Endocrine Abstracts

JOINT730

Recurrent primary pituitary abscesses are exceptionally rare in paediatric populations. They pose significant diagnostic and therapeutic challenges, often requiring a multidisciplinary approach for effective management. We report the case of a 14-year-old female who presented with vomiting and a year-long history of progressively severe headaches. This was associated with polyuria, polydipsia, and a five-month history of secondary amenorrhea. Neurological examination was unremarkable with no abnormalities in visual acuity, colour vision, or visual fields. There was a past medical history of autoimmune hypothyroidism, associated with raised TPO antibodies. Magnetic resonance imaging (MRI) of the head demonstrated a suprasellar lesion impinging on the optic chiasm with restricted diffusion. Investigations revealed normal prolactin (472 mIU/L), IGF-1 (23.7 nmol/L), cortisol (415 nmol/l)and gonadotrophins with undetectable oestradiol. She underwent transsphenoidal decompression, during which caseous yellow purulent material was encountered. Histopathology revealed non-neoplastic anterior pituitary tissue with acute inflammatory exudate, consistent with a pituitary abscess, and no evidence of adenoma. Postoperatively, she received a two-week course of intravenous antibiotics and six weeks of oral antibiotics. Further investigations excluded sarcoidosis and tuberculosis. Postoperatively, she developed diabetes insipidus (serum osmolality 296 mOsm/kg, urine osmolality 93 mOsm/kg), managed with sublingual desmopressin. Hydrocortisone was initially started but stopped after confirming normal adrenal axis on a short synacthen test (SST). Menstrual cycles resumed within a month. Three months postoperatively, she developed recurrent headaches. MRI showed a cystic sellar lesion with slight stalk deviation, suggesting recurrence. A second transsphenoidal surgery six months later revealed chronic inflammation consistent with a ruptured Rathke cleft cyst. No antibiotics were given postoperatively, and cortisol response to SST was satisfactory (peak cortisol of 618 nmol/L). Seven months later, severe headaches recurred. MRI demonstrated an enlarging sellar cystic lesion, necessitating a third surgery. Histology revealed a mixed inflammatory process. The lesion was treated as a pyogenic abscess with six weeks of intravenous Ceftriaxone and Meropenem. Recovery was favourable, with no further recurrences. Postoperative endocrine evaluations were satisfactory with normal cortisol on SST. She remains on levothyroxine for autoimmune hypothyroidism and desmopressin for diabetes insipidus. A nine-month follow-up MRI showed abscess regression, and she remains asymptomatic 13 months post-surgery. This case underscores the complexities of diagnosing and managing recurrent pituitary abscesses in adolescents. The literature suggests that infectious pituitary abscess usually requires prolonged broad-spectrum intravenous antibiotics. Early recognition, prolonged intravenous antibiotics and vigilant follow-up are essential to prevent recurrences and optimise outcomes.