Abstract
Case presentation A 25-year-old female presented to emergency with 2 days of severe bifrontal headache associated with nausea and rigors. This was on the background of a 3-month history of progressively worsening episodic left-sided frontal headache. Non-contrast magnetic resonance imaging (MRI) of her brain 2 months prior demonstrated a 19x11x13mm pituitary cystic mass. At the time, macroadenoma was the provisional diagnosis and outpatient neurosurgical follow up was arranged. She had no medical history and worked as a doctor.
On admission she was alert and afebrile, with an unremarkable neurological exam. Tests on admission showed a mild neutrophilia, low T3/T4 with normal TSH. MRI demonstrated a 10x21x13mm cystic sellar mass with peripheral contrast enhancement. The lesion was hypointense on T1 and hyperintense on T2.
Immediately after her scan she became febrile, developed nuchal rigidity and confusion. She was treated empirically for meningo-encephalitis. Lumbar puncture(LP) revealed a white cell count of 1777x106 (70% polymorphonuclear, 30% mononuclear cells), protein 0.83g/L and glucose 2.3mmol/L. The possibility of a pituitary abscess(PA) was raised and she was transferred to a neurosurgical unit.
The next day trans-sphenoidal drainage was performed where frank pus was drained, confirming the diagnosis. Histopathology showed a Rathke’s cleft cyst with superimposed infection. No pathogen was isolated. Post-operatively she developed diabetes insipidus, low cortisol and hypothyroidism. The patient was commenced on hormonal replacement and completed 4 weeks of IV ceftriaxone and metronidazole.
Post-operative MRI showed a reduction in size of the lesion. Follow up at 4 weeks revealed resolution of her symptoms.
