Pituitary Abscess Manifesting as Meningitis and Photophobia Associated With Rathke's Cleft Cyst in a Child -Case Report-

Abstract

A 12-year-old girl presented with complaints of headache, lethargy, photophobia, and fever. Cerebrospinal fluid examination revealed bacterial meningitis. Magnetic resonance (MR) imaging showed a cystic lesion with peripheral enhancement in the pituitary fossa. The patient underwent transnasaltranssphenoidal surgery (TSS). The diagnosis was pituitary abscess associated with Rathke's cleft cyst. Postoperatively, the patient recovered rapidly. However, recurrence of the pituitary abscess causing meningitis occurred four times and required repeated TSS. She had diabetes insipidus and received hormone replacement. This case requiring repeated emergency surgeries shows that follow-up examinations including MR imaging and pituitary endocrine evaluation are necessary because the rate of recurrence is high in patients with pituitary abscess associated with Rathke's cleft cyst.

Abscess formation within a Rathke's cleft cyst

“…The majority of the previously reported cases of RCC abscess have presented with clinical features typical of mass effect, namely; visual impairment, endocrine disturbance and headache [3]. Systemic features such as leukocytosis and pyrexia are atypical but may also manifest [3–5].…”

“…Although the identification of RCCs has become more common with the advent of MRI, abscess formation within a RCC remains an unusual condition and difficult to identify preoperatively. The majority of the previously reported cases of RCC abscess have presented with clinical features typical of mass effect, namely; visual impairment, endocrine disturbance and headache [ 3 ]. Systemic features such as leukocytosis and pyrexia are atypical but may also manifest [ 3 – 5 ].…”

“…The majority of the previously reported cases of RCC abscess have presented with clinical features typical of mass effect, namely; visual impairment, endocrine disturbance and headache [ 3 ]. Systemic features such as leukocytosis and pyrexia are atypical but may also manifest [ 3 – 5 ]. The majority of RCC abscesses seem to occur spontaneously, although previous pituitary surgery, irradiation of the gland and immunosuppressive therapy are speculated to be risk factors [ 1 , 2 ].…”

“…Although haematogenous spread and direct extension of adjacent infection such as sphenoid sinusitis, thrombophlebitis or a contaminated cerebrospinal fluid fistula have been postulated as means by which RCCs become infected. Patients typically lack evidence of infection elsewhere [ 3 ].…”

Rathke cleft cyst masquerading as pituitary abscess

“…[15,28] The limitation of our case was that routine cytology test and bacterial culture were not conducted, though the pathological test showing no inflammation cell infiltration partially proved the lesion not to be infectious. The clinical progression of our patient mainly included symptomatic deteriorations, severe hyponatremia, and consciousness disturbance.…”