A 31-year-old man presented at the Emergency Department with a six day history of severe headache and vomiting. No history of trauma or neurosurgery was reported. The patient mentioned an important visual loss in the left eye and a decreased libido for at least two years. No history of rhinorrhea was reported.
On admission, clinical examination revealed a normal level of consciousness. Complete left eye blindness with no deficit of other cranial nerves was observed. No rhinorrhea was detected. Body temperature was of 38 C. Computerized tomography (CT) and magnetic resonance imaging (MRI) disclosed a large, invasive pituitary lesion, which extended to the cavernous sinuses, to the sphenoid sinus and to the third ventricle, compressing the optic chiasm (Figure 1, Figure 2). No intratumoral hemorrhage was observed. Through CT scan an extensive disruption of the sellar floor with tumor extension within the sphenoid sinus were observed. Laboratory tests revealed an elevated C-reactive protein (305 mg/L, N <10 mg/L), a white blood cell count of 13,000/mul (4,000-10,000/mul) a mild hyponatremia (131 mEq/L, N 135-145 mEq/L), with a glycaemia of 127 mg/dl (70-100 mg/dl). Prolactin level was 9000 ng/ml (2.5-11 ng/ml); the other hormone measurements were suggestive of an associated panhypopituitarism (Table 1). At lumbar puncture, a purulent CSF was obtained, containing 11,900 white blood cells/mul (0-5/mul), 2680 red blood cells/mul, 6.3 g/L proteins (0.15-0.45 g/L), 39 mg/dl glucose (45-80 mg/dl) and 81 mg/dl lactate (10-22 mg/dl). These findings were consistent with a diagnosis of meningitis associated with a macroprolactinoma. Ceftriaxone was administered intravenously at the dose of 2 g x 2/24 h for 14 days, with favorable clinical evolution and normalization of inflammatory tests. CSF Gram stain and culture was negative for bacteria. Cryptococcal antigen testing was negative. Culture and polymerase chain reaction assay for detection of Mycobacterium tuberculosis were negative. Polymerase chain reaction for detection of viruses was also negative. A replacement therapy with hydrocortisone was initiated, alongside a treatment with cabergoline at the dose of 0.5 mg twice a week. A replacement therapy by levothyroxine at progressive doses was also administered.
At endoscopic transsphenoidal approach a large bony defect in the inferior part of the sphenoid sinus was detected, obstructed by a massive tumor protrusion. Intraoperatively, a dural defect was not clearly identified. A significant reduction in tumor size was achieved through surgery, confirmed by MRI imaging. Histopathology confirmed the diagnosis of pituitary adenoma. No evidence of hemorrhage or necrosis was detected. No recovery from visual loss and panhypopituitarism was observed. Treatment with cabergoline 0.5 mg twice a week and levothyroxine 75 mug per day was continued, with normalization of serum prolactin and free T4 (Table 1). Hydrocortisone at a dose of 30 mg per day was also pursued as a follow up treatment.