Pituitary Apoplexy, Meningitis and Cerebral Infarction - A Perplexing Trifecta

Pituitary apoplexy (PA) is a clinical diagnosis comprising a sudden onset of headache, neurological deficits, endocrine disturbances, altered consciousness, visual loss, or ophthalmoplegia. However, clinically, the presentation of PA is extremely variable and occasionally fatal. While meningitis and cerebral infarcts are themselves serious diseases, they are rarely seen as manifestations of PA and are exceedingly rare when present together. We present the case of a 20-year-old male with a rapid progression of symptoms of meningitis, PA and stroke. The present article seeks to emphasize a rare manifestation of PA with an attempt to understand the intricacies of its evaluation and management.

Apoplexy in sporadic pituitary adenomas: a single referral center experience and AIP mutation analysis

ABSTRACT Objective: To analyze the clinical, laboratory, and radiological findings and management of patients with clinical pituitary apoplexy and to screen for aryl hydrocarbon receptor-interacting protein (AIP) mutations. Subjects and methods: The clinical findings were collected from the medical records of consecutive sporadic pituitary adenoma patients with clinical apoplexy. Possible precipitating factors, laboratory data, magnetic resonance imaging (MRI) findings and treatment were also analyzed. Peripheral blood samples were obtained for DNA extraction from leukocytes, and the entire AIP coding region was sequenced. Results: Thirty-five patients with pituitary adenoma were included, and 23 (67%) had non-functioning pituitary adenomas. Headache was observed in 31 (89%) patients. No clear precipitating factor was identified. Hypopituitarism was observed in 14 (40%) patients. MRI from 20 patients was analyzed, and 10 (50%) maintained a hyperintense signal in MRI performed more than three weeks after pituitary apoplexy (PA). Surgery was performed in ten (28%) patients, and 25 (72%) were treated conservatively with good outcomes. No AIP mutation was found in this cohort. Conclusion: Patients with stable neuroophthalmological impairments can be treated conservatively if no significant visual loss is present. Our radiological findings suggest that hematoma absorption lasts more than that observed in other parts of the brain. Additionally, our study suggests no benefits of AIP mutation screening in sporadic patients with apoplexy.

Apoplejía hipofisaria en posoperatorio inmediato de cirugía cardiaca: a propósito de un caso / Postoperative pituitary apoplexy: case report after a cardiac surgery

Pituitary apoplexy is caused by ischemia or hemorrhage and is considered a medical emergency. A percentage of undiagnosed pituitary adenomas may be diagnosed in the postoperative period of cardiac surgery. The clinical picture is a consequence of the increase in pressure which causes compression on cerebral structures (optic chiasm, cranial nerves) and hormonal deficit. We present a clinical case of a 69-year-old Caucasian male, who debuted with a clinical syndrome of the left cavernous sinus in the immediate postoperative period of cardiac surgery. Clinical and imaging studies (MRI) confirmed the diagnosis of pituitary apoplexy. The condition was solved satisfactorily with replacement therapy. She underwent urgery sixth days later due to persistence of visual symptoms.

La apoplejía hipofisaria se produce por un infarto o una hemorragia en dicha glándula y se considera una emergencia médica. Un porcentaje de adenomas hipofisarios no diagnosticados debutan clínicamente así, pudiéndose producir en el postoperatorio de cirugía cardiaca. El cuadro clínico es consecuencia del aumento de presión y volumen en el interior de la silla turca, lo que origina compresión de las estructuras cerebrales colindantes (quiasma óptico, silla turca, nervios craneales, etc.) y déficit hormonal. Presentamos un caso clínico de un varón de raza caucásica de 69 años, el cual debuta con un síndrome clínico de seno cavernoso izquierdo en el posoperatorio inmediato de una cirugía cardiaca. La clínica y los estudios de imagen (RMN) confirmaron el diagnóstico de apoplejía hipofisaria. El cuadro se resolvió satisfactoriamente con tratamiento esteroideo sustitutivo y cirugía al sexto día del inicio de los síntomas por persistencia de los síntomas visuales.

Spontaneous remission of acromegaly: apoplexy mimicking meningitis or meningitis as a cause of apoplexy? / Remissão espontânea da acromegalia: meningite simulando apoplexia ou meningite como causa da apoplexia?

Pituitary apoplexy is a rare but potentially life-threatening clinical syndrome characterized by ischemic infarction or hemorrhage into a pituitary tumor. The diagnosis of pituitary tumor apoplexy is frequently complicated because of the nonspecific nature of its signs and symptoms, which can mimic different neurological processes, including meningitis. Several factors have been associated with apoplexy, such as dopamine agonists, radiotherapy, or head trauma, but meningitis is a rarely reported cause. We describe the case of a 51-year-old woman with acromegaly due to a pituitary macroadenoma. Before surgical treatment, she arrived at Emergency with fever, nausea, vomiting and meningismus. Symptoms and laboratory tests suggested bacterial meningitis, and antibiotic therapy was initiated, with quick improvement. A computerized tomography (CT) scan at admission did not reveal any change in pituitary adenoma, but a few weeks later, magnetic resonance imaging (MRI) showed data of pituitary apoplexy with complete disappearance of the adenoma. Currently, her acromegaly is cured, but she developed hypopituitarism and diabetes insipidus following apoplexy. We question whether she really experienced meningitis leading to apoplexy or whether apoplexy was misinterpreted as meningitis. In conclusion, the relationship between meningitis and pituitary apoplexy may be bidirectional. Apoplexy can mimic viral or bacterial meningitis, but meningitis might cause apoplexy, as well. This fact highlights the importance of differential diagnosis when evaluating patients with pituitary adenomas and acute neurological symptoms.

