RESUMO
Coronavirus disease (SARS-CoV-2/COVID-19) is responsible for a wide variety of extrapulmonary manifestations, among which direct or indirect neurological compromise stands out. Pituitary apoplexy is a clinical and neurosurgical entity of variable severity, usually associated with a pituitary adenoma. Literature is scarce regarding the association between these diseases. This paper reports a case of pituitary apoplexy, manifested concomitantly to the diagnosis of COVID 19 in a patient with unknown pituitary macroadenoma, and its therapeutic management, reviewing the mechanisms potentially underlying the link between both entities.
La infección por coronavirus (SARS-CoV-2/COVID-19) es responsable de un diverso rango de manifestaciones extrapulmonares entre las cuales se destaca el compromiso neurológico directo o indirecto. La apoplejía hipofisaria es una entidad médica y neuroquirúrgica de gravedad variable que suele asociarse a la presencia de un adenoma subyacente. Un escaso número de reportes han vinculado estas dos enfermedades entre sí. Este trabajo describe un caso de apoplejía hipofisaria manifestada clínicamente en forma concomitante al diagnóstico de COVID 19, en un paciente con macroadenoma hipofisario desconocido y su manejo terapéutico, revisando los mecanismos potencialmente subyacentes al nexo entre ambas entidades.
Assuntos
Adenoma , COVID-19 , Apoplexia Hipofisária , Neoplasias Hipofisárias , Humanos , SARS-CoV-2 , COVID-19/complicações , Apoplexia Hipofisária/etiologia , Apoplexia Hipofisária/complicações , Neoplasias Hipofisárias/complicações , Neoplasias Hipofisárias/diagnóstico , Neoplasias Hipofisárias/cirurgia , Adenoma/complicações , Adenoma/diagnóstico , Adenoma/cirurgiaRESUMO
Pituitary apoplexy (PA) is a clinical diagnosis comprising a sudden onset of headache, neurological deficits, endocrine disturbances, altered consciousness, visual loss, or ophthalmoplegia. However, clinically, the presentation of PA is extremely variable and occasionally fatal. While meningitis and cerebral infarcts are themselves serious diseases, they are rarely seen as manifestations of PA and are exceedingly rare when present together. We present the case of a 20-year-old male with a rapid progression of symptoms of meningitis, PA and stroke. The present article seeks to emphasize a rare manifestation of PA with an attempt to understand the intricacies of its evaluation and management.
Assuntos
Humanos , Masculino , Adulto , Apoplexia Hipofisária/cirurgia , Apoplexia Hipofisária/etiologia , Meningites Bacterianas/complicações , Acidente Vascular Cerebral/complicações , Punção Espinal/métodos , Apoplexia Hipofisária/diagnóstico por imagem , Infarto Cerebral/complicações , Endoscopia/métodosRESUMO
ABSTRACT Objective: To analyze the clinical, laboratory, and radiological findings and management of patients with clinical pituitary apoplexy and to screen for aryl hydrocarbon receptor-interacting protein (AIP) mutations. Subjects and methods: The clinical findings were collected from the medical records of consecutive sporadic pituitary adenoma patients with clinical apoplexy. Possible precipitating factors, laboratory data, magnetic resonance imaging (MRI) findings and treatment were also analyzed. Peripheral blood samples were obtained for DNA extraction from leukocytes, and the entire AIP coding region was sequenced. Results: Thirty-five patients with pituitary adenoma were included, and 23 (67%) had non-functioning pituitary adenomas. Headache was observed in 31 (89%) patients. No clear precipitating factor was identified. Hypopituitarism was observed in 14 (40%) patients. MRI from 20 patients was analyzed, and 10 (50%) maintained a hyperintense signal in MRI performed more than three weeks after pituitary apoplexy (PA). Surgery was performed in ten (28%) patients, and 25 (72%) were treated conservatively with good outcomes. No AIP mutation was found in this cohort. Conclusion: Patients with stable neuroophthalmological impairments can be treated conservatively if no significant visual loss is present. Our radiological findings suggest that hematoma absorption lasts more than that observed in other parts of the brain. Additionally, our study suggests no benefits of AIP mutation screening in sporadic patients with apoplexy.
