Pituitary apoplexy secondary to dengue fever-induced-thrombocytopenia:A case report and review of literature

Rationale:Pituitary apoplexy(PA)is a rare endocrine emergency that requires prompt diagnosis and management.Dengue fever-induced-thrombocytopenia may rarely predispose to PA.Patient’s Concern:A 58-year-old male patient having known pituitary macroadenoma presented to the emergency department with fever,a sudden onset severe headache,and altered sensorium.Diagnosis:Pituitary apoplexy caused by dengue fever-induced-thrombocytopenia.Interventions:Conservative management with fluids,mannitol,dexamethasone and symptomatic treatment.Outcomes:The patient responded well to the treatment and was discharged uneventfully.Lessons:Although dengue hemorrhagic fever is a rare cause of pituitary apoplexy,it should be considered if a patient presents with headache and altered sensorium,and prompt initiation of treatment is crucial to prevent fatality and neuro-ophthalmic deficits.

Personalized Management of Chronic Myeloid Leukemia Presenting with Ovarian Apoplexy and Review of Health Emergency Cases

Introduction: Chronic myeloid leukemia (CML) may significantly affect quality of life and life expectancy in the accelerated and acute phases, especially if presented with health emergencies. Objective: The purpose of the study was the evaluation of the personalized management milestones in CML cases presented with ovarian apoplexy and the analysis of the international experience on health emergencies in this leukemia. Materials and Methods: An original, case-report study was performed. The diagnosis was confirmed by cytological, cytogenetic and molecular examinations of the peripheral blood and bone marrow at the comprehensive research cancer center— Institute of Oncology from Moldova. The real-time PCR was performed for quantitative detection of BCR-ABL gene p210 and p190 transcripts. The ECOG Scale and complete hematologic response (CR) estimated the short-term results. The ECOG performance status served as a measure of functional status. Its scores range from 0 to 5 and correlate with the level of patient functioning. CR is the disappearance of all detectable clinical and hematological signs of malignant neoplasm in response to treatment. CR span was assessed in months. The overall and relapse-free survivals asserted the long-term results of treatment, and were evaluated in months as a case. Results: CML may be manifested by life-threatening conditions, including infections and thrombotic events, splenic infarcts and ruptures, bleedings, etc. CML with the uncommon onset under the form of the ovarian apoplexy is described. The hematological CR was obtained under the treatment with imatinib mesylate. The molecular CR and the long-lasting overall survival (197.5 months) were achieved after the treatment with nilotinib. Under the treatment with tyrosine kinase inhibitors, the patient did not experience the disease burden and side effects, and resumed her work, with a good life quality (ECOG score is 0). Discussion: CML may be manifested by life-threatening health emergencies, especially thrombotic events, splenic infarcts and ruptures, bleedings, etc. The CML patients with high leukocyte and platelet counts may experience also different symptoms of hyperviscosity: tinnitus, priapism, stupor, visual abnormalities and cerebrovascular accidents. However, the management of CML with the life-threatening conditions, especially in the accelerated and acute phases, should be realized with participation of the multidisciplinary teams. Conclusions: The ovarian apoplexy may serve as a presenting feature of CML in young females with a highly elevated leukocyte count. The reported CML case underwent successful personalized management with 2 generations of tyrosine kinase inhibitors, even if designated with Socal intermediate-risk score and complicated by a health emergency.

Pituitary Apoplexy: A MRI Finding Case and Literature Review

Introduction: Pituitary apoplexy is an ischemic or hemorrhagic rearrangement within a pituitary adenoma. Pituitary apoplexy is a rare disease that constitutes a diagnosis and therapeutic emergency. Most of the time, apoplexy is the manifestation inaugural of an adenoma unknown, but it can also complicate a known adenoma. All adenomas can be concerned with the occurrence of apoplexy, with an equivalent risk, whether they are secreting or not and whatever the type of secretion. We report the case of a patient in whom the cranio-encephalic MRI enabled to make the diagnosis. Observation: A 57-years-old woman abruptly presented severe cephalodynia, followed by a left visual field defect. The clinical examination revealed an alteration of the consciousness to the type of obstruction and a decrease in left visual acuity is 4/10th. The cranio-encephalic MRI performed revealed an expansive intrasellar process with suprasellar extension of heterogeneous signal on all the sequences performed alternating hemorrhagic stigmata in the central tumor zone suggesting a macroadenoma having bled, compatible with pituitary apoplexy. She received medical treatment and hormonotherapy, followed by surgical excision. The outcome was satisfactory. Conclusion: Pituitary apoplexy is a rare but serious complication of pituitary adenomas. It is responsible for various neuro-ophthalmologic. Pituitary apoplexy involves the patient’s functional and vital prognosis due to acute panhypopituitarism. It is a diagnostic and therapeutic emergency. MRI is a major contribution to diagnosis. Treatment is based on the combination of hormone replacement therapy and trans-sphenoidal tumor excision.

