A diagnosis of pituitary adenoma in the wake of cerebral meningitis

Abstract

We report a case of untreated pituitary adenoma complicated by bacterial meningitis that was diagnosed following nasal endoscopic surgery. A 68-year-old woman developed a headache and feeling of discomfort in the left ear. The patient was rushed to a nearby physician due to the lack of improvement. Head MRI showed inflammatory changes in the left papillary foci and sinuses, and the patient was transferred to our hospital with a provisional diagnosis of bacterial meningitis from sinusitis or otitis media. On arrival at the hospital, she exhibited a decreased state of consciousness, and acromegaly was suspected based on physical examination. Contrast-enhanced computed tomography showed a lesion with a contrast-enhancing effect from the left ethmoid sinus to the sphenoid sinus and bone defect in the skull base. It was necessary to differentiate between nasal intracranial complications, sinus tumors, and brain tumors and to drain any abscesses causing cerebral meningitis; thus, emergency nasal endoscopy and drainage were planned. While relieving the posterior ethmoid sinus, the partially whitened blood flowed out in a pulsatile manner, and an irregular pulsatile mass was confirmed and biopsied. The open wound was filled with the inferior turbinate mucosa in consideration of the possibility of cerebrospinal fluid leakage. Staphylococcus aureus was detected in the intraoperative wound culture. After pathological examination, with a diagnosis of pituitary adenoma was confirmed. Immediately after the surgery, the patient’s state of consciousness improved. In conclusion, this patient developed bacterial meningitis due to bony destruction of the ethmoid sinus canopy caused by an enlarged pituitary adenoma, and prompt drainage by nasal endoscopic surgery seems to have been useful.