Assuntos
Humanos , Neoplasias Hipofisárias/genética , Neoplasias Hipofisárias/diagnóstico por imagem , Apoplexia Hipofisária/etiologia , Apoplexia Hipofisária/genética , Adenoma/genética , Adenoma/diagnóstico por imagem , Encaminhamento e Consulta , Testes Genéticos , Peptídeos e Proteínas de Sinalização Intracelular/genética , MutaçãoRESUMO
OBJECTIVE: To analyze the clinical, laboratory, and radiological findings and management of patients with clinical pituitary apoplexy and to screen for aryl hydrocarbon receptor-interacting protein (AIP) mutations. METHODS: The clinical findings were collected from the medical records of consecutive sporadic pituitary adenoma patients with clinical apoplexy. Possible precipitating factors, laboratory data, magnetic resonance imaging (MRI) findings and treatment were also analyzed. Peripheral blood samples were obtained for DNA extraction from leukocytes, and the entire AIP coding region was sequenced. RESULTS: Thirty-five patients with pituitary adenoma were included, and 23 (67%) had non-functioning pituitary adenomas. Headache was observed in 31 (89%) patients. No clear precipitating factor was identified. Hypopituitarism was observed in 14 (40%) patients. MRI from 20 patients was analyzed, and 10 (50%) maintained a hyperintense signal in MRI performed more than three weeks after pituitary apoplexy (PA). Surgery was performed in ten (28%) patients, and 25 (72%) were treated conservatively with good outcomes. No AIP mutation was found in this cohort. CONCLUSION: Patients with stable neuroophthalmological impairments can be treated conservatively if no significant visual loss is present. Our radiological findings suggest that hematoma absorption lasts more than that observed in other parts of the brain. Additionally, our study suggests no benefits of AIP mutation screening in sporadic patients with apoplexy.
Assuntos
Adenoma , Apoplexia Hipofisária , Neoplasias Hipofisárias , Adenoma/diagnóstico por imagem , Adenoma/genética , Testes Genéticos , Humanos , Peptídeos e Proteínas de Sinalização Intracelular/genética , Mutação , Apoplexia Hipofisária/etiologia , Apoplexia Hipofisária/genética , Neoplasias Hipofisárias/diagnóstico por imagem , Neoplasias Hipofisárias/genética , Encaminhamento e ConsultaRESUMO
Background: Pituitary apoplexy is a clinical syndrome reflecting a rapid expansion of sellar content, typically secondary to a stroke in a previous pituitary adenoma. This pathology is a rare complication, and, therefore, underdiagnosed. The consequences of a delay in the diagnosis are translated into serious functional and even deadly complications for the patient. Case report: We present the case of a 42-year-old male patient, who began his condition with a diffuse clinical setting, characterized by headache, amblyopia, and alterations of consciousness. The diagnosis was pituitary apoplexy, and secondary hypopituitarism, and it was treated in a conservative way, with steroid anti-inflammatories and hormonal substitution. The patient presented a psychotic episode induced by steroids, due to the supraphysiological doses used, necessary to reverse the existing neurological damage; however, it ended in a restitutio ad integrum 15 days after medical treatment, without requiring neuro-surgical intervention. Conclusions: The clinical case presented and its resolution are clear evidence of the importance of a timely and adequate diagnosis, given that being detected in early stages, and treated early according to the evolution of the pathology, will not always require surgical intervention, allowing a total neurological restitution.
Introducción: la apoplejía hipofisaria es un síndrome clínico que refleja la existencia de una rápida expansión del contenido selar, comúnmente tributario a un infarto hemorrágico o isquémico en un adenoma hipofisario previo. Esta patología es una complicación poco común y, por lo tanto, infradiagnosticada. Las consecuencias de un retraso en el diagnóstico se traducen en complicaciones funcionales graves e incluso mortales para el paciente. Caso clínico: se presenta el caso de un paciente hombre de 42 años, el cual inició su padecimiento con un cuadro clínico difuso, caracterizado por cefalea, ambliopía y alteraciones de la conciencia. El diagnóstico se resolvió como apoplejía hipofisaria e hipopituitarismo secundario, cuyo tratamiento se hizo de manera conservadora, con antiinflamatorios esteroideos y sustitución hormonal. El paciente presentó un episodio psicótico inducido por esteroides, esto a causa de las dosis suprafisiológicas utilizadas necesarias para revertir el daño neurológico existente; sin embargo, finalizó en una restitución funcional ad integrum a los 15 días postratamiento médico, sin requerir intervención neuroquirúrgica. Conclusiones: el caso clínico presentado y su resolución son evidencia clara de la importancia de un diagnóstico oportuno y adecuado, ya que de ser detectado en etapas tempranas y tratado precozmente, de acuerdo con la evolución de la patología, no siempre requerirá intervención quirúrgica, lo cual permitirá una restitución neurológica total.
