Endocrine Abstracts

Introduction: Pituitary apoplexy is both an endocrine and a neurosurgical emergency, and can typically present with sudden onset of headaches, impaired level of consciousness, fever, visual disturbances, nausea or vomiting. Apoplexy ensues when pre-existing pituitary tumour presumably outgrows its blood supply leading to ischaemia, necrosis and haemorrhage or infarction.

Case: A 31-year-old man presented to the hospital with 3 months’ history of gradual onset of headaches. He was found to be pyrexial at presentation (39 C). He also complained of progressive worsening of his left and right eye vision. He developed complete ptosis of his right eye 3 days prior to admission. His other background problems include long-standing gynaecomastia and low libido, and inflammatory bowel disease. Examination findings revealed no light perception on the left eye, 6/21 vision on the right eye, right partial third nerve palsy with ptosis and asymmetry pupil. His Glasgow Coma Scale (GCS) was 15/15. The blood test showed WCC 14.9 10*9/L and CRP 331 mg/L. TSH 0.99 mU/L, FT4 6.8 pmol/L, FT3 1.7 pmol/L, cortisol 427 nmol/L, LH 1.4 iu/L, FSH 1.5 iu/L, prolactin 3597 miu/L, testosterone 1.2 nmol/L, IGF-1 139 ng/ml. His MRI pituitary revealed macroadenoma with suprasellar extension with central necrosis and pus in the sphenoid and ethmoid sinus. He was treated with iv antibiotics and had image-guided endoscopic transsphenoidal drainage of sphenoid and ethmoid pus. His vision improved postoperatively. Immunohistochemical staining for pituitary was positive for prolactin.

Discussion: Pituitary apoplexy remains a potentially life-threatening condition. Its presentation may vary from relatively benign to a catastrophic presentation with neurological deficits. The presentation with gradual onset of headaches and gradual deterioration of vision and clinical features of sepsis is atypical and may lead to delayed diagnosis. Involvement of neurosurgical and endocrine team is vital for the right treatment of the patient.