scholarly journals Change in Character of Headache in a Young Female Patient With Prolactin Secreting Pituitary Adenoma Complicated With Mild Hemorrhage

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A577-A577
Author(s):  
Yuzana Myint Soe ◽  
Marium Ghani ◽  
Pushplata Siroya
Keyword(s):  
Prolactin Level ◽  
Human Growth ◽  
Moderate Intensity ◽  
Visual Field Defects ◽  
High Signal ◽  
Total Testosterone ◽  
Pituitary Mass ◽  
Pituitary Fossa ◽  
Gradual Improvement ◽  
Mri Brain

Abstract Background: Prolactin (PRL) secreting tumors are the most common functional neoplasms of the pituitary and are commonly subdivided into microprolactinomas (<10 mm) and macroprolactinomas (≥10 mm) according to their baseline diameter. The diagnosis of macroadenomas is usually straightforward and these large tumors may be associated with mass effects such as severe headache, nerve palsies or visual changes. Hyperprolactinemia can be due to other causes like pregnancy, drugs, hypothyroidism, and pituitary stalk effect should be considered in the differential. Clinical Case: A 30 year female having symptoms of prolactinoma showing amenorrhea of 3 years, galactorrhea, decrease libido who presented to the clinic for headache recently associated with anxiety. Headache initially frequently with 2-3 times in a week, moderate intensity lasting few hours, on one side of head and sometimes on the forehead, associated with blurry vision. Patient was on oral contraception taking on and off, but not on any medication currently. Initial work up consistent with hyperprolactinemia: elevated prolactin level 737.6 ng/ml (n 3.0-30 ng/ml), however other pituitary hormones are within normal limit, ACTH 32 pg/ml (n 6-50 pg/ml),FSH 3.2 mid/ml, LH 0.3miu/ml, total testosterone 13 ng/dl (n 2-35 ng/dl),TSH 1.6 mid/l (N 0.35-3.7 mid/l), FT4 0.92 ng/dl (N 0.76-1.46 ng/dl), human growth hormone <0.1ng/ml (N <=7.1 ng/dl), random cortisol 14.6 ug/dl (N 4.3-22.4 ug/dl). Pregnancy test is also negative. MRI Brain with and without contrast revealed a mass within the pituitary fossa producing smooth depression of the floor and suprasellar extension just the right of midline producing mild impingement on the undersurface of the optic chiasm, craniocaudal dimension of the tumor approximately 1.85 cm by 1.8 cm mediolateral by 1.4 cm anteroposterior without encasement or diminution of carotid arteries flow. Within the sella there is a spherical collection of T1 high signal displaying a fluid level strongly concerning for hemorrhage within the pre-existing tumor. There is no prior CT Head or MRI Brain available. Ophthalmology evaluation showed normal dilated retinal exam and no visual field defects. Medical treatment with Cabergoline 0.25 mg PO twice weekly was given on the visit, however patient did not start it yet and repeat prolactin level with 629 ng/ml. Patient endorsed that headache is better with less frequent about once in two weeks but still with absence of menstruation. Conclusion: This is the case of prolactin secreting pituitary macroadenoma with the change in character of headache due to hemorrhage in the tumor, having gradual improvement of headache which may be due to spontaneous resolving of hemorrhage from the pre-existing pituitary mass. It is very important to inform the patient with pituitary tumor go to ED if there is change in headache or vision.​

scholarly journals Underappreciation of the “Hook Effect” leading to Mismanagement of a Patient, a Tale of Preventable Disaster

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A617-A617
Author(s):  
Mehdia Amini ◽  
Harsimranjit Kaur ◽  
Mandip Kang ◽  
Soe Naing
Keyword(s):  
Pituitary Adenoma ◽  
Immune Complex ◽  
Prolactin Level ◽  
Third Ventricle ◽  
Pituitary Hormone ◽  
Pituitary Mass ◽  
Blurred Vision ◽  
Mri Brain ◽  
Hook Effect ◽  
Complex Formations

