Endocrine Abstracts

A 40-year-old female presented with lethargy, poor mobility and blurred vision for 2 weeks and 6 months of amenorrhoea. On examination she was markedly Cushingoid with proximal myopathy and normal visual fields. She was hypertensive, with peripheral oedema and leg ulcers. Bloods revealed leucocytosis, hyperglycemia, and ketonuria. She was commenced on insulin. CXR was clear.

Endocrine review diagnosed Cushings syndrome. Cortisol did not suppress overnight with 1 mg dexamethasone but poor compliance limited a 24 h urine collection. Prolactin, TFTs, IGF1 were normal. MRI showed deviated pituitary stalk but no adenoma. CT chest and abdomen showed mild consolidation in the right lung but no masses or adrenal abnormalities.

Two weeks later, she collapsed with marked hypoxia and hypotension. CXR revealed a white-out of left lung. Despite ventilation and inotropes she died later that day. Post-mortem revealed a 9 mm basophilic pituitary adenoma containing both fresh and old haemorrhage. ACTH levels (returning subsequently) were elevated. A diagnosis of fatal pituitary apoplexy was made. During resuscitation on ITU the patient had not been given glucocorticoids. The Coroner declared accidental death as the patient had been prescribed prophylactic clexane.

Though the reported incidence of pituitary apoplexy is around 10% in pituitary tumors, it rarely occurs in Cushings disease. It is usually seen in macroadenomas and there are only very few reported cases in literature of apoplexy in ACTH secreting microadenomas. Classical symptoms are headache, visual problems and meningism. In some cases patients may be asymptomatic like our case. Precipitating factors are trauma, aniticoagulation, pregnancy, pituitary stimulation tests, large tumour growth etc.

Apoplexy should be suspected in collapsed patients even with suspected, but unproven pituitary disease and steroid treatment initiated empirically in such emergencies. Also apoplexy, though rare, may be a higher risk in patients treated with even low dose anticoagulants.