Assuntos
Adenoma/complicações , Apoplexia Hipofisária/etiologia , Neoplasias Hipofisárias/complicações , Adenoma/diagnóstico por imagem , Adulto , Humanos , Imageamento por Ressonância Magnética , Masculino , Neoplasias Hipofisárias/diagnóstico por imagem , Tomografia Computadorizada por Raios XRESUMO
Pituitary apoplexy is caused by ischemia or hemorrhage and is considered a medical emergency. A percentage of undiagnosed pituitary adenomas may be diagnosed in the postoperative period of cardiac surgery. The clinical picture is a consequence of the increase in pressure which causes compression on cerebral structures (optic chiasm, cranial nerves) and hormonal deficit. We present a clinical case of a 69-year-old Caucasian male, who debuted with a clinical syndrome of the left cavernous sinus in the immediate postoperative period of cardiac surgery. Clinical and imaging studies (MRI) confirmed the diagnosis of pituitary apoplexy. The condition was solved satisfactorily with replacement therapy. She underwent urgery sixth days later due to persistence of visual symptoms.
La apoplejía hipofisaria se produce por un infarto o una hemorragia en dicha glándula y se considera una emergencia médica. Un porcentaje de adenomas hipofisarios no diagnosticados debutan clínicamente así, pudiéndose producir en el postoperatorio de cirugía cardiaca. El cuadro clínico es consecuencia del aumento de presión y volumen en el interior de la silla turca, lo que origina compresión de las estructuras cerebrales colindantes (quiasma óptico, silla turca, nervios craneales, etc.) y déficit hormonal. Presentamos un caso clínico de un varón de raza caucásica de 69 años, el cual debuta con un síndrome clínico de seno cavernoso izquierdo en el posoperatorio inmediato de una cirugía cardiaca. La clínica y los estudios de imagen (RMN) confirmaron el diagnóstico de apoplejía hipofisaria. El cuadro se resolvió satisfactoriamente con tratamiento esteroideo sustitutivo y cirugía al sexto día del inicio de los síntomas por persistencia de los síntomas visuales.
Assuntos
Humanos , Masculino , Idoso , Apoplexia Hipofisária/etiologia , Apoplexia Hipofisária/diagnóstico por imagem , Procedimentos Cirúrgicos Torácicos/efeitos adversos , Complicações Pós-Operatórias , Apoplexia Hipofisária/terapia , Imageamento por Ressonância MagnéticaRESUMO
OBJECTIVE: Symptomatic pituitary apoplexy is a rare but life-threatening condition caused by sudden hemorrhage or infarction of a pituitary adenoma. In the current study, we aim to evaluate the clinical presentation, management, and clinical outcomes in a cohort of patients who were treated for this condition in our center in the last 16 years. METHODS: We performed a retrospective analysis of all patients who underwent endoscopic endonasal surgery for treatment of symptomatic pituitary apoplexy between 2001 and 2016 in our center. RESULTS: A total of 39 patients were included in the study, mean age of 54.9 years (range, 18-70 years) and mean follow-up 5.1 years (range, 0.6-16 years). Most of the patients had nonfunctioning adenomas (32 patients). Headache (89%), visual impairment (79%), and hypopituitarism (86%) were the most common preoperative findings. Surgical treatment led to gross total resection in 31 patients (79.4%). During follow-up, visual fields and oculomotor improvement was observed in 23 (74.1%) and 21 (67.7%) of the patients, respectively. Intractable headache also improved in all patients. Hypopituitarism was present in 77% of patients after surgery. In this series, no cerebrospinal fluid leak, vascular injury, or infection was observed. There was no postoperative mortality. CONCLUSIONS: The endoscopic endonasal transsphenoidal approach is an effective modality to treat pituitary apoplexy with a high rate of success and minimal risk in selected cases. Although reversion of preoperative visual deficits is often observed, hormonal deficits tend to persist, and require long-term hormonal therapy, even after successful endoscopic endonasal surgical resection.
Assuntos
Adenoma/cirurgia , Cirurgia Endoscópica por Orifício Natural/métodos , Neuroendoscopia/métodos , Apoplexia Hipofisária/cirurgia , Neoplasias Hipofisárias/cirurgia , Adenoma/complicações , Adolescente , Adulto , Idoso , Vazamento de Líquido Cefalorraquidiano/epidemiologia , Feminino , Humanos , Hipopituitarismo/epidemiologia , Masculino , Pessoa de Meia-Idade , Cavidade Nasal , Apoplexia Hipofisária/etiologia , Neoplasias Hipofisárias/complicações , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Osso Esfenoide , Infecção da Ferida Cirúrgica/epidemiologia , Lesões do Sistema Vascular/epidemiologia , Adulto JovemRESUMO
Pituitary apoplexy is a rare but potentially life-threatening clinical syndrome characterized by ischemic infarction or hemorrhage into a pituitary tumor. The diagnosis of pituitary tumor apoplexy is frequently complicated because of the nonspecific nature of its signs and symptoms, which can mimic different neurological processes, including meningitis. Several factors have been associated with apoplexy, such as dopamine agonists, radiotherapy, or head trauma, but meningitis is a rarely reported cause. We describe the case of a 51-year-old woman with acromegaly due to a pituitary macroadenoma. Before surgical treatment, she arrived at Emergency with fever, nausea, vomiting and meningismus. Symptoms and laboratory tests suggested bacterial meningitis, and antibiotic therapy was initiated, with quick improvement. A computerized tomography (CT) scan at admission did not reveal any change in pituitary adenoma, but a few weeks later, magnetic resonance imaging (MRI) showed data of pituitary apoplexy with complete disappearance of the adenoma. Currently, her acromegaly is cured, but she developed hypopituitarism and diabetes insipidus following apoplexy. We question whether she really experienced meningitis leading to apoplexy or whether apoplexy was misinterpreted as meningitis. In conclusion, the relationship between meningitis and pituitary apoplexy may be bidirectional. Apoplexy can mimic viral or bacterial meningitis, but meningitis might cause apoplexy, as well. This fact highlights the importance of differential diagnosis when evaluating patients with pituitary adenomas and acute neurological symptoms.