Abstract Introduction: When evaluating pituitary adenomas, one needs to be cognizant of the “hook effect” - an assay artifact leading to under-reporting of extremely high prolactin levels. We report a case of a patient with a macroprolactinoma with an initial reported prolactin level of less than 1.0 ng/dl. Such an extreme case of the “hook effect” in a prolactinoma has not been reported yet. Case Presentation: A 53-year-old male with a medical history of type II DM initially presented in 2017 with blurred vision. Vital signs and labs, including pituitary hormone levels, were all within normal range. Prolactin level was reported as less than 1.0 ng/dl (normal 2-18 ng/dl). MRI brain showed a large pituitary mass and he was diagnosed with a non-secreting pituitary macroadenoma with mass effect. The patient subsequently underwent transsphenoidal resection of the pituitary adenoma. Prolactin level was noted to be elevated at 1608 ng/dl after the procedure. Unfortunately, the patient was lost to follow up. Two years later, the patient presented again with persistent headaches and worsening vision. MRI brain revealed a large suprasellar mass, measuring at 4.9 x 4 x 3 cm, with extension into the third ventricle and left cavernous sinus, indicating a recurrence of the pituitary adenoma. Prolactin levels measured were elevated 12,030 ng/dl. At this time, the patient was started on cabergoline with significant improvement in symptoms and reduction in prolactin levels to 1792 ng/dl within 4 weeks after initiation of therapy. He is currently still in remission with weekly cabergoline therapy. Conclusion: The most used prolactin assay typically reports the presence of detectable heterotrimeric immune complex formations made up of prolactin antigens sandwiched between ‘capture antibodies‘ at one end and ‘reported antibodies’ at the other end of the prolactin antigen. In prolactinomas, prolactin levels are usually present in relative excess to the two assay antibodies. This leads to the oversaturation of antibody sites with most of prolactin being complexed to only a single antibody instead of two antibodies, thus impairing adequate immune complex formation. Only a few remaining prolactin antigen are “sandwiched” to form the heterotrimeric complex and are therefore reported as “detectable.” As a result, true prolactin levels are substantially underreported, potentially leading to incorrect diagnosis, treatment delay, exposure to surgical risk and complications and increased economic burden to the patient and the healthcare system. The best method to avoid the “hook effect” and to correctly interpret prolactin values would be to obtain prolactin levels in appropriately diluted serum specimens (10-100-fold dilution of the sample). This will lead to appropriate immune complex formations and increase the sensitivity and specificity of the prolactin assay.

scholarly journals Forbes albright syndrome: galactorrhea–amenorrhea associated with a pituitary tumour: a case report

2021 ◽  
Vol 8 (1) ◽  
pp. 27-29
Author(s):  
Rupak Chatterjee ◽  
Prantiki Halder ◽  
Sudeshna Mallik ◽  
Bibhuti Saha
Keyword(s):  
Case Report ◽  
Prolactin Level ◽  
Pituitary Tumour ◽  
Serum Prolactin ◽  
Loss Of Consciousness ◽  
Pituitary Macroadenoma ◽  
Serum Prolactin Level ◽  
Mri Brain ◽  
Menstrual Irregularities ◽  
Albright Syndrome

Forbes Albright syndrome is a hyperprolactinemia syndrome characterised by galactorrhea and amenorrhea associated with a pituitary tumour. Here we report a case of 30 years female who was admitted with menstrual irregularities for 4 months, galatorrhea and headache with recurrent episodes of loss of consciousness for 3months. Her serum prolactin level was highly raised. MRI brain (plain plus contrast) showed enlarged pituitary gland- pituitary macroadenoma. She was diagnosed as a case of Forbes Albright Syndrome and was treated with Tablet Cabergoline. With the medication, size of her tumour markedly reduced and symptoms resolved as she was followed up after 3 months.

scholarly journals Heparin-Induced Pituitary Apoplexy Presenting as Isolated Unilateral Oculomotor Nerve Palsy: A Case Report and Literature Review

