Case Report

Acute Psychoses: An Unusual Presentation of Empty Sella Syndrome

Abstract Abhishek Singhai,

We report a case of a 54‑year‑old female admitted to our hospital with altered behavior. We found Karan Kapur,
that severe hyponatremia (116 mEq/L) was the cause of the patient’s status. In turn, hyponatremia Sagar Khadanga,
was due to panhypopituitarism. Mild‑to‑moderate hyponatremia had been previously detected in this
patient; however, it was overlooked. The clinical onset of panhypopituitarism is often characterized Aparna
by mild nonspecific symptoms, especially in the older people, and it is often overlooked. Although Paramanandam
hyponatremia is a common electrolyte disorder in the elderly, physicians should not forget that it could Department of General
be the leading manifestation of panhypopituitarism. Panhypopituitarism may be easily diagnosed; Medicine, All India Institute
however, clinical suspicion is needed. Due to the high mortality associated with panhypopituitarism, of Medical Sciences, Bhopal,
Madhya Pradesh, India
hormone assays should be included in the initial diagnostic workup of hyponatremia.

Keywords: Hyponatremia, hypopituitarism, metabolic encephalopathy

Introduction panhypopituitarism.[1,2] Hyponatremia, as

the presenting manifestation of ESS, is rare.
Panhypopituitarism is a condition of loss
Here, we describe a case of middle‑aged
of function of anterior pituitary gland
female who presented with acute psychoses
characterized by the inadequate or absent
due to hyponatremia, and who, later on,
production of anterior pituitary hormones.
found to have panhypopituitarism with
It is a rare condition that can present at
empty sella.
any age and is caused by pathology of the
hypothalamic‑pituitary axis or one of the Case Report
many gene mutations. The symptoms and
signs of panhypopituitarism may occur A 54‑year‑old female presented with
over several years and can be nonspecific dullness, irrelevant talking, and inability to
or related to the effects of underlying recognize her relatives for 5 days. She had
disease or due to hormone deficiencies. abnormal behavior, with decreased sleep.
Panhypopituitarism is a condition that is There was no history of fever, headache,
often misdiagnosed. Panhypopituitarism is head trauma, or violent behavior. For the
an underinvestigated endocrine disorder in above complaints, she was admitted to the
the elderly since its clinical features are psychiatry department. She had similar
Submission: 04-Oct-18
nonspecific and more commonly present episode 1 year back for which she took Revised : 13-Nov-18
to aging itself and related comorbidities.[1,2] symptomatic treatment and improved. Accepted : 28-Nov-18

Although diagnosis of panhypopituitarism On examination, the patient was dull,

is easy if clinical suspicion is high.[1‑3] drowsy, and disoriented to time, place, and Address for correspondence:
person. She had madarosis, hoarseness of Dr. Abhishek Singhai,
Empty sella syndrome (ESS) is where the voice, and diffusely sparse hairs over the Department of General
pituitary gland shrinks or becomes flattened, body (axillary and pubic hair). Neck rigidity Medicine, All India
filling the sella turcica with cerebrospinal Institute of Medical
was absent and both planters were flexor. Sciences, Bhopal ‑ 462 020,
fluid on imaging instead of the normal Pulse was 60/min, and blood pressure was Madhya Pradesh, India.
pituitary. ESS can be found in the diagnostic on a lower side of around 90/60 mmHg on E‑mail: drabhisheksinghai@
workup of pituitary disorders, or as an repeated measurements, and other systemic gmail.com
incidental finding when imaging the brain. examination findings were normal.
Hyponatremia is a common electrolyte Her investigations showed hemoglobin Access this article online
disorder, especially in the elderly;[4‑7] 8.6 g/dl (11–15), white blood cell count Website: www.cjhr.org
however, it is also a laboratory sign of 3530/mm3 (4000–11,000), mean corpuscular DOI: 10.4103/cjhr.cjhr_139_18
volume 88.2 fl (80–100), platelet count Quick Response Code:
This is an open access journal, and articles are 145,000/mm3 (150,000–450,000), random
distributed under the terms of the Creative Commons
Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, How to cite this article: Singhai A, Kapur K,
as long as appropriate credit is given and the new creations are Khadanga S, Paramanandam A. Acute psychoses:
licensed under the identical terms. An unusual presentation of empty sella syndrome.
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 Singhai, et al.: An unusual presentation of empty sella syndrome

