Endocrine Abstracts

Introduction

Neurological complications related to COVID-19 are described. The pituitary expresses ACE which is known as the entrance for Sarscov2 through binding to viral S-protein. Pituitary apoplexy (PA) is due to the sudden hemorrhagic infarction of pre-existing pituitary tumors or the gland itself and its symptoms and radiological findings can be similar to acute hypophysitis (AH) caused by viral infections.

Subjects and methods

We report a recent case of an 84-year-old caucasian male admitted to emergency department for sudden intense frontal headache for one day. The patient had been discharged three weeks earlier for SARS-CoV-2 pneumonia. He had type 2 diabetes mellitus and ischemic heart disease on acetylsalicylic acid therapy. At admission, an episode of atrial fibrillation occurred for which anticoagulation with enoxaparin was started.

Results

The nasopharyngeal swab for the SARS-CoV-2 virus RNA was positive, neutrophilic leukocytosis with marked increase of inflammation indexes were revealed, head CT scan showed a sellar mass in contact with the lower profile of the optic chiasm without sign of bleeding and chest CT showed bilateral sub-pleural densities with crazy-paving patterns compatible with late-stage SARS-CoV-2 pneumonia. Enoxaparin therapy was confirmed. The headache persisted with photophobia, nausea and vomiting. Later, third cranial nerve deficit with bilateral ptosis, ophthalmoplegia and anisocoria occurred followed by hypotension and confusion so that a cerebral magnetic resonance imaging (MRI) with contrast agent revealed the presence of necrotic-hemorrhagic regression in enlarged sellar tissue referable to PA in pituitary adenoma. Cortisol was < 5 mg/dl. Enoxaparin was interrupted and hydrocortisone was started followed by dexamethasone. Other anterior pituitary hormones were low and thyroxine was started. A second MRI was unchanged while a third MRI three weeks later showed change of pituitary lesion likely referable to combined AH. Accordingly, inflammation markers decreased after dexamethasone was started and the clinical conditions improved with partial recovery of ptosis and complete headache resolution.

Conclusions

PA as well as AH are very rare conditions. In this case a concomitant PA in an unknown macroadenoma and a likely AH have been found coexisting in a patient with SarsCov2 pneumoniae. We speculated on what connections between the two events might be present. Some triggering factors are recognized in PA, including anti-coagulation therapy as in our case. Moreover, SarsCov2 infection can induce reversible AH. Pituitary must be considered as a target organ in patients with Covid-19 for the rare though possible development of apoplexy or hypophysitis.