Pituitary Apoplexy Masquerading as Intractable Headache in a 66-Year-Old Man: A Case Report

Pituitary apoplexy is a rare but potentially life-threatening endocrine emergency caused by acute hemorrhage or infarction of the pituitary gland, typically in the setting of a preexisting adenoma. It often mimics other acute neurologic conditions, leading to delayed diagnosis.

We describe the case of a 66-year-old man who presented twice to the emergency department with progressively worsening headache. On the initial visit, a noncontrast computed tomography was obtained and was normal, but on return visit, imaging revealed a pituitary macroadenoma. Fever and cerebrospinal fluid pleocytosis subsequently raised concern for meningitis, but the clinical context supported chemical meningitis secondary to apoplexy. This case highlights the diagnostic complexity of pituitary apoplexy and emphasizes the need for advanced imaging and early endocrine consultation in evolving headache syndromes. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case emphasizes the diagnostic challenge of pituitary apoplexy, particularly when initial imaging is nondiagnostic and clinical symptoms evolve. Emergency physicians should maintain a high level of suspicion in patients with severe or recurrent headaches, even in the absence of classic visual or endocrine symptoms. Pituitary apoplexy, although rare, is a critical consideration in the differential diagnosis of sudden, severe headaches. Normal computed tomography imaging does not exclude the diagnosis, and evolving neurologic signs warrant advanced imaging. Cerebrospinal fluid abnormalities may mimic meningitis, but are often sterile in origin. Early recognition, corticosteroid therapy, and multidisciplinary management are essential to prevent permanent deficits.