Case 1: A 43-year-old man presented with two day history of sudden onset of headache and vomiting associated with diplopia and declining vision in the left eye for a few months. On admission he had a high grade fever. Neurological examination was unremarkable except for left sided blindness and blurred vision in right eye.
Initial investigations revealed CRP of 181. CT head reported no haemorrhage or infarct. CSF analysis: WCC 24 (polymorphs 60% lymphocytes 40%), protein 0.92, glucose 3.3, no bacterial growth.
After further deterioration in the right eye vision and no response to antibiotics and antiviral therapy, an urgent brain MRI was arranged which confirmed a pituitary macroadenoma with suprasellar extension causing compression and stretching of the optic chiasm. Subsequently, the patient underwent a successful transsphenoid debulking of the pituitary lesion. Postoperatively the patient regained partial right eye vision but the left eye remained blind.
Case 2: A 75-year-old type 2 diabetic male presented with a three day history of mild headache, diplopia and drowsiness. Initial investigations: Na 125, K 4.1, glucose 7.7, random cortisol 482, CT head findings consistent with cerebral atrophy. CSF analysis: WCC 1, glucose 4.9, protein 0.80.
Within 48 h of admission, GCS dropped to 3/15 with flaccid tetraparesis and arreflexia He subsequently developed poluyuria and diabetes insipidus. MRI head confirmed pituitary fossa lesion with elevated optic chiasm. GCS improved to 15/15 after initiation of steroids. He also developed a right 6th nerve palsy. He was deemed unfit for neurosurgical intervention. Six months later, he remains stable with steroid and thyroxine replacement.
Conclusion: The diagnosis of pituitary apoplexy is often delayed due to atypical presentation. Due to the serious complications of pituitary apoplexy, timely recognition and appropriate management is critical.