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Ann Pediatr Endocrinol Metab > Volume 28(1); 2023 > Article
Finsterer: Pituitary apoplexy is not uncommon in pediatric patients and can be a manifestation of neuro-COVID
To the editor,
We read with interest the article by Agrawal et al. [1] about a 16.5-year-old male with pituitary apoplexy following haemorrhage into a pre-existing pituitary adenoma and concomitant occlusion of both intracranial carotid arteries leading to unilateral, left-sided partial stroke in the territory of the left middle cerebral artery. The patient largely recovered after surgical tumour debulking and hormone substitution during a 2-year follow-up [1]. The case was enlightening but raises concerns that should be discussed.
The main limitation of the report was that the patient was not tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [1]. There is increasing evidence that SARS-CoV-2 infections can manifest as either hypophysitis or apoplexy with or without preexisting pituitary adenoma [2]. In a narrative literature review of patients with involvement of the pituitary gland in SARS-CoV-2 infections, 14 patients were described as of the end of December 2021 [2]. Since then, a number of other cases have been reported [3].
We disagree with the statement that the index is only the third patient with pituitary apoplexy in adolescence [1]. In a study of 33 patients with pituitary apoplexy, the age ranged from 15 to 76 years [4]. Therefore, at least 1 patient was an adolescent. In a review about pituitary involvement in SARS-CoV-2 infections, vaccination, and post-COVID syndrome, one patient was 20 years of age [5]. In another report, pituitary apoplexy was induced by a cortico-tropin releasing hormone test in a 14-year-old female [6]. Another 14-year-old female experienced pituitary apoplexy after cardiac surgery [7]. Several other adolescent patients with pituitary apoplexy have been reported.
We also disagree with the notion that occlusion of the internal carotid artery was "more extensive" on the left than the right side. Occlusion cannot be more or less. It can be only occlusion or stenosis. Because Fig. 3 shows occlusion of both ophthalmic segments of the internal carotid arteries, why ischemic stroke only occurred in the territory of the left middle cerebral artery remains unclear. Was supra-occlusional embolism on the left but not the right side considered?
Overall, this interesting case report has some limitations and inconsistencies that call the results and interpretation into question. Addressing these limitations could further strengthen and reinforce the findings. In the ongoing SARS-CoV-2 pandemic, pituitary apoplexy as a complication of SARS-CoV-2 infection should be ruled out. Pituitary apoplexy is not infrequent, even in pediatric patients.


Conflicts of interest

No potential conflict of interest relevant to this article was reported.


1. Agrawal P, Newbold S, Al Busaidi A, Kapoor RR, Thomas N, Aylwin SJ, et al. Pituitary apoplexy in an adolescent male with macroprolactinoma presenting as middle cerebral artery territory infarction. Ann Pediatr Endocrinol Metab 2022;27:320–4.
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2. Finsterer J, Scorza F. The pituitary gland in SARS-CoV-2 infections, vaccinations, and post-COVID syndrome. Clinics (Sao Paulo) 2022;78:100157.
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3. Aliberti L, Gagliardi I, Rizzo R, Bortolotti D, Schiuma G, Franceschetti P, et al. Pituitary apoplexy and COVID-19 vaccination: a case report and literature review. Front Endocrinol (Lausanne) 2022;13:1035482.
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4. Falhammar H, Tornvall S, Höybye C. Pituitary apoplexy: a retrospective study of 33 cases from a single center. Front Endocrinol (Lausanne) 2021;12:656950.
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5. Chan JL, Gregory KD, Smithson SS, Naqvi M, Mamelak AN. Pituitary apoplexy associated with acute COVID-19 infection and pregnancy. Pituitary 2020;23:716–20.
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6. Fonseca L, Borges Duarte D, Freitas J, Oliveira MJ, Ribeiro I, Amaral C, et al. Asymptomatic pituitary apoplexy induced by corticotropin-releasing hormone in a 14 year-old girl with Cushing's disease. J Pediatr Endocrinol Metab 2021;34:799–803.
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7. Naito Y, Mori J, Tazoe J, Tomida A, Yagyu S, Nakajima H, et al. Pituitary apoplexy after cardiac surgery in a 14-year-old girl with Carney complex: a case report. Endocr J 2019;66:1117–23.
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