Case Presentation: A 50-year-old man visited our hospital with complaints of malaise, appetite loss, diarrhea, and arthralgia, all of which he had experienced for 5 days before the visit. Although he had been previously healthy and fit, he had visited a different hospital one month earlier because of the sudden onset of a headache and accommodation-related disturbance. However, examination by an ophthalmologist and internist and reports of neuroimaging tests including head MRI revealed no appreciable abnormality. These symptoms had gradually and spontaneously improved. On the day of the visit to our hospital, the patient was conversing in a confused manner in the waiting room and lost consciousness (Glasgow Coma Scale score 14). His vital signs were not unstable except for low blood pressure (83/65 mmHg). Although physical examination revealed that his peripheral limbs were cold and hyperactive bowel sound was observed, he did not show hemiplegia or any other neurological irregularity. A quick blood glucose test indicated hypoglycemia (glucose level 20 mg/dl). After he regained consciousness following a glucose injection, he underwent a head CT scan to identify other causes, if any, of impaired consciousness besides hypoglycemia. Head CT scan and MRI revealed pituitary gland enlargement and bleeding, which suggested pituitary apoplexy (PA). His vital signs, symptoms, and hypoglycemic condition were consistent with the characteristics of secondary adrenal failure due to PA. He was hospitalized for further examination and therapy.
After admission, his consciousness levels were not impaired, possibly due to steroid replacement therapy. A decompression surgery for PA was not performed since his visual symptoms such as accommodation-related disturbance did not deteriorate again. Laboratory examination of blood revealed panhypopituitarism due to PA and secondary adrenal insufficiency, which was confirmed by combined pituitary function-test performed later. The patient continued out-patient follow up after an uneventful discharge.

Discussion: PA is an acute clinical syndrome caused by either hemorrhagic or non-hemorrhagic necrosis of the pituitary gland. An existing pituitary macro adenoma is usually present (60%–90%). Its typical characteristics include headache, visual deficits, ophthalmoplegia, and altered mental status, all of which were observed in our case. Acute secondary adrenal insufficiency, which is the major cause of mortality in PA, is reported in about two-thirds of patients. CT is often the first imaging tool in PA. An MRI examination could confirm hemorrhage within the pituitary gland and compression on the optic chiasm. Urgent corticosteroid replacement with hydrocortisone is needed in patients with suspected hypoadrenalism. Sudden deterioration of vision, blindness, and impaired consciousness necessitate emergency surgery.

Conclusions: Typical PA symptoms include headache, visual deficits, ophthalmoplegia, and altered mental status. Acute secondary adrenal insufficiency, which is the major cause of mortality in PA, is often reported in patients with PA. Urgent replacement of corticosteroids is life-saving.