Benign tumor mimicking malignancy: Atypical presentation of hemorrhagic macroadenoma

Mohammed Yaseen Ahmed Siddiqui; Abdul Moqeeth Mohammed; Mohammed Al Fatih; Naseer Masoodi; Abdel-Naser Elzouki

doi:10.4103/LJMS.LJMS_6_20

CASE REPORT

Year : 2020 | Volume : 4 | Issue : 2 | Page : 84-86

Benign tumor mimicking malignancy: Atypical presentation of hemorrhagic macroadenoma

Mohammed Yaseen Ahmed Siddiqui, Abdul Moqeeth Mohammed, Mohammed Al Fatih, Naseer Masoodi, Abdel-Naser Elzouki
Department of General Internal Medicine, Hamad Medical Corporation, Doha, Qatar

Date of Submission	02-Feb-2020
Date of Acceptance	03-Apr-2020
Date of Web Publication	22-May-2020

Correspondence Address:
Dr. Mohammed Yaseen Ahmed Siddiqui
Department of General Internal Medicine, Hamad Medical Corporation, Al Rayyan, 3050 Doha
Qatar

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/LJMS.LJMS_6_20

Abstract

Pituitary macroadenoma is a benign tumor of the pituitary gland usually presenting with headache, vomiting, visual symptoms, altered mental state, and hormonal abnormalities. Occasionally, it undergoes hemorrhagic transformation resulting in an acute presentation of severe headache and at times associated with visual impairment with ocular palsies. We present a patient with marked weight loss, fatigue, and dizziness and the workup for malignancy revealed a hemorrhagic macroadenoma; although there are many case reports of patients presenting with the above-mentioned common symptoms, according to the authors' review of literature, ours is a first case report of a patient with hemorrhagic macroadenoma, presenting with significant weight loss in the absence of other contributing factors.

Keywords: Hemorrhagic macroadenoma, pituitary apoplexy, pituitary macroadenoma

How to cite this article:
Ahmed Siddiqui MY, Mohammed AM, Al Fatih M, Masoodi N, Elzouki AN. Benign tumor mimicking malignancy: Atypical presentation of hemorrhagic macroadenoma. Libyan J Med Sci 2020;4:84-6

How to cite this URL:
Ahmed Siddiqui MY, Mohammed AM, Al Fatih M, Masoodi N, Elzouki AN. Benign tumor mimicking malignancy: Atypical presentation of hemorrhagic macroadenoma. Libyan J Med Sci [serial online] 2020 [cited 2023 Mar 27];4:84-6. Available from: https://www.ljmsonline.com/text.asp?2020/4/2/84/284692

Introduction

Pituitary macroadenoma is a benign tumor of the pituitary gland usually presenting with headache, vomiting, visual symptoms, altered mental state, and hormonal abnormalities.^[1] In one report, the prevalence of pituitary apoplexy among patients with nonfunctioning pituitary macroadenomas was 8%.^[2] The clinical presentation of patients is greatly variable depending upon the extent of hemorrhage. The most common presentation is with sudden-onset severe headache and is present in more than 80% of patients.^[3] The presentation usually includes hypopituitarism, visual defects, and diplopia, with third cranial nerve being the most commonly involved;^[4] however, involvement of the sixth and other multiple cranial nerves has also been frequently reported.^[5],[6] In a series of 35 patients with pituitary apoplexy seen at one center, 97% had headache, 71% had visual field impairment, and 66% had decreased visual acuity, and only a minority had clinical manifestations of hormonal excess or deficiency, but there was biochemical evidence of gonadotropin deficiency in 79%, adrenocorticotropic hormone deficiency in 76%, and thyroid-stimulating hormone deficiency in 50%. Magnetic resonance imaging (MRI) revealed hemorrhage more often than did computed tomography (CT).^[7]

Although there are many case reports of patients presenting with the above-mentioned common symptoms, according to the authors' review of literature, ours is a first case report of a patient with hemorrhagic macroadenoma presenting primarily with significant weight loss in the absence of other contributing factors.

Case Report

We present a 68-year-old man with a medical history of hypertension, ischemic heart disease, and benign prostate hypertrophy, referred to the hospital for the evaluation of unintended weight loss of 30 kg over the past 6 months associated with a history of nausea with occasional nonbloody vomiting and loss of appetite. The patient's initial physical examination was unremarkable, and his complete blood count including a complete metabolic panel with electrolytes and renal and liver function tests were all normal.

Of the differential diagnosis, excluding malignancy was a top priority, and the patient was investigated on the same line with gastrointestinal endoscopies which revealed only gastritis and no suspicious lesions. CT scan with contrast of the chest, abdomen, and pelvis was done which did not reveal any sinister findings. Serum markers for various malignancies were sent including cancer antigen (CA) 125, CA 15-3, CA 19-9, and carcinoembryonic antigen that were normal. The patient was followed up in the next clinic appointment, and on further review of history, he reported occasional dizziness, especially when he stood up after prolonged sitting or standing up from lying down position. Repeat physical examination was unremarkable, except for significant orthostatic hypotension. This prompted us to investigate his cortisol levels which came very low; subsequently, other hormonal profile was ordered which revealed deficiencies in other hormones as well [Table 1].

Table 1: Hormonal laboratory values

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MRI scan of the head revealed a 21 mm × 16 mm mass expanding the pituitary fossa displacing the infundibulum superiorly and invading the right cavernous sinus, features suggestive of a macroadenoma with pituitary apoplexy [Figure 1] and [Figure 2]. A diagnosis of pituitary macroadenoma with apoplexy was made, the patient was started on steroids and was referred to neurosurgery, and he underwent transphenoidal resection of the macradenoma and made a full recovery and decent weight gain.

