gms | German Medical Science

Objective: Fungal abscess is an extremely rare sellar mass lesion with only a handful of cases described in the literature. Infection is often related to immunodeficiency. Herein, we present our own patient series with intrasellar fungal lesions.

Method: We screened the histopathological database of patients treated at our hospital and identified three patients with sellar fungal abscesses. Clinical findings, pathological data and final outcomes were reviewed. All patients underwent microneurosurgical transsphenoidal surgery.

Results: All patients were immunocompetent. Patient 1, a 58-year-old female, with a history of heavy snuff tobacco abuse presented clinically with headache. Her MRI revealed heavy swelling of the mucosa of the paranasal and sphenoid sinuses as well as an intrasellar mass. Patient 2, a 68-year-old male, had been treated with an yttrium implant for acromegaly 44 years prior to admission when he presented with cerebrospinal fluid leakage, headache and meningism. MRI showed intracranial air and scar tissue in the sella. The third patient was a 37-year-old female with a history of one prior transsphenoidal surgery, corticoid therapy and radiotherapy was admitted under the suspicion of lymphocytic hypophysitis. She presented clinically with diplopia, ptosis and headache. Her MRI revealed abnormal mucosa and a solid mass in both the sphenoid sinus and the sella. A delineation between sella and sphenoid could not be seen. Histopathological and microbiological examination revealed aspergillosis in all cases. Postoperatively, all patients were treated with liposomal amphotericin B intravenously for several weeks. A good outcome was noticed in cases # 1 and 3. Case # 2 had a poor outcome due to an extra- and intracerebral haemorrhage from a concomitant mycotic aneurysm of the internal carotid artery.

Conclusions: Our small case series shows that fungal sellar abscesses should be included in the differential diagnosis of immunocompetent patients with sellar mass lesions, especially if the pathogen can enter the sellar space by contiguous extension from the sinuses as in case # 2. In case # 3, the direct introduction of the pathogen by prior surgery and its promotion of growth by corticoid therapy must be considered a potential pathogenetic mechanism. Snuff tobacco may carry a high load of fungus spores. Intrasellar aspergillosis associated with snuff tobacco abuse has been described in the literature before and we assume this to be the infection-promoting mechanism in case # 1.