Case Report
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Oct 26, 2019; 7(20): 3259-3265
Published online Oct 26, 2019. doi: 10.12998/wjcc.v7.i20.3259
Gonadotrophin-releasing hormone agonist-induced pituitary adenoma apoplexy and casual finding of a parathyroid carcinoma: A case report and review of literature
Vanessa Triviño, Olga Fidalgo, Antía Juane, Jorge Pombo, Fernando Cordido
Vanessa Triviño, Olga Fidalgo, Antía Juane, Fernando Cordido, Department of Endocrinology, Complejo Hospitalario Universitario A Coruña, A Coruña 15006, Spain
Jorge Pombo, Department of pathological anatomy, Complejo Hospitalario Universitario A Coruña, A Coruña 15006, Spain
Author contributions: Triviño V and Fidalgo O were the patient’s endocrinologists, reviewed the literature and contributed to manuscript drafting; Juane A reviewed the literature and contributed to manuscript drafting; Pombo J performed the microscope study of the tissue and immunohistochemistry, took the photographs and contributed to manuscript drafting; Cordido F was responsible for revision of the manuscript for relevant intellectual content; all authors issued a final approval for the version to be submitted.
Supported by FIS del Instituto de Salud Carlos III (FEDER from E.U.), Spain, No. PI13/00322 and PI16/00884.
Supported by FIS del Instituto de Salud Carlos III (FEDER from E.U.), Spain, No. PI13/00322 and PI16/00884
Informed consent statement: Informed written consent was obtained from the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
CARE Checklist (2016) statement: The manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Fernando Cordido, MD, PhD, Professor, Department of Endocrinology, Complejo Hospitalario Universitario A Coruña, University of A Coruña, As xubias 84, A Coruña 15006, Spain. fernando.cordido.carballido@sergas.es
Telephone: +34-981-176442
Received: April 6, 2019
Peer-review started: April 8, 2019
First decision: September 9, 2019
Revised: September 24, 2019
Accepted: October 5, 2019
Article in press: October 5, 2019
Published online: October 26, 2019
Abstract
BACKGROUND

Pituitary apoplexy represents one of the most serious, life threatening endocrine emergencies that requires immediate management. Gonadotropin-releasing hormone agonist (GnRHa) can induce pituitary apoplexy in those patients who have insidious pituitary adenoma coincidentally.

CASE SUMMARY

A 46-year-old woman, with a history of hypertension and menorrhagia was transferred to our hospital from a secondary care hospital after complaints of headache and vomiting, with loss of consciousness 5 min after an injection of GnRHa. The drug was prescribed by her gynecologist due to the presence of uterine myomas. The clinical neurological examination revealed right cranial nerve III palsy, ptosis and movement limitation of the right eye. Our first clinical consideration was a pituitary apoplexy. Blood hormonal analysis revealed mild hyperprolactinemia and high follicle stimulating hormone level; PTH and calcium was high with glomerular filtration rate mildly to moderately decrease. A computed tomography scan, revealed an enlarged pituitary gland (3.5 cm) impinging upon the optic chiasm with bone involvement of the sella. Following contrast media administration, the lesion showed homogeneous enhancement with high-density focus that suggests hemorrhagic infarction of the tumor. Transsphenoidal endoscopic surgery was perfomed and adenomatous tissue was removed. Immunohistochemistry was positive for luteinizing hormone (LH) and follicular-stimulating hormone (FSH). A solid hypoechoic nodule (14 mm x 13 mm x 16 mm) was found in the caudal portion of the right thyroid lobe after a parathyroid ultrasound. A genetic test of Multiple Endocrine Neoplasia type 1 (MEN1) was negative. A right lower parathyroidectomy was performed and the pathologic study showed the presence of an encapsulated parathyroid carcinoma of 1.5 cm. A MEN type 4 genetic test was performed result was negative.

CONCLUSION

This case demonstrates an uncommon complication of GnRH agonist therapy in the setting of a pituitary macroadenoma and the casual finding of parathyroid carcinoma. It also highlights the importance of suspecting the presence of a multiple endocrine neoplasia syndrome and to carry out relevant genetic studies.

Keywords: Pituitary apoplexy, Pituitary adenoma, Primary hyperparathyroidism, MEN type 1, MEN type 4, Parathyroid carcinoma, Case report

Core tip: Pituitary apoplexy represents one of the most serious, life threatening endocrine emergencies. Gonadotropin-releasing hormone agonist can develop pituitary apoplexy in those who have insidious pituitary adenoma coincidentally. What will be discussed in this article is the case of the first female patient who has develop pituitary apoplexy after receiving triptorelin, which is prescribed to regulate the menstrual cycle due menorrhagia, and uterine fibroids through pituitary down regulation. This case demonstrates an uncommon complication of gonadotropin-releasing hormone agonist therapy in the setting of a pituitary macroadenoma and the casual finding of parathyroid carcinoma. It also highlights the importance to suspect the presence of a multiple endocrine neoplasia syndrome and to carry out relevant genetic studies.