A bloody surprise: rare presentation of pituitary apoplexy with epistaxis-a case report

Pituitary apoplexy (PA) is an endocrine emergency caused by haemorrhage or infarction of the pituitary gland, often occurring in patients with known tumours. Classical presentation includes headache, visual disturbances, and cranial nerve palsies. We describe a rare presentation of PA with epistaxis in a 71-year-old man with a known non-functioning pituitary macroadenoma. On admission, he had acute confusion, worsening headache, and left-sided epistaxis with signs of Cranial Nerve (CN) III palsy and reduced consciousness. Initial Computerized Tomography (CT) showed a stable macroadenoma without acute changes. Laboratory evaluation showed panhypopituitarism and features of vasopressor deficiency. Rapid clinical deterioration prompted repeat CT and Magnetic Resonance Imaging (MRI), which demonstrated interval enlargement of the adenoma with haemorrhage and mass effect. MRI also revealed a catastrophic left middle cerebral artery infarct secondary to M1 segment thrombosis. Despite intensive care support, the patient failed to recover neurologically and passed away. Our case report describes the rare occurrence of epistaxis in PA, due to tumour extension into the sphenoid sinus and erosion of the sellar floor. We emphasize the importance of an early MRI and endocrinology review for timely diagnosis and management. We underscore the need to consider PA in patients with known adenomas and acute neurological decline, even with atypical symptoms. Our case report adds to the limited literature on epistaxis as a presenting sign of PA and associated high morbidity.