Pituitary apoplexy precipitating diabetes insipidus after living donor liver transplantation

Abstract

Pituitary apoplexy occurring after surgery is a rare but life-threatening acute clinical condition that follows extensive hemorrhagenous necrosis within a pituitary adenoma. Pituitary apoplexy has been reported to occur spontaneously in the majority of cases or in association with various inducing factors. Reported is a case of pituitary apoplexy complicated by diabetes insipidus following living donor liver transplantation (LDLT). To the best of our knowledge, this has not been previously reported. A 56-year-old woman with nonalcoholic steatohepatitis underwent LDLT from her daughter. The patient also required dopamine support and transfusions because of massive intraoperative bleeding. Postoperatively, her coagulopathy continued, and she underwent a second laparotomy because of unknown bleeding on postoperative day 7, when she needed transfusions and dopamine support to maintain her vital signs. She complained of severe headache, excessive thirst, frequent urination, and diplopia from postoperative day 10. She also had polyuria greater than 300 ml/h and was diagnosed with pituitary apoplexy precipitating diabetes insipidus on postoperative day 13. She was treated conservatively without surgery because of the hormonally inactive status and slight mass effect of her tumor. It is important for anesthesiologists and critical care personnel in LDLT settings to take into consideration this complication as a differential diagnosis.

Cure of Acromegaly and Diabetes Mellitus After Pituitary Apoplexy

“…This syndrome is classically characterized by sudden severe headaches, meningeal irritation, with or without monocular or binocular visual loss, ptosis and ophthalmoplegia (11). In some rare cases there is diabetes insipidus (2,12). Exceptionally an association with cerebral infarction is observed with hemiplegia and alteration in consciousness (13).…”

“…Pituitary apoplexy is a rare, but life-threatening acute clinical condition secondary to an extensive haemorrhage or necrosis within a pituitary adenoma (1,2). Its real mechanism is still unknown.…”

“…Its real mechanism is still unknown. Clinical observations showed this condition is usually spontaneous, but may occur under various conditions such as medication intake (3), surgery (2,4), anesthesia (5), pregnancy (6,7), and probably in subjects with classical cardiovascular risk factor for bleeding.…”

Encephalopathy, Chiasmal Compression, Ophthalmoplegia, and Diabetes Insipidus in Pituitary Apoplexy

“…1 Pituitary apoplexy, in a patient with a known or unknown adenoma, can be precipitated during pregnancy, postpartum, following surgery, and during treatment with bromocriptine or anticoagulation. [4][5][6][7][8][9] It is often idiopathic, and clinically mimics rupture of a Rathke cyst, craniopharyngioma, or central nervous system lymphoma. 10,11 Case reports of apoplexy occurring without a mass lesion, such as after cardiac surgery and postpartum, offer several pathophysiologic mechanisms of action, including hypotension with haemorrhage after infarction or microemboli.…”

“…[2][3][5][6][7][8]10,11,17 Of these, diabetes insipidus can cause high output of dilute urine (5200 mOsm/kg) with a specific gravity of less than 1.005.7 Subsequently, the serum osmolality can rise to over 300 mOsm/kg, with resultant hypernatraemia. 6,17 The level of electrolyte imbalance can induce a mild change in mental status to coma.…”