Background: Pituitary abscess is a rare but potentially fatal entity. It represents ~0.21% of all pituitary lesions. The symptoms are usually nonspecific. The proper interpretation of imaging studies is of extreme importance to the differential diagnoses.
Case: Man, 40 years old, begins complaining of occipital headache (25.04.2011), initially with good response to treatment, without associated symptoms. It became progressively more intense, generalized, and refractory to therapy, associated with photophobia, blurred vision and anorexia. No other neurological, respiratory symptoms or fever were present. There was no previous history of sinusitis or migraine. At the emergency department (ED) (30.04.2011) a cerebral CT was performed with no significant alterations. Because persistence of the symptoms a MRI was performed revealing an apparent enlargement of the adenohypophysis and sphenoid sinusitis. Analgesic therapy was optimized without improvement. The patient was again evaluated at the ED (04.05.2011), the MRI was repeated revealing sphenoid sinusitis and hypophysitis with possible intra pituitary abscess. Analytical study showed increased inflammatory markers. Therapy with prednisolone, ceftriaxone and metronidazole was started and left sphenoidectomy was performed in 06.05.2011. Pituitary function was evaluated 5 days after steroids therapy revealing low cortisol and ACTH (supression), total testosterone 0.81 ng/ml (2.88.0) with normal FSH (1.512.4) and LH (1.78.6), prolactin 3.5 ng/ml (4.015.2) and thyroid function in lower limit of normal. The patient showed progressive clinical improvement and no symptoms of pituitary hypofunction. Resolution of the pituitary abscess was observed in the MRI. Revaluation of pituitary function, 2 weeks after corticosteroid therapy suspension, revealed normal levels of cortisol, ACTH and testosterone.
Discussion: The diagnosis of pituitary abscess remains a challenge even with the aid of imaging techniques.