HIDDEN IN PLAIN SIGHT

PITUITARY APOPLEXY IN A PATIENT PRESENTING WITH VISUAL LOSS AND CONJUNCTIVITIS

Abstract

INTRODUCTION
Apoplexy, a rare complication of pituitary tumors, may be the initial manifestation of a previously unknown pituitary pathology. It usually presents with headache, visual impairment or ophthalmoplegia which may be severe and of sudden-onset. Imaging will reveal a pituitary mass with hemorrhagic component.

CASE
A 72-year-old male was admitted due to headache and blurring of vision. He was hypertensive, with history of ischemic stroke (2014) and bilateral renal cell carcinoma post-nephrectomy of the left kidney (2008). One week prior, he was given an initial dose of Pazopanib, a kinase inhibitor used in advanced renal cell carcinomas. He developed headache, anorexia and weakness after 4 days. Blurring of vision with lid swelling and mucoid discharge occurred a day prior to admission. Assessment was bacterial conjunctivitis, hence he was started on antibiotic eye drops. Visual acuity was reduced to light perception in both eyes during this time. Due to headache persistence, cranial MRI was done to rule out metastasis or stroke. There was a 2.8x1.9x2.2 cm mass in the sellar region with heterogenous internal signal displacing the optic chiasm. Pituitary apoplexy was considered, and hormonal work-up revealed central adrenal insufficiency, central hypothyroidism and hypogonadotropic hypogonadism. Steroid replacement was initiated followed by thyroid hormone supplementation then transphenoidal endoscopic pituitary surgery. Histopathology confirmed pituitary adenoma with hemorrhage and necrosis. He was sent home improved on levothyroxine and prednisone.

CONCLUSION
Pituitary apoplexy is a rare endocrine emergency. It can be a diagnostic challenge, hence, a high index of suspicion should be exercised by clinicians.