Unusual association of a pituitary adenoma and a neurological emergency: case report and diagnostic steps

A 44-year-old female patient was admitted to the Emer-gency Department with a 2-day complaint of severeheadache in the left frontal region. Her menstrual andpathological history was uneventful. Since 25 years she hadbeen suffering from recurrent headache episodes withvomiting; in the last few years she had been taking oralestroprogestin contraceptives, with a concomitant symptomrelief regarding frequency and severity. The latest attackhad begun insidiously and was described as not differentfrom the usual pattern; no features suggesting raised intra-cranial pressure, such as worsening at night or with therecumbent position, were reported. Incidentally, the patientreported the recent appearance of galactorrhea and discov-ery of elevated PRL serum concentrations (3,952 pmol/L,n.v.\1,100 pmol/L = 24.2 ng/mL). Finding on emergencycomputerized tomography (CT) imaging was a roundishisodense sellar mass; a presumptive diagnosis of pituitaryadenoma was made.The patient was admitted to our Department of InternalMedicine. She appeared alert and attentive, orientated butsuffering from intense pulsatile headache with nausea, onlytemporarily relieved by tramadole and ketorolac i.v. Theendocrinological work-up disclosed serum PRL levels2,486 pmol/L and undetectable gonadotropins compatiblewith the assumption of estroprogestin pill, stopped atadmission; the patient was not assuming other drugspotentially responsible of hyperprolactinemia. The possi-bility of artifactually low values due to the ‘‘hook effect’’was excluded using a 1:100 dilution of serum; the searchfor macroprolactinemia yielded negative results. Thyroidfunction was normal (TSH 2 mU/L; free thyroxine14 pmol/L; free triiodothyronine 4.8 pmol/L) as well ascorticotropin plasma concentration (4.8 pmol/L) andadrenal response to a low-dose ACTH test (1