A CASE REPORT ON PITUITARY APOPLEXY FOLLOWING ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY AND LAPAROSCOPIC CHOLECYSTECTOMY

Abstract

BACKGROUND
Pituitary apoplexy is a rare neurosurgical emergency increasingly being precipitated by minor surgical procedures.

CASE
A 49-year-old male underwent ERCP and laparoscopic cholecystectomy for acute cholangitis. Two days post- operatively, he complained of dizziness with horizontal diplopia and slight left eye ptosis. Five days postoperatively, he became drowsy, with complete ptosis and blurred vision of the left eye and decreased motor strength on all extremities. Cranial CT Scan showed a sellar/suprasellar ovoid soft tissue focus. Pituitary MRI confirmed a sellar/ suprasellar heterogeneous mass measuring 1.5 cm x 2.5 cm x 1.8 cm, hyperintense on T1 and hypointense on T2. Hormonal workup showed low IGF-1 [63.50 ng/mL, reference value (RV) 74-196], GH (0.60 ng/mL, RV 0-0.97), LH (0.16 mIU/mL, RV 1.5-9.3). total testosterone (<10 pg/ mL, RV 164-753), ACTH (<5 pg/mL, RV 5-46), 0800H cortisol (<1.00 μg/dL, RV 3.7 19.4), PRL (1.11 ng/mL, RV 2.1-17.7), TSH (0.23 uIU/mL, 0.55-4.78) and FT3 (2.23 pg/mL, RV 2.3- 4.2). He was managed as panhypopituitarism (secondary adrenal insufficiency, hypothyroidism, hypogonadism) secondary to pituitary macroadenoma with pituitary apoplexy. He was given hydrocortisone and underwent endoscopic transsphenoidal pituitary mass excision. He was discharged improved on prednisone 7.5 mg/day and levothyroxine 100 μg/day.

CONCLUSION
Pituitary apoplexy should be considered in patients with abrupt neuro-ophthalmological deterioration even after minor gastrointestinal surgeries. Early diagnosis allows immediate intervention to preserve vision and provide hormonal replacement.