Primary pituitary abscess: case report

Pituitary abscesses are potentially life-threatening lesions if not appropriately diagnosed and treated. The authors have operated on more than five hundred cases of pituitary tumors and only one represented a case of pituitary abscess. A 35-year-old woman was investigated for chronic frontal headache. CT scan showed a cystic sellar lesion with ring enhancement after contrast injection leading to an initial diagnosis of pituitary adenoma. She underwent a sublabial transsphenoidal approach to the pituitary gland. After dural opening, purulent material was obtained and no tumor or other associated lesion was detected. There was no evidence of current or previous septicemic illness, meningitis, cavernous sinus thrombosis or sinus infection. Cultures were negative. She was put on antibiotics and discharged after 4 weeks. Nowadays, 10 years after treatment, she is doing well, with no anterior pituitary hormone deficit. MRI shows a partially empty sella without residual lesion and the pituitary stalck is in the midline. The early diagnosis and adequate treatment of this life-threatening lesion may result in excellent prognosis.     

Twelve-year-old girl with intracranial epidural abscess and sphenoiditis

We report the case of a 12-year-old girl with an intracranial epidural abscess and sphenoiditis. Although she had no history of sinusitis, she developed acute severe headache, fever, and vomiting. Emergent CT and MRI showed a spherical space-occupying lesion of diameter 3 cm in the right cranial fossa with rim enhancement. The lesion was thought to be an epidural abscess adjacent to the right sphenoiditis. On the basis of the MRI findings, we performed emergent surgery to drain the abscess and sinusitis because of severe and rapidly worsening headaches. The patient showed great improvement the day after the operation. Intravenous antibiotics were administered for 8 days. She has completely recovered, with neither sequelae nor recurrence at 7 months after the operation. We believe that this report will be a useful reference for cases of acute onset headache and may be helpful in diagnosis and treatment decisions for severe sinusitis-related intracranial abscess in childhood.     

A clinically diagnosed lymphocytic hypophysitis presenting as recurrent meningitis]

A 55-year-old woman was admitted to our hospital complaining of severe headache with fever and apparent neck stiffness. Neutrophilic pleocytosis was demonstrated in cerebrospinal fluid (CSF) and bacterial meningitis was strongly suspected, but bacterial culture of CSF was negative. After the symptoms normalized within a few days, she developed diabetes insipidus and gadolinium (Gd)-enhancement of the enlarged hypophysis and stalk was observed on cranial MRI. A Lymphocytic Hypophysitis (LH) was clinically diagnosed. Follow-up studies demonstrated spontaneous remission of serological, radiological, and CSF findings, and she was discharged on hormonal replacement therapy with desmopressin. Three months later, she returned to our hospital complaining of headache again under adenohypophysial hypofunction and expanding pituitary lesion on MRI. CSF analysis showed meningitis but there was no evidence of infection by microorganisms. Our diagnosis was relapsing LH with aseptic meningitis, and the patient was administered methylprednisolone pulse therapy, which induced rapid improvement in clinical, endocrinological, and radiological findings. This case showed a possible unique clinical presentation of LH characterized as recurrent aseptic meningitis. It is important to recognize this phenotype of LH, and to prescribe corticosteroid therapy after appropriate endocrinological and radiological studies.     

A case of craniopharyngioma with chemical meningitis as an initial symptom]

We reported a rare case of craniopharyngioma with chemical meningitis due to spontaneous rupture of the tumor. A 50-year-old woman was admitted with high fever, headache, and nausea. On physical examination, she had nuchal rigidity. The examination of her cerebral spinal fluid(CSF) revealed pleocytosis(mononuclear cell dominant), low value of glucose level and high content of protein. The feature of her CSF findings suggested tuberculosis or fungal meningitis, but bacteriologic culture of the CSF was negative. The CT scan showed an isodensity mass in the suprasellar region and a spotty calcification in the third ventricle. The MRI with gadolinium enhancement suggested that the tumor must be craniopharyngioma and that meningitis was a type of chemical meningitis due to spontaneous rupture of craniopharyngioma. The corticosteroid therapy was rather effective to the symptoms of fever and headache. Then the operation was performed by neurosurgeons, and the diagnosis of craniopharyngioma was pathologically confirmed. Spontaneous rupture of craniopharyngioma rarely occurred and was followed by chemical meningitis. This case was an extremely rare condition that presented with chemical meningitis as an initial symptom.     

