Endocrine Abstracts

Section 1: Case history: We present a case of a 75-year-old male with hypopituitarism on the background of recent COVID-19 infection. The patient was COVID-19 swab positive six weeks prior and suffered mild hypoxia, however declined hospital admission at that time. He presented one month later with sudden onset severe headache associated with fever; drowsiness and abdominal pain. He was discharged with antibiotics for suspected diverticulitis. His GP subsequently performed a pituitary panel, revealing hypopituitarism, and advised urgent admission. The patient reported symptoms of lethargy, memory loss, peripheral oedema and light-headedness. Systemic examination revealed no evidence of chronic pituitary insufficiency. There was no neurological or visual deficit on examination. The patient was started on intravenous hydrocortisone replacement pending further investigations.

Section 2: Investigations: A pituitary panel revealed anterior pan-hypopituitarism. Computerised tomography imaging demonstrated a rounded mass within the pituitary fossa of increased attenuation corresponding with a fresh blood clot. A subsequent magnetic resonance imaging scan performed revealed a 12 mm mass located within the pituitary gland, extending into the suprasellar cistern but not compressing the optic chiasm. Within the pituitary there was a large area of high signal on T1-weighted imaging consistent with haemorrhage into a pre-existing pituitary macroadenoma, confirming pituitary apoplexy. Formal assessment of the patient’s visual fields was normal.

Section 3: Results and treatment: The patient was treated with hydrocortisone on arrival and later commenced on thyroid replacement. His symptoms improved after two weeks and repeat MRI revealed reduction in size of the haemorrhagic lesion. Multidisciplinary team discussion decided no neurosurgical input was required, and advised continuation of hormone replacement therapy and to monitor the pituitary macroadenoma with a repeat MRI after six months.

Section 4: Conclusions and points for discussion: Our understanding of how COVID-19 affects different bodily systems remain incomplete. This case demonstrates a potential link between COVID-19 and pituitary apoplexy in a patient with no recognised risk factors for apoplexy, although this remains speculative. A growing number of similar cases have been reported in a variety of ages and genders during the pandemic. Speculation on possible links between COVID-19 and apoplexy include haemodynamic instability, direct CNS viral invasion and insulin resistance with glycaemic disarray. Despite the rarity of this pathology, the prevalence of COVID-19 suggests that more patients with underlying pituitary tumours will be exposed to COVID-19, increasing their risk of pituitary apoplexy. We must be vigilant in recognising this endocrine emergency, and further elucidate the underlying pathophysiology.