Ectopic Prolactinoma Presenting as Bacterial Meningitis: A Diagnostic Conundrum

Accepted Manuscript Ectopic Prolactinoma Presenting as Bacterial Meningitis: A Diagnostic Conundrum Oluwaseun O. Akinduro PII:

S1878-8750(18)30155-4

DOI:

10.1016/j.wneu.2018.01.112

Reference:

WNEU 7310

To appear in:

World Neurosurgery

Received Date: 18 December 2017 Revised Date:

14 January 2018

Accepted Date: 15 January 2018

Please cite this article as: Akinduro OO, Ectopic Prolactinoma Presenting as Bacterial Meningitis: A Diagnostic Conundrum, World Neurosurgery (2018), doi: 10.1016/j.wneu.2018.01.112. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Abstract

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Introduction: Prolactinomas may rarely present with meningitis and cerebrospinal fluid (CSF)

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rhinorrhea secondary to erosion of the wall of the sella turcica. It is even more un-common for

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this abnormal communication to be caused by an ectopic prolactinoma arising from the

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sphenoid sinus and eroding into the sella. This atypical growth pattern makes diagnosis very

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difficult, as there may be no displacement of the normal pituitary gland. The authors present

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the first reported case of a patient with an ectopic prolactinoma presenting primarily with

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meningitis, and discuss the management strategy as well as surgical and non-surgical treatment

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options for these patients.

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Case Report: A 48-year-old woman presented with confusion, low-pressure headache, and

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fever. A lumbar puncture revealed Streptococcus pneumonia meningitis and she was placed on

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penicillin G. After initiation of antibiotics, she noticed salty tasting post-nasal fluid leakage.

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Imaging was remarkable for bony erosion of the sphenoid sinus wall by a soft tissue mass

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growing from within the sinus, with no disruption of the normal pituitary gland. We then

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performed a biopsy with an endoscopic transnasal transsphenoidal (TNTS) approach and

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repaired the CSF leak with a pedicled nasoseptal flap. The final pathology was prolactinoma and

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she was placed on cabergoline.

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Discussion: Ectopic prolactinomas may rarely present as meningitis secondary to retrograde

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transmission of bacteria through a bony defect in the sphenoid sinus, and must be included in

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the differential diagnosis of any sphenoid sinus mass. Management should first address the

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infection, followed by surgical repair of the bony defect.

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Word count: 249

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Running Title: Bacterial Meningitis from Ectopic Prolactinoma

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Keywords: prolactinoma, nasoseptal flap, cerebrospinal fluid leak, ectopic pituitary tumor,

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meningitis

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Abbreviations: CSF: cerebrospinal fluid, TNTS: transnasal transsphenoidal

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Introduction

Cerebrospinal fluid (CSF) leakage following treatment of invasive prolactinomas is a rare

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but well-known entity. This most commonly occurs in the setting of tumor regression following

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treatment with a dopaminergic agonist, such as cabergoline or parlodil, but also may occur

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spontaneously 1-3 4. CSF leakage prior to treatment is extremely rare, and bacterial meningitis as

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the presenting symptom has only been reported 10 previous times 5-7,8,9,10,11,12. Ectopic origin of

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a prolactin secreting pituitary tumor is a rare, but well-known entity, arising from either the

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sphenoid sinus or clivus 13-17 18,19. These tumors are known to arise from the sphenoid sinus, but

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erosion of these tumors through the wall of the sphenoid sinus has not been reported. We

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present the first reported case of a patient with an ectopic prolactinoma presenting primarily

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with bacterial meningitis after erosion into the sella caused an abnormal connection for

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potential bacterial regress. MR imaging revealed that the tumor arose from the sphenoid sinus

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and eroded into the sella with no suprasellar extension or displacement of the normal pituitary

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gland; therefore the diagnosis of prolactinoma seemed unlikely. We hypothesize that the tumor

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had no suprasellar extension because of a strong diaphragma sella. Erosion of the bony wall of

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the sella allowed leakage of CSF and intracranial communication with the paranasal sinuses,

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leading to retrograde flow of bacteria and meningitis. This case highlights the difficulty of

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radiographic and pathologic diagnosis of an ectopic prolactinoma arising from the sphenoid

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sinus and discusses the natural history of this pathology as well as management strategies.