2019 ◽  
Vol 2019 ◽  
pp. 1-5 ◽  
Author(s):  
Bakr Swaid ◽  
Frank Kalaba ◽  
Ghassan Bachuwa ◽  
Stephen E. Sullivan
Keyword(s):  
Nerve Palsy ◽  
Pituitary Apoplexy ◽  
Significant Coronary Artery Disease ◽  
Clinical Syndrome ◽  
Oculomotor Nerve ◽  
Oculomotor Nerve Palsy ◽  
Visual Field Defects ◽  
Pituitary Mass ◽  
Atypical Chest Pain ◽  
Coronary Syndrome

Introduction. Pituitary apoplexy (PA) is a rare and potentially life-threatening clinical syndrome resulting from pituitary gland hemorrhage and/or infarction. Anticoagulation is a risk factor for triggering PA. Isolated oculomotor nerve palsy is an atypical presentation of PA. Case Presentation. A 65-year-old African American female with no past medical history of pituitary disease presented to the emergency department (ED) with nonspecific abdominal pain that was thought to be secondary to fecal stasis and subsequently improved with laxatives. She also reported atypical chest pain that was concerning for unstable angina. She was started on aspirin, clopidogrel, and intravenous (IV) heparin. Later, coronary catheterization showed no significant coronary artery disease (CAD). Twelve hours after the procedure, the patient developed acute complete left oculomotor nerve palsy with a severe headache. Magnetic resonance imaging (MRI) of the head showed a large pituitary mass. Pituitary apoplexy was suspected and the patient eventually underwent a successful trans-sphenoidal pituitary resection. Discussion. We report a case of PA manifesting as isolated left oculomotor nerve palsy without visual field defects in the setting of using dual antiplatelet therapy (DAPT) and IV heparin for acute coronary syndrome. To the best of our knowledge, this unique combination has not been previously reported.

017 Paradoxical reaction in tuberculous meningitis: a tertiary referral hospital retrospective experience of concomitant immunosuppression therapy

2018 ◽  
Vol 89 (6) ◽  
pp. A8.1-A8
Author(s):  
David Ledingham ◽  
Shadi El-Wahsh ◽  
Cecilia Cappelen-Smith ◽  
Suzanne Hodgkinson ◽  
Alan McDougall ◽  
...  
Keyword(s):  
Tuberculous Meningitis ◽  
Case Series ◽  
Corticosteroid Treatment ◽  
Asia Pacific ◽  
High Dose ◽  
Neck Stiffness ◽  
Gradual Improvement ◽  
Mri Brain ◽  
Thalamic Infarction ◽  
History Of

IntroductionTuberculous meningitis (TBM) accounts for <1% of all tuberculosis (TB) presentations. Paradoxical reactions (PR) in non-HIV patients are a common manifestation of anti-tuberculosis therapy characterised by clinico-radiological deterioration. We report a case series of TBM admissions to our institution, including two cases with corticosteroid-refractory PR who responded to adjuvant cyclosporin.MethodsRetrospective review of 12 HIV-negative patients admitted to Liverpool Hospital, Sydney (2005–2017) with laboratory and/or radiologically confirmed TBM.ResultsMedian age 40 (range 22–81 years), 7 males. Eleven patients were of Asia-Pacific origin. All eleven presented with central nervous system manifestations and 1 had preceding miliary TB. Nine patients had extra-cranial TB involvement, including 8 with past or current pulmonary disease. Cerebrospinal fluid (CSF) TB PCR/culture was positive in 10 patients. One patient had multi-resistant TB. PR of TBM developed in 5 patients despite concomitant corticosteroids in 4. Two cases had refractory PR.Case 1. 22 year old Vietnamese male presented with 6 week history of progressive headache and neck stiffness. CSF demonstrated 61 WCC (75% neutrophils), protein 2.67 g/L (n<0.45), glucose 2.1 mmol/L. Despite concomitant anti-tuberculosis and high-dose corticosteroid treatment, he developed worsening headaches and altered mentation with interval MRI brain increase in size and number of tuberculomas, hydrocephalus, and left thalamic infarction. Cyclosporin was added with gradual improvement and ultimately good outcome.Case 2. 47 year old Filipino male presented with 3 week history of headache and neck stiffness and 3 day history of fever, dysarthria and diplopia. MRI brain showed basal meningitis, hydrocephalus and left putaminal infarction. CSF demonstrated 245 WCC (35% neutrophils), protein 0.68 g/L, glucose 1.8 mmol/L. Despite concomitant anti-tuberculosis and corticosteroid treatment, the patient developed PR-induced worsening hydrocephalus necessitating ventriculo-peritoneal shunting. Cyclosporin was added with gradual PR resolution.ConclusionOur case series highlights the importance of concomitant corticosteroids in TBM and the potential role of cyclosporin in refractory PR.

