Pituitary apoplexy following shoulder arthroplasty: a case report

Abstract

IntroductionPituitary apoplexy following a major surgical procedure is a catastrophic event and the diagnosis can be delayed in a previously asymptomatic patient. The decision on thromboprophylaxis in shoulder replacements in the absence of definite guidelines, rests on a careful clinical judgment.Case presentationA previously healthy 62-year-old Caucasian male patient who underwent shoulder arthroplasty developed hyponatremia resistant to correction with saline replacement. The patient had a positive family history of deep vein thrombosis and pulmonary embolism and heparin thromboprophylaxis was considered on clinical grounds. The patient developed hyponatremia resistant to conventional treatment and later developed ocular localizing signs with oculomotor nerve palsy. The diagnosis was delayed due to other confounding factors in the immediate post-operative period. Subsequent workup confirmed a pituitary adenoma with features of pituitary insufficiency. The patient was managed successfully on conservative lines with a multidisciplinary approach.ConclusionsA high index of suspicion is required in the presence of isolated post-operative hyponatremia resistant to medical correction. A central cause, in particular pituitary adenoma, should be suspected early. Thromboprophylaxis in shoulder replacements needs careful consideration as it may be a contributory factor in precipitating this life-threatening condition.

Pituitary apoplexy presenting with anorexia and hyponatraemia

“…Precipitating factors have been identified in up to 40% of cases of pituitary apoplexy 2. Previous reports of atypical cases have identified several precipitating factors such as orthopaedic operation,7 9 cardiac operation8 and pregnancy 6. Long-standing hypertension, the most common (26%) predisposing factor,2 seemed to be a precipitating factor in our case.…”

Pituitary Apoplexy Following Elective Total Hip Replacement

“…This is of particular concern with an acute reduction in systemic blood pressure (hemodynamic shift) that may decrease blood flow to the pituitary adenoma and further precipitate apoplexy [ 11 ]. However, only a handful of case reports document postoperative apoplexy in elective surgeries such as hip or knee arthroplasty without hemodynamic compromise, as seen in our patient [ 12 ]. Importantly, our patient was receiving prophylactic heparin during his hospital course.…”

Heparin-Induced Pituitary Apoplexy Presenting as Isolated Unilateral Oculomotor Nerve Palsy: A Case Report and Literature Review

“…Also in 2003, Nagarajan et al reported a case of PA with blurry vision, ptosis, and ophthalmoplegia with involvement of the third, fourth, and sixth cranial nerves 36 hours after administering DAPT and therapeutic LMWH for ACS [17]. Moreover, PA stemming from the use of LMWH for thromboprophylaxis in the perioperative period of shoulder arthroplasty was reported by Madhusudhan et al [18] Again, in that case, the patient had visual deficits and the third nerve palsy was pupil-sparing.…”