Dissociated hypopituitarism after spontaneous pituitary apoplexy in acromegaly
A 55-year-old smoker male presented to our out-patient clinic in 2004 with complaints of gradual onset increase in the size of hands and feet, bilateral knee pain, increased sweating and blurring of vision. Patient denied any history of headache. Physical examination revealed coarse facial features, large spade like hands, large feet, macroglossia, oily skin, and excessive sweating. The patient was hemo-dynamically stable with a blood pressure of 150/96 mm Hg.\nInvestigations revealed a normal complete blood count, liver and kidney function tests and electrolytes and evidence of left ventricular hypertrophy on electrocardiogram. Previously undiagnosed diabetes mellitus was uncovered by casual blood glucose of 243 mg/dl and HbA1c of 8.5%. GH suppression test using 75 g oral glucose showed a 60 min GH of 105 ng/ml. The basal levels of other pituitary and target hormones are depicted in . Magnetic resonance imaging (MRI) of the sellar region showed a 12.0 mm × 10.0 mm pituitary adenoma not compressing the optic chiasm []. The patient refused insulin and was started on metformin and glimepiride, and planned for transsphenoidal tumor decompression. However, the patient was lost to follow-up.\nEight years later, he presented in the emergency department of our institute with sudden onset headache, vomiting and decreased level of consciousness of 1 day duration. Examination revealed a Glasgow coma scale of 10 with right sided oculomotor nerve palsy and facial features suggestive of acromegaly. His blood pressure was 90/60 mm Hg. Subsequent investigations revealed random blood glucose of 67 mg% and normal electrolytes. Computed tomography scan of the head with focus on the sella was suggestive of apoplexy which was later confirmed by the MRI of the sellar region []. The patient was initially stabilized using intravenous glucocorticoids after which a transsphenoidal tumor debulking was done. Post-surgery the patient's condition improved. His post-operative endocrine workup after the apoplexy revealed a GH (post-glucose challenge) level of 1.48 ng/ml and secondary adrenal insufficiency and central hypothyroidism []. At present, the patient is doing well on metformin 500 mg, levothyroxine 75 μg/day and hydrocortisone 7.5 mg.