scholarly journals MON-260 Sinonasal Papilloma Masquerading as a Pituitary Macroadenoma

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Melissa Cohen ◽  
John Wilson ◽  
Daniel Joseph Toft
Keyword(s):  
Squamous Cell Carcinoma ◽  
Cell Carcinoma ◽  
Squamous Cell ◽  
Medical Attention ◽  
Total Testosterone ◽  
Invasive Squamous Cell Carcinoma ◽  
Sellar Mass ◽  
Pituitary Mass ◽  
Prepontine Cistern ◽  
Sinonasal Papilloma

Abstract Background: Sinonasal tumors are rare, with annual worldwide incidence of approximately 1 in 100,000, and are not commonly considered in the differential diagnosis of pituitary tumors (1). Sinonasal tumors are well known for their invasiveness, tendency to recur and association with malignancy. We present a case of sinonasal papilloma presenting as a large suprasellar mass. Clinical Case: A 61 year-old male with a past medical history including type 2 diabetes mellitus presented with chief complaints of headaches and visual disturbances over the past 6 months. Prior to admission he experienced episodes of left eye midline deviation associated with diplopia. New onset dysphagia associated with leftward tongue deviation prompted him to seek medical attention. The social history was notable for chemical exposures in his work at a hair salon; he is sexually active with his husband. He has had no sexually transmitted infections and has been vaccinated against human papilloma virus (HPV). CT of the brain showed a large sellar mass. A subsequent MRI of the pituitary demonstrated a large destructive mass centered on the clivus elevating the pituitary gland into the suprasellar cistern. The mass measured 6 cm x 4.5 cm in the axial plane with displacement without invasion of the cavernous sinuses. The mass extended anteriorly into the ethmoid sinuses and extended posteriorly into the prepontine cistern displacing the basilar artery. Pituitary hormonal analysis included a 250 mcg Cosyntropin stimulation test resulting with a random cortisol of &lt;1.0 ug/dl rising to 17.7 ug/dl following Cosyntropin administration. Additional anterior pituitary results included FSH of 3.8 mIU/ml (1.5-14 mIU/ml), LH of 1.3 mIU/ml (1.4-7.7 mIU/ml), total testosterone of 230 ng/dl (300-700 ng/dl), and prolactin 11.1 ng/ml (2.6-13 ng/ml). Ophthalmology was consulted for visual field testing which proved normal, however a partial left cranial nerve VI palsy was noted likely secondary to cavernous sinus involvement. A biopsy of the sellar mass was obtained by bedside nasal endoscopy. The initial biopsy was consistent with a non-dysplastic, inverted sinonasal papilloma with negative HPV and P16 serologies. The patient underwent resection of the pituitary mass, with surgical pathology showing superficially invasive squamous cell carcinoma arising from sinonasal papilloma. Conclusion: This is one of the very few cases reported in the literature of a sinonasal papilloma masquerading as a pituitary mass. Sinonasal papilloma should be considered when evaluating large destructive suprasellar tumors. Although a benign tumor, the local aggressiveness of sinonasal papilloma and the potential to give rise to squamous cell carcinoma highlights the significance of identifying this lesion.

scholarly journals P137 Growing up on biologics: a case report of development of NMDAr encephalitis in a young person with JIA on abatacept

