Pituitary Apoplexy Mimicking Pituitary Abscess: Case Report

摘要

We are reporting an uncommon case of febrile apoplexy of a pituitary macroadenoma eroding into sphenoid sinus.A 58-year-old female was transferred with confusion, fever, headaches and visual abnormalities. She had CSF pleocytosis and a presumptive diagnosis of meningitis and was on antibiotics.CT showed a large pituitary mass 21×19×21mm, an increased density on the left of the mass compatible with hemorrhage, a moderate soft tissue density and mild inflammatory change in left sphenoid sinus, erosion of the floor of the sella on the left primarily and right deviation of the midline bony septum of the sphenoid sinus. MRI confirmed these findings.The pituitary mass was debulked. Pathology revealed scant foci of poorly preserved pituitary adenoma with extensive necrosis, active inflammation and granulation tissue. Cultures were again negative.Pituitary apoplexy is an important noninfectious entity to keep in mind beside pituitary abscess when a patient presents with fever and acute neurological, visual and endocrine manifestations. Introduction Pituitary apoplexy (PAp), an acute hemorrhagic infarction of the pituitary gland with abrupt neurological impairment, usually occurs in an existing macroadenoma (> 10 mm). It is an uncommon event that takes place in an estimated range of 0.6%1 (typical symptomatic PAp with significant hemorrhagic and necrotic changes) to 27.7%2 (only MRI criteria without clinical evidence of apoplexy or blood discovered in specimens of asymptomatic patients) of cases of pituitary adenoma, although the figure is probably closer to 10%3.A macroadenoma may extend beyond the confines of the sella turcica, upward toward the optic chiasm and hypothalamus, downward toward the sphenoid sinus and laterally toward the cavernous sinuses. PAp is a big imitator of other intracranial pathological entities. It frequently manifests itself by signs and symptoms that may resemble those of different intracranial pathological processes. Headache, photophobia, stiff neck, and oculomotor palsy may mimic a ruptured intracranial aneurysm, whereas fever, meningismus, and lethargy can appear to indicate bacterial or viral meningitis4,5,6. Periorbital edema from compression of the venous plexus contained in the cavernous sinus paired with defects resulting from encroachment on adjacent cranial nerves can emulate cavernous sinus thrombosis. Unilateral ptosis and mydriasis, in addition to restriction of adduction, elevation, and downward gaze, may raise consideration of the presence of a posterior communicating artery aneurysm or, if lacking the inclusion of pupillary dilation, diabetic third nerve palsy.We are reporting an uncommon case of febrile apoplexy of a large pituitary tumor eroding into sphenoid sinus that was managed by our medical team. Case A 58-year-old female was transferred to us from another hospital where she presented with confusion, fever, headaches and visual field defects. She had a presumptive diagnosis of meningitis and was put on Rocephin, Doxycycline, Acyclovir and Bactrim. On physical exam she had third cranial nerve abnormalities but a supple neck. She had a history of diabetes mellitus II and hypertension. A lumbar puncture performed prior to transfer revealed 31 white cells, poly predominant, with elevated glucose and protein levels. Cerebrospinal fluid (CSF) gram stain and cultures had failed to demonstrate any organisms.Her vitals on transfer were temperature 100.5 °F, pulse 76/minute, respiratory rate 21/minute and blood pressure 147/52 mmHg. Lab analyses showed WBC 6.5 x109 /litre, PMN 85%, decreased prolactin and TSH levels and normal blood and urine osmolarity levels.We ordered brain CT that showed evidence of a fairly large mass involving the sella and pituitary gland 21×19×21mm. There was increased density on the left of the mass compatible with hemorrhage. The mass impinged upon the optic chiasm as well as the hypothalamus with the displacement of these structures upwards. There was evidence of a