ODP288 A Cautionary Tale of Two Endocrine Emergencies- A Patient with Pituitary Macroadenoma Presenting with Acute Adrenal Crisis Leading to Pituitary Apoplexy

Abstract

Abstract A 56 year old male with history significant for myasthenia gravis, non-functional pituitary macroadenoma and age related macular degeneration (ARMD), who presented to the hospital with 3 days of diplopia, nausea, vomiting, generalized weakness, and bitemporal headaches. Two months prior to presentation, he was diagnosed with an idiopathic disseminated rash for which he was treated with high dose steroids. Steroids were tapered rapidly and stopped abruptly 4 days ago. Initial presentation was significant for hypotension with BP of 95/64, hyponatremia [sodium 127(136 - 145 mmol/L)], chloride was 90 (98 - 107 mmol/L), potassium 5.9 (3.4 - 5.3 mmol/L) consistent with acute adrenal crisis. He was immediately initiated on high dose Solu-Cortef and intravenous fluids. Of historical significance was new visual field deficit which had occurred in the background of his existing ARMD. This raised the suspicion for pituitary apoplexy. MRI pituitary showed enlarging pituitary adenoma (2.1×2. 0×2.6 cm from 1.6×1.6×2.3 cm 5 months prior) with necrotic changes and internal signal complexity. Ophthalmology was consulted stat and on confirmation of new right optic neuropathy, urgent surgical decompression was performed via transnasal endoscopic resection of pituitary tumor by neurosurgical and ENT team. Further lab testing revealed secondary adrenal insufficiency and pan hypopituitarism. Patient's vision recovered remarkably well post operatively and he was initiated on thyroid hormone supplementation in addition to continuing steroids. He was discharged with recommendations to follow up with endocrinology outpatient for further management. Conclusion Pituitary apoplexy although well known can easily be missed clinically without a high degree of suspicion. While our patient presented with acute adrenal crisis leading to some of the presenting complaints, his new visual field deficits were unaccounted for. This case highlights the importance of a through history and examination to delineate between acute and chronic visual field symptoms especially in the background of pre-existing retinal diseases. Secondly, although the patient's adrenal insufficiency could be due to apoplexy, we hypothesize that it is more likely that it could have resulted due to abrupt discontinuation of high dose steroids leading to adrenal crisis. The fluctuation in BP in turn could have triggered an apoplectic event in an otherwise stable macroadenoma leading to two independent but interrelated endocrine emergencies. Presentation: No date and time listed