Atypical pituitary abscess lacking rim enhancement and diffusion restriction with an unusual organism, Moraxella catarrhalis: A case report and review of the literature

Background: Pituitary abscess (PA) can be fatal if diagnosed late. Rim enhancement is a typical radiological finding of PA on postgadolinium T1-weighted magnetic resonance imaging (MRI). Diffusion-weighted imaging is helpful in distinguishing PA from other sellar cystic lesions. Herein, we report the first atypical case of PA showing neither rim enhancement nor diffusion restriction with an unusual organism, Moraxella catarrhalis. Case Description: A 77-year-old woman presented with headache, polyuria, polydipsia, and fatigue for a month before presenting to a local hospital. MRI showed pituitary enlargement with contrast enhancement. She had neither fever nor visual deficits and was followed up with hormonal replacement. Six months later, she complained of visual impairment, and MRI showed further pituitary enlargement with a thickened stalk compressing the optic chiasma. Neither rim enhancement nor diffusion restriction was observed. Endoscopic endonasal transsphenoidal surgery was performed based on the radiological diagnosis of lymphocytic hypophysitis or pituitary tumors. A thick, creamy yellow pus was drained from the sellar lesion. Intraoperative rapid histopathological findings revealed polymorphonuclear leukocytes infiltrating the pituitary gland. PA was diagnosed, and irrigation and open drainage of the abscess was performed. Bacterial culture of the pus detected M. catarrhalis by mass spectrometer, confirming the diagnosis. She underwent appropriate antibiotic administration, and her visual deficits improved. Conclusion: We report the first atypical case of PA showing neither rim enhancement nor diffusion restriction with M. catarrhalis. Even if preoperative findings are not suggestive of PA, it should be considered as a differential diagnosis. Intraoperative rapid histopathological findings are useful for accurately diagnosing PA and initiating appropriate surgical treatment.

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Lymphocytic hypophysitis: a rare or underestimated disease?

Acta Endocrinologica ◽

10.1530/eje.0.1490363 ◽

2003 ◽

Vol 149 (5) ◽

pp. 363-376 ◽

Cited By ~ 140

Author(s):

A Bellastella ◽

A Bizzarro ◽

C Coronella ◽

G Bellastella ◽

AA Sinisi ◽

...

Keyword(s):

Visual Field ◽

Plasma Cells ◽

Immunohistochemical Analysis ◽

Spontaneous Remission ◽

Lymphocytic Hypophysitis ◽

Pituitary Hormone ◽

Endocrine Disorders ◽

Pituitary Cells ◽

Optic Chiasma ◽

Pituitary Enlargement

Lymphocytic hypophysitis (LYH) is an uncommon autoimmune disease in which the pituitary gland is infiltrated by lymphocytes, plasma cells and macrophages and its function is usually impaired. It has to be suspected in pregnant women and in women with recent delivery presenting with hyperprolactinemia, headache, visual field alterations and changes of one or more pituitary hormone secretions with secondary impairment of related peripheral target glands, especially when associated with other autoimmune endocrine or non-endocrine disorders. It can also occur less frequently in prepubertal or post-menopausal women and in men. Headache, visual field impairment and more rarely diplopia are due to extrasellar pituitary enlargement with optic chiasma compression and/or to invasion of cavernous sinuses. Among the 'isolated' pituitary hormone deficiencies, ACTH deficit is usually the earliest and most frequent hormonal impairment and in rare cases can induce an acute secondary hyposurrenalism as the first sign of the disease, with high mortality in affected patients. Histopathological findings from pituitary biopsy show lymphoplasmacytic infiltrate with lymphoid aggregates surrounding atropic acini of pituitary cells; immunohistochemical analysis shows numerous mast cells randomly distributed and also localized in the vicinity of capillaries, suggesting a possible influence on capillary permeability and angiogenesis, thus favoring the inflammatory and immunological aggression against pituitary cells. Nuclear magnetic resonance imaging shows uniform sellar floor depression and an extrasellar symmetrical pituitary enlargement, usually displacing the optic chiasma, which shows a rapid homogeneous enhancement after gadolinium also involving the adjacent dura (dural tail). Antipituitary antibodies have been detected in several patients with LYH but their role needs to be clarified. Since a possible spontaneous remission can occur, a careful follow-up is required in subclinical patients without important hyposurrenalism or symptomatic extrasellar expansion. Medical (immunosuppressive, replacement and antiprolactinemic) and neurosurgical (decompression) treatments are needed in clinical symptomatic patients.