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Case Report

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A 48-year-old woman with recently diagnosed diabetes presented to an outside

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institution with confusion, low-grade fever of 100.1 F, and a low-pressure headache worsened

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with standing and relieved by laying down. Her headaches had increased in severity over the

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prior 6 months. Laboratory testing revealed leukocytosis (15.1 x 109/L) and hyperglycemia

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(223mg/dL). Blood cultures were positive for Candida albicans, so she was placed on

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intravenous fluconazole. A lumbar puncture revealed an opening pressure of 36mmHg of H20,

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43,000 white blood cells (93% polynuclear), protein count of >600mg/dL and glucose of

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<20mg/dL. The CSF culture grew Streptococcus pneumoniae and she was placed on high dose

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intravenous penicillin G (24 million units) for 3 weeks. Soon after the initiation of antibiotics,

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there were copious amounts of clear fluid dripping from the left nare, of which she described as

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tasting “salty”. This fluid tested positive for beta 2 transferrin, confirming the diagnosis of CSF

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leakage. She was transferred to our institution after imaging revealed a soft tissue mass arising

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from the right sphenoid sinus. Computed tomography (CT) imaging revealed bony erosion of

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the lateral wall and floor of the sella turcica with no signs of acute hemorrhage (Figure 1a-b).

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Magnetic resonance imaging (MRI) revealed that the lesion infiltrated the clivus, right

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cavernous sinus, and right sphenoid sinus (Figure 1c-d). It was clear that the lesion originated

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from the sinus and extended intra-cranially rather than originating intra-cranially and extending

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into the sphenoid sinus, as the lesion was discrete from the pituitary gland with no

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displacement of the gland. It entered the right cavernous sinus and completely surrounded the

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cavernous carotid artery, obviating any chance of a safe gross total resection. Differential

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diagnosis at this point included a fungal infection such as mucormycosis, or a tumor growing

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out of the sphenoid sinus such as squamous cell carcinoma, metastasis, neuroendocrine tumor,

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lymphoma, or adenoid cystic carcinoma. Plasmacytomas are also known to infiltrate the sella

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and cause significant bony destruction. We decided the best management approach would be

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to obtain tissue diagnosis with a biopsy and then repair the CSF leak with a pedicled nasoseptal

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flap.

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We performed an endoscopic transsphenoidal approach, opening the right maxillary sinus for extended access to the lesion. The CSF leak was identified and repaired with no intra-

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operative complications. The intra-operative frozen section was suggestive of carcinoid tumor

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and the final pathology confirmed this diagnosis. We initially scheduled the patient with a

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radiation oncology visit, as carcinoid is a radiosensitive tumor. However, an addendum to the

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final pathology returned as invasive prolactinoma after further stains had been completed. At

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this point, prolactin levels were drawn and revealed a level of 820 ng/mL (reference 2-29ng/mL

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for females). She was seen by endocrinology, at which time cabergoline was initiated. She had

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no further CSF leakage or recurrence of meningitis 10 months post-op. However, soon after

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being started on cabergoline, she described transient recurrence of the same “salty” taste. This

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resolved spontaneously with no further recurrence. It is unclear whether this was a CSF leakage

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or not, as it resolved prior completion of any laboratory testing, but the patient stated that the

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fluid tasted identical to the fluid she tasted during her admission. Repeat serum prolactin levels

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after 2 months of cabergoline treatment measured 140 ng/mL, demonstrating some response

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to therapy. She then had repeat imaging and prolactin levels drawn after 5 months of

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treatment revealing radiographic regression of the tumor as well as a significantly reduced

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serum prolactin level of 6.1 ng/mL (Figure 3). She continued to have no further fevers, night

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sweats, or headaches at most recent follow up.

