Pituitary apoplexy masquerading as meningitis

Abstract

Pituitary apoplexy is an uncommon condition and medical emergency that classically presents with abrupt onset of severe headache, nausea, fever, impaired level of consciousness, visual disturbances and a variable degree of ocular paresis. The constellation of signs, symptoms and cerebrospinal fluid findings in keeping with meningitis is considered a rare presentation of pituitary apoplexy and often leads to a misdiagnosis of infectious meningoencephalitis. We present the case of a 52 year old male admitted with a diabetic ketoacidosis who subsequently developed a severe headache with features of meningism. Haematological tests revealed an elevated white cell count and C-reactive protein, and lumbar puncture demonstrated a marked neutrophilic pleocytosis and elevated protein. Ceftriaxone was commenced for the presumptive diagnosis of bacterial meningitis, but resulted in no improvement in the patient’s condition and so imaging studies were performed which revealed the presence of an incidental pituitary macroadenoma with intra-lesional haemorrhage, thus providing the diagnosis of pituitary apoplexy. The patient recovered with conservative management consisting of hormonal replacement therapy and continues to follow up at our facility.