Rheumatology ◽  
2020 ◽  
Vol 59 (Supplement_2) ◽  
Author(s):  
Rosie Close ◽  
Peter Bale ◽  
Kathy Gallagher ◽  
Gautam Ambegaonkar ◽  
Thomas Rossor ◽  
...  
Keyword(s):  
Jc Virus ◽  
Autoimmune Disorders ◽  
Ovarian Teratoma ◽  
Cns Infection ◽  
High Signal ◽  
Mri Brain ◽  
Nmdar Encephalitis ◽  
First Case ◽  
Increased Risk ◽  
Biologic Medication

Abstract Background A 12-year-old female with JIA on biologic medication (IV abatacept every three weeks) presented with a first generalised tonic-clonic seizure on background of preceding headache and fatigue. The seizure self-terminated but disorientation and encephalopathy ensued. MRI brain demonstrated lesions with high signal intensity in the left periventricular and right occipital regions. The clinical picture and radiological imaging suggested a broad differential diagnosis including CNS infection, JC virus associated progressive multifocal leucoencephalomalacia (PML), acute disseminated encephalomyelitis (ADEM) and Anti-N-methyl-d-aspartate receptor (NMDAr) encephalitis. She was commenced on IV ceftriaxone, acyclovir and clarithromycin. All bloods including inflammatory markers and infection serology were unremarkable. CSF was acellular and JC virus PCR negative. NMDAr encephalitis was initially considered unlikely (pre-existing immunosuppression, abnormal MRI brain and no evidence of ovarian teratoma on abdominal MRI pelvis). However more classical clinical features developed including further seizures, significant movement disorder, cognitive dysfunction, sleep and speech dysfunction. Anti-NMDAr antibodies in both serum and CSF were positive. She made a good recovery following IV steroids, plasmapheresis and rituximab and was discharged home after a 10-week admission. NMDAr encephalitis developed three years after commencing abatacept treatment. Previous immune modulating treatment included methotrexate (since age 2 years), Etanercept (age 5-8 years) and Tocilizumab (aged 8-10 years). Flares of disease following a period of control necessitated the changes in therapy. Methods A literature review was conducted to explore the relationship between NMDAr encephalitis and biologic medication. A yellow card report and information request to abatacept manufacturer were also submitted. Results No previous cases of NMDAr encephalitis in patients on abatacept or paediatric cases related to biologic therapy are described. There are reports of adults developing NMDAr encephalitis on Adalumimab for Crohn’s disease and etanercept for rheumatoid arthritis. NMDAr encephalitis has also been described in patients on immune checkpoint inhibitors for malignant melanoma (nivolumab and ipilimumab). Known triggers of production of anti-NMDA receptor antibodies include tumours (ovarian teratoma; rarely associated in patients under 12 years) and viral infections. Developing autoimmune disorders on biologic medication is well reported, most notably psoriasis and inflammatory bowel disease. In relation to abatacept specifically, the development of anti-nuclear antibodies (ANA) and psoriasis have been described. However, patients with autoimmune disorders are known to be of increased risk for additional immune disease. A new cohort of patients are emerging who have received multiple biologic medications and the development of autoimmune conditions despite immunosuppression needs to be considered. Conclusion We describe the first case of NMDAr encephalitis occurring in a child on abatacept therapy, and the first case in JIA. We are unable to determine what contribution a history of autoimmune disease or immunomodulating therapy has made on its development in this case. Disclosures R. Close: None. P. Bale: None. K. Gallagher: None. G. Ambegaonkar: None. T. Rossor: None. N. Abbassi: None. K. Armon: None.

