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An unusual cause of acute bacterial meningitis
  1. I Stephenson,
  2. M J Wiselka
  1. Department of Infectious Diseases and Tropical Medicine, Leicester Royal Infirmary, Leicester LE1 5WW, UK
  1. Dr Stephensonistephen{at}globalnet.co.uk

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A 31 year old man was admitted after a 24 hour febrile illness with headache and confusion. On examination he was unwell, pyrexial at 39.4oC, tachycardic, and uncooperative. He became increasingly confused and agitated and exhibited signs of meningism. There was no rash or focal localising neurological signs, and visual fields to confrontation were normal.

He required intubation and sedation to control his agitation and was admitted to the intensive care unit. Lumbar puncture revealed turbid cerebrospinal fluid (CSF) containing 8300 × 106/l white blood cells (95% polymorphs), protein 4.6 g/l, glucose 1.4 mmol/l (blood glucose 5.9 mmol/l), with negative Gram stain and culture. Blood and throat cultures were sterile. Nasal swabs cultured methicillin resistant Staphylococcus aureus. Computed tomography of his head with contrast showed expansion of the sella and generalised cerebral oedema. Further imaging with magnetic resonance and coronal computed tomography of the pituitary fossa was obtained (fig 1). Thyroid function, random cortisol, follicle stimulating hormone, and luteinising hormone were normal but raised values of prolactin (15400 IU/l) and decreased testosterone concentrations (9.0 nmol/l) were found.

Figure 1

Coronal magnetic resonance image of the brain.

He received two weeks of intravenous ceftriaxone, vancomycin, and metronidazole and made an uncomplicated recovery. CSF rhinorrhoea was noted by the patient on bending forwards. Subsequent CSF cultures, obtained from the rhinorrhoea, was sterile.

Questions

(1)
What is the lesion shown on the magnetic resonance imaging scan?
(2)
How does this usually present?
(3)
How may this condition present with meningism?
(4)
What is the treatment of the underlying lesion?
(5)
What are the causes of hyperprolactinaemia?

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