An altered state of consciousness while using anticoagulants and the incidental discovery of a pituitary lesion: considering pituitary apoplexy

Pituitary apoplexy (PA) is a medical emergency with complex diagnosis and management. In this study, we describe a case of PA in a 63-year-old male treated with oral anticoagulant therapy for atrial fibrillation. In the patient, PA manifested itself with asthenia and severe headache not responsive to common analgesics. Despite the finding of a pituitary mass through CT, and in anticipation of the endocrinological evaluation and pituitary MRI, the patient's clinical condition worsened with an escalation of headache and asthenia associated with deterioration of the visual field and impairment of consciousness level. The emergency assessments revealed an adrenal failure, whereas MRI showed a haemorrhagic pituitary macroadenoma with compression of the optic chiasm. Intravenous fluids repletion and high-dose hydrocortisone were started with a rapid improvement of the patient's health and visual field abnormalities. Hydrocortisone was gradually reduced to a replacement dose. During the follow-up, panhypopituitarism was documented, and replacement therapies with l-thyroxine and testosterone were introduced. Three months later, a pituitary MRI showed a 50% reduction in the pituitary adenoma volume.

Automated summary

Pituitary apoplexy is a complex medical emergency that is difficult to diagnose and manage. This study presents a case of pituitary apoplexy in a 63-year-old male with atrial fibrillation treated with oral anticoagulant therapy. The patient presented with asthenia and severe headache that did not respond to common analgesics. Further evaluation revealed a haemorrhagic pituitary macroadenoma compressing the optic chiasm. Treatment with intravenous fluids and high-dose hydrocortisone resulted in rapid improvement of the patient's health and visual field abnormalities.