Silent pituitary infarction of an uncommon etiology.

Pituitary apoplexy (PA) is an uncommon, life-threatening clinical syndrome that occurs after acute pituitary hemorrhage or infarction. PA may occur in a pituitary gland with no prior pathological process, but usually occurs as a complication of an adenoma.1 Its clinical presentation varies widely, and may consist of a nonspecific clinical picture, typical signs and symptoms (headache, nausea, vomiting, visual changes) or, in most severe cases, pituitary insufficiency leading to coma and death. Subclinical presentation is most uncommon. This, combined with the low prevalence of the syndrome, makes diagnosis difficult, with the resultant increase in morbidity and mortality. We report the case of a patient with no relevant personal history who experienced PA secondary to tooth extraction, an etiology not previously reported. A 41-year-old male was referred to our endocrinology outpatient clinic by his family physician for hypotension and chronic anemia. The patient had an unremarkable family and personal history, except for tooth extraction four years before with bleeding of approximately 2 L that required hospital admission and treatment with plasma expanders. The patient had had since then a nonspecific clinical picture consisting of anorexia and weight loss, abdominal discomfort, intolerance to cold, normocytic normochromic anemia, and decreased libido without impotence. Physical examination found low blood pressure levels (90/60 mmHg), normal weight (height 172 cm and weight 68.7 kg), no goiter on palpation, and dry and rough skin. No abnormal findings were made in cardiopulmonary, abdominal, or limb examination. Hypopituitarism was suspected, and baseline hormone tests were therefore performed with the following results: basal serum cortisol (1st and 2nd measurements): 2.3 and 3.15 g/dL (normal: 5--30), ACTH 6.7 pg/mL (10--80), prolactin 6.8 ng/mL (2.5--7.5), TSH 0.15 U/mL (0.30--5.5), FT4 3.9 pg/mL (8.5--18), LH 6.95 mU/mL (0.6--12), FSH 3 mU/mL (1.0--8.0), and total testosterone 3.92 ng/mL (1.8--18.5). Based on a diagnosis of corticosteroid and thyroid deficiency, replacement therapy was started with hydrocortisone and