Pituitary apoplexy associated with COVID-19 infection: review and a case report

Pituitary apoplexy (PA) is a clinical syndrome caused by a hemorrhage and/or infarction in a pituitary adenoma due to a diverse group of pathophysiological mechanisms. The clinical spectrum consists of severe headaches, visual disturbances, cranial nerve involvement and hormonal deficiencies. There have been a growing number of case reports of pituitary apoplexy with a possible association with Coronavirus disease 2019 (COVID-19) recently. The aim of this paper is to review and analyze the possible connection between pituitary apoplexy and the novel coronavirus SARS-CoV-2. The literature review was conducted by searching the term 'COVID-19 pituitary apoplexy' in the PubMed database. Seventeen results were screened. We identified 12 cases of patients with pituitary apoplexy with a possible connection to COVID-19. The pathophysiological mechanisms include infarction and acute hemorrhage. COVID-19 could contribute to pituitary apoplexy due to a series of predisposing factors, like hemodynamic instability, increase in intracranial pressure, coagulopathy, endothelial dysfunction and hypercoagulative state. The possible association between COVID-19 and pituitary apoplexy is still debatable. Finally, we report a case of a 63-year-old female presenting with pituitary apoplexy with an onset of symptoms 15 days after initial positive polymerase chain reaction (PCR) testing for SARS-CoV-2. The patient was hospitalized for COVID-19 due to associated pneumonia for 12 days. Three days after discharge from the hospital, the patient developed a severe onset headache. Magnetic resonance imaging revealed a pituitary macroadenoma with pituitary apoplexy. In the presented case, the most probable reason for the pituitary apoplexy is infarction and not acute hemorrhage.