PITUITARY APOPLEXY AND PROLACTINOMAS

A CASE SERIES

Abstract

BACKGROUND
Pituitary apoplexy describes the ischemic or hemorrhagic phenomenon that occurs in a pituitary adenoma. It may be the first manifestation of a pituitary gland adenoma.

CASES
Case 1 is a 31-year-old female with macroprolactinoma treated irregularly with cabergoline for three months. She had amenorrhea since age 14, and subsequent decreased visual acuity and oppressive headache. MRI revealed pituitary apoplexy. She was discharged with cabergoline and prednisone. Days later, she had vaginal bleeding and was found to be pregnant at 12 weeks.

Case 2 is a 40-year-old male with sexual dysfunction for six months. He had a two-month history of bitemporal hemianopsia, headache and nausea. Tests revealed prolactin >1000 ng/dL and low pituitary hormones. MRI revealed pituitary apoplexy in a 3.5 cm adenoma.
Case 3 is a 53-year-old male who presented with visual acuity deterioration and bilateral gynecomastia. Tests revealed elevated prolactin and pituitary gland adenoma on MRI. At 6 months on cabergoline, he had improvement in visual acuity, and decreased prolactin levels and tumor size. At 8 months, he experienced intense headache, vomiting and sensorium deterioration. MRI revealed extensive area of necrosis and intratumoral hemorrhage.

CONCLUSION
We present 3 cases of prolactinomas that presented with apoplexy associated with pregnancy, large adenoma size and treatment with cabergoline. Pituitary stimulation by estrogens in the pregnant state was likely. Pituitary apoplexy in large tumors is generally more frequent in non-functioning adenomas. Rarely, dopaminergic agonists increase the risk for pituitary apoplexy from lactotroph apoptosis.