A Case of Pituitary Apoplexy Induced by a Bromocriptine Test With a TSH- and GH-Producing Pituitary Adenoma : The Endocrinologist

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00019616-200803000-00005ReportThe EndocrinologistThe Endocrinologist© 2008 Lippincott Williams & Wilkins, Inc.18March 2008 p 65-67A Case of Pituitary Apoplexy Induced by a Bromocriptine Test With a TSH- and GH-Producing Pituitary AdenomaCase ReportMonden, Tsuyoshi MD, PhD*; Satoh, Teturou MD, PhD†; Hashizume, Hiroyuki MD†; Hashimoto, Koshi MD, PhD†; Hashida, Tetsu MD, PhD†; Sato, Minoru MD, PhD*; Oyama, Tetsunari MD, PhD‡; Yamada, Masanobu MD, PhD†; Kasai, Kikuo MD, PhD*; Mori, Masatomo MD, PhD†From the *Department of Endocrinology and Metabolism, Dokkyo Medical University School of Medicine, Tochigi; †Department of Medicine and Molecular Science; Gunma University Graduate School of Medicine, Gunma; and ‡Department of Anatomic and Diagnostic Pathology, Dokkyo Medical University School of Medicine, Tochigi, Japan.Reprints: Tsuyoshi Monden, Department of Endocrinology and Metabolism, Dokkyo Medical University School of Medicine, 880 Kitakobayashi, Mibu, Shimotuga-gun, Tochigi 321-0293, Japan. E-mail: [email protected] report a 54-year-old Japanese woman with enlargement of her hands and feet, and tachycardia over the previous 3 years. She had a TSH- and GH-producing pituitary adenoma 3.5 × 3.0 × 2.0 cm. A bromocriptine test was performed. Bromocriptine was slightly effective for GH inhibition, but, she complained of headaches, nausea, and impaired vision 24 hours after bromocriptine administration. MRI examination showed heterogeneous mixed intensity lesions in the pituitary adenoma, compatible with pituitary apoplexy. The tumor was removed by the transsphenoidal approach 24 hours later, and histologic examination confirmed the diagnosis of pituitary apoplexy. Although pituitary apoplexy associated with bromocriptine is very rare, this case suggests a casual relationship is possible in some instances.Pituitary apoplexy is a rare but life-threatening disorder presenting with a sudden onset of headache, visual loss, vomiting, and alteration in mental status.1 The syndrome is caused by hemorrhage into, or infarction of, the pituitary gland. Pituitary apoplexy usually occurs in patients with large pituitary adenomas.2 It is generally accepted that endocrine stimulation testing with TRH,3 GnRH,4 both,5–8 or the triple bolus test (TRH + GnRH + Insulin)9,10 can occasionally induce pituitary apoplexy. To our knowledge, there has been only one report of pituitary apoplexy after a bromocriptine test in a patient with a GH- and prolactin-producing pituitary adenoma.11 We describe here a rare case of pituitary apoplexy induced by a bromocriptine test in a patient with a TSH- and GH-producing pituitary adenoma.CASE REPORTA 54-year-old Japanese woman had suffered from tachycardia and enlargement of her hands and feet over the previous 3 years. In December 2001, she had an MRI examination in another hospital, which revealed a large pituitary tumor. In April 2002, she was admitted to Gunma University Hospital for further evaluation and treatment of the pituitary tumor. She was 160 cm tall and weighed 45.0 kg. Her body temperature was 36.4°C, blood pressure was 128/70 mm Hg, and pulse rate was a regular 106/min. Exophthalamos and enlarged thyroid were not observed. Deep tendon reflexes were normal. Laboratory data indicated hyperthyroidism (free T3; 13.3 pg/mL, free T4; 4.5 ng/dL), TSH, however, was not suppressed (4.86 μU/mL). Elevated serum GH (41.4 ng/mL) was not suppressed by an oral glucose test (OGTT) and a slightly elevated serum prolactin (PRL) (42.6 ng/mL) were observed. The anti-TSH receptor antibody was within the normal range (6.1%). The serum TSH-α subunit was high at 1.9 ng/mL (Table 1). MRI examination revealed a large pituitary tumor (3.5 × 3.0 × 2.0 cm), compressing the visual nerves (Fig. 1A). These physiological and endocrine findings were consistent with the diagnosis of GH- and TSH-producing pituitary adenoma. For further endocrine evaluation, hormone inhibition tests were performed. On the 7th hospitalized day, an octreotide test was performed using 100 μg octreotide intravenously. This examination revealed that serum GH and TSH but not PRL levels were suppressed (Table 2). Next, on the 15th hospitalized day, a bromocriptine test was performed. Oral bromocriptine 2.5 mg slightly inhibited GH and TSH, but strongly suppressed PRL levels (Table 2). Twenty-four hours after bromocriptine administration, she complained of headaches, nausea, and impaired vision. An MRI examination revealed heterogeneous mixed intensity lesions in the pituitary (Fig. 1B), suggesting pituitary apoplexy. The visual field worsened, the tumor was removed by the