Disclosures: Tomas W. Salazar, MD: Nothing to disclose

Case Description: 56-year-old female with history of pituitary macroadenoma status post resection presented with progressively worsening headaches and bitemporal hemianopsia for over a year. Imaging revealed pituitary tumor recurrence, and she underwent endoscopic endonasal transsphenoidal resection. Post-operatively, she developed vision loss and cerebrospinal fluid (CSF) rhinorrhea, in which both symptoms persisted despite a hematoma evacuation and lumbar drain. She was then transferred to acute inpatient rehabilitation with neurosurgical recommendations of no leaning forward and bed rest as needed.

Setting: Acute Inpatient Rehabilitation Hospital

Patient: 56-year-old female developed meningitis after transsphenoidal resection of a pituitary macroadenoma.

Assessment/Results: She was progressing well in rehabilitation until she developed an acute onset of agitation and delirium, quickly followed by unresponsiveness on post-operative day 11. She was diagnosed with bacterial meningitis from a CSF leak. Despite aggressive antibiotic treatment, her infection was ultimately fatal.

Discussion: Transsphenoidal pituitary resections are regarded as relatively safe procedures with low morbidity and mortality. CSF leaks and meningitis are uncommon complications, occurring in less than 4% and 2% of cases, respectively. Risk for meningitis in this patient was increased due to the CSF leak by 4-18 times per multiple studies. It was also increased by over 4 times by prior operations in the same site. Her presenting symptom was not any of the usual triad of fever, neck stiffness, or headache but rather agitation. Moreover, surgical intervention has been shown in multiple studies to significantly reduce infection rates and is indicated when conservative management fails to prevent the risk of meningitis.

Conclusion: This case demonstrates a rare and potentially fatal complication of a transsphenoidal pituitary tumor resection. Clinicians should keep meningitis high on the differential in patients with CSF rhinorrhea, and reparative surgery must be emergently considered in any patient with a change in mental status to avoid misdiagnosis and delay in care.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/meningitis-after-transsphenoidal-resection-of-a-pituitary-macroadenoma-a-case-report/