Background: pituitary abscess is a rare but potentially life-threatening disease that could lead to panhypopituitarism. It is important to suspect the diagnosis, especially in regions of the world with endemic infectious diseases.
Clinical Case: a 55-year, farmer, with a history of consumption of unpasteurized dairy products, began in February 2023 with headache, impaired consciousness and fever. Initial tests were consistent with neuroinfection: lumbar puncture with cerebrospinal fluid (CSF) with elevated proteins (>200 mg/dL, n <45 mg/dL), decreased glucose (14 mg/dL with a serum glucose of 76 mg/dl), pleocytosis (800 mm3, n <5 mm3). Head CT-scan did not report alterations. Treatment with ceftriaxone, vancomycin, ampicillin and acyclovir was started due to diagnosis of acute meningitis. Later Brain MRI was performed showing ventriculitis; the pituitary gland was heterogeneous with the presence of an 8x8mm abscess. Pituitary axis hormones were evaluated, showing results compatible with panhypopituitarism with central hypothyroidism (normal serum TSH 1.05 mIU/L (n 0.3-5 mIU/L), decreased free T4 0.57 ng/dL (n 0.63-1.34 ng/dL), decreased total T3 0.47 ng/mL (n 0.64-1.81 ng/mL)), central hypocortisolism (decreased morning cortisol levels 5.72 mcg/dL (n 6.7-22.6 mcg/dL) and ACTH 20 pg/mL (n 10-50 pg/ml)), central hypogonadism (decreased LH <0.20 mUI/mL (n 1.24-862 mUI/mL), decreased FSH 0.37 mUI/mL (n 1.27-19.26 mUI/mL), decreased testosterone 0.24 ng/mL (n 1.75-7.81 ng/mL)), growth hormone deficiency (decreased IGF-1 9.99 ng/mL (n 61-206 ng/mL)). Hormone replacement treatment with hydrocortisone and levothyroxine was started. Due to the epidemiological background, Rose Bengal test for Brucella spp. was performed, with positive results (n negative) and 2-mercaptoethanol Brucella agglutination test was also positive >1:20 (n <1:20). Diagnosis of neurobrucellosis was made and treatment with doxycycline, rifampin and ceftriaxone was started. Neurosurgery service suggested conservative management with antibiotics. Patient showed improvement in his
neurological status and infectious symptoms disappeared. Subsequent pituitary MRI showed pituitary intraglandular abscess with a 15% decrease. The patient was discharged six weeks later with prednisone, levothyroxine, somatropin and testosterone, as well as doxycycline and rifampin for another 4 months.
Conclusion: Pituitary abscess should be considered in a differential diagnosis of patients with neuro infection symptoms, panhypopituitarism and heterogenous image in the MRI. Opportune medical management may result in a lower mortality and a higher recovery of pituitary hormone function.