Ptosis and hyponatremia: A diagnosis not to miss

ABSTRACT

Introduction: Pituitary apoplexy (PA) is a rare but life-threatening condition. Sometimes, atypical clinical presentations can be misleading and delay the diagnosis. Case report An 86-year-old women presented at our emergency department (ED) with asthenia, nausea, vomiting, diarrhea. Ten days earlier, she presented at the ED of another hospital with complaints of right eye ptosis, headaches, myalgia and lower extremity edema. She was discharged with diagnosis of SARS-Cov-2 (positive PCR) and congestive heart failure and treated with diuretics. She had a medical history of arterial hypertension, type II diabetes, chronic kidney failure and a history of benign non-functional pituitary macroadenoma that was surgically removed in 1994. To note, atrial fibrillation was recently discovered, and she was taking oral anticoagulant therapy. The physical examination showed right eye ptosis, unstable gait, and lower extremity edema. Initial biology tests showed severe hypotonic hyponatremia (117 mmol/L, 238mOsm/kg) with decreased natriuresis (<10mmol, <9 mmol/24h, 183mOsml/kg). Brain CT scan was normal. The patient was admitted in the geriatric ward for further management of supposed syndrome of inappropriate antidiuretic hormone secretion (SIADH). Evolution during the first days was unsatisfactory with persistent hyponatremia despite well conducted fluid restriction. Six days after her admission, she developed acute right ophthalmoplegia, right visual loss, areactive mydriasis, complete right ptosis and worsening of headaches. An urgent brain MRI led to the diagnosis of macroadenoma with intra-adenomal hemorrhage. Recent introduction of anticoagulation therapy could have precipitate adenomal hemorrhage. Pituitary hormone function tests confirmed the diagnosis of PA. Urgent surgery was performed and the patient was discharged a few days later. Discussion(s) PA is a rare disease and most usually occurs due to sudden hemorrhage of non-functioning pituitary adenoma. This sudden hemorrhage causes an enlargement of the pituitary gland and subsequent pituitary stalk compression. This can lead to a large panel of symptoms (headaches, visual field impairment and decreased visual acuity) and biological findings (hypopituitarism and rarely acute cortisol deficiency). Our case presented early signs of compressive macroadenoma i.e., palpebral claudication and biological findings of SIADH. The latter has been described in cases of pituitary insufficiency and PA but is rather an uncommon initial finding. This atypical presentation could therefore have delayed the diagnosis in our patient. Moreover, hyponatremia is a frequent disorder which is commonly associated to more frequent diseases or medications and PA is a rather rare condition. The initial cerebral CT-scan performed in the ED was also misleading as it described enlargement of the pituitary gland without signs of compression. In conclusion, physicians should also think of PA in case of severe hyponatremia. MRI is the preferred technique for pituitary imaging.