SHM Converge Scientific Abstract ePoster Gallery-A Rare Case of Pituitary Apoplexy Presenting as Aseptic Meningitis

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This case describes a rare presentation of pituitary apoplexy mimicking aseptic meningitis. A 62-year-old woman with diabetes, hypertension, and hypothyroidism developed sudden severe posterior headache with nausea and vomiting, followed by lethargy and confusion over five days. Initial CT and CTA were negative, but inflammatory markers were markedly elevated, and lumbar puncture showed sterile CSF pleocytosis with elevated protein, leading to treatment for possible meningitis.<br /><br />MRI later revealed a 1.9 cm pituitary macroadenoma with imaging features of hemorrhage, consistent with pituitary apoplexy. The mass abutted the optic chiasm but did not compress it, and she had no visual symptoms. Endocrine testing showed low morning cortisol, indicating adrenal insufficiency, while other pituitary hormones were largely normal, supporting a clinically nonfunctioning adenoma.<br /><br />Her presentation was thought to result from leakage of blood or necrotic tumor contents into the subarachnoid space, causing meningeal irritation and CSF pleocytosis that clinically resembled meningitis. Recognized risk factors included hypertension and a nonfunctioning pituitary macroadenoma. Once pituitary apoplexy was identified, hydrocortisone was started, antimicrobials were stopped, and she underwent endoscopic transsphenoidal resection. Her symptoms resolved, and she was discharged on physiologic hydrocortisone.<br /><br />The key lesson is that pituitary apoplexy can present with headache, altered mental status, meningeal signs, and CSF pleocytosis, closely imitating aseptic meningitis. It should be considered in patients with severe headache and meningitis-like findings, especially when imaging or endocrine abnormalities suggest pituitary disease.

Asset Subtitle

Henri Wathieu

Meta Tag

Author List Arkadiy Finn, Henri Wathieu

Category Clinical Vignettes

Concept Pituitary Apoplexy

Concept Secondary Adrenal Insufficiency

Concept Pituitary Macroadenoma

Concept Glucocorticoid Replacement

Concept Aseptic Meningitis

Distinguished Non-Finalist

Presenter Organization Brown University Internal Medicine Program

Presenting Author Henri Wathieu

Track Adult

Keywords

pituitary apoplexy

aseptic meningitis

pituitary macroadenoma

CSF pleocytosis

severe headache

adrenal insufficiency

MRI hemorrhage

endoscopic transsphenoidal resection

meningeal irritation

nonfunctioning adenoma

Pituitary Apoplexy

Secondary Adrenal Insufficiency

Pituitary Macroadenoma

Glucocorticoid Replacement

Aseptic Meningitis