垂体脓肿的诊断和经蝶显微手术治疗

目的探讨垂体脓肿的诊断及治疗方法。方法回顾性分析我院15例垂体脓肿患者的临床表现、影像学特征、诊断和治疗。结果15例患者中术前主要表现为头痛8例,视力下降或颞侧偏盲6例,垂体前叶功能低下7例,尿崩4例,发热1例。MRI增强示病灶均呈环形强化。15例患者均采用经鼻蝶手术入路清除脓肿。术后1W,8例头痛患者症状均消失,6例视力下降患者中4例改善;术后随访至第3个月,4例尿崩患者有2例恢复正常,7例垂体功能减退患者中4例好转,另3例患者继续予以药物替代治疗;术后6个月,另2例仍多饮多尿患者和3例垂体功能仍低下者均恢复正常。15例患者均无复发。结论垂体脓肿术前诊断较困难,对鞍区囊性病变应考虑到垂体脓肿的可能性。及早采用微创手术、合理应用抗生素及恰当的对症治疗是治疗垂体脓肿的关键。     

垂体脓肿的诊断和治疗(14例报告和文献复习)

目的:探讨垂体脓肿的临床特征和治疗。方法:回顾性分析14例垂体脓肿患者的临床表现、影像学特征、诊断和治疗,并结合文献进行分析。结果:14例患者中头痛13例,垂体功能低下6例,视力视野影响6例,多饮多尿3例,发热3例。MRI增强病灶均呈环状强化。11例经蝶手术治疗,3例经开颅手术。术后随访头痛缓解者10例,视力、视野改善者4例,尿崩者2例恢复正常,垂体功能低下者中4例恢复正常,3例开颅手术者中2例复发,再经蝶手术治愈。结论:应用常规CT和MR术前诊断垂体脓肿困难,对鞍区囊性病变应考虑到垂体脓肿的可能。及早手术、正确选择手术入路、围手术期合理应用抗生素和适当的对症治疗是治疗垂体脓肿的关键。     

Pituitary tumor apoplexy presenting as infective meningoencephalitis

We report on a case of a 80-year-old man who developed progressive drowsiness with headache, fever and signs of meningeal irritation 2 days after a head trauma. Suspecting an infective meningoencephalitis, the patient was treated with wide spectrum antibiotic and antiviral therapy. Brain CT scan revealed a previously unknown pituitary expansive lesion. A brain MRI study confirmed the presence of an intrasellar lesion, which presented remarkable contrast ring enhancement, and showed non-specific inflammatory tissue on the clivus, possibly responsible of the clinical features of sterile meningitis. A biopsy proven diagnosis of pituitary apoplexy was made. This case highlights MRI as an important investigation for earlier recognition of pituitary apoplexy that can present with a clinical picture resembling an infective meningoencephalitis.     

Multiple brain abscesses due to Actinomyces species

We report a case of multiple brain abscesses due to Actinomyces species in a 35-year-old immunocompetent man who presented with a 2-month history of headache, diplopia, fever, and weight loss. Despite receipt of broad-spectrum antibiotics for over a month, he continued to have headaches and diplopia. He subsequently underwent right anterior temporal lobectomy and evacuation of abscesses. The diagnosis was aided by identification of sulfur granule on histopathological examination of cerebral cavitary lesion and Gram-positive filamentous rods seen on tissue-Gram stain.     

Intrachiasmal craniopharyngioma: treatment with a cisternal catheter drainage and radiation.

A 54-year-old woman who presented with headaches and bitemporal visual field loss had an MRI that disclosed a cystic lesion within the optic chiasm. Craniotomy yielded an inconclusive biopsy; incisional decompression of the cyst provided only temporary improvement in vision. When vision declined 3 months later, an MRI showed recurrence of the cyst. The patient underwent a second craniotomy with biopsy that revealed an adamantinomatous craniopharyngioma. Because of the dangers of surgical removal, the cyst was left in place and connected by catheter to the prechiasmatic cisternal subarachnoid space. She received 54 Gy of three-dimensional conformal x-irradiation. At the time of her last follow-up examination 28 months postoperatively, the patient had marked improvement in her visual acuity and visual fields; an MRI demonstrated that the cyst remained decompressed. Cisternal catheter drainage represents a novel approach to the treatment of this rare variant of craniopharyngioma.     

