Endocrine Abstracts

Introduction: Prolactinomas, prevalent among young women, are the most frequently encountered secreting pituitary tumors. Pituitary apoplexy is a rare and severe complication of prolactinomas, which manifests with rapid onset symptoms like severe headaches, visual disturbances, hormonal imbalances, requiring urgent medical care.

Case report: We report the case of a 46-year-old female patient with history of type 2 diabetes, early menopause (30 years old, without prior investigations) that presented in the Emergency Department for symptoms of intracranial hypertension. Head CT scan revealed a pituitary adenoma of 24 x 32 x 33 mm, that proved to be an invasive macroprolactinoma, therefore she was started on Cabergoline 2 mg/week. After one month, the patient returned to the emergency room with recurrence of intracranial hypertension and CSF (cerebrospinal fluid) rhinorrhea. Both CT scan and pituitary MRI were performed, showing pituitary apoplexy, with important pneumoencephaly, lysis of the sellar floor and the prolaps of the pituitary adenoma into the sphenoidal sinus. The ablation of the tumoral mass with the repair of the craniodural defect were performed and the treatment with Cabergoline was stopped. However, meningitis was confirmed and double antibiotherapy was administered, with favorable outcomes. Pathological examination confirmed the presence of a mixed pituitary neuroendocrine tumor, with immunohistochemistry positive for prolactin and GH. Six weeks postoperative, the patient reported residual CSF rhinorrhea, and the prolactin level was 107 ng/ml (normal values: 5-25 ng/ml). The 3 months follow-up confirmed the presence of pituitary insufficiency (central hypogonadism and hypothyroidism), with normal somatotroph axis function, while prolactin levels were persistently elevated (1310 ng/ml). Therefore, the patient was started on levothyroxine 50 mg/day and cabergoline 0.5 mg twice per week, with favourable outcomes (repeated prolactin after 1 month of Cabergoline= 29 ng/ml).

Conclusions: The initial high doses of Cabergoline could have led to the fast and severe shrinkage of the tumour, causing pituitary apoplexy. The persistence of the CSF rhinorrhoea long after the repair of the CSF leak is uncommon and rises the risk of meningitis. CT scan is best for determining CSF rhinorrhea, while MRI for the characteristics of pituitary adenoma. While Cabergoline is recommended as first-line treatment for macroprolactinomas > Knosp 2 according to the latest international Consensus, surgery is needed in the case of pituitary apoplexy complicated with CSF rhinorrhea. At the same time, repairing the cranio-dural defect is more important than the complete removal of the tumour.