Pituitary apoplexy associated with gram-negative meningitis following transsphenoidal surgery

Abstract

Abstract Background Pituitary apoplexy (PA) is a rare but potentially life-threatening condition. While it is uncommon, it can present with findings that are clinically indistinguishable from acute bacterial meningitis. We report an unusual case of simultaneous coexistence of bacterial meningoencephalitis and pituitary apoplexy following transsphenoidal surgery (TSS) for pituitary macroadenoma, emphasizing the possibility of coexistence of the two entities. Case presentation A 62-year-old man was admitted with a moderate headache, gait disturbance, and progressively decreasing vision. Sellar magnetic resonance imaging showed a giant pituitary tumor of 4 × 5 cm with invasion of the cavernous sinus bilaterally, and a mass effect on the optic chiasm. The patient underwent a TSS and partial resection of a giant pituitary tumor. On postoperative day 11, he presented with an acute, severe headache and altered sensorium. An urgent computed tomography (CT) scan revealed hemorrhagic swelling of the residual. A complete analysis of the anterior pituitary hormones revealed panhypopituitarism. Administering steroid ameliorated the clinical features, but after decreasing the dose, the patient continued to deteriorate in his neurological status, a high fever, and marked stiffness were noted on postoperative day 14. Given the neck stiffness, leukocytosis, and high C-reactive protein level, acute meningitis was suspected, and the cerebrospinal fluid (CSF) was tested, which was consistent with acute bacterial meningitis. In the results of the bacterial cultures of the CSF, E. coli was identified and switched to ceftriaxone. The patient's neurological status and body temperature improved gradually. CSF test results returned to normal levels, and ceftriaxone was discontinued on day 10. Conclusions This is a report on a case of a giant pituitary tumor that developed late postoperative PA after having undergone a partial tumor resection. A postoperative CT scan showed hemorrhagic expansion of the residual tumor mass. Further, the patient exhibited typical symptoms of acute meningoencephalitis, the result of the cultures of the CSF was positive, and the patient's general condition deteriorated. In addition, laboratory findings indicated leukocytosis, an elevated C-reactive protein level, and neutrophilic pleocytosis. We highlighted diagnostic challenges and therapeutic delays arising as a result of rare concomitance.

Keywords

• Pituitary apoplexy
• Pituitary macroadenoma
• Bacterial meningoencephalitis
• Transsphenoidal surgery
• Cortisol