Optic Neuropathy, Secondary to Ethmoiditis, and Onodi Cell Inflammation during Childhood: A Case Report and Review of the Literature

2019 ◽  
Vol 50 (06) ◽  
pp. 341-345 ◽  
Author(s):  
Marina Mazzurco ◽  
Piero Pavone ◽  
Milena Di Luca ◽  
Pierluigi Smilari ◽  
Elena Pustorino ◽  
...  
Keyword(s):  
Optic Neuropathy ◽  
Visual Field Defects ◽  
Ischemic Optic Neuropathy ◽  
Resonance Imaging ◽  
Gradual Improvement ◽  
Cerebral Magnetic Resonance Imaging ◽  
Presenting Symptoms ◽  
Onodi Cell ◽  
Acute Form

AbstractOptic neuropathy consists of several etiological events. The primary etiologies of its acute form include optic neuritis, ischemic optic neuropathy, inflammatory (nondemyelinating) disorders, and trauma. Its subacute and chronic forms are most often linked to compressive, toxic, nutritional, or hereditary-genetic causes. Visual loss, dyschromatopsia, and visual field defects are the presenting symptoms. The Onodi cell (sphenoethmoidal air cell) is an anatomic variant located laterally and superior to the sphenoid sinus; it is closely related to the optic nerve. Onodi cell disorders are rare and may be unnoticed in differential diagnoses of patients with ocular and neurological manifestations. Here, we present the case of a 12-year-old boy with headache and acute loss of sight characterized by hemianopsia in the left eye and retrobulbar optic neuropathy caused by left sphenoethmoidal sinusitis with the presence of Onodi cell inflammation. The diagnosis was confirmed by multilayered paranasal computed tomography and cerebral magnetic resonance imaging. Therapeutic treatment resulted in gradual improvement: at the 2-week follow-up, the patient no longer had headaches and his visual acuity returned to normal. Inflammation of Onodi cells should be considered in children with headache and abnormal vision.

scholarly journals Cluster Headache Secondary to Macroprolactinoma with Ipsilateral Cavernous Sinus Invasion

2012 ◽  
Vol 2012 ◽  
pp. 1-3
Author(s):  
M. J. Levy ◽  
I. Robertson ◽  
T. A. Howlett
Keyword(s):  
Cluster Headache ◽  
Dopamine Agonist ◽  
Cavernous Sinus ◽  
Pituitary Tumour ◽  
Serum Prolactin ◽  
Pituitary Fossa ◽  
Cavernous Sinus Invasion ◽  
Mri Brain ◽  
Episodic Cluster Headache

We present a 25 year-old man with episodic cluster headache that was refractory to all standard pharmacological prophylactic and abortive treatments. Because of the lack of response, an MRI brain was performed which showed a large pituitary tumour with ipsilateral cavernous sinus invasion. The serum prolactin was significantly elevated at 54,700 miU/L (50–400) confirming a macro-prolactinoma. Within a few days of cabergoline therapy the headache resolved. He continues to be headache free several years after starting the dopamine agonist. This case highlights the importance of imaging the pituitary fossa in patients with refractory cluster headache, It also raises the potential anatomical importance of the cavernous sinus in pituitary-associated headache.

scholarly journals SAT-LB54 Acute Sterile Meningitis as a Primary Manifestation of Pituitary Apoplexy

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Gayane Tumyan ◽  
Yogamaya Mantha ◽  
Rahul Gill ◽  
Mark Feldman
Keyword(s):  
Pituitary Adenoma ◽  
Bacterial Meningitis ◽  
Pituitary Apoplexy ◽  
Peripheral Vision ◽  
Imaging Modality ◽  
Cranial Nerves ◽  
Acute Bacterial Meningitis ◽  
Total Testosterone ◽  
Pituitary Mass ◽  
Neurological Exam

