(13.05) Pituitary macroadenoma unmasked after Covid-19 infection

Introduction : Pituitary macroadenomas are fourth common intracranial tumors. Almost 80% of them are non-functioning and present either with mass effects or signs and symptoms caused by suppression of the hypothalamic-pituitary axis. We present an unusual case of pituitary adenoma that was revealed after COVID-19 infection. Our patient presented with orthostatic hypotension which is not the usual presentation for secondary adrenal insufficiency.

Case(s) Description : A 76-year-old man with a past medical history of hypertension, hyperlipidemia, and recent COVID-19(1 and a half months prior) presented to hospital initially with weakness and dizziness ongoing since COVID.
During his admission for COVID, the patient reported mild symptoms, he did not require supplemental oxygen and was not treated with steroids, although was discharged to rehab due to weakness and dizziness.
Upon discharge from rehab to home, he had multiple near falls due to continued dizziness, prompting the emergency department visit almost one month after the initial covid illness. In emergency department he was found to have orthostatic hypotension and was treated with intravenous hydration and discharged to rehab with midodrine without any further meaningful investigation. Due to continued orthostatic hypotension, morning cortisol was checked in rehab and noted to be significantly low. The eventual work-up revealed secondary adrenal insufficiency due to pituitary macroadenoma as the underlying cause of his symptoms. Interestingly, he had no symptoms of adrenal insufficiency or hypotension before Covid, and was on anti-hypertensives, hence, indicating Covid as the stressor that let out the previously asymptomatic adrenal insufficiency due to pituitary macroadenoma. 

Discussion :

Pituitary macroadenomas are one of the common intracranial tumors, they are usually silent tumors but when symptomatic, the usual presentation is headache and visual symptoms due to the encroachment of tumor on optic chiasm. They can also present with endocrine hypofunction due to compression of normal pituitary tissue by the tumor. Signs and symptoms of secondary adrenal insufficiency can sometimes be the first sign of pituitary adenoma.

Adrenal insufficiency has varied presentations ranging from severe morbidity with acute adrenal crisis to non-specific symptoms like fatigue. Orthostatic hypotension can be present although is more common in primary adrenal insufficiency due to volume depletion caused by aldosterone deficiency. In secondary adrenal insufficiency, the mechanism of orthostatic hypotension is low cortisol levels.

Due to vague early symptoms, the diagnosis of adrenal insufficiency is usually delayed and is often made once an adrenal crisis sets in secondary to some stressor. In our case, the stressor was covid 19 which precipitated the symptoms, but fortunately, our patients did not develop adrenal crises.

This case emphasizes the importance of maintaining high clinical suspicion in diagnosing adrenal insufficiency, any new onset hypotension after a stressor should be investigated thoroughly to prevent the dangers of adrenal crises in case the patient has underlying adrenal insufficiency.