blood glucose values were always below 100 mg/dl on treated with 50 mcg of thyroxine, prednisolone 5 mg in the
repeated measurements, serum creatinine 0.71 mg/dl morning, and 2.5 mg in the evening with fludrocortisone
(0.5–0.9), blood urea 17 mg/dl (20–40), serum sodium 0.1 mg once a day. Gradually, the patient’s general
116 mEq/L (136–145), serum potassium 3.58 mEq/L condition improved with the above treatment, serum
(3.5–5.1), serum chloride 87 mEq/L (98–107), serum sodium was corrected, and the patient was discharged after
bilirubin 0.63 mg/dl (0.3–1.2), alanine aminotransferase 8 days of hospitalization in stable condition.
52 IU/L (0–35), aspartate aminotransferase 99 IU/L (0–
35), alkaline phosphatase 83 IU/L (30–120), erythrocyte Discussion
sedimentation rate 10 mm (1–10), and serum albumin This case report highlights the importance of extensive
4.10 (3.5–5.5). Then, the patient was referred to physician workup in a case of hyponatremia. Panhypopituitarism is
in view of hyponatremia. The patient was treated with 3% a relatively rare disorder, with its incidence and prevalence
saline. being 4.2 per 100,000 per year and 45.5 per 100,000,
Further workup for hormone assays and radiological respectively.[1] Panhypopituitarism usually develops
investigation was planned and reports were as follows:
T3 0.22 ng/ml (0.6–1.81), T4 0.7 mcg/dl (4.5–10.9), free
T4 0.11 (0.89–1.77), thyroid‑stimulating hormone 2.85 mcg
U/ml (0.35–5.5), random serum cortisol 1.45 mcg/dl
(4.30–22.40), adrenocorticotropic hormone 14.50 pg/
ml (<46.00), and follicle‑stimulating hormone 12.41 mU/
ml (15.9–54). These investigations were suggestive of
panhypopituitarism. Table 1 shows the symptoms and
clinical signs that favor hypopituitarism. No significant
brain parenchymal abnormality was seen on noncontrast
computed tomography head. After this, magnetic resonance
imaging brain with contrast was planned, which showed
empty sella with a significantly reduced size of the anterior
pituitary gland (approximately 1.5‑mm thickness) with no
adenoma [Figure 1]. The posterior pituitary bright spot is
seen normal, the pituitary stalk is seen normal in position,
Figure 1: Magnetic resonance imaging brain showing empty sella with
and a tiny focus of microhemorrhage is noted involving significantly reduced size of anterior pituitary gland (approximately 1.5‑mm
right paraventricular region. Following this, the patient was thickness) with no adenoma

Table 1: Anterior pituitary hormones and presentation of their deficiency

Deficient hormone Symptoms in this case Signs in this case Relevant investigations done in this case
TSH Asthenia, dullness Coarse, dry hair T3 0.22 ng/ml (0.6-1.81)
Weakness Dry skin T4 0.7 mcg/dl (4.5-10.9)
Hair loss Free T4 0.11 (0.89-1.77)
TSH 2.85 mcgU/ml (0.35-5.5)
GH Difficult to concentration Dry, thin skin
and lack of memory
Decreased muscle mass
and strength
Very low energy levels
Fatigue and/or tiredness
ACTH Weight loss Low blood pressure (hypotension) Low serum cortisol 1.45 mcg/dl (4.30-22.40)
Muscle weakness (value of around 90/60 mmHg on Low ACTH 14.50 pg/ml (<46.00)
repeated measurements)
Abnormal behavior Persistent low blood glucose values
Irrelevant talking Hyponatremia (low blood sodium levels)
Inability to recognize
relatives
FSH Amenorrhea Low FSH 12.41 mU/ml (15.9–54)
(contradicting to an expected increased FSH
values in a postmenopausal female)
TSH: Thyroid‑stimulating hormone, GH: Growth hormone, ACTH: Adrenocorticotropic hormone, FSH: Follicle‑stimulating hormone

