Category: Pituitary Disorders/Neuroendocrinology

Monitor: 15


Saturday, Apr 27
11:00 AM – 11:30 AM

Objective : With advances in diagnostics, the prevalence of pyrexia of unknown origin (PUO) has decreased however, the relative proportion of undiagnosed PUO has steadily increased. We describe a case of PUO which was related to pituitary apoplexy. 

Methods : N/A

Results : N/A

Discussion :

74-year-old female presented with progressive fevers, headache, and confusion. Physical examination showed temperature 102.9 F, blood pressure 75/42 mm Hg, pulse 127 per minute with dry mucous membranes, without signs of meningitis.  Labs showed white count 15.6 K/UL, lactate 3.6 MEQ/L, creatinine 1.91 MG/DL with negative blood, urine, sputum cultures and a negative influenza PCR. CT scan of the chest, abdomen, pelvis and head were negative. Lumbar puncture was unsuccessful. She was admitted to intensive care unit and broad-spectrum antibiotics were administered, which failed to resolve her fever. AM cortisol level was 8.2 UG/DL. Hydrocortisone was initiated in the settings of shock, which resulted in resolution of fevers. Patient improved and was discharged. She was readmitted with fevers and somnolence. She had a temperature of 102.7 F.  Further investigation with 10-day blood-culture, peripheral smear, rickettsia, mycoplasma, borrelia, parvovirus B19, HIV, ANA, serum and urine immuno-electrophoresis, bone marrow biopsy, and QuantiFERON were negative. Antibiotics were stopped to rule out drug fever.  TSH, LH and FSH were low. Cosyntropin test was positive. MRI brain showed enlarged pituitary gland measuring about 11 mm in height with increased signal on T1-weighted views consistent with blood, indicative of pituitary apoplexy. Patient was started on hormone replacement therapy including hydrocortisone, levothyroxine and desmopressin. Patient’s fevers resolved and she was discharged home with follow up MRI scheduled within 1 month. 


Conclusion :

Pituitary Apoplexy can be a life threatening endocrinological emergency. Review of the literature reveals scattered cases of pituitary apoplexy presenting with fevers, but majority of them were accompanied with ophthalmological or neurological abnormalities. Headache accompanied by visual symptoms is the most commonly reported presentation.
This case emphasizes the importance of considering Endocrinological etiologies in diagnosing PUO and that Pituitary Apoplexy can occur even in the absence of visual and neurological symptoms. 
Management remains controversial.Conservative management is usually preferred over surgical decompression in patients without visual and  neurological symptoms. 


Puneet Dhillon

Abington Jefferson Health
Willow Grove, Pennsylvania

I'm a second year Internal Medicine Resident at Abington Jefferson Health. I have always been fascinated by Endocrinology.

Ahmad Arslan

Abington Jefferson Health, Pennsylvania

Third Year Internal Medicine Resident

Babatunde Ogunnaike

Abington Jefferson Health

Second year Internal Medicine Resident

Jaspreet Virdi

Attending Physician
Abington Memorial Hospital
Abington, Pennsylvania

Attending Physician

Harshwant Grover

Abington Jefferson Health
Willow Grove, Pennsylvania

Second Year Internal Medicine Resident.