A 26-year-old man is brought to the emergency department due to a severe headache that started 2 hours ago and has steadily become worse. The patient says the pain is dull, diffuse, and associated with nausea, vomiting, lightheadedness, and blurred vision. Medical history is unremarkable, although he is currently being evaluated for loss of libido and erectile dysfunction. A week ago, laboratory results showed low testosterone, low gonadotropins, and high prolactin levels; TSH and free T4 were normal. The patient does not use tobacco, alcohol, or illicit drugs.
Temperature is 36.7 C (98 F), blood pressure is 80/50 mm Hg, and pulse is 114/min. He is diaphoretic and appears to be in significant distress, although he is awake and oriented to time, place, and person. Pupils are 4 mm, symmetric, and reactive to light. There is ptosis of the right eyelid and decreased adduction of the right eyeball on left gaze. Visual field examination on confrontation shows bitemporal visual field defects. There is no nuchal rigidity. The remainder of the examination is unremarkable.
Laboratory results are as follows:
What is the most appropriate immediate next step in management of this patient?

Question

A 26-year-old man is brought to the emergency department due to a severe headache that started 2 hours ago and has steadily become worse.  The patient says the pain is dull, diffuse, and associated with nausea, vomiting, lightheadedness, and blurred vision.  Medical history is unremarkable, although he is currently being evaluated for loss of libido and erectile dysfunction.  A week ago, laboratory results showed low testosterone, low gonadotropins, and high prolactin levels; TSH and free T4 were normal.  The patient does not use tobacco, alcohol, or illicit drugs.
Temperature is 36.7 C (98 F), blood pressure is 80/50 mm Hg, and pulse is 114/min.  He is diaphoretic and appears to be in significant distress, although he is awake and oriented to time, place, and person.  Pupils are 4 mm, symmetric, and reactive to light.  There is ptosis of the right eyelid and decreased adduction of the right eyeball on left gaze.  Visual field examination on confrontation shows bitemporal visual field defects.  There is no nuchal rigidity.  The remainder of the examination is unremarkable.
Laboratory results are as follows:
 What is the most appropriate immediate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_95f2_d606_853d_e117983f0ddd_MD0002_00 This patient most likely has a prolactinoma with hyperprolactinemia and central hypogonadism. He now has clinical features worrisome for acute pituitary hemorrhage (pituitary apoplexy), which commonly presents with severe headache, bitemporal visual field defects, and paresis of the oculomotor nerve (CN III). Most cases of pituitary apoplexy are due to hemorrhage into a pituitary adenoma, but hemorrhage into a normal pituitary gland may occur in rare cases. Hemorrhage may be spontaneous or can be precipitated by head injury or coagulopathy. Pituitary apoplexy is an endocrine emergency, and the outcome can be catastrophic if it is not diagnosed and treated appropriately. Some patients may develop meningeal signs that may lead to misdiagnosis of subarachnoid hemorrhage or meningitis. Pituitary apoplexy is complicated by acute secondary adrenal deficiency in more than two-thirds of patients, which can be life-threatening and lead to severe, refractory hypotension. This patient has features of adrenal insufficiency and needs immediate high-dose glucocorticoid therapy. Given the frequency of adrenal insufficiency in pituitary apoplexy, empiric glucocorticoid therapy is recommended even in patients without features of adrenal insufficiency. (Choices A, D, and E) The diagnosis of pituitary apoplexy can be confirmed by MRI of the brain; CT scan is less sensitive. If pituitary hemorrhage is confirmed, patients with significant neurologic complications warrant surgical decompression (although patients with less severe manifestations may improve adequately with glucocorticoid therapy alone). However, glucocorticoid therapy should not await results of imaging studies. (Choice B) Treatment with a dopamine agonist (eg, bromocriptine, cabergoline) may be initiated later, after the diagnosis of prolactinoma is confirmed. Educational objective: Pituitary apoplexy commonly presents with acute headache, bitemporal visual field defects, and paresis of the oculomotor nerve (CN III). Most cases are due to hemorrhage into a pituitary adenoma. Pituitary apoplexy is often complicated by acute secondary adrenal insufficiency, which can be life-threatening. Patients with suspected pituitary apoplexy should therefore receive immediate high-dose glucocorticoid therapy. __________ References: Pituitary apoplexy. (http://www.ncbi.nlm.nih.gov/pubmed/25732655)

A 26-Year-Old Man Is Brought to the Emergency Department Due