Endocrine · Year 2 · from Endocrine
Case 3: Pituitary Apoplexy
Patient Demographics
- Age: 48 years
- Sex: Male
- Occupation: Construction supervisor
Chief Complaint
"I have the worst headache of my life and I can't see properly."
History of Present Illness
A 48-year-old man with no significant past medical history presents to the emergency department with sudden onset of severe headache that began 3 hours ago while lifting heavy equipment at work. The headache is described as "thunderclap" in nature, with associated nausea, vomiting, and progressive visual changes. He reports seeing double and notes that his right eyelid is drooping. His wife states he seems confused compared to his baseline.
Physical Examination
- Vital Signs: BP 88/52 mmHg, HR 110 bpm, Temp 37.8°C
- General: Diaphoretic, appears acutely ill
- HEENT:
- Right ptosis with dilated pupil (CN III palsy)
- Restricted eye movements on right
- Visual field testing limited by mental status but appears to have decreased temporal fields bilaterally
- Neurologic: Oriented to person only, meningismus present
- Cardiovascular: Tachycardia, regular rhythm
Workup
- Laboratory Studies:
- Sodium: 132 mEq/L
- Glucose: 68 mg/dL
- Cortisol (random): 3.1 μg/dL (inappropriately low for acute stress)
- Prolactin: 156 ng/mL (elevated)
- CT Head: Sellar mass with hemorrhage
- MRI Pituitary: 2.0 cm pituitary mass with areas of hemorrhage and necrosis, suprasellar extension with optic chiasm compression
Diagnosis
Pituitary apoplexy (hemorrhagic infarction of a pituitary adenoma)
Treatment
- Immediate: IV hydrocortisone 100 mg bolus (critical before any other intervention)
- Fluid resuscitation for hypotension
- Urgent neurosurgical consultation for transsphenoidal decompression given:
- Visual impairment
- Altered mental status
- Cranial nerve palsy
- Post-operative hormone evaluation and replacement as needed
Clinical Pearl
Pituitary apoplexy is a medical and often surgical emergency. The sudden hemorrhage or infarction within a pituitary adenoma (often previously undiagnosed) causes rapid expansion with compression of surrounding structures. The clinical presentation includes sudden severe headache, visual loss, ophthalmoplegia (due to cavernous sinus involvement), and altered mental status. Acute adrenal insufficiency may occur and is life-threatening. Immediate glucocorticoid administration should not be delayed for diagnostic testing. Surgery is indicated urgently when there is significant visual impairment or altered consciousness.
Clinical Image
Axial CT scan showing hemorrhage within an enlarged pituitary gland (pituitary apoplexy).
Image Source: Radiopaedia - "Pituitary apoplexy" License: CC BY-NC-SA 3.0 URL: https://radiopaedia.org/cases/pituitary-apoplexy-1