The patient has pituitary apoplexy from a pituitary tumor. The initial symptoms of pituitary apoplexy are related to the increased pressure in and around the pituitary gland. The most common symptom, in over 95% of cases, is a sudden-onset headache located behind the eyes or around the temples. It is often associated with nausea and vomiting.  The patient’s clinical presentation is also consistent with acute (secondary) adrenal insufficiency due to inadequate ACTH production from the pituitary gland. Adrenal insufficiency manifests in this patient as hypotension, fatigue, abdominal pain, and hyponatremia. It is also associated with hyperkalemia, and hypoglycemia. Hydrocortisone is the preferred steroid to administer because it provides both glucocorticoid and mineralcorticoid effects. Clinical improvement is usually seen within few hours of steroid administration.

Intravenous 3% saline (hypertonic saline) (A) is most commonly reserved for cases of acute hyponatremia associated with neurologic abnormalities. Intravenous mannitol is an osmotic agent used as a therapy to temporarily reduce intracranial pressure. The patient’s symptoms are due to compression of a pituitary tumor on the optic nerve.  Mannitol (C) is not going to relieve this process. Radiation therapy (D) has no role in the acute setting. Treatment is surgical and generally requires transsphenoidal surgery.

Zull D: Thyroid and Adrenal Disorders, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch) 126:p 1671-1675




# Mini Board Review: March 2013 EditionDiane Gilliland 2013-03-07 20:37
Thank you for putting together the questions for the mini board review. I find them very helpful!
# Mini Board reviewDr Zahn 2013-03-10 09:37
Good review....but alot of medical info, very specific...not known when you are out for years in practice.
# MDSam Morale 2013-03-11 17:06
Thanks for your effort. Nice to review uncommon diseases to keep us up to speed. It is amazing how many diseases, pathogens etc... have had their names changed : Granulomatosis with Polyangiitis (GPA) (formerly referred to as Wegener’s granulomatosis) .
# Robert Ditrolio 2013-03-12 17:10
Excellent review questions. Please keep them coming in future issues!

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