MON-422 A Case Report of Pituitary Abscess in the Setting of Recurrent Meningitis

Introduction: Pituitary abscess is a rare but life threatening condition. There have been a few cases reporting the association of pituitary abscess and recurrent meningitis. Due to the nonspecific clinical features and ambiguous imaging findings, definitive diagnosis can only be made post operatively. Case description: A 27-year-old Hispanic male with history of type 2 diabetes was admitted for a third episode of meningitis in two years. Each of the three times, he experienced similar symptoms of headache, fever, chills and neck stiffness. Within this time frame, he also started to experience polyuria, polydipsia, decreased body hair and infertility. Following two admissions for presumed bacterial meningitis, his third lumbar puncture revealed aseptic meningitis with no organism isolated on all three cerebrospinal fluid cultures. He was treated with intravenous vancomycin and ceftriaxone for presumed bacterial meningitis for these recurrences. MRI of brain with contrast revealed a non-enhancing mildly thick walled cystic 1.3 x 1.5 AP x 1.7 cm pituitary mass centered within sellae with suprasellar extention concerning for macro-adenoma versus pituitary abscess. There was no compression of the optic chiasm. His physical exam was normal except poor dentition. Patient underwent urgent trans-sphenoidal surgery (TSS) for excision of the pituitary mass. The surgical pathology revealed necrotic inflammatory debris and foam cells compatible with pituitary abscess. Post-operatively, he experienced pan-hypopituitarism and required hormone replacement therapy including hydrocortisone, levothyroxine and desmopressin. A significant clinical response was noted with improvement in polydipsia and polyuria. Later, the surgical pituitary abscess culture grew Antinomyciodontolyticus susceptible to penicillin. Patient endorsed having dental abscess requiring a tooth extraction four years ago and it was thought to be the likely source of an intracranial abscess. Antibiotics were de-escalated to IV penicillin G for 6 weeks followed by oral amoxicillin. He continued to do well on three month follow up. He requires lifelong multiple hormone-replacements for permanent pan-hypopituitarism. Discussion: In this report, we present a rare case of recurrent meningitis leading to pituitary abscess and complicated by pan-hypopituitarism, successfully treated with trans-sphenoidal resection, prolonged antibiotics and lifelong hormonal replacement. Most cases of pituitary abscess with meningeal involvement are aseptic, and the exact pathogen remains unclear. Definite diagnosis can be made postoperatively. TSS with biopsy is diagnostic and possibly curative for pituitary abscess. As with other pituitary surgeries, the risk of pan-hypopituitarism is high, and may require multiple hormone replacement post operatively.