Fatal Pituitary Tumor Apoplexy Presenting With Behavioral Disorder

Pituitary apoplexy (PA) is a rare but potentially fatal ischemic or hemorrhagic phenomenon, with an annual incidence around 1.2 per million. It is often misdiagnosed because most patients have subclinical pituitary adenomas and its presentation can be confused with neurological or, very rarely, psychiatric processes. Here, we present a 31-year-old man, with history of hypertension and chronic renal disease on hemodialysis of unknown etiology, admitted in the Department of Psychiatry of our Hospital with altered behavioral symptoms. Neuroimaging studies showed an increase of the pituitary gland due to an intraparenchymatous lesion. He was found dead on his room floor. In the autopsy, we observed a pituitary increased in weight and size, which in sagittal section showed an extensive hemorrhagic area located in the anterior lobe. Histological examination revealed a 9 mm adrenocorticotrophic adenoma (ACTH-secreting adenoma), with an extensive intratumoral hemorrhage. PA is often a difficult diagnosis, since it can mimic other clinical situations. Clinicopathologic effects of PA are caused by a rapid increase in the size of the contents of the pituitary fossa and the subsequent rise of intrasellar pressure, with additional pressure on the hypothalamus and midbrain. This would possibly explain the alteration of vital functions and consciousness. Pituitary hemorrhage normally produces an acute stroke which causes characteristic symptoms; the extremely rare case that we present exemplifies how it may also have subclinical/insidiously course for days. To our knowledge, this is the first time to report that a so obvious macroscopic image of post-mortem pituitary with this rare disease.