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Transient Pituitary Enlargement with Central Hypogonadism Secondary to Bilateral Cavernous Sinus Thrombosis

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Transient Pituitary Enlargement with Central Hypogonadism Secondary to Bilateral Cavernous Sinus Thrombosis European Journal of Endocrinology (2009) 160 873–875 ISSN 0804-4643 CASE REPORT Transient pituitary enlargement with central hypogonadism secondary to bilateral cavernous sinus thrombosis: pituitary oedema? Michael Joubert1, Renaud Verdon2 and Yves Reznik1 1Endocrinology Unit, University Hospital of Caen, 14033 Caen Cedex, France and 2Infectious Diseases Unit, University Hospital of Caen, 14033 Caen Cedex, France (Correspondence should be addressed to M Joubert; Email: [email protected]) Abstract Design: We report the case of an incidental pituitary mass discovered in the context of bilateral cavernous sinus thrombosis due to a bacterial pansinusitis. Conclusions: Magnetic resonance imaging features of the pituitary lesion, together with transient central hypogonadism and total regression of the mass after anticoagulation and antimicrobial therapy, suggest that this lesion is a pituitary oedema of vascular mechanism. Other possible causes of pituitary mass in such a situation are also discussed. European Journal of Endocrinology 160 873–875 Introduction protein. Skull CT scan showed air–fluid levels, mucosal oedema, and air bubbles within maxillary, frontal, Clinically unsuspected lesions within the pituitary are ethmoidal and sphenoidal sinuses. Cerebrospinal fluid found in up to 10% of autopsy series and in up to 38% (CSF) examination excluded subarachnoid haemor- of magnetic resonance imaging (MRI) series (1, 2). rhage but revealed a white blood cell count above Availability and sensitivity of MRI raises the question 1000/ml, low glucose concentration, high protein of how to manage these previously unrecognized lesions. concentration (650 mg/dl) and the presence of a Pituitary adenomas are the first aetiology for sellar methicillin-sensitive Staphylococcus aureus, all features masses, accounting for 10% of all intracranial suggestive of bacterial meningitis. The bacteria was also neoplasms and 80% of pituitary masses. Less frequently identified in blood and probably originated from the involved lesions include craniopharyngioma, Rathke pansinusitis previously diagnosed. An i.v. antimicrobial cyst, meningioma, chordoma, pituitary carcinoma, therapy including cloxacilline (12 g/day), gentamicin pituitary granuloma, metastases and pituitary abscess (3 mg/kg per day) and metronidazole (1.5 g/day) was (3). Pituitary abscess occur exceptionally from localized initiated promptly and the clinical and biological sepsis or generalized infection and surgical drainage is resumed rapidly. Thereafter, the patient unexpectedly generally mandatory for its cure (4). We report an developed a bilateral orbital oedema. A skull MRI was incidentally discovered pituitary mass in a patient with performed; on coronal contrast-enhanced T1-weighted septic bilateral cavernous sinus thrombosis. The image, sinus thrombosis involving both cavernous spontaneous resolution of the lesion suggests an sinuses was seen, which narrowed the carotid within original mechanism involving an oedema of the its cavernous portion and bulged the cavernous sinus pituitary secondary to cavernous sinus thrombosis. with irregular gadolinium enhancement. A homo- geneous pituitary enlargement bordering the optic chiasm was also observed (Fig. 1A). On T2-weighted Case report image, pituitary enlargement was iso-intense. Anterior pituitary hormone testing revealed hypogonadotrophic A 32-year-old woman presented with generalized head- hypogonadism while other pituitary functions were ache together with 39 8C fever. On clinical examination, normal (Table 1). Diuresis and electrolytes analysis photophobia and typical signs of meningitis were showed no diabetes insipidus. Intravenous heparin observed. Neither neurological symptom nor altered trial was initiated then replaced by an oral vitamin K mental status was found. Standard biological screening inhibitor for 3 months together with antimicrobial showed accelerated erythrocyte sedimentation rate, therapy maintained for 4 months. Periorbital oedema elevated white blood cell count and high C-reactive resumed within 1 week. q 2009 European Society of Endocrinology DOI: 10.1530/EJE-08-0954 Online version via www.eje-online.org Downloaded from Bioscientifica.com at 09/25/2021 08:15:50PM via free access 874 www.eje-online.org driven not only through portaldeficiency. vessels Anterior but pituitary also blood through supply istransient principally pituitary enlargement and pituitaryVascular hormone anatomy ofthe the context pituitary ofoedema may bilateral secondary explain cavernousWe to sinus hypothesize the that thrombosis. reduced our patient venous developedDiscussion a drainage pituitary in