Clinical case discussions-Hypopituitarism and pituitary apoplexy caused by pituitary Adenomas

A case of“Hypopituitarism and pituitary apoplex induced by pituitary Adenomas”was collected in the Third Affiliated Hospital of Inner Mongolia medical University Geriatric Department.A rare and atypical disease as it is,delayed diagnosis and treatment is easily seen among those cases.Therefore,the paper aims to investigate the difference of clinical characteristics and treatment outcome of pituitary adenomas in elder patient through the case analysis.Clinically,patients with pituitary dysfunction may have life-threatening crisis so that timely diagnosis and aggressive treatment can be effective in reducing the pituitary crisis and reducing the misdiagnosis rate.

Diagnosis and management of pituitary apoplexy:a Tunisian data

Background Pituitary apoplexy(PA)is defined as the hemorrhage or the infraction of a pituitary adenoma.Aiming to determine the epidemiological,clinical,paraclinical characteristics as well as management and outcomes of PA in our population,we conducted this cross-sectional study.Methods This cross-sectional study was conducted at the Department of Endocrinology of Hedi chaker university hospital,Sfax.Data was collected from medical charts of patients with pituitary apoplexy admitted in our department between 2000 and 2017.Results We included 44 patients with PA.Their mean age was 50±12.6 years.Among them,31.8%had a known pituitary adenoma,and it was in all cases a macroadenoma,predominantly a prolactin secreting tumor(42.8%).A triggering factor of PA was encountered in 31.8%of cases and it was mainly:head trauma,dopamine antagonists,and hypertension.The clinical presentation of PA encompassed headaches(84.1%),visual disturbances(75%),and neurological signs(40.9%).Gonadotropin deficiency was the most frequent form of hypopituitarism noted(59.1%),followed by corticotropin deficiency(52.3%),thyrotropin deficiency(47.7%),and somatotropin deficiency(2.3%).Hormonal assessment at PA onset,concluded that 23 had a secreting adenoma:18 prolactinomas,3 ACTH-secreting adenomas,and 2 GH-secreting adenomas.In the 21 remaining cases,the tumor was non-functioning(47.7%).Pituitary MRI was performed in 42 cases(95.5%),revealing infraction and or hemorrhage in the pituitary gland in 33 cases;a heterogenous signal or a fluid level within the adenoma,in nine cases.Urgent administration of intra venous hydrocortisone was required in 19 cases.Mannitol administration was mandatory in a patient who had severe intracranial hypertension.Surgical management of the PA was imperative in 24 patients(54.5%):15 suffered from severe visual impairment,4 had an intracranial hypertension,2 cases demonstrated an impaired consciousness,2 patients experienced a tumor enlargement and one case had a severe Cushing’s disease.Operative complications found were rhinorrhea attributable to cerebral spinal fluid leakage,insipidus diabetes associated with rhinorrhea,isolated insipidus diabetes,and hydrocephalus in one case each.Long-term follow-up concluded that headaches persisted in five cases,owing to the tenacity of a macroprolactinoma regardless of cabergoline treatment in one case,the recurrence of an adenoma in two cases and its persistence despite the medical and the surgical treatment in two patients.Concerning the visual acuity defects,only two patients had persistent diminished visual acuity at long-term follow-up.Among 25 patients,13 were diagnosed with definitive thyrotropin deficiency.Similarly,14 patients had persistent corticotropin deficiency(CD).Additionally,CD was de novo diagnosed in two patients.Otherwise,gonadotropin deficiency prevailed in all cases.Persistent prolactin deficiency was seen in two patients.Disappearance of the pituitary tumor was encountered in 11 out of 24 cases at long-term follow-up.Overall,surgery was associated with better outcome than conservative management.Pituitary apoplexy is a challenging condition due to its variable course,its diagnosis difficulty and management,as gaps remain to determine the best approach to treat this condition.Conclusions To conclude,pituitary apoplexy is a challenging condition due to its variable course,its diagnosis difficulty and management,as gaps remain to determine the best approach to treat this condition.Further studies are thus needed.

