Recognizing Complex Post-operative Endocrinopathies in a Patient With Sellar Meningioma Surgery: A Case Report

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Abstract Introduction: Surgery to the pituitary can result in endocrinopathies which are usually more common in the immediate postoperative period. We present a case of delayed onset of endocrinopathies after a trans-sphenoidal sella turcica surgery. Case: A 53-year-old male presented with a 1-week history of altered mental status and polydipsia. 4 weeks before, the patient had undergone an endoscopic endonasal resection of tuberculum sella meningioma. Post-surgery, he was discharged on a dexamethasone taper with nighttime DDAVP. Vital signs showed BP 85/58 mmHg, pulse 87 bpm. Labs showed sodium 126, potassium 6.6, CO2 13, creatinine 24.3, GFR <2, and glucose 65. EKG showed widened QRS complexes. Despite ampoules of D50, the blood glucose did not improve and D10W infusion was started. The patient was started on norepinephrine. Cortisol levels were ordered initially before initiation of hydrocortisone 100mg q8h. Serum Cortisol was 1.1ug/dl whereas it was 8.9 ug/dl post surgery. The elevation in creatinine and low GFR was changed from 2 weeks ago when his creatinine was 0.8 with a GFR of >90. Due to acute renal failure, urgent hemodialysis was initiated. Clinical improvement was noted over the next 48 hours, and vasopressors were weaned off. We learned that the patient had abruptly stopped taking his dexamethasone and DDAVP. He was noted to have a urine output of 11.6L over the next 24 hours, Urine osmolality was ordered and found to be 157. He was given a dose of DDAVP and urine osmolality was checked hourly for 3 hours with levels of 336, 424, and 408. He was started on IV DDAVP. With improving GFR and normalization of urine output, the patient was transitioned to oral nighttime DDAVP. On the day of discharge, the patient's creatinine was 1.1, GFR 79. Discussion: Hypoglycemia, hypotension, hyponatremia, and hyperkalemia together suggest the diagnosis of adrenal insufficiency (AI). In this case, surgical manipulation near the pituitary sella increased the risk for central diabetes insipidus (CDI) along with disturbance to ACTH secretion causing low cortisol levels. We also noted the patient's initial presentation of acute renal failure with Cr of 24 developing over days due to extracellular fluid depletion from mineralocorticoid deficiency and reduced cardiac index causing hypoperfusion due to glucocorticoid deficiency, additionally confounded with increased water intake. The incidence of transient postoperative DI is 7.5%, permanent DI 1.6% in patients who had transsphenoidal surgery and should be suspected even if the presentation is delayed.

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