Young patient with Pituitary Macroadenoma treated successfully

in Max Super Speciality Hospital, Dehradun

Feb 01 , 2023

An 18-year-old male presented to the emergency with complaints of severe headache and multiple episodes of vomiting for 2 days. On initial assessment in the ER, he had a heart rate of 40 beats per minute. An urgent cardiac evaluation was done which was normal. His blood sugar level at the time of presentation was 85mg/dl for which 25% dextrose was started.

In view of low blood sugar, despite dextrose administration, inj hydrocortisone was started and NCCT head was done which was normal. On day 2, the patient also complained of diplopia and on further evaluation was found to have bitemporal hemianopia.

In view of persistant bradycardia and hypoglycemia, MRI of the brain was done which was suggestive of a sellar /supracellar pituitary mass showing heterogenous signal intensity. The mass measured approximately 1.5 x 2 x 2.1 cm (AP x TR x CC). The optic chaisma appeared superiorly displaced and mildly compressed. Rest of the brain showed normal physiology.

Pituitary hormone tests were done which showed low levels of prolactin, growth hormone, thyrotropin releasing hormone and cortisol. A neurosurgery reference was taken and the patient was advised for trans-nasal trans-sphenoidal (TNTS) tumor excision with navigation. The patient had a successful surgery and at discharge was advised for medications.

Pituitary apoplexy is characterised by sudden increase in pituitary gland volume secondary to ischemia or necrosis, usually a pituitary adenoma. The clinical manifestations of sellar lesions vary depending upon the anatomical location of the mass and the direction of its extension. Headache is the most common feature of pituitary adenomas, even if the adenoma is intrasellar. However, the intensity of the headache does not vary with the extension of the adenoma.

In this case, the extension was supracellar which led to visual disturbances like bitemporal hemianopia. The investigation of choice for pituitary sellar lesions remains magnetic resonance imaging. Unlike this case, if a pituitary microadenoma (size less than 1 cm) is discovered incidently in the absence of any hormone hypersecretion, an annual MRI should be done for the monitoring microadenomas.