Diagnosis and Treatment > Signs and Symptoms > Visual impairment

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Anne Soejbjerg Department of Internal Medicine, Silkeborg Regional Hospital, Silkeborg, Denmark

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Suzan Dyve Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark

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Steen Baerentzen Department of Pathology, Aarhus University Hospital, Aarhus, Denmark

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Georg Thorsell Department of Hematology, Aarhus University Hospital, Aarhus, Denmark

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Per L Poulsen Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark

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Jens O L Jorgensen Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark

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Ulla Kampmann Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark

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Summary

Solitary sellar plasmacytomas are exceedingly rare and difficult to distinguish from other pituitary tumors. We report a case of a 62-year-old woman presenting with blurred vision of the right eye and tenderness of the right temporal region, which was interpreted as temporal arteritis. MRI revealed a pituitary mass lesion (20mm×14mm×17mm) without compression of the optic chiasm and her pituitary function was normal. Pituitary surgery was undertaken due to growth of the lesion, and histopathological examination showed a highly cellular neoplasm composed of mature monoclonal plasma cells. Subsequent examinations revealed no evidence of extrasellar myeloma. The patient received pituitary irradiation and has remained well and free of symptoms apart from iatrogenic central diabetes insipidus. Until now, only eight cases of solitary sellar plasmacytoma have been reported. Most frequent symptoms stem from compression of the cranial nerves in the cavernous sinus (III, IV, V), whereas the anterior pituitary function is mostly intact.

Learning points

  • A solitary plasmacytoma is a rare cause of a sellar mass lesion.

  • The radiological and clinical features are nonspecific, but cranial nerve affection and intact pituitary function are usually present.

  • The diagnosis is made histologically and has important therapeutic implications.

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Apostolos K A Karagiannis Department of Endocrinology, Diabetes and Metabolism, Korgialeneio Benakeio EES, Peripheral General Hospital Athens, Athens, Greece

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Fotini Dimitropoulou Department of Endocrinology, Diabetes and Metabolism, Korgialeneio Benakeio EES, Peripheral General Hospital Athens, Athens, Greece

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Athanasios Papatheodorou Department of Radiology, Korgialeneio Benakeio EES, Peripheral General Hospital Athens, Athens, Greece

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Stavroula Lyra Department of Radiology, Korgialeneio Benakeio EES, Peripheral General Hospital Athens, Athens, Greece

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Andreas Seretis Department of Neurosurgery, General Hospital of Athens ‘G. Gennimatas’, Athens, Greece

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Andromachi Vryonidou Department of Endocrinology, Diabetes and Metabolism, Korgialeneio Benakeio EES, Peripheral General Hospital Athens, Athens, Greece

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Summary

Pituitary abscess is a rare life-threating entity that is usually misdiagnosed as a pituitary tumor with a definite diagnosis only made postoperatively. Over the last several decades, advances in healthcare have led to a significant decrease in morbidity and mortality due to pituitary abscess. We report a case of a 34-year-old woman who was admitted to our department for investigation of a pituitary mass and with symptoms of pituitary dysfunction, headaches and impaired vision. During her admission, she developed meningitis-like symptoms and was treated with antibiotics. She eventually underwent transsphenoidal surgery for excision of the pituitary mass. A significant amount of pus was evident intraoperatively; however, no pathogen was isolated. Six months later, the patient was well and had full recovery of the anterior pituitary function. Her menses returned, and she was only on treatment with desmopressin for diabetes insipidus that developed postoperatively.

Learning points

  • Pituitary abscess is a rare disease and the reported clinical features vary mimicking other pituitary lesions.

  • The diagnosis of pituitary abscess is often very difficult to make and rarely included in the differential.

  • The histological findings of acute inflammatory infiltration confirm the diagnosis of pituitary abscess.

  • Medical and surgical treatment is usually recommended upon diagnosis of a pituitary abscess.

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Niki Margari Department of Endocrinology and Diabetes, Royal London Hospital, Barts Health NHS Trust, London, UK

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Jonathan Pollock Department of Neurosurgery, Queens Hospital, Barking Havering and Redbridge University Hospitals NHS Trust, Romford, Essex, UK

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Nemanja Stojanovic Department of Endocrinology and Diabetes, Queens Hospital, Barking Havering and Redbridge University Hospitals NHS Trust, Romford, Essex, UK

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Summary

Prolactinomas constitute the largest subsection of all secretory pituitary adenomas. Most are microprolactinomas and are satisfactorily treated by medical management alone. Giant prolactinomas, measuring more than 4 cm in diameter, are rare and usually occur more commonly in men. Macroprolatinomas tend to present with symptoms of mass effect rather than those of hyperprolactinaemia. Dopamine agonists (DA) are the treatment of choice for all prolactinomas. Surgery is usually reserved for DA resistance or if vision is threatened by the mass effects of the tumour. We describe the case of a 52 year-old woman with a giant invasive prolactinoma who required multiple surgical procedures as well as medical management with DA. One of the surgical interventions required a posterior approach via the trans cranial sub occipital transtentorial approach, a surgical technique that has not been previously described in the medical literature for this indication. The giant prolactinoma was reduced significantly with the above approach and patient symptoms from the compressing effects of the tumour were resolved. This case highlights the importance of a multidisciplinary approach to the management of such patients who present with florid neurological sequelae secondary to pressure effects. Although this presentation is uncommon, surgery via a sub occipital transtentorial approach may be considered the treatment of choice in suitable patients with giant invasive prolactinomas compressing the brainstem.

Learning points

  • Giant prolactinomas present with symptoms of mass effect or those of hyperprolactinaemia.

  • Interpretation of the pituitary profile is crucial to guide further investigations and management.

  • Treatment of giant invasive prolactinomas may involve a combination of medical management and multiple surgical interventions.

  • Treatment with DA may cause pituitary haemorrhage or infarction in patients with these tumours.

  • A sub occipital transtetorial approach may be considered the treatment of choice in invasive prolactinomas compressing the brainstem.

  • Multidisciplinary approach of such patients is fundamental for a better outcome.

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