Heparin-Induced Pituitary Apoplexy Presenting as Isolated Unilateral Oculomotor Nerve Palsy: A Case Report and Literature Review.

Bakr Swaid,Frank Kalaba,Stephen E Sullivan,Ghassan Bachuwa

doi:10.1155/2019/5043925

Bakr Swaid, Frank Kalaba + Show 2 more

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https://doi.org/10.1155/2019/5043925

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Abstract

Introduction Pituitary apoplexy (PA) is a rare and potentially life-threatening clinical syndrome resulting from pituitary gland hemorrhage and/or infarction. Anticoagulation is a risk factor for triggering PA. Isolated oculomotor nerve palsy is an atypical presentation of PA. Case Presentation A 65-year-old African American female with no past medical history of pituitary disease presented to the emergency department (ED) with nonspecific abdominal pain that was thought to be secondary to fecal stasis and subsequently improved with laxatives. She also reported atypical chest pain that was concerning for unstable angina. She was started on aspirin, clopidogrel, and intravenous (IV) heparin. Later, coronary catheterization showed no significant coronary artery disease (CAD). Twelve hours after the procedure, the patient developed acute complete left oculomotor nerve palsy with a severe headache. Magnetic resonance imaging (MRI) of the head showed a large pituitary mass. Pituitary apoplexy was suspected and the patient eventually underwent a successful trans-sphenoidal pituitary resection. Discussion We report a case of PA manifesting as isolated left oculomotor nerve palsy without visual field defects in the setting of using dual antiplatelet therapy (DAPT) and IV heparin for acute coronary syndrome. To the best of our knowledge, this unique combination has not been previously reported.

Highlights

Pituitary apoplexy (PA) is a rare and potentially life-threatening clinical syndrome resulting from pituitary gland hemorrhage and/or infarction
We present a case of PA with atypical presentation of isolated third nerve palsy without visual eld de cits likely resulting from the use of IV heparin in the setting of a suspected acute coronary syndrome
We report a case of a 65-year-old lady with no known history of pituitary disorder prior to admission who su ered from pituitary apoplexy manifesting as severe frontal headache with isolated complete le oculomotor nerve palsy and intact visual elds shortly a er coronary angiography, likely resulting from the combination of dual antiplatelet therapy (DAPT) and IV heparin given for acute coronary syndrome (ACS)

Summary

Introduction

Pituitary apoplexy (PA) is a clinical syndrome resulting from pituitary gland hemorrhage and/or infarction usually in the setting of pituitary macroadenoma. When presenting classically, it is characterized by acute onset headache, vomiting, visual changes, ophthalmoplegia, and loss of consciousness [1]. In 2007, Lau et al reported the rst case of spontaneous pituitary apoplexy resulting in isolated bilateral oculomotor nerve palsies [8]. We present a case of PA with atypical presentation of isolated third nerve palsy without visual eld de cits likely resulting from the use of IV heparin in the setting of a suspected acute coronary syndrome

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