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| LETTER TO EDITOR |
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| Year : 2014 | Volume
: 62
| Issue : 1 | Page : 92-93 |
Dengue hemorrhagic fever: A rare cause of pituitary apoplexy
Sudhansu Sekhar Mishra, Souvagya Panigrahi, Srikanta Das
Department of Neurosurgery, S.C.B. Medical College and Hospital, Cuttack, Odisha, India
| Date of Submission | 05-Jan-2014 |
| Date of Decision | 26-Jan-2014 |
| Date of Acceptance | 26-Jan-2014 |
| Date of Web Publication | 7-Mar-2014 |
Correspondence Address:
Souvagya Panigrahi
Department of Neurosurgery, S.C.B. Medical College and Hospital, Cuttack, Odisha
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.128350
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 |
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.
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 | |  |
| 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. 
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| 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.
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| 3. | Sanjay S, Wagle AM, Au Eong KG. Optic neuropathy associated with dengue fever. Eye (Lond) 2008;22:722-4.
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| 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.
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| 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.
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[Figure 1]
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