Endocrine Abstracts

A sudden and severe headache caused by spontaneous pituitary apoplexy (PA) in a previously undiagnosed pituitary adenoma is a rare but potentially life-threatening condition that can also result in permanent vision loss. We present the case of a 70-year-old man who presented with a thunderclap headache persisting for four days, along with nausea and meningism, his vision was unaffected. A CT scan, initially done to exclude subarachnoid haemorrhage, showed a hyperdense mass in the suprasellar region. An MRI of the pituitary confirmed haemorrhage within a macroadenoma, confirming PA. Biochemically a globally low pituitary profile was seen with TSH: 0.22, T4:10.4, Random cortisol: 34, FSH:2.7, IGF-1 89.3, Testosterone:1.8, LH:1.0, Prolactin of <6, patient was also hyponatremic. The patient was given a stat dose of 100 mg IV hydrocortisone to prevent adrenal crisis. He was then started on a stress dosing of hydrocortisone (40, 20, 20), thyroxine and testosterone replacement. His hyponatremia was corrected once he was started on treatment. The above approach was taken as clinically stable patients with mild symptoms and the absence of neuro-ophthalmologic symptoms can be managed conservatively as per Society of Endocrinology guidelines. Conservative management involves starting steroids, thyroid, and hormone replacement as required. Management of unstable patients requires early surgical intervention. Criteria for surgical intervention would be reduced visual acuity, visual field defects, and deteriorating level of consciousness. Patients with PA will also require repeat assessment of pituitary and visual function at 4-6 weeks. Thereafter they will be followed up at 6-12 month intervals to titrate treatment and to monitor progression or re-occurrence on imaging. The case highlights the importance of considering PA as a differential in presentations of severe headaches, visual disturbances, and meningism. It also acts as a reminder of the guidelines for the management of pituitary apoplexy.