Review
Pituitary apoplexy associated with cabergoline therapy

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Abstract

Pituitary apoplexy is a rare medical emergency which results from hemorrhage or infarction in the pituitary gland. One of the predisposing factors is treatment with dopamine agonists, especially bromocriptine. We report a 20-year-old Chinese man with prolactinoma who developed pituitary apoplexy 6 weeks after initiation of cabergoline. He was treated conservatively with supportive therapy, and recovered well with no loss of pituitary function. A literature search was conducted and a review of the reported patients with pituitary apoplexy during treatment with dopamine agonists is discussed.

Introduction

Pituitary apoplexy is an uncommon but life-threatening condition. It usually occurs in a pre-existing adenoma, although a normal pituitary gland can also develop apoplexy, especially during pregnancy. Patients usually present with severe headache, visual disturbances, cranial nerve palsies, nausea, vomiting, altered consciousness, and impaired pituitary function. The majority of patients do not have a particular cause but predisposing factors include radiotherapy, thrombocytopenia, pituitary dynamic testing, trauma, recent surgery, diabetes mellitus, hypertension, and medications such as anticoagulants and dopamine agonists. Most reports of pituitary apoplexy in patients with adenomas are related to treatment with bromocriptine. We report a patient with prolactinoma who developed apoplexy 6 weeks after cabergoline treatment.

Section snippets

Illustrative case report

A 20-year-old Chinese man presented to a neurologist with a 5 year history of chronic right sided headache requiring intermittent analgesia for pain relief. MRI of the brain revealed a intrasellar lesion extending to the suprasellar region resulting in compression of the optic chiasm. He was referred to our endocrinology service for assessment of tumor functionality.

He was an otherwise healthy individual and not taking any regular medications. He had no complaints of polyuria, polydipsia,

Discussion

The use of dopamine agonists has been listed as one of the risk factors for pituitary apoplexy. They cause apoptosis of lactotroph cells and this in turn decreases the metabolic demands. At the same time, the angiogenesis is inhibited but an imbalance between the two leads either to infarction with hemorrhage or hemorrhage only.

A literature search for patients reported between 1985 and 2011 revealed 10 patients1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and two case series11, 12 of pituitary apoplexy with

Conclusions

Pituitary apoplexy is a rare condition, and can be associated with treatment of adenomas with dopamine agonists. Although the dopamine agonists precipitate apoplexy, therapy can be continued after the apoplexy for biochemical and anatomical remission of prolactinoma. Whilst apoplexy is more widely reported with the use of bromocriptine, physicians should also be aware that it can also occur with cabergoline.

Conflicts of interest/disclosures

The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.

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