Endocrine Abstracts

Introduction: Pituitary apoplexy is a rare and potentially life-threatening disorder defined by hemorrhage or infarction of the pituitary gland. Occasionally, it may be the first manifestation of an underlying adenoma.

Case report: We present a case of a 70-year-old male, who was admitted in our clinic for an incidentally discovered pituitary macroadenoma accompanied by severe left hemicrania, otalgia and left eyelid ptosis.

Medical history: Two weeks ago, the patient was hospitalized for SARS-COV2 infection, with a moderate form of pneumonia and was administered anticoagulation and glucocorticoid therapy, antipyretics, rehydration fluids, no intubation needed.

During that stay, he suddenly developed a vertebrobasilar syndrome, which prompted an imagistic evaluation, revealing a pituitary macroadenoma with optochiasmatic and cavernous sinus compression, with no signs of acute bleeding or intracerebral lesions, thus excluding a stroke/brain hemorrhage.

Admission to endocrine clinic: Clinical examination showed pale skin, multiple post-anticoagulation hematomas, a remitting left eyelid ptosis, unstable gait, narrowed visual field, no polyuria or polydipsia.

Biological assessment identified microcytic hypochromic anemia, normal platelet count, inflammatory syndrome, elevated D-dimer level, low iron level.

Endocrine evaluation revealed pituitary insufficiency(adrenocorticotropic, tireotropic and gonadal) with a bilateral narrowing of the peripheral visual field.

The pituitary contrast MRI revealed a macroadenoma(21/17/20 mm)within a precocious subacute state hemorrhage with optochiasmatic and cavernous sinus compression. Since the patient was hemodynamically stable, conscious and further evaluations didn’t show signs of worsening, we opted for conservative management and corticotherapy. Patient was discharged with improved evolution, and under hormonal therapy.

Second endocrine admission: After two weeks, he was readmitted urgently for severe headache and right eyelid ptosis. We initiated glucocorticoid therapy in anti-inflammatory doses, with remission of clinical symptoms. The second MRI showed a shrinking macroadenoma(18/17/17 mm) with no rebound hemorrhage. During this stay, patient accused mild discomfort in his left iliac region, rapidly progressing to severe pain, with abdominal muscle defense, inflammatory syndrome and increased markers of sepsis. He was sent for exploratory surgery and diagnosed with an abscessed hematoma of the left iliopsoas muscle compartment. The patient was released with a positive outcome and reevaluated regularly.

At 3 months, MRI showed a much smaller adenoma(18/7/15 mm), with withdrawn hemorrhage.

Conclusions: As awareness of COVID-19-associated coagulopathy increases, thrombotic manifestations are implicated in mortality. This case report unveils a rare and never cited before, association between two life-threatening pathologies, that could both be linked to anticoagulation therapy and/or prothrombotic status.