Case Report: Pituitary apoplexy temporally associated with acute alcohol intoxication, presenting as complete oculomotor nerve palsy in an SF-1 lineage gonadotroph PitNET

Pituitary apoplexy (PA) is an acute, potentially life-threatening neuroendocrine emergency caused by hemorrhage or infarction within the pituitary gland, most often arising in a previously unrecognized pituitary neuroendocrine tumor (PitNET). Reported precipitants include surgery, anticoagulation, dynamic pituitary testing, hypertension, and head trauma; alcohol is rarely implicated. We report a 61-year-old man with long-standing hypertension, type 2 diabetes mellitus and coronary artery disease (on aspirin after coronary stenting) who developed sudden thunderclap headache and complete right oculomotor nerve palsy the morning after consuming approximately 250 ml of distilled liquor (baijiu). Magnetic resonance imaging showed a 2.7 cm × 1.9 cm × 1.9 cm sellar mass with heterogeneous hemorrhagic signal, suprasellar extension and optic chiasm contact. Perioperative endocrine evaluation demonstrated secondary adrenal insufficiency, central hypothyroidism and low gonadotropins, consistent with multi-axis hypopituitarism. After aspirin withdrawal and immediate parenteral hydrocortisone, the patient underwent endoscopic endonasal transsphenoidal resection on day 8. Histopathology confirmed an SF-1 lineage gonadotroph PitNET with extensive infarction (Ki-67 2%; FSH+, SF-1+, PIT-1-, T-PIT-). At 3 months, the right oculomotor palsy had partially recovered, with improvement in ptosis and ocular motility but incomplete resolution. Follow-up contrast-enhanced magnetic resonance imaging showed no residual or recurrent tumor, a decompressed optic chiasm and a midline pituitary stalk, and the markedly elevated presenting 24h urinary free cortisol had returned to the laboratory reference range. Anterior pituitary function nonetheless remained deficient across the corticotroph, thyrotroph, and gonadotroph axes, and the patient continued stable hydrocortisone and levothyroxine replacement. This case adds to the limited literature on PA temporally associated with alcohol intake, illustrates the value of World Health Organization 2022 lineage-based PitNET classification, and supports individualized, semi-elective surgery in haemodynamically stable patients without acute visual-pathway compromise.