Introduction: Pituitary macroincidentalomas are rare, being found in only 0.2%0.3% of the patients that undergo imaging studies for an unrelated reason. The majority of them are non-functioning adenomas.
Case Report: Woman, 77 years-old, with type 2 diabetes mellitus, hypertension and primary hypothyroidism. She was referred to Endocrinology due to a pituitary incidentaloma (18 mm of maximal diameter, with extension to the cavernous sinus and to the optic chiasm) diagnosed in a CT scan that was performed due to syncopal episodes. The patient also reported sporadic headaches and visual acuity loss. No endocrinopathy stigmata were found on physical examination. Laboratory study revealed a high late night salivary cortisol, a high ACTH and a positive 1-mg overnight dexamethasone suppression test (6.2 μg/dl). An elevated plasmatic cortisol in the low dose dexamethasone suppression test (29.2 μg/dl) confirmed the diagnosis of Cushing Syndrome. One week after the diagnosis, the patient presented to the Emergency Department (ER) with severe headaches, nausea, vomits and psychomotor impairment. Blood tests shown severe hyponatremia (114 mEq/l). Despite the ER head CT scan revealed no significant alterations, the patient was given 100 mg of hydrocortisone and she was hospitalized due to the clinical suspicion of a pituitary apoplexy. The hormonal study revealed panhypopituitarism (serum cortisol 12 μg/dl; ACTH 41.3 ng/l; TSH 0.04 μUI/l; FSH 2.14 mU/ml; LH 0.23 mUI/ml; prolactin 4.6 ng/ml) and the pituitary MRI demonstrated features of tumoral haemorrhage, confirming the apoplexy hypothesis. She maintained glucocorticoid therapy with symptomatic improvement and progressive correction of the sodium levels.
Conclusions: Pituitary apoplexy is rare but it can be a serious health issue if not promptly recognized. In this particular case, the apoplexy led to hypercortisolism resolution. Thus, if the revaluation MRI shows significant tumoral shrinking, the patient will no longer have surgical indication.