A case of bacterial sphenoid sinusitis accompanied by a pituitary abscess

The sphenoid sinus is adjacent to the cavernous sinus, pituitary gland, optic nerve, and internal carotid artery, and sphenoid sinusitis can cause various inflammation of these surrounding structures. However, intracranial complications of sinusitis are quite rare. We experienced a case of sinusitis with a pituitary abscess. A 64-year-old man with uncontrolled diabetes complained of fatigue, and blood tests revealed possible adrenal insufficiency. Supplementary steroid treatment improved his symptom. The patient then experienced diplopia due to left abducens nerve paralysis, and subsequent enhanced magnetic resonance imaging (MRI) of the head revealed left sphenoid sinusitis, left cavernous sinus inflammation, an epidural abscess contiguous to the cavernous sinus, and an intra-sellar pituitary abscess. Antibiotic treatment with vancomycin (2 g/day), cefepime (6 g/day), and metronidazole (1.5 g/day) was started immediately, and left-side endoscopic sinus surgery (ESS) was performed. Histological examination revealed fungal growth in the erosive mucosa, but it was present only on the surface of the mucosa, and we assessed the pathophysiology as a bacterial infection rather than an invasive fungal infection. Culture tests of the pus drained from the sphenoid sinus during ESS were negative for bacteria, fungi, and mycobacteria. ESS and antibiotic treatment for 6 weeks, as is used for treating osteomyelitis, improved the MRI findings and left eye movement. Despite the development of antibiotic treatments, the prognosis of patients with intracranial abscess remains poor. However, early diagnosis has been reported to reduce the mortality and residual neurologic disturbance rates, and early enhanced MRI should be considered.