Case Presentation: K.H. is an 80M with a PMH of CAD, Afib on warfarin, urothelial carcinoma, stable non-functioning pituitary adenoma, complaining of a day long history of fever, neck pain, headache, nausea, and vomiting. He was febrile, HR 130, and hypotensive at 80/55. On exam, he was mildly confused and had an irregular heart rate, negative Brudzinski sign, and right eye miosis, ptosis, and minimal extraocular movements. Labs were notable for a bicarbonate 17, Cr 2.6, WBC 13.7k, Hgb 9.3, lactic acid 4.1, INR 7.5 for which he received 1 unit FFP. No source of infection was found on chest X-ray or CTAP. LP could not immediately be performed. CT head showed a stable pituitary macroadenoma. He remained hypotensive despite 3L of IVF and was sedated the following day.His presentation was concerning for septic shock. Therefore, he was started on broad-spectrum antimicrobials and IV steroids. Further workup revealed negative blood cultures and urine cultures >100k of Pseudomonas aeruginosa. MRI brain showed the stable pituitary adenoma, measuring 2.3 cm, causing mass effect on the optic apparatus. Morning cortisol was 1.4. Repeat MRI, obtained due to continued encephalopathy despite antibiotics, demonstrated hemorrhagic transformation of the adenoma. Further testing was notable for an ACTH < 3, TSH 0.26, FSH 1.8, LH 0.9, prolactin 1.8, testosterone 5. Neurosurgery performed transsphenoidal pituitary resection.
Discussion: Hypotension is a common presentation for hospitalization and, therefore, it is essential to consider a broad differential diagnosis including secondary adrenal insufficiency and/or hypovolemia due to diabetes insipidus from pituitary apoplexy. Pituitary apoplexy is rare but is a life-threatening endocrine emergency. Patients usually present with headache and may additionally have symptoms such as vomiting, visual defects, ophthalmoplegia, and even meningeal signs. It is caused by pituitary infarction, which can result from compression of the pituitary’s blood supply from a mass or hemorrhage of the pituitary gland. In most cases, it occurs without any precipitating factors, but can be associated with major surgeries, radiation therapy, or coagulopathies either from primary or secondary causes (medications such as vitamin K antagonists or platelet inhibitors or in infection). Treatment includes stabilization with IVF, glucocorticoids, and hormone replacement therapy. Surgical management may be indicated if the patient has a deteriorating level of consciousness or visual defects.
Conclusions: Remember that there may be coexisting conditions causing shock, such as in this patient who presented with sepsis and secondary adrenal insufficiency.