Abstract
BackgroundMeningitis is an uncommon complication of an untreated pituitary macroadenoma. Meningitis may occur in patients with macroadenomas who have undergone transsphenoidal surgery and radiotherapy and is usually associated with rhinorrhea. Less commonly, cerebrospinal fluid rhinorrhea has been reported as a complication of treatment of prolactinomas by dopamine agonists. Cerebrospinal fluid rhinorrhea in cases of untreated pituitary macroadenoma is reported only in isolated cases. Acute bacterial meningitis without rhinorrhea in patients with an untreated pituitary macroadenoma is an exceptional finding with only three previously reported cases.Case presentationA 31-year-old male was urgently admitted for headache, fever and visual loss. Neuroimaging disclosed an invasive pituitary lesion. Cerebrospinal fluid leakage was not clinically detected. Lumbar puncture showed acute meningitis. Blood tests revealed increased inflammatory markers, a serum prolactin of 9000 ng/ml (2.5-11 ng/ml) and panhypopituitarism. Intravenous antibiotics and hydrocortisone replacement therapy were initiated, leading to a favorable clinical outcome. An endoscopic transsphenoidal debulking procedure was performed, it showed that the sphenoid floor was destroyed and the sinus occluded by a massive tumor.ConclusionsMeningitis should be ruled out in patients with a pituitary mass who present with headache and increased inflammatory tests, even in the absence of rhinorrhea.
Highlights
Meningitis is an uncommon complication of an untreated pituitary macroadenoma
We report a case of an untreated invasive macroprolactinoma revealed by acute meningitis
In a study of 664 patients surgically treated for pituitary adenomas, typical symptomatic pituitary apoplexy was observed in 0.6% of patients but hemorrhagic and necrotic changes were seen in 9.6% of surgical specimens [6]
Summary
Typical signs leading to the diagnosis of invasive macroadenoma are visual impairment, hypogonadism and rarely signs of intracranial hypertension. Meningitis is an unusual first clinical manifestation of an invasive pituitary adenoma. Meningitis in a patient with an invasive pituitary macroadenoma is generally due to an infection of cerebrospinal fluid (CSF) leaking through the disrupted bony skull into the sphenoid sinus, allowing the entry of nasopharyngeal organisms [1,2]. CSF leakage in an uninfected patient commonly manifests as clear rhinorrhea This is an uncommon but well known complication of transsphenoidal surgery and radiotherapy. CSF rhinorrhea in an untreated pituitary macroadenoma has been reported only in isolated cases. A purulent CSF was obtained, containing 11,900 white blood cells/μl (0-5/μl), 2680 red blood cells/μl, 6.3 g/L proteins (0.15-0.45 g/L), 39 mg/dl glucose (45–80 mg/dl) and 81 mg/dl lactate (10–22 mg/dl) These findings were consistent with a diagnosis of meningitis associated with a macroprolactinoma. Hydrocortisone at a dose of 30 mg per day was pursued as a follow up treatment
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