Mini Board Review: March 2013 Edition

#8

ANSWER B.

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.

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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.

Ref
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

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