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Discussion

Prolactinomas are a rare cause of CSF leakage and may present with CSF rhinorrhea. It

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has been hypothesized that a strong and competent diaphragma sella, coupled with a thick fold

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of evaginated arachnoid membrane, may force pituitary tumors to expand inferiorly favoring

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CSF leakage into the sphenoid sinus, resulting in a direct route of entry for nasopharyngeal

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organisms 20. These leaks can cause a sterile ventriculitis 21 22, abscess 23, and rarely, meningitis

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initial presentation of a patient with invasive prolactinoma. Diagnosis can be challenging in

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cases with no suprasellar growth of the tumor. Previously reported cases had a component of

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suprasellar extension and fullness of the sella turcica, making the diagnosis of prolactinoma

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more apparent 8,10. As seen in our case, prolactin secreting tumors may originate in the

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. There have been 11 previously reported cases of culture positive bacterial meningitis as the

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sphenoid sinus with little to no suprasellar extension or deviation of the pituitary gland 24.

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Ectopic prolactinomas are a well-known pathology, which may rarely be located in the sphenoid

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sinus. In our patient, the aggressive tumor eroded through the wall of the sinus and this

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connection allowed retrograde transmission of bacteria leading to meningitis. Most lesions

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located the sphenoid sinus are most commonly inflammatory in nature 25. Our patient was

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recently diagnosed with diabetes mellitus, raising concern for mucormycosis, which has a well-

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known complication of intra-cranial extension 26 27. Mucormycosis is a fungal infection with a

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predilection for the sinuses and is most commonly seen in patients with uncontrolled diabetes.

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Because of the seemingly unlikely diagnosis of a pituitary tumor, endocrine laboratory work-up

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was not initiated until after histopathologic diagnosis. Another confounding factor in our case is

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the histopathologic similarity between many hormone-secreting neuroendocrine tumors 28.

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These tumors require further staining with prolactin and CAM-5 for a final diagnosis, which may

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take several days (Figure 2). Our case was initially reported as carcinoid, another

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neuroendocrine tumor known to arise from the sphenoid sinus 29 30, but after further staining,

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the diagnosis of prolactinoma was revealed. Ectopic prolactionoma should be considered in the

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differential diagnosis of lesions involving the sphenoid sinus and parasellar region, and

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hormonal testing should be completed in these patients. It is also possible that the tumor arose

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from the pituitary and grew into the sphenoid sinus, but it is highly unlikely for a tumor of this

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size to cause such minimal alteration of the pituitary gland and stalk if it truly originated in the

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gland. Primary pituitary tumors tend to case deviation of the pituitary stalk, as the direction of

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least resistance would be superiorly rather than inferiorly through the bony floor of the sella.

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Management of a prolactinoma presenting with meningitis is first aimed at treatment of

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the acute infection. Streptococcus pneumoniae is one of the most common causes of bacterial

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meningitis, and is the most common cause of bacterial meningitis associated with transmission

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from the sinuses 31. S pneumoniae was the causative bacteria in 6 of the previous reports of

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prolactinoma-induced meningitis as well. In our patient, we started treatment with penicillin G

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and allowed the symptoms to partially abate prior to surgery. Prolactinoma-induced meningitis

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can have a rapidly fatal course despite the initiation of antibiotics, as seen in 3 previous cases

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5,10 9

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prevent further egress of CSF. This may be accomplished endoscopically with a tensor fascia

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lata graft or pedicled nasoseptal flap26 32. We opted for repair using a nasoseptal flap, which

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resulted in cessation of CSF flow (Video 1). The nasoseptal flap provides a durable vascularized

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repair that can withstand post-operative radiation therapy if necessary 33. The patient did well

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after surgery, and was placed on cabergoline. Unfortunately, because of uncontrollable

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socioeconomic variables, cabergoline was not started until 7 months later, allowing for the

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tumor to grow in the interval period. Weeks after the cabergoline was started, the patient

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reported transient post-nasal dripping of “salty tasting fluid”, which likely indicated medication

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induced shrinking of the tumor after interval growth. This lasted for only 1 day and did not

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recur. Honeggar et al reported a similar case in which a patient with an invasive prolactinoma

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had recurrent CSF leakage despite endoscopic repair of a CSF leak using a fascia lata graft once

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treatment with a dopamine agonist was initiated 2.

