RATHKE’S CLEFT CYST AND ASSOCIATED CSF RHINORRHEA PRESENTING AS RECURRENT ASPIRATION PNEUMONITIS

Abstract

SESSION TITLE: Allergy and Airway SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Cerebrospinal fluid (CSF) rhinorrhea is a rare and potentially devastating condition, occurring when an abnormal communication exists between the subarachnoid space and sinonasal tract[1], which can be traumatic, iatrogenic, or spontaneous. We present a case of a healthy male presenting with nasal discharge and cough, found to have a Rathke’s cleft cyst causing spontaneous CSF rhinorrhea, complicated by recurrent aspiration, resulting in chronic pneumonitis. This diagnosis is frequently mistaken for allergic rhinitis, particularly if accompanied by atypical respiratory complications. CASE PRESENTATION: A 44 year old male presents with a chief complaint of clear rhinorrhea and cough for two months. He was diagnosed with allergic rhinitis and treated with intranasal fluticasone. Unremitting symptoms led to multiple Emergency Room visits, several antibiotic prescriptions, but with minimal improvement. Pulmonary function tests revealed a moderate restrictive disorder with a positive bronchodilator response and mild reduction of diffusion capacity. Lab work showed elevated eosinophils and immunoglobulin E of 722. CT chest showed right lower lobe consolidation with air bronchograms and multiple nodular densities in the right lower lobe consistent with an inflammatory process. Bronchoalveolar lavage was negative and transbronchial biopsies showed chronic inflammation. Due to persistent rhinorrhea and un-resolving right lower lobe infiltrate, CT scan of the sinuses was ordered, which showed enlarged sella turcica with partially empty sella and left sphenoid sinus disease. Subsequent MRI of the brain visualized a Rathke’s cleft cyst causing posterior compression of the pituitary gland. Patient was referred to otolaryngology and neurosurgery for treatment.While awaiting his neurosurgery appointment, the patient developed new headaches and diplopia, expediting the surgery. The osteodural defect was repaired via left endoscopic endonasal approach with cyst drainage. The patients post-operative course was unremarkable with complete resolution of his pulmonary symptoms. DISCUSSION: Spontaneous CSF leaks have been attributed to intracranial lesions causing mass effect, hydrocephalus, or elevated intracranial pressure. Rathke’s cleft cyst, a benign intra-pituitary growth, and predominantly asymptomatic, is one such lesion[2]. In our case, the cyst led to compromise of the sphenoid sinus, resulting in the CSF leak. Our patient’s atypical presentation of chronic CSF aspiration causing pneumonitis, along with abnormal PFTS, elevated eosinophil count, and IgE level likely delayed our ultimate diagnosis. CONCLUSIONS: CSF rhinorrhea is a diagnosis that must be considered in the appropriate clinical setting of unresolving rhinorrhea and chronic aspiration pneumonitis, in order to prevent potentially harmful complications such as meningitis, pneumocephalus, and even lung disease secondary to chronic CSF aspiration. Reference #1: Sarkar, A. and N. Sharma, Spontaneous CSF Rhinorrhea Our Experience. Indian J Otolaryngol Head Neck Surg, 2016. 68(1): p. 126-9 Reference #2: Naik, V.D. and N.R. Thakore, A case of symptomatic Rathke's cyst. BMJ Case Rep, 2013. 2013. DISCLOSURES: No relevant relationships by Jenny Kim, source=Web Response No relevant relationships by eman rashed, source=Web Response No relevant relationships by Peter Rattner, source=Web Response