Transient central diabetes insipidus followed by pituitary apoplexy treated in a conservative way

Abstract

apoplexia hipofisária com TraTamenTo conservador seguido por diabeTes insipidus cenTral TransiTório 2,3 . These findings are often accompanied by various degrees of hypopituitarism, even without surgical management of the apoplexy. Even though, posterior pituitary function is nearly always preserved, a few cases of diabetes insipidus have been described 5,6 . Diabetes insipidus occurs transiently in about 4% of patients with apoplexy and persistently in only 2 % of these patients [5][6][7] . We report a patient with a previously non diagnosed nonfunctioning pituitary tumor that developed central diabetes insipidus following pituitary apoplexy. caseA 49-year-old man, previously diagnosed with systemic arterial hypertension, presented to emergence room with severe headache. On physical examination blood pressure was 160x100 mm Hg. After 10 hours, despite of blood pressure normalization, the headache persisted and was followed by ophthalmoplegia, meningeal irritation signs and consciousness impairment. A lumbar puncture was performed and meningitis was excluded. Brain computed tomography was done and only maxillary sinusitis was detected. Three days after, the patient developed hypotension. Magnetic resonance imaging demonstrated a macroadenoma of 20x15x15 mm with supra-sellar extension and intratumoral hemorrhage (Figure). At that moment, pituitary function tests were normal (thyrotropin: 1.46 mcUI/mL; RV: 0.3 a 5.0 mcUI/mL; free T4: 1.3 ng/dL; RV: 0.8-1.9 ng/dL; prolactin: 3.4 ng/dL; RV: 2,0 a 15,2 ng/mL) except for a low cortisol level (5.7 Figure. MRI (T1 weighed, coronal) showing a macroadenoma with supra-sellar extension and intratumoral hemorrhage, before gadolinium injection (A) and after gadolinium injection (B).

Apoplexy in sporadic pituitary adenomas: a single referral center experience and AIP mutation analysis

“…In our study, we observed a frequency of 54% at admission that progressed to 60% at the last evaluation. Similarly, other studies showed that improvement in pituitary function after PA, independent of treatment should not be expected (6,37,42,46). One limitation of our study was that we could not precisely estimate the frequency of hypocortisolism in our patients because many patients were admitted to other centers before being transferred to ours and were already using high doses of dexamethasone/hydrocortisone or oral corticosteroids at admission in our center.…”

Central diabetes insipidus emerging after steroid replacement in pituitary apoplexy

“…Central diabetes insipidus is a rare complication of pituitary apoplexy, presenting in, it is estimated, less than 5% of cases, and is usually transient. 8 In some cases, it emerges after steroid replacement or postoperatively from pituitary resection. 3,7,9 The hypothalamus produces antidiuretic hormone, which migrates to the posterior pituitary gland with several sites above the gland involved in secretion of antidiuretic hormone.…”

“…Pituitary apoplexy more often involves only the anterior pituitary gland; the posterior gland or pituitary stalk may be involved if substantial mass effect or interruption in blood supply is present. 8 Glucocorticoid replacement may precipitate diabetes insipidus in the setting of adrenal insufficiency (Figure 4). Low cortisol levels will stimulate the release of antidiuretic hormone, increasing water reabsorption in the kidney, which can be inhibited by exogenous steroids, thereby rapidly manifesting diabetes insipidus; 10 this was likely the situation in this patient's course.…”