Perera Isuru, Fernando Hiruni, Janaka Kvc, Gamaarachchi Dimithri, Rathnayake Harsha
Internal Medicine, Sri Jayawardenepura General Hospital, Colombo, LKA.
Cureus. 2025 Mar 16;17(3):e80666. doi: 10.7759/cureus.80666. eCollection 2025 Mar.
Pituitary apoplexy is a life-threatening condition caused by a rapid expansion of the pituitary tumor due to hemorrhage or infarction. It usually presents with acute onset severe headache and can also be associated with visual field defects and ophthalmoplegia. Similarly, ocular myasthenia gravis, which is an autoimmune condition causing muscle fatiguability, also presents with ophthalmoplegia, commonly ptosis and diplopia. A 53-year-old male patient with a past history of adrenal insufficiency presented with acute onset headache. On examination, he had bilateral asymmetrical partial ptosis and left-side medial rectus palsy with mild fatiguability. He had normal visual fields and sparing of the pupils. Acetylcholine receptor antibodies were positive but failed to demonstrate a decremental response in nerve conduction studies. The patient was started on neostigmine on clinical suspicion of ocular myasthenia gravis. A magnetic resonance imaging (MRI) scan of the brain was arranged to look for any intracranial pathology for persistent headache and it revealed evidence of pituitary apoplexy with compression of optic chiasm and partial obliteration of bilateral cavernous sinuses. In view of MRI findings, a diagnosis of pituitary apoplexy with third cranial nerve involvement was considered the first differential diagnosis, and the patient was started on replacement hormones while temporarily withholding neostigmine. Following multidisciplinary input, it was decided to manage the patient conservatively. A repeat MRI brain was planned to assess the evolution which revealed resolution of pituitary apoplexy. Despite this, the patient continued to have ophthalmoplegia and fatigable partial ptosis. Pyridostigmine was restarted following which the patient fully recovered, confirming the diagnosis of ocular myasthenia gravis presenting concomitantly with pituitary apoplexy.
垂体卒中是一种由垂体肿瘤因出血或梗死而迅速扩大所导致的危及生命的病症。它通常急性起病，表现为严重头痛，还可能伴有视野缺损和眼肌麻痹。同样，眼肌型重症肌无力是一种导致肌肉易疲劳的自身免疫性疾病，也表现为眼肌麻痹，常见上睑下垂和复视。一名有肾上腺功能不全病史的53岁男性患者出现急性头痛。检查发现，他有双侧不对称性部分上睑下垂和左侧内直肌麻痹，伴有轻度易疲劳性。他视野正常，瞳孔未受累。乙酰胆碱受体抗体呈阳性，但神经传导研究未显示递减反应。临床怀疑为眼肌型重症肌无力，遂开始给予患者新斯的明治疗。安排了脑部磁共振成像（MRI）扫描以查找持续性头痛的任何颅内病变，结果显示有垂体卒中的证据，视交叉受压，双侧海绵窦部分闭塞。鉴于MRI检查结果，首先考虑诊断为累及第三脑神经的垂体卒中，开始给予患者补充激素，同时暂时停用新斯的明。经过多学科会诊后，决定对患者进行保守治疗。计划再次进行脑部MRI检查以评估病情演变，结果显示垂体卒中已消退。尽管如此，患者仍有眼肌麻痹和可疲劳性部分上睑下垂。重新开始给予吡啶斯的明治疗后，患者完全康复，证实诊断为眼肌型重症肌无力与垂体卒中同时存在。
