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Acute Sterile Meningitis as a Primary Manifestation of Pituitary Apoplexy
Gayane Tumyan1, Yogamaya Mantha1, Rahul Gill1
1Department of Internal Medicine, Texas Health Presbyterian Hospital of Dallas, Dallas, Texas.
Objective:
We report a case of pituitary apoplexy (PA) with negative radiographic findings for PA and cerebrospinal fluid (CSF) analysis consistent with neutrophilic meningitis. PA is a rare endocrinopathy requiring prompt diagnosis and treatment. Presentation with acute neutrophilic meningitis is uncommon.
Methods:
The diagnostic modalities included pituitary function tests (adrenocorticotropic hormone, thyroid-stimulating hormone, luteinizing hormone, prolactin), brain computed tomography and magnetic resonance imaging (MRI), and CSF analysis.
Results:
A 67-year-old man presented with worsening headache, nausea, and retching. He was somnolent with an overall normal neurologic examination other than a peripheral vision defect in the left eye. MRI showed a pituitary mass bulging into the suprasellar cistern with optic chiasm elevation, consistent with pituitary macroadenoma. Laboratory evaluation revealed decreased levels of adrenocorticotropic hormone, random cortisol, thyroid-stimulating hormone, thyroxine, luteinizing hormone, and testosterone. He had worsening encephalopathy with left eye ptosis and decreased vision, prompting a repeat computed tomography and MRI, showing no interval change in the pituitary adenoma or evidence of bleeding. CSF analysis revealed a leukocyte count of 1106/mm3 (89% neutrophils), a total protein level of 138 mg/dL, red blood cell count of 2040/mm3 without xanthochromia, and glucose level of 130 mg/dL. The CSF culture result was negative. Transsphenoidal resection revealed a necrotic pituitary adenoma with apoplexy.
Conclusions:
Including PA in the differential diagnosis of acute headache is important, particularly in patients with visual disturbances. PA can present with sterile meningitis, mimicking acute bacterial meningitis. While neuroimaging can help detect PA, the diagnosis of PA remains largely clinical.
Insights
Pituitary apoplexy (PA) can mimic meningitis, even with normal imaging. This case highlights the importance of considering PA in patients with acute headache and visual changes, despite atypical presentations.
Area of Science:
- Endocrinology
- Neurology
- Neurosurgery
Background:
- Pituitary apoplexy (PA) is a rare but serious endocrinopathy requiring prompt diagnosis and management.
- Clinical presentation can be diverse, making early recognition challenging.
Observation:
- A 67-year-old male presented with severe headache, nausea, and visual disturbances.
- Initial neuroimaging was negative for typical PA findings, but revealed a pituitary macroadenoma.
- Cerebrospinal fluid (CSF) analysis showed neutrophilic meningitis, without evidence of bacterial infection.
Findings:
- Despite negative initial radiographic findings for PA, the patient's clinical presentation and hormonal deficiencies suggested the diagnosis.
- Surgical resection confirmed a necrotic pituitary adenoma with apoplexy.
- The CSF profile mimicked acute bacterial meningitis, presenting as sterile meningitis.
Implications:
- Pituitary apoplexy should be included in the differential diagnosis for acute headache, especially with accompanying visual disturbances.
- Sterile meningitis can be an atypical presentation of PA, challenging initial diagnostic pathways.
- While neuroimaging is valuable, the clinical diagnosis of PA remains paramount, particularly in ambiguous cases.
