SUN-270 The Exploding Pituitary - A Case of Atypical Meningitis

Introduction: Pituitary apoplexy is a rare presenting pathology of a pituitary mass. Apoplexy means “sudden attack”, which is a fitting description of the patient’s presentation. Apoplexy is breakdown of the pituitary gland due to insufficient blood flow, leading to ischemia, necrosis, and hemorrhage. Two proposed mechanisms exist: 1. Supra-sellar masses can outgrow their blood supply, 2. Growth inside the suprasellar fossa can constrict blood flow. Patients with pituitary apoplexy typically present with abrupt onset of severe headache, nausea, vomiting, altered level of consciousness, visual impairment and endocrine deficiency. Sheehan took credit for obstetric associated pituitary necrosis however, apoplexy can also be life threatening outside of pregnancy. Case Presentation: This case features 68-year-old females w history of migraines, bradycardia requiring a pace maker, CAD s/p stents, Rheumatoid Arthritis, and urothelial carcinoma of the left kidney which resulted in unilateral nephrectomy. Following surgery: Patient developed generalized weakness, weight loss, Headache. Presented later to ED with severe headache, photophobia, and hypotension. CT Head showed growth of suprasellar mass, edema of hypothalamus and thalamus. Laboratory tests showed Free T4 0.39 (08-1.7), LH < 0.3, FSH 3.7, Ptolactin diluted 85.7, Low Utine Osm 105, cortisol baseline 6.9, cortisol 60 min value post high dose Cosytropin stimulation was 15.5.Spinal fluid analysis was suggestive of aseptic meningitis. Our patient was treated for 10 days in ICU for Sepsis syndrome and viral meningitis before Endocrine consult was obtained, then he got started on hormonal treatment and referred to pituitary Neurosurgeon. Patient underwent Transphenoidal surgery. Pathology revealed Metastasis of Urothelial cancer to pituitary. DISCUSSION & CONCLUSION: Apoplexy causing an atypical meningitis is a rare presentation. We theorize apoplexy can lead to aseptic meningitis by leakage of blood or necrotic tissue into the subarachnoid space. Either agent can induce a cytokine mediated response and the presentation of meningitis. Based on CTs, our patient’s pituitary tumor grew significantly in 30 days. Medical management of pituitary apoplexy includes fluid electrolyte balance, glucocorticoids, hemodynamic monitoring, replacement of missing hormones, and the use of Decadron to decreases cerebral edema. Diabetes insipidus was an alarming symptom for possible metastatic cancer to pitutary CONCLUSION This case highlights the difficulty in diagnosing pituitary pathologies and the rare presentation of apoplexy. Aseptic meningitis and a decrease in centrally controlled hormones should alert Physicians to include pituitary apoplexy in the differential diagnosis. Metastatic urothelial cancer to pituitary is extraordinarily uncommon.