Category: Pituitary Disorders/Neuroendocrinology
We are presenting a rare case of Pituitary disease to increase awareness and understanding of these cases which can prove fatal if misdiagnosed.
Methods : Case presentation.
A 75 year-old woman with a history of rheumatoid arthritis, on adalimumab, presented with generalized weakness and dizziness for 1 month. During work up, we discovered a pituitary macroadenoma with central necrosis measuring 15.1 x 12.7 x 12.2 cm. Endocrine testing suggested secondary adrenal insufficiency and hypothyroidism in addition to low LH and FSH with mildly elevated prolactin. Prolactin with serial dilutions did not show hook effect. She started levothyroxine and hydrocortisone with improvement of her symptoms. While recovering, she developed diabetes insipidus and was, therefore, started on desmopressin.
After 3 months, she developed periodic bouts of fever, headache, and visual abnormalities. These symptoms lasted several days, subsided for 2-3 weeks then came back repeatedly. Non-invasive infectious work up was negative. Due to these symptoms, a repeat MRI was obtained that demonstrated a more aggressive mass, so she underwent transsphenoidal surgery. When the dura was opened, a typical pus material was evacuated. Culture was positive for staphylococcus aureus. She was treated with antibiotics. Post-operative MRI showed complete resolution of the abscess. She felt dramatically better after treatment.
Pituitary abscess (PA) is a rare pituitary lesion that presents similarly to other pituitary lesions. The challenge is to distinguish PA from other lesions.
PA may occur in normal pituitary gland or, in pre-existing pituitary lesions like our patient. Previous irradiation, surgical procedures, and immunosuppression are additional risk factors. In most cases, etiology is unknown. Our patient presented with intermittent bouts of fever, headaches, and visual changes (common symptoms of PA) including symptoms of pituitary hormone deficiency.
Our patient had typical picture of PA but progressive aggressive appearance of the pituitary mass made it difficult to diagnose sooner as other pathologies were being explored.
PA present usually with panhypopituitarism and intermittent fevers, headaches and/or visual changes. PA usually has similar appearance to pituitary adenoma on MRI. When a patient has pituitary hormonal abnormalities and recurrent fever of unknown origin, PA should be part of differential diagnosis.
Tariq Alrasheed– Endocrinology Fellow, MSU Endocrinology fellowship program
Naveen Kakumanu– Assistant Professor of Medicine, MSU Endocrinology
Ghaydaa Adawi– Endocrinology Fellow, MSU Endocrinology, Holt, Michigan
George M Hebdon– Endocrinology Fellowship Director, MSU Endocrinology
Saleh Aldasouqi– Professor of Medicine and Chief of Endocrinology, Michigan State Universtiy
MSU Endocrinology fellowship program
Currently endocrinology fellow at MSU endocrinology
Assistant Professor of Medicine
Dr. Kakumanu joined the Department of Medicine at MSU on October, 2013. He graduated from Saint George’s University, School of Medicine in Grenada. He completed his residency in Internal Medicine at the Detroit Medical Center, Wayne State University and was Chief Medical Resident, ambulatory clinic preceptor at Harper/Hutzel University Hospital, Detroit Medical Center. He completed a Geriatric Fellowship at Wayne State University and received the Lavoisier Cardozo Award for Excellence in Geriatric Medicine. Endocrinology fellowship was completed at Henry Ford Hospital in 2013. He is board certified in Internal Medicine, Geriatric Medicine and Endocrinology. Has presented multiple posters and abstracts at the Endocrine Society, American Association of Clinical Endocrinologists and American Society for Bone and Mineral Research. His specialty in Endocrinology is diverse with interest in thyroid disorders, diabetes and bone metabolism.
Endocrinology fellow at MSU Endocrinology
Endocrinology Fellowship Director
G. Matthew Hebdon M.D., Ph.D. received his Ph.D. from the National Institute for Medical Research in London U.K. for work on the transport of Ca++ through lipid bilayers and the synthesis of lipid-selective photo-activated probes. Following post-Doctoral Research he was appointed Director of Chemotherapy for Glaxo Pharmaceuticals.
Dr. Hebdon received his M.D. from the University of North Carolina at Chapel Hill and completed Residencies in Internal Medicine and Pediatrics and Fellowships in Adult and Pediatric Endocrinology Nutrition and Metabolism at the University of Michigan. Before coming to Michigan State University he was at the University of Maryland. He is the Program Director for the Endocrinology and Metabolism Fellowship at M.S.U.