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Endgames Picture Quiz

A 45 year old patient with headache, fever, and hyponatraemia

BMJ 2015; 350 doi: (Published 24 February 2015) Cite this as: BMJ 2015;350:h962
  1. Athanasios Fountas, resident of endocrinology,
  2. Maria Andrikoula, endocrinologist,
  3. Agathocles Tsatsoulis, professor of medicine, endocrinology
  1. 1Department of Endocrinology, University of Ioannina, 45110, Ioannina, Greece
  1. Correspondence to: A Tsatsoulis atsatsou{at}

A 45 year old man was admitted to hospital with rapid onset headache, fever, confusion, photophobia, and hypotension. His wife confirmed a six month history of frequent headaches relieved by analgesics.

Neck stiffness was identified on clinical examination. He had no signs of water retention (ankle pitting oedema) or dehydration (dry mucous membrane, reduced skin elasticity). Initial biochemical evaluation showed raised inflammatory markers and hyponatraemia. Renal and liver function tests were within normal limits (table 1).

View this table:
Table 1

 Laboratory findings at admission

The lumbar puncture report was diagnostic of aseptic meningitis (raised lymphocyte count with raised cerebrospinal fluid (CSF) protein and a normal CSF:plasma glucose ratio) (table 2). CSF culture and Gram stain were negative for microbial infection. CSF analysis for xanthochromia was also negative.

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Table 2

 Cerebrospinal fluid (CSF) findings at admission

Hormonal evaluation identified panhypopituitarism and magnetic resonance imaging showed a large pituitary adenoma with signs of haemorrhaging (fig 1).

Fig 1 Magnetic resonance imaging of the patient showing a large pituitary adenoma with signs of haemorrhaging (arrow)


  • 1. What is the final diagnosis?

  • 2. What is the cause of hyponatraemia?

  • 3. How is this condition treated?


1. What is the final diagnosis?

Short answer

Pituitary apoplexy.

Long answer

Pituitary apoplexy is a rare but potentially life threatening condition with an incidence of 0.6-10.5% in patients with a pituitary adenoma.1 It is usually caused by infarction or haemorrhage of the pituitary gland. In more than 80% of patients, apoplexy is the first presentation of the underlying pituitary tumour,2 so the diagnosis can be difficult and delayed. The differential diagnosis is often wide because clinical symptoms overlap with other common medical conditions, such as meningitis, meningoencephalitis, and subarachnoid haemorrhage.3

The clinical manifestations of pituitary apoplexy are the result of a rapid increase in size of the intrasellar contents, which leads to an increase in intrasellar …

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