SAT-093 - Pituitary Apoplexy Associated With Clomiphene Therapy In A Patient With An Undiagnosed Pituitary Adenoma

Background:
Pituitary apoplexy (PAp) is a rare, life-threatening emergency caused by hemorrhage or infarction of the pituitary gland. It typically presents with sudden severe headache, visual disturbances, altered mental status (AMS), and acute adrenal insufficiency (AI), most often in the setting of a pituitary adenoma (PA). Reported precipitants include pregnancy, anticoagulation, endocrine stimulation testing, and use of phosphodiesterase-5 inhibitors. Clomiphene-associated apoplexy is rarely described. We present a case of PAp associated with clomiphene use in a patient with an unrecognized PA.


Case Presentation:
A 63-year-old man was brought to the ED with a sudden severe headache, nausea, vomiting, presyncope, and confusion. He was found to have hypotension, tachycardia, left ptosis, left ophthalmoplegia, and right temporal visual field loss. Magnetic resonance imaging revealed a 3.8 × 3.7 x 4.6 cm PA with mass effect on the optic chiasm and signs of internal hemorrhage. Endocrine evaluation demonstrated panhypopituitarism with low TSH 0.07 µIU/mL, low free T4 0.49 ng/dL, ACTH < 5 pg/mL, low prolactin 1.1 ng/mL, low-normal IGF-1 46 ng/mL, and FSH and LH < 1.0 µIU/mL. He received intravenous levothyroxine and hydrocortisone prior to undergoing urgent transsphenoidal resection. His postoperative course was complicated by persistent diabetes insipidus for which desmopressin was given.

As his mental status improved, he shared that 2 months prior to admission he had been started on clomiphene for treatment of hypogonadism. For the past year he had been experiencing worsening erectile dysfunction, weight gain, depressed mood, and hot flashes. In the 2 months prior to admission, laboratory evaluation had included two early-morning total testosterone levels of 7.0 and < 3.0 ng/mL (both very low), along with low-normal FSH (2.5 µIU/mL) and low LH (1.4 µIU/mL). It was also noted that in the 8 months prior to admission, he had two normal TSH levels with low free T4.

Conclusion:
Pituitary apoplexy carries substantial morbidity and mortality if not recognized early. Hypopituitarism may precede PAp and should prompt evaluation for an underlying sellar lesion. Pituitary imaging is important in patients with central hypogonadism in whom clomiphene therapy is being considered. Clomiphene leads to increased hormone production that may lead to high blood flow in a low-pressure system, increasing risk of hemorrhage. Our case highlights the importance of being suspicious for PAp in patients who present with acute headache, visual symptoms, or AMS following initiation of clomiphene therapy.

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