APOPLEXY IN MICROPROLACTINOMA

Abstract

INTRODUCTION/BACKGROUND
Pituitary adenoma apoplexy is uncommon and often occurs spontaneously as a result of infarction, haemorrhage or a combination of both. Pituitary apoplexy is potentially life threatening and has long term consequences resulting in permanent hormonal deficiencies. It is often associated with pituitary macroadenoma and occurrence with pituitary microadenoma is rare.

CASE
We report a case of micro-prolactinoma with pituitary apoplexy on follow-up pituitary MRI. A 29-year-old female who presented with secondary oligomenorrhea in December 2021 was subsequently diagnosed with micro-prolactinoma. Cabergoline therapy was initiated promptly. However, her serial prolactin level while on treatment would fluctuate between normal range and up to three times the upper limit. During her initial few months of treatment, she would develop intermittent headache which subsequently subsided. A repeat pituitary MRI was initially planned due to this complaint to exclude pituitary apoplexy, but MRI was postponed due to patient’s claustrophobia. The repeat pituitary MRI was only performed in early 2023 revealing the presence of pituitary apoplexy with intratumoral haemorrhage. At the same time, she would also be diagnosed with hypocortisolism and hypothyroidism. Hydrocortisone and thyroxine replacement therapy were initiated and cabergoline therapy was stopped. During her follow-up she did not exhibit overt symptoms of hypocortisolism,hypothyroidism, or visual field defects.

CONCLUSION
This case illustrated that pituitary apoplexy could present in pituitary microadenoma and may present with subtle symptoms. Without a high index of suspicion, pituitary apoplexy can be overlooked leading to delay or missing diagnosis. Pituitary apoplexy requires prompt diagnosis with imaging and treatment can improve the clinical outcomes of patients.