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Conclusion

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. Once the patient is stable, clinicians may elect for surgical repair of the sellar wall to

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Erosion of the wall of the sphenoid sinus by an ectopic prolactin secreting pituitary

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adenoma can predispose to bacterial meningitis. Ectopic pituitary adenomas should be included

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in the differential diagnosis of any sphenoid sinus or parasellar mass, and endocrine laboratory

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testing should be performed during the workup. Diagnosis may be exceptionally difficult in

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tumors with atypical growth patterns and no suprasellar extension. Management should be

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aimed at treatment of the infection, followed by surgical repair of the bony defect and any CSF

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leakage. The timing for initiation of anti-dopaminergic medication is important, as delayed

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initiation may allow for interval growth of the tumor followed by medication induced shrinkage

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and potential for recurrent CSF leakage.

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References

19 20 21 22 23 24 25 26 27 28

1.

2.

3.

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M AN U

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2

Leong KS, Foy PM, Swift AC, Atkin SL, Hadden DR, MacFarlane IA. CSF rhinorrhoea following treatment with dopamine agonists for massive invasive prolactinomas. Clin Endocrinol (Oxf). 2000;52(1):43-49. Honegger JB, Psaras T, Petrick M, Beuschlein F, Reincke M. Spontaneous cerebrospinal fluid rhinorrhea in untreated macroprolactinoma--an indication for primary surgical therapy. Zentralbl Neurochir. 2006;67(3):149-154. Astaf'eva LI, Kadashev BA, Kutin MA, Kalinin PL. [Complications of treatment of prolactinoma by dopamine agonists]. Zh Vopr Neirokhir Im N N Burdenko. 2011;75(2):41-50; discussion 50.

8

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9. 10. 11. 12.

13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26.

RI PT

8.

SC

7.

M AN U

6.

TE D

5.

Lam G, Mehta V, Zada G. Spontaneous and medically induced cerebrospinal fluid leakage in the setting of pituitary adenomas: review of the literature. Neurosurg Focus. 2012;32(6):E2. Onoda N, Kamezu Y, Takagi S, Shinohara Y, Osamura RY. An autopsy case of invasive pituitary adenoma (prolactinoma) with rapid fatal clinical course due to streptococcal meningitis. Acta Pathol Jpn. 1992;42(11):832-836. Bouchal S, Razzouki H, Elkhyat SI, et al. [Bacterial meningo-vasculitis revealing a pituitary adenoma]. Pan Afr Med J. 2015;20:7. Aslan K, Bekci T, Incesu L, Ozdemir M. Giant invasive basal skull prolactinoma with CSF rhinorrhoea and meningitis. Clin Neurol Neurosurg. 2014;120:145-146. Margari N, Page S. Bacterial meningitis as a first presentation of pituitary macroprolactinoma. Endocrinol Diabetes Metab Case Rep. 2014;2014:140028. Laszewski MJ, Moore SA. Occult invasive pituitary adenoma predisposing to fatal bacterial meningitis. Clin Neuropathol. 1990;9(2):101-105. Robert T, Sajadi A, Uske A, Levivier M, Bloch J. Fulminant Meningoencephalitis as the First Clinical Sign of an Invasive Pituitary Macroadenoma. Case Rep Neurol. 2010;2(3):133-138. Honegger J, Psaras T, Petrick M, Reincke M. Meningitis as a presentation of macroprolactinoma. Exp Clin Endocrinol Diabetes. 2009;117(7):361-364. Chentli F, Akkache L, Daffeur K, Haddad M, Azzoug S. Suppurative meningitis: A life-threatening complication in male macroprolactinomas. Indian J Endocrinol Metab. 2013;17(Suppl 1):S117121. Hattori N, Ishihara T, Saiwai S, et al. Ectopic prolactinoma on MRI. J Comput Assist Tomogr. 1994;18(6):936-938. Rebai R, Rekik N, Boudawara MZ, et al. [Ectopic prolactinoma of the sphenoidal sinus: case report]. Ann Endocrinol (Paris). 2002;63(3):226-230. Yang BT, Chong VF, Wang ZC, Xian JF, Chen QH. Sphenoid sinus ectopic pituitary adenomas: CT and MRI findings. Br J Radiol. 2010;83(987):218-224. Ajler P, Bendersky D, Hem S, Campero A. Ectopic prolactinoma within the sphenoidal sinus associated with empty sella. Surg Neurol Int. 2012;3:47. De Witte O, Massager N, Salmon I, Meyer S, Dooms G, Brotchi J. Ectopic prolactinoma in the clivus. Acta Chir Belg. 1998;98(1):10-13. Heitzmann A, Jan M, Lecomte P, Ruchoux MM, Lhuintre Y, Tillet Y. Ectopic prolactinoma within the sphenoid sinus. Neurosurgery. 1989;24(2):279-282. Borit A, Blanshard TP. Sphenoidal pituitary adenoma. Hum Pathol. 1979;10(1):93-96. Nutkiewicz A, DeFeo DR, Kohut RI, Fierstein S. Cerebrospinal fluid rhinorrhea as a presentation of pituitary adenoma. Neurosurgery. 1980;6(2):195-197. Boscolo M, Baleriaux D, Bakoto N, Corvilain B, Devuyst F. Acute aseptic meningitis as the initial presentation of a macroprolactinoma. BMC Res Notes. 2014;7:9. Jayasekera BA, Hall J, Pearce S, Jenkins AJ. Ventriculitis from a pituitary prolactinoma: bacterial or chemical? Br J Neurosurg. 2017;31(2):262-263. Rubio-Almanza M, Camara-Gomez R, de San Roman-Mena LP, et al. Brain abscess as the initial presentation of a macroprolactinoma: Case report. Neurocirugia (Astur). 2015;26(1):48-51. Imran SA, Shankar J, Hebb ALO, Croul SE, Clarke DB. Radiological Growth Patterns of Prolactinomas and Nonfunctioning Adenomas. Can J Neurol Sci. 2017;44(5):508-513. Friedman A, Batra PS, Fakhri S, Citardi MJ, Lanza DC. Isolated sphenoid sinus disease: etiology and management. Otolaryngol Head Neck Surg. 2005;133(4):544-550. Gupta AK, Mann SB, Khosla VK, Sastry KV, Hundal JS. Non-randomized comparison of surgical modalities for paranasal sinus mycoses with intracranial extension. Mycoses. 1999;42(4):225230.