Pituitary apoplexy complicated with subarachnoid hemorrhage caused by incidentaloma following a head injury:case report

Plituitary apoplexy is a rare clinical syndrome caused by acute enlargement of pituitary adenomas, which may be secreting or nonfunctioning, and symptomatic or asymptomatic, resulted from hemorrhage or infarction. Subarachnoid hemorrhage （SAH） is an unusual presentation in patients with pituitary apoplexy, and that following a head injury is more infrequently reported. Here, we report a case of pituitary apoplexy complicated with subarachnoid hemorrhage caused by an incidentaloma after head trauma in an aged man, who experienced a spontaneous regression of the tumor.

Gonadotrophin-releasing hormone agonist-induced pituitary adenoma apoplexy and casual finding of a parathyroid carcinoma:A case report and review of literature

BACKGROUND Pituitary apoplexy represents one of the most serious,life threatening endocrine emergencies that requires immediate management.Gonadotropin-releasing hormone agonist(GnRHa)can induce pituitary apoplexy in those patients who have insidious pituitary adenoma coincidentally.CASE SUMMARY A 46-year-old woman,with a history of hypertension and menorrhagia was transferred to our hospital from a secondary care hospital after complaints of headache and vomiting,with loss of consciousness 5 min after an injection of GnRHa.The drug was prescribed by her gynecologist due to the presence of uterine myomas.The clinical neurological examination revealed right cranial nerve III palsy,ptosis and movement limitation of the right eye.Our first clinical consideration was a pituitary apoplexy.Blood hormonal analysis revealed mild hyperprolactinemia and high follicle stimulating hormone level;PTH and calcium was high with glomerular filtration rate mildly to moderately decrease.A computed tomography scan,revealed an enlarged pituitary gland(3.5 cm)impinging upon the optic chiasm with bone involvement of the sella.Following contrast media administration,the lesion showed homogeneous enhancement with high-density focus that suggests hemorrhagic infarction of the tumor.Transsphenoidal endoscopic surgery was perfomed and adenomatous tissue was removed.Immunohistochemistry was positive for luteinizing hormone(LH)and follicular-stimulating hormone(FSH).A solid hypoechoic nodule(14 mm x 13 mm x 16 mm)was found in the caudal portion of the right thyroid lobe after a parathyroid ultrasound.A genetic test of Multiple Endocrine Neoplasia type 1(MEN1)was negative.A right lower parathyroidectomy was performed and the pathologic study showed the presence of an encapsulated parathyroid carcinoma of 1.5 cm.A MEN type 4 genetic test was performed result was negative.CONCLUSION This case demonstrates an uncommon complication of GnRH agonist therapy in the setting of a pituitary macroadenoma and the casual finding of parathyroid carcinoma.It also highlights the importance of suspecting the presence of a multiple endocrine neoplasia syndrome and to carry out relevant genetic studies.

Pituitary macroadenoma apoplexy as a rare complication of Bruton tyrosine kinase inhibitor in chronic lymphoid leukaemia

