A case of pituitary apoplexy mimicking viral meningitis

Pituitary apoplexy (PA) is a clinical syndrome caused by ischemia or hemorrhage of the pituitary gland, typically in the context of an adenoma. It typically presents with a thunderclap headache and sterile cerebral spinal fluid (CSF). The authors identify a case of PA, which initially presented with the signs and symptoms of viral meningitis. PRESENTATION OF CASE: A 44-year-old man presented to the emergency department with headache, nuchal rigidity, fever, and delirium. The patient reported a 10-year history of chronic that were partially responsive to acetaminophen. Four days after admission, the patient developed right-sided cranial nerve III, IV, and VI palsies. Labs revealed anemia and hyponatremia. The CSF was leukocytic, lymphocyte-predominant, and had elevated protein. In addition to these results, negative CSF bacterial cultures led the care team to believe this case was viral meningoencephalitis. Routine MRI of the brain at presentation revealed a 3.1×2.5×3.2 (craniocaudal×anterior posterior×transverse) expansile mass centered within the sella turcica. An endocrine workup revealed hypopituitarism. The diagnosis of PA was then made. A microscopic transsphenoidal resection of the sellar mass was performed, and histopathologic analysis confirmed necrotic pituitary adenoma tissue. Following an uncomplicated procedure, the patient recovered fully from his cranial nerve palsies and continues to do well. DISCUSSION: Because life-threatening hypotension from acute adrenal insufficiency can be caused by PA, timely diagnosis is crucial. When a patient presents with meningism, PA should be included in the differential diagnosis. CONCLUSION: This report illustrates a case of PA presenting with symptoms and a CSF profile classically associated with viral meningitis.