Pituitary abscess during pregnancy: Management dilemmas

Abstract

of meningismus in the patient. Investigations revealed normal peripheral blood picture and total white blood cells count was normal, with 77% neutrophils. She was non-diabetic and her viral markers for human immuno deficiency virus (HIV) were negative. Hormonal evaluation was normal except serum Thyroid Stimulating Hormone, which was slightly raised and serum cortisol, which was low. Thyroxine at 50 µg/day and prednisolone at 15 mg/day in divided doses were started before surgery.Plain magnetic resonance imaging (MRI) was done before being referred to our hospital. It showed a well-defined sellar mass with supra-sellar extension and compressing the chiasma. It was hypointense to gray matter in the center with a peripheral isointense rim on T1 weighted scans and on T2 weighted image central hyperintensity with peripheral isointense rim was noted [ Figures 1 and 2]. A provisional radiological diagnosis of pituitary adenoma with apoplexy was considered. In view of recent onset, rapid deterioration in vision, patient was operated through a trans-nasal trans-sphenoidal approach. Intra operatively, the sphenoid sinus wall was normal, sellar floor was globular with moderate bulge and normal thickness of the bone. There was no evidence of sinusitis and the dura appeared normal. On opening the dura, normal pituitary was encountered, which was slit vertically. To our surprise about 15 ml of yellowish non-foul smelling pus was drained [ Figure 3]. Cavity was entered and a biopsy from the wall of the cavity was taken. Since, the yield of the biopsy was minimal each time; repeated aggressive attempts were made, which led to arachnoid INTRODUCTIONThe normal pituitary gland may enlarge 50-70% during pregnancy. [1] This predominantly occurs because of estrogen stimulated hyperplasia of prolactin producing lactotropes. [2] Pregnancy may also promote growth of a pre-existing pituitary adenoma. [3] However, a pituitary abscess in a pregnant patient is very rare. There has only been one such case reported in the literature. We report pituitary abscess in a 35-year old pregnant woman, which was drained through a trans-sphenoidal route and discuss the unique challenges we faced in the diagnosis and management. CASE REPORTA lady aged 35 years, who was 28 weeks primigravida, presented with recent onset progressive visual loss. Until now, she had an uncomplicated pregnancy with unremarkable medical history. No features of sinusitis, sepsis or endocrinopathy were present. On examination, her visual acuity was normal in the right eye and 2/60 in the left eye. Perimetry revealed bi-temporal hemianopia. Fundus examination was normal. There were no signs A b s T R A C TPituitary abscess is a rare disorder and only one case of pituitary abscess in pregnancy has been reported in the literature. Since, its presenting manifestations are non-specific; the diagnosis is usually made per-operatively. A 35-year-old pregnant lady, with a sellar mass was managed successfully with trans-sphenoidal drainage of the abscess and antibiotic therapy. We disc...