SUN-421 Leuprolide Injection Induced Pituitary Apoplexy

Background: Gonadotropin-releasing hormone (GnRH) agonists are used for various treatment purposes including for fertility, hormone mediated malignancies such as prostate cancer, and suppression of sex hormones. Clinical Case: 32 year old female with no significant medical history undergoing infertility treatment with Leuprolide presented to the emergency room with an intractable headache, nausea and vomiting. Prior to her presentation, patient was in her usual state of health and developed these symptoms within thirty minutes of administering the Leuprolide injection. She previously did not have any symptoms or physical manifestations of overt hormonal over-or-under secretion. There was no report of double vision or visual changes. Upon initial presentation, patient was found to be mildly tachycardic with heart rate elevated to 110 bpm. Physical exam was unrevealing for any pertinent positives or negatives. Patient had a CT head without contrast that showed a pituitary macroadenoma. It was followed by a MRI of the pituitary which showed a large complex mixed cystic and solid seller and suprasellar pituitary lesion (1.5 x 2.2 x 2.1 cm). There was compression on the undersurface of the optic chiasm. The infundibulum was markedly compressed and displaced superiorly. At the time of admission, her TSH was 2.8 mIU/L (n 0.46-4.68 mlU/L) with a free T3 and T4 of 3.8 pg/mL (n 2.3-4.3 pg/mL) and 1.6 ng/dL (n 0.8-1.8 ng/dL), respectively. Prolactin was found to be 17.9 ng/mL (n 3.0-30.0), IGF-1 of 100 ng/mL (n 53-331ng/mL), FSH of 5.3 IU/mL (normal in follicular phase 2.5-10.2 IU/mL) and LH of <0.2 IU/mL (normal in follicular phase 1.9-12.5 IU/mL). She was treated at the time of initial presentation with IV Dexamethasone 10mg which provided minimal relief for her headache. Due to the worsening nature of her headache and the unusual appearance of the pituitary on MRI, there was a strong suspicion for pituitary apoplexy. She subsequently had a transsphenoidal resection of the pituitary macroadenoma. There were no complications reported from the procedure and her headaches and nausea significantly improved post surgery. Conclusion: There have been several reported cases of Leuprolide induced pituitary apoplexy in elderly males undergoing treatment for prostate cancer but very rarely reported in young females undergoing fertility treatment. Our patient was unaware of her underlying diagnosis of a pituitary macroadenoma prior to the initiation of Leuprolide which subsequently led to an infarction of her pituitary gland. It is not routine for clinicians to screen for pituitary adenomas using imaging modalities such as MRI prior to starting a patient on a GnRH agonist. We hope to caution clinicians about the risks of pituitary apoplexy with the use of GnRH agonists such as Leuprolide.