Pituitary aspergilloma

Case contributed by Aoun Rizvi

Presentation

Recurrent headaches in an immunosuppressed renal transplant patient.

Patient Data

Age: 55 years
Gender: Male

Initial MRI

mri

A non-contrast MRI of the brain was performed due to poor renal function.

Mild paranasal mucosal thickening. Mastoid air cells are clear. There are multiple scattered periventricular and subcortical T2 FLAIR hyperintense foci. There is no vasogenic edema. No sulcal or ventricular effacement. No extra-axial collection.

No other intracranial pathology.

Note: no definitive cause of symptoms found.

Patient re-presented 4 months later with a persistence and worsening of his recurrent headaches.

MRI 4 months later

mri

There is a 15mm x 20mm x 17mm hypointense mass that is expanding in the sella turcica that could represent a pituitary macroadenoma. There is slight extension of the mass into the suprasellar cistern but there is no concomitant compression of the optic chiasma. 

Normal optic tracts and optic nerves. 

There is moderate left sphenoid sinusitis and minor right sphenoid sinusitis.

There is no hydrocephalus, no intracranial hemorrhage, and normal anatomy of the craniocervical junction. 

Several days later, the patient developed a left cranial nerve III palsy and complained of diplopia. He was therefore transferred to a neurosurgical center at a tertiary hospital, where at first a transsphenoidal pituitary biopsy was performed. The lesion was seen to contain pus and be oozing macroscopically at surgery.

pathology

Transsphenoidal biopsy: fibrous connective tissue with dense mixed acute and chronic cell infiltrate with colonies of fungal hyphae and spores (ie fungal balls). The fungus demonstrates acute angle branching with septae – consistent with Aspergillus. No evidence of angioinvasion. Occasional preserved pituicytes. No evidence of malignancy. Aspergillus Fumigatus grown.

The patient soon after underwent neurosurgical evacuation of the pituitary fossa. At the 2 month follow-up, the patient reported resolution of his headaches and diplopia, and was able to resume working.

Case Discussion

The diagnosis of pituitary aspergilloma was made in this patient who had received a renal transplant and was on immunosuppressive agents. Before the advent of immunosuppressants, fungal infections of the central nervous system were rare. Reported cases of primary pituitary aspergillosis often have associated sinus aspergillosis, as demonstrated in the above case, where the patient had sphenoid sinus disease and fungal colonization.

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