the bacteriological study no organisms could be identified.
Postoperative course ocurred without any incidence. Empiric antibiotics were started.
Three months post-operatively, a repeat MRI didn´t show any residual mass. However
she had established permanent panhypopituitarism and needed long-term hormone-
replacement therapy.

Conclusion
Secondary pituitary abscess are very rare, yet life-threatening condition that can
present with an array of symptoms, including fever, headache, visual disturbances,
hormone disturbances… The key to successful management is a high index of suspicion
and early proactive management. Multimodal transphenoidal surgical evacuation
combined with antibiotics or antifungal therapy is the mainstay of treatment. Although
most symptoms resolve following surgical decompression, endocrinopathies improve
only rarely.