A 37 year old gentleman with no significant past medical history presented with 2 day history of acute onset headache, nausea, vomiting, photophobia and fever. He was pyrexial. He had no focal neurological deficit but marked neck stiffness. His inflammatory markers were raised. CT head showed large pituitary tumour. He was started on Dexamethasone and IV Ceftriaxone and transferred to tertiary centre. MRI brain showed large pituitary macroadenoma projecting into right cavernous and sphenoid sinuses, not compressing optic chiasma. CSF analysis was in keeping with bacterial meningitis. It showed high proteins, 9000/cumm WBCs with >95% polymorphs. It was positive for pneumococcal antigen which was confirmed with PCR. His hormonal profile showed raised prolactin (11040 mIU/L), hypogonadotrophic hypogonadism and normal TFTs. He improved with Ceftriaxone which was given for 2 weeks, followed by Phenoxymethylpenicillin for prophylaxis. He subsequently had a normal SST. He had no CSF leak on provocation testing and was started on Cabergoline and discharged. He was readmitted after 2 days with CSF rhinorrhoea and cabergoline was discontinued. He had trans-sphenoidal repair of CSF leak using tensor fascia lata. He was discharged home after CSF rhinorrhoea settled completely. Considering the risk of CSF rhinorrhoea and lack of any pressure effects of the tumour, it was decided to defer the therapy and to keep him under surveillance with monitoring of his Prolactin and tumour size. Plan is to continue Phenoxymethylpenicillin for few months after restarting DA therapy due to possibility of CSF rhinorrhoea which will predispose him to meningitis. He was also given conjugate pneumococcal vaccine.
Discussion: This is rare presentation of a common tumour. We could find only 6 cases of pituitary macroadenoma where the initial presentation was meningitis. Prompt diagnosis and correct management is important to improve outcome as pituitary tumour may be associated with various hormonal abnormalities.
Declaration of interest: There is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.
Funding: No specific grant from any funding agency in the public, commercial or not-for-profit sector.