Figure 1: Pituitary apoplexy magnetic resonance imaging sagittal section

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Figure 2: Pituitary apoplexy magnetic resonance imaging coronal section

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Discussion

In case of pituitary apoplexy, one would expect the patient to present with more common clinical presentations of headache, nausea and vomiting, visual disturbances, ophthalmoplegia, and altered level of consciousness.^[8] More than 80% of the patients with pituitary apoplexy present with headache which is generally the initial manifestation.^[3] Pituitary apoplexy typically causes an acute onset of severe frontal or retro-orbital headache.^[9] In a retrospective study, 95% of patients with pituitary apoplexy presented with headache.^[10] More than half of the patients with pituitary apoplexy have visual disturbances, due to the compression of optic chiasm or optic nerves,^[3] and have ocular motor palsy, due to functional impairment of 3^rd, 4^th, and/or 6^th cranial nerves.^[11] Nausea/vomiting may occur in pituitary apoplexy due to meningeal irritation, hypothalamic dysfunction, adrenal insufficiency, or raised intracranial pressure.^[11] Our patient had persistent nausea due to one or more of the above-mentioned reasons, which might led to his decreased appetite and weight loss. While bleeding inside the pituitary gland may occur occasionally without causing any symptoms,^[11] a typical presentation of an acute pituitary apoplexy is usually a catastrophic clinical manifestation.

Initial treatment after pituitary apoplexy diagnosis is hemodynamic stabilization, correction of electrolyte imbalances, and corticosteroids.^[12] Glucocorticoids should be administered in supraphysiological doses not only to serve as the replacement for endogenous hormone deficiency but also to help control the effect of edema.^[11]

Endocrine deficiencies are usually found in macroadenomas; signs and symptoms of low cortisol levels are generally seen in the early stages after apoplexy onset. However, occasionally, they may not be noticed or ignored by the patient till they start causing alarming symptoms as happened in the present patient. Hypothyroidism, hypogonadism, and growth hormone deficiency are very frequent and may occur progressively over weeks, months, or years. Hence, a periodic re-evaluation of the pituitary function is recommended.^[13]

It has been suggested that pituitary deficiencies, once established, usually do not recover, regardless of the treatment.^[12] Patients with low levels of prolactin exhibit a lower probability of pituitary function recovery after surgery. Hyponatremia, seen in 40% of patients, can be found secondary to hypocortisolism or inappropriate antidiuretic hormone secretion.^[12]

Conclusion

Unintentional weight loss is a red flag, and malignancy remains the most important serious diagnosis to be ruled out in the absence of chronic infectious causes. Proper detailed history and physical examination and reviewing the history and physical again with the patient are of paramount importance in the search of the correct diagnosis in such cases.

Significant weight loss can be due to a combination of factors resulting from pituitary dysfunction and should be included early in the differential diagnoses to help in the proper utilization of medical resources and avoid unnecessary investigations.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Briet C, Salenace S, Bonneville JF, Laws ER, Chanson P. Pituitary apoplexy. Endocr Rev 2015;36:622-45.
2.	Vargas G, Gonzalez B, Guinto G, Mendoza V, López-Félix B, Zepeda E, et al. Pituitary apoplexy in nonfunctioning pituitary macroadenomas: A case-control study. Endocr Pract 2014;20:1274-80.
3.	Briet C, Salenave S, Chanson P. Pituitary apoplexy. Endocrinol Metab Clin North Am 2015;44:199-209.
4.	Bahmani Kashkouli M, Khalatbari MR, Yahyavi ST, Borghei-Razavi H, Soltan-Sanjari M. Pituitary apoplexy presenting as acute painful isolated unilateral third cranial nerve palsy. Arch Iran Med 2008;11:466-8.
5.	Hage R, Eshraghi SR, Oyesiku NM, Ioachimescu AG, Newman NJ, Biousse V, et al. Third, fourth, and sixth cranial nerve palsies in pituitary apoplexy. World Neurosurg 2016;94:447-52.
6.	Komurcu HF, Ayberk G, Ozveren MF, Anlar O. Pituitary adenoma apoplexy presenting with bilateral third nerve palsy and bilateral proptosis: A case report. Med Princ Pract 2012;21:285-7.
7.	Randeva HS, Schoebel J, Byrne J, Esiri M, Adams CB, Wass JA. Classical pituitary apoplexy: Clinical features, management and outcome. Clin Endocrinol (Oxf) 1999;51:181-8.
8.	Shavadia J, Mwanzi S, Hameed K. Pituitary apoplexy: Report of two cases. East Afr Med J 2008;85:142-4.
9.	Johnston PC, Hamrahian AH, Weil RJ, Kennedy L. Pituitary tumor apoplexy. J Clin Neurosci 2015;22:939-44.
10.	Bills DC, Meyer FB, Laws ER Jr., Davis DH, Ebersold MJ, Scheithauer BW, et al. A retrospective analysis of pituitary apoplexy. Neurosurgery 1993;33:602-8.
11.	Chang CV, Felicio AC, Toscanini AC, Teixeira MJ, da Cunha-Neto MB. Pituitary tumor apoplexy. Arq Neuropsiquiatr 2009;67:328-33.
12.	Glezer A, Bronstein MD. Pituitary apoplexy: Pathophysiology, diagnosis and management. Arch Endocrinol Metab 2015;59:259-64.
13.	Albani A, Ferraù F, Angileri FF, Esposito F, Granata F, Ferreri F, et al. Multidisciplinary Management of pituitary apoplexy. Int J Endocrinol 2016;2016:7951536.