Pituitary apoplexy mimicking stroke and myocardial infarction: A case report

Abstract

Background: Pituitary apoplexy is a rare and life-Threatening condition presenting with sudden headache and vomiting, visual disturbances, extraocular palsies and altered sensorium. Generally, it is caused by a hemorrhagic or infarcted preexisting pituitary adenoma. While cerebral ischemia due to intracranial arteries compression or vasospasm has rarely been associated with pituitary apoplexy, a stroke mimic, specifically a stroke-like focal neurological deficit lasting for more than 24 hours without evidence of cerebral infarction, has never been described in the context of this disease. However, what makes this case even more unique, is the simultaneous occurrence of a stroke mimic and a myocardial infarction mimic, namely Takotsubo syndrome, as the clinical presentation of pituitary apoplexy. Case Description: We present the case of an 80-year-old man affected by atrial fibrillation on warfarin and mild cognitive impairment, who presented at the Emergency Department with drowsiness, left facio-brachio-crural hemiparesis and T-wave inversion in antero-lateral leads with troponin elevation and haemodynamic instability. After an extensive and challenging diagnostic work-up, the patient was diagnosed with pituitary apoplexy with secondary adrenal insufficiency, Takotsubo syndrome and transient left-sided hemiparesis, which, we speculate, was attributable to the marked endocrine, metabolic and electrolyte disturbances observed in this case. The patient was started on hormone replacement therapy with gradual subsidence of all signs and symptoms, which persisted through the one-year follow-up. Conclusions: To the best of our knowledge, this is the first literature report describing the simultaneous occurrence of a stroke mimic and Takotsubo syndrome as the clinical presentation of pituitary apoplexy. Emergency physicians should be aware that uncommon complications of this rare disease can confound the clinical picture, leading to wrong diagnoses and, in turn, mismanagement.