Coronavirus disease 2019 infection and pituitary apoplexy: A causal relation or just a coincidence? A case report and review of the literature

Abstract

Background: Pituitary tumor apoplexy (PA) is an emergency condition caused by hemorrhage or infarction of the preexisting adenoma. Many factors are currently well-known to predispose to PA. However, during the period of coronavirus disease 2019 (COVID-19) pandemic, case reports of PA associated with COVID-19 infection have been sequentially published. To the best of our knowledge, four cases have been reported so far in the English literature. We herein report the fifth case of this association and review the pertinent literature.

Case description: A 55-year-old male patient with confirmed COVID-19 infection presented by progressive decrease in visual acuity and oculomotor nerve palsy. His medical history is notable for diabetes mellitus, hypertension, and pituitary macroadenoma resection 11 years ago. He was on hormonal replacement therapy for panhypopituitarism that complicated the surgery. Previous magnetic resonance (MR) imaging studies were consistent with enlarging residual pituitary adenoma. During the current hospitalization, computed tomography revealed hyperdensity of the sellar and suprasellar areas. MR imaging revealed PA in a recurrent large adenoma. Endoscopic endonasal transsphenoidal resection was uneventfully undertaken with near total excision of the adenoma and partial improvement of visual loss and oculomotor palsy. Histopathological examination demonstrated classic features of PA. However, his chest condition progressed and he had to be transferred to COVID-19 intensive care unit in the referring hospital where he was intubated and put on mechanical ventilation. One week later, the patient unfortunately passed away due to complications of severe COVID-19 pneumonia.

Conclusion: We report the fifth case of PA associated with COVID-19 infection. Based on our patient's clinical findings, review of the other reported cases, as well as the available literature, we put forth a multitude of pathophysiological mechanisms induced by COVID-19 that can possibly lead to the development of PA. In our opinion, the association between both conditions is not just a mere coincidence. Although the histopathological features of PA associated with COVID-19 are similar to PA induced by other etiologies, future research may disclose unique pathological fingerprints of COVID-19 virus that explains its capability of inducing PA.

Keywords: Coronavirus disease 2019; Endoscopic; Pituitary apoplexy; Transsphenoidal.

Figure 1:

Magnetic resonance imaging (MRI) images of the sella 3 months after the first endoscopic endonasal excision of a large pituitary macroadenoma demonstrating residual tumor (a-d). Residual tumor enlargement is noted in the follow-up MRI done 3 years later (e-h).

Figure 2:

Magnetic resonance imaging (MRI) images of the current presentation. Preoperative T1-weighted images reveal a large recurrent pituitary macroadenoma with minimal patchy enhancement after gadolinium injection (a and b). Postoperative T1-weighted images with contrast revealed near total excision of the adenoma (c and d).

Figure 3:

Intraoperative views during endoscopic endonasal transsphenoidal tumor excision. (a) Bluish discoloration of the dura caused by apoplexy of the underlying tumor is evident at the initial exposure. (b) Dark blood (asterisk) is seen on initial dural opening. (c) View of the necrotic purple adenoma tissue being resected from within the sella. (d) A pituitary ring curette elevates the downward bulging cistern and a pituitary Rongeur is used to excise the superior part of the tumor. (e) The uppermost tumor components (double asterisks) have been separated from the arachnoid of the suprasellar cistern. (f) Final view after tumor resection. Note the fat from previous surgery (arrowheads).