Secondary pituitary abscess following transsphenoidal surgery with recurrent meningitis

Abstract

Rationale:The transsphenoidal surgical (TS) approach to sellar masses is the preferred surgical route in most cases. Secondary pituitary abscess (PA) following TS is an extremely rare but serious postoperative complication with potentially high disability and mortality.Patient concerns:We describe an uncommon case of secondary PA in a 42-year-old woman, who underwent uncomplicated transsphenoidal procedures without cerebrospinal fluid leak, to treat primary Rathke cleft cyst. Without obvious cause, the patient suffered recurrent meningitis with complaints of headache, hyperpyrexia, and chills from 1 month after the operation.Diagnosis:There were no significant imaging findings until a new rim-enhancement lesion was seen in the sellar region on magnetic resonance imaging during the 6th episode of meningitis 11 months after the initial surgery. A diagnosis of secondary PA was considered;Interventions:Therefore, she underwent a 2nd TS with pus evacuation and antibiotic treatment.Outcomes:She improved remarkably and had no recurrence of symptoms during the 9-month follow-up.Lessons:Our aim was to present this rare case and discuss the most likely etiologies and preventive measures for this condition. In patients with recurrent meningitis but dormant imaging manifestations after TS, the possibility of secondary PA should considered. Adequate surgical drainage with microbiology-guided antibiotic therapy is the 1st choice for treatment.

Pituitary abscess: A descriptive analysis of a series of 19 patients: a multi-center experience

“…Ciappetta used TSS to eliminate the abscess, triiodomethane gauze to drain pus, and antibiotics for three weeks postoperatively to achieve a favorable outcome [40] . According to the literature, more than 60% of patients recovered completely, 30% of those with hormonal impairment or visual disturbance improved, and approximately 10% died after surgical and medical treatment [41] . Vates reported that approximately 54.2% of patients suffered from endocrine dysfunction before surgery, of which 38.5% did not improve postoperatively without developing a new pituitary dysfunction [42] .…”

Characteristics of inflammatory and infectious diseases of the pituitary gland in patients undergoing transsphenoidal surgery

“…Secondary pituitary abscess accounts for about 30% of the cases and typically occurs in patients with pre-existing pituitary lesions, most commonly adenomas [ 6 ], or iatrogenic, e.g. following pituitary surgery [ 8 ]. They can arise either from continuous spread from nearby structures, or hematogenous dissemination from distant sites.…”