Pituitary crush

Excerpt

A 77-year-old cachectic man presented with a 1-month history of dizziness, nausea, vomiting, poor appetite, and weight loss. Four months earlier, he had peptic ulcer perforation and superior mesenteric artery pseudoaneurysm successfully treated with surgical repair. Reduced visual acuity was detected in both eyes. He had a right relative afferent pupillary defect along with the pale optic disc. Serum sodium was 108 mEq/L. Further investigations revealed secondary adrenal insufficiency with a morning cortisol of 2.5 mcg/dL and an adrenocorticotropic hormone (ACTH) level of 16 pg/mL. Low free thyroxine levels of 0.68 ng/dL (reference range, 0.93–1.6) and low thyroid-stimulating hormone (TSH) of 0.074 mIU/L (reference range, 0.35–4.94) were also discovered. Serum testosterone was <20 ng/dL with low follicle-stimulating hormone (FSH) of 1.1 mIU/mL, and high prolactin levels of 53.5 ng/mL (reference range, 4.0–15.2). Hormonal investigations were compatible with panhypopituitarism. Dizziness and hyponatremia were rapidly resolved after glucocorticoid and levothyroxine replacement. Magnetic resonance imaging (MRI) of the pituitary showed bilateral giant internal carotid arteries aneurysms with pressure effect to the pituitary gland (Fig. 1). The final diagnosis was unruptured bilateral cavernous carotid aneurysm. Due to patient frailty, he received conservative management. Six weeks later, he passed away from severe pneumonia.

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