Transient central diabetes insipidus followed by pituitary apoplexy treated in a conservative way.

Dra. Mônica R. Gadelha – Rua Nascimento Silva 555 / 101 22421-020 Rio de Janeiro RJ Brasil. E-mail: [email protected] Pituitary apoplexy is an acute clinical syndrome resulting from hemorrhage and/or infarction of the pituitary gland or adenoma. The frequency of sub clinical apoplexy may be as high as 25%. The clinical syndrome has typical features with abrupt onset of severe headache, visual impairment, ophthalmoplegia, vomiting and/or altered mental status. These findings are often accompanied by various degrees of hypopituitarism, even without surgical management of the apoplexy. Even though, posterior pituitary function is nearly always preserved, a few cases of diabetes insipidus have been described. Diabetes insipidus occurs transiently in about 4% of patients with apoplexy and persistently in only 2 % of these patients. We report a patient with a previously non diagnosed nonfunctioning pituitary tumor that developed central diabetes insipidus following pituitary apoplexy. case A 49-year-old man, previously diagnosed with systemic arterial hypertension, presented to emergence room with severe headache. On physical examination blood pressure was 160x100 mm Hg. After 10 hours, despite of blood pressure normalization, the headache persisted and was followed by ophthalmoplegia, meningeal irritation signs and consciousness impairment. A lumbar puncture was performed and meningitis was excluded. Brain computed tomography was done and only maxillary sinusitis was detected. Three days after, the patient developed hypotension. Magnetic resonance imaging demonstrated a macroadenoma of 20x15x15 mm with supra-sellar extension and intratumoral hemorrhage (Figure). At that moment, pituitary function tests were normal (thyrotropin: 1.46 mcUI/mL; RV: 0.3 a 5.0 mcUI/mL; free T4: 1.3 ng/dL; RV: 0.8-1.9 ng/dL; prolactin: 3.4 ng/dL; RV: 2,0 a 15,2 ng/mL) except for a low cortisol level (5.7