An Unusual Initial Manifestation of Prolactinoma with Posttraumatic Pituitary Apoplexy

ABSTRACT Objective: Posttraumatic pituitary apoplexy (PPA) is a rare entity, especially in hormonally active pituitary adenomas. There are no case reports of PPA-like initial manifestations of prolactinoma. Methods: We present a case report of PPA in a 46-year-old patient with unknown macroprolactinoma. Likewise, we present a literature review of PPA. Results: Patient was admitted to the emergency room due to traumatic brain injury, with altered state of consciousness. Physical examination revealed hypotension, tachycardia, bilateral periorbital ecchymosis, left ptosis, mydriasis, and abnormal reflexes by cranial nerves II, III, IV, VI, and VIII. Non-contrasted computed tomography was performed on the patient's head, revealing only an incidental sellar lesion with hemorrhagic infarct. Supportive measures to ensure hemodynamic stability and hydrocortisone replacement were initiated. There was evidence of hypocortisolism, central hypothyroidism, hypogonadotropic hypogonadism, and hyperprolactinemia evidenced by a prolactin level of 6,213 ng/dL. Levothyroxine replacement was established after corticosteroid medication. Cranial magnetic resonance imaging revealed a sellar lesion of 21 × 42 × 52 mm, with hemorrhagic infarction. We diagnosed PPA in a macroprolactinoma, however it was not possible perform neurosurgery so cabergoline treatment (1.5 mg/week) was initiated. Patient had a successfully clinical evolution; only decreased visual acuity of the left eye resulted as a sequela (visual acuity 20/400). At follow-up, adequate hypopituitarism replacement, normogonadism, normalization of prolactin, and shrinking of the tumor were observed. Conclusion: This is the first case report of a patient with PPA concurrent with a prolactinoma. PPA can result in a life-threatening event that requires prompt resuscitation and corticosteroid replacement. Surgical intervention should be considered in patients with severely reduced visual acuity, severe and persistent visual field defects, and deteriorating level of consciousness. Abbreviations: CN cranial nerve; PA pituitary apoplexy; PPA posttraumatic pituitary apoplexy