nous sinus and pituitaryanticoagulation aspect. and antimicrobial therapy,homogeneous normalization enlargement of (arrow). caver- (B)sinus After with 3 irregular months enhancement; ofintra-cavernous arrowheads) oral segment and of pituitary theimage). carotid (A) artery Bilateral and cavernous bulging sinusFigure of thrombosis the (narrowing 1 of the tion ( cavernous thrombosis and sphenoidalcomplete sinuses regression infiltra- were of all normalized ( thefunctions pituitary and enlargement, menstrual biological cycles inflammatoryacute were parameters episode, normal. she was Anterior free of pituitary any symptom and her When the patient was discharged 3 months after the Fig. 1 M Joubert and others Pituitary MRI (coronal contrast-enhanced T1-weighted B). Table 1 ). Serial MRI study showed Table 1 Basal and stimulated pituitary hormonal evaluation during the hospitalization for bilateral cavernous sinus thrombosis (initial evaluation) and 3 months later. Initial evaluation Evaluation 3 months later EUROPEAN JOURNAL OF ENDOCRINOLOGY (2009) Hypothalamic–pituitary axis Basal (normal range) Stimulated (normal range) Basal (normal range) Stimulated (normal range) Corticotroph Cortisol 8:00: 524 nmol/l (140–690) After tetracosactide 250 mg IV: Cortisol 8:00: 207 nmol/l (140–690) After tetracosactide 250 mg IV: O O Downloaded fromBioscientifica.com at09/25/202108:15:50PM ACTH 8:00: 1 pmol/l (2–11) Cortisol: 1048 nmol/l ( 550) ACTH 8:00: 5 pmol/l (2–11) Cortisol: 772 nmol/l ( 550) Gonadotroph Oestradiol: 59 pmol/l (70–220) ND Oestradiol: 99 pmol/l (70–220) After GnRH 100 mg IV: FSH: 0.6 UI/l (1.4–9.6) FSH: 5.4 UI/l (1.4–9.6) FSH: 8 UI/l LH: 0.2 UI/l (0.8–26) LH: 4.2 UI/l (0.8–26) LH: 21 UI/l Somatotroph GH: 3.3 mUI/l (!15) ND GH: 10 mUI/l (!15) ND IGF-1: 249 ng/ml (150–350) IGF-1: 250 ng/ml (150–350) Lactotroph Prolactin: 13 mg/l (2–15) ND Prolactin: 10 mg/l (2–15) After TRH 200 mg IV: Prolactin: 55 mg/l Thyrotroph Thyrotrophin: 3 mU/l (0.5–5) ND Thyrotrophin: 4.4 mU/l (0.5–5) After TRH 200 mg IV: Thyroxine: 13.7 pmol/l (11–22) Thyroxine: 16.5 pmol/l (11–22) Thyrotrophin: 33 mU/l Triiodothyronine: 4.5 pmol/l (3–9) Triiodothyronine: 4.3 pmol/l (3–9) ND, not documented. 160 via freeaccess EUROPEAN JOURNAL OF ENDOCRINOLOGY (2009) 160 Pituitary oedema 875 arterial branches of the hypophyseal arteries (5). Altogether, the hypothesis of the involvement of a Venous drainage from the anterior pituitary principally pituitary oedema secondary to bilateral cavernous extends to the cavernous sinuses, directly through sinus thrombosis seems the most probable cause sparse and probably insignificant lateral veins and explaining the occurrence of a sellar mass in this indirectly through posterior pituitary veins. A fraction patient. To our knowledge, this new mechanism of of venous blood from the anterior pituitary also enters transient pituitary enlargement and hormone defici- the posterior pituitary capillary bed by a retrograde flow ency has not been previously described, and may be through posterior stalk portal vessels towards the treated medically with an anticoagulant therapy median eminence of hypothalamus (6). In the present together with anti-infectious drugs. case, pituitary oedema might have resolved after anticoagulation treatment since blood flow through the cavernous sinuses should have been restored, Declaration of interest allowing normal pituitary venous drainage. In this All the authors declare that there is no conflict of interest that could be context, transient central hypogonadism may have perceived as prejudicing the impartiality of the research reported. resulted from increased intrasellar pressure, consecutive to cavernous sinuses thrombosis (7). Pituitary venous Funding drainage allowed to restore gonadal function and to decrease serum prolactin. This research did not receive any specific grant from any funding Apart from this vascular mechanism, this case report agency in the public, commercial or not-for-profit sector. first suggested an infectious process of the pituitary region. Pituitary abscess is a rare condition, often favoured by an adjacent sinusitis, which may extend to the sellar region. It may complicate a pre-existing References intrasellar tumour, i.e. a pituitary adenoma, a cranio- pharyngioma or a Rathke’s cleft cyst, or may result from 1 Teramoto A, Hirakawa K, Sanno N & Osamura Y. Incidental pituitary lesions in 1000 unselected autopsy specimens. Radiology locoregional extension or haematogenous spreading of 1994 193 161–164. sphenoidal sinusitis, meningitidis, cavernous sinus 2 Chong BW, Kucharczyk W, Singer W & George S. Pituitary gland thrombophlebitis or a contaminated CSF leakage (8). MR: a comparative study of healthy volunteers and patients Its clinical presentation includes tumour signs i.e. with microadenomas. American Journal of Neuroradiology 1994 15 headache, visual field defect and/or endocrine defici- 675–679.
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