Chu, Chun, MD

Kinney, Rachel, DO

Perilli, Gretchen A, MD

Smith, Stacey, MD, FACP

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksDepartment of MedicinePituitary Apoplexy Mimicking aMeningoencephalitis.Chun Chu MDLehigh Valley Health Network, Chun.Chu@lvhn.orgGretchen A. Perilli MDLehigh Valley Health Network, gretchen_a.perilli@lvhn.orgRachel Kinney DOLehigh Valley Health Network, rachel.kinney@lvhn.orgStacey Smith MD, FACPLehigh Valley Health Network, Stacey_J.Smith@lvhn.orgFollow this and additional works at: https://scholarlyworks.lvhn.org/medicinePart of the Endocrinology, Diabetes, and Metabolism Commons, and the Internal MedicineCommonsThis Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by anauthorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtChu, C. Perilli, G. Kinney, R. Smith, S. (2018, May). Pituitary Apoplexy Mimicking a Meningoencephalitis. Poster Presented at: ThePennsylvania Osteopathic Medical Association (POMA), Philadelphia, PA.© 2018 Lehigh Valley Health NetworkCASE REPORTDay 1: 85 year-old male presented with a sudden intractable headache for a few hours. Associated with nausea, vomit, neck pain. Denied fever, chills, vision change, photophobia, weakness, or paresthesia. Vitals stable, no focal neurologic deficits. Labs unremarkable. CTH revealed no acute intracranial hemorrhage or infarct; prominent pituitary, concerning for pituitary adenoma.Day 2: Fever (103F), leukocytosis (12.4), photophobia, blurred vision,  and ophthalmoplegia. Lumbar puncture (LP) showed clear CSF, opening pressure (OP) 5.5, WBC 45 with 91% neutrophils, RBC 20, elevated protein 69.8 and glucose 76. IV ceftriaxone, vancomycin, ampicillin,  and acyclovir were started after LP for suspicious ME.Days 3-10: CSF cultures and ME panel came back negative. Patient’s condition declined with worsening neurological deficits and electrolyte disturbances, including lethargy, visual field deficit, photophobia, hypo-tension, hypoglycemia, hyponatremia, and hypopituitarism (decreased levels of TSH, FT4, ACTH, Cortisol, Prolactin, IGF-1, LH, and Testosterone).Day 11: MRI brain (Figure 1) showed pituitary apoplexy. Days 12-28: Patient’s condition improved after hormone replacement therapy (hydrocortisone and synthroid) and transsphenoidal decompression. Pathology (Figure 2) showed pituitary adenoma tissue with necrosis  and hemorrhage.LITERATURE REVIEWTo date, 21 cases of pituitary apoplexy mimicking ME have been reported on PubMed since the year of 2000. CSF 1 2 3 4 5 6 7 8 9 10 11 12 13 14OP 5.5 17.5 22 26 26.5WBC 45 580 13 426 174 986 140 908 500 70 110 260 2,408 2,200PMN% 91 84 73 predo predo 97 95 90 93 95 90 88 98 90RCB 20 2,330 53 0* 40 124 22 25 15 290Protein 69.8 153.4 90 90 100 239 80 119 85 80 90 87 113Glucose 76 136 70 61.3 12 64.9 45 36 39.6 57 51* xanthochromic cerebrospinal fluid (CSF)CSF FEATURES IN THESE CASES: •  Neutrophil predominant pleocytosis in 100% cases (14/14); •  WBC < 1000/ul in 86% cases (12/14);•  RBC exists in 93% cases (13/14); •  Elevated protein in 100% cases (14/14): 69.8 ~ 239 mg/dl; •  Glucose level varies: 12 ~ 136 mg/dl, but > 40 mg/dl in 73% cases (8/11) CONCLUSION•  Meningism could be major clinical manifestation of pituitary apoplexy. In this condition, CSF pleocytosis, erythrocytes, and elevated protein may be present, which could be confused with SAH and infectious ME. •  Consider pituitary apoplexy as a differential diagnosis in these cases, especially when the patient is found with sudden headache, endocrine dysfunction, vision symptoms, or sellar/suprasellar lesion on neuroimages (CT, MRI).•  MRI is the gold standard for preoperative diagnosis. Sensitivity is reported of 91%; 94.4% (17/18) in our study. •  Rapid and early diagnosis allows for aggressive endocrine management and surgical decompression, which decreases mortality and morbidity rates from 100% to 6.7%.INTRODUCTION•  Pituitary apoplexy is a clinical syndrome resulting from infarction or hemorrhage of pituitary adenoma. •  The most common symptoms: headache, visual deficits, oph-thalmoplegia, hypopituitarism, fever, and meningism. •  It is a rare and life-threatening medical condition which may require urgent surgical inter-vention. Unfortunately, it tends to be misdiagnosed as a sub-arachnoid hemorrhage (SAH) or meningoencephalitis (ME). •  We present a case whose initial clinical picture was suggestive of ME, but instead had pituitary apoplexy. We analyze the similar cases published on PubMed and highlight learning points on how to aid earlier diagnosis and the importance of considering this as a differential diagnosis.Pituitary Apoplexy Mimicking a MeningoencephalitisC. Chu, MD,* G. A. Perilli, MD,** R. E. Kinney, DO,* S. Smith, MD**Department of Internal Medicine and **Department of Endocrinology, Lehigh Valley Health Network, Allentown, Pa. Figure 2. Pathology showed pituitary adenoma with extensive necrosis, hemorrhage, and hemosiderin depositionFigure 1. MRI findings are consistent with subacute pituitary hemorrhage, including peripheral hyperintensity (blue arrow) on coronal T1 sequence (A), rim enhancement on sagittal post-gadolinium sequence (B), and hypointensity (green arrow) on axial gradient echo sequence (C)ACKNOWLEDGEMENTI appreciate Dr. Smith, Dr. Perilli, Dr. Kinney, Dr. Brown, and Dr. Williams for their great support in this poster presentation.N05519_ChunChu_Poster.indd   1 4/25/18   9:45 AM

Pituitary Apoplexy Mimicking a Meningoencephalitis.

https://scholarlyworks.lvhn.org/cgi/viewcontent.cgi?article=2522&context=medicine

Pituitary Apoplexy Mimicking a Meningoencephalitis.

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