Assuntos
Acromegalia/etiologia , Adenoma/metabolismo , Hormônio do Crescimento Humano/metabolismo , Meningites Bacterianas/diagnóstico , Apoplexia Hipofisária/diagnóstico , Neoplasias Hipofisárias/metabolismo , Acromegalia/patologia , Diabetes Insípido/etiologia , Diagnóstico Diferencial , Feminino , Humanos , Hipopituitarismo/etiologia , Imageamento por Ressonância Magnética , Meningites Bacterianas/complicações , Pessoa de Meia-Idade , Regressão Neoplásica Espontânea , Apoplexia Hipofisária/etiologia , Remissão Espontânea , Tomografia Computadorizada por Raios XRESUMO
Pituitary apoplexy is a rare but potentially life-threatening clinical syndrome characterized by ischemic infarction or hemorrhage into a pituitary tumor. The diagnosis of pituitary tumor apoplexy is frequently complicated because of the nonspecific nature of its signs and symptoms, which can mimic different neurological processes, including meningitis. Several factors have been associated with apoplexy, such as dopamine agonists, radiotherapy, or head trauma, but meningitis is a rarely reported cause. We describe the case of a 51-year-old woman with acromegaly due to a pituitary macroadenoma. Before surgical treatment, she arrived at Emergency with fever, nausea, vomiting and meningismus. Symptoms and laboratory tests suggested bacterial meningitis, and antibiotic therapy was initiated, with quick improvement. A computerized tomography (CT) scan at admission did not reveal any change in pituitary adenoma, but a few weeks later, magnetic resonance imaging (MRI) showed data of pituitary apoplexy with complete disappearance of the adenoma. Currently, her acromegaly is cured, but she developed hypopituitarism and diabetes insipidus following apoplexy. We question whether she really experienced meningitis leading to apoplexy or whether apoplexy was misinterpreted as meningitis. In conclusion, the relationship between meningitis and pituitary apoplexy may be bidirectional. Apoplexy can mimic viral or bacterial meningitis, but meningitis might cause apoplexy, as well. This fact highlights the importance of differential diagnosis when evaluating patients with pituitary adenomas and acute neurological symptoms.
A apoplexia é uma síndrome clínica rara, mas potencialmente fatal, caracterizada por infarto isquêmico ou hemorragia em um tumor pituitário. O diagnóstico de apoplexia de tumor pituitário é frequentemente complicado pela natureza inespecífica dos seus sinais e sintomas, que podem simular diferentes processos neurológicos, incluindo a meningite. Vários fatores estão associados com a apoplexia, como o uso de agonistas dopaminérgicos, radioterapia ou trauma da cabeça, mas a meningite foi raramente relatada. Descrevemos o caso de uma mulher de 51 anos de idade com acromegalia por um macroadenoma pituitário. Antes do tratamento cirúrgico, ela foi trazida ao pronto-socorro com febre, náusea, vômitos e meningismo. Os sintomas e análises laboratoriais sugeriram meningite bacteriana e o tratamento com antibióticos foi iniciado, com melhora rápida dos sintomas. Uma tomografia computadorizada (CT) na admissão ao hospital não revelou nenhuma alteração no adenoma pituitário, mas algumas semanas depois uma ressonância magnética (MRI) mostrou informações de apoplexia pituitária, com desaparecimento completo do adenoma. Atualmente, a acromegalia está curada, mas ela desenvolveu hipopituitarismo e diabetes insipidus depois da apoplexia. Questionamo-nos se a paciente realmente apresentou meningite que levou à apoplexia ou se a apoplexia foi mal interpretada como sendo meningite. A relação entre a meningite e a apoplexia pode ser bidirecional. A apoplexia pode simular a meningite viral ou bacteriana, mas a meningite também pode causar apoplexia. Esse fato enfatiza a importância do diagnóstico diferencial ao se avaliar pacientes com adenomas pituitários e sintomas neurológicos.