Pituitary apoplexy as a consequence of lymphocytic adenohypophysitis in a pregnant woman: a case report

OBJECTIVE AND IMPORTANCE: A patient with pituitary apoplexy resulting from lymphocytic adenohypophysitis, which caused visual disturbance during pregnancy, is described. This is the first report of such case. CLINICAL PRESENTATION: A 23-year-old primigravida in her 25th week of gestation experienced headache and bitemporal hemianopsia of sudden onset. Magnetic resonance imaging (MRI) revealed a large pituitary mass with intratumoral hemorrhage. Although conservative treatment with intravenous glycerol improved the symptoms partially, the visual symptoms worsened again 6 weeks later. After delivering a girl by scheduled caesarean section her visual symptoms improved. Despite the symptomatic improvement, MRI showed the chiasmatic compression by the enlarged pituitary gland had not changed. Therefore, trans-sphenoidal surgery to decompress the chiasm was performed. Necrotic tissue was seen exuding behind the enlarged pituitary gland and adenohypophysitis with bleeding (apoplexy) was diagnosed histologically. After follow-up for 40 months, she was doing well without any visual or neurological deficits. CONCLUSION: Although relatively rare, pituitary apoplexy as a consequence of lymphocytic adenohypophysitis should be borne in mind when a pregnant woman presents with headache and visual disturbance of sudden onset.     

MRI findings of brain-stem tuberculoma in a case of tuberculous meningitis]

A 54-year-old woman developed headache and slight fever. When she consulted a physician, she could not move either of her eyes to the right. Cranial CT scan revealed no significant findings. Lumbar puncture was performed and CSF examination showed the cell count of 10,304/mm3, glucose level of 10 mg/dl, and total protein value of 270 mg/dl. Her symptoms and laboratory findings suggested meningitis and she was admitted to our hospital. Neurological examination revealed bilateral dilated pupils with sluggish light reflex, right gaze palsy, and hypesthesia of the left side of her face. A diagnosis of tuberculous meningitis was established by a positive test for acid-fast bacillus in CSF, and anti-tuberculous therapy was started at once. One month after the onset of symptoms, her main complaints were double vision and cerebellar ataxia. Both CT and MRI revealed a right brain-stem lesion. Pre-contrast CT could not clearly visualize the lesion but with contrast medium a homogeneously-enhanced circular lesion was shown. MRI on T2WI demonstrated the right brain-stem lesion to have a central bright core with hypointense periphery, which in turn was surrounded by hyperintensity. The lesion appeared isointense with cerebral white matter and the "central bright core" area was demonstrated to be slightly hypointense on T1WI. On post-contrast T1WI (with Gd-DTPA), the lesion showed strong homogeneous enhancement. The CT and MRI findings indicated a brain-stem tuberculoma, which was regarded as the cause of the ocular movement paralysis and cerebellar ataxia. As the clinical symptoms gradually resolved with anti-tuberculous treatment, the MRI appearance of the lesion also improved.(ABSTRACT TRUNCATED AT 250 WORDS)     

Massive reduction of tumour load and normalisation of hyperprolactinaemia after high dose cabergoline in metastasised prolactinoma causing thoracic syringomyelia

In 1970 a 20 year old woman presented with a pituitary chromophobe adenoma for which she underwent transfrontal pituitary surgery. In 1978 she had to be reoperated on because of local tumour recurrence, resulting in hypopituitarism. Bromocriptine (5 mg/day) was given for 15 years, but the plasma prolactin levels remained elevated. In 2000 the patient presented with signs and symptoms suggestive of a spinal cord lesion at the mid-thoracic level. A magnetic resonance imaging (MRI) scan showed an extensive leptomeningeal mass extending from the brainstem to L5, with a thoracic syringomyelia at the T7-T8 level. The plasma prolactin level was very high (5114 microg/l). A biopsy showed the presence of a metastasised prolactinoma.On administration of high dose cabergoline, 0.5 mg twice a day orally, the plasma prolactin levels decreased within one month and then normalised within 26 months. Tumour load reduced considerably but unfortunately, her signs and symptoms did not improve. This case illustrates that a high dose dopamine agonist might be an important therapeutic option in patients with a metastasised prolactinoma.     

