History and Clinical Findings:
A 35-year-old female patient presented with a complaint of fever persisting for 7 days and an intolerable headache for the last 3–4 days. Upon further inquiry, the patient reported experiencing headaches on and off for the past 2–3 years, which had previously responded to NSAIDs. This time, however, the headache was exceptionally severe, rated as 10/10 in intensity, and did not improve with painkillers. The patient denied experiencing muscle weakness, sensory loss, changes in eyesight, including ophthalmoplegia, diplopia, or ptosis. The patient denied experiencing any changes in her menstrual cycle, infertility, or galactorrhea. The patient's vital signs were as follows: temperature, 100.3°F; heart rate, 104/min; blood pressure, 110/80 mm Hg; oxygen saturation, 98% on room air. Upon examination, motor strength and reflexes were normal in all four limbs, and there was no sensory loss. The examination of her vision was also normal. The rest of the physical examination yielded results within normal limits.
Diagnostic Assessment:
The laboratory results indicated the following values: hemoglobin (Hb) = 10.4 mg/dL, white blood cell count (WBC) = 10,200 cells/µL, neutrophil/lymphocyte ratio of 82/14, platelet count = 193,000 cells/µL. The patient's C-reactive protein (CRP) level was 0.95 mg/dL. Urine routine and microbiology tests returned within normal limits. The quantitative buffy coat (QBC) test for malarial parasites was negative, as were the Widal tests for typhoid fever and paratyphoid fever. The testing for dengue using RT-PCR also produced negative results.
Given the persistent headache with a marked change in character from previous episodes and non-responsiveness to NSAIDs, an MRI of the brain was performed, revealing a pituitary cystic adenoma measuring 2 cm x 1.5 cm x 1 cm in size.
Cerebrospinal fluid (CSF) investigation and blood culture results were normal. An ophthalmologist was consulted to conduct a fundus examination to rule out papilledema, which revealed no signs of papilledema or retinopathy.
Hormonal levels were also assessed, with results showing: thyroid-stimulating hormone (TSH) = 0.92 mIU/L, follicle-stimulating hormone (FSH) = 4.73 IU/L, luteinizing hormone (LH) = 3.54 IU/L, and prolactin = 10.99 ng/ml.
Therapeutic Intervention and Follow-up:
The patient received supportive treatment, including Tab Clonazepam 0.5 mg once daily for 4 days, Inj Pantoprazole 40 mg twice daily, Inj Ondansetron 4 mg three times daily, Inj Ceftriaxone 1 g twice daily, and Inj Paracetamol 150 mg three times daily for 4 days. Upon discharge, the patient was prescribed the following medications: Tab Pantoprazole 40 mg once daily, Tab Clonazepam 0.5 mg once daily for 5 days, Tab Naproxen 500 mg three times daily for 10 days, and Tab Domperidone 10 mg three times daily for 10 days. The patient was referred to a neurosurgeon, and surgical removal of the tumor was successfully performed. The surgery was uncomplicated, and the patient was discharged after a 2-day observation period.
The timeline for the case is given in Table 1
Table 1
| Time | Event |
| July 13, 2022 | ● Patient presented with a fever and headache ● Imaging reveals pituitary cystic adenoma |
| July 14, 2022 | ● Neurosurgery consulted ● Opthalmology consulted ● Further investigation suggests non-functioning pituitary adenoma |
| July 15, 2022 | ● Patient was operated and the tumor removed |
| July 17, 2022 | ● Patient discharged |
| July 22, 2022 | ● Patient doing well on follow-up |