Endocrine Abstracts

Introduction: Since the outbreak of the COVID-19 pandemic, several cases of pituitary apoplexy following a SARS-CoV-2 infection have been described in several countries. Here, we describe a case series of pituitary apoplexy occurring in the aftermath of a SARS-CoV-2 infection to alert physicians about possible neuro-endocrinological damage caused by the virus that can lead to visual sequelae and hypopituitarism.

Methods: We retrospectively identified all the adult patients treated at Amiens University Hospital between March 2020 and May 2021 for pituitary apoplexy confirmed by cerebral imaging and following an RT-PCR-confirmed SARS-CoV-2 infection.

Results: Eight cases (6 women, 2 men) occurred between March 2020 and May 2021 and were reviewed in this study. The mean age at diagnosis was 67.5 ± 9.8 years. Only one patient had a ‘known’ non-functional pituitary macroadenoma. Pituitary apoplexy occurred within 0-16 weeks after COVID-19. The most common symptom of pituitary apoplexy was a sudden headache. Visual disturbances and/or ocular palsies occurred in six patients while seven patients presented with corticotropic and thyrotropic insufficiencies. There was no diabetes insipidus. Brain imaging was typical in all cases. Only two patients required decompression surgery, whereas the others were managed conservatively. The clinical outcome was favorable for all patients but without recovery of their pituitary deficiencies. No death occurred in our series.

Conclusion: Being the largest case series in the literature, our study provides support for the hypothesis that SARS-CoV-2 may be a new precipitating factor for pituitary apoplexy. The ruling out of various known precipitating factors of pituitary apoplexy reinforces the plausibility, strength, consistency, and coherence of the causal association between SARS-CoV-2 infection and pituitary apoplexy. The main hypothesis to explain the neurotropism of SARS-CoV-2 involves direct infection by the virus, with the olfactory bulb constituting a gateway in the early phase of infection via neuronal pathways, notably via nasal cells during aerosolization. Although angiotensin converting enzyme 2 (ACE2), the cellular receptor for SARS-CoV-2, is not expressed in olfactory neurons, it is expressed in sustentacular and perivascular cells which have structural and protective roles on olfactory neurons. The other putative gateway is via hypothalamic tanycytes glial cells which have been shown to express ACE2 and type 2 transmembrane protease serine (TMPRSS2), both of them are implicated in virus entry. It is essential that practitioners be alerted about possible pituitary disease due to the virus so that such patients are recognized and appropriately managed, hence improving their prognosis.