SHM Converge Scientific Abstract ePoster Gallery-An Unlikely Source of Shock

Pdf Summary

This case describes an 80-year-old man with CAD, atrial fibrillation on warfarin, urothelial carcinoma, and a known non-functioning pituitary adenoma who presented with fever, headache, neck pain, nausea, vomiting, hypotension, and right eye miosis, ptosis, and restricted extraocular movements. Initial concern was for septic shock and possible meningitis, especially given confusion and inability to immediately perform lumbar puncture. However, his persistent hypotension, worsening mental status, and known pituitary mass raised concern for pituitary apoplexy with secondary adrenal insufficiency.<br /><br />Workup showed supratherapeutic INR (7.5), elevated lactate, and later morning cortisol of 1.4 with multiple pituitary hormone deficiencies, including low ACTH, TSH, FSH, LH, prolactin, and testosterone. MRI initially showed a stable pituitary adenoma causing optic apparatus mass effect, but repeat MRI demonstrated interval hemorrhagic transformation of the adenoma and abutment of the right CN III. Neurosurgery performed transsphenoidal resection, and pathology confirmed pituitary apoplexy with hemorrhage and necrosis.<br /><br />The patient was also found to have a Pseudomonas urinary tract infection and was treated with cefepime; his shock was therefore likely multifactorial, combining sepsis and adrenal insufficiency from pituitary apoplexy. He was started on IV steroids, then discharged on hydrocortisone and levothyroxine replacement. Warfarin was discontinued due to repeated supratherapeutic INR, though he declined DOAC therapy despite stroke risk.<br /><br />Teaching points: pituitary apoplexy is a rare but life-threatening endocrine emergency that should be considered in patients with known pituitary adenomas who present with headache, visual symptoms, ophthalmoplegia, meningismus, or shock. Prompt corticosteroid administration is essential, and surgical intervention is considered when consciousness or vision worsens. All patients require long-term endocrine follow-up and surveillance imaging.

Asset Subtitle

Naomi Vather-Wu

Meta Tag

Author List Amie Ogunsakin, Naomi Vather-Wu

Category Clinical Vignettes

Concept Pituitary Apoplexy

Concept Corticosteroid

Concept Headache

Concept Visual Symptoms

Concept Hemodynamic Stabilization

Distinguished Non-Finalist

Presenter Organization University of Iowa

Presenting Author Naomi Vather-Wu

Track Adult

Keywords

pituitary apoplexy

adrenal insufficiency

pituitary adenoma

hemorrhagic transformation

secondary adrenal insufficiency

ophthalmoplegia

septic shock

Pseudomonas urinary tract infection

transsphenoidal resection

hydrocortisone replacement

Pituitary Apoplexy

Corticosteroid

Headache

Visual Symptoms

Hemodynamic Stabilization