ENOXAPARIN INDUCED PITUITARY APOPLEXY –AN UNRECOGNIZED RISK! S. S. Chennapragada MBBS, S. Bhayani, MD Department of Internal Medicine, LSU Health Sciences Center, Shreveport, Louisiana. INTRODUCTION: Pituitary apoplexy is a rare endocrine emergency complicating 2-12% of patients with pituitary masses. The risk factors of pituitary apoplexy include surgery, irradiation, systemic hypertension, head trauma and rarely anticoagulation. Patients usually present with headaches, visual field defects, ophthalmoplegia or altered mental status. CASE: A59 year oldmanwithHypertension, DiabetesMellitus, Seizuredisorder, UlcerativeColitis, chronic untreatedDVTpresented with complaints of nausea, vomiting and abdominal pain. Review of records demonstrated a stable 2.3 cm pituitary mass. The patient was non-compliant with anticoagulation and enoxaparin was started on admission. He was found to be hypotensive, hyponatremic (serum sodium of 125) and had mild leukocytosis. Initial blood cultures were negative. Despite goal directed volume resuscitation, hypotension and hyponatremia did not improve. On day 4 of admission, the patient developed ptosis of left eyelid and mydriasis of the left pupil. Bitemporal visual field defects, ophthalmoplegia and a fixed, dilated left pupil were noted. He also was found to have refractory hypoglycemia. The signs of third cranial nerve palsy along with refractory hypotension, hyponatremia and hypoglycemia raised suspicion for mass effect of a pituitary adenoma. A repeat CT head showed grossly unchanged macro-adenoma. However, endocrine studies showed panhypopituitarism (previously normal). The patient was started on stress dose steroids and urgent Ophthalmology and Neurosurgical consultations were obtained. MRI brain showed an increase in the size of the macroadenoma compared to prior head CT with an area of hyper-intensity suggestive of pituitary apoplexy. DISCUSSION: Pituitary apoplexy, although rare has seen resurgence due to widespread anticoagulant use. DAPT and heparin induced apoplexy, first reported by Bakr et al., are a known, yet underreported, and often under recognized risk factor for apoplexy. Our case highlights the importance of recognizing this risk inpreexistingnonfunctional adenomas. Ahigh index of suspicion even in the absence of altered mentation and negative head CT should prompt further evaluation. Our patient underwent urgent reversal of anticoagulation with protamine sulfate prior to successful endoscopic trans-sphenoidal resection of the pituitary mass. Postoperatively, visual field defects resolved and ptosis improved.
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