SUN-092 - Pituitary Abscess Mimicking Macroadenoma/Apoplexy with Acute Bilateral Vision Loss and Rapid Visual Recovery After Emergent Transsphenoidal Drainage

Pituitary Abscess Mimicking Macroadenoma/Apoplexy with Acute Bilateral Vision Loss and Rapid Visual Recovery After Emergent Transsphenoidal Drainage
Authors: Tanya Sandhu, BS; Sinan Abdul-Wahab, MD; Sarah Tariq, MD
Affiliation: University of Arizona, College of Medicine - Tucson

Background: Pituitary abscesses are rare sellar infections that can radiographically resemble pituitary adenoma or apoplexy. Lack of fever or elevated inflammatory markers are common, which can complicate early identification. Delayed recognition can result in irreversible vision loss and hypopituitarism.

Case Description: We report a 31-year-old man with a history of migraine with aura who presented with an abrupt headache followed by rapidly progressive vision loss over 12-18 hours. He eventually progressed to no light perception in the left eye and a temporal visual field deficit in the right eye. His stroke workup was negative. Ophthalmologic exam demonstrated a marked relative afferent pupillary defect with otherwise normal anterior and posterior segment findings, concerning for compressive optic neuropathy. MRI revealed a 1.8 cm sellar/suprasellar lesion with severe mass effect on the optic chiasm and edema along the left optic pathway. Given the rapid clinical progression, emergent transnasal transsphenoidal decompression was performed for presumed apoplexy. Intraoperatively, gross purulence under pressure was encountered and drained. Cultures grew oxacillin-susceptible coagulase-negative Staphylococcus epidermidis and Cutibacterium species. Broad-spectrum antimicrobials were narrowed and transitioned to oral therapy with interval imaging confirming resolution of the sellar collection.

Results: Visual recovery was rapid, improving to 20/20 in the right eye and ~20/40 in the left eye within days post-operatively. Endocrine evaluation showed no persistent hypopituitarism, and patient’s transient postoperative cortisol suppression was attributed to perioperative dexamethasone exposure.

Conclusion: Pituitary abscess should be considered in the differential diagnosis of acute headache and visual loss with a sellar lesion, even in the absence of systemic infectious signs, and highlights the importance of prompt decompression, targeted antimicrobials, and structured endocrine surveillance after sellar surgery.

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