Category: Pituitary Disorders/Neuroendocrinology
Aspergillosis is a well-recognized cause of paranasal sinus infection. Mucormycosis is a rare opportunistic infection, usually found in immunocompromised hosts. Both very rarely involve the pituitary gland, but can be misdiagnosed as pituitary tumors, which may delay appropriate treatment.
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A 68 year-old woman with past medical history of well controlled type 2 diabetes mellitus and pituitary adenoma that was resected in 1999 with resulting panhypopituitarism, requiring chronic hydrocortisone and levothyroxine replacement, presented to our hospital with complaint of 8 months of headaches, worsening vision in the left eye and acute on chronic confusion. On exam, the patient was afebrile, and hemodynamically stable. She was somnolent and oriented only to person. She had left eye ptosis and was unable to count fingers with left eye. Otherwise, the remainder of the exam was unremarkable. Blood count and biochemical profile were normal. Brain MRI showed a 16 x 19 x 24mm heterogeneously enhancing sellar/suprasellar mass with enhancement of the optic chiasm, left optic nerve and hypothalamus and extension into the sphenoid sinus and bilateral cavernous sinuses. Recurrence of pituitary tumor was suspected, with limited role for surgical excision due to the chronic nature of the vision loss. The patient underwent transsphenoidal surgical resection with findings of a very firm mass, invading into the left optic nerve and left carotid artery, as well as a dusky, deformed and thin left optic nerve. Pathology showed fungal elements. Since infection was not originally suspected microbial culture were not sent. PCR of tissue was positive for Aspergillus, however, morphologically it was thought to be Mucorales. She was treated with Ambisome, micafungin and voriconazole with plan to continue voriconazole for at least 6 months. Subsequently, the patient suffers persistent vision loss in the left eye, but mental status and headache has improved with the patient now alert and oriented.
This is an unusual case of fungal infection of the pituitary gland. Less than 10 cases of pituitary aspergillosis and only one case of mucorales infection have been described in the literature, and most of these were found post-mortem on autopsy. Our patient has two risk factors that could have attributed to this infection, including diabetes and previous history of pituitary surgery. Although fungal infections of the pituitary gland are very rare, they should be considered, especially in patients with previous history of pituitary surgery and in tumors with unusual features. In those cases, microbial cultures of the surgical sample should be sent for definitive diagnosis.
Clinical Endocrinology Fellow
University of Southern California
Los Angeles, California
Dina Kamel, MD, is a second year clinical endocrinology fellow at the University of Southern California. Dr. Kamel is board certified in internal medicine. She attended medical school at Loma Linda University school of medicine and complete a residency in internal medicine and the Los Angeles County + University of Southern California Medical Center. Her areas of interest included pituitary disease, thyroid disease and diabetes mellitus.
Associate Professor of Clinical Medicine;Co-Director, Pituitary Program at Keck Medical Center
University of Souther California
John D. Carmichael, MD, is Associate Professor of Clinical Medicine in the Department of Medicine's Division of Endocrinology & Diabetes, and Department of Neurological Surgery, and Co-Director of the USC Pituitary Center at the Keck School of Medicine of USC.
Dr. Carmichael is board certified in internal medicine and diabetes, endocrinology and metabolism. His clinical and research interests include the diagnosis and treatment of pituitary disease.
He sits on the editorial board for Pituitary and currently serves on the Board of Directors for the Pituitary Society. He is also a member of the Endocrine Society, where he has served on the Special Programs committee and the American association of Clinical Endocrinologists where he serves on the Pituitary Scientific Committee.
After finishing his clinical training at NYU in 2004, Dr. Carmichael worked as a clinical researcher at NYU focusing on clinical trials in pituitary disease. He received a grant from Genentech to support his work during this time. In 2006, he went on to work at Cedars-Sinai Medical Center in their pituitary center. His work included care of patients with pituitary disease and clinical research in the diagnosis and treatment of patients with pituitary tumors. He held an appointment in the department of medicine at UCLA, devoting his time to the education of medical students, residents and fellows in multiple topics related to pituitary disorders. In 2014, Dr. Carmichael joined the faculty at the Keck School of Medicine of USC. Since that time he has directed a multidisciplinary team at the USC Pituitary Center. He is the course director for the Annual Southern California Pituitary Symposium held at USC in the spring, now in its 4th year.