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Histopathological findings suggest the diagnosis in an atypical case of Pendred syndrome

Clinical Otolaryngology ◽

10.1046/j.1365-2273.1999.00308.x ◽

1999 ◽

Vol 24 (6) ◽

pp. 523-526 ◽

Cited By ~ 3

Author(s):

H. Gill ◽

L. Michaels ◽

P. D. Phelps ◽

W. Reardon

Keyword(s):

Pendred Syndrome ◽

Atypical Case ◽

Histopathological Findings

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Role of Diffusion Weighted Imaging in Characterization of Intracranial Rim Enhancing Lesions

Nepalese Journal of Radiology ◽

10.3126/njr.v9i2.27417 ◽

2020 ◽

Vol 9 (2) ◽

pp. 17-23

Author(s):

Ajit Thapa ◽

Sundar Suwal ◽

Dinesh Chataut ◽

Kamal Subedi

Keyword(s):

Brain Abscess ◽

Sensitivity And Specificity ◽

Diffusion Weighted Imaging ◽

Primary Brain Tumor ◽

Diffusion Restriction ◽

Diffusion Weighted ◽

Rim Enhancement ◽

Mri Characteristics ◽

Normal White Matter

Introduction: The differentiation of rim enhancing abscess from high grade necrotic lesions is difficult in conventional imaging. Our purpose was to assess the role of diffusion weighted imaging of intracranial rim enhancing lesions to differentiate the etiologies. Methods: Fifty one patients, 32 male and 19 female with mean age of 48.47 years and with rim enhancing intracranial lesions in magnetic resonance imaging, who underwent surgery from January 2012 to December 2012, were studied for different characteristics of the lesions in DWI and pathologically correlated the observed findings. Results: Out of 58 rim enhancing lesions 21 were primary brain tumor, 18 abscess, 14 metastasis and 5 neurocysticercosis. Twenty lesions had restricted diffusion in center, 22 lesions had thin smooth enhancing rim and 23 lesions were with low T2 complete rim. Diffusion restriction at non enhancing center of the lesion and thin smooth enhancing rim have sensitivity and specificity of 88.89% and 90.24% (p <0.0001) for brain abscess and 83.33% and 80.49% (p <0.0001) for other lesions. ADC ratio of center to that of normal white matter showed sensitivity and specificity of 88.9% and 90% respectively (p <0.0001) at cut off point of 1.09. Lesions with thin smooth rim enhancement with diffusion restriction in nonenhancing center are 100% specific for brain abscess. Conclusions: On studying the different MRI characteristics of rim enhancing lesions, combining enhancement characteristic with DWI is more helpful in coming to the proper diagnosis.

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The Posterior Transpetrosal Approach in a Case of Large Retrochiasmatic Craniopharyngioma: Operative Video and Technical Nuances

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0037-1620252 ◽

2018 ◽

Vol 79 (S 02) ◽

pp. S205-S207 ◽

Cited By ~ 1

Author(s):

Moujahed Labidi ◽

Kentaro Watanabe ◽

Marie-Pier Loit ◽

Shunya Hanakita ◽

Sébastien Froelich

Keyword(s):

Adjuvant Therapy ◽

Third Ventricle ◽

Tumor Resection ◽

Mass Effect ◽

Venous Anatomy ◽

Endoscopic Endonasal ◽

Optic Chiasma ◽

Visual Deficits ◽

The Third ◽

Accelerated Growth

Objectives To discuss the use of the posterior petrosal approach for the resection of a retrochiasmatic craniopharyngioma. Design Operative video. Results In this case video, the authors discuss the surgical management of a large craniopharyngioma, presenting with mass effect on the third ventricle and optic apparatus. A first surgical stage, through an endoscopic endonasal transtubercular approach, allowed satisfactory decompression of the optic chiasma and nerves in preparation for adjuvant therapy. However, accelerated growth of the tumor, with renewed visual deficits and mass effect on the hypothalamus and third ventricle, warranted a supplementary resection. A posterior transpetrosal1 2 (also called “retrolabyrinthine transtentorial”) was performed to obtain a better exposure of the tumor and the surrounding anatomy (floor and walls of the third ventricle, perforating vessels, optic nerves, etc.)3. Nuances of technique and surgical pearls related to the posterior transpetrosal are discussed and illustrated in this operative video, including the posterior mobilization of the transverse–sigmoid sinuses junction, preservation of the venous anatomy during the tentorial incision, identification and preservation of the floor of the third ventricle during tumor resection, and a careful multilayer closure. Conclusion Retrochiasmatic craniopharyngiomas are difficult to reach tumors that often require skull base approaches, either endoscopic endonasal or transcranial. The posterior transpetrosal approach is an important part of the surgical armamentarium to safely resect these complex tumors.The link to the video can be found at: https://youtu.be/2MyGLJ_v1kI.

