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Despoina Manousaki, Cheri Deal, Jean Jacques De Bruycker, Philippe Ovetchkine, Claude Mercier and Nathalie Alos

was not febrile and her vital signs were normal, but due to a Glasgow score of 12, she was intubated and given broad-spectrum i.v. antibiotics (ceftriaxone and metronidazole). After 24 h, following extubation, she presented with horizontal diplopia and

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Ilaria Teobaldi, Vincenzo Stoico, Fabrizia Perrone, Massimiliano Bruti, Enzo Bonora and Alessandro Mantovani

Classification (TUC) 2D) with tendon exposure that was treated with honey dressings in addition to systemic antibiotic therapy, surgical toilette and skin graft. Case presentation A 79-year-old Caucasian male patient with type 2 diabetes was admitted to

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Apostolos K A Karagiannis, Fotini Dimitropoulou, Athanasios Papatheodorou, Stavroula Lyra, Andreas Seretis and Andromachi Vryonidou

significant percent of cases. Its management is mainly surgical, while some cases have been treated only with antibiotics ( 4 , 5 ). It may occur either de novo or as a result of hematogenous spread or spread from a contiguous focus of infection such as

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Alessandro Mantovani, Maddalena Trombetta, Chiara Imbriaco, Riccardo Rigolon, Lucia Mingolla, Federica Zamboni, Francesca Dal Molin, Dario Cioccoloni, Viola Sanga, Massimiliano Bruti, Enrico Brocco, Michela Conti, Giorgio Ravenna, Fabrizia Perrone, Vincenzo Stoico and Enzo Bonora

foot ulcers appeared since 1 month, and had been treated, in the first instance, with a conservative approach by dressings with topical antiseptic and oral antibiotic therapy such as amoxicillin, according to Staphylococcus aureus methicillin

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Anna Tortora, Domenico La Sala and Mario Vitale

hypoalbuminemia and for the thyroid hormonal exams not yet in adequately therapeutic target (TSH: 4.1 mIU/mL). Therefore, we slightly increased LT4 dose of oral solution and prescribed specific antibiotic (metronidazole 250 mg three times a day for seven days) for

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Derick Adams and Philip A Kern

fibrosis. Culture of the surgical specimen showed two species of alpha hemolytic Streptococcus , Staphylococcus capitis and Prevotella melaninogenica . After the diagnosis of pituitary abscess and before antibiotics were initiated, blood and urine

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Raluca Maria Furnica, Julie Lelotte, Thierry Duprez, Dominique Maiter and Orsalia Alexopoulou

thick peripheral ring enhancement. Mortality and morbidity are reduced by early transsphenoidal surgery, appropriate antibiotic therapy and hormonal replacement treatment. A close follow-up is necessary, given the risk of recurrence and the high rate of

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Niki Margari and Simon Page

Summary

A 56-year-old man was brought to the Emergency Department after being found collapsed at his office with a reduced level of consciousness. From clinical examination and initial investigations, he was diagnosed as having bacterial meningitis and was promptly commenced on empirical i.v. antibiotics. Computed tomography of the brain revealed a parenchymal mass at the base of the skull and subsequent magnetic resonance imaging of the head 4 days later confirmed a large soft tissue mass, which extended through to the cavernous sinus. Examination of the cerebrospinal fluid (CSF) following lumbar puncture confirmed pneumococcal meningitis and antibiotics were continued for 2 weeks in total. During the admission, hormone profiling revealed a grossly elevated prolactin. When coupled with the initial results of the brain imaging, this result helped to confirm a macroprolactinoma that was invading the postnasal space. A final diagnosis of pneumococcal meningitis secondary to invading prolactinoma was made. The patient was started on cabergoline and was followed up in the outpatient clinic upon discharge. He made a full recovery from the meningitis. Over the next few months, prolactin levels returned to be normal and the prolactinoma shrank significantly in size. The patient remains on cabergoline that will most likely be continued indefinitely.

Learning points

  • Bacterial meningitis is a rare first presentation of pituitary macroprolactinoma.
  • Patients with invasive macroprolactinoma do not always present with CSF leakage.
  • Prompt treatment with antibiotics and a dopamine agonist is of great importance for a favourable outcome.
  • Close monitoring of the patient for signs of raised intracranial pressure is essential in the management of macroprolactinoma.
  • Note the risk of CSF leakage after initiation of dopamine agonist therapy irrespective of concomitant meningitis in macroprolactinoma.

Open access

Carlos Tavares Bello, Emma van der Poest Clement and Richard Feelders

successfully treated with broad-spectrum antibiotics (piperacillin-tazobactam and ciprofloxacin followed by levofloxacin monotherapy). After the procedure, the patient gradually improved regarding hypertension, hyperglycaemia and psychotic symptoms. One month

Open access

Takuma Hara, Hiroyoshi Akutsu, Tetsuya Yamamoto, Eiichi Ishikawa, Masahide Matsuda and Akira Matsumura

Summary

Gastrointestinal perforation is a complication associated with steroid therapy or hypercortisolism, but it is rarely observed in patients with Cushing's disease in clinical practice, and only one case has been reported as a presenting symptom. Herein, we report a rare case of Cushing's disease in which a patient presented with gastrointestinal perforation as a symptom. A 79-year-old man complained of discomfort in the lower abdomen for 6 months. Based on the endocrinological and gastroenterological examinations, he was diagnosed with Cushing's disease with a perforation of the descending colon. After consultation with a gastroenterological surgeon, it was decided that colonic perforation could be conservatively observed without any oral intake and treated with parenteral administration of antibiotics because of the mild systemic inflammation and lack of abdominal guarding. Despite the marked elevated levels of serum cortisol, oral medication was not an option because of colonic perforation. Therefore, the patient was submitted to endonasal adenomectomy to normalize the levels of serum cortisol. Subsequently, a colostomy was successfully performed. Despite its rarity, physicians should be aware that gastrointestinal perforation may be associated with hypercortisolism, especially in elderly patients, and immediate diagnosis and treatment of this life-threatening condition are essential. If a perforation can be conservatively observed, endonasal adenomectomy prior to laparotomy is an alternative treatment option for hypercortisolism.

Learning points

  • Thus far, only one case of gastrointestinal perforation as a presenting clinical symptom of Cushing's disease has been reported.
  • Physicians should be aware that gastrointestinal perforation might be associated with hypercortisolism in elderly patients because elevated levels of serum cortisol may mask the clinical signs of perforation. Because of this masking effect, the diagnosis of the perforation also tends to be delayed.
  • Although parenteral administration of etomidate is a standard treatment option for decreasing the elevated levels of serum cortisol, endonasal adenomectomy prior to laparotomy is an alternative treatment option if etomidate therapy is unavailable.