Direct Gram staining of blood culture sample enabled the early diagnosis of brain abscess due to Listeria monocytogenes]

A 58 year old woman had a long history of immunocompromised state. Since age 28 she had multiple endocrine neoplasm type 2A: her thyroid gland and bilateral adrenal glands were removed because of pheochromocytoma and thyroid medullary carcinoma. Corticosteroid and levothyroxine were supplemented. At age 57 she was afflicted with systemic lupus erythematodes and nephrotic syndrome. Prednisolone therapy was started. Two months later she developed fever, lethergy, headache and left hemiparesis. MRI revealed multiple ring-enhancing lesions in the right cerebrum. CSF was negative for microorganisms. Blood culture hemolysed after 24 hours. Direct gram staining of the blood culture sample revealed gram-positive short rods without spore, suggested listeria. This enabled prompt initiation of high dose penicillin therapy before the official report of listseria infection. Neurological abnormality including left hemiparesis disappeared completely within one month. Enhancement of abscess wall decreased every month, but it persisted for five months despite continuous intravenous penicillin therapy. Listeria monocytogenes is well-recognized as an opportunistic pathogen. It requires prolonged therapy with antibiotics, since it is the intracellular organism. Monitoring of the brain abscess wall by the enhanced MRI is useful to determine the completion of therapy. Since listerial contamination is common among raw meat and unpasteurized milk, immunocompromised patients should be alarmed not to eat uncooked food products.     

Use of urokinase in the treatment of tuberculous meningitis hydrocephalus

We present a patient with hydrocephalus after tuberculous meningitis successfully treated with urokinase. She presented with multiple episodes of headache, fever, and vomiting. She underwent external ventricular drainage and was treated with urokinase in addition to dexamethasone, acetazolamide, and 4 antituberculous drugs. She was evaluated clinically, radiologically, and by laboratory work-up. On short-term clinical follow-up (3 months), she was asymptomatic after the treatment with urokinase. She was radiologically evaluated 3 weeks after the treatment. An MRI of the brain showed a decrease in ventricular size. Urokinase can be considered as a safe and promising adjunctive treatment for tuberculous meningitis hydrocephalus.     

Fulminant leptomeningeal carcinomatosis from a malignant melanoma arising in a cerebellopontine epidermoid cyst: A rare case with diagnostic pointers

A malignant component in an epidermoid cyst is rare. We report an exceptionally rare case of a malignant melanoma arising in an epidermoid cyst located in the cerebellopontine (CP) angle. A 26‐year‐old woman presented with headache, vomiting, ataxia and difficulty in swallowing over the previous 3 months. The radiological finding suggested an epidermoid cyst and the lesion was excised. The histopathology confirmed a CP angle epidermoid cyst. Within 1 month of discharge, she developed hydrocephalus for which a ventriculo‐peritoneal shunt was performed. Postoperatively she developed weakness in lower limbs. A contrast‐enhanced MRI was done which showed dilated CSF cisternal spaces with a small enhancing lesion in the pineal region and enhancement of meninges extending to the spinal cord. Re‐exploration showed gelatinous material with gross adhesions in the CP angle cistern. A dural biopsy was done which showed sheets of poorly differentiated tumor cells which expressed S100 and Melan A and were immunoreactive with Human Melanoma Black (HMB)‐45 antibody, consistent with the diagnosis of malignant melanoma. Histology of the excised epidermoid cyst was re‐evaluated in deeper sections and showed scattered atypical melanocytes in the basal layer of the epidermis which were highlighted with HMB‐45 antibody. The patient expired within 3 days of the second procedure due to respiratory failure. A very aggressive fulminant course of the disease was evident after surgery for the epidermoid cyst. Treatment options are limited. Criteria for identification of malignancy in an intracranial epidermoid cyst were identified in our case retrospectively and have been highlighted.     