transsphenoidal adenomectomy 24 hours after the onset of symptoms. The tumor was softened, indicating that necrosis was followed by hemorrhage and infarction into the adenoma. Postoperative MRI showed near total removal of the adenoma. The symptoms disappeared the day after operation. GH and TSH became undetectable, and PRL levels decreased into the normal range. The slightly elevated PRL levels before resection of the pituitary adenoma were considered due to the effects of the adenoma in the pituitary stalk. Diabetes inspidus and hypopituitarism occurred transiently, but the endocrine status without hypothyroidism recovered in 4 months. During the follow-up period of 3 years, no recurrence of pituitary adenoma was observed.JOURNAL/endst/04.03/00019616-200803000-00005/table1-5/v/2021-02-17T201845Z/r/image-tiff Endocrinologic Data on AdmissionJOURNAL/endst/04.03/00019616-200803000-00005/figure1-5/v/2021-02-17T201845Z/r/image-tiff Magnetic resonance image (MRI) of the pituitary. A, A large pituitary tumor was shown on admission with T1-weighted with contrast enhancement. B, Low-density areas in the pituitary tumor were shown at the onset of pituitary apoplexy with T2-weighted without contrast.JOURNAL/endst/04.03/00019616-200803000-00005/table2-5/v/2021-02-17T201845Z/r/image-tiff Endocrinologic Examination (Sandostatin Test and Bromocriptine Test)DISCUSSIONIn this case, the cause of pituitary apoplexy occurred after the single-dose administration of 2.5 mg bromocriptine. Possible precipitating factors of pituitary apoplexy are estrogen treatment, radiation, head trauma, major surgery, bromocriptine therapy, and endocrine stimulation test.1,2 None of these precipitating factors were present in our case. The tumor was big, compressing the optic nerves before pituitary apoplexy. Tumor size was likely to be a major contributor to pituitary apoplexy in this case.Bromocriptine, a dopamine agonist drug, is widely used in patients with macroprolactinemia.12 It is sometimes used in patients with acromegaly when inhibition of GH is observed with the bromocriptine test. Octreotid is generally used instead of bromocriptine for GH-producing tumors.13 As far as we know, only one case of pituitary apoplexy after a bromocriptine test in a patient with a GH- and prolactin-producing pituitary adenoma has been reported.11 In addition, single-dose octreotide and cabergoline loading has never been reported to induce pituitary apoplexy. On the other hand, pituitary apoplexy during treatment with bromocriptine has been reported.14–16In summary, we report a case of pituitary apoplexy probably induced by a single-dose bromocriptine administration.REFERENCES1. Sibal L, Ball SG, Connolly V, et al. Pituitary apoplexy: a review of clinical presentation, management and outcome in 45 cases. Pituitary. 2004;7:157–163.[Context Link][Full Text][CrossRef][Medline Link]2. Semple PL, Webb MK, de Villiers JC, et al. Pituitary apoplexy. Neurosurgery. 2005;56:65–72.[Context Link][Full Text][CrossRef][Medline Link]3. Szabolcs I, Kesmarki N, Bor K, et al. Apoplexy of a pituitary macroadenoma as a severe complication of preoperative thyrotropin-releasing hormone (TRH) testing. Exp Clin Endocrinol Diabetes. 1997;105:234–236.[Context Link][CrossRef][Medline Link]4. Hernandez Morin N, Huet D, Hautecouverture M. 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Effects of preoperative octreotide treatment on different subtypes of 90 GH-secreting pituitary adenomas and outcome in one surgical centre. Eur J Endocrinol. 2001;145:137–145.[Context Link][CrossRef][Medline Link]14. Chattopadhyay A, Bhansali A, Masoodi SR. Long-term efficacy of bromocriptine in macroprolactinomas and giant prolactinomas in men. Pituitary. 2005;8:147–154.[Context Link][Full Text][CrossRef][Medline Link]15. Yamaji T, Ishibashi M, Kosaka M, et al. Pituitary apoplexy in acromegaly during bromocriptine therapy. Acta Endocrinol (Copenh). 1981;98:171–177.[Context Link][Medline Link]16. Alhajje A, Lambert M, Crabbe J. Pituitary apoplexy in an acromegalic patient during bromocriptine therapy. Case report. 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A, A large pituitary tumor was shown on admission with T1-weighted with contrast enhancement. B, Low-density areas in the pituitary tumor were shown at the onset of pituitary apoplexy with T2-weighted without contrast. Endocrinologic Examination (Sandostatin Test and Bromocriptine Test)A Case of Pituitary Apoplexy Induced by a Bromocriptine Test With a TSH- and GH-Producing Pituitary AdenomaMonden Tsuyoshi MD PhD; Satoh, Teturou MD, PhD; Hashizume, Hiroyuki MD; Hashimoto, Koshi MD, PhD; Hashida, Tetsu MD, PhD; Sato, Minoru MD, PhD; Oyama, Tetsunari MD, PhD; Yamada, Masanobu MD, PhD; Kasai, Kikuo MD, PhD; Mori, Masatomo MD, PhDCase ReportCase Report218p 65-67