Clinical Case 7.5

A 47-year-old bank clerk woke one morning with severe chest pain radiating to both arms. He was taken to his local hospital and, although his electrocardiogram was normal, he was considered to have suffered an acute myocardial infarction. He was treated intravenously with an infusion of streptokinase and subsequently heparin and oral aspirin. Two hours after finishing the streptokinase, he complained of a sudden severe headache, diplopia (double vision) and blurred vision. On examination, he was fully conscious but with right 3rd and 6th cranial nerve palsies and a left temporal visual field defect. On transfer to Neurosurgery, a CT scan revealed a large pituitary mass with suprasellar extension and evidence of a recent hemorrhage within the mass Box 7.29. This hemorrhage into his existing pituitary tumor was caused by his treatment for a suspected myocardial infarction. As a result there was a sudden swelling of the tumor into the cavernous sinus that caused compression of the 3rd and 6th cranial nerves. His sudden onset of headache caused by the hemorrhage is termed pituitary apoplexy.

Measurement of his serum prolactin (213 000 mU/l, NR <400 mU/l) indicated he had a prolactin- secreting tumor, a prolactinoma. Concerns that he may have suffered a recent myocardial infarction, coupled with the recent therapy with fibrinolytic drugs resulted in medical treatment being preferred to surgical decompression of the optic chiasm and 3rd and 6th cranial nerves. He was treated with the dopamine agonist, cabergoline, to inhibit prolactin secretion. Within hours, clinical improvement was seen and after 3 days the headache disappeared; the cranial nerve palsies recovered after one month. Six months later his serum prolactin concentration was 84 mU/l, fluid within the tumor was no longer visible and the tumor was much reduced in size.

Box Icon

Box 7.29

CT scan of Clinical Case 7.5. The lower axial scan demonstrates the expansion of the mass into the right cavernous sinus leading to the cranial nerve lesions. The upper, reformatted image demonstrates the extension of the mass above the pituitary fossa. (more...)

From: Chapter 7, The pituitary gland

Cover of Endocrinology
Endocrinology: An Integrated Approach.
Nussey S, Whitehead S.
Copyright © 2001, BIOS Scientific Publishers Limited.

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