Abstract Background: Pituitary apoplexy (PA) is a rare endocrinopathy that requires prompt diagnosis and treatment. Presentation with acute neutrophilic meningitis is uncommon. Clinical Case: A 67-year-old man presented to our hospital with a 2-week history of worsening bilateral frontal headache, nausea, and dry heaving. On admission, the patient was somnolent with a score of 13 on the GCS assessment (E2, V5, M6). The neurological exam was overall normal with normal ocular motion and intact cranial nerves, except for a left eye peripheral vision defect. Plain head CT revealed a well-circumscribed ovoid pituitary mass with suprasellar enlargement, consistent with a pituitary macroadenoma. Sellar MRI showed a pituitary mass, roughly 20 x 19 x 24 mm, bulging into the suprasellar cistern with optic chiasm elevation. Analysis of pituitary function revealed low ACTH concentration of 2.8 pg/mL (n = 7.2 - 63.3 pg/mL), a low random cortisol level of 1.7 ug/dL (n = 2.9 - 19.4 ug/dL), a low TSH of &lt; 0.1 uIU/mL (n = 0.35 - 4.9 uIU/mL), a low free T4 level of 0.72 ng/dL (n = 0.77 - 1.48 ng/dL), a low LH of 0.8 IU/L (n = 1.7 - 8.6 IU/L) with a very low total testosterone level of &lt; 3 ng/dL (n = 300 - 720 ng/dL) and normal prolactin, IGF-1 and GH levels. On hospital day 2, the patient had worsening encephalopathy with left eye ptosis and decreased vision. Repeat CT and MRI showed no interval change in the pituitary adenoma or evidence of bleeding. An immediate lumbar puncture was performed and CSF analysis revealed an increased leukocyte count of (1106/mm3) with 89% neutrophilic granulocytes, and increased total protein level of 138 mg/dL (n = 15 - 40 mg/dL), red blood cell count of 2040 without xanthochromia and glucose of 130 mg/dL (n = 40 - 70 mg/dL). Based on the laboratory results and new symptoms, empirical antibiotic (vancomycin, ceftriaxone, and ampicillin) therapy was started for suspected bacterial meningitis before the confirmation of the CSF culture study. CSF culture did not grow any organisms. Given the sudden visual impairment and neurological deterioration, the patient underwent transsphenoidal resection of the tumor with free nasal mucosal graft reconstruction. Histological examination revealed a necrotic pituitary adenoma with apoplexy and no evidence of hemorrhage. Postoperatively, his neurological exam greatly improved. His left pupil was reactive to light and the third palsy was improving. Conclusion: This case reinforces the importance of including PA in the differential diagnosis of acute headache, particularly in patients presenting with visual disturbances. Patients with PA often present with sterile meningitis due to increased debris and blood in the subarachnoid space which closely mimics acute bacterial meningitis. While MRI remains a sensitive imaging modality for the detection of PA, the latter remains a clinical diagnosis. Timely diagnosis with high clinical suspicion and treatment is essential.

Use of a clinicoradiological score to determine the presurgical diagnosis of autoimmune hypophysitis in a teenage girl

2013 ◽  
Vol 11 (3) ◽  
pp. 335-339
Author(s):  
Vivek Bose ◽  
Patrizio Caturegli ◽  
Jens Conrad ◽  
Wael Omran ◽  
Stephan Boor ◽  
...  
Keyword(s):  
Pituitary Surgery ◽  
Pathological Examination ◽  
Visual Field Defects ◽  
High Dose ◽  
Teenage Girl ◽  
Resonance Imaging ◽  
Pituitary Mass ◽  
Autoimmune Hypophysitis ◽  
Secondary Hypogonadism ◽  
Field Defects

The distinction between autoimmune hypophysitis and other non–hormone secreting pituitary masses is often difficult to determine with certainty without pituitary biopsy and pathological examination. To aid in this distinction, the authors recently published a clinicoradiological scoring system, which they used in the case of a 15-year-old girl presented here. The patient presented with headache, visual field defects, polydipsia, and polyuria, and she was found to have secondary hypogonadism and hypoadrenalism. Magnetic resonance imaging showed a pituitary mass of approximately 2 cm in diameter. Application of the clinicoradiological parameters gave a score of −6, which favored a diagnosis of hypophysitis over that of adenoma. The presence of pituitary autoantibodies substantiated the diagnosis of hypophysitis. The patient was treated conservatively with high-dose prednisolone, and her symptoms improved markedly. This case illustrates the utility of using a clinicoradiological score when autoimmune hypophysitis is suspected since it can identify patients who can be treated without the need for pituitary surgery.

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