Corticotroph adenoma and pituitary fungal infection: a rare association

Abstract

Summary: Pituitary infections, particularly with fungus, are rare disorders that usually occur in immunocompromised patients. Cushing's syndrome predisposes patients to infectious diseases due to their immunosuppression status. We report the case of a 55-year-old woman, working as a poultry farmer, who developed intense headache, palpebral ptosis, anisocoria, prostration and psychomotor agitation 9 months after initial diabetes mellitus diagnosis. Cranioencephalic CT scan showed a pituitary lesion with bleeding, suggesting pituitary apoplexy. Patient underwent transsphenoidal surgery and the neuropathologic study indicated a corticotroph adenoma with apoplexy and fungal infection. Patient had no preoperative Cushing's syndrome diagnosis. She was evaluated by a multidisciplinary team who decided not to administer anti-fungal treatment. The reported case shows a rare association between a corticotroph adenoma and a pituitary fungal infection. The possible contributing factors were hypercortisolism, uncontrolled diabetes and professional activity. Transsphenoidal surgery is advocated in these infections; however, anti-fungal therapy is still controversial.

Learning points: Pituitary infections are rare disorders caused by bacterial, viral, fungal and parasitic infections. Pituitary fungal infections usually occur in immunocompromised patients. Cushing's syndrome, as immunosuppression factor, predisposes patients to infectious diseases, including fungal infections. Diagnosis of pituitary fungal infection is often achieved during histopathological investigation. Treatment with systemic anti-fungal drugs is controversial. Endocrine evaluation is recommended at the time of initial presentation of pituitary manifestations.

Keywords: 2020; ACTH; Acyclovir*; Adult; Agitation; Anisocoria; Blood pressure; CT scan; Corticotrophic adenoma; Cortisol; Cortisol (serum); Cushing's syndrome; DPP4 inhibitors; Diabetes mellitus type 2; FSH; FT4; Fatigue; Female; GH; Gliclazide; Glucocorticoids; Groccots methenamine stain*; Haematoxylin and eosin staining; Haemoglobin A1c; Headache; Histopathology; Hydrocortisone; Hypercortisolaemia; Hypertension; Hypopituitarism; IGF1; Immunohistochemistry; Infectiology; Insulin glargine; LH; MRI; March; Metformin; Oestradiol (E2); Pituitary; Pituitary adenoma; Pituitary apoplexy; Portugal; Prolactin; Ptosis; Resection of tumour; Sitagliptin; Spironolactone; TSH; Thyroxine (T4); Transsphenoidal surgery; Unique/unexpected symptoms or presentations of a disease; White.

Figure 1

Unenhanced T1 MRI coronal section showing a pituitary expansive lesion (arrow) with heterogeneous signal suggestive of pituitary macroadenoma apoplexy.

Figure 2

Unenhanced T1 MRI coronal section, 3 months after surgery.

Figure 3

Pituitary adenoma with necrosis to the left and nodular areas with necrosis and septate hyphae to the right. Hematoxylin and eosin stain. ×100.

Figure 4

Photomicrograph of the intra-pituitary mass showing fungal organisms with septate hyphae and typical dichotomous branching. Hematoxylin and eosin ×400.

Figure 5

Groccot’s methenamine stain method used as a screening for fungal organisms. The cell walls of these organisms are outlined in black ×200.

Figure 6

Pituitary adenoma with a positive staining for adrenocorticotropic hormone (ACTH) on immunohistochemistry ×400.