Endocrine Abstracts

Introduction: Pituitary apoplexy is a rare, potentially life-threatening syndrome caused by ischemic infarction or hemorrhage, generally into a pituitary tumor. The clinical manifestations of PA usually manifest suddenly and include headache, nausea/vomiting, altered awareness and visual abnormalities. Regarding endocrine deficiencies, signs and symptoms of cortisol deficiency are generally observed in the early stage after apoplexy onset, as occurred in our patient. Hypothyroidism, hypogonadism, and growth hormone deficiency are frequent and may occur progressively during weeks, months, or years. In cases with severe, visual or neurological manifestations, surgical decompression is indicated; patients with mild, stable clinical picture can be managed conservatively.

Case presentation: We describe the case of a 67-year-old man with spondylolisthesis L5-S1 who was admitted to Trauma University Hospital in preparation for a scheduled surgery. His medical history included type 2 Diabetes, arterial hypertension, dyslipidemia. In 2020 he was hospitalized with inferior paraplegia and his head CT was normal. He was dismissed from the hospital with some diagnosis including diabetic polyneuropathy and anxiety disorder. The patient appeared to be recovering well until two days later, when it was noticed that he was lethargic and disoriented. His examination resulted in low blood pressure 86/60 mmHg, regular pulse rate of 113 bpm. During the neurological examination he was unresponsive of verbal stimulations, but responsive of dolent stimuli. His pupils were equal in size and both had normal direct and consensual responses to light. The neurologist recommended a head MRI in which resulted in pituitary apoplexy. In his blood work resulted glycemia – 68 mg/dl, normal BUN, sodium - 120 mmol/l (136-145), potassium – 4.5 mmol/l (3.5-5.1), TSH -1.6 mUI/ml (0.4-4), prolactin – 8.5 ng/ml (3.5-19.4), LH – 4.1 mUI/ml (1.6–15.2), FSH – 2.9 IU/ml (3- 8.1), ACTH – 5.5 pg/ml (6-50), cortisol – 1.8 mg/dl (3.7-19.4). Management included hemodynamic stabilization, correction of electrolyte disturbances and corticosteroid administration: intravenous hydrocortisone was administered with the dose of 100 mg every 8 hours for 24 hours, then transitioned to oral hydrocortisone 20 mg in the morning (08.00) and 10 mg at noon (16.00). After hydrocortisone admission the patient regained his normal mental status with no further episodes of confusion. On the ophthalmologic examination the patient had no visual deficits so a conservative approach was considered safe. After 6 days he was dismissed from the hospital on glucocorticoids replacement.

Discussion: This case illustrates the prompt and accurate diagnosis of pituitary apoplexy after a major surgery leading to optimal patient outcome.