Abstract
Disclosure: D. Tahir: None. R. Nadeem: None. I. Bhatti: None. F. Pooja: None. F. Ahmed: None. Introduction: Pituitary apoplexy coexisting with pituitary adenoma is rare, life-threatening, and often misdiagnosed, with an incidence of around 0.2% annually. The mass effect, ischemia, and necrosis lead to hypopituitarism. We present an interesting case of a patient with a recent diagnosis of pulmonary embolism (PE) who started on anticoagulation and acutely developed bruises and headaches. He was ultimately diagnosed with pituitary macroadenoma with pituitary apoplexy. Case: An 82-year-old male with hypertrophic cardiomyopathy and early-stage prostate cancer (in remission) presented with dyspnea for 2 weeks. Admission vitals were notable for hypertension and an unremarkable initial physical examination. His pertinent lab was an elevated D-dimer with CT pulmonary angiography, which revealed multiple bilateral PEs and lower extremity ultrasound unmasked an acute deep vein thrombosis (DVT) in the right popliteal vein, prompting heparin initiation. On the second day of hospitalization, he developed diffuse groin bruises and persistent headaches. The initial CT head was negative for any acute intracranial pathology. Due to the persistent headache, an MRI of the brain (with/without contrast) was pursued and revealed a large pituitary adenoma (2.2 x 2.5 x 3.0 cm) with extension into the cavernous sinus with high signal intensity consistent with pituitary apoplexy. Endocrinology workup was notable for low free and total testosterone, normal TSH but low free T4, suggesting central hypothyroidism, and low-normal cortisol with a normal ACTH level. Prolactin, LH, FSH, IGF-1, GH, and all other hormones were within normal range. He immediately underwent IVC filter placement followed by an urgent endonasal trans-sphenoidal resection of a hemorrhagic and necrotic pituitary macroadenoma (biopsy proven). Subsequently, hormone replacement therapy commenced with levothyroxine, prednisone, testosterone, and lifelong rivaroxaban for unprovoked PE. A repeat MRI of the brain in 3 months revealed resolution of hemorrhagic pituitary adenoma. Discussion: Pituitary apoplexy is a surgical and medical emergency often complicated by hypopituitarism. Therefore, our case aims to educate physicians on the imperatives of prompt identification, especially with patients on anticoagulation, necessitating further timely evaluation, even if initial imaging is unremarkable. A high clinical suspicion is warranted for diagnosis, surgical intervention, and hormone replacement therapy. The involvement of multidisciplinary teams improves overall survival. Presentation: Monday, July 14, 2025