Pituitary region abscesses are rare, comprising less than 1% of all pituitary lesions.
They are classified as either primary or secondary, with primary abscesses occurring
in a normal pituitary gland and secondary abscesses associated with underlying intrasellar
pathologies such as craniopharyngioma, Rathke’s cleft cyst, or pituitary adenoma.
Approximately one-third of pituitary region abscesses are secondary. Craniopharyngioma,
a slow-growing benign tumor of the sellar and suprasellar regions, can cause significant
endocrinological and neurological deficits due to its proximity to the hypothalamus
and pituitary stalk. This study presents two cases of secondary pituitary abscesses
within papillary craniopharyngiomas, highlighting their clinical presentation, management,
and outcomes.
Case I: A 60-year-old male presented with a history of a sellar and suprasellar lesion diagnosed
7 years earlier, with progressive symptoms of hypogonadism, hypothyroidism, and headaches
over the past three years. He experienced fatigue, nausea, mental status changes,
and found to have bitemporal hemianopsia, severe hypopituitarism, and hyponatremia.
A new brain MRI revealed an enlarging cystic lesion with diffusion-weighted imaging
(DWI) changes. Endoscopic endonasal approach (EEA) surgery revealed a white viscous
material, and cultures grew Staphylococcus and Corynebacterium species. Pathology confirmed a papillary craniopharyngioma with a BRAF mutation.
The patient showed significant improvement following surgery, antibiotic therapy,
and correction of hypopituitarism, with full recovery of vision and no recurrence
on serial imaging.
Case II: Patient is 61-year-old female who was initially diagnosed with a sellar and suprasellar
lesion 17 years before in another country. She underwent endocrinological assessment
revealing diabetes insipidus (DI) and has been treated with desmopressin. She presented
to emergency department with a 1-week history of progressive headaches, decreased
energy, nausea, fevers, bitemporal hemianopsia, and severe hypopituitarism, with a
new brain MRI revealing a large cystic lesion in the sellar and suprasellar space
with DWI changes within the lesion. Patient underwent an EEA) which revealed a white,
viscous material. The cyst was evacuated. Sella was reconstructed. Pathology was nondiagnostic
and cultures showed no growth. Patient improved after the surgical treatment, antibiotherapy
and correction of hypopituitarism and her vision recovered. She represented to ED
2 weeks later with worsening vision and a new MRI showed recollection of the cyst.
She was taken back marsupialization. New pathology sample confirmed papillary craniopharyngioma.
Her vision recovered. She has been followed up by serial imaging with no recurrence.
Conclusion: Secondary pituitary abscesses within craniopharyngiomas, although extremely rare,
are serious conditions with a high mortality rate. They require urgent surgical intervention,
antibiotic therapy, and management of endocrinological abnormalities. Both cases demonstrated
significant clinical improvement posttreatment, emphasizing the importance of timely
diagnosis and comprehensive and multidisciplinary management in these patients.
