Case history: A 51-year-old lady with a background of classical migraine and amenorrhoea conceived successfully via IVF, without prior endocrine assessment. Symptoms during the third trimester of pregnancy led to the diagnosis of a pituitary mass lesion (see Table). Possible differential diagnoses, on subsequent endocrine review, included macroprolactinoma, microprolactinoma with expansion during pregnancy, or lymphocytic hypophysitis.
After 6 years of dopamine agonist therapy, the patient was then admitted with progressive generalised headaches and vomiting (similar to her symptoms during pregnancy and different from her usual migraine). Neurological assessment, including a comprehensive autoimmune workup and gallium scan, were all unremarkable. CSF analysis was normal except for a mildly elevated protein. A repeat MRI demonstrated new diffuse meningeal thickening. Hypertrophic pachymeningitis (patchy widespread inflammatory thickening of the dura mater) was diagnosed.
|Time-line||History||Prolactin (<700 mIU/l)||MR imaging|
|2002||Fertility clinic/IVF therapy|||||
|2002||Pregnancy 36 weekssignificant headaches, small left temporal field defect||||Macroadenoma|
|2002||Rapid resolution of field defect postpartum without intervention|||||
|2003||Persistent amenorrhoea 6 months postpartum, Cabergoline started||3818||Macroadenoma unchanged|
|2004||Cabergoline 500 μg/week||36||Excellent involution of pituitary lesion|
|02/2008||Cabergoline reduced to 250 μg/week||33||Pituitary appearance unchanged|
|08/2008||Disabling headaches||60||Pituitary appearance unchanged|
|01/2009||Pachymeningitis diagnosed. Cabergoline weaned and stopped 07/2009||41||Diffuse dura mater thickening. Pituitary appearance unchanged|
|20092010||Headaches resolved within weeks of Cabergoline withdrawal||5991990||Complete resolution of meningeal thickening. Pituitary appearance unchanged|
Conclusion: We report the rare association of pituitary pathology, treated with an ergot-derived dopamine agonist, and hypertrophic pachymeningitis. Withdrawal of the cabergoline (implicated in cardiac valvular fibrosis) coincided with rapid resolution of the clinical and radiological features associated with pachymeningitis. Whilst this could be purely coincidental, a causal link cannot be definitively excluded.