A 30 years old female was evaluated 6 months back for rapid weight gain and amenorrhea and found to have diabetes, hypertension, and obstructive sleep apnea. She presented with acute onset of a severe headache and syncope.
O/E She is afebrile, BP: 130/80 (80/60 mmHg on standing), signs of meningeal irritation are positive. She has ptosis of the right eye and pupil is deviated downwards and laterally. BSR is 56 mg/dl. ABGs show chronic compensated respiratory acidosis.
What is the most likely cause of this acute presentation?
What is the underlying diagnosis?
What are the important investigations required to confirm your diagnosis?
How will you manage this case?
Key for the above questions is given below. candidates should try to solve the questions prior to looking at the key.
Question 1: What is the most likely cause of this acute presentation?
Answer: Pituitary apoplexy
Question 2: What is the underlying diagnosis?
Answer: Pituitary adenoma
Question 3: What are the important investigations required to confirm your diagnosis?
Answer: MRI of the pituitary gland and pituitary hormonal assay
Question 4: How will you manage this case?
Answer: Surgical decompression/ resection of the adenoma and hormonal replacement therapy
A brief discussion about pituitary apoplexy
Pituitary apoplexy is the sudden onset of hemorrhage into the pituitary gland. Hemorrhage into the pituitary gland can be seen in bleeding disorders and aneurysms but it is most commonly seen in patients with pituitary adenoma.
Sudden bleeding into the pituitary fossa causes pressure symptoms. Pressure on the third (oculomotor) cranial nerve is manifested by the sudden onset of a severe headache and diplopia (double vision).
On the other hand, pressure on the pituitary gland can lead to hypopituitarism. All pituitary hormones can become deficient but the most important hormone which needs emergency treatment is cortisol deficiency.
Hypocortisolism is secondary to ACTH deficiency in this case. Reduced cortisol is manifested by hypotension and hypoglycemia.
Treatment of Pituitary Apoplexy
Treatment is aimed at surgical decompression. Surgical decompression can rapidly alleviate symptoms of a headache and double vision. This can also improve the pituitary function.
As the blood is reabsorbed, improvement in the hormonal profile can be seen which may be seen in weeks to months. High dose steroids can also be used to treat pituitary apoplexy.
The hormonal profile should be tested after six weeks of the episode and managed accordingly.
What is the most likely cause of this acute presentation?
The most likely cause of acute headache, meningeal irritation, postural hypotension with hypoglycemia is acute pituitary failure possibly due to pituitary apoplexy
What is the underlying diagnosis?
Patient based on the comorbidites of diabetes, hypertension and OSA suggest the possibility of pituitary macroadenoma leading to cushings/ acromegaly
What important investigations are required to confirm your diagnosis?
MRI brain
complete hormonal assay
How will you manage this case?
Management starts with taking complete history, examination, investigatons and then treatment of acute condition in emergency with correction of hypoglycemia, blood pressure, decreasing intracerebral pressure etc
Dr. Haseeb. ? 10/10
will post the key in a while
Q1. Sub arachanoid hemorrhage
Q2. CAH ( 17OHase deficiency)
Q3. All precursors ll be raised and DHEAs androstinedione ll be low.
4. Steroids. And supportive treatment. Drainage if necessary for SAH
great thinking!
the patient developed weight gain, amenorrhea, diabetes, hypertension and OSA 6 months back.
normal menstrual cycles and blood pressure 6 months before should keep the diagnosis of CAH down the list.
Furthermore, there is no mention of a hypertensive crisis which could have led to SAH (BP is 130/80).
anyways, excellent thinking. your answer made me think
Sir i had pituitary dysfunction in mind but i couldnt fit SAH, HTN, amd the cranial nerve palsy. I also thought it could be meningiococcal meningitis as adrenal hemorrharge can occur but then no fever and the reat of the history doesnt fit. But still very confusing.
1. Postpartum hemorrhage
2. Panhypopituitarism
there is no mention of a postpartum state. what about the neurological signs?
1. Postpartum hemorrhage
2. Panhypopituitarism
3. Mri brain
4. Hormonal replacement and steriods
Look like the pt is having Sheehans syndrome
Difficult question sir