Clinical Observation on Treatment of Sequelae of Apoplexy With Eye and Body Acupuncture

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Clinical Observation on Acupuncture Treatment of 36 Cases of Pseudobutbar Paralysis Syndrome Caused by Apoplexy

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CLINICAL OBSERVATION ON THE TREATMENT OF APOPLEXY BY ACUPUNCTURE COMBINED WITH DRUGS

Apoplexy involves cerebrovascular accident, such as cerebral hemorrhage, cerebralthrombosis, cerebral infarction, subarachaoid hemorrhage, etc. and its sequelae in modern medicine. The author treated 81 cases of apoplexy using acupuncture combined with drugs. AIn0ng them, 36cases were male, accounting for 44%; 45 cases female, accounting for 56 %. The oldest was 82 yearsold, and youngest 28 years old. The shortest course of disease was one day, and the longest over 3years The treatment results show that 60 cases were cured, accounting for 74. 07%; 16 casesmarkedly effect, acc0unting for 19. 75 %; 3 cases improved, accounting for 3. 7 %; 2 cases ineffective,accounting for 2. 48 %. The total effect rate was 97. 52 %.

REVIEW AND PROSPECT OF THE TREATMENT OF APOPLEXY BY ACUPUNCTURE

By review of clinical reports on the treatment of apoplexy in the recent ten years, the authors analyse the main factors influencing the effect of treatment, and point out that for further improvement of the treatment effect of this disease, a strict design of the subject is needed, and it is necessary for the causes and pathogenesis of apoplexy to be analysed, so as to get a clear understanding of the relations among various factors affecting the effect of the treatment and the principal and subordinate position, then the best plan for treatment can only be selected.

ELONGATED-NEEDLE TREATMENT OF URINARY INCONTINENCE CAUSED BY APOPLEXY

In the present paper, the effect of deep insertion of elongated needle onto pelvic nerve(pelvic plexus) for treatment of 32 cases of urinary incontinence caused by apoplexy was observed andcompared to that of filiform needle group (25 cases). Results showed that the total effective rates ofthe elongated needle group and the filiform needle group were 96. 88 % and 68 % respectively, display-ing a significant difference (P【0.05) between the two groups. In addition, mechanisms of elongatedneedle in treatment of incontinence of urine were analyzed preliminarily.

CLINICAL INVESTIGATION ON TREATMENT OF ISCHEMIC APOPLEXY BY ACUPUNCTURE ALONG DU MERIDIAN

In the present study,245 patients suffering from lschemic apoplexy were dividedinto treatment group and control group.The 148 cases in the treatment group were punctured mainlyat points on the Du meridian and the other 97 cases in the control group were punctured on routineacupoints.It was noticed that 87.2％ of the cases in the treatment group and 52.6％ of the cases inthe control group were improved or cured by our treatment.The effective rate of the treatment groupwas 96.6％ and that of the control was 89.7％.There was a statistically significant difference in thetherapeutic effects between the two groups（P【0.05）.The blood rheological indexes were also examinedto study the mechanisms of this therapy primarily.

COMPARATIVE ANALYSIS ON THERAPEUTIC EFFECTS OF APOPLEXY TREATED BY XINGNAO KAIQIAO ACUPUNCTURE METHOD AND WESTERN MEDICINE

The therapeutic effects of Xingnao Kaiqiao (醒脑开窍) acupuncture method and West-ern medicine treating apoplexy were compared in this paper. The results show that the total effectiverate is over 90. 00% in acupuncture group for treating motor dysfunction of limbs and main clinicalsymptotns, especially for treating paralysis of extremities, the total effective rate is up to 97. 72%,which is obviously better than that of Western medicine; moreover, the acupuncture has a special ef-fectiveness for restoring the function of cerebral tissue, and treating aphasia and central facial palsy.The characteristics of Xingnao Kaiqiao acupuncture method were described too.

CLINICAL OBSERVATION ON 44 CASES OF APOPLEXY WITH ZHU'S SCALP ACUPUNCTURE

88 cases of apoplexy of recovering and sequela phases were divided randomly intotwo groups,group of Zhu’s Scalp Acupuncture and group of somatic acupuncture There were 44 Casesin each group.Clinical effect of Zhu’s Scalp Acupuncture was better than that of somatic acupuncture,percentage of basic cure and marked effect of the former was markedly higher than that of thelatter（P【0.05）.Clinical effect of Zhu’s Scalp Acupuncture on recovering phase of apoplexy wasmarkedly better than that on sequela phase（P【0.01 for the rate of basic cure and marked effect andP【0.05 for the total effective rate）.Clinical effect of Zhu’s Scalp Acupuncture on hemorrhagicapoplexy hadn’t marked difference with that on ischemic apoplexy（P】0.05）.Applying Zhu’s ScalpAcupuncture to treat apoplexy,only need a few points,it is easy to manipulate,the needling sensationsare intensive,the clinical effecct is good,it is easy to accept by patients.

CLINICAL OBSERVATION ON TREATMENT OF CEREBRAL APOPLEXY-INDUCED APHASIA BY ACUPUNCTURE

Acupuncture therapy was adopted in the present study to treat aphasia caused by cerebral apoplexy. Among the 24 patients in treatment group, 13 cases were cured, 6 were markedly improved, 4 improved and 1 ineffective. The total effective rate of this group was 95. 8%. Of the patients in the control group, 6 cases were cured, 5 markedly improved, 10 improved and 3 ineffective.The overall curative rate was 87. 5%. The therapeutic results of these two groups were statistically significantly different (P<0.05), the result of the treatment group superior to that of the control group. The obtained results indicate that the acupuncture therapy is an effective way for this illness.

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.

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.

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.

Clinical Research of Buyang Huanwu Teng（补阳还五汤）Granulein Treatment of lschemic Apoplexy

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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.

脑中风辨证分型施护浅析

脑中风分肝阳暴亢、痰热腑实、风痰阻络、气虚血瘀四型。指出:发病七日内,及时治疗,护理措施得当,预后较好。