A 28-year-old male presented with sudden onset of severe headache associated with projectile vomiting and dizziness for the last 7 days. There was no history of fever, altered sensorium, seizures, CSF rhinorrhea, or epistaxis. He had history of dull aching headache, visual deficits, and poor beard growth for the last 2 years. He did not have history of decreased libido or erectile dysfunction. He was married for the last 1 year, but had no children. There was no history of hypertension, head injury, or any recent surgery. On examination, he was conscious and oriented with pulse rate 78 min and BP 100/70 mmHg. He had sparse beard and mustache. He did not have ocular cranial nerve palsy, hemiparesis, or neck rigidity. There were no features of acromegaly, Cushing’s syndrome, or any symptoms suggestive of diabetes insipidus. Ophthalmic evaluation revealed bitemporal hemianopia, normal visual acuity, and no papilledema. Noncontrast CT of head revealed a mass in the sellar–suprasellar region with hyperdense area suggestive of hemorrhage. MR imaging showed a sellar mass 4.4 × 3.5 × 2.5 cm with suprasellar extension abutting the optic chiasm along with parasellar and infrasellar extension with a hyperintense area on T1W images suggestive of hemorrhage. Biochemistry revealed serum sodium 142 mEq/L, potassium 4.6 mEq/L, creatinine 0.4 mg/dl, random blood glucose 76 mg/dl, corrected serum calcium 8.2 mg/dl, and phosphate 3.7 mg/dl. Hormonal workup showed serum prolactin 25,990 ng/ml (4–15), cortisol 216 nmol/L (>900), T4 7.3 μg/dl (4.8–12.7), TSH 1.1 μIU/ml (0.27–4.2), LH 2.32 mIU/ml (1.7–8.6), FSH 3.36mIU/ml (1.5–12.4), testosterone 6.2 nmol/l (9.9–27.8), iPTH 41 pg/ml, and 25 (OH)D 6.6 ng/ml. With this clinical, radiological, and hormonal profile, he was diagnosed to have macroprolactinoma with apoplexy. He was started on dexamethasone 4 mg i.v. 6 hourly and tablet cabergoline 0.5 mg twice weekly. His vitals and neurological parameters were monitored closely. With treatment, headache and dizziness improved and there were no new-onset neurological deficits. Mutational analysis for MEN1 was negative. Dexamethasone was tapered after a week and he was advised oral hydrocortisone. At 4 weeks, his serum prolactin was 1,500 ng/ml and the dose of cabergoline was increased to 1 mg twice weekly.
KeywordsPituitary Adenoma Pituitary Tumor Serum Prolactin Serum Prolactin Level Pituitary Apoplexy
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