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28. 29. 30. 31.

32. 33.

Anand VK, Alemar G, Griswold JA, Jr. Intracranial complications of mucormycosis: an experimental model and clinical review. Laryngoscope. 1992;102(6):656-662. Lapshina AM, Voronkova IA, Marova EI. [Histological and immunohistochemical characteristics of ACTH-secreting tumors]. Arkh Patol. 2013;75(3):8-13. Stephenson KA, Lubbe DE. Primary atypical carcinoid tumour of the sphenoid sinus rostrum. Case Rep Otolaryngol. 2014;2014:753964. Hong SL, Kim SD, Roh HJ, Cho KS. The sphenoid sinus: an unusual presentation of a typical carcinoid tumor. J Craniofac Surg. 2014;25(5):e483-485. Okike IO, Ribeiro S, Ramsay ME, Heath PT, Sharland M, Ladhani SN. Trends in bacterial, mycobacterial, and fungal meningitis in England and Wales 2004-11: an observational study. Lancet Infect Dis. 2014;14(4):301-307. Psaltis AJ, Schlosser RJ, Banks CA, Yawn J, Soler ZM. A systematic review of the endoscopic repair of cerebrospinal fluid leaks. Otolaryngol Head Neck Surg. 2012;147(2):196-203. Thorp BD, Sreenath SB, Ebert CS, Zanation AM. Endoscopic skull base reconstruction: a review and clinical case series of 152 vascularized flaps used for surgical skull base defects in the setting of intraoperative cerebrospinal fluid leak. Neurosurg Focus. 2014;37(4):E4.

