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Polymyalgia rheumatica — USMLE Step 2 CK MCQ

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HardInternal MedicinePolymyalgia rheumaticaUSMLE Step 2 CK

A 48-year-old man with a known pituitary macroadenoma develops sudden severe headache, ophthalmoplegia, bitemporal visual loss, hypotension and sodium 128 mEq/L. CT shows hemorrhage into the sellar mass. Which immediate treatment is most important while neurosurgery evaluates decompression?

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Correct answer: D — Give stress-dose intravenous hydrocortisone immediately

Pituitary apoplexy can abruptly destroy ACTH secretion and cause life-threatening secondary adrenal insufficiency. Hemodynamic instability, hyponatremia and neuro-ophthalmic deficits warrant immediate stress-dose hydrocortisone without waiting for cortisol results; urgent multidisciplinary evaluation determines the need for transsphenoidal decompression, especially with severe visual compromise. Desmopressin is reserved for documented diabetes insipidus. Bromocriptine does not stabilize adrenal crisis, lumbar puncture is unnecessary after diagnostic sellar imaging, and thyroid hormone before glucocorticoid replacement can worsen adrenal collapse.

Reference: NCBI Bookshelf: Pituitary apoplexy. https://www.ncbi.nlm.nih.gov/books/NBK559222/