Intern Case Report

Intern Case Report

Case Report Rachel Cooley MD November 21, 2014 Presentation 76 yr old male presents to ED with 2 week history of significantly worsening headache 2 days prior to arrival the headache pain worsened and he was sensitive to light and

also c/o nausea and vomiting Tried Norco with no relief of pain Past couple of years he has noticed graying of vision that worsens when he bends forward and at times has tunnel vision Presentation Past Medical History Pituitary

macroadenoma Hypertension Hyperlipidemia Atrial Fibrillation GERD Carotid Artery Stenosis Past Surgical History Appendectomy

Thyroidectomy Presentation Medications Amiodarone

Norco Levothyroxine Xarelto Vitamin B complex Prednisone Lisinopril Presentation Social History Married for 56 years Truck driver after discharge from service in Army

Served in Army in artillery division Quit smoking 35 years ago Presentation Review of Systems Constitutional: Positive for chills and malaise/fatigue.

Negative for fever and diaphoresis. HENT: Positive for sore throat and neck pain. Respiratory: Negative for cough, hemoptysis and sputum production. Cardiovascular: Negative for chest pain, orthopnea and leg swelling. Gastrointestinal: Positive for nausea and vomiting. Negative for abdominal pain, diarrhea, constipation, blood in stool and melena. Musculoskeletal: Positive for joint pain. Negative for myalgias. Skin: Negative for itching and rash. Neurological: Positive for weakness

Presentation Physical Exam Vitals : 98.2 F Pulse: 64 Resp: 16 BP: 166/76 mmHg SpO2: 97 % Pain Score: 7 Constitutional: Well-developed and wellnourished. No acute distress Head: Normocephalic and atraumatic. Mouth/Throat: Oropharynx is clear and moist. Patient is tender to palpation over left posterior occiput. Eyes: Conjunctivae and EOM are normal. PERRL. Retro-orbital pain with extremes of eye abduction. Visual fields full to

confrontation grossly. Presentation Cardiovascular: Normal rate, regular rhythm. No gallop, no rub, no murmur. Pulmonary/Chest: Effort normal and breath sounds normal. Abdominal: Soft. Bowel sounds are normal. No distension. Nontender. No guarding. Neurological: He is alert. No cranial nerve deficit. He exhibits normal muscle tone. Coordination normal. Psych: Normal mood and affect. Thought content normal.

Labs SODIUM 134 POTASSIUM 4.5 CHLORIDE 98 CARBON DIOXIDE 23 BUN 23 CREATININE 1.33 GLUCOSE 160 CALCIUM 8.6 SGOT (AST) 39 SGPT (ALT) 58 ALKALINE PHOSPHATASE 39 BILIRUBIN, TOTAL 0.7

PROTEIN, TOTAL 7.1 ALBUMIN 4.0 WBC 18.5 HEMOGLOBIN 12.7 HEMATOCRIT 38.1 PLATELET COUNT 360 INR 1.9

Imaging Imaging Presentation Imaging CT head: no acute intracranial abnormality. Findings consistent with pituitary macroadenoma without significant change MRI read from August at OSH: solid enhancing mass arises from the sella turcica, measuring 2.8x1.4x1.5cm (width by AP by CC). It extends into

the suprasellar cistern and displaces the optic chiasm superiorly and also extends into the right cavernous sinus and partially encircles (slightly greater than 50%) the ipsilateral right cavernous carotid artery. The pituitary stalk is thickened and deviated to the left. Clinical Course Patient was admitted with pituitary

macroadenoma with extrasellar extension Endocrinology was consulted and recommended ordering FSH, LH, TSH, prolactin, IGF-1, ACTH Neurosurgery consulted and recommended MRI with pituitary protocol Symptom control with Dilaudid and Phenergan MRI Clinical Course Hospital Day 2

Labs: Prolactin: 2 (3-30) LH: 0.7 (1.2-8.6) FSH: 2.1 (1.3-19.3) TSH: 0.07 NSG recommended ophthalmology visual field testing. Also recommended reversal of INR Patients HA was well controlled with Dilaudid. Antiplatelet agents were held. Plan to go to ophthalmology clinic the next day for formal visual field testing. Clinical Course

Hospital Day 3 HA not controlled. Rating it a 10/10. C/o nausea and being very dizzy PE: appears in distress. Lying in bed with cloth covering eyes. Patient started on decadron 4mg IV q6h to avoid adrenal insufficiency. Also started patient on dilaudid PCA to help with pain control. Ophthalmology assessed the patient and it was decided he was too unstable for VF testing. Will try again on Monday if headache improves. Clinical Course

Hospital Day 4 Improvement in headache Hospital Day 5 HA worse 8/10. Patient confused and not oriented. Agitated overnight. Hospital Day 6 Patients HA better controlled. Not oriented to where he is/

why he is here. Concerns for hallucinations. Unstable for visual field testing today as he is requiring Dilaudid PCA. NSG didnt recommend emergency surgery as his neuro status hadnt acutely changed and there are no gross visual field deficits. Recommend treating sinusitis seen on presentation. Clinical Course Hospital Day 7-Discharge Mental status improved. Continued treatment of sinusitis for 2 weeks.

Transitioned to PO pain medications. Steroid taper Outpatient follow-up with Neurosurgery, Endocrinology and Ophthalmology Pituitary Apoplexy Overview of Pituitary Anatomy What is it?

Rare and potentially fatal condition first described in 1898 Recognized as a clinical syndrome in 1950 Syndrome of violent headache, visual impairment, cranial nerve disturbance, vomiting, panhypopituitarism Occurs in 1.6-1.8% of patients with macroadenomas Pathogenesis

Unknown Subacute, excessive growth of preexisting adenoma which outgrows its blood supply leading to ischemic necrosis followed by hemorrhage Tumor compression of the infundibulum and superior pituitary arteries leads to infarction of the pituitary gland Risk Factors

Hypertension Diabetes mellitus Anticoagulants Bromocriptine Radiotherapy Diagnosis Requires findings on imaging + clinical symptoms

CT is often the first imaging study done Shows areas of hyperdensity within the sellar region Low sensitivity 21-46% MRI Sensitivity 88-90% Treatment Patients who are unstable should

immediately be started on steroids Need for surgical intervention is controversial No randomized controlled trials on optimal management Follow-up is important Repeat imaging 3-6 months after PA and every year for atleast 5 years Patient Update

Seen in neurosurgery clinic 1 month after hospitalization Repeat MRI showed significant resolution of the suprasellar mass with no contact at all with the optic nerves or chiasm. A very small enhancing region was still noted in the sella. Recommend f/u MRI in 6 months References

Boellis, B et al. Pituitary apoplexy: an update on clinical and imaging features. Insights Imaging. 2014 Oct 16 Bujawansa, S et al. Presentation, management and outcomes in acute pituitary apoplexy: a large single-centre experience from the United Kingdom. Clinical Endocrinology (2014) 80, 419-424 Bi, W et al. Pituitary apoplexy. Endocrine. 2014 July 26

Rajasekaran, S et al. UK Guidelines for the Managament of pituitary apoplexy. Clinical Endocrinology (2011) 74, 9-20. Thank you!

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