7486 Pulmonary Embolism following Transsphenoidal Surgery in a Patient with Cushing’s Disease
Authors: Davis Adam N , Elshimy Ghada , Vender John 
Published: October 2024

Abstract
Disclosure: A.N. Davis: None. G. Elshimy: None. J. Vender: None.
Introduction: Cushing’s Disease (CD) is associated with increased risk of venous thromboembolism (VTE), especially in the perioperative period. There is no standard of practice for thromboprophylaxis for CD patients. We present a patient with CD who had a pulmonary embolism (PE) postoperatively. Case: Patient is a 42-year-old female with no known history of pituitary adenoma who presented on 11/7/22 as transfer from outside hospital after presenting with left ptosis, diplopia, and headache with CT head showing sellar mass. Vital signs were stable. Physical exam revealed left eye ptosis with inability to abduct the right eye. ACTH level at 12:28 AM was 102pg/mL. Dexamethasone 10mg IV was given at 1:18 AM and then continued at 4mg IV q6 hours. Cortisol at 8:38 AM was 79.73mcg/dL. Calcium was 12.3mg/dL and PTH 741pg/mL, consistent with primary hyperparathyroidism. MRI brain pituitary protocol 11/8/22 revealed a peripherally enhancing 2.1 x 4.2 x 3.6 cm sellar mass extending into both cavernous sinuses, suspicious for apoplexy. Transsphenoidal surgery was performed 11/8/22 for debulking. Pathology was consistent with pituitary adenoma staining positive for ACTH. Postoperative labs included cortisol 16.45mcg/dL on 11/10/23 at 3:34PM while still on dexamethasone 4mg IV q6 hours. Inpatient rehab was recommended by PT, however patient declined. She was discharged home on 11/29/22 on hydrocortisone 20mg PO QAM and 10mg PO early afternoon and desmopressin 0.1mg PO QHS for central diabetes insipidus. Of note, she received thromboprophylaxis with Lovenox 60mg SQ the night of 11/7/22 followed by heparin 7500u q8h SQ until discharge. No thromboprophylaxis was continued at discharge. She was readmitted 12/12/22 after presenting with shortness of breath, and she was found to have a large saddle PE with right heart strain for which she was given tPA. She was discharged on apixaban 3 days later. She had parathyroidectomy 2/22/23 with removal of left inferior parathyroid adenoma with evidence of biochemical cure. Genetic testing was negative for MEN1. Unfortunately, three months later, the patient was admitted for moderate volume subarachnoid hemorrhage and was discharged to a rehabilitation facility after which she was lost to follow up. Discussion: CD is associated with increased risk of VTE, especially in the perioperative period, and this has been attributed to changes in the coagulation cascade. Our patient had increased risk of VTE in the setting of poor functional status and CD with evidence of persistent disease postoperatively. Primary hyperparathyroidism may also be associated with increased risk of VTE, likely due to the effect of hypercalcemia on the coagulation cascade. It is unclear whether continued thromboprophylaxis after discharge may have prevented her PE. There is a need for clear consensus guidelines on patient selection for thromboprophylaxis and duration of thromboprophylaxis.
Presentation: 6/1/2024