188 CHRISMED Journal of Health and Research | Volume 6 | Issue 3 | July-September 2019
 Singhai, et al.: An unusual presentation of empty sella syndrome

gradually and insidiously; symptomatology is unspecific so Table 2: New class of drugs for hyponatremia
that diagnosis is often delayed.[2,3] Drug class Dosage Mechanism of action
There are two types of ESS which are as follows: primary Tolvaptan Oral Selective vasopressin 2
and secondary. Primary ESS happens when a small Lixivaptan receptor antagonists
anatomical defect above the pituitary gland increases (not FDA approved)
pressure in the sella turcica and causes the gland to flatten Satavaptan
(not FDA approved)
out along the interior walls of the sella turcica cavity.
Mozavaptan
Primary ESS is associated with obesity and an increase in
Conivaptan Given as IVNonselective V1 and V2
intracranial pressure in women.[8] In most cases, especially
infusion bocker, maximally blocks
in people with primary ESS, there are no symptoms and V2
it does not affect life expectancy. Some researchers have IV: Intravenous, FDA: Food and drug administration
estimated that less than 1% of affected people ever develop
symptoms of the condition. conditions such as panhypopituitarism.[3] The onset of
Secondary ESS is the result of the pituitary gland panhypopituitarism may be insidious and sometimes
regressing within the cavity after an injury, surgery, or with mild nonspecific symptoms. Symptoms such as loss
radiation therapy. Individuals with secondary ESS due to of energy, fatigue, and decreased libido are common in
the destruction of the pituitary gland have symptoms that the elderly, thus physicians often fail in misdiagnosis
reflect the loss of pituitary functions such as intolerance to and consider hyponatremia as a normal consequence of
stress and infection. aging.[1,3] Table 2 shows the new class of drugs available
for the treatment of hyponatremia.
Stable patients who are diagnosed with panhypopituitarism
have a favorable prognosis with replacement hormone Conclusion
therapy; however, patients with acute decompensation are
in critical condition and may have a high mortality rate. ESS is a rare disease, and most of the time it left
Four retrospective studies from the United Kingdom and undiagnosed, and patients with panhypopituitarism are
Sweden showed that mortality is increased by 1.3–2.2 at high mortality risk; hence, hormone assays should be
fold in patients with panhypopituitarism, compared with included in the initial diagnostic workup of hyponatremia.
age‑ and sex‑matched cohorts.[9] Morbidity is variable and Declaration of patient consent
may depend on hormone deficiency, underlying disease, or
inadequate long‑term replacement therapy. The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
Recent studies have shown that people with a previous given his/her/their consent for his/her/their images and
traumatic brain injury, spontaneous subarachnoid other clinical information to be reported in the journal. The
hemorrhage (a type of stroke), or radiation therapy involving patients understand that their names and initials will not
the head have a higher risk of panhypopituitarism.[10] be published and due efforts will be made to conceal their
After traumatic brain injury, as much as a quarter have identity, but anonymity cannot be guaranteed.
persistent pituitary hormone deficiencies.[11] Many of these
people may have subtle or nonspecific symptoms that are Financial support and sponsorship
not linked to pituitary problems but are attributed to their Nil.
previous condition. Hence, it is possible that many cases
of panhypopituitarism remain undiagnosed, and the annual Conflicts of interest
incidence would rise to 31 per 100,000 annually if the There are no conflicts of interest.
people are from these risk groups were to be tested.[4]
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