A apoplexia é uma síndrome clínica rara, mas potencialmente fatal, caracterizada por infarto isquêmico ou hemorragia em um tumor pituitário. O diagnóstico de apoplexia de tumor pituitário é frequentemente complicado pela natureza inespecífica dos seus sinais e sintomas, que podem simular diferentes processos neurológicos, incluindo a meningite. Vários fatores estão associados com a apoplexia, como o uso de agonistas dopaminérgicos, radioterapia ou trauma da cabeça, mas a meningite foi raramente relatada. Descrevemos o caso de uma mulher de 51 anos de idade com acromegalia por um macroadenoma pituitário. Antes do tratamento cirúrgico, ela foi trazida ao pronto-socorro com febre, náusea, vômitos e meningismo. Os sintomas e análises laboratoriais sugeriram meningite bacteriana e o tratamento com antibióticos foi iniciado, com melhora rápida dos sintomas. Uma tomografia computadorizada (CT) na admissão ao hospital não revelou nenhuma alteração no adenoma pituitário, mas algumas semanas depois uma ressonância magnética (MRI) mostrou informações de apoplexia pituitária, com desaparecimento completo do adenoma. Atualmente, a acromegalia está curada, mas ela desenvolveu hipopituitarismo e diabetes insipidus depois da apoplexia. Questionamo-nos se a paciente realmente apresentou meningite que levou à apoplexia ou se a apoplexia foi mal interpretada como sendo meningite. A relação entre a meningite e a apoplexia pode ser bidirecional. A apoplexia pode simular a meningite viral ou bacteriana, mas a meningite também pode causar apoplexia. Esse fato enfatiza a importância do diagnóstico diferencial ao se avaliar pacientes com adenomas pituitários e sintomas neurológicos.

Dengue hemorrhagic fever: A rare cause of pituitary tumor hemorrhage and reversible vision loss.

Dengue hemorrhagic fever leading to hemorrhage in pituitary adenoma is not reported till date: We herein report the first case of bilateral visual loss secondary to pituitary adenoma hemorrhage associated with dengue hemorrhagic fever. Urgent transnasal trans sphenoidal decompression of the macroadenoma prevented permanent visual loss in this patient. Pituitary apoplexy should be considered as differential diagnosis of visual deterioration apart from retinal hemorrhage, maculopathy, and optic neuropathy in cases of dengue hemorrhagic fever. Early decompression of optic nerves helped in the restoration of vision.

Pituitary tumor apoplexy / Apoplexia em tumor hipofisário

Pituitary tumor apoplexy is a medical emergency due to acute infarction or hemorrhage in the pituitary gland. In this review, the authors discuss the sellar anatomy, the pituitary gland and adenomas' vascularization and the general aspects of the syndrome such as its ethiopatogenesis, predisposing factors, clinical features, treatment and prognosis.

A apoplexia em tumor hipofisário é uma emergência médica decorrente do infarto agudo ou hemorrágico na glândula hipófise. Nesta revisão os autores discutem a anatomia da região selar, a vascularização da hipófise e adenomas hipofisários, e demais aspectos da síndrome como etiopatogenia, fatores predisponentes, quadro clínico, tratamento e prognóstico.

Apoplejía en metástasis hipofisiaria de carcinoma de células renales: caso clínico con 7 años de seguimiento / Pituitary apoplexy secondary to a metastatic renal cell carcinoma: report of a case followed for 7 years

We report a man in whom a 15 cm. renal tumor was excised at the age of 49. The pathological examination showed a clear cell carcinoma. Five years later, he presented with headache, vomiting and unilateral palpebral ptosis. Imaging studies showed a sellar tumor with pituitary apoplexy. The tumor was excised and the pathological study disclosed a clear cell tumor, positive for vimentin, cytokeratins AE1 and AE3 and immunohistochemically negative for LH, TSH, ACTH and GH. Considering the similar histopathological features, it was considered as a metastasis of the renal tumor. The patient was supplemented with thyroid, adrenal and gonadal hormones. Seven years later, he presented a new tumor in the remaining kidney, that corresponded to a cystic papillary renal cell carcinoma. Afterwards, he presented a transitional urinary bladder tumor. Mortality associated to renal cell tumors is 90 percent at 5 years, and pituitary metastases are extraordinarily uncommon

Apoplexia hipofisária em macro-prolactinomas durante tratamento com bromocriptina oral e injetável: relato de 2 casos / Pituitary apoplexy in macro-prolactinomas during treatment with oral and injected bromocriptine: report of 2 cases

Apoplexia hipofisária é caracterizada clinicamente por cefaiéia súbita, frequentemente acompanhada por vômitos e sinais de irritaçao meníngea, além de alteraçoes de campo visual e oftalmoplegia. Descrevemos 2 casos de pacientes com macroprolactinomas que, durante o tratamento com bromocriptina oral ou injetável, desenvolveram apoplexia. O primeiro caso foi tratado clinicamente e o segundo através de cirurgia transesfenoidal. Ambos apresentaram melhora clínica e tomográfica. A apoplexia hipofisária é uma entidade pouco frequente em macroprolactinomas tratados com bromocriptina. Esta última, apesar de ter sido utilizada nos 2 casos relatados, nao poderia ser responsabilizada como fator causal.