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MON-241 Dome Shaped Pituitary Enlargement Warrants Detailed Endocrine Evaluation Prior to Neuro-Surgical Intervention: Case Series & Analysis

Journal of the Endocrine Society ◽

10.1210/jendso/bvaa046.1242 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

Author(s):

Satyam Chakraborty

Keyword(s):

Short Stature ◽

Surgical Intervention ◽

Case Series ◽

Primary Amenorrhea ◽

Conservative Approach ◽

Post Contrast ◽

Optic Chiasma ◽

Imaging Characteristics ◽

Pituitary Enlargement ◽

Severe Short Stature

Abstract Pituitary tumours diagnosed incidentally on imaging as sellar-suprasellar masses, often undergo unwarranted Neuro-surgical intervention, often leading to the requirement of life-long post-operative hormone supplementation. Although surgery remains the primary modality in most of the Functional (except Prolactinomas) & Non-Functional Pituitary Macro-Adenomas abutting the Optic Chiasma, Several cases are feed-back adenomas due to untreated Hypothyroidism or Drug- Induced Hyperprolactinemia which require a conservative approach. These Pituitary enlargements may not only be Sellar but also at times extend Supra-sellar mimicking a surgically resctable one. In adolescents they come with a constellation of features like severe short stature & primary Amenorrhea in Females. Noteworthy that these symptoms appear commonly in both groups of surgically resectable masses as well as the secondary pituitary enlargements which need conservative approach, thus often resulting in inadvertent Surgical misadventures. We report 3 cases of Adolescent females referred from peripheral centre to the Neuro-Surgical take of our Institute. Both the females had severe short stature with primary amenorrhea. The imaging characteristics in all the three patients were unique in the sense that they had uniform enlargement of the entire Pituitary extending supra-sellar without any focal hypo-intensities without any obvious mid-line shift of the Pituitary stalk & enhanced uniformly in Post-Contrast studies. We also observed that the upper margin of the masses had a uniform convexity resembling a “DOME”. Thorough Endocrine work-up revealed severe Untreated Hypothyroidism with S.TSH greater then 100micro IU/ml. The patients were treated conservatively with Levo-thyroxine supplementation. The patients had significant Height gain with menarche in the following 4-6 months of Therapy. S.TSH normalized after 2-3 months of therapy. Repeat imaging after 6 months of therapy revealed normal Pituitary architecture without the presence of any focal lesions or enlargement. Feedback Adenomas of the Pituitary have been depicted in the literature. “DOME” shaped Pituitary enlargement seems quite unique to all Pituitary masses which can be treated with conservative means. Pituitary masses should therefore undergo thorough Endocrine intervention before any Neuro-Surgical intervention is contemplated, specifically when the incidentally discovered masses have a “DOME” shaped symmetrical upward convexity on imaging.

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Ultrastructure of the lesion induced by toxin T-514 isolated from K. humboldtiana in the alveolar region of the lung

Proceedings, annual meeting, Electron Microscopy Society of America ◽

10.1017/s042482010012360x ◽

1992 ◽

Vol 50 (1) ◽

pp. 640-641

Author(s):

Julio Sepúlveda-Saavedra ◽

Beatriz González-Corona ◽

Víctor A. Tamez Rodríguez ◽

Ma. Victoria Bermúdez de Rocha ◽

Alfredo Piñeyro López

Keyword(s):

Electron Microscope ◽

Guinea Pig ◽

Macaca Fascicularis ◽

Osmium Tetroxide ◽

Lead Citrate ◽

Severe Damage ◽

Thin Sections ◽

Alveolar Region ◽

Histopathological Findings

It has been shown in previous studies that the toxin T-514 isolated from K. humboldtiana induces severe damage to the lung in treated rodents. Histopathological findings include edema, and alveolar hemorrage. However, the ultraestructure of the lesion has not been investigated. In this study we used two species of rodents: Hamster and guinea pig, and a primate: Macaca fascicularis. Animals received different single dosis of the toxin via intraperitoneal. Control animals received only the vehicle (propylen glycol). Inmediately after spontaneous death, lung samples were fixed in Karnovsky-Ito fixative, post fixed in osmium tetroxide and embedded in epon. Thin sections were prepared with an Ultratome V LKB, stained with uranly acetate and lead citrate, and studied in an electron microscope Zeiss-EM109.

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