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Figure 1. A. Non-enhanced axial computed tomography (CT) of the head revealing a soft tissue lesion destroying the right body of sphenoid bone. B. Coronal CT of the head in bone window. The black arrow highlights bony erosion of the lateral wall of the right sphenoid bone. C. Sagittal CT with black arrow highlighting bony erosion of the clivus. D. Axial post-gadolinium T1 weighted magnetic resonance imaging (MRI) of the brain demonstrating an approximately 1.7 x 1.5 x 2 cm (CC, TR, AP) soft tissue lesion with extension into the right cavernous and sphenoid sinus. The lesion is isointense on T1 with intense enhancement and destroys the right dorsum sella, floor of the sella turcica and right superolateral wall of the sphenoid sinus. The remainder of the right sphenoid sinus is filled with inflammatory mucosal secretions. E. Coronal postgadolinium T1 weighted MRI of the brain reveals that the lesion appears discrete from the pituitary gland with the infundibulum slightly displaced to the left. There is no narrowing of the right cavernous carotid artery encased by the tumor. F. Sagittal post-gadolinium T1 weighted MRI of the brain with visualization of the pituitary stalk in normal position and no significant deviation.

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Figure 2. A. Histopathological staining of the lesion at 20x magnification reveals a very cellular tumor. B. 40x magnification with multiple clear vacuoles, which are often seen in secretory tissue. This tumor has a monomorphic cell growth pattern lacking the reticulin framework seen in normal pituitary gland. C. This tumor stains intensely positive for prolactin. D. CAM 5.2 is a cytokeratin stain, which is positive in neuroendocrine, germ cell tumors, renal cell, and even meningioma. It is negative in most of the cells.

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Figure 3. A. Coronal post-gadolinium T1 weighted magnetic resonance imaging (MRI) of the brain obtained 5 months after initiation of cabergoline reveals that the lesion appears to have diminished in size since the previous MRI imaging taken prior to biopsy of the lesion. B. Axial post-gadolinium T1 weighted magnetic resonance imaging (MRI) demonstrating some size reduction compared with previous imaging.

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Video 1. Surgical video highlighting our endoscopic endonasal transphenoidal approach for biopsy of the sphenoid sinus mass with raising of a nasoseptal flap for repair of the bony defect and cerebrospinal fluid leakage.

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Table 1. Characteristics for Cases of Prolactinoma Presenting with Bacterial Meningitis Year

Age/S ex

Bacterial organism

Antibiotic used

Death

Method for repair of CSF leak

Akinduro et al.

Curre nt

48/F

Streptococcus Pneumoniae

Penicllin G

No

Pedicled Nasoseptal Flap

Aslan et al.

2014

50/M

Streptococcus Oralis

Not specified

Bouchal et al.

2015

48/F

Streptococcus mitis

Ceftriaxone (3g/12hrs) for 2 weeks

Chentli et al.

2013

22/M

Not specified

Not specified

Chentli et al.

2013

49/M

Not specified

Not specified

Chentli et al.

2013

25/M

Streptococcus pneumoniae

Not specified

Honegger et al.

2009

64/M

Streptococcus Pneumoniae

Laczewski et al.

1989

69/F

Margari et al.

2014

Onoda et al. Robert et al.

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Right Craniotomy

No

Endonasal transphenoidal (unspecified)

No

No surgical intervention

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No

No surgical intervention

No

No surgical intervention

Penicillin and Ceftriaxone

No

Fascia Lata Graft

Streptococcus Pneumoniae

Penicillin

Yes

N/a

56/M

Streptococcus Pneumoniae

IV Ceftriaxone (2 g/day) & Amoxicillin (2 g/4 h) for 2 weeks

No

No surgical intervention

1992

44/M

Group A Streptococcus

Not specified

Yes

N/a

2010

32/F

Streptococcus pneumoniae

Ceftriaxone (6 g/day) & vancomycin (750 mg/day)

Yes

N/a (decompressive craniotomy for cerebral edema)

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No

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Highlights

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Prolactinomas may rarely present with meningitis and cerebrospinal fluid (CSF) rhinorrhea secondary to erosion of the wall of the sella turcica Ectopic pituitary adenomas should be included in the differential diagnosis of any sphenoid sinus or parasellar mass, and endocrine laboratory testing should be performed during the workup. The timing for initiation of anti-dopaminergic medication is important, as delayed initiation may allow for interval growth of the tumor followed by medication induced shrinkage and potential for recurrent CSF leakage

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Abbreviations: CSF: cerebrospinal fluid, TNTS: transnasal transsphenoidal, CT: Computed tomography, MRI: Magnetic resonance imaging,