Meningitis Complicating an Occult Infected Nasal Epidermoid Cyst in a Child

Congenital nasal epidermoid cyst without associated facial dysmorphism is an uncommon anomaly that is often asymptomatic. We report a case of occult nasal epidermoid cyst in a 12-year-old boy with initial nonspecific symptoms of fever, headache, abdominal pain, vomiting, and diarrhea. An enhanced magnetic resonance imaging (MRI) showed a cystic lesion in the frontal skull base with expansion of the foramen cecum and the perpendicular plate of the ethmoid bone, accompanied with meningitis. An emergent surgical intervention was undertaken, and an infected epidermoid cyst was confirmed by pathology. He recovered uneventfully during a 4-week treatment with parentally-administered antibiotics. This significant case report demonstrates the importance of MRI in the early diagnosis of a life-threatening intracranial infection from an otherwise occult infected congenital nasal epidermoid cyst in children.     

A case of probable cytomegalovirus encephalitis who restored from persistant disturbance of consciousness

A 50-year-old woman presented with confusion, fever and drowsiness following an episode of headache and dizziness. On admission, neurological examination found positive pyramidal tract signs, meningeal irritation, and bilateral myoclonus in her arms. Laboratory tests revealed liver dysfunction, positive inflammatory reaction, elevated serum IgM antibody against cytomegalovirus, and increased cerebrospinal fluid protein of 67 mg/dl. MRI of brain by diffusion weighted imaging showed a wide spread hyperintense lesion in white matter and limbic areas. We administered aciclovir, ganciclovir and steroid pulse therapy that showed a limited effect in the initial stage. In spite of all these therapies, she suffered from status epilepticus, followed by persistent disturbance of consciousness for about 2 months. However, her level of consciousness and motor deficit were gradually improved by continuous administration of ganciclovir. The present case indicates that prolonged disturbance of consciousness due to cytomegalovirus encephalitis could be restored with continuous ganciclovir administration.     

Clinical features,management and recurrence of symptomatic Rathke’s cleft cyst

Rathke’s cleft cyst (RCC) is a rare lesion of the pituitary gland that is often asymptomatic. The objective of this study was to further characterise the presenting symptoms, endocrinopathy and potential for recurrence of this lesion in an Australian population. The files of 12 patients with pathologically confirmed RCCs were reviewed retrospectively. Common presentations included headache, endocrinopathy, and visual disturbance. Uncommon presentations included 1 patient with pituitary apoplexy. The cysts varied in size from 6 mm to 20 mm; 8 had a suprasellar component. 1 patient had evidence of a RCC with xanthogranulomatous change. RCC recurrence was noted on follow-up MRI in 5 patients. In conclusion, RCCs are rare lesions that can present with an array of clinical symptoms. The relatively high rate of recurrence may indicate a link between this pathology and craniopharyngioma, although many patients with recurrent RCC do not require repeat resection and remain asymptomatic.     

Bright splenium of a psychotic mind

A twenty-one-year old primigravida presented two weeks postpartum with new onset of behavioral alteration and irrelevant talking without fever, headache, or seizures. Magnetic resonance imaging (MRI) of brain showed a lesion with diffusion restriction in splenium of corpus callosum. A possibility of postpartum psychosis was considered after ruling out various etiologies for splenium hyperintense lesion. Near complete resolution of symptoms was noted after initiation of antipsychotic medications. Literature has described multiple etiologies for lesions involving splenium of corpus callosum on brain imaging. We present this case as a unique clinical presentation of splenial pathology in the form of postpartum psychosis.     

Coexistence of a cerebellopontine epidermoid cyst with a pituitary adenoma

We report on an 18-year-old girl with the coexistence of an epidermoid cyst in the cerebellopontine angle (CPA) with a pituitary adenoma. The clinical course and histopathological characteristics were reviewed. The patient presented with headache, vision loss and amenorea. Computerised tomographic (CT) scan and magnetic resonance imaging (MRI) examinations demonstrated a solid sellar lesion with supra-sellar extension. There was another mass lesion in the CPA with prepontine extension. The tumours were removed surgically. Histopathological examination revealed an epidermoid cyst in the prepontine area and a pituitary adenoma in the sellar region. This has been the second case to be reported in the literature with the coexistence of an epidermoid cyst and a pituitary adenoma.