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LETTER TO EDITOR
Year : 2014  |  Volume : 62  |  Issue : 1  |  Page : 92-93

Dengue hemorrhagic fever: A rare cause of pituitary apoplexy


Department of Neurosurgery, S.C.B. Medical College and Hospital, Cuttack, Odisha, India

Date of Submission05-Jan-2014
Date of Decision26-Jan-2014
Date of Acceptance26-Jan-2014
Date of Web Publication7-Mar-2014

Correspondence Address:
Souvagya Panigrahi
Department of Neurosurgery, S.C.B. Medical College and Hospital, Cuttack, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.128350

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How to cite this article:
Mishra SS, Panigrahi S, Das S. Dengue hemorrhagic fever: A rare cause of pituitary apoplexy. Neurol India 2014;62:92-3

How to cite this URL:
Mishra SS, Panigrahi S, Das S. Dengue hemorrhagic fever: A rare cause of pituitary apoplexy. Neurol India [serial online] 2014 [cited 2020 Feb 23];62:92-3. Available from: http://www.neurologyindia.com/text.asp?2014/62/1/92/128350


Sir,

Dengue hemorrhagic fever (DHF) is associated with low platelet counts, but a case leading to apoplexy in pituitary adenoma is extremely rare, only few cases have been reported. We report one such an interesting case of pituitary apoplexy.

A 43-year-old man presented with fever of 103°F of 5 days duration. There was no history of petechial rash and spontaneous bleeding from mucosal surfaces. He had not taken any medication or had bleeding disorder prior to this presentation. Complete blood count showed low platelet counts (47,000/cumm) and positive dengue serology both immunoglobulin G and M. 1 day after admission, he had sudden diminution of vision in both eyes with headache and vomiting. Examination revealed decreased visual acuity, hand movement and finger counting at 1 m in the right and left eye, respectively and bitemporal hemianopsia. Optic disc/retinal examination of both eyes was normal. Magnetic resonance imaging (MRI) brain revealed a homogenously enhancing T1 isointense, T2 subtle hyperintense sella and suprasellar mass (23 mm × 21 mm × 20 mm) with evidence of acute hemorrhage [Figure 1]a. Serum prolactin was 14.33 ng/ml (normal 4-30 ng/ml) and serum thyroid stimulating hormone was 1.46 μIU/ml (normal 0.3-3.0 μIU/ml). A diagnosis of pituitary apoplexy was made and urgent transnasal transsphenoidal decompression of the macroadenoma was done, after platelet transfusion (>100,000/cumm). Intraoperatively, there was evidence of bleed inside the tumor. Histopathologic examination revealed pituitary adenoma diffusely infiltrated by red blood cells [Figure 1]b. Post-operative computed tomography showed near complete tumor resection [Figure 1]c. Post-operative period was uneventful with progressive visual improvement from the second post-operative day till 3 months. Vision was 6/60 and 6/36 in the right and left eye respectively, with residual bilateral temporal field defects after 3 month follow-up.
Figure 1:

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Pituitary apoplexy is a condition where spontaneous hemorrhage occur into the pituitary adenoma with development of sudden deterioration of vision, headache and vomiting. DHF is one of the causes of low platelet count leading to petechial rash and spontaneous bleeding from mucosal surfaces. Our patent was a diagnosed case of DHF with a low platelet count without any rash or systemic bleeding. MRI of the brain revealed pituitary macroadenoma with apoplexy. This catastrophe had arisen due to acute bleeding into the pituitary adenoma, probably predisposed by the thrombocytopenia and pituitary stimulation due to the acute systemic illness associated with DHF. Only few cases with this association have been reported in medical literature. [1],[2] This rare association of DHF with pituitary apoplexy indicates that a low platelet count due to DHF may cause pituitary apoplexy. Our patients suggests that sudden onset headache with visual disturbances in patients with DHF warrants MR-imaging to exclude pituitary apoplexy. Other causes of visual deterioration in patients with dengue fever are optic neuropathy, maculopathy, retinal capillary occlusion, foveolitis, and retinal hemorrhage. [3],[4],[5] If the diagnosis is made in time, urgent treatment in the form of decompression of optic nerves may help to save vision as in the presented case.

 
  References Top

1.Kumar V, Kataria R, Mehta VS. Dengue hemorrhagic fever: A rare cause of pituitary tumor hemorrhage and reversible vision loss. Indian J Ophthalmol 2011;59:311-2.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.Wildemberg LE, Neto LV, Niemeyer P, Gasparetto EL, Chimelli L, Gadelha MR. Association of dengue hemorrhagic fever with multiple risk factors for pituitary apoplexy. Endocr Pract 2012;18:e97-101.  Back to cited text no. 2
    
3.Sanjay S, Wagle AM, Au Eong KG. Optic neuropathy associated with dengue fever. Eye (Lond) 2008;22:722-4.  Back to cited text no. 3
    
4.Siqueira RC, Vitral NP, Campos WR, Oréfice F, de Moraes Figueiredo LT. Ocular manifestations in Dengue fever. Ocul Immunol Inflamm 2004;12:323-7.  Back to cited text no. 4
    
5.Su DH, Bacsal K, Chee SP, Flores JV, Lim WK, Cheng BC, et al. Prevalence of dengue maculopathy in patients hospitalized for dengue fever. Ophthalmology 2007;114:1743-7.  Back to cited text no. 5
    


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