Background Pituitary apoplexy is a neurosurgical emergency and is a known yet rare complication of pituitary macroadenoma.Patients typically present with visual field defects,headache and altered sensorium.There are multiple risk factors for this complication and a thorough drug history is essential to exclude iatrogenic causes of disease.We present an extremely rare case of newly diagnosed pituitary insufficiency unveiled by ibrutinib therapy(a Bruton tyrosine kinase inhibitor).Furthermore,after initial withdrawal of ibrutinib because of the erroneous diagnosis of Syndrome of Inappropriate Antidiuretic Hormone Secretion(SIADH),its re-administration led to the development of classical pituitary apoplexy 4 months after treatment was restarted.Case presentation A male patient in his 60s with a background of chronic lymphocytic leukaemia(CLL)on ibrutinib and venetoclax presents with acute confusion and deranged electrolytes.He is found to be hyponatraemic and is diagnosed with Syndrome of Inappropriate Antidiuretic Hormone Secretion(SIADH)and treated with fluid restriction.He represents again 3 weeks later with hyponatraemia and further investigations reveal pituitary insufficiency and macroadenoma.He was restarted on ibrutinib and venetoclax at the time of discharge.Four months later,he presents with sudden retro-orbital headache associated with vomiting.Clinical findings include cranial nerve III,IV and XI palsy.Humphrey’s visual field examination revealed a left visual field index(VFI)of only 1%while the right was 64%with temporal hemianopia.Both pupils were mid-dilated and poorly reactive to light.MRI pituitary with contrast showed features of pituitary apoplexy and optic nerve compression.He was urgently referred to the neurosurgical team and underwent an emergency trans-sphenoidal hypophysectomy with circumferential excision of the macroadenoma.Post-operative recovery was uneventful with marked improvement in vision bilaterally.The patient was restarted on ibrutinib and venetoclax 2 weeks post-operatively.Approximately 1 year post-treatment,he remains in radiological,clinical and biochemical remission from CLL and all medications have been withdrawn.Conclusions This is a unique and rare case of pituitary macroadenoma apoplexy following the commencement of ibrutinib for CLL.Central nervous system haemorrhage is a rare side effect of ibrutinib due to its platelet dysfunction effects.A thorough assessment is required to assess the risks and benefits of using ibrutinib in patients with pituitary macroadenoma to avoid serious complications.

Risk factors for the incidence of apoplexy in pituitary adenoma: a single-center study from southwestern China

Background:Although the incidence and clinical manifestations of pituitary apoplexy were reported by a few researches,the results are not consistent.This study aimed to explore the risk factors associated with an incidence of apoplexy in pituitary adenomas.Methods:The clinical information of 843 patients with pituitary adenoma from the Department of Neurological Surgery,1st Affiliated Hospital of Kunming Medical University,was reviewed.The incidence,clinical manifestation,and potential risk factors for pituitary apoplexy were analyzed by a case-control study.Results:In total,121 patients(14.4%)with macroadenoma were suffered from pituitary apoplexy.Headache,vomiting,and visual impairment are the top 3 symptoms for the pituitary apoplexy.Logistic regression results showed that the hypertension(hypertension vs non-hypertension OR=2.765,95%CI:1.41~5.416),tumor type(negative staining vs.positive staining,OR=1.501,95%CI:1.248~5.235),and tumor size(diameter>2 cm vs.diameter≤2 cm,OR=3.952,95%CI:2.211~7.053)are independent factors associated with pituitary apoplexy.Conclusion:Our results indicate that the risk factors for the incidence of pituitary apoplexy depend mainly on properties of the tumor itself(tumor size and pathologic type)and the blood pressure of patients.

Spontaneous remission of acromegaly or gigantism due to subclinical apoplexy of pituitary growth hormone adenoma

Background Subclinical apoplexy of pituitary functional adenoma can cause spontaneous remission of hormone hypersecretion. The typical presence of pituitary growth hormone （GH） adenoma is gigantism and/or acromegaly. We investigated the clinical characteristics of patients with spontaneous partial remission of acromegaly or gigantism due to subclinical apoplexy of GH adenoma. Methods Six patients with spontaneous remission of acromegaly or gigantism were enrolled. The clinical characteristics, endocrinological evaluation and imageological characteristics were retrospectively analyzed. Results In these cases, the initial clinical presences were diabetes mellitus or hypogonadism. No abrupt headache, vomiting, visual function impairment, or conscious disturbance had ever been complained of. The base levels of GH and insulin growth factor-1 （IGF-1） were normal or higher, but nadir GH levels were all still 〉1 μg/L in 75 g oral glucose tolerance test. Magnetic resonance imaging detected enlarged sella, partial empty sella and compressed pituitary. The transsphenoidal surgery was performed in 2 cases, and the other patients were conservatively managed. All the patients were in clinical remission. Conclusions When the clinical presences, endocrine evaluation, biochemical examination and imageology indicate spontaneous remission of GH hypersecretion in patients with gigantism or acromegaly, the diagnosis of subclinical apoplexy of pituitary GH adenoma should be presumed. To these patients, conservative therapy may be appropriate.