Meningitis as a Presentation of Macroprolactinoma

Abstract

Background: Cerebrospinal fluid (CSF) rhinorrhea and consecutive meningitis are well recognised clinical features of macroprolactinomas invading the skull base and are mainly observed under a dopamine-agonist therapy regimen. To our knowledge, a clinical case of primary meningitis due to an untreated macroprolactinoma, without any history of rhinorrhea, has not been reported previously in the English literature.

Case Report: A 64-year-old patient presented with acute meningitis. He had no prior episode of CSF rhinorrhea. Neuroradiological imaging revealed a pituitary tumour with invasion and destruction of the skull base. Massive hyperprolactinaemia was proof of a prolactinoma. The patient underwent transsphenoidal adenomectomy. The skull base defect was sealed with a fascia lata graft. In the postoperative course, no further episode of meningitis and no CSF rhinorrhea occurred. The invasive residual tumour was successfully treated with cabergoline.

Conclusion: Macroprolactinomas can present with meningitis without any prior history of CSF rhinorrhea. Surgical repair of the skull base defect is the treatment of choice in order to prevent further episodes of meningitis. Pituitary tumours should be considered as a cause of otherwise unexplained meningitis.

Key words

pituitary adenoma - cancer - prolactinoma - transsphenoidal surgery - CSF rhinorrhea - meningitis

References

• 1 Barlas O, Bayindir C, Hepgül K, Can M, Kiris T, Sencer E, Ünal F, Aral F. Bromocriptine-induced cerebrospinal fluid fistula in patients with macroprolactinomas: report of three cases and a review of the literature.  Surg Neurol. 1994;  41 486-489
• 2 Bilo HJ, Ponssen H, Veen EA van der, Wolbers JG. Rhinorrhoea as the presenting symptom of pituitary adenoma.  Clin Neurol Neurosurg. 1984;  86 47-49
• 3 Bronstein MD, Musolino NR, Benabou S, Marino R. Cerebrospinal fluid rhinorrhea occurring in long-term bromocriptine treatment for macroprolactinomas.  Surg Neurol. 1989;  32 346-349
• 4 Cole IE, Keene M. Cerebrospinal fluid rhinorrhoea in pituitary tumours.  J R Soc Med. 1980;  73 244-254
• 5 Couldwell WT, Rovit RL, Weiss MH. Role of surgery in the treatment of microprolactinomas.  Neurosurg Clin N Am. 2003;  14 89-92
• 6 Domingue JN, Wilson CB. Pituitary abscesses: report of seven cases and review of the literature.  J Neurosurg. 1977;  46 601-608
• 7 Hanel RA, Prevedello DM, Correa A, Antoniuk A, Araujo JC. Cerebrospinal fluid fistula as the presenting manifestation of pituitary adenoma: case report with a 4-year follow-up.  Arq Neuropsiquiatr. 2001;  59 263-265
• 8 Hewage UC, Colman PG, Kaye A. Cerebrospinal fluid (CSF) rhinorrhoea occurring six days after commencement of bromocriptine for invasive macroprolactinoma.  Aust N Z J Med. 2000;  30 399-400
• 9 Honegger J, Fahlbusch R, Bornemann A, Hensen J, Buchfelder M, Müller M, Nomikos P. Lymphocytic and granulomatous hypophysitis: experience with nine cases.  Neurosurgery. 1997;  40 713-723
• 10 Honegger J, Psaras T, Petrick M, Beuschlein F, Reincke M. Spontaneous cerebrospinal fluid rhinorrhea in untreated macroprolactinoma – an indication for primary surgical therapy.  Zentralbl Neurochir. 2006;  67 149-154
• 11 Hubbard JL, MacDonald TJ, Pearson BW, Laws ER. Spontaneous cerebrospinal fluid rhinorrhea: evolving concepts in diagnosis and surgical management based on the Mayo Clinic experience from 1970 through 1981.  Neurosurgery. 1985;  16 314-321
• 12 Landolt AM. Cerebrospinal fluid rhinorrhea. A complication of therapy for invasive prolactinomas.  Neurosurgery. 1982;  11 395-401
• 13 Molitch ME. Management of prolactinomas during pregnancy.  J Reprod Med. 1999;  44 1121-1126
• 14 Molitch ME. Medical management of prolactin-secreting pituitary adenomas.  Pituitary. 2002;  5 55-65
• 15 Nutkiewicz A, DeFeo DR, Kohut RI, Fierstien S. Cerebrospinal fluid rhinorrhea as a presentation of pituitary adenoma.  Neurosurgery. 1980;  6 195-197
• 16 Obana WG, Hodes JE, Weinstein PR, Wilson CB. Cerebrospinal fluid rhinorrhea in patients with untreated pituitary adenoma: report of two cases.  Surg Neurol. 1990;  33 336-340
• 17 Onoda N, Kamezu Y, Takagi S, Shinohara Y, Osamura RY. An autopsy case of invasive pituitary adenoma (prolactinoma) with rapid fatal clinical course due to streptococcal meningitis.  Acta Pathol Jpn. 1992;  42 832-836
• 18 Ohtakara K, Matsubara T, Kojima T, Taki W, Waga S. Cerebrospinal fluid rhinorrhea associated with untreated prolactinoma: case report.  Neurol Med Chir (Tokyo). 2000;  40 413-418
• 19 Roux FX, Nataf F, Page P, Devaux B, Brami F. The role of surgery in the treatment of prolactinomas.  Gynecol Obstet Fertil. 2002;  30 367-373
• 20 Suliman SGI, Gurlek A, Byrne JV, Sullivan N, Thanabalasingham G, Cudlip S, Ansorge O, Wass JAH. Nonsurgical cerebrospinal fluid rhinorrhea in invasive macroprolactinoma: incidence, radiological, and clinicopathological features.  J Clin Endocrinol Metab. 2007;  92 3829-3835
• 21 Utsuki S, Oka H, Tanaka S, Iwamoto K, Hasegawa H, Hirose R, Fujii K. Prolactinoma with a high adrenocorticotropic hormone level caused by meningitis: case report.  Neurol Med Chir (Tokyo). 2004;  44 86-89
• 22 Webster J, Piscitelli G, Polli A, Ferrari CI, Ismail I, Scanlon MF. A comparison of cabergoline and bromocriptine in the treatment of hyperprolactinemic amenorrhea.  N Engl J Med. 1994;  331 904-909

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