Spontaneous cerebrospinal fluid rhinorrhoea as the presenting feature of an invasive macroprolactinoma

Abstract

A 29-year-old male university student, with no prior history of trauma, presented with a 1 year history of clear fluid leaking intermittently from his left nostril. His past medical history included bilateral gynaecomastia since age 12, and recent low libido. β2-transferrin analysis of the nasal fluid confirmed a diagnosis of cerebrospinal fluid (CSF) rhinorrhoea. The serum prolactin was grossly elevated at 42 700 mU/l and brain magnetic resonance imaging (MRI) revealed a large parasellar/sellar mass. A diagnosis of invasive macroprolactinoma complicated by spontaneous CSF rhinorrhoea was made. The patient was commenced on treatment with cabergoline, but while awaiting surgery to repair the CSF leak he developed streptococcus mitis and sanguis meningitis. He made an uncomplicated recovery with antibiotic treatment. Immediately following this episode, the CSF rhinorrhoea resolved spontaneously. Subsequently, a repeat MRI scan revealed dramatic involution of the pituitary mass and the serum prolactin had fallen to 604 mU/l.

Cerebrospinal fluid rhinorrhea in primary treatment of large and giant prolactinomas with dopamine agonists

“…вания фистулы в структурах основания черепа [24]. В принятый в ННПЦН стандарт выявления назальной ликвореи входят: осмотр ЛОР-врача, наличие глюкозы в истекаемой жидкости и проведение КТцистернографии.…”

“…Помимо этого существует тест на β 2 -трансферрин в отделяемой жидкости. Он является более точным диагностическим тестом, с более высокими чувствительностью (≈100%) и специфичностью (≈95%) в отличие от стандартного метода измерения глюкозы [24,25]. Благодаря этому тесту возможно дифференцировать назальную ликворею с аллергическим ринитом [12].…”

Acute aseptic meningitis as the initial presentation of a macroprolactinoma

“…Less frequently, CSF rhinorrhea may be induced by dopamine agonists, as a consequence of the shrinkage of a medically treated macroprolactinoma. Exceptionally, CSF rhinorrhea may occur in untreated pituitary macroadenomas [ 4 , 5 ].…”

Controversial issues in the management of hyperprolactinemia and prolactinomas – An overview by the Neuroendocrinology Department of the Brazilian Society of Endocrinology and Metabolism

“…Additional indications for TSS surgery are complications of the prolactinomas, particularly the management of symptomatic apoplexy (178) and the surgical repair of CSF leaks (179). The latter can occur spontaneously due to tumor invasion of the sphenoid sinus or result from a rapid tumor shrinkage induced by DA therapy (180)(181)(182). In a recent review, more than 90% of cases of cerebrospinal fluid leakage were related to the use of DA, with a mean time of 3.3 months between the start of